Assigning Care When the Only RN Leaves the Unit
You are the licensed practical nurse (LPN) on a 30-bed medical-surgical unit during a 1900–0700 shift. Staffing is one RN, you, and two unlicensed assistive personnel (UAPs) for 28 patients. At 2015 the RN is called to a rapid response on another unit and says, "You're in charge until I get back - I don't know how long." Your assignment includes: Mr. A, post-operative day 1 after a bowel resection, who is to ambulate for the first time and whose last hemoglobin was 7.9 g/dL; Ms. B, admitted 40 minutes ago with new substernal chest pain, awaiting a troponin and ECG; Mr. C, who has dysphagia after a stroke and needs to be fed; Ms. D, a newly diagnosed diabetic who needs a point-of-care glucose; and four stable patients who need repositioning and vital signs. Facility policy permits UAPs to take vital signs, perform accu-checks on trained units, reposition patients, and ambulate patients who a licensed nurse has assessed as stable. Both UAPs are experienced and have current competencies on file.
1. Sort the pending tasks into what you may delegate to the UAPs, what you must do yourself, and what can safely wait. Explain the principles that drive each decision.
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Delegate now: vital signs and repositioning for the four stable patients (predictable, no nursing judgment required), and the point-of-care glucose for Ms. D if the UAP is trained - but the interpretation of the result and any insulin decision stay with you.
Do yourself: Ms. B's chest pain. She is unstable and undiagnosed; assessment, interpretation, and nursing judgment cannot be delegated, and the UAP cannot recognize deterioration. Mr. C's feeding needs your judgment because dysphagia carries an aspiration risk requiring positioning, swallow evaluation, and pacing; feeding him is not a "feeding" task, it is an assessment.
Conditional: Mr. A may be ambulated by a UAP only after you assess him - a hemoglobin of 7.9 g/dL post-op day 1 makes orthostatic instability plausible, and his stability is not yet established. Assess, then hand off with explicit limits (distance, gait belt, stop-and-sit criteria).
Can wait briefly: routine vitals on the four stable patients until Ms. B is stabilized. Every delegation still requires the right task, circumstance, person, direction, and supervision - and you remain accountable for the outcome.
2. Ms. B's chest pain is unrelieved. What will you do in the first 10 minutes, and how will you communicate with the RN and the covering provider?
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Stay with the patient and call for help. Position her upright or as comfort allows, apply oxygen if SpO2 is below 90% or per protocol, obtain full vital signs, and get a 12-lead ECG within 10 minutes. Place her on continuous cardiac monitoring if available, establish IV access if within your scope and policy, and begin a focused assessment: character, radiation, duration, diaphoresis, nausea, shortness of breath, history of cardiac disease, and any recent use of a phosphodiesterase-5 inhibitor (which would make nitroglycerin unsafe).
Give only ordered medications - sublingual nitroglycerin if ordered and systolic BP is at least 90 mmHg, aspirin if ordered - and recheck vitals and pain after each. Do not delay the ECG to complete paperwork.
Report with SBAR: "Ms. B, 58, substernal pressure 8/10 for 20 minutes, radiation to the left jaw, BP 148/92, HR 102, SpO2 94% on room air, ECG obtained and showing ST changes, nitro given at 2022 with pain now 5/10." Ask explicitly for orders and for the RN's return. Document times and responses.
3. Ten minutes later a UAP reports, "Mr. A doesn't want to walk - he says he's dizzy and he looks really pale." What is your response and what is your reasoning?
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Do not push the ambulation. The UAP's report is a trigger for nursing assessment, not permission to proceed, and a change in a post-operative patient overrides the plan of care.
Go to Mr. A and assess: level of consciousness, skin color and temperature, heart rate, blood pressure lying and sitting, pain, abdominal distention, and the surgical dressing and drains for bleeding. Check his last hemoglobin trend against 7.9 g/dL and look for tachycardia, hypotension, or a falling urine output that would suggest ongoing bleeding. Palpate for a distended bladder, which can cause hypotension and restlessness.
Hold the ambulation and keep him in bed until he is assessed and, if needed, volume-resuscitated. Notify the provider with SBAR and request a repeat CBC and any orders. Praise the UAP for reporting - that is exactly the behavior you want repeated. Document the assessment, the provider notification, and the decision to defer ambulation.