Charge Nurse on a Short-Staffed Unit: New Confusion, a Transfusion, and a Feeding Tube
At 06:30 you are the charge nurse on a 28-bed medical-surgical unit. Two RN positions are unfilled because of call-outs, leaving one RN, one LPN, and one unlicensed assistive personnel (UAP) for the shift. Assignments: RN - rooms 1 to 8, including Mr. A, who is postoperative day 1 from an open bowel resection with HR 118, BP 98/60, 15 mL/hr of urine for two hours, new confusion, and a firm abdomen; LPN - rooms 9 to 16 plus routine oral medications and dressing changes; UAP - vital signs, ambulation, and blood glucose checks. At 06:45 three demands arrive at once: a new order to transfuse 2 units of packed RBCs to a stable patient with Hgb 7.1; Mr. C's PEG tube feeding is two hours overdue and his gastric residual is 250 mL; and Mr. A's wife stops you at the desk to ask why her husband 'isn't making sense.' Facility policy: only an RN may initiate blood products, and an LPN may not perform the initial assessment of a patient whose condition has changed.
1. Which of the three 06:45 demands do you address first, and how do you delegate the other two? Explain the reasoning behind each assignment.
Read the worked answer
Go to Mr. A yourself, now. The reasoning, in order of what kills first:
- New confusion plus HR 118, SBP 98, urine output of 15 mL/hr and a firm abdomen on postoperative day 1 after a bowel resection is a hypoperfusion picture, not sundowning. Change in mental status is often the earliest sign of intra-abdominal bleeding, and it is the one assessment that cannot be handed off.
- Policy blocks both alternatives: the LPN may not do the initial assessment of a changed patient, and the UAP may not assess at all. Sending either one creates a documentation and safety gap.
- The other two demands are real but time-tolerant. A stable Hgb 7.1 transfusion can safely wait 30 to 60 minutes, and a 250 mL residual means hold the feeding and reassess, not push it through.
Delegation:
- LPN - hold the residual feeding and the next scheduled feed for Mr. C per protocol, document the residual, and complete vital signs for rooms 9 to 16. Report anything outside parameters directly to you.
- UAP - obtain a full set of vital signs on Mr. A (manual cuff, apical pulse, orthostatic if tolerable), measure urine output, get a pain score with a scale you name, and report numbers to you before charting. The UAP does not interpret the findings.
- RN for rooms 1 to 8 - after you finish your assessment and call the surgeon, this RN or you initiates the transfusion with the second-RN bedside verification.
What would change the order: if the Hgb 7.1 patient were actively bleeding or symptomatic, the transfusion would take priority and you would send the team RN to Mr. A immediately.
2. The UAP says she was 'checked off' on hanging blood at her previous hospital and offers to start the transfusion so you can stay with Mr. A. What is your response, and what may the UAP legitimately do for that patient?
Read the worked answer
Say no, briefly and without apology, then give her a job she can do.
- Competency does not travel with an employee. Delegation is governed by state nurse practice law, this facility's policy, and a current competency validated here - a check-off at another hospital meets none of those.
- Transfusion is a high-alert procedure that requires two licensed staff to verify the unit at the bedside against the order and the patient's identification, plus RN monitoring of the first 15 minutes when most hemolytic reactions declare themselves. The UAP cannot perform the verification, cannot assess a reaction, and cannot stop and treat one.
- Letting her hang the unit shifts accountability to you and leaves no licensed observer at the bedside if Mr. A decompensates at the same moment.
What the UAP may do: take and record the pre-transfusion vital signs, transport and retrieve the unit from the blood bank if your policy permits, obtain and record vital signs at 15 minutes and per protocol while an RN is nearby, report subjective complaints such as chills, flank pain, or 'something feels wrong' immediately, and fetch help.
What she may not do: spike the bag, regulate the rate, start the line, or chart the transfusion. Tell her plainly that she is not being criticized - the limit is the procedure - and thank her for offering, then redirect her to Mr. A's vital signs.
3. Write your next 20 minutes of escalation and documentation for Mr. A. What must be in the record, and what orders do you anticipate?
Read the worked answer
Assessment first, then the call. Full set: level of consciousness using a consistent tool, pupils, skin color and temperature, capillary refill, abdominal exam (distention, firmness, tenderness, dressing and drain output including character), urine output and color, two large-bore IV sites or a second access if only one exists, and vital signs every 15 minutes.
SBAR to the surgeon: 'Mr. A, 62, POD 1 open bowel resection. At 06:45 he is confused compared with 22:00, HR 118, BP 98/60, urine 15 mL/hr for two hours, abdomen firm and more distended, dressing dry. I suspect intra-abdominal bleeding; I need you at the bedside and orders for stat CBC, type and crossmatch, and a Foley.'
Anticipated orders: stat hemoglobin and hematocrit, platelets, coagulation studies, type and screen, lactate, fluid bolus, indwelling catheter to measure hourly output, possible return to the operating room, keep NPO, and hold routine anticoagulant prophylaxis.
Documentation must include: the time the change was identified, the objective findings, the exact time the provider was notified and by what route, what was ordered, what was done, the patient's response, the wife's statement and what you told her, and any delay in the scheduled transfusion with the reason. Do not chart 'MD aware' as a substitute for the findings and plan. Notify the oncoming charge nurse and the rapid response team if the pressure does not respond to a fluid bolus.