Lecture 12: Prioritization and Delegation
Organ: what is the function of the brain stem?
Midbrain - motor coordination Pons - controls respiratory centers/ regulates breathing Medulla oblongata -Cardiac -Respiratory -Vasomotor -Vomiting, coughing, swallowing Cerebellum -coordinates muscle movement -posture -equilibrium -muscle tone
Which is more important between the diagnosis and modifying phrase?
Modifying phrase
What is an example of countertransference?
A pt reminds the nurse of her dad so you treat the patient rudely because the nurse doesn't like her dad.
Delegation: #2: Who should the LPN check? A. patient with angina pectoris with crushing substernal chest pain who was admitted 3 days ago, but is on nitroglycerin B. patient subtotal thyroidectomy 2 days ago who says, "Why are they washing elephants in the parking lot?"
A- LPN 'Crushing substernal pain' is a shiny penny answer, but it is expected with angina pectoris B- RN Subtotal thyroidectomies have symptoms of storm which one is delirium
Pharm/guessing strategy: #3: If you got a drug that was a CNS drug, but you didn't know the side effects. What would you choose: A. Drowsiness B. Tachycardia C. Diarrhea
A. Drowsiness TIP: Pick a side effect in the same body
Which parts of the answer format are irrelevant?
Age and gender Note: in a pediatrics question, you have to pay attention to age. In a prioritization question, you do not pay attention to age. A 2 year-old is not more valuable than a 90 year-old. They are both humans. Women are not more valuable than men and vice versa.
OB/guessing strategy: What is the ace of spades answer in OB?
Check fetal heart rate
#2: Who is your highest priority? A. COPD B. CHF C. Appendicitis D. 2 hrs post-cholecystectomy E. 2nd day post-op coronary artery bypass F. radical neck dissection
D. 2 hrs post-cholecystectomy Fresh post-op > medical or other surgical Fresh post-op is the first 12 hrs
Example question: #1: Who is your highest priority? A. COPD B. CHF C. Appendicitis D. 2 hrs post-cholecystectomy E. 2nd day post-op coronary artery bypass
D. 2 hrs post-cholecystectomy Fresh post-op > medical or other surgical Fresh post-op is the first 12 hrs
Which parts of the answer format are important?
Diagnosis and modifying phrase
Med Sx/guessing strategy: What is the first thing you do in a med surg question if you are guessing?
Establish an airway
Nutrition/guessing strategy: What type of food do you pick for a toddler?
Finger food
Nutrition/guessing strategy: What do you pick if chicken is not there?
Fish, but not shellfish like lobster b/c they are high in cholesterol Pick the scale fish, not the shellfish
Organ location and function: What are the brain lobes? (list)
Frontal Parietal Occipital Temporal
When is the only time you should use guessing strategies?
Use the strategies when you don't know what is going on
Nutrition/guessing strategy: Why do preschoolers not need the food that the toddler needed?
Growth curve of a preschooler plateaus vs. toddlers have a steep growth curve When the kid goes from being a toddler to preschooler, the growth curve bottoms out He's not eating like he used to b/c he's not growing like he used to
Nutrition/guessing strategy: What are examples of finger foods?
Hot dogs, tofu, and french fries
Staff management: #6: When you have a problem with someone else, what do you always talk in?
'I' not 'you'
Delegation: What assessments are LPNs not allowed to do?
- Admission + First Assessment - Transfer - Discharge
Organs: What is the function of the temporal lobe?
-auditory center -Wernicke's (understand speech (words))
Organs: What is the function of the frontal lobe?
-judgment/ reasoning/ concentration -broca's area (speech)
Organs: What is the function of the parietal lobe?
-pain, touch, temperature, and pressure -spatial perception
Organs: What is the function of the occipital lobe?
-visual area
Staff management: What are the 4 answers that always show up for how to manage inappropriate behavior of another staff member? Which answer choice is never the answer?
1) tell supervisor 2) confront them and take over immediately 3) at a later date, talk to them about it. 4) ignore it. Summary: confront, tell supervisor, talk later, ignore (more to least aggressive) NEVER THE ANSWER: Ignore- you never ignore inappropriate behavior of staff. You always take it as an opportunity to teach and change behavior.
What are the 4 parts of the answers for prioritization questions?
1. Age 2. Gender 3. Diagnosis 4. Modifying phrase
What is the order of organ vitality?
1. Brain 2. Lungs 3. Heart 4. Liver 5. Kidneys 6. Pancreas << brain and breathing heart lives kids and pancakes
Delegation: What responsibilities are not allowed to be delegated to an UAP? (List)
1. Charting 2. No medication administration except topical, OTC, barrier creams 3. No assessments except for vital signs and accuchecks 4. No treatments except for enemas [Summary] Assessments, Meds, Charting
Delegation: What responsibilities are not allowed to be delegated to an UAP? Explain about charting.
1. Charting they can chart what they did, but they cannot chart about the patient. For example: They can chart the 'side rail is up, bed low, call light in reach' They cannot chart 'patient is less anxious, tolerated ambulating well'
Staff management: If the staff member's action is harmful and illegal, what do you do?
1. Confront and take over immediately 2. Tell supervisor
What 4 things are always unstable regardless if it is unexpected or not?
1. Hemorrhage 2. High fevers 105F and up 3. Hypoglycemia 4. Pulseless and breathlessness [uphill] -pulseless and breathless -hypoglycemia -hemorrhage -high fevers 105F and up
Staff management: For staff management of inappropriate behavior, what questions should you always ask your self? (List)
1. Is what they are doing illegal? 2. Is anyone (patient, co-worker, or staff member) in immediate physical or psychological harm?
#3: What are the 3 things that result in a black tag in an unwitnessed accident?
1. Pulselessness 2. Breathlessness 3. Fixed and dilated pupils (even if still breathing and they have a pulse)
#2: Who is the higher priority? A. angina pectoris with unstable BP B. myocardial infarction with stable vital signs
Answer A. angina pectoris with unstable BP Always pay more attention to the modifying phrase
Example questions: #1: If you had the following patients, who would be the higher priority? A. COPD B. CHF C. Appendicitis
Answer Appendicitis Acute illness> chronic illness Note: if you use ABCs, your highest priority answer would be COPD and this is wrong
Pharm/guessing strategy: #1: If you got a drug that was a GI drug, but you didn't know the side effects. What would you choose: A. Drowsiness B. Tachycardia C. Diarrhea
Answer C. Diarrhea TIP: Pick a side effect in the same body system where the drug is working
#1: Who is your highest priority? A. COPD B. CHF C. Appendicitis D. 2 hrs post-cholecystectomy E. 2nd day post-op coronary artery bypass
Answer D. 2 hrs post-cholecystectomy Fresh post-op > medical or other surgical Fresh post-op is the first 12 hrs
Nutrition/guessing strategy: What's a better meal for a toddler, hotdog and french fries or tofu bean curry?
Hotdog and french fries even though the other option is more nutritious; it is about what they can eat on the run
#1: Who is the highest priority? A. 16 y.o. With meningococcal meningitis who has had a temp of 103.8F since admission 3 days ago B. A 67 y.o. Male with IBS who spiked a temp of 100.3F this afternoon. Explain your answer
Answer: B. A 67 y.o. Male with IBS who spiked a temp of 100.3F this afternoon. rationale: • 16-year-old: o Dx: meningococcal (acute)—high o Who has had (constant)—low o Temp of 103.8 (expected)—low o Admitted 3 days ago (>24 hours)—low • 67-year-old: o Dx: Irritable bowel syndrome (chronic)—low o Temp spiked (changed)—high o This afternoon (acute)—high TIP: Look at the Dx and modifying phrase components & tally up the low and high priorities per patient
Delegation: #1: Can you leave the restraints off of my dad while I am here and I will call you before I leave?
Answer: No, do not delegate a safety responsibility to a family member Saunders says yes- which is wrong!! The RN cannot delegate to non-hospital caregivers
#1: If you had the following patients, who would be the higher priority? A. COPD B. CHF C. Appendicitis
Appendicitis Acute illness> chronic illness Note: if you use ABCs, your highest priority answer would be COPD and this is wrong
#2: When is pulseless and breathless the lowest priority?
At the scene of an unwitnessed accident - b/c they are likely dead. If you witness the problem, pulseless and breathless are highest priority TIP: It depends on witness vs. not witnessed for breathless/pulseless prioritizing.
Example question: #1: Who is unstable? A. Pt with creatinine of 17.8 B. Pt with potassium of 6.1
B. Pt with potassium of 6.1 This is a D vs. A lab value comparison
Pharm/guessing strategy: #2: If you got a drug that was a heart drug, but you didn't know the side effects. What would you choose: A. Drowsiness B. Tachycardia C. Diarrhea
B. Tachycardia TIP: Pick a side effect in the same body system where the drug is working
#1: Who is the higher priority? A. angina pectoris B. myocardial infarction
B. myocardial infarction
Psych: #1:You have a schizophrenic that is about to stab you. What is the most important thing to do? A. Establish a trusting relationship B. run the other way
B. run the other way -use common sense!
Pharm/guessing strategy: What should you never tell a child that medicine is?
Candy; they will think medicine is candy at home
Nutrition/guessing strategy: What food item should you never pick for children?
Casserole
Pharm/guessing strategy: What is the strategy if you see a drug in a question and you have no idea what it is?
If the drug is po, pick a GI side effect
Staff management: When you get a staff question, what is the second question you should ask yourself?
Is anyone (patient, co-worker, or staff member) in immediate physical or psychological harm?
Staff management: Which answer would you choose? #1: You suspect that a RN is diverting narcotics for private sale and use. 1) tell supervisor 2) confront them and take over immediately 3) at a later date, talk to them about it. 4) ignore it.
Is that illegal? Yes, tell supervisor
Staff management: If no ones' in harm's way, what question should you ask yourself?
Is this behavior legal, not harmful, but simply inappropriate? If yes, what do you pick? If yes → approach them later on and talk to them about the incident; there is no rush
Staff management: #5: You are a LPN and the RN always gives report and says exaspiration instead of exacerbation when referring to COPD. 1) tell supervisor 2) confront them and take over immediately 3) at a later date, talk to them about it. 4) ignore it.
Is this illegal? No. Is anyone being harmed? No. Talk to them later about it.
Staff management: #4: You are a circulating LPN in the OR and you notice the surgeon contaminates the pinky of his left hand. What do you do? 1) tell supervisor 2) confront them and take over immediately 3) at a later date, talk to them about it. 4) ignore it.
Is this illegal? No. Is anyone in harm's way? Yes (the patient) → Confront - tell the surgeon their hand is contaminated and give them a new glove.
Staff management: Which answer would you choose? #2: You are a LPN and walk by the room of an aide who is giving perineal care and the aide is not wearing gloves. 1) tell supervisor 2) confront them and take over immediately 3) at a later date, talk to them about it. 4) ignore it.
Is this illegal? No. Is anyone in harm's way? Yes, the aide - RN should go in and take over. Confront and take over the task.
Staff management: #7: You are an RN and one of your fellow RNs was passing narcotics to a bunch of patients. You notice that he is somewhat incoherent and not as attentive as usual. What would you do?
Is this illegal? Yes Is anyone in harm's way? Yes, the patients 1. Confront 2. Tell the supervisor
Staff management: Which answer would you choose? #3: You are an LPN and notice an RN going home everyday with bulging pockets. 1) tell supervisor 2) confront them and take over immediately 3) at a later date, talk to them about it. 4) ignore it.
Is this illegal? Yes. → tell the supervisor.
Staff management: - When you get a staff question, what is the first question you should ask yourself?
Is what they are doing illegal?
Nutrition/guessing strategy: Preschoolers: How many meals/day are okay for preschoolers?
Leave them alone - one meal a day is okay
Med Sx/guessing strategy: What is the first thing you assess in a med sx situation?
Level of consciousness THEN ABCs
Nutrition/guessing strategy: What is the rule about food and medication for children?
Never mix medication in a child's food
Delegation: Can a UAP give elase ointment?
No Elase is a widely used ointment consisting of a combination of 2 proteolytic enzymes, fibrinolysin and deoxyribonuclease (DNAse). It is said to promote debridement of necrotic and purulent debris from skin ulcers.
Delegation: #4: What if a mother asks the RN to leave the side rail down so she can put it up after bathing the baby? What is the appropriate response?
No, I will stay with you to help you with the bath and when you are finished I will put the side rails up The RN will be in trouble if the mom does not put the side rail up quickly and the baby rolls off the bed
Delegation: Can UAP give nitroglycerin ointment?
No, it is topical, but it is not OTC
Nutrition/guessing strategy: Before you mix medication in anyone's food, what must you ask for?
Permission
Pharm/guessing strategy: If you know what a drug does, but you don't know the side effects, how should you proceed?
Pick a side effect in the same body system where the drug is working
Delegation: #1: In report, the nurse says I think I heard new crackles on the guy in room 52. Who should go assess the patient.. RN or LPN?
RN ; the RN must check this pt b/c there is a new onset/change in s/s
What words are used to describe a patient that is stable vs. unstable? 1. Stable vs. unstable term 2. Type of illness 3. Post-op time frame 4. Type of anesthesia 5. Lab abnormalities 6. Discharge status/ time of admission 7. Assessment status 8. S/S
STABLE Stable chronic Post-op greater than 12 hrs Local or regional anesthesia Level A or B -Ready for discharge -to be discharged -admitted longer than 24 hrs Unchanged assessment (there is nothing new) Experiencing typical s/s of the disease they were dx with UNSTABLE unstable acute Post-op less than 12 hrs General anesthesia in the first 12 hrs Level C or D -newly diagnosed -newly admitted -not ready for discharge -admitted less than 24 hrs ago Changing or changed assessment Experiencing unexpected s/s r/t to the dx [Summary] Unstable vs. stable Assessment & s/s & discharge Anesthesia & post-op U-AA
What will a person with a fever of 105F and up do?
Seize
#1: What do you do if you find 2 patients engaging in sexual intercourse?
Shut the door and give them privacy
#2: What do you do if you find a patient engaging in masturbation?
Shut the door and give them privacy
Pharm/guessing strategy: What is the most commonly tested area in pharmacology?
Side effects
Stable or unstable: angina pectoris
Stable - chronic condition
#2: If someone has kidney stones and they have severe colic pain, are they stable or unstable?
Stable b/c severe colicky pain is an expected s/s of kidney stones
Stable or unstable: angina pectoris crushing substernal chest pain
Stable- this is an expected s/s s of angina
Staff management: If the staff member is engaging in illegal activity, what is the answer that you always choose?
Tell supervisor
Delegation: What responsibilities is the UAP allowed to do?
The RN can delegate ADLs (activities of daily living); however, the UAP should never do the first of any ADLs
Psych/guessing strategy: If you are clueless on psych questions, what is the best answer?
The nurse will examine their own feelings about ___. Why? b/c you won't engage in countertransference (treating the patient a certain way b/c of past experience) Establish a trust relationship Why? b/c if you pick something else, you are communicating that it is not that important to establish a trusting relationship
Delegation: Why can LPN do a lot of things in an extended care facility?
The patients are stable
Nutrition/guessing strategy: What do you know about preschool eating habits?
They eat when they're hungry They may eat one meal per day They may eat the same thing everyday There is no such thing as anorexia nervosa of preschoolers
What is the mistake that most students make when deciding who to prioritize? Explain.
They prioritize based on s/s severity rather than s/s expectedness. If someone has severe pain and someone else has mild pain, alway
Example question: #1: A client has DIC and hemophilia. He is hemorrhaging. Are they unstable or stable?
Unstable - even if it is expected, it is a high priority. Hemorrhaging is always bad even if it is expected. Note: do not confuse hemorrhaging with bleeding.
Stable or unstable: angina not relieved by rest or 3 nitroglycerin
Unstable- the definition of angina is chest pain relieved by rest and nitroglycerin; if it is unrelieved, it is now considered MI which is unstable
#3: If someone has mild pain with a chest x-ray, are they stable or unstable?
Unstable; mild pain with a chest x-ray is not expected. You should have no pain with a chest x-ray.
Nutrition/guessing strategy: When is the guessing strategy for nutrition?
When all else fails, pick chicken - not fried chicken, but baked chicken
Delegation: #3: Can the mother give a 3 y.o. an insulin shot? Is this allowed?
Yes, as long as you document that you taught the parent how to give it; you must document teaching in the chart
Delegation: Can UAP give A & D ointment?
Yes; it is a topical OTC medication A&D ointment: This medication is used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations (e.g., diaper rash, skin burns from radiation therapy).
Delegation: #2: Can a RN delegate to a sitter?
Yes; they are a trained hospital staff member They can only do what the RN teaches them
What are you determining when the question asks you to prioritize between 4 patients?
You are deciding which patient is sickest or healthiest. You need to know which you are looking for - sometimes you need to look for the sickest highest priority or the lowest healthiest priority.
What are the 4 rules of prioritization?
[PRIORITIZATION RULES] 1. acute conditions > chronic conditions 2. Fresh post-op (first 12 hrs) > medical or other surgical 3. Unstable patients> stablepatients 4. Tie breaker rule- *The more vital the organ, the higher the priority. We are talking about the organ of the modifying phrase, not the dx itself. unstable > stable acute> chronic post-op tie breaker
Delegation: What responsibilities should not be delegated to a LPN?
[Summary] IV and Lines -- NO IV start, hang/mix, or push -- NO blood admin -- NO Central lines Care planning -- NO planning -- NO initial teaching Patients -- RN goes first (b/c the first of anything is assessment or making the care plan) -- NO unstable Cannot start an IV Cannot hang or mix IV meds Cannot push IV push meds; they can maintain and document the flow Cannot administer blood or mess with central lines (no flushing central line or change the dressing) Cannot plan care; the LPN can implement care, but the RN does the care plan Cannot perform or develop teaching; LPNs can reinforce teaching Cannot take care of unstable patients Cannot do the first of anything- the RN should do it first b/c the first of anything is assessment or making the care plan
Practice question: Who is the highest priority? a. You have a 23-year-old male with CHF with K+ of 6.6 and no EKG changes. b.Chronic Renal failure with a creatinine of 24.7, and pink, frothy sputum c. Acute Hepatitis with jaundice increased ammonia who you cannot arouse
a. You have a 23-year-old male with CHF (chronic—low) with K (6.6—high), and no EKG changes (constant—low) Organ: Heart (potassium) b.Chronic Renal failure b. Chronic Renal failure (chronic low) with a creatinine of 24.7 (expected—low), and pink, frothy sputum (unexpected—high) Organ: Lung (frothy) c. Acute Hepatitis (acute—high) with jaundice (expected—low), increased ammonia (expected—low) who you cannot arouse (unexpected—high) Organ: Brain (He Wins!!!) Rule #4 (35:34) Tie breaker rule The more vital the organ, the higher the priority. We are talking about the organ of the modifying phrase, not the dx itself. What is the order of organ vitality? 1. Brain 2. Lungs 3. Heart 4. Liver 5. Kidneys 6. Pancreas
Staff management: If someone (patient, co-worker, or staff member) is in immediate physical or psychological harm, how should the nurse respond?
confront them and take over immediately You do not go tell the supervisor b/c delaying in order to tell the supervisor would the patient at risk; you may still need tell the supervisor later, but you need to deal with it right then and there b/c of the immediate danger
What organ can be damaged by hypoglycemia?
brain
Apply ____ _____ before using any rule.
common sense
#1: There has been a disaster in your town and you have to discharge one of the following people to make room for incoming wounded patients. Who would you discharge? → Which type of patient would you look for in the answer choices? A. highest priority client B. lowest priority client
healthiest patient/ lowest priority patient
Delegation: What should NOT be delegated to family members?
safety responsibilities
#2: You receive a report on the following 4 patients. Which patient will you check first when you get out of report? → Which type of patient would you look for in the answer choices? A. highest priority client B. lowest priority client
sickest patient/highest priority
Organ location: Where are the locations of the heart valves?
• The Aortic valve is located in the 2nd intercostal space, right of the sternal border • The Pulmonic valve is located in the 2nd intercostal space, left of the sternal border • The Erb point is rarely asked on the exam o It is located in the 3rd intercostal space, left of the sternal border o Erb point is between the pulmonic and the tricuspid valve • The Tricuspid valve is located in the 4th intercostal space, left of the sternal border Page 90 of 92 • The Mitral valve is located in the 5th intercostal space at the midclavicular line
