Charge Nurse Assignment With an Unfamiliar Float and a Supratherapeutic aPTT
You are the charge nurse on a 24-bed progressive care unit at 1900. Two night RNs have called out. The house supervisor sends a float RN from the orthopedic unit who has not managed titratable cardiac infusions in two years. Your staff also includes an RN who has been off orientation for six weeks and a float UAP. The assignment includes: a patient on milrinone 0.375 mcg/kg/min via central line with a PA catheter; a patient with a new tracheostomy on 40% trach collar; four telemetry patients on heparin drips, one with aPTT 118 seconds; and an incoming chest pain rule-out from the ED.
1. How do you construct the assignment? Give your reasoning, including what you would say to the house supervisor.
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Match acuity to validated competence, not to who is available.
A defensible plan:
- Experienced RN or you: milrinone/PA catheter patient (titratable inotrope, hemodynamic monitoring) plus the heparin patient with aPTT 118 (needs interpretation and a provider call).
- New grad: two stable telemetry patients plus the incoming chest pain rule-out if it is low-risk, with you as a designated resource and scheduled check-ins.
- Float RN: the most stable telemetry patients and the tracheostomy patient only if she can demonstrate or describe suctioning, trach emergency management, and humidification - otherwise give her stable telemetry alone with explicit parameters and tell her to call you for any change.
- Ten-minute orientation for the float: monitor alarms, code cart, call system, escalation expectations, and who her buddy is.
Then call the supervisor back: state the staffing is unsafe for this acuity, request an additional resource, and document the conversation and the assignment rationale. If the unit cannot safely manage a titratable inotrope, advocate for transfer to a higher level of care. Delegation and assignment are professional judgments with accountability attached - not a puzzle to be solved by spreading the work evenly.
2. What will you delegate to the float UAP, and what will you not delegate?
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Delegate (per policy and verified training): vital signs including SpO2, weights, intake and output, blood glucose checks, ADLs and bathing, repositioning and ambulation, transport, stocking, specimen collection, and answering call bells - each with specific parameters and explicit "call me if" instructions.
Do not delegate: admission assessments, interpretation of rhythms or aPTT results, titration of any infusion, IV push medications, patient teaching, discharge planning, evaluation of response to treatment, or the initial assessment of the chest pain patient.
Also confirm the float UAP's training - she may not know unit-specific tasks or equipment. Give her a named RN to report to. Delegation transfers a task, not accountability: the RN remains responsible for assessment, follow-up, and the outcome, so build in a way to hear back.
3. The aPTT of 118 seconds is reported. What is your clinical and professional response?
Read the worked answer
- Follow the weight-based heparin protocol: usually hold the next bolus/dose and reduce the rate; verify the exact ordered parameters rather than improvising.
- Assess for bleeding: gums, urine, stool, puncture and incision sites, neurologic status, back or flank pain; check platelets (HIT) and hemoglobin.
- Notify the provider with the result, current rate, and the trend of recent aPTTs; obtain a specific order and repeat the aPTT in 4–6 hours.
- Look for error before biology: confirm pump programming, concentration, line placement, and any bolus given, plus interacting drugs (NSAIDs, antiplatelets, antibiotics). A sudden jump may be a systems problem, not just a dosing problem.
- Document the finding, the call, the order, and the patient's response; reassess and escalate if bleeding develops.
This task is exactly why the float should not carry a heparin titration she has not done recently - the judgment, not the task, is the risk.