Need a new perspective here....

3 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.
You asked what you could do differently. And now you know where to find stupid buried old labs. no big deal.

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 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.

Quote from Bill E. RubinI'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.

Quote from Bill E. RubinI'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.

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!

Quote from ChinupBSNRNMy 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?

Quote from SanukI 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.

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.

Quote from roser13OP 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.

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.

All of the comments and feedback here are so great! Since I am so new to the profession, everyday is a big learning experience and I constantly find new things to learn and remember.Ironically, this was the first pt I have ever had on a heparin drip! My ICU deals with a lot of liver failure and elevated INR so anticoag drips are not the norm. But now I know to look for a Q12 or Q6 lab draw when I do have a pt on heparin gtt.Also, thanks to all the comments here, I am going to be checking all the previous orders rather than just new ones. I know I make mistakes, and I think the hardest part was that when I asked for help from my coworker I just got a negative response. Ehhh those things happen too. I think the advice and tools you all have given me will help me greatly! As usual......AN rocks!!