Charge Nurse Assignments With Limited Staffing
You are the charge nurse on a 12-bed medical-surgical unit at 1900. The staff includes two RNs (including you), one LPN, and one UAP. There are 10 patients. Assignments include: a 72-year-old on contact precautions for Clostridioides difficile with profuse diarrhea; a 58-year-old on postoperative day 0 after a total knee arthroplasty with a femoral nerve block and urinary catheter; a 45-year-old admitted for chest pain ruled out for myocardial infarction, awaiting discharge; a 26-year-old with sickle cell crisis requesting pain medication; and six stable patients. One RN is newly graduated and still in orientation. The UAP has 5 years of experience and reports that the LPN asked her to perform a dressing change. The unit has one telemetry monitor for the postoperative patient. The emergency department is holding two admissions.
1. Make patient assignments for the two RNs, the LPN, and the UAP. Justify each assignment using acuity, scope of practice, and supervision needs.
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Assign the postoperative knee arthroplasty patient to an RN-preferably the charge nurse or the experienced RN-because of the femoral nerve block, urinary catheter, telemetry, and risk of hypotension, bleeding, and falls. The new graduate should not take this patient without direct support. Give the new graduate the chest pain patient awaiting discharge and two stable patients, with the charge nurse as a resource; this builds assessment skills without exceeding capability. The LPN can take the C. difficile patient and stable patients who require oral medications and routine care; LPNs can perform routine dressing changes within scope but cannot delegate them to UAP. The UAP should take vital signs, intake and output, weights, and hygiene for stable patients, and should not be assigned sole care of the unstable postoperative patient or the complex C. difficile care. The charge nurse retains overall responsibility, monitors the telemetry, and coordinates admissions.
2. How do you respond to the report that the LPN asked the UAP to perform a dressing change?
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Intervene immediately and privately: 'Dressing changes require nursing assessment and are not delegated to UAP in this unit; please do it yourself or tell me if the dressing is complex.' Clarify that the UAP can assist by gathering supplies, positioning, and reporting drainage, but cannot perform the dressing. Review the delegation five rights: right task, circumstance, person, direction and communication, and supervision and evaluation. If the LPN is unsure, demonstrate and document competency. Do not embarrass the LPN in front of the patient. Follow up to ensure the dressing was done and the site assessed. If this is a pattern, escalate to the nurse manager for education. The charge nurse remains accountable for safe delegation.
3. The emergency department is holding two admissions and there is only one telemetry monitor. How do you prioritize and escalate?
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First stabilize the postoperative patient and confirm the telemetry monitor is on that patient. The two admissions can be held briefly if the ED has capacity, but the charge nurse should call the ED and bed management with a realistic timeline. Discharge the chest pain patient if orders are complete to free a bed; use the UAP to prepare rooms and the LPN to complete stable admission paperwork. If either admission is unstable, escalate for additional staff and ask the house supervisor for help. Do not assign the new graduate to a complex admission without support. Communicate delays to the ED and document them. The charge nurse should not leave the unit without a designated nurse in charge. Reassess staffing and call in per diem staff if available.