K and mag values overlooked

[mikasa]

I work at an ICU and started as a new grad. I've been an RN for a little over a year now. I floated and had a pt that had labs drawn at 0200, I came in at 0700. There K was WNL but mag was a little low. However they were not on a replacement protocol, usually they are if they are a cardiac pt, so I didn't think anything of it. The night RN also didn't think anything of it. I didn't see this pt being a cardiac pt, this was not a cardiac ICU. However, this pt has been getting one time doses of lasix.

Sooo, I get floated back down to my unit. The charge calls me 3 hrs later, right at the end of my shift and said that she just didn't understand the situation. Basically saying why didn't this pt's k and mag get replaced especially when she is getting lasix and is a cardiac pt? She was having rhythm changes at this time. She also said "I won't write you up since it is not fully your responsibility to check labs, the cardiac MD should have also been aware."

I was kicking myself!!!! I really didn't even think about it and didn't really see this pt as a cardiac pt. I was also pissed that the charge nurse was thinking about writing me up. It made me so scared. I feel stupid and I was making constant excuses in my head..like the night RN should have replaced it blah blah blah. And I was thinking about the pt the whole time and hoping that they were ok. I just can't stop thinking about this situation.

[Double-Helix, BSN, RN]

I'm sorry that this happened to you. I agree that it is the MD's responsibility and not yours to make sure that the patient has magnesium and potassium replacement orders written. If no standing orders exist at your facility, these are orders that should be put in on admission, not when the first lab comes back abnormal. While it's normal to feel guilty and responsible, more than one RN didn't catch it or didn't bring it up.

You intended to do what was best for the patient, and you thought you were doing so. There is absolutely no reason for you to be written up. The patient will be just fine- electrolytes can be stabilized quite easily- and this will be a lesson that will make your practice better.

[MrNurse(x2), ADN]

Being floated creates a mental block on its own, unless that is what is expected of you every shift. I am assuming you were floated to a m/s floor, that can present another obstacle, perception. You have ICU experience exclusively, by your initial sentence. There is a lot of info and a lot of 1:1 interaction with physicians which are not available to m/s nurses. This gives an advantage to ICU nurses in terms of knowledge base and experience, and this can lead to a pride that the m/s floors are "below" the hierarchy in the hospital. Perhaps there was an attitude you took onto that floor that was validated by the night nurse not being concerned and changed your standard of practice to where you may have assumed it is on the m/s floor. This may have not had anything to do with it, but it may be something to keep in the forefront if there could be a hint of truth. This is the best way to learn and you really aren't comfortable until 2-3 years, so you are still in that learning abundantly phase.

[NotReady4PrimeTime, RN]

The only thing that would bother me about your patient is the rhythm changes. Being mildly hypokalemic and mildly hypomagnesemic aren't huge issues... unless there are rhythm changes. And it doesn't matter if the patient is a cardiac one or not. Rhythm changes are always a concern. End of story. So the only ball you dropped was the rhythm one. The patient was not actually harmed by the oversight. Five hours had passed between the lab draw and the start of your shift... so really, you probably didn't even drop that ball. It was already on the floor. If this was your patient in the ICU, you would have reported it as soon as the results came in and if it was considered significant, an order for a mag bolus would have been written. Learn from this and move on.

[Double-Helix, BSN, RN]

So the only ball you dropped was the rhythm one.

My understanding from the OP was that the patient didn't develop rhythm changes until several hours after the OP had returned to his/her regular unit.

[kataraang, BSN]

In general, it IS the nurse's responsibility to address lab values, even if they don't write the replacement orders. Not to say the MD is off the hook. But that if the MD does drop the ball, the nurse is really the one that catches these things. Don't think about what previous nurses before you missed or ignored. It's about what YOU are doing. It doesn't hurt to page the doctor to ask if there is a plan for replacement. It takes them just a minute to go in the computer and put an order in. For example, my patient was stable, sinus on monitor, but K was 3.3. I called and got a one time KCl dose. It's okay to be extra cautious. Patients on continuous monitoring may not be "cardiac" patients, but they have been identified as needing a cardiac monitor. I am very vigilant about the electrolytes.

However, you didn't deserve to be spoken to like that. You didn't do anything wrong. Just learn from this experience! That's pretty cool that you got ICU right out of school :)

[iluvivt, BSN, RN]

I just was wondering if the Mag was WNL or was it flagged as low and not WNL.If it was flagged as not WNL.then to always to be safe,just call the provider.As others have said I would not get into the habit of thinking that these things only matter if you are a cardiac patient. I do think the charge murse made too much out of it and the culture of writing nurses up has gotten out of hand at many facilities.This should have been a learning experience and approached as such because then you would be open to learning instead of being worried and frightened unnecessarily.So stop fretting now,learn the lesson and move on!

[BedsideNurse]

"Rhythm changes" can happen for a variety of reasons, and blaming you due to a normal K+ and slightly low Mg++ (5 hours before your shift even) is absolutely ridiculous. Try to stop ruminating and feeling bad about it. I think the real take home here is some people are crazy.

[Loving-and-Learning]

I would echo the above comments--don't torture yourself over this because it can become an obstacle to your practice. However, even though an abnormal lab should get addressed by the nurse on whose shift the value is reported and the MD is responsible for ordering treatment according to abnormal values, I would contribute 2 takeaways here: 1) If you are given the responsibility of taking care of the patient, and you saw the lab, follow up. It's irrelevant that previous nurses didn't pick it up. Unless you're given in report that there is a reason for inaction, you should follow up. It's not uncommon that something gets missed by one nurse after another, shift after shift and part of that is a nurse assuming that the previous nurse would've done something about it if it mattered. Also we as nurses are with a small number of patients for the entire day (versus physicians who have to think about many patients). Physicians count on us to keep our eyes open and our brains working and alert them as needed. That's what makes us a team. Patient care is a collaboration. Always have that in mind. So. Apart from where the responsibility falls ultimately, go forth with the mindset that you should take action as needed. 2) Try not to get stuck in the mindset of labeling each patient as "cardiac" or " GI" etc. That closes your brain to the creative and critical thinking you need to be a great nurse and it sounds like possibly this is what got in your way this time. As previous posters stated, cardiac patient or not, cardiac issues can still develop. Big picture.