Problems in Delegation: A Busy Day on the Floor

During the admission of pediatric client with a compound fracture of the right femur following a sports injury, which delegation by the charge nurse is most appropriate?

Request that the nursing assistant obtain equipment for the client's care while the RN talks with the client and the family. Asking the nursing assistant to obtain the equipment is the better delegation for several reasons. First, best practice is for the admitting RN to perform the first set of vital signs, so the nursing assistant or LPN/LVN should not do this; in addition, the RN should speak with both the new pediatric client and the family, as opposed to just the family. Recall that LPN/LVNs cannot assess patients, and obtaining phone orders from the admitting physician would be premature without admission data including vital signs and patient and family history.

The charge nurse is developing patient care assignments for the evening shift and needs to assign clients to a licensed practical nurse/licensed vocational nurse (LPN/LVN) and a certified nursing assistant (CNA). Which clients should the nurse assign to the LPN/LVN based on skill level and scope of practice? (Select all that apply.)

A client requiring frequent suctioning, A client requiring a dressing change to the foot, A client requiring reinforcement of teaching about a diabetic diet Appropriate tasks to assign to an LPN/LVN include tasks for stable patients with predictable outcomes such as suctioning, reinforcing patient teaching performed by an RN, performing sterile and unsterile dressing changes, and administering nonparenteral medications. Nursing assistants are considered unlicensed assistive personnel, and as such, the RN must carefully consider the strategies for successful delegation to unlicensed personnel. Tasks such as performing range of motion exercises and collecting a urine specimen are appropriate to delegate to the CNA as they do not involve assessment, interpretation, or decision making.

The charge nurse is preparing the patient care assignments for the day shift, assigning clients to a LPN/LVN and a certified nursing assistant (CNA). Which clients should be assigned to the CNA? (Select all that apply.)

A client requesting assistance packing his belongings for discharge later today., A client pending discharge after a laparoscopic hernia repair who is requesting to ambulate to the bathroom. Unlicensed assistive personnel such as a CNA cannot apply sterile dressings, suction, or care for patients post-procedure (such as a lumbar puncture); these patient care assignments are beyond the scope of a ULAP. Reinforcing diabetic diet teaching and suctioning a patient should be delegated to the LPN/LVN, not the CNA. Assisting a patient packing for discharge and assisting with ambulation are part of a CNA's scope of work.

Which pediatric client care assignment is most appropriate for the charge nurse to delegate to the LPN/LVN?

A school-aged child with a fractured femur who is in balanced suspension traction The child with a fractured femur who is on bed rest due to balanced suspension traction is the least acute patient, and therefore should be assigned to the LPN/LVN. That patient has a problem with a predictable outcome. The toddler with laryngotracheobronchitis (croup) requires airway assessment. The infant with congestive heart failure also requires frequent assessment, as does the child requiring a gastric lavage. Thus, these patients are unstable and should be assigned to an RN. The LPN/LVN should be assigned to a stable patient with a predictable outcome.

The charge nurse is determining morning care assignments for several elderly clients awaiting discharge to an assisted living facility, including a client on bed rest with a skin tear and hematoma from a fall 5 days ago. What is the best care assignment for this client?

Assign a nursing assistant to help the client with self-care activities. The goals of the delegated task should focus on the right circumstance, which in this case is a patient with a risk for falls. Assigning the right personnel (a nursing assistant or unlicensed assistive personnel) to assist the patient with self-care activities may prevent falls and also allow the patient independence. Delegating complete care of this patient to either an RN or a ULAP would be inappropriate and an example of improper delegation (in assigning the RN to care for patient needs that could be handled by assistive personnel), or underdelegation (as the ULAP is not able to care for all the patient's needs). Supervising a nursing assistant for skin care addresses only one small aspect of care and would be an incomplete delegation.

Which task is appropriate for the nurse to delegate to the experienced nursing assistant?

Obtain a urine specimen from a client with an indwelling Foley catheter. The charge nurse should delegate activities to the unlicensed assistive personnel as suggested by the National Council on State Boards of Nursing (2010). Collecting a urine specimen from a closed indwelling urinary catheter is a routine procedure that does not involve teaching, assessing, interpretation, or decision making, and therefore is an appropriate task to delegate to the nursing assistant. Assisting a patient with select fluid replacement involves patient teaching and is not appropriate for unlicensed assistive personnel such as a nursing assistant. Collecting of NG drainage for a patient whose NG tube is connected to intermittent suction is an inappropriate delegation, as the UAP cannot disconnect the suction to empty the NG suction container. Observing a client practicing any self-medication injections requires both assessment and patient teaching, and thus cannot be delegated.

A charge nurse is planning client activities for the day. Which tasks should the charge nurse delegate to the nursing assistant? (Select all that apply.)

Restock pediatric patient care rooms with oral rehydration fluids using a standardized check list., Empty and record the amount of urine out of Foley bags at the end of each shift., Assist with delivering breakfast trays to clients after checking for correct patient, room number, and diet., Take and record temperatures, pulses, respirations, and blood pressures on all assigned patients. Assisting the pharmacy technician is outside of the scope of an ULAP; any aspect of medication preparation and/or administration is not allowed by state board of nursing policy. The emergency cart contains medications, so it would be outside the scope of practice for the ULAP to check or refill medications. All other patient care activities can be safely delegated to unlicensed assistive personnel.

The charge nurse of a step-down coronary care unit has 24 clients in varying degrees of cardiac rehabilitation. The charge nurse must assign the clients to a team consisting of RNs, LPN/LVNs, and one CNA. What is the primary factor for the charge nurse to consider when delegating care?

Skill level and scope of practice of each staff member The scope of practice and the level of competence are the most important considerations when delegating patient care assignments. The individual state practice act as well as the American Nurses Association (ANA) and the National Council on State Boards of Nursing (NCSBN) all contain scope of practice and delegation information.

Which instruction provided by the nurse reflects effective communication regarding delegation to assistive personnel?

Take vital signs every two hours for the patient with the cholecystectomy in Room 6022. The goals of the delegated task should be communicated clearly, identifying any limitations and a time frame for completing the task. The charge nurse must communicate what, how, and by when the delegated tasks should be completed. Words such as "significant," "excessive," or "sometime" are not specific or clear enough. The instruction "Take vital signs every two hours for the patient with the cholecystectomy in Room 6022" is the only answer choice that is clear and complete.

The charge nurse (an RN) must determine how best to assign another RN and one licensed practical nurse/licensed vocational nurse (LPN/LVN) to provide care to a group of clients on the day shift. What is the appropriate assignment?

The RN is assigned to care for an unemployed 26-year-old woman, newly diagnosed with acquired immunodeficiency syndrome (AIDS). Recall that the RN is assigned to care for the most acute patient, and the RN should be assigned to those patients requiring assessment, interpretation, teaching, or decision making. A patient with a newly diagnosed disease and requiring physical, psychosocial and financial supports is the most complicated patient and should be assigned to the RN. Assigning an RN to obtain vital signs is overdelegation. An LPN/LVN should not be assigned to a patient requiring surgical assessment, discharge teaching, or teaching about an acute disease such as malignant melanoma.