The Abdomen Exception, Delegation and the SBAR Call

Why the abdomen is different. Percussing or palpating first mechanically stimulates the bowel and changes the frequency and character of the very sounds you are about to count. So for the abdomen it is inspect, auscultate, percuss, palpate — and everywhere else it stays inspect, palpate, percuss, auscultate.

The five rights of delegation. Right task · right circumstance · right person · right direction and communication · right supervision and evaluation. Some items that stay out of the UAP’s hands may fall within an LPN/LVN scope depending on your state and facility — medication administration is the classic example — but assessment, teaching and evaluation of response remain the RN’s.

Medication safety, since it never gets delegated to a UAPFive rights: patient, drug, dose, route, time, plus documentation, reason, response, right to refuse and education. Verify against the record three times — taking it from storage, preparing it, and again at the bedside. Two identifiers: full name and date of birth, or name and medical record number — a room number is never an identifier, and scanning the wristband does not replace asking the patient to say their name. High-alert drugs (insulin, heparin and other anticoagulants, opioids, concentrated electrolytes, chemotherapy, neuromuscular blockers) get an independent double check. Time-critical medications go within 30 minutes before or after the scheduled time. Write unit not U, daily not QD, always a leading zero (0.5 mg) and never a trailing zero (5 mg) — a misread decimal is a tenfold error. If the patient says that pill is usually pink, stop and verify. The patient is often right.

Numbers that trigger a call. Urine output under 0.5 mL/kg/hr, or under 30 mL/hr for two consecutive hours. Oliguria under 400 mL/24 h; anuria under 100 mL/24 h. Post-void residual over 100 mL deserves attention and over about 200 mL is abnormal. Ileostomy output over roughly 1,200 mL/day is a dehydration emergency in the making. And in an older adult, an oral temperature of 37.2 °C (99 °F) — or a rise of 1.1 °C (2 °F) above their own baseline — may be the only sign of serious infection. New confusion is a vital sign in its own right.

The most common weakness in a student SBAR is the R. “I just wanted to let you know” is not a recommendation. Say what you want — come now, give an order, transfer the patient — and if you do not get it and you are still worried, escalate up the chain. Chain-of-command is a patient-safety tool, not an act of insubordination.