Delegation Decisions
Who can the RN delegate IV medications to
Another RN
To prevent medication errors in regards to blood product transfusion, treatments, and medications.
A patient tells the RN they want to leave the hospital against medical advice. The RN says "If you try to leave I will call the police." What is the error in this situation and what repercussions can occur due to this response?
The RN cannot physically prevent the patient from leaving if they are alert and oriented. This situation could be considered false imprisonment. You should: explains the risks of leaving, notify the provider, have them sign an AMA form, and document the situation. Competent adults have the right to refuse treatment.
Using Maslow's Hierarchy, which patient should you assess first:
A. Patient requesting pain medication
B. Patient who is difficult to arouse following outpatient procedure
C. Patient c/o new onset of urticaria following administration of IV antibiotics
D. Patient with oxygen saturation of 87%
D. Patient with oxygen saturation of 87%
Physiological needs, especially oxygenation and breathing, are the foundation of Maslow's Hierarchy and take priority.
True or False: Case managers provide direct patient care
False
The UAP reports a BP of 88/52. Who is accountable for the abnormal finding and what should be done?
The RN remains accountable for the abnormal finding. The RN should conduct an assessment, and evaluate the validity of the low BP, determine if intervention is needed, and notify the provider.
Your patient is confused and keeps trying to get out of bed. She has a high fall risk score. Can you apply a vest restraint without a provider order? Why or why not?
No! Applying restraints without a provider order constitutes false imprisonment, which is an intentional tort. You must first try less restrictive alternatives (bed alarm, frequent rounding, family presence, moving closer to the nurse's station). Restraints require a provider order, must be the least restrictive option available, and require frequent monitoring.
You witness a physician yell at a patient and call them "stupid" for not following diet instructions. The patient is visibly upset. What tort might this be, and what's your professional responsibility?
This could be considered assault and potentially defamation of character.
Your responsibilities include:
1. Provide emotional support to the patient
2. Document the incident objectively
3. Report to your charge nurse/manager and complete and incident report
4. Follow your facility's chain of command for reporting unprofessional conduct
5. Act as a patient advocate throughout the process
You receive these reports at the start of the shift. Which patient requires immediate attention?
A. Post-op Day 1 with pain 7/10
B. Diabetic patient with a glucose of 58
C. Patient requesting to speak with you about discharge plans
D. Patient whose family is threatening to call the CNO if something is not done quickly
B. Hypoglycemia is potentially life-threatening if not addressed immediately.
A patient is being discharged after hip replacement surgery. What are three services a case manager might coordinate for safe discharge home?
Physical therapy for mobility and strength
Durable medical equipment (walker, shower chair, raised toilet seat)
Occupational therapy for ADL adaptations
Transportation for follow-up appointments
Home health services for wound care or assessment
An LPN has been delegated wound care by the charge nurse. He states the wound "looks worse" but doesn't describe it further. What are the three things this situation requires?
1. Reassessment of the wound by the RN
2. Provide feedback to the LPN regarding proper wound assessment and documentation
3. Determine if the wound changes require provider notification or care plan modification.
You're caring for a post-op patient with a PCA pump. The family member says "He's sleeping so soundly, I've been pushing the button for him every 10 minutes so he won't wake up in pain." What are the immediate safety concerns and your actions?
Immediate concerns: Patient may be over-sedated, risk of respiratory depression, altered level of consciousness.
Immediate actions:
1. Assess the patient's respiratory status (RR, O2 Saturation, and level of sedation)
2. Stop the family from pushing the PCA button
3. Educate the family that only the patient should push the button
4. Assess for opioid overdose signs
5. Notify the HCP
6. Continue close monitoring
7. Document all findings and interventions
A psychiatric patient was voluntarily admitted yesterday. Today they say "I'm feeling better, I want to leave now." The physician says "They're not ready, keep them here." What type of admission allows the patient to leave, and what are your legal obligations?
A voluntary admission means the patient applied for treatment willingly and can request to leave.
Legal Obligations:
1. Inform the patient of their right to leave
2. Notify the physician of the patient's request
3. If the physician believes the patient is a danger to themselves or others, they may initiate involuntary commitment proceedings (requires court order)
4. Patient cannot be held without proper legal process - doing so is false imprisonment
5. Follow facility policy for voluntary patient discharge requests
You're caring for four patients when SUDDENLY:
Patient 1 (post-op) hits their call light, requesting bathroom assistance.
Patient 2's heart monitor begins alarming, showing an irregular rhythym
Patient 3's family member approaches you in the hallway with questions
Patient 4's blood pressure is due
What order would you place these patient's in and why?
Patient 2
Patient 1
Patient 4
Patient 3
An elderly patient with CHF has been hospitalized three times in two months. The case manager discovers the patient can't afford medications and doesn't understand the low-sodium diet. What is the case manager's role in preventing future readmissions?
Refer to social services or pharmaceutical assistance programs to help with medication costs
Arrange for a dietician consultation
Coordinate home health for medication management and monitoring
Set up telemonitoring if available for daily weights and symptoms
Ensure follow-up appointments are scheduled with transportation arranged
Connect patient with community resources
Evaluate if patient needs higher level of care or assisted living
You're the charge nurse with an LPN and UAP. You have the following tasks:
a. Discharge teaching for a diabetic patient going home
b. Changing a post-op surgical dressing
c. Feeding a stable stroke patient
d. Initial admission assessment for a new patient
Assign each task to the RN, LPN, and UAP
RN: Discharge teaching and initial admission assessment
LPN: Changing the post-op surgical dressing
UAP: Feeding the stable stroke patient
You're doing medication reconciliation on admission. The patient says he takes "a little white pill" for his BP but can't remember the name. He also mentions he sometimes takes his wife's pain pills. What are the patient safety risks here and what's your action plan?
Safety Risks:
1. Unknown medication identity could lead to errors or duplications
2. Taking someone else's prescriptions (likely controlled substance) is dangerous and illegal
3. Incomplete medication history could cause drug interactions or gaps in therapy.
Action Plan:
1. Ask the patient to bring in his medication bottles or have family bring them
2. Contact the patient's pharmacy for a medication list
3. Contact PCP for medication history
4. Educate the patient about the dangers of taking others' medications
5. Do not assume medications until verified
6. Document thoroughly including patient's statement about wife's pain medication
You gave insulin to Mr. Jones in Room 12. Twenty minutes later, you realize you gave it to the wrong patient - it should have gone to Mr. Jones in Room 21. The patient you gave it to is not diabetic. What are your immediate actions, legal responsibilities, and documentation responsibilities?
Immediate actions:
1. Assess the patient who received the insulin - check blood glucose immediately
2. Stay with the patient and monitor for signs of hypoglycemia
3. Notify the charge nurse and physician immediately
4. Give glucose/food as ordered
5. Continue frequent blood glucose monitoring
Legal Responsibilities
This is considered a medication error/negligence - you had a duty of care, breached it (wrong patient), causing potential harm. You must complete an incident report, document factually in the medical record (what happened, notifications, interventions, patient response), notify risk management per policy.
Documentation: Chart time of error discovery, patient assessment findings, physician notification and orders, interventions, ongoing monitoring - be factual, never alter records.
You're triaging in a clinic. Four patients arrive simultaneously:
A. 35 y/o female with reports of migraine, pain 8/10
B. 28 y/o who is unable to bear weight on his left ankle
C. 5 y/o with fever of 104 that has not been treated
D. 60 y/o with chest discomfort and nausea
Rank them in priority order with rationale.
D.
C.
B.
A.
A case manager must balance cost-efficiency with quality care. A patient needs a wheelchair. An electric wheelchair costs $5,000 but would give the patient independence. A manual wheelchair costs $300 but requires a caregiver to push. Discuss how the case manager makes this decision considering the patient's best interest AND institutional goals.
Assess patient's functional ability
Evaluate home environment and caregiver availability
Consider patient's goals and quality of life needs
Review insurance coverage and what's medically necessary vs. what's convenient
Analyze long-term costs
Consult with PT/OT for professional recommendation
You delegated ambulation of Mr. Davis to your UAP. Thirty minutes later, you see Mr. Davis still in the bed. The UAP states "He refused". What are the problems with this situation?
1. UAP didn't report the patient's refusal of the task
2. The RN didn't specify when to ambulate or when to report back
3. RN didn't follow up to ensure task completion
4. UAP may not have understood this was important
A confused patient pulls out their IV and foley catheter. Your new grad nurse documents: "Patient is difficult and non-compliant. Pulled out lines. Patient should be restrained." Identify FOUR documentation errors.
1. "Difficult"
2. "Non-compliant"
3. "Should be restrained"
4. Lacks objective observations
A 17-year-old patient tells you she's pregnant and wants information about abortion options, but says "please don't tell my parents." Can she consent to treatment?
Age of consent varies by state; you must know your state's laws.
1. Maintain confidentiality as appropriate by law
2. Provide non-judgmental support
3. Give accurate information within your scope
4. Encourage open family communication while respecting her autonomy.
You can provide information and emotional support, but cannot make decisions for her. Encourage her to involve parents while respecting her privacy rights per state law. Refer to social services, counseling, and appropriate healthcare providers who can discuss all options. Document discussions without violating confidentiality. If state law requires parental notification, explain this honestly to the patient.
You're the charge nurse making assignments for the shift. You have: 1 experienced RN, 1 new grad RN, 1 LPN, 1 UAP. Patients include:
A. Post-CABG with 72/35 BP
B. Newly diagnosed diabetic with BG 534 who states they don't know how to check their BG
C. Stable med/surg patient who has requested their bath
D. Hospice patient requiring frequent narcotics and family support.
Create Assignments
Experienced RN Patient A, Patient D
New Grad RN Patient B
LPN Patient C
UAP Assist with ADL's and Vital Signs on stable patients
A homeless patient with uncontrolled diabetes is ready for discharge. They have no insurance, no PCP, no place to store insulin, and no transportation. The physician wants to discharge them today. As the case manager, what are your responsibilities, what barriers must you address, and what ethical principles guide your advocacy?
Advocate for the patient - this discharge is unsafe and likely to result in immediate readmission and crisis
Convene interdisciplinary meeting with physicians, social workers, pharmacy, and nursing staff
Barriers to Address:
Housing
Insurance
Medications
Storage
Primary Care
Transportation
Ethical Principles
Patient advocacy
Beneficence
Non-maleficence
Justice
You may need to delay discharge until a safe plan is established, even if it conflicts with institutional pressure for bed turnover. Documents all attempts to secure resources and rationale for discharge delays.