Staffing shortfall, a slow infusion and a paediatric paracetamol request
You are the nursing officer of a 36-bed general medical ward in a Delhi hospital. On 1 August, 24 beds are occupied. The sanctioned strength is 12 staff nurses, but 3 are on leave (two maternity, one medical), leaving 9 available. The ward protocol fixes the nurse-to-patient ratio for every shift at 1:6 and runs three 8-hour shifts a day; each nurse is rostered for 6 shifts a week (48 hours). Alongside the staffing problem, two orders are running. A patient is to receive 500 mL of Ringer lactate intravenously over 6 hours through a set that delivers 20 drops per mL. At the 2-hour check the bag shows only 120 mL has infused, and the patient complains of pain and swelling at the cannula site. In the side room, a 14 kg child has an order for syrup paracetamol 15 mg/kg/dose every 6 hours; the bottle is labelled 250 mg/5 mL. The mother, whose child last received a dose 4 hours ago, asks you to give the next dose now because the fever has come back.
1. Calculate the number of staff nurses the ward needs each week and the shortfall, then state what you do about it.
Read the worked answer
Requirement 14 nurses; 9 available; shortfall 5.
Step-by-step:
- Occupied beds = 24. Ratio 1:6, so nurses required per shift = 24 ÷ 6 = 4.
- Shifts per day = 3, so nurse-shifts per day = 4 × 3 = 12.
- Nurse-shifts per week = 12 × 7 = 84.
- Each nurse works 6 shifts a week, so nurses required = 84 ÷ 6 = 14.
- Available = 12 − 3 = 9. Shortfall = 14 − 9 = 5 nurses, i.e. about 36% of the requirement.
Judgement, not just arithmetic: the ratio cannot be quietly abandoned. Write to the nursing superintendent the same day with these figures, request redeployment of 3–5 nurses from low-dependency areas (OPD, day-care) or a relief pool, and in the interim prioritise - bedside observation and medication rounds first, documentation and non-urgent transport delegated to ward attendants/ward boys within their permitted role, and admissions capped or diverted with the duty medical officer's written concurrence. Record every escalation, because an adverse event on an understaffed shift is defensible only if the shortfall was reported in writing beforehand.
2. What should the drip rate have been, and what do you do now that only 120 mL has infused in 2 hours with pain and swelling at the site?
Read the worked answer
Prescribed rate ≈ 28 drops/min; the line has infiltrated, so the answer is to stop and restart, not to speed up.
- Total drops = 500 mL × 20 drops/mL = 10,000 drops. Time = 6 × 60 = 360 minutes.
- Rate = 10,000 ÷ 360 = 27.8 ≈ 28 drops/min.
- Expected volume at 2 hours = 500 × 120/360 = 166.7 mL. Actual = 120 mL, so the infusion is about 47 mL behind - a real discrepancy, not rounding.
- Never correct a deficit by turning the roller clamp up. Pain and swelling at the cannula site indicate infiltration/extravasation. Stop the infusion, disconnect, remove the cannula, elevate the limb, and inform the doctor; do not massage the site.
- Re-site a fresh cannula (preferably in the opposite arm, above the previous site) and restart. Recalculate from what is actually left: remaining volume 380 mL over the remaining 4 hours = (380 × 20) ÷ 240 = 31.7 ≈ 32 drops/min, which is a legitimate recalculation, and document the incident, the new site and the new rate.
- Check and record hourly: site, rate, volume remaining, and patient comfort. Exam point: recalculating a rate for the remaining volume is correct practice; raising the rate to “catch up” a lost volume is not.
3. Calculate the paracetamol dose and volume, and decide whether to give the dose now.
Read the worked answer
Dose 210 mg = 4.2 mL; do not give it at 4 hours just because the fever has returned.
- Dose = 15 mg/kg × 14 kg = 210 mg.
- Volume: the syrup is 250 mg in 5 mL, so 1 mL = 50 mg. Volume = 210 ÷ 50 = 4.2 mL.
- Daily ceiling check: 4 doses × 210 mg = 840 mg per day = 60 mg/kg/day, which is below the usual 75 mg/kg/day maximum, so the prescribed schedule itself is safe.
- The mother's request: the order is every 6 hours, and the last dose was 4 hours ago, so giving it now shortens the interval and stacks doses towards hepatotoxicity. Paracetamol is not given on demand; the minimum interval must be respected. Explain this to the mother in plain language, and offer the non-drug measures - tepid sponging, loose clothing, oral fluids - while recording the temperature and informing the doctor if the fever is high or persistent.
- Verification before pouring: confirm the child's current weight (14 kg is a growing child's weight, re-weigh if in doubt), the time and dose of the last administration, and that no other paracetamol-containing preparation has been given at home. Exam point: the commonest paediatric medication error is a shortened dosing interval, not a wrong single dose.