Lecture 12 Prioritization, Delegation, Staff Management

LECTURE 12 PRIORITIZATION, DELEGATION, STAFF MANAGEMENT PRIORITIZATION: • testing to see how you prioritize 4 different PT’s • you are deciding which PT is sickest or healthiest! - pay attention to which one you’re being asked for! - ex. if question is asking “Who do you discharge?” ! -> asking for your lowest priority/healthiest client! - ex. “Who would you assess/check first after report?” ! -> the highest priority/sickest client • Priority answers always have 4 parts:! a) age! b) gender! c) a diagnosis! d) a modifying phrase! - ex. a 10 yr. old male with hypospadias who is throwing up ! bile stained emesis! - 2 of these are irrelevant & you don’t need them in ! your answer = age & gender! *** pay attention to age in paediatric teaching but in ! prioritization questions, you don’t! - the modifying phrase is the most important! ** don’t get stuck doing ABC’s 4 Rules for Prioritization: • a) acute beats chronic! - an acutely ill person is a higher priority • b) fresh post-op (12 hrs.) beats medical/other surgical • c) unstable beats stable ! - know the words in a modifying phrase that mean ! stable & unstable! STABLE stable chronic illness post-op greater than 12 hours local or regional anesthesia lab abnormalities of an A or B level “ready for discharge”, “to be discharged”, “admitted longer than 24 hours ago” unchanged assessments PT is experiencing the typical expected S&S of the disease with which they were diagnosed UNSTABLE unstable acute illness post-op less than 12 hours general anesthesia lab abnormalities of a C or D level “not ready for discharge”, “newly admitted”, “newly diagnosed”, “admitted less than 24 hrs. ago” changing/changed assessments PT is experiencing unexpected S&S - don’t mix up symptom severity w/ unexpected symptoms ! (ex. PT w/ kidney stones having severe pain is lower ! priority than PT w/ mild chest pains when having an x-ray! - 4 things that always make you unstable ! (regardless of whether it’s expected or not):! i. hemorrhage (don’t confuse w/ bleeding)! ii. high fevers (over 105) -> risk for seizure! iii. hypoglycemia -> even if it’s a normal value (if ! they say it, it is it)! iv. pulselessness & breathlessness! -> it’s lowest priority only at the scene of a ! unwitnessed accident • 3 things that result in a black tag in an unwitnessed accident: (tag them black & ship them last)! - pulselessness! - breathlessness! - fixed & dilated pupils -> brain death • d) the more vital the organ, the higher the priority! —> only use as a tie breaker! - talking about the organ of the modifying phrase (not ! the diagnosis)! - Order of Organ Vitality:! i. brain! ii. lungs! iii. heart! iv. liver! v. kidney! vi. pancreas! *** after that no one agrees DELEGATION: • DO NOT delegate the following to RPN’s:! a) starting an IV! -> don’t assume they have IV certification ! b) hanging or mixing IV meds! c) pushing IV push meds! ** they can maintain & document IV flow! d) administer blood or mess w/ central lines! -> no flushing! -> if only option is “change central line dressing”, then ! pick that otherwise, they shouldn’t do that either! e) cannot plan care! -> they implement, RN’s plan! f) can’t perform or develop teaching! -> they can reinforce teaching! g) can’t take care of unstable PT’s! h) not allowed to do the first of anything! -> should be the RN (because they can plan)! i) cannot do the following assessments:! - admission! - discharge! - transfer! - the first assessment after there has been a change • DO NOT delegate the following to a nursing aid:! —> they are unlicensed personnel! - no charting! -> though, they can chart what they did but not ! about the PT! - can’t give meds! -> except for topical, OTC barrier creams! - no assessments (except for vitals & accu-checks)! -> for cost reasons! -> watch for words like “evaluating”! - no treatments (except for enema’s)! - be cautious about allowing them to catheterize (if ! that’s the only option, pick that) • Aids can do ADL’s (i.e. bed baths etc.) but shouldn’t do the first of anything • In extended care facilities, RPN’s can many of the things listed that they can’t do because in that setting, the PT population is a generally stable one. • DO NOT DELEGATE TO THE FAMILY SAFETY RESPONSIBILITIES! - the nurse is responsible for that! - you cannot delegate safety to a non-hospital ! caregiver! -> you can to a sitter but they can only do what you ! teach them to do and document that you taught ! them (& their competency)! - ex. If a PT’s family member asks that you remove ! restraints while they are there because they are ! watching them and that you can put them back on ! once they leave -> NO STAFF MANAGEMENT: • How do you intervene w/ inappropriate behavior of staff? (handling your staff when they do stupid things) • There are always 4 answers:! *** the same answers show up all the time! a) tell supervisor! b) confront them and/or take over immediately! c) at a later date just talk to them! d) ignore it —> NEVER the answer (you never ignore ! inappropriate behavior by staff)! - the first 3 could be right or wrong depending on the ! situation so you need to learn how to choose ! between them • When you get a staff question ask yourself: ! a) first -> “Is what they are doing illegal?”! YES = always choose “tell supervisor”! NO = go to the next question! b) “Is anyone (PT or staff) in immediate danger of ! physical or psychological harm?”! YES = “confront immediately &/or take over” (so no ! one gets hurt; “telling supervisor” delays you ! doing something putting others at risk) ! NO = go to next question! c) “Is this behavior legal, not harmful, but simply ! inappropriate?”! YES = “approach later”, no rush! *** if a situation is both illegal & harmful you need to ! confront/do something first & then call supervisor ! (because you don’t want to add more risk for harm ! by delaying) BUT if it’s just illegal, tell supervisor LOCATIONS • point & click questions • abdomen quadrants:! - i.e. what quadrant an organ is located etc. • locations for auscultating the heart valves:! -> you have to know exact spots! - aortic = 2nd intercostal at R sternal border! - pulmonic = 2nd intercostal at L sternal border! - tricuspid = 4th intercostal at L sternal border! - mitral = 5th intercostal at mid-clavicular line (where ! the apical pulse is) • pulses: ! - carotid - femoral - posterior tibial! - radial - popliteal - dorsalis pedis! - brachial TEST TAKING TIPS • expect to do guessing on the test! -> that’s the nature of computer adaptive testing • How do you guess???! a) use your knowledge first!! b) common sense! c) a guessing strategy GUESSING Strategies: (ONLY when you don’t know what’s going on; use knowledge & common sense first!) • Psych Questions:! - the best answer (if you’re totally clueless) is “the ! nurse will examine their own feelings about…”! -> that way you don’t counter-transfer (ex. the PT ! reminds you of your dad & you didn’t like your ! dad so you treat him badly)! - “establish a trust relationship”! -> if you pick something else you’re saying it’s not ! that important to establish trust! -> BUT use common sense first! (ex. if a PT is ! coming at you w/ a knife, safety first duh!) • Nutrition/Food Questions:! - in a tie, pick chicken (obvs. not fried)! - if chicken is not there, pick fish! -> not shellfish! - never pick casseroles for children (won’t eat it)! - never mix medication in children’s food! -> if doing it for an adult, ask permission first! - toddlers = finger-food! -> might not be very healthy but they need stuff that ! they can eat on the run! - preschoolers = leave them alone (one meal a day ! is ok -> they eat when their hungry & usually picky) • Pharmacology:! - the most common area tested is side effects! -> don’t memorize dosages! routes! frequencies!! -> FOCUS ON SIDE EFFECTS = we assess side ! effects, see if things are working (don’t prescribe)! - if you know what a drug does but you don’t ! know the side effects:! -> pick a side effect in the same body system where ! the drug is working! - if you have no clue what the drug is:! -> see if it’s PO & if it is pick a GI side effect! - never tell a child that medicine is candy • OB Questions:! - “check fetal heart rate” • Med-Surge Questions:! - first thing you assess = LOC (not airway)! -> before you do compressions you call out the PT’s ! name/try to wake them up which is LOC! - first thing you do = establish an airway • Pediatric Questions:! - growth & development questions are all based on ! the principle “always give the child more time” (to ! grow & develop, don’t rush it)! -> 3 Rules:! i. when in doubt, call it normal (in med-surge, ! when in doubt, call it abnormal so you don’t ! make safety mistakes)! ii. when in doubt, pick the older age (the older ! age of the 2 that it could be, not the oldest; gives ! more time)! iii. when in doubt, pick the easier task (gives ! more time for the child to learn it) • General guessing skills:! - rule out absolutes ! -> generally not good answers because they don’t ! apply to many situations! -> don’t forget your knowledge & common sense (i.e. ! certain things are absolute like “never push IV K+” ! or doing checks for med. administration)! - if 2 answers say the same thing, neither is right ! - if 2 answers are opposite, one of them is ! probably right! - the umbrella strategy:! -> “which answer is more global”! * ex. certain questions where you want to say “all ! of the above” but that’s not an option -> look for ! an answer that is broad enough that covers all ! the things you need (covers all the other answers)! - if the question gives you 4 right answers & asks ! you to pick the one that is highest priority:! -> different from picking between 4 PT’s; usually the ! question is about 1 PT & you’re picking between ! 4 different needs! -> think “worst consequences” for each option & ! pick the answer that has the worst outcome if you ! don’t pick it! - when you’re stuck between 2 answers, read the ! question (it will have the clue!!) • Sesame Street rule:! - you can use the rule when (& ONLY when) your only ! remaining option is to give up -> WHEN NOTHING ! ELSE WORKS! - “ 3 of these things is not like the other”! - the right answer tends to be different than the others! -> because it is the only one which is correct! -> usually the more unique & different option! - the wrong answers are similar because they share ! something in common! -> they are all wrong • don’t be tempted to answer a question based on your ignorance instead of your knowledge:! - base answers on what you know, not what you don’t know! - if you don’t know something in a question, pull that ! out and focus on the things you do know! - USE COMMON SENSE! boards test obscure things ! to test your common sense • if something really seems right, it probably is! - go w/ your gut!! -> unless you can prove that a different answer is ! superior (not “just as good”) 3 Expectations You’re NOT Allowed to Have: • expectations that are not met breed negativity which badly affects your test taking • a) don’t expect 75 questions! - prepare yourself for 250 questions! - if you get to 200 it doesn’t mean you’re failing (it ! would have shut off earlier if you were) • b) don’t expect to know everything! - because it’s computer adaptive -> it will give you ! stuff you don’t know! - know what everyone else needs to know • c) don’t expect everything to go right! - don’t expect a perfect day ! !