Charge Nurse at 06:45: Triage, Delegation, and an Unfamiliar Float RN

1st - Room 412. This is the only patient showing a trajectory, not a single abnormal number. HR 118 + BP 96/54 + urine 15 mL/hr for 3 hours (below 0.5 mL/kg/hr) is the classic pattern of early hypovolemic/hemorrhagic shock on postoperative day 1. A dry dressing does not rule out bleeding into the retroperitoneum, the abdominal wall, or the GI tract.

• Do: full assessment (dressing and flanks, abdomen, mentation, capillary refill, orthostatic tolerance), repeat vitals, review the CBC trend, and notify the surgeon.
• Trap: the PCA. Morphine can cause hypotension and sedation, but RR 22 and a normal temperature make opioid effect an incomplete explanation. Assess pain score and sedation scale before attributing the vitals to the PCA - do not simply stop the pump and move on.

2nd - Room 418. New hypoxemia (SpO2 90% on 2 L) plus 1.8 kg overnight weight gain in heart failure means worsening pulmonary edema. The furosemide is time-sensitive, but the assessment (lung sounds, work of breathing, whether she needs more oxygen or noninvasive ventilation) determines whether you give it at the bedside or escalate first.

3rd - Room 415. Glucose is corrected but K is 3.4 on an insulin infusion - insulin drives potassium intracellularly, so the potassium will keep falling. This is arrhythmogenic but not immediately unstable.

Why the rest wait: cefazolin (420), warfarin teaching (421), and fall precautions (424) are time-flexible and can be delegated with supervision. Reassess 412 after intervention; if the BP does not respond to a fluid bolus, escalate to rapid response.

The boundary is the nursing process: assessment, initial teaching, and any task requiring clinical judgment stay with the RN; the LPN performs stable, predictable interventions within state scope; the UAP performs tasks with a predictable outcome after competency validation.

Task	Who	Reasoning
(a) First ambulation, PCA	RN	First mobilization of a POD 1 patient with an opioid PCA requires pre/post assessment for orthostasis, sedation, and pain response. Never delegate a first ambulation.
(b) Fingerstick glucose	UAP (if validated)	The poke is a task; the interpretation and titration of the insulin infusion is the RN's. Be explicit: "report the number to me, do not change the rate."
(c) IV cefazolin	LPN if state scope and hospital policy permit	Stable patient, peripheral line, routine antibiotic. Verify before assigning.
(d) Turning/repositioning and skin inspection	Split - UAP turns and reports; RN does the skin assessment	Surveillance for a new pressure injury is assessment.
(e) Lung sounds	RN	Assessment cannot be delegated.
(f) Initial warfarin teaching	RN	Initial teaching requires the nursing process; the LPN may reinforce after the RN has taught and evaluated understanding.

Say the rule out loud during handoff: delegation transfers the task, not the accountability.

Assign the float RN the most stable, protocol-driven patients (420, 421, and 424 once a sitter is present) - not the two unstable ones. Rationale: unfamiliarity with the unit is the risk, not incompetence; she is an RN and can assess.

Before she starts:

• Orient to unit-specific equipment and protocols: PCA pump, insulin infusion protocol, glucometer, code cart, emergency call system, and the escalation number.
• Verify competency documentation for the insulin drip and PCA per hospital policy - if not verified, that patient stays with you.
• Pair her geographically with the LPN so the LPN can answer "where is everything" questions.
• Set a check-in at 30–60 minutes.

Change the plan if: she reports she has never titrated an insulin infusion, a patient's acuity rises, or she cannot locate the protocol - reassign immediately and document. Also re-check the whole assignment after you send 412 for a stat Hgb or to the OR, because your own capacity changes.