Hey everyone!I had an experience at work yesterday, and I have mulled it over in my head a million times so I need a fresh perspective and thoughts on what could have been done differently.I am a new ICU nurse, off orientation for a month now. I work days, it is super busy and my patients are super busy. No surprise....every nurse is busy! So yesterday, I had a post op patient on an anticoag drip. (not pressors or anything like that). The pt was supposed to go to the floor, but due to this drip, they had to go ICU status. When I called to get report, their original nurse was off the unit so the fill-in gave me a very vague, and I mean bare-bones no details report. They were an outside consult, so not much H/P in the computer either. I asked if the original RN could call me back and give report, and I got a feeble "maybe" as the answer. 10 minutes later the pt arrived on my unit. Admitting had not transferred them yet so I could not see anything except for vitals. I did a full assessment, hooked up monitors, paged MD about pain medication, etc. All was good. Finally got them admitted to our unit computer, released pending orders, and looked at MAR and labs/orders. The only pended orders were to start a peripheral, hang NS drip, and advance diet as tolerated. No lab draws were in my specimen collect folder. I did the IV, started fluids, started water sips, ordered up more anticoag drips, the usual stuff. Pt was stable, tolerating pain meds and fluids. Shift change rolled around. I reported off to the night nurse. I used to work nights, so I know the night staff. The RN I reported off too is nice, very smart and a great RN. That said, she can be a little moody (as we all can be) and I noticed when she came on unit that it was not a good mood day for her. Reported off on first pt and all was good. Started report on the post op new admit. I told her his drips, fluids, etc. She went back through his OR orders and asked why I didn't draw a certain lab. I told her that I wasn't aware the lab draw was needed. It was a PRN lab draw that PACU did not set up on a time schedule according to when the anticoag drip was initiated. She found the order when she went to the area where you modify/discontinue orders. The order was buried in the surgical orders. The night nurse got ***** with me about it, stomped off, drew the lab, and then had a nasty attitude during the rest of report. I felt really bad and asked her what I should have done differently since that lab draw was from surgical orders, not post-op ICU orders. She just rolled her eyes, mumbled something, and then walked off again. At this point, I started to feel really bad that I really messed something up, and I just wanted some guidance and answers from her. I know I am new, and while I feel competent in what I do, I also know that I still have a lot to learn. The night RN has been a nurse for 6 years. I know I can learn a lot from her. I was a little mad that when I asked what I could have done differently to see this order, she just blew me off.My question is this......as a new RN, how was I supposed to A. know to dig through surgical orders to find this lab, and B. approached this with the RN in a different way so I could have learned something from this?Thank you all for your help here.....I want to learn and grow everyday, and I seem to have hit a brick wall with this one.
raskol 53 Posts Specializes in cardiac stepdown, pre-hospital. Oct 20, 2011 You asked what you could do differently. And now you know where to find stupid buried old labs. no big deal.
Bill E. Rubin 1 Article; 366 Posts Specializes in Neuro, Cardiology, ICU, Med/Surg. Has 7 years experience. Oct 20, 2011 I'm guessing the pt is on a heparin gtt (or argatroban or some such) and the night nurse was looking for a PTT? There is usually a therapeutic goal and an institutional policy about when to draw a PTT if it's therapeutic vs sub/supra therapeutic (12 hrs vs 6 hrs). It's something that will be second nature to you as you get more experience. Of course I could be wrong.Keep your chin up. It takes so long to get your confidence up, and an interaction like the one you described can undermine your self confidence at this vulnerable time.
Sanuk 191 Posts Specializes in ER. Has 8 years experience. Oct 20, 2011 I don't work med/surg, but as a type A, I would probably look at all the orders my patient had prior to arrival and verify that they were completed. OT, I find it appalling that a patient was sent to the floor (ICU no less) without an IV access.
ChinupBSNRN 29 Posts Oct 20, 2011 I'm guessing the pt is on a heparin gtt (or argatroban or some such) and the night nurse was looking for a PTT? There is usually a therapeutic goal and an institutional policy about when to draw a PTT if it's therapeutic vs sub/supra therapeutic (12 hrs vs 6 hrs). It's something that will be second nature to you as you get more experience. Of course I could be wrong.Keep your chin up. It takes so long to get your confidence up, and an interaction like the one you described can undermine your self confidence at this vulnerable time.Thank you so much! Yep, heparin and alteplase. The PRN was to be Q6 after initiation of the heparin. What didn't red flag me was there were no titrate orders on the MAR plus no scheduled lab drawsThank you for the kind words. It is so intimidating to be on your own ome days.
DookieMeisterRN 315 Posts Specializes in Cardiac, PCU, Surg/Onc, LTC, Peds. Oct 20, 2011 I'm guessing the pt is on a heparin gtt (or argatroban or some such) and the night nurse was looking for a PTT? There is usually a therapeutic goal and an institutional policy about when to draw a PTT if it's therapeutic vs sub/supra therapeutic (12 hrs vs 6 hrs). It's something that will be second nature to you as you get more experience. Of course I could be wrong.Keep your chin up. It takes so long to get your confidence up, and an interaction like the one you described can undermine your self confidence at this vulnerable time.I agree, as a new nurse you wouldn't exactly know what labs are most likely standard protocol for heparin gtts. The PTT is important to keep track of and make sure it's drawn to titrate your hep gtt. Always ask when you're unsure and learn to be more assertive when accepting a patient. As for the moody nurse, she'll get over it LOL. Don't let it bother you, you'll be working with a lot of moody women in this job.
kool-aide, RN 594 Posts Specializes in Cardiac. Has 5 years experience. Oct 20, 2011 That's a load of crap. It's not as if you were trying to get out of doing the work, you just didn't know it was there! You can't know everything, nobody can! You did the right thing by asking her what you can do differently next time, but if it were me and I got an attitude in response from the other nurse, I would have confronted her about it. You need to stop that buck in it's tracks. Sounds like you're doing a great job, keep up the good work!
APRN., DNP, RN, APRN, NP 995 Posts Specializes in Family Practice, Mental Health. Has 32 years experience. Oct 20, 2011 My question is this......as a new RN, how was I supposed to A. know to dig through surgical orders to find this lab, and B. approached this with the RN in a different way so I could have learned something from this?I've had nurses who I've admired in the past get short with me when I've not been a perfect nurse. What I've found helpful, is to look 'em in the eye and say "I value your input, and recognize your knowledge, however, I just wish you would not.......(do or say x,y,z thing that bothered me at the time).Say it as a matter of fact. End of story, and move on. Immediately.They had their moment, and you just had yours by stating the above. It short circuits the snark-loop and everyone involved can focus on other things.
roser13, ASN, RN 6,504 Posts Specializes in Med/Surg, Ortho, ASC. Has 17 years experience. Oct 20, 2011 I don't work med/surg, but as a type A, I would probably look at all the orders my patient had prior to arrival and verify that they were completed. OT, I find it appalling that a patient was sent to the floor (ICU no less) without an IV access.OP stated that Admitting hadn't yet transferred the patient to her unit, so she was unable to look up orders prior to the patient's arrival.
Altra, BSN, RN 6,255 Posts Specializes in Emergency & Trauma/Adult ICU. Oct 20, 2011 I do find it unsettling that at some point in your orientation you didn't cover Heparin gtts and the importance of monitoring PTTs. This is a common, not exotic, intervention.So now you've learned something. Right now as a new nurse you're focused on "did I complete all the orders?" With some time, you should move toward "what needs to be done for the patient?" and hopefully you'll gain a better big-picture sense of what might be "missing" from orders.
Sanuk 191 Posts Specializes in ER. Has 8 years experience. Oct 20, 2011 OP stated that Admitting hadn't yet transferred the patient to her unit, so she was unable to look up orders prior to the patient's arrival.Oh, I wasn't saying that. What I meant was when the patient arrived to the floor, I would have looked through the orders that were written in the admitting department. I didn't express myself well, sorry
Ruby Vee, BSN 67 Articles; 14,023 Posts Specializes in CCU, SICU, CVSICU, Precepting & Teaching. Has 40 years experience. Oct 20, 2011 you said the patient was on an anticoagulant drip. i would have been looking for orders to draw a ptt -- and if i hadn't found them, i might have asked for orders. (or just drawn it myself -- not a good habit to get into and a horrible one to get out of.) that said, now you know. good on you for asking what you could have done differently.
