Question

The new staff nurse working on the intensive care unit is concerned about her client's status. The client has continued to decline throughout the shift. The client's blood pressure, heart rate, and oxygen saturation have progressively dropped in a relatively short period of time. The nurse inquires with the charge nurse assigned to that shift. The charge nurse says "Don't worry, the client will be fine, he always does that." Which of the following actions should the nurse take?

A. The nurse should call the nursing supervisor on duty to assist.
B. the nurse should wait and see how the client does.
C. The nurse should agree with the charge nurse because that nurse has more experience.
D. The nurse should discuss this with other nurses on the unit.

Answer 1

The new staff nurse should take immediate action in response to the patient's declining vital signs by escalating the situation according to ICU protocols. This includes continued close monitoring, notifying the medical team, and potentially calling for emergency assistance. It is crucial to advocate for the patient's safety and not rely solely on past experiences or dismissive attitudes.

Step-by-step explanation:

The staff nurse working in the intensive care unit (ICU) should prioritize patient safety above all. When observing declining vital signs in a patient, such as blood pressure, heart rate, and oxygen saturation, it is critical to take immediate action rather than adopting a 'wait and see' approach or solely relying on another nurse's past experience with the patient. The nurse should use her clinical judgment and escalate the situation if the patient's condition appears to be deteriorating. In such cases, actions may include continuing to monitor the patient closely, notifying the patient's healthcare provider or physician, and possibly calling for a rapid response or medical emergency team if the patient's status warrants it. It is vital that the staff nurse acts as a patient advocate, ensuring that a thorough assessment is carried out and voicing any concerns in a professional manner to the appropriate parties, including the charge nurse, physician, and if necessary, the nursing supervisor on duty. In the ICU environment, where patients are critically ill, a decline in vital signs could indicate a serious underlying condition that requires immediate attention.

Patient safety protocols, such as checklists and team reviews, are integral to ICU operations. They serve to prevent mistakes and promote optimal patient care. In this scenario, the charge nurse's dismissal of the new nurse's concerns is not in line with the culture of safety that should be maintained in a high-stakes environment like the ICU. The new nurse should advocate for the patient by seeking further advice or intervention. By doing so, she contributes meaningfully to the team and ensures that the patient receives the necessary attention.