Mark Klimek - Prioritization/Delegation

Prioritization questions will always have:

-Age

-Gender

-Diagnosis

-Modifying Phrase

What is important?

IGNORE age/gender

Most important = modifying phrase

Angina Pectoris vs Myocardial Infarction - who is higher priority?

MI

Angina Pectoris with unstable BP vs Myocardial Infarction with stable vital signs - who is higher priority?

Angina pectoris with unstable BP

(modifying phrase more important)

4 rules for prioritization

1. acute > chronic

2. fresh postop (first 12 hrs) > medical or other surgical

3. Unstable > stable

4. More vital the organ, the higher the priority (organ of the modifying phrase) (only use this as a tie-breaker)

What is the tie-breaker used for prioritization questions?

More vital the organ, the higher the priority

Vital Organs - order

Brain

Lung

Heart

Liver

Kidney

Pancreas

Who is the priority?

COPD

CHF

Appendicitis

Appendicitis (acute)

Who is the priority?

COPD

CHF

Appendicitis

2 hour post-op cholecystectomy

3 day post-CABG

2 hour post-op cholecystectomy

(fresh post-op within 12 hr)

Who is the highest priority?

A. 23 yr old male with CHF with a potassium of 6.6 and no ECG changes.

B. Chronic Renal Failure with a creatinine of 20.7 and pink, frothy sputum.

C. Acute hepatitis with jaundice and increased ammonia level, who you cannot arouse.

C. Acute hepatitis with jaundice and increased ammonia level, who you cannot arouse.

Potassium = heart (3rd organ)

Pink, frothy sputum is PE = Lung (2nd organ)

Cannot arouse = brain (1st organ)***

UNSTABLE words

-Unstable

-Acute illness

-Post-op <12 hrs

-General anesthesia (12 hrs)

-Lab abnormalities of a C or D

-Not ready for discharge

-Newly admitted

-Newly diagnosed

-Admitted less than 24 hrs ago

-Changed assessments

-Unexpected signs/symptoms

STABLE words

-Stable

-Chronic illness

-Post-op >12 hrs

-Local/Regional anesthesia

-Lab abnormalities of an A or B level

-Ready for discharge

-Admitted more than 24 hrs ago

-Unchanged assessment

-Experiencing the typical expected signs/symptoms with which they were diagnosed

Stable or Unstable: Kidney stones with severe colicky pain

STABLE because expected sign

Stable or Unstable: Mild pain while having a chest x-ray

UNSTABLE because unexpected sign

Who is the highest priority patient?

1. 16 yr-old female with meningitis who has had a temp of 103.8 since admission 3 days ago

2. 67 yr-old male with IBS who spiked a temp of 100.3 this afternoon

2. 67 yr-old male with IBS who spiked a temp of 100.3 this afternoon

BECAUSE...A patient with Meningitis is expected to have a fever. A patient with IBS who recently developed a fever is an unexpected and new symptom.

Always high priority (5)

Hemorrhage

Fever >105 (seizures)

Hypoglycemia (<70)

Pulseless

Breathlessness

Black tag (triage)

Pulselessness

Breathlessness

Fixed and dilated pupils

LPNs can NOT:

-Starting an IV

-Hang or mix IV meds

-IV push meds

-Administer blood

-Central lines (no flushing, dressing changes, etc)

-Care plans

-Perform or develop teaching

-Take care of unstable patients

-Cannot do the 1st of anything (1st assessment, 1st post-op dressing, 1st feeding after stroke, etc)

-Admission, discharge, transfer, first assessment after a change

LPNs can:

-Maintain and document IV flow

-Reinforce teaching

-

UAP's can NOT:

-Chart about the patient

-Give meds (except topic OTC barrier creams)

-Do assessments or treatments (except enema's)

-Be cautious with catheters*

UAP's can:

-Vitals

-Accu-checks

-Enemas

-ADLs (but they should never do the first)

UAP's can give what meds?

Topical, over-the-counter, barrier creams

DO NOT delegate what you can EAT!

E - evaluate

A - assess

T - teach

Do NOT delegate safety responsibilities to....

family

How do you intervene with inappropriate behavior of staff?

There is always 4 answers:

1. Tell supervisor --> illegal activity

2. Confront them and take over immediately --> harmful/danger

3. At a later date, talk to them about the situation --> not harmful, but inappropriate

4. Ignore it --> NEVER the answer

HOW TO ANSWER:

1. Is what they are doing illegal? --> Tell Supervisor

2. Is anyone (patient/staff) in immediately danger? --> Confront them and take over immediately

3. Is this behavior legal, not harmful, but inappropriate? --> Approach them later on and talk to them

Is what they are doing illegal?

If so, tell the supervisor. If not, next question

Is what they are doing physically or psychologically dangerous to staff or pt?

Confront and take over immediately

How to remember heart auscultation points:

A PeT Monkey

A - 2nd right ICS at sternal border

P - 2nd left ICS at sternal border

T - 4th left ICS at sternal border

M - 5th left ICS midclavicular line

How do you guess on the NCLEX?

1. Knowledge

2. Common sense

3. Guessing Strategy:

Psych questions:

-the nurse examine their own feelings about something in psych nursing

-establish a trust relationship

Food Questions:

-In a tie, pick chicken

-NEVER pick casseroles for children

-Never mix medications in children's food

-Never mix medications in food without permission

-Toddlers = finger food (hot dogs and french fries, even though its not healthy)

Pharmacology:

-Memorize side effects

**-You know what a drug does but don't know the side effects --> pick a side effect in the same body system that a drug is working** examples:

-GI drug --> pick diarrhea

-Heart drug --> pick tachycardia

-CNS drug --> pick drowsiness

-If it's PO --> pick a GI side effect

NEVER tell a child that medicine is

candy

MedSurg - what is the first thing you assess?

Level of Consciousness

OB question - what do you pick when you don't know the answer?

Check Fetal Heart Rate

What is the first thing you do in a Medsurg situation?

Establish an airway

3 rules of growth and development questions (always give child more time to grow, dont rush it)

1. When in doubt, call it normal

2. When in doubt, pick the older age

3. When in doubt, pick the easier task

General guessing skills

1. Rule out absolutes

2. If two answers say the same thing, both are wrong

3. If two answers are opposite, one of them is probably right

4. Umbrella --> which answer is more global? An answer that is very broad and covers everything else

5. Always think, what is the WORST that can happen?

Post-hip replacement. What is most important to do?

-Sips of water

-Put side rails up --> Because if you didn't do it, then you could break your hip again, etc

-give pain meds

-use abductor pillow

***Sesame street rule: only when NO other way. Right answer tends to be ____ than others. Wrong answers are similar. When something really ____ right it probably is- go with your gut

Right answers tend to be DIFFERENT than the others. Wrong answers are similar. When something really feels right it probably is. GO WITH YOUR GUT.

***Countertransference

Refers to the nurse's behavioral and emotional response to the client

Transference

the patient's transfer to the analyst of emotions linked with other relationships

The first 10 questions...

USE COMMON SENSE!!!

NEVER have these expectations:

1. Don't expect 75 questions

2. Don't expect to know everything

3. Don't expect everything to go right