Floated to an Unfamiliar Unit: Titratable Drip, Trach, and a Fifth Patient
You are an RN with 14 months of experience on a 32-bed medical-surgical unit. Ten minutes into your shift, the house supervisor floats you to the 10-bed cardiac step-down unit, where you have never worked. You receive four patients. Mr. R. is on a titratable IV diltiazem infusion at 10 mg/hr with a target heart rate of 60–100; the unit protocol lets the bedside RN titrate between 5 and 15 mg/hr. Ms. T. has a three-day-old tracheostomy and needs suctioning every 1–2 hours. The UAP assigned to your patients says she was trained to suction at her last facility and offers to 'cover the trach' so you can take your lunch break. Five minutes later the charge nurse says an admission is arriving and asks you to take it because 'the other nurse is in a code.' You have not completed the step-down unit's dysrhythmia or titratable-infusion competency.
1. What is your immediate response to the float assignment and the diltiazem infusion? Lay out the decision sequence, not simply 'refuse the assignment.'
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The issue is competency for this specific assignment, not the float itself.
Floating is generally within an RN's scope; the question is whether you can safely meet these patients' needs. A titratable diltiazem infusion is a high-alert cardiac drip, and most organizations require documented competency validation (dysrhythmia recognition, titration parameters, hold parameters, heart-rate targets) before an RN manages one independently. You have not had that validation.
Acting sequence:
- Accept with a stated exception. Say it plainly: 'I can take the four patients, but I am not validated on titratable diltiazem and I need a competent resource.' That protects the patients without abandoning them.
- Ask for a buddy RN who is validated to titrate and co-sign, or ask the charge nurse to reassign that patient.
- Read the protocol - titration range 5–15 mg/hr, target heart rate, hold parameters, and whether an unvalidated RN may titrate under direct supervision.
- Escalate to the house supervisor if neither a resource nor reassignment is available, and document the concern and the response.
Walking off the unit without transferring care is abandonment. Silently accepting the drip and guessing at titration is worse. The defensible path is to accept what you can do safely, declare the limit out loud, secure oversight, and document.
2. The UAP offers to suction Ms. T.'s tracheostomy. Using a delegation framework, decide whether you can accept this, and state what you would say and do.
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Delegation requires four things: scope, validated competency, a predictable patient, and retained RN accountability.
- Scope: In many settings tracheostomy suctioning may be delegated to a UAP or LPN, but only if the state nurse practice act and facility policy permit it.
- Competency: 'I was trained at my last facility' is not verification. You need this facility's competency record.
- Predictability: Ms. T.'s trach is three days old. Suctioning here requires judging secretion amount, colour and consistency, breath sounds, stoma condition, and oxygen response - assessment stays with the RN.
- Accountability: You cannot document or sign off a task you neither performed nor directly supervised.
Response: thank her, decline for now, and say why - 'I need your competency validated here before I can delegate this.' Suction Ms. T. yourself before your break, or ask an RN or LPN with validated competency to cover. Then follow up with the unit educator so the UAP can be validated and safely used in future. Refusing the offer is not a judgement about the UAP; it is about unverified competency with a fresh airway.
3. The charge nurse now wants you to take a fifth patient. How do you handle this request, and what do you document?
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You already have an unresolved competency gap and a high-acuity assignment; adding an admission compounds both.
Reasoning:
- A step-down assignment of four patients including a titratable cardiac drip and a fresh tracheostomy is already at the limit of what an unfamiliar nurse can manage safely.
- The request is driven by staffing, not by the patient's needs, and the stated reason ('the other nurse is in a code') is temporary.
Response: give a conditional answer rather than a flat no - 'I can take the admission if the diltiazem patient is reassigned or a resource RN is assigned to me.' Offer concrete alternatives: hold the admission in the ED or PACU until a bed and nurse are available, call in the on-call nurse, or have the charge nurse take the admission herself.
If the charge nurse insists, move up the chain of command to the house supervisor or nursing supervisor, state the objective facts (unfamiliar unit, no infusion competency, fifth patient) and request a written staffing decision.
Documentation: date and time, the assignment given, the specific competencies you stated you lacked, the resources you requested, who you notified, and the response. Objective facts only - no editorializing about the charge nurse. This record protects the patients and gives the quality committee real data about float and staffing practice.