Nursing Implementation
The 20 common problems nurses manage in an acute-care hospital
You're asking for a practical guide to what nurses actually do on hospital units: what problems to look for, how to assess and chart them, what interventions typically happen, what comes next, and how to keep contributing when your basic responsibilities are complete.
The most useful way to learn acute-care nursing is to think in terms of patient problems and their progression, rather than memorizing isolated diseases or medications.
The examples below are a general adult acute-care study guide, not a verified ranking of the 20 most frequent problems at every hospital. The mix varies by unit—medical-surgical, cardiac, neurological, surgical, emergency, and intensive care units see different patterns.
First: the pattern behind almost every patient problem
1. Observe
What is different from baseline? What does the patient report? What do the vital signs, examination, chart, and laboratory results show?
2. Assess and document
Record objective findings, relevant patient statements, trends, assessment time, and pertinent context according to documentation policy.
3. Intervene and escalate
Perform appropriate nursing interventions, follow orders and protocols, and notify the responsible clinician or activate emergency response when indicated.
4. Reassess and continue
Did the intervention work? Is the problem improving, recurring, or worsening? What needs follow-up, a revised plan, or handoff to the next shift?
Safety comes before routine tasks. New severe breathing difficulty, acute neurological changes, unresponsiveness, significant chest pain, major bleeding, or other signs of deterioration require immediate assessment and escalation according to the emergency protocol—not waiting to finish documentation or routine rounds.
The 20 problems: what to look for, chart, address, and follow through on
1. Pain that is new, persistent, or uncontrolled
Observe: Location, severity, onset, character, radiation, associated symptoms, functional impact, and whether the pain differs from the patient's usual pain.
Chart: Patient's description, pain score using the appropriate scale, relevant findings, intervention, and reassessment of response.
Address: Perform a focused assessment, provide prescribed analgesia or appropriate nonpharmacological comfort measures, and investigate concerning new pain.
What happens next: Reassessment determines whether treatment worked. Persistent or changing pain may prompt diagnostic testing, a medication review, or a different treatment plan.
2. Shortness of breath and low oxygen saturation
Observe: Respiratory rate and effort, oxygen saturation, ability to speak, skin color, breath sounds when within your assessment responsibilities, and mental status.
Chart: Oxygen saturation, respiratory findings, oxygen delivery and settings if applicable, symptoms, interventions, and response.
Address: Assess immediately, position the patient appropriately, provide oxygen according to orders or emergency protocols, and escalate new or severe respiratory distress.
What happens next: The team may investigate pneumonia, pulmonary edema, pulmonary embolism, asthma, or other causes and initiate targeted treatment.
3. Fever and suspected infection
Observe: Temperature trends, HR, BP, respiratory status, mental status, pain, wound or line changes, and urinary or respiratory symptoms.
Chart: Vital signs, symptom onset, relevant examination findings, suspected source if known, tests ordered, and response to interventions.
Address: Follow infection-control precautions and ordered investigations and treatments. Escalate suspected sepsis or acute deterioration promptly.
What happens next: Depending on the findings, the team may obtain cultures, laboratory tests, imaging, and administer antimicrobial treatment or fluids when indicated. Follow trends and treatment response.
4. Hypotension, dizziness, or fainting
Observe: BP relative to baseline, HR, dizziness, weakness, syncope, bleeding, hydration, and recent medication administration.
Chart: BP and HR, symptoms, position during measurement, medication timing, interventions, and reassessment.
Address: Prevent falls, assess promptly, follow medication hold parameters and escalation protocols, and investigate possible causes.
What happens next: The team may review medications, fluid status, bleeding, infection, or cardiac causes and adjust treatment under authorized orders.
5. Hypertension or abnormal heart rate
Observe: Repeat measurements when appropriate, symptoms, rhythm-monitor findings if available, medication timing, and trends.
Chart: Actual measurements, symptoms, rhythm findings within your scope, relevant medications, and escalation or provider communication.
Address: Assess the patient rather than treating the number alone. Escalate severe abnormalities or associated chest pain, neurological changes, or breathing difficulty.
What happens next: The team may obtain an ECG, investigate underlying causes, review medications, and initiate treatment based on the patient's condition.
6. Chest pain or possible cardiac ischemia
Observe: Onset, location, quality, radiation, duration, associated sweating, nausea, breathlessness, vital signs, and relevant cardiac history.
Chart: Symptom onset and description, vital signs, ECG or test results as available, actions taken, and the time of escalation.
Address: Treat new or concerning chest pain as urgent. Activate the appropriate response and follow the acute chest-pain pathway.
What happens next: The team may perform serial ECGs, cardiac biomarkers, monitoring, imaging, or urgent cardiac treatment. Never delay escalation to complete routine tasks.
7. Fluid overload, edema, or worsening heart failure
Observe: New swelling, breathlessness, lung findings, weight trends, intake/output, oxygen needs, and ability to lie flat.
Chart: Edema location and degree, weights, fluid balance, respiratory findings, and response to prescribed treatment.
Address: Assess respiratory stability, follow fluid-management orders, and report worsening symptoms.
What happens next: The team may review cardiac and renal function, adjust diuretics, manage fluid intake, and investigate the cause.
8. Dehydration or inadequate fluid intake
Observe: Poor intake, vomiting, diarrhea, dizziness, dry mouth, urine output, BP changes, weight trends, and laboratory findings.
Chart: Intake and output, relevant symptoms, vital signs, weight changes, and laboratory trends when available.
Address: Identify the cause, monitor fluid balance, assist with appropriate oral intake when safe, and implement prescribed fluid replacement.
What happens next: The team evaluates renal function and electrolytes and decides whether oral or IV fluids and further investigation are needed.
9. Abnormal blood glucose
Observe: Glucose results, timing of meals and insulin, sweating, tremor, confusion, excessive thirst, and changes in consciousness.
Chart: Glucose value and time, symptoms, food intake when relevant, medication timing, intervention, and repeat result.
Address: Follow the facility's hypoglycemia or hyperglycemia protocol and prescribed treatment. Severe symptoms require immediate escalation.
What happens next: The team may adjust insulin or other medications, meal timing, monitoring frequency, or the broader diabetes plan.
10. Abnormal kidney function or electrolytes
Observe: Creatinine and eGFR trends, potassium and sodium, urine output when indicated, fluid status, weakness, and relevant medication exposure.
Chart: Actual values, comparison with baseline, symptoms, urine output when required, and communication about concerning results.
Address: Follow critical-result procedures, assess the patient, review relevant medication monitoring requirements, and escalate significant changes.
What happens next: The team may repeat testing, review medications and fluid balance, treat electrolyte disturbances, or involve nephrology for selected cases.
11. Nausea, vomiting, or abdominal discomfort
Observe: Frequency and character of vomiting, abdominal pain, distension, bowel history, hydration, and ability to tolerate food or medication.
Chart: Symptoms, episodes, intake, relevant examination findings, medications administered, and treatment response.
Address: Assess severity, follow fluid and dietary orders, administer prescribed antiemetics when appropriate, and escalate concerning abdominal symptoms.
What happens next: The team may investigate medication effects, infection, obstruction, or other causes and adjust treatment.
12. Constipation or possible bowel obstruction
Observe: Last bowel movement, stool pattern, abdominal discomfort, distension, vomiting, mobility, fluid intake, and opioid exposure.
Chart: Bowel history, relevant abdominal findings, stool characteristics when needed, interventions, and response.
Address: Encourage mobility and fluids if safe and permitted; implement ordered bowel regimens. Escalate severe pain, marked distension, or vomiting.
What happens next: The team may adjust constipating medications, prescribe laxatives, or investigate possible obstruction or another cause.
13. Diarrhea or gastrointestinal bleeding
Observe: Stool frequency and appearance, abdominal pain, fever, hydration, BP, HR, and medications that increase bleeding or diarrhea risk.
Chart: Number and character of stools, associated symptoms, intake/output, relevant exposures, and interventions.
Address: Follow infection-control procedures when indicated, assess fluid loss, and promptly escalate suspected bleeding or significant deterioration.
What happens next: The team may order stool tests, blood tests, fluid replacement, medication review, or targeted treatment depending on the cause.
14. Urinary retention, reduced urine output, or urinary symptoms
Observe: Difficulty voiding, lower abdominal discomfort, urine output, urinary symptoms, catheter status, and relevant medication exposure.
Chart: Output and timing, symptoms, urine appearance when relevant, bladder scan results if obtained, and interventions.
Address: Assess the patient, check equipment or catheter issues where relevant, and follow bladder-scan and catheter protocols.
What happens next: The team may investigate obstruction, infection, renal dysfunction, or medication effects and order further treatment.
15. Wounds, pressure injuries, and impaired skin integrity
Observe: Skin color and temperature, pressure areas, wound edges, drainage, odor, surrounding redness, pain, and changes in tissue condition.
Chart: Location, size and appearance using the required wound documentation method, drainage, surrounding skin, interventions, and progress.
Address: Reposition according to the care plan, reduce pressure, provide ordered wound care, and follow infection-prevention practices.
What happens next: Wound-care specialists may be consulted; treatment may include dressings, pressure redistribution, nutrition support, or evaluation for infection.
16. Falls, impaired mobility, or functional decline
Observe: Gait, balance, strength, transfer ability, dizziness, sedation, footwear, and ability to use mobility aids.
Chart: Functional status, fall-risk assessment, mobility assistance required, falls or near-falls, interventions, and changes.
Address: Implement individualized fall precautions, assist with transfers, and follow post-fall assessment procedures if a fall occurs.
What happens next: Physical or occupational therapy may assess the patient, mobility aids may be arranged, and the discharge plan may need additional support.
17. Acute confusion, delirium, or change in consciousness
Observe: Change from baseline, attention, orientation, speech, behavior, alertness, oxygenation, glucose when indicated, and neurological signs.
Chart: Onset and progression, objective neurological findings, baseline comparison, relevant vital signs, and escalation.
Address: Treat sudden changes as potentially serious. Assess promptly and activate the appropriate emergency or neurological pathway for acute deterioration.
What happens next: The team investigates possible causes such as infection, medication effects, metabolic disturbances, stroke, or other acute illness and treats the underlying problem.
18. Stroke-like symptoms or new neurological deficits
Observe: New facial asymmetry, unilateral weakness, speech or vision changes, sudden balance problems, severe unusual headache, or altered consciousness.
Chart: Exact time last known well when obtainable, symptom discovery time, neurological findings, glucose if required by protocol, and escalation times.
Address: Activate the stroke or emergency pathway immediately. Do not delay escalation to complete routine charting or give food, fluids, or oral medications before swallowing safety is established.
What happens next: The team performs urgent neurological evaluation and imaging, then determines eligibility for time-sensitive stroke treatment.
19. Medication adverse effects or medication discrepancies
Observe: New symptoms after a medication, sedation, rash, dizziness, BP changes, duplicate ingredients, missed doses, or a mismatch between home medications and current orders.
Chart: Medication and dose, administration time, symptom onset, objective findings, actions taken, provider notification, and response.
Address: Assess severity, follow medication-specific hold and escalation requirements, and clarify discrepancies before proceeding when safety is uncertain.
What happens next: The team may discontinue or change a medication, adjust monitoring, order tests, or initiate specific treatment. The nurse documents and follows up on the authorized plan.
20. Discharge barriers and inability to manage safely at home
Observe: Difficulty understanding medications, impaired mobility, lack of transport, limited support, cost or access barriers, inability to perform self-care, and unresolved follow-up needs.
Chart: Specific barriers, patient and caregiver understanding, functional needs, education provided, referrals, and outstanding tasks.
Address: Begin discharge planning early and coordinate with case management, social work, pharmacy, rehabilitation, and the care team as appropriate.
What happens next: The plan may include home health, equipment, rehabilitation, caregiver education, follow-up appointments, medication access support, or another appropriate discharge setting.
2. What usually happens after the first intervention?
The first intervention is rarely the end of the nursing process. For every problem, you should know what the next step is.
The problem improves
Reassess and document the response, continue the prescribed plan, and monitor for recurrence. For example, pain improves after prescribed analgesia, so you document the response and continue monitoring.
The problem persists
Verify the assessment, review relevant trends and interventions, and notify the responsible clinician when indicated. The team may order further testing, adjust treatment, or seek specialist input.
The patient deteriorates
Prioritize immediate assessment, emergency escalation, and interventions within your scope and protocol. Documentation must not delay care.
The problem is stable but unresolved
Continue monitoring, confirm the ongoing plan, communicate at handoff, and make sure pending tests, consultations, and follow-up tasks have clear ownership.
3. How to chart a problem clearly
Good nursing documentation answers five questions:
What did you observe?
What did the patient report?
What did you do?
Who did you notify, and when, if applicable?
What happened afterward?
Here is an illustrative example of a non-emergency finding:
Assessment: Patient reports dizziness when standing. BP and HR obtained and documented; findings compared with available baseline. Patient assisted to a safe position. Relevant medication timing and other symptoms reviewed.
Intervention: Focused assessment completed. Fall precautions implemented as appropriate. Responsible clinician notified according to clinical findings and protocol.
Response/follow-up: Repeat assessment completed at the appropriate interval. Patient's symptoms and subsequent findings documented. Further orders and ongoing monitoring plan reviewed.
This is a structure, not a completed clinical note. In actual documentation, replace generic phrases with the patient's real findings, exact values, times, actions, and response. Never document an assessment, notification, or intervention that did not occur.
4. What can you do when your basic responsibilities are complete?
This is an excellent question for a nurse who wants to become more capable rather than simply finish a task list.
First, make sure essential care is complete and ask the charge nurse or assigned RN what the highest priority is. Then use available time for activities that improve safety, anticipate needs, and strengthen your understanding of the patient's course.
1. Review the patient's trends
Look at changes in vital signs, laboratory values, intake/output, pain scores, oxygen needs, mobility, and medication response. Ask: What is improving, what is worsening, and what needs follow-up?
2. Anticipate the next need
Check whether pain reassessment is due, a patient needs assistance to the bathroom, intake is adequate, a mobility goal remains unmet, or a planned intervention is pending. Follow the assigned care plan and unit workflow.
3. Prepare patients for what comes next
Reinforce approved education, assess whether patients understand their medications, identify barriers to discharge, and alert the RN or care coordinator to unresolved needs.
4. Check prevention and safety measures
Review fall precautions, pressure-injury prevention, line and catheter necessity according to unit policy, infection prevention, mobility, and whether equipment is functioning appropriately.
5. Follow up on unresolved items
Check pending orders, test results, consultation recommendations, medication clarifications, and discharge tasks. Ensure important results and actions are communicated to the responsible clinician.
6. Learn from the cases you are seeing
Ask your preceptor or RN to explain the reasoning behind an unfamiliar medication, abnormal result, diagnosis, procedure, or change in the care plan. Use approved learning resources and patient privacy safeguards.
A useful priority order during quiet periods
Safety first: Check whether any patient is deteriorating or needs immediate assistance.
Time-sensitive work: Complete due assessments, medication-related reassessments, treatments, and ordered monitoring.
Unresolved clinical issues: Follow up on abnormal results, pending tests, and communication with the care team.
Prevention and comfort: Address mobility, hygiene, nutrition, skin protection, toileting, and other individualized needs.
Discharge and education: Identify barriers before they delay discharge.
Learning and unit support: Ask where you can help, review an unfamiliar case, or assist with approved unit tasks.
Do not create unnecessary interventions, order tests, change medications, or perform tasks outside your role simply to stay busy. If you are a student or new nurse, ask your assigned RN or preceptor before undertaking unfamiliar work. Patient privacy, supervision, delegation, and facility policy still apply.
5. What should you keep working on to become a stronger acute-care nurse?
The most valuable habit is to develop a short clinical summary for every patient you are responsible for.
By the end of your assessment, try to be able to explain:
Why is this patient here?
What are the most important current problems?
What findings could signal deterioration?
Which medications and treatments are being used, and what needs monitoring?
What has changed since the previous assessment or shift?
What is the next planned intervention, test, or decision?
What must be completed or communicated before handoff or discharge?
You do not need to solve every diagnostic question yourself. You need to recognize important findings, assess within your scope, communicate effectively, perform authorized interventions, and follow through.
6. Practice applying the workflow
Choose a case to work through
Practice identifying the priority assessment, documentation, initial action, and follow-up. These are educational scenarios, not live clinical instructions.
A patient's oxygen saturation drops and breathing becomes more labored.
Creatinine has increased, and the patient takes a diuretic and an ACE inhibitor.
A patient continues to report severe pain after prescribed medication.
A medically improving patient cannot explain the home medication schedule.
What would you prioritize first?
Finish routine charting, then repeat observations later.
Assess the patient immediately, initiate the appropriate urgent response, and document after care is underway.
Wait for the next scheduled medication round.
Check my answer
The overall goal is to become the nurse who can explain not only what task is due, but also why it matters, what change to watch for, what to do about it, and who needs to know. That is what connects bedside observation, chart review, treatment, care planning, and safe discharge.
Health promotion
• Environmental controls
• Promoting bedtime routines
• Promoting safety
• Promoting comfort
• Promoting activity
• Stress reduction
• Bedtime snacks
• Pharmacological approaches
Acute care
• Environmental controls
• Promoting comfort
• Establishing periods of rest and sleep
• Promoting safety
• Stress reduction
Restorative or continuing care
• Maintaining activity
• Controlling physiological disturbances
• Pharmacological approaches
Reminiscing is a nonpharmacological intervention to reduce anxiety and depression, help reorient, and support self-esteem
you ask the group to discuss family activities or childhood memories, adapting questions to the group’s size, structure, process, goals, and activities to meet its members’ needs.
Taking time to ask questions about past experiences and listening attentively conveys to an older adult your attitudes of respect and concern.
commentary
Encourage patient to help as much as possible
Take position close to patient (or object being lifted).
Tighten abdominal muscles and keep back, neck, pelvis, and feet aligned. Avoid twisting.
Use arms and legs (not back).
Slide X toward your body using friction-reducing pull sheet or slide board.
Person with heaviest load leads drill
Coordinate efforts of the team by counting to three.
explain why this works
Simultaneous lifting minimizes load for any one lifter.
Performing manual lifting is a last resort
only do it if it does not involve lifting most or all of patient’s weight.
Reduces risk of injury to lumbar vertebrae and muscle groups. Twisting increases risk of injury.
A broad base of support increases stability. Maintains center of gravity.
Leg muscles are stronger, larger muscles capable of greater work without injury.
Sliding requires less effort than lifting. Friction-reducing sheet minimizes shearing forces, which can damage patient’s skin.
explain what we are going to be looking out for
there is a lot that goes into this
I will be assisting and supervising;
you are being transferred for the first time after prolonged bed rest/extensive surgery/critical illness/or spinal cord trauma.
there are mobility restrictions,
i need to measure any changes in blood pressure (BP), so you will be wearing this
I will be trying to look for sensory alterations that may affect safe transfer (e.g., medicated or confused).
i want you to observe X, and report back anything such as dizziness or your ability/inability to assist.
our next option is to use a stand-assist lift device
clinical intervention involves asking a dying person specific questions about their life history, proudest achievements, and the lessons they want to pass on.
transform the tone of clinical care simply by asking the individual:
"What do I need to know about you as a person to give you the best care possible?
Facilitate non-clinical spaces for
storytelling,
creating photo journals
leaving voice recordings for family members
Even as choices narrow, maximizing control over daily routines preserves self-worth. Allow them to
choose their meals
decide the timing of their care
control their environment (e.g., lighting, music, or visitors)
Prioritize Personal Appearance:
Maintaining regular hygiene, grooming, and clothing choices prevents the "patient" identity from fully taking over. Simple gestures like brushing hair the way they always styled it or keeping whiskers trimmed protect personal pride
Preserve Absolute Physical Privacy:
Always maintain bodily privacy by keeping the individual covered during medical or hygiene tasks, explaining actions before touching them, and ensuring clear communication
Acknowledge Personhood Over Illness:
Never speak about the individual in the third person if they are in the room, regardless of their cognitive or responsiveness status. Address them directly, using their preferred name
A nurse intervenes whenever a patient assessment reveals an actual health problem, a potential risk, or a change in condition that requires clinical action to improve health, safety, or comfort
dont start working on their treatment until you've done ADP first
Nurses follow a continuous cycle—Assessment, Diagnosis, Planning, Implementation, and Evaluation—and intervention (implementation) occurs right after the care plan is planned, or immediately during assessment if an urgent safety or life threat appears:
OpenStax +2
Immediate/Emergency Assessment: If a patient's condition is unknown or changing (such as sudden distress or pain), the nurse's first intervention is to assess the patient (e.g., check vital signs, check airways) before acting.
YouTube·Nexus Nursing Institute
Active Problem Solving: When a specific nursing or medical diagnosis is identified (e.g., ineffective airway clearance, high fall risk, or acute pain), the nurse carries out targeted actions.
American College of Education +1
Continual Reassessment: Nurses constantly re-evaluate patients to detect new changes that require modifying the care plan or calling a provider.
Types of Nursing Interventions
Independent (Nurse-Initiated): Actions nurses can legally and independently perform based on clinical judgment, such as repositioning a patient for comfort, teaching safe walker use, or providing basic health education.
Nevada State University +2
Dependent (Physician-Initiated): Actions that require a provider's order, such as administering prescribed medications, starting intravenous (IV) fluids, or inserting a urinary catheter.
JoVE +2
Interdependent (Collaborative): Actions performed alongside other healthcare team members (like physical therapists, dietitians, or social workers) to manage complex or multi-disciplinary needs
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