Archer: Prioritization and Delegation

ABC

airway, breathing, circulation

airway

-foreign body in the airway

-obstruction in the throat

-edema - swelling of throat

-goal is a patent airway

-if no patent airway what do?

(intubate or tracheal tube)

Sign and Symptoms of Airway Blockage

-Unable to speak

-Auditory Stridor

-Wheezing that stops

-Drooling

What to do in Airway Blockage

Intubation - if that does not work than trach patient

breathing

-adequate respirations -RR is sufficient or shallow

-bilateral breath sounds

-good air entry

-breathing insufficient? -bag mask ventilation = breath for them

Sign and Symptoms of breathing trouble

-Shortness of Breath

-Tripod position

-Workload of breathing increase

-Accessory Muscle Use

circulation

-enough blood flow thru tissue

-providing oxygen to organs

-good pulses - plus 2, equal on both sides.

-brisk cap refill - less than 3 seconds.

-warm skin

-appropriate color

-insufficient circulation - give fluid or vasopressor 2nd

Sign and Symptoms of circulation trouble

-Hypotension - low blood pressure.

-Map below 65

-Tachycardia

dopamine is a

vasoconstrictor - increase BP, if the BP is high on dopamine then discontinue it

unstable pt.

-changing condition

-acute

-unexpected

-recently admitted

-new onset

-newly diagnosed

-critical lab values

-hemorrhage

stable pt.

-chronic

-expected finding

-ready for discharge

-consistent lab values

-consistent vital signs

-unchanging

first try to use

ABC, and then unstable or stable to determine prioritization; if that doesnt work then use maslow's hierarchy of needs; then last use nursing process

eliminate what you know is wrong first

-read each answer choice individually

-if you know it is wrong, mark it out

-if part is wrong then the whole answer is wrong (mark it out)

Maslow's Hierarchy of Needs

maslow's 1st physiological needs

-food, water, warmth, rest, sepsis, oxygen

-IV fluids, nutritional needs

maslow's 2nd safety

-security, safety

-fall risk

-safe room environment

-suicide risk

maslow's 3rd belongingness and love

-intimate relationship

-friends

-therapeutic communication

-fam support

maslow's 4th esteem needs

-therapeutic accomplishment

-prestige

-feeling of accomplishment, belonging

maslow's 5th self actualization

-achieving one's full potential

-including creative activities

nursing process (ADPIE)

assessment, diagnosis, planning, implementation, evaluation

assessment

-data collection (subjective, objective)

-interpreting data

-knowing normal

-documenting assessment

diagnosis

-analyze the date and identify problems at risk

-decide what primary problem is

plan

-choose interventions

-priority interventions

-SMART (specific, measurable, achievable, realistic, timely) goals

-develop plan of care

implementation

-put plan into place

-implement the interventions

-take action on goals

evaluation

-evaluate how interventions affected pt.

-vital sign changes

-therapy goals

-document in plan of care

five rights of delegation

-right task

-right circumstance

-right person

-right communication

-right supervision

right task

-can i delegate this?

-is it within scope of UAP such as nursing assistance

-is it a low risk task

right circumstance

what is going on w pt.

-are they stable? if unstable - then should not be delegated

what about person delegating to?

-how much training they have?

-how many pt. do they have - are they able to complete the task youre delegating to them

-do you feel comfortable delegating the task?

right person

who delegating to?

do they have appr training?

do they have exp w this task?

are they competent in task delegated?

right communication

-explain what delegating?

-what do you do expect them to do?

-do you expect them to follow up and report back to you?

right supervision

-always ensure completed properly

-accountability is not transferred to the person you are delegating to, LVN is ultimately responsible

if you delegate

you are responsible for what happens; and do not delegate nursing judgement or any activity that will involve nursing judgement or critical decision making

for example listening to pt lung sounds or initial assessment needs judgement

unlicensed assistive personnel (UAP) scope of practice

YES:

-ambulate

-turning

-bathing

-intake output

-oral care

-toileting

-feeding (If safe swallow)

-vital signs (cannot interpret them)

-weights

-linen change

NO:

-IV

-administer meds

-assessments

-delegate a task

LVN scope of practice

YES:

-Everything that the UAP does plus

-gathering data

-taking care of stable pt.

-wound care (basic)

-ostomy care

-reinforcement of teaching (never initial teaching)

-can reassess and perform on a stable patient

-Give oral meds, IM, SQ Injection -Not high-risk meds

-Initial inserting IV? No. Only maintaining and removing the IV and secondary IV insertions. Can not titrate, Can not give blood, cannot do IV Push. Cannot give TPN

NO:

-teaching and education

-assessment on unstable pt.

-planning

-evaluation

-interpreting data

-taking care of unstable pt.

(the nursing process is specific to RN)

RN scope of practice

-assessment

-evaluation

-teaching

-education

-all meds

-blood transfusions

-invasive procedure

-developing care plan

group drug classes together and recall what their names look like

antianxiety: -pam/-lam

TCA (Tricyclic antidepressants): -ptyline

ACE inhibitors (high blood pressure, heart problems): -pril

beta blockers (chest pain, heart failure, arrhythmias, heart attack): -lol

antibiotic: -mycin

penicillin: -cillin

antifungal: -azole

loop diuretic: -mide

calcium channel blockers (lower BP): ve rap -zem after dipine in the calcium channel

-KNOW ANTIDOTES

most at risk?

right answer will be pt. with the most

-tally up risk factors and choose pt w the most

do not pick an answer if you:

do not know what it means; if you havent heard of it, no one else has too

-expected to be a brand new nurse w 2 weeks of general knowledge

know the why behind signs and symptoms

-why something is happening

ex: polyuria (such as in diabetes) => fluid volume deficit => shock

heart failure => pump not moving blood forward => decr blood flow to kidneys => decr. UOP => fluid retention (edema, crackles, rales, short of breath)

hypoxia => not enough oxygen getting to tissues => not enough oxygen to brain => anxious pt/change in LOC

-examples of diseases w hypoxia: sickle cell crisis, shock, COPD, pulmonary embolism)

SIADH (inappropriate antidiuretic hormone) => fluid retention

cause body to retain water (symptoms such as edema, weight gain, decr. urine production)

hypertension with fluid retention

when urine is increased (there is a low urine specific gravity)

when urine is decreased (there is a high urine specific gravity)

think like a new nurse

-you are not expected to know everything

-keep the pt. SAFE

ALWAYS PROTECT THE PT.

-safety first

-test is to protect public

-assume the worst: fix the problem

pick the least invasive option first

-nonpharmacologic interventions before medication

-non opioid analgesics before opioid

-PT/OT before surgery

-restraints are last resort

only call health care provider if there is nothing that you the nurse can do for the pt.

if there is an immediate intervention you can take to help then do it first

prolapse umbilical cord: priority is to lift presenting part of fetus off the cord, not call the HCP

pt. with appendicitis

if they have high pain and then no pain at all be worried for rupture = you have to notify healthcare provider

for priority questions, pick the answer most likely to kill the pt.

-pain doesnt kill pt.

-anxiety doesnt kill pt.

-hypoxia kills

-acidosis kills

-resp distress kills

-losing airway kills

-some arrhythmias kill (VT, VF, asystole = fatal)

if the answer puts work onto someone else it is

WRONG

-you should be doing work

-save for the next shift is wrong

if the answer ignores what a pt. is saying it is wrong

-pt. focused answers

-always listen to pt.

-always take pt. concerns seriously

-use therapeutic communication

SATA

treat each answer as true or false

-all could be right

-one could be right

on a topic dont know

-think back to what you do know

-remember the whys between sign and symptoms

-eliminate what you know is wrong

-pick the dangerous answer that can kill pt.