Lecture 12: Prioritization, Delegation, Staff Management, and Guessing Strategies

Introduction to Prioritization and Management

• This lecture is considered the most important in the entire review series.
• There will be a minimum of $15$ questions on this section alone on the examination.
• Most exam takers engage in "dead guessing" for this section; the goal of this material is to learn the rationale to avoid guessing.

Prioritization Concepts

• Prioritization involves deciding which patient is the sickest (highest priority) or the healthiest (lowest priority).
• The objective depends on the specific scenario provided in the question:     - Disaster scenario: If you are making room for wounded individuals after a town disaster, you look for the lowest priority patient to discharge.     - Handoff/End-of-shift report: When receiving reports on $4$ patients, you must identify the highest priority patient to check first.

The Four Components of Prioritization Questions

• Questions typically provide four pieces of information about a patient:     - $1.$ Age     - $2.$ Gender     - $3.$ Diagnosis (Dx)     - $4.$ Modifying phrase
• Irrelevant Data: Age and gender are generally not important for prioritization. Age only becomes a significant factor in pediatric cases.
• Crucial Data: The modifying phrase is the most important part of the four components.
• Example Comparison:     - A $10$-year-old male with hypospadias is throwing up bile-stained emesis.     - Age: $10$-year-old (Irrelevant).     - Gender: Male (Irrelevant).     - Diagnosis: Hypospadias.     - Modifying phrase: "throwing up bile-stained emesis" (This is the priority factor).

Rules for Prioritization

Rule 1: Acute Beats Chronic

• An acutely ill patient always takes higher priority than a patient with a chronic condition.
• Example: Between a patient with COPD (chronic obstructive pulmonary disease), CHF (congestive heart failure), and appendicitis, the patient with appendicitis is the highest priority because appendicitis is an acute condition while the others are chronic.

Rule 2: Fresh Post-Op Beats Medical or Other Surgical

• "Fresh post-op" is defined as surgery occurring less than $12\,\text{hours}$ ago.
• Surgery performed within the last $12\,\text{hours}$ takes precedence over medical conditions or other surgical conditions outside that window.
• Example Scenarios (Comparing to Fresh Post-Op):     - A patient $2\,\text{hours}$ post-cholecystectomy is a higher priority than a patient with COPD.     - A patient $2\,\text{hours}$ post-cholecystectomy is a higher priority than a patient with acute appendicitis.     - A patient $2\,\text{hours}$ post-cholecystectomy is a higher priority than a patient with a radical neck dissection (if the neck dissection is not fresh post-op).     - A patient $2\,\text{hours}$ post-cholecystectomy is a higher priority than a patient with a bilateral above-the-knee amputation.     - A patient $2\,\text{hours}$ post-cholecystectomy is a higher priority than a patient with a right frontal craniotomy.

Rule 3: Unstable Beats Stable

• Unstable patients always take priority over stable patients.
• Criteria for a STABLE Patient:     - Use of the word "Stable."     - Chronic illness.     - Post-operative status greater than $12\,\text{hours}$.     - Patient is under local or regional anesthesia.     - Lab abnormalities categorized as Level A or B (e.g., Creatinine, BUN, Hemoglobin between $8$ and $11$, Bicarbonate, elevated Hematocrit, elevated BNP, elevated Sodium, off-count RBCs).     - Phrases like "Ready for discharge," "To be discharged," or "Admitted longer than $24\,\text{hours}$."     - Unchanged clinical assessment.     - Experiencing the typical, expected signs and symptoms of their diagnosed disease.
• Criteria for an UNSTABLE Patient:     - Use of the word "Unstable."     - Acute illness.     - Post-operative status less than $12\,\text{hours}$.     - General anesthesia within the first $12\,\text{hours}$.     - Lab abnormalities categorized as Level C or D (e.g., INR in the $4\text{s}$, Potassium (K) in the $6\text{s}$, pH in the $6\text{s}$, $CO_2$ in the $50\text{s}$, low $O_2$ saturation, high WBC, low ANC, low CD4 count, low platelets).     - Phrases like "Newly diagnosed," "Newly admitted," "Not ready for discharge," or "Admitted less than $24\,\text{hours}$."     - Assessment that is changing or has changed.     - Experiencing unexpected signs and symptoms.
• The Four Always Unstable Conditions:     - $1.$ Hemorrhage (Note: disparate from simple bleeding).     - $2.$ High fevers over $105\,^{\circ}\text{F}$ (Risk of seizure).     - $3.$ Hypoglycemia (Risk of brain damage).     - $4.$ Pulseless or Breathless (e.g., V-fib or asystole).
• Mass Casualty Exception:     - At the scene of an unwitnessed accident, pulseless and breathless patients are actually low priority because they are likely already deceased.     - Black Tag Criteria: In mass casualty incidents, patients receive a black tag if they are pulseless, breathless, or have fixed and dilated pupils (even if still breathing). The mantra is "Tag them black and ship them last."
• Example of Stable vs. Unstable:     - Patient A: A $16$-year-old female with meningococcal meningitis (acute) with a temperature of $103.8\,^{\circ}\text{F}$ since admission $3\,\text{days}$ ago.     - Patient B: A $67$-year-old male with irritable bowel syndrome (chronic) who spiked a temperature of $103.4\,^{\circ}\text{F}$ this afternoon.     - Result: Patient B is the higher priority. Although A has an acute Dx, the symptoms are expected and stable over $3\,\text{days}$. Patient B had a chronic Dx but has a changing assessment ("spiked") and a new acute symptom ("this afternoon").

Rule 4: Tie-Breaker (Vital Organs)

• If the first three rules do not distinguish priority, the more vital the organ involved in the modifying phrase determines the priority.
• Organ Priority Hierarchy:     - $1.$ Brain     - $2.$ Lung     - $3.$ Heart     - $4.$ Liver     - $5.$ Kidney     - $6.$ Pancreas
• Tie-Breaker Example:     - Patient A: $23$-year-old male with CHF (chronic diagnosis, low priority), Potassium of $6.6$ (high priority lab), no EKG changes (stable). Organ: Heart.     - Patient B: Chronic Renal Failure (chronic diagnosis, low priority), Creatinine of $24.7$ (expected for diagnosis, low priority), pink frothy sputum (unexpected, high priority). Organ: Lung.     - Patient C: Acute Hepatitis (acute diagnosis, high priority), jaundice and increased ammonia (expected, low priority), cannot be aroused (unexpected/change in LOC, high priority). Organ: Brain.     - Result: Patient C is the highest priority because the brain is the top-tier organ.

Delegation of Responsibility

Licensed Practical Nurse (LPN) Restrictions

• LPNs cannot start an IV.
• LPNs cannot hang or mix IV medications.
• LPNs cannot administer IV Push medications; they can only maintain an IV and document the flow.
• LPNs cannot administer blood or manipulate central lines (no flushing, no dressing changes).
• LPNs cannot create a care plan; they may only implement one.
• LPNs cannot perform or develop initial teaching; they can only reinforce existing teaching.
• LPNs cannot care for unstable patients.
• LPNs cannot perform the "first" of any task. The first instance of a task involves assessment or planning.     - Examples of "Firsts":         - The RN must perform the first tube feeding.         - The RN must perform the first post-op dressing change; the LPN should not do this on the day of surgery.         - The RN must perform the first feeding for a stroke patient.         - The RN must be the one to first ambulate a post-op patient or take them out of bed.         - The RN must take the first set of post-operative vital signs.
• LPNs cannot perform assessments related to admission, discharge, transfer, or the first assessment following a clinical change.
• Clinical Example: If an LPN reports hearing new crackles in a patient, the RN must go perform the assessment personally because it represents a new onset or change in symptoms.

Unlicensed Assistive Personnel (UAP) Restrictions

• Charting: UAPs can chart what tasks they performed (e.g., "side rail is up," "bed is lowered"), but they cannot chart patient responses or clinical observations (e.g., "patient less anxious," "tolerated ambulating well").
• Medication: UAPs cannot administer medications EXCEPT for OTC topical barrier creams (e.g., A&D ointment). They cannot give Nitroglycerin or Neosporin because those are not OTC. They cannot give hydrocortisone.
• Assessments: UAPs cannot perform assessments except for vital signs or Accu-Chek for diabetes.
• Treatments: UAPs cannot perform treatments except for enemas.
• ADLs: RNs can delegate Activities of Daily Living to UAPs, but a UAP should never perform an ADL task for the first time.

Delegation to Family and Friends

• Never delegate safety responsibilities to family members.
• Example: If a family member asks to leave restraints off and promises to call when they leave, the RN must refuse.
• Safety tasks can only be delegated to non-hospital caregivers if they are trained (e.g., as a sitter) and the training is documented in the patient's record.
• Exception: A mother can give an insulin shot to her $3$-year-old child if the nurse teaches her and documents the teaching.
• Example: If a mother asks to leave the crib railing down while she bathes her baby, the RN should stay in the room until the task is done to ensure the rail is put back up immediately.

Staff Management

• Handling inappropriate behavior from staff involves four possible answers:     - $1.$ Tell Supervisor     - $2.$ Confront them and take over the task immediately     - $3.$ Talk to them later     - $4.$ Ignore it (Always the wrong answer)
• Decision Logic:     - Is it Illegal? If YES, Tell Supervisor. (Example: RN diverting narcotics; RN going home with bulging pockets).     - Is anyone in immediate Physical or Psychological Harm? If YES, Confront immediately and take over. (Example: Aide giving perineal care without gloves; Surgeon contaminating gloves).     - Is the behavior simply Inappropriate but not illegal or harmful? If so, Talk to them later. (Example: RN consistently using the word "exasperation" instead of "exacerbation" during report).
• Special Case: If an act is both illegal and harmful, first take over the task to protect the patient, then report it to the supervisor.
• Professional Boundaries: If you find patients engaging in sexual intercourse or a patient masturbating, shut the door and provide privacy.

Clinical Skills: Point and Click

• Auscultation Over Heart Valves (A PET M):     - Aortic: $2 ext{nd}$ intercostal space, right of the sternal border.     - Pulmonic: $2 ext{nd}$ intercostal space, left of the sternal border.     - Erb's Point: $3 ext{rd}$ intercostal space, left of the sternal border (located between pulmonic and tricuspid).     - Tricuspid: $4 ext{th}$ intercostal space, left of the sternal border.     - Mitral: $5 ext{th}$ intercostal space at the midclavicular line (same location as the apical pulse).
• Pulses: Be prepared to identify the location of pulses, such as the popliteal pulse, on a diagram.

Guessing Strategies

Psychiatric Nursing

• Choose: "I will examine my feelings" (to prevent countertransference, where the nurse projects feelings about someone else onto the patient).
• Choose: "Establish a trust relationship."

Nutrition

• If unsure, pick "baked chicken." If chicken isn't available, pick fish (but avoid shellfish like lobster, crab, or shrimp due to high cholesterol).
• Never choose casseroles for children; they won't eat them.
• Never mix medications in children's food. Always ask adult patients for permission before mixing meds with food.
• Toddlers: Pick "finger foods" that they can eat on the go (e.g., Hot dogs, tofu, French fries).
• Preschoolers: "Leave them alone"; one meal a day is acceptable as their growth curve plateaus.

Pharmacology

• Focus on memorizing side effects rather than dosage or route.
• If you know the drug's purpose but not its side effects, pick a side effect in the same body system the drug targets.     - GI drug -> Diarrhea.     - Cardiac drug -> Tachycardia.     - CNS drug -> Drowsiness.     - If the drug is PO and you have no idea what it is, pick a GI side effect.
• Never tell a child medication is "candy."

Medical-Surgical and Obstetrics

• OB: Always check the Fetal Heart Rate.
• Med-Surg First Assessment: Check Level of Consciousness (LOC) first. Example: Before ABCs in a code, you shout "Sir, Sir! Are you okay?" to check LOC.
• Med-Surg First Action: Establish an airway.

Pediatrics (The Growth and Development Mantra)

• Always aim to give the child more time.
• Rule 1: When in doubt, call it "Normal."
• Rule 2: When in doubt between two ages, pick the "Older" age (e.g., walking at $12$ vs $14\,\text{months}$, pick $14$).
• Rule 3: When in doubt between two tasks, pick the "Easier" task (e.g., rolling over vs sitting with support at $6\,\text{months}$, pick rolling over).
• Remember: "NORMAL, OLDER, EASIER."

General Tactics

• Rule Out Absolutes: (Exception: Never push Potassium).
• Avoid Same-Meaning Answers: If two answers mean the same thing (e.g., "increased bowel sounds" and "borborygmi"), neither is correct.
• Opposite Answers: If two answers are opposites, one is likely correct.
• Umbrella Strategy: If multiple answers seem correct, look for the "global" or most all-encompassing answer (e.g., safety and body mechanics).
• Worst Consequences Game: For priority questions, ask "What is the worst thing that would happen if I did NOT do this?" The answer that prevents the worst outcome (e.g., being DEAD) is the priority.
• Sesame Street Rule: If one answer choice is structurally or conceptually different from the others, it is likely the correct one.
• Common Sense over Ignorance: If you don't know a specific drug (like Amikacin), use your knowledge of the delivery method (Piggybacks require a pump) rather than guessing based on the drug name.

Examination Expectations

• Expectation 1: The test will not be what you expect. Do not expect to stop at $75$ (RN) or $85$ (LPN) questions. Prepare mentally for the maximum of $265$ or $285$ questions. Getting to $200$ does not mean failure; it means you are still in the game.
• Expectation 2: Do not expect to know everything.
• Expectation 3: Do not expect a perfect day (perfect parking or seat partners). Focus on perseverance and one question at a time.