Welcome to Lovanurse Memorial Hospital! You are a new hire RN with five years’ experience and have been assigned to a medical surgical floor that has high staff and patient turnover. In addition to standard medical-surgical patients, your floor also is assigned to do telemetry overflow if there are not enough beds available on the telemetry floor. Telemetry is full today.
As luck would have it, two of your RN colleagues have called in sick today. So, it’s you, the only RN, two LPNs, and one CNA. Your floor has 15 beds, which are full. Today, there are at least four possible discharges, six planned surgeries that will require admission, and a possible patient in the Emergency Department. So, this means that you’re going to have to work with the bed coordinator to shift patients to different units. Fun!
Your staff for today:
LPN 1: Macy: 40 year old Hispanic female who has been a LPN for 12 years. She speaks English but prefers to speak Spanish because her accent is rather strong. She volunteers to take Spanish speaking patients. She is a hard worker and handles delegation well. She does not know how to perform peritoneal dialysis procedures. She has not been IV certified.
LPN 2: Mike: 57 year old Caucasian male who is going through a divorce. He is known to resist delegation, especially from new staff. He is a smoker who takes at least 6 breaks a shift, regardless of permission from the manager or charge nurse. He is extremely smart and is thinking about going back to school to get his RN degree. He is a wiz at wound care and is IV certified, which means he can start IVs, give IV medications, etc.
CNA: Gilda: 24 year old Asian female who just finished her CNA training three months ago. She is quiet and because of her cultural beliefs often seems subservient. She is in school now to get her BSN but needed money to help her get through school. She is afraid to work with patients who are in a great deal of pain or male patients.
You are still acclimating to the hospital, charting/medication dispensing system, etc. Your manager is in Hawaii. The administrator on call is aware of what is going on and says that you have enough staff because you have 2 LPNs who can take patients.
It is 0700, and the off going shift nurses want to give report.
Your unit is set up in pods with 5 beds in each pod. Typically, each nurse takes a complete pod to help patients and other staff know who will be in charge of that area’s patients. However, it is okay to assign nurses to two pods, but not more than two. You must take a minimum of four patients. LPNs, at your hospital, may be assigned up to six patients as long as you review their assessment findings and notes. You must also cosign their notes at the end of the shift.
Your unit’s patients include:
• Pod 1
o Mr. Black (70-year-old male, diagnosis: urinary tract infection). Mr. Black is alert but is experiencing some confusion. Vital signs are ordered every four hours. He is experiencing urinary frequency. He needs to be reminded to use the urinal rather than getting out of bed on his own to use the bathroom.
o Ms. Swanson (58-year-old female, diagnosis: admitted for a hysterectomy). Ms. Swanson had a hysterectomy two days ago. Her postoperative course has been uncomplicated. The surgeon wants Ms. Swanson to ambulate three times per day. Her vital signs are stable. She is alert, oriented, and cooperative. She could possibly be discharged today if her daughter can arrange home care for her.
o Mr. Johnson (25-year-old male, new admit, diagnosis: suspected Crohn’s disease).Mr. Johnson has been having abdominal pain and severe bouts of diarrhea for the past several months. He was admitted this morning. He is NPO to rest his bowels and to prepare for an upper gastrointestinal series. He has IV fluids running and prn pain medications.
o Mrs. Tolento (66-year-old female, diagnosis: congestive heart failure). Mrs. Tolento is a new transfer to your unit. She was admitted four days ago with fluid overload. She has history of CHF and takes diuretics, digoxin, and an ACE inhibitor at home. She is alert and oriented. She is on 2L of O2 with oxygen saturation at 93%. Vital signs are ordered every four hours. She is on strict I&O. She has a Foley catheter.
o Mr.Raynor (53-year-old male, diagnosis: diabetic foot ulcer). Mr. Raynor is well known to your unit as he is frequently admitted to ICU for diabetic ketoacidosis and is then transferred to your floor. He has another diabetic foot ulcer that is severely infected. He is receiving IV antibiotics q 8 hours, dressing changes BID, and often requires assistance to the bathroom. He is also notorious for screaming at staff and refuses to have Mike as a nurse as they almost came to blows over which team was better: the Yankees or Mets.
• Pod 2
o Mrs.Flanco (61-year-old female, diagnosis: s/p colectomy, postoperative day (POD) 2). Mrs. Flanco’s vitals are stable, but she did have two episodes of hypotension last night, which required IV fluid boluses. She is currently having 7/10 pain despite recent pain medication. Morphine makes her vomit, and her current medication that is ordered (dilaudid) is ineffective.
o Ms.Levin(22-year-old female, new transfer from ICU: s/p attempted suicide) Ms. Levin is stable and has now had her 1:1 observation requirement lifted. She still requires q 2 hr observation, q 4 hour vitals, and is having some GI upset from the charcoal she ingested in the ED. She will be released to a psych facility in 1-2 days.
o Mr.Smith (75 year old male, diagnosis: pneumonia)Mr. Smith is still having fevers of 101-102. He requires IV antibiotics, IV fluid for hydration, and anti-emetics. He requires vitals q 4 hours and occasionally has incontinence issues which requires frequent pajama changes. His wife helps him most of the time, but he does need help from the CNA at times.
o Mr.Smith (70 year old male, diagnosis: atrial fibrillation): Mr. Smith has a history of heart attack x 2. He has had COPD x 6 years and now is admitted with atrial fibrillation. His rate is stable. He is on IV heparin and will be starting po anti-coagulants tonight. He requires daily labs and will not be discharged for at least 6 days.
o Mr.Smith (68 year old male, diagnosis: GI bleed). Mr. Smith has been on an oral anti-coagulant for years. He recently developed a GI bleed with a resultant hemoglobin drop to 5. He has required 3 units of blood and may require more pending his labs. He is receiving IV Lasix between units of blood, vitals q 2-4 hours, and oxygen therapy at 2 L/NC. He is on telemetry which shows sinus tachycardia.
• Pod 3
o Ms. Harper (30 year old female, diagnosis: stage 3 breast cancer s/p left mastectomy, POD 1)Ms. Harper is having moderate pain and requires q 4 hours pain medication. She requires dressing changes daily. Otherwise, she is stable.
o Mr. Reddington (45 year old male, diagnosis: gunshot wound to abdomen). Mr. Reddington was shot in the abdomen when a gang member shot him for his wallet. He was transferred from the ICU 2 days ago. He has very few bowel sounds, still has nausea, and has not had a bowel movement in six days. He has a temperature of 100.5. His labs this morning show his WBC increased from 9 to 16. His physician wants to observe him for now and does not feel that he warrants ICU management.
o Mrs. Stewart (41 year old female, diagnosis: diabetic ketoacidosis)Mrs. Stewart is a Type 2 diabetic who has not been able to take her insulin secondary to being unable to afford it. She presented to the ED with a glucose of 1100. She was transferred from the ICU yesterday. Her blood sugar is now 350. She still requires blood sugar checks q 2 hours.
o Mr. Moretz (35 year old male, diagnoses: night sweat, weight loss, cough) Mr. Moretz just returned from a missionary trip to Haiti about a month ago. Since he has been home, he has been having night sweats, weight loss (currently has lost 30 lbs in a month), and a persistent cough. He has been admitted to your floor because your floor is the only unit that has a negative pressure room for TB observation. He is still having night sweats, temperature spikes to 101 at night, and cough that only responds to codeine. Codeine makes Mr. Moretz vomit. He has had 1 positive AFB but has not been officially diagnosed with TB yet.
o Mrs. Walnut (80-year-old female: diagnosis: aspiration pneumonia)Mrs. Walnut has early Alzheimers and frequently wanders off the unit if not closely observed. She has swallowing issues and is now in the hospital with aspiration pneumonia. She is to undergo a barium swallow to evaluate for aspiration. She will most likely need a PEG feeding tube. Her husband stays with her at night, but Mrs. Walnut sometimes forgets who he is and screams in the middle of the night. She is requiring q 4 hour vitals, frequent wellness checks, and assistance with all ADLs.
Please complete the following activities:
1. Divide the patients according to acuity, needs, and requirements. Keep in mind the nurses’ attributes/limitations as you create an assignment. Explain your rationale.
2. Which patients will you assign to the Gilda? Will she be involved with a select population, all of the patients, etc? Explain your rationale.
3. Which patients would you select to move to other med surgunits if beds are needed? Should some patients be moved to different pods? If so, why? If not, why not? Explain your rationale.
4. In which pod will you place the six different surgery patients? Explain your rationale.
5. In addition to your own patient load, what will be some areas that you will need to focus on during your shift? Explain your rationale.