Question

You are the nurse assigned to this group of patients. There are 2 RN’s (one is you: the charge nurse and a staff member, plus another RN), and you have an LPN and 2 nursing assistants. Plan your day/ evening. What is the priority for each patient and what tasks/ skills can be delegated to the LPN, the aid ant the other RN for each patient? Pt #1 Jennifer Hoffman

33-year-old female present to the Emergency Department. Has a history of asthma, with several ED visits in the last year. Presents anxious, coughing and chest tightness Peak Flow levels are decreasing Tracheostomy tube placed during last admission 3 months ago Vitals RR: 30 BP 138/84 HR: 92 Sat 89% RA Albuterol 2.5 mg/ 2.5 ml via trach Solumedrol 100 mg IV available 125 mg/2ml NSS 80 ml/hr Epi Pen prn Trach care q shift

Pt#3 Skyler Hanson 18 –year- old male in diabetic ketoacidosis three days ago. Transferred to the medical surgical floor after being in the ICU for three days. He had been on an Insulin drip and received IV hydration. RR: 18 BP 118/74 HR:78 Sat 99% RA D5W 150 ml/hr NPH insulin 22 units SQ Novalog Insulin 6 units SQ 1800 ADA diet Urine for ketones NKA Blood Glucose 650

Pt#4 Doris Bowman Patient is a 39-year-old who underwent a total abdominal hysterectomy with bilateral salpingoopherectomy. Tolerated the procedure well. Postoperative day 2. She has an abdominal incision covered with a 4x4 gauze dressing. Foley draining 200 ml clear yellow output. Arrives back from x-ray unresponsive. RR: 12 BP 124/84 HR: 92 Sat 88% RA LR 125 ml/hr Morphine Sulfate 2 mg IVP for pain Ondansetron hydrochloride (Zofran) 4 mg IVP Naloxone hydrochloride (Narcan) 0.4 mg/ml IVP PRN for sedation WNL

Pt #5 William Edwards A 65-year-old male with a history of HTN, CAD and NIDDM. Smokes a pack of cigarettes a day. He presented to the emergency department around 10 am after waking up around 7am with right sided weakness. Upon arrival he has slurred speech and right upper extremity flaccid. You are taking over care. RR: 36 BP: 180/90 HR: 95 Sat 88% RA NSS 75 ml/hr Labetalol 5 mg IVP Aspirin 325 mg CT scan r/o bleed HOB elevated 30 degrees WNL

Pt # 6 Liling Sung A 62-year-old who presented to the emergency department after her AICD fired 6 times in the past two hours. She has been stabilized in the emergency room. Transferred to the medical floor. The AICD was placed 2 years ago, after she went into ventricular tachycardia resulting in cardiac arrest RR: 16 BP: 109/58 HR: 110 Sat 100% 2L NSS 100 ml/hr Diazepam (Valium) 5 mg/IV prn Morphine Sulfate 2 mg IV prn Propranolol 25 mg PO WNL

Pt# 7 Charles Jones 68- Year –old male with a history of congestive heart failure, admitted to the intensive care unit from his family physician office after developing severe dyspnea, orthopnea, bilateral lower edema and 10 pound weight gain. Rales are noted in the posterior lobes bilaterally. O2 4 L NC History of hypertension, atrial fib and hyperlipidemia RR: 24 BP: 96/44 HR: 102 Sat 93% 4L Nesiritide (Natrecor) IV bolus 2 mcg/kg Nesiritide (Natrecor) IV maintenance 0.01 mcq/kg/min Lasix 80 mg IV BUN Creatine BNP Electrolytes

Pt#8 Tony Wallace 24-year-old male with sickle cell anemia with severe pain every 2-3 weeks. He presented to the emergency department 3 days ago with acute pain in left arm and left leg. He is receiving IV hydration and pain medication without control. RR: 18 BP: 116/72 HR: 82 Sat 97% Temp 97.8 NSS 120 ml/hr Morphine PCA 2 mg/hour

Pt #9 Bobby Davis 28-year-old presents to the emergency department 45 minutes ago with severe right sided flank pain. Smokes 1 pack of cigarettes a day. Pain has been intermittent for the past 2 day. Started vomiting earlier this morning. Was lifting weights earlier in the day thought he pulled a muscle when he heard something pop. RR: 18 BP: 148/88 HR: 90 Sat 100% Temp 98.8 NSS 125 ml/hr Morphine Sulfate 2 mg q hour Promethazine hydrochloride (Phenergan) 25 mg IVP Toradol 30 mg IV 32 French Chest tube to 20 CM suction Restart IV

Pt #10 Ruth Living ston 80-year-old female who fell at home. Presents with external rotation of the right leg. Fixation tomorrow RR: 20 BP: 150/76 HR: 88 Sat 96% RA Temp 98.9 NSS 75 ml/hr Morphine Sulfate 2 -4mg q hour Zofran 4 mg Place foley cath Pre Op

Pt # 11 Dale Mayman 51-year-old with known liver disease secondary to alcoholic cirrhosis admitted with increased confusion, Increased ammonia levels ETOH level elevated RR: 22 BP: 130/83 HR: 88 Sat 97% RA Temp 98.7 Lactulose 30 ml/day Haldol 5 mg IM for agitation Ativan protocol ETOH 350 Ammonia 200mcq/dl

Pt 12 Geraldine Yost 88 –year-old pt presents to the medical surgical floor as a direct admission from the nursing home. Pt is lethargic. Has received the first cycle of antibiotic in the ED. RR: 26 BP: 90/62 HR: 118 Sat 90% RA Temp 102.4 NSS 500 ml/hr Zyvox (linezolid) 600 mg q 12 hours Azitromycin (Zithromax) 750 mg IV Vancomycin 1g IV Tylenol 650mg via peg tube WBC 30

Answer 1

1.  Pt #1 Jennifer Hoffman - 33 year old female

Sympoms:

• Anxious, coughing and chest tightness Peak Flow levels are decreasing
• Tracheostomy tube placed during last admission 3 months ago

Vitals

• RR: 30 BP 1378/84 HR: 92 Sat 89% RA

Medications:

• Albuterol 2.5 mg/ 2.5 ml via trach
• Solumedrol 100 mg IV available 125 mg/2ml
• NSS 80 ml/hr
• Epi Pen prn

Others:

• Trach care q shift

Role of charge nurse:

Responsibility: RN 1

• Allot the patient to RN 1
• The RN will instruct the Nursing assistant to position the patient in semifowler's or fowlers position
• The RN should administer oxygen as per order
• The RN 1will then check the vital signs, and
• The RN 1 will secure an IV line and with the help of charge nurse will calculate the medication dosage and will administer the medications as ordered
• she will also provide the tracheostomy care during that shift
• Instruct the NA to monitor urine output

Pt#3 Skyler Hanson 18 –year- old male in diabetic ketoacidosis three days ago. Transferred to the medical surgical floor after being in the ICU for three days. He had been on an Insulin drip and received IV hydration. RR: 18 BP 118/74 HR:78 Sat 99% RA D5W 150 ml/hr NPH insulin 22 units SQ Novalog Insulin 6 units SQ 1800 ADA diet Urine for ketones NKA Blood Glucose 650

Responsibility: RN 1

RN 1 -

• Check vitalsigns and blood gluciose levels. - 1st priority
• Instruct the NA to obtain urine sample for ketones
• To administer IV fluids and insulin in liason with charge nurse - 2nd priority
• Plan ADA with dietician and ensure that the diet is followed

Pt#4 Doris Bowman

A 39-year-old who underwent a total abdominal hysterectomy with bilateral salpingoopherectomy. Tolerated the procedure well. Postoperative day 2. She has an abdominal incision covered with a 4x4 gauze dressing. Foley draining 200 ml clear yellow output. Arrives back from x-ray unresponsive. RR: 12 BP 124/84 HR: 92 Sat 88% RA LR 125 ml/hr Morphine Sulfate 2 mg IVP for pain Ondansetron hydrochloride (Zofran) 4 mg IVP Naloxone hydrochloride (Narcan) 0.4 mg/ml IVP PRN for sedation WNL

Responsibility: RN 1

THE PRIORITY

• The RN 1 positions the patient & assesses ABC and the surgical site for any evidence of bleeding
• simultaneously, the LPN starts the patient on oxygen
• The RN 2 informs the doctor on call
• The RN 1 in liason with charge nurse administers the medication as per order
• follows the doctor's instructions

Pt #5 William Edwards A 65-year-old male with a history of HTN, CAD and NIDDM. Smokes a pack of cigarettes a day. He presented to the emergency department around 10 am after waking up around 7am with right sided weakness. Upon arrival he has slurred speech and right upper extremity flaccid. You are taking over care. RR: 36 BP: 180/90 HR: 95 Sat 88% RA NSS 75 ml/hr Labetalol 5 mg IVP Aspirin 325 mg CT scan r/o bleed HOB elevated 30 degrees WNL

Responsibility: RN 2

• The RN2 monitors vital signs and level of consciousness Q30 minutes
• The NA maintains Q2h position change ensuring that the HOB is at 30 degrees
• The NA also meets the hygienic needs and the nutritional neeeds of the patient
• The RN 2 with the charge nurse calculates, loads and administers the medication

Pt # 6 Liling Sung A 62-year-old who presented to the emergency department after her AICD fired 6 times in the past two hours. She has been stabilized in the emergency room. Transferred to the medical floor. The AICD was placed 2 years ago, after she went into ventricular tachycardia resulting in cardiac arrest RR: 16 BP: 109/58 HR: 110 Sat 100% 2L NSS 100 ml/hr Diazepam (Valium) 5 mg/IV prn Morphine Sulfate 2 mg IV prn Propranolol 25 mg PO WNL

Responsibility: LPN 1

• Q15 minutes vitalsigns monitoring by LPN
• Getting ready and being vigilant of cardiac care
• administering medications inliason with charge nurse

Pt# 7 Charles Jones 68- Year –old male with a history of congestive heart failure, admitted to the intensive care unit from his family physician office after developing severe dyspnea, orthopnea, bilateral lower edema and 10 pound weight gain. Rales are noted in the posterior lobes bilaterally. O2 4 L NC History of hypertension, atrial fib and hyperlipidemia RR: 24 BP: 96/44 HR: 102 Sat 93% 4L Nesiritide (Natrecor) IV bolus 2 mcg/kg Nesiritide (Natrecor) IV maintenance 0.01 mcq/kg/min Lasix 80 mg IV BUN Creatine BNP Electrolytes

Responsibility : RN 2

• Monitoring vitalsigns q30 minutes including lung auscultation
• Grading edema once during the shift
• Maintaining IV fluids and administering medications in liason with the charge nurse
• Instructing NA to monitor urine output and maintaining I/O chart

Pt#8 Tony Wallace 24-year-old male with sickle cell anemia with severe pain every 2-3 weeks. He presented to the emergency department 3 days ago with acute pain in left arm and left leg. He is receiving IV hydration and pain medication without control. RR: 18 BP: 116/72 HR: 82 Sat 97% Temp 97.8 NSS 120 ml/hr Morphine PCA 2 mg/hour

Responsibility : RN 2

• Monitoring vitalsigns q2h including pain assessment
• Maintaining IV fluids and administering medications in liason with the charge nurse
• Instructing NA to monitor urine output and maintaining I/O chart

Pt #9 Bobby Davis 28-year-old presents to the emergency department 45 minutes ago with severe right sided flank pain. Smokes 1 pack of cigarettes a day. Pain has been intermittent for the past 2 day. Started vomiting earlier this morning. Was lifting weights earlier in the day thought he pulled a muscle when he heard something pop. RR: 18 BP: 148/88 HR: 90 Sat 100% Temp 98.8 NSS 125 ml/hr Morphine Sulfate 2 mg q hour Promethazine hydrochloride (Phenergan) 25 mg IVP Toradol 30 mg IV 32 French Chest tube to 20 CM suction Restart IV

Responsibility : LPN

• Vital signs Q2h
• Pain assessment Q2h
• Chest tube assessment Q30 min
• Administer IV fluids and administering medications in liason with the charge nurse

Pt #10 Ruth Living ston 80-year-old female who fell at home. Presents with external rotation of the right leg. Fixation tomorrow RR: 20 BP: 150/76 HR: 88 Sat 96% RA Temp 98.9 NSS 75 ml/hr Morphine Sulfate 2 -4mg q hour Zofran 4 mg Place foley cath Pre Op

Responsibiity : RN1

• Charge nurse should ensure presence of consent
• Preop preparation in liason with NA
• Catheterization in liason with NA
• Administer IV fluids and administering medications in liason with the charge nurse

Pt # 11 Dale Mayman 51-year-old with known liver disease secondary to alcoholic cirrhosis admitted with increased confusion, Increased ammonia levels ETOH level elevated RR: 22 BP: 130/83 HR: 88 Sat 97% RA Temp 98.7 Lactulose 30 ml/day Haldol 5 mg IM for agitation Ativan protocol ETOH 350 Ammonia 200mcq/dl

Responsibility: RN 1

• Assess level of consciousness and vital signs Q2h
• Safety restraints in liason with charge nurse and NA
• Lab tests for serum ammonia in collaboration with lab technician
• Administer  medications in liason with the charge nurse

Pt 12 Geraldine Yost 88 –year-old pt presents to the medical surgical floor as a direct admission from the nursing home. Pt is lethargic. Has received the first cycle of antibiotic in the ED. RR: 26 BP: 90/62 HR: 118 Sat 90% RA Temp 102.4 NSS 500 ml/hr Zyvox (linezolid) 600 mg q 12 hours Azitromycin (Zithromax) 750 mg IV Vancomycin 1g IV Tylenol 650mg via peg tube WBC 30

Responsibility: RN 2

• NA to check vital signs and inform RN 2
• NA to start cold aplication like cold compress and ice cap in liason with RN 2
• RN 2 - to administer medicine in liason with Charge nurse