Charge nurse on a short-staffed medical ward: assignment and escalation

Rank by risk of harm in the next 8 hours, then match to scope and supervision.

1. DKA on an insulin infusion - keep for myself as charge nurse or give to the most experienced RN. Hourly capillary glucose, potassium and acid-base monitoring with titration of a continuous IV infusion is an RN-only, high-frequency task where a 30-minute delay can cause hypoglycaemia, hypokalaemia or cerebral oedema. A new graduate in week 3 cannot hold sole accountability for titration.
2. New stroke with a failed swallow screen - experienced RN. Aspiration risk peaks in the first 24–48 hours. The RN must keep the patient NPO, repeat the screen with the physician, sit the patient upright, manage secretions, start IV fluids and watch for deterioration.
3. Confused patient climbing out of bed - ward assistant with 1:1 observation under RN direction. This is a supervision/non-clinical task that the assistant can do once the RN has assessed falls risk, applied the bed alarm and reviewed sedation and analgesia. Observation is delegated; the falls assessment is not.
4. Two contact-precaution patients - practical nurses. Hygiene and oral/IM medicines are within their validated scope; PPE and cohorting rules must be restated at handover.

Five rights of delegation check: right task (no IV push, no blood products, no titration by practical nurses), right circumstance (acuity too high tonight), right person (new graduate paired as a buddy, never alone on the acute side), right direction (clear parameters: 'call me if glucose <4 or >15, if systolic <90, or if the stroke patient coughs on fluids'), right supervision and evaluation.

Tell the team the plan aloud at 19:15, write it on the assignment board, and document the staffing shortfall and the rationale in the ward log.

Answer: no as the sole nurse, yes as a supervised learner.

Say plainly: 'You will learn this, but not tonight with no buddy and no float. You will be with me for the first hour, then you will do the hourly checks under my supervision while I remain accountable for the titration.' This protects the patient and protects the new graduate's licence; refusing a learning opportunity is not the same as refusing learning.

First 30 minutes:

• Confirm the DKA admission has two large-bore IVs, a fluid order, an insulin infusion pump with the correct concentration, hourly glucose and 2–4 hourly potassium ordered, and a cardiac monitor if potassium is abnormal.
• Walk the new graduate through the infusion order, the pump programming and the hypoglycaemia protocol as a teaching episode at the bedside, then have them repeat it back.
• Confirm the stroke patient is NPO, positioned at 30°, with a working suction and oxygen at the bedside, and that the swallow screen result is written in the notes.
• Assign the practical nurses their medication rounds and hygiene list, and confirm who covers the contact-precaution patients.
• Call the nursing supervisor and the hospital administrator on call, state the numbers (30 patients, 3 RNs, 2 practical nurses, one new graduate), and request a float or permission to close a bed. Put the request and the response in writing.
• Notify the medical team that nurse-to-patient ratio is below the unit standard so they can prioritise reviews and consider high-dependency transfer for the DKA patient.

Attend to the DKA patient first, because the risk is immediate and physiological, then delegate the family conversation rather than abandon the infusion.

Glucose 22 mmol/L in DKA means the protocol may call for a change in insulin rate and, depending on the local protocol, addition of dextrose-containing fluid; potassium must be checked at the same time. This is a time-critical titration the charge nurse or RN must do personally.

Delegation of the family: ask the most senior RN not occupied with the infusion, or page the on-call physician, to sit with the family in a private room. Their script is: explain what a stroke is, why leaving now risks aspiration, deterioration and a second stroke, and that the patient can only leave against advice if he has capacity to decide. The physician documents capacity. If he has capacity, the standard against-medical-advice process applies: explain the risks in the family's own language if possible, offer a follow-up appointment, obtain the signature, and document who explained what and to whom.

Then return to the DKA patient, reassess glucose, potassium, vital signs, fluid balance and level of consciousness, and document the sequence of events with times. If the family physically obstructs care, call security through the standard hospital route and inform the supervisor - do not let a family dispute pull you away from a titrated infusion.