MARK K LECTURE 12

DON’T EXPECT 75 OR 85, PREPARE FOR 150 QUESTIONS

NEGATIVITY AFFECTS PERFORMANCE

NEGATIVITY COMES FROM OUR EXPECTATIONS

DON’T EXPECT EVERYTHING TO GO RIGHT

YOU HAVE PERSVERANCE

Prioritization

  • Deciding with pt is sickest or healthiest

  • The answers will have: Age, gender, diagnosis, and modifying phrase

    • Age and Gender are IRELEVANT

    • BUT in peds, age is important

  • Modifying phrase is ALWAYS more important than diagnosis

    • Ex: Angina pectoris vs MI - MI “would” be High priority

      • BUT With unstable BP (AP) vs stable VS (MI)

      • Angina pectoris becomes High Priority

      • PAY ATTENTION TO MODIFYING PHRASE

RULE #1 ACUTE BEATS CHRONIC

  • Ex: COPD, CHF, APPENDICITIS

    • Appendicitis is acute

    • COPD and CHF are chronic

RULE #2 FRESH POSTOP (12HRS) BEATS MEDICAL or OTHER SURGICAL

  • Ex: COPD, CHF 2day post coronary bipass, APPENDICITIS 2hr post coloy

    • 2hr post coloy is priority

    • Doesnt matter how bad the surgery is, if it AINT WITHIN 12 HRS YOU AINT PRIORITY

RULE #3 UNSTABLE BEATS STABLE

  • Unstable is higher priority than stable people

    • Unstable characteristics:

      • Unstable

      • Acute Illness

      • Post-op LESS THAN 12 HRS

      • General Anesthesia

      • Lab Abnormalities of a C or D level

      • Not Ready for Discharge, Newly Admitted, New Diagnosed, Admitted LESS THAN 24 HRS

      • Changing or Changed assessments (Something new occurred)

      • Experiencing unexpected signs and symptoms (Mild pain with chest xray, no pain should be expected)

    • Stable characteristics:

      • Stable

      • Chronic Illness

      • Post-op GREATER THAN 12 HRS

      • Local or Regional Anesthesia

      • Lab Abnormalities of an A or B level

      • Ready for Discharge, To be Discharge, Pt admitted LONGER than 24 HRS

      • Unchanged Assessments (same assessments, nothing new discovered)

      • Experiencing the typical, expected signs and symptoms of the disease with which they were diagnosed. (Kidney stones with severe colicky pain is expected)

    • At the scene of a unwitness access, and the person is breathless and pulseless, they are low priority because they might be dead.

    • But if you witness what happened, then they are high priority

  • CAUTION ONLY USE AS A TIEBREAKER

    • The more vital the organ, the higher the priority

      • Organ of the modifying phrase is happening, not the diagnosis itself

      • Most vital organs in order

        • 1: Brain

        • 2: Lungs

        • 3: Heart

        • 4: Liver

        • 5: Kidney

        • 6: Pancreas

Delegation

  • Cannot be delegated to LPN:

    • Starting an IV

    • Hanging or mix IV meds

    • Pushing IV push meds

    • Administer blood or mess with central lines (no flushing)

    • Cannot plan care - they can implement it

    • Cannot perform or develop teaching - can reinforce teaching

    • Cannot take care of UNSTABLE PTs

    • CANNOT DO THE FIRST OF ANYTHING

    • Cannot do these Assessments:

      • Admission

      • Discharge

      • Transfer

      • First assessment after a change

  • Cannot be delegated to UAP:

    • Charting abt pts but can chart about what they did

    • Cannot give meds, can give topcial otc barrier creams

    • Cannot do assessment except VS

    • Cannot do tx except for enemas

    • Can do ADLS and Bed Baths

      • NEVER THE FIRST OF THESE ONLY THE RN

DO NOT DELEGATE SAFTEY RESPONSIBILITES TO THE FAMILY

  • DONT LET THEM CATHERIZE

STAFF MANAGEMENT

  • How do u intervene with inappropriate behavior of staff

    • Always 4 answers

    • First answer is like tell supervisor

    • Second answer is like confront them and take over immediately

    • Third answer is like at a later date just talk to them

    • Fourth answer is ignore it *THIS IS NEVER THE ANSWER

      • Is what they are doing illegal?

      • IF SO TELL SUPERVISOR

      • IF NO, is anyone in harms way?

      • IF YES, CONFRONT IMMEDIATELY AND TAKE OVER

        • Telling the supervisor will delay the issue

      • IF it is not harmful- Tell supervisor

      • IS THIS BEHAVIOR LEGAL, AND NOT HARMFUL, BUT SIMPLY INAPPROPRIATE

        • Counsel them later on, no hurry, no rush

Aortic - Second Right Intercostal

Pulmonic- Second Left Intercostal

Erbs point: Third Left Intercostal

Tricuspid - Fourth Left Intercostal

Mitral/Apical - Fifth Midclavicural Line

HOW DO YOU GUESS

  • Use your knowledge

  • When knowledge fails, use common sense

  • When common sense fails, GUESS

  • Psych questions (If you don’t know what is going on)

    • The nurse will examine their own feelings abt a specific topic

    • Establish a trust relationship

  • Nutrition questions (If you don’t know what is going on)

    • 75% Right

    • In a tie, pick CHICKEN, not fried chicken

    • BAKE CHICKEN OR FISH WINS (except shell fish)

    • Never pick casseroles for children, children will not eat it

    • Never mix meds in children’s food

      • You must ask permission before mixing people’s food

    • Toddler’s like finger food

    • Preschooler’s leave them alone: ONE MEAL A DAY IS OKAY

  • Pharmacology questions

    • Remember Side Effects

    • IF you know what a drug does, but not the side effects: PICK A SIDE EFFECT IN THE SAME BODY SYSTEM WHERE THE DRUG IS WORKING

    • IF you have no clue what drug is, if it is PO, pick a GI SIDE EFFECT

    • Never tell a child a medication is candy

  • OB

    • FIRST Check fetal HR

  • MEDSURGE

    • FIRST ASSESSMENT: Check lvl of consciousness

    • FIRST ACTION: Establish Airway

  • Pediatrics (Growth and Development)

    • Based on the principle on giving the child more time

      • Dont rush children’s growth and development

            Rule #1: WHEN IN DOUBTCALL IT NORMAL

            They give you ages and task to see if you will give them time

            Rule #2: WHEN IN DOUBT PICK THE OLDER AGE

            It always gets narrowed down to 2 choices

            The older age has more time

             Rule #3 WHEN IN DOUBT PICK THE EASIER TASK

            The easier task is given more time

             Than doing a harder one

  • RULE OUT ABSOLUTES

  • IF TWO ANSWERS SAY THE SAME THING, NEITHER ONE IS RIGHT

  • IF TWO ANSWERS ARE OPPOSITE ONE OF THEM IS PRB RIGHT

  • THE UMBRELLA STRAT

    • Which answer is more global or broad

    • Look for answer that covers all the others without saying it does

    • SAFTEY

  • IF A QUESTION HAS 4 RIGHT ANSWERS, WHICH IS THE HIGHEST PRIORITY NEED

    • But if they give you one patient which of the following needs

    • The best answer is the one if you dont do it has the worst outcome

    • HIGHEST PRIORITY is preventing anything that can lead to death or harm

  • IF YOU ARE STUCK BETWEEN TWO ANSWERS, REREAD THE QUESTION

  • SEASAME STREET RULE

    • Use when and only when, the only remaining option is to

    • Right answers tend to be different than the others

    • The wrong answers are usually all have something in common

    • Right answer is the most unqie

DIABETES

  • Def: Error of Glucose metabolization

  • Diabetes Inspidus (Polyuria, Polydipsia, Leading to dehydration due to LOW ADH):

    • Not a type of diabetes mellitus

    • Low or High urine output?

  • SIADH is opposite of diabetes inspidus