Six Patients, Two Assistants, Twenty Minutes Behind
You are the charge nurse on a 32-bed medical-surgical unit at 07:00. Staffing is you, one LPN, and one unlicensed assistive personnel (UAP); there is no unit secretary, and report ran 20 minutes late. Your six patients: (1) a 78-year-old with COPD, SpO2 89–91% on 2 L/min (his documented baseline is 88–92%), waiting for discharge teaching on two new inhalers; (2) a 54-year-old POD 1 laparoscopic cholecystectomy, pain 7/10, morphine PCA running, RR 14, no nausea; (3) an 88-year-old with mild dementia who keeps trying to climb over the side rail and has not had a bowel movement in 3 days; (4) a 62-year-old receiving IV antibiotics for cellulitis with an IV site that is tender and warm; (5) a stable 45-year-old waiting for a 10:00 transfer to rehab; (6) a 70-year-old with a new colostomy who turns his face away whenever the pouch is mentioned.
1. Make the assignment for the next 30 minutes: who sees which patient, in what order, and what is delegated to the LPN and the UAP? Defend each choice.
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Principle: match the task to the scope, then order by risk of harm and by work only the RN can do.
- UAP to patient 3 right now, and stay. Continuous presence and redirection is within UAP scope; it is not restraint, and it prevents a fall until you get there.
- You to patient 3 first. A new behavior in a patient with mild dementia is a new symptom (delirium), not "just his dementia." Assessment, cause-hunting, and any restraint decision cannot be delegated.
- LPN to patient 4, then patient 2. The LPN can assess the IV site, stop the infusion, and report phlebitis findings; and can obtain vital signs and a pain rating on the PCA patient. Neither is unstable.
- You to patient 1. An SpO2 of 89–91% sits inside his COPD target, so this is not the emergency the number suggests - but the respiratory assessment and inhaler teaching are RN work and the discharge is blocked without them.
- UAP: vitals, intake and output, help patient 5 prepare for transfer. You: brief supportive contact with patient 6 once the first four are settled.
Reassess patient 1 immediately if SpO2 drops below 88% or work of breathing increases.
2. Patient 3 is now standing at the bedside, unsteady, saying he needs to go find his car. What do you do in the next 10 minutes, and what will you deliberately not do?
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Do not physically hold him down, apply restraints as a first move, or argue the facts ("You're in the hospital, you don't have a car"). Arguing escalates a confused patient.
- Approach from the front at eye level, calm and slow, use his name, and join his goal: "You want to get to your car - let's walk to the bathroom first and I'll help you after."
- Ambulate him to the toilet. Three days without a bowel movement plus possible urinary retention are the most likely drivers and are fixable.
- Environment: bed low and locked, floor mat, bed or chair alarm, non-skid footwear, clear path, call light in reach, glasses and hearing aids on.
- Hunt the cause: bladder scan, last BM, pain, pulse oximetry, glucose, temperature and urinalysis, and a medication review for anticholinergics, opioids, and benzodiazepines.
- Reorient with concrete cues: clock, calendar, daylight, family at the bedside, consistent staff.
- Restraints only for imminent harm after less restrictive measures have failed, and then only with a provider order, the required time limits, face-to-face evaluation, and monitoring.
Document the behavior, every intervention tried, and his response.
3. At 09:20 the UAP says, "His daughter keeps pushing the PCA button and now he's hard to wake." What is your immediate priority, and what system problems does this expose?
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Immediate: go to the bedside. Stimulate him by name, assess responsiveness, respiratory rate, SpO2, and sedation scale. Pause the PCA - do not simply lower the rate and leave. Apply oxygen, position, call for help or rapid response, and notify the prescriber. Give naloxone per protocol if the respiratory rate is depressed or he is unarousable, titrated to respiratory rate rather than to full wakefulness. Stay with him.
Then: the PCA button belongs to the patient alone. "PCA by proxy" by family is a well-recognized cause of oversedation; families usually believe they are helping with pain. Document the event, notify the provider, update the care plan, and educate the daughter at a calm moment. Put a note on the pump.
System problems: no visitor education at admission about the button; no visual cue on the pump; and a UAP who may not know that reporting immediately - and never touching the pump or rate - is the whole job. File an incident report. The goal is a fix, not a name.