What are priorities for care-priority nursing interventions

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Reference no: EM133854614

Assignment:

The staff for day shift 0700

2 LVNs - one is pregnant 30 weeks gestation

2 MA's - one is new and still in orientation

1 RN - charge nurse on unit

Make assignments using 5 rights of delegation - give rationale for your choice

Patient at medical surgical unit

1.R.T. is 48 y/o man with uncontrolled DMII, R femur fracture.

2.J.R. is a 72 y/o female with atrial fibrillation, HTN, L hip fracture.

3.A.C. is a 3 y/o female with CMV.

4.T.W. is a 74 y/o male with C-diff, S/P Cholecystectomy.

5.A.T. is a 24 y/o male, HIV + with fever of unexplained origin.

6.E.S. is a 69 y/o female with bilateral bacterial pneumonia.

7.B.G. is a 4 y/o male with exacerbation of cystic fibrosis.

8.Y.Q. is a 86 y/o female with Pseudomonas pneumonia.

After you have made the assignments, there is a change of patient status on the unit:

  • 11:35 pm: J.R. (72 y/o female with atrial fibrillation, HTN, L hip fx)
  • Fell out of bed
  • VS - T 38.0, P 88, R 20, BP 166/92
  • Head to toe assessment: Abnormal findings include -
  • Change in LOC, hit head, one pupil dilated
  • L arm very bruised with hematoma
  • Pain 8 /10 in left arm and lower back

ANSWER the following questions:

1. What are the priorities for care, priority nursing interventions?

2. Provide SBAR to provider

3. How do you rearrange assignments? Or do you recommend transfer patient to another unit/ level of care?

4. Complete an incident report.

Reference no: EM133854614

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