SESSION 1 Prioritization Either who is sickest or healthiest. Read closely. (Who to discharge- lowest priority. Who to see first- highest priority.) These have age, gender, diagnosis, and a modifying phrase. Forget the age and gender- they do not affect prioritization. Though dx is important, the modifying factor is the most important in this section. - PT with angina pectoris vs pt with myocardial infarction- you initially think MI is a higher priority. What if it is angina pectoris with unstable BP vs MI with stable vital signs? The angina pectoris now takes higher priority. THIS IS WHY ABC DOESN’T ALWAYS WORK. BREAK TIE WITH MODIFYING PHRASE. RULE 1: ACUTE BEATS CHRONIC (Acute is a higher priority than chronic) - COPD, CHF, Appendicitis- Appendicitis bc Acute (NOT ABCs!) Acute gut higher priority than chronic lung. RULE 2: FRESH POST OP (<12HRS) BEATS MEDICAL OR OTHER SURGICAL - COPD, CHF, Acute Appendicitis, 2 hr post choley, and 2 day post coronary artery bypass graft. Highest priority would be 2 hr post choley bc its within the 12 hours. And a radical neck dissection? Still 2 hr post choley. And a bilateral above the knee amputation? Still 2 hr post choley. Right frontal craniotomy? STILL 2 hr post choley. LESS THAN 12 HRS EXTREMELY UNSTABLE. RULE 3: UNSTABLE BEATS STABLE - Unstable are higher priorities than stable people. Not as simple as it seems. - Stable: use of the word stable (don't overthink/add info!), chronic illness, post-op >12 hrs, local or regional anesthesia, lab abnormalities of A or B level*, phrases ready for discharge- to be discharged- or admitted >24 hrs ago, unchanged assessments, experiencing the typical expected signs and symptoms of the disease with which they were diagnosed. - Unstable: use of the word unstable, acute illness, post-op <12 hrs, general anesthesia (w/in 12 hrs), lab abnormalities of C or D level, phrases not ready for discharge- newly admitted- newly diagnosed- or admitted <24 hrs ago, changing/changed assessments, experiencing unexpected signs and symptoms of the disease with which they were diagnosed. *A- Abnormal (do nothing) *B- Be concerned (assess/monitor) *C- Critical (do something) *D- Deadly/Dangerous (do something NOW) - Don’t always focus on SEVERE/MILD symptoms. A pt with kidney stones is EXPECTED to have severe colic pain, they are stable. MILD pain with a chest x-ray? This pt is unstable because that is NOT EXPECTED. - Test Yourself: Who is higher priority? 16 yo female with meningococcal meningitis who has had a temp of 103.8 since admission 3 days ago OR 67 yo male with IBS who spiked a temp of 103 this afternoon. 16 yo is stable and expected, even though she has an acute diagnosis. 67 is unstable and unexpected, even though his diagnosis is stable, so he is the highest priority. - - 4 things that are ALWAYS UNSTABLE regardless of whether or not it is expected: 1. Hemorrhage (even if expected, unstable- say DIC and Hemophilia- hemorrhaging may be expected but it is STILL unstable even if expected. Also- hemorrhaging high always. Bleeding may be high or low depending on whether or not it is expected). 2. HIGH fever over 105 (even if expected, the pt will begin to seize). 3. Hypoglycemia (Blood glucose of 8- NEVER stable, even if expected. Pt is in trouble). 4. Pulselessness or breathlessness- Pt with Vfib or Asystole- you may expect no pulse, but the patient is not okay! High priority. If a person is pulseless or breathless at the scene of an unwitnessed accident- they become the lowest priority. If witnessed, highest priority. - 3 things that result in a black tag at an unwitnessed accident- Pulselessness, Breathlessness, Fixed and Dilated Pupils (even if they’re breathing and have a pulse). RULE 4: MORE VITAL THE ORGAN, THE HIGHER THE PRIORITY (organ of the modifying phase- use this ONLY as a tie-breaker) - This is talking about the organ of the modifying phrase, not of the diagnosis. Most vital in order: Brain -> Lung -> Heart -> Liver -> Kidney -> Pancreas. Test yourself- Who is highest priority? A. 23 yo male with CHF (low priority bc chronic) with a potassium of 6.6 (now high- level C/D lab) and no EKG changes (lowers his priority, heart not affected yet). HEART B. A chronic renal failure (low bc chronic) with a creatinine of 24.7 (low priority bc A level lab/expected) and pink frothy sputum (now high bc that is not expected). LUNG (modifying phrase, not dx) C. A pt with acute hepatitis (high) with jaundice (low- expected), an increased ammonia (expected) who you cannot arouse (high- not expected). BRAIN (modifying phrase, not dx) - Due to tie-breakers, pt C is the highest priority because the brain is a concern. - Review: Angina Pectoris? Stable because it is chronic. With crushing chest pain? Still stable, expected. Not relieved by rest or 3 nitro? Unstable, it is now MI. - Delegation Do NOT delegate the following tasks to an LPN: Starting an IV, hanging or mixing IV medications, pushing IV push medications. They can not administer blood or mess with central lines (no flushing, usually no dressing change). They are not allowed to plan care (The RN creates the care plan, and the LPN can implement it). They are not allowed to perform or develop teaching, but they can reinforce it). They are not allowed to take care of unstable patients. They are not allowed to do the first of anything (RN should do first with assessment and care plan). Can they do a tube feed? Yes. Can they do the first tube feed after a g-tube placement? No. Can they change post-op dressings? Yes. Can they change the first post-op dressing? No. Can they feed stroke patients? Yes. But they can’t be the first to feed them. Can they ambulate patients? Yes. Should they be the first to get a client out of bed after surgery? No. Can they get vitals? Yes. Should they get the first set of vitals after surgery? No. They are not allowed to do the following - - - - - - assessments: admission, discharge, transfer, or the first assessment after there has been a change (must be RN). What can LPNs do? Maintain the IV and document the flow. They can implement care plans. They can reinforce teaching. Check the expected patients- a client with angina pectoris that has crushing substernal chest pain who was admitted 3 days ago and is on nitroglycerin (LPN) seems severe, but expected. - a pt with a subtotal thyroidectomy 3 days ago who says “Why are they washing elephants in the parking lot?” (RN) possibly Thyroid storm, delirium. Do NOT delegate the following tasks to an Aide/ UAP: Charting- they can chart what they did, but they can’t chart about the patient. So they could say “bed rails raised, bed low, call light given”, but not “pt less anxious today, tolerated ambulation”. UAPs cannot give medications except topical OTC barrier creams. Nitro ointment is topical but not OTC. Neosporin is topical but not a barrier. A&D is an OTC topical barrier cream, so UAPs can apply it. UAPs are not allowed to do assessments except vitals and accuchecks. UAPs are not allowed to do treatments except for enemas. If catheterize seems like the only option, it may be correct but it is generally least preferred. What can UAPs do? UAPs can do ADLs including bed baths, peri care, weights (but not the first!). DO NOT delegate safety responsibilities to the family. Staff Management How do you intervene with inappropriate behavior of staff? There are always 4 answers: Tell a supervisor, confront them and take over immediately, just talk to them at a later date, ignore it. Is what they are doing illegal? Yes- Tell a supervisor. No- is anyone in harm's way? YesConfront immediately and take over. If illegal and harmful- confront first to prevent harm, then supervisor. No one in harm’s way? Is the behavior legal, not harmful, but simply inappropriate? Yes- just talk to them at a later date. NEVER choose to ignore it. Guessing Skills Psych Questions: - If you truly don’t know, the best answer is that the nurse will examine their own feelings about it. This prevents countertransference. - Second best would be to establish a trust relationship- if you don’t choose that, it insinuates that something else is more important than trust (but safety becomes more important- think common sense before these rules). Nutrition: - In a tie, pick chicken. No chicken? Pick fish- but not shellfish. - Never pick casseroles for children- may be nutritious but they won’t eat it. - Never mix meds in children’s foods. If ever mixing for adults, must ask before. - Toddlers- pick finger foods. - Pre-K- leave them alone. 1 meal a day is okay. They eat when they’re hungry. - - - - Pharmacology: - Side effects are most common. - 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. Say you get a GI drug- diarrhea. Cardiac- tachycardia. CNS- Drowsiness. - If you’ve never heard of the drug. If it is PO? Pick a GI side effect. - Never tell a child that medicine is candy. OB - Check the FHT. Med Surg - First thing to assess? LOC- not airway! You’re in a code, you try calling their name/ checking LOC before airway. - First thing you DO? Establish an airway. Pediatrics - Growth and development- They are all based on the principle “give the child more time”- meaning don’t rush it. 1. When in doubt, call it normal. 2. When in doubt, pick the older age (after you narrow down to two)- you give them more time. 3. When in doubt, pick the easier task. Narrow down then pick the easier to give them more time to do the task. General Guessing - Rule out absolutes. There are a few absolutes- never push potassium IV, never give a med to a pt unless you can identify. Rule out absolutes when you lack knowledge. - If two answers say the same thing, they are never correct. - If two answers are opposite, one is probably correct. - The umbrella strategy- which answer is more global? This answer would cover the others without saying it. It is broad, and by doing it, you likely do all of the others. For example- wheelchair safety- get chair close to bed, lock chair, use safety and proper body, or lean in with dominant foot- use safety includes all other correct answers, making it most correct. - When you are given 4 correct answers and you need the highest priority. One patient- which NEEDS are highest? Use the worst consequences game. Take each answer and say “if i didn’t do this, what is the worst that could happen?” The highest priority would include the worse outcome. *Rules are different when prioritizing different patients rather than actions. - When stuck between 2 answers, go back and read the question. Did you miss something? The question is the only way you will figure out the correct answer, not comparing the two answer choices over and over. - Sesame Street Rule- Use when and only when this is your last option. Right answers tend to be different from the others because its the only correct one. Wrong answers are similar. So right is most unique. - - Don’t be tempted to answer a question based on ignorance over knowledge. If you don’t know a term, reread the question without it to see if you missed other important things that help you answer the question. Boards will give you things that you have never heard of to assess your common sense. THIS happens A LOT in your first 10 questions! Don’t answer as a nurse, answer as your aunt with no medical background. What seems the most ambiguous, the most vague, the most clear direct answer? Go with that! STOP going against your gut answer unless you can prove that the other option is superior! Not equal, but must be superior! If you don’t know the correct answer, you do know it. Just use common sense. SESSION 2 Obstetrics Fetal Heart Tones/ L&D Stage 1: - Low Fetal HR (<110) is bad! When you see this, you do LION - (L)eft side, (I)ncrease IV, (O)2, (N)otify the Dr. (And if Pit was running, stop it.) - High Fetal HR (>160) is no big deal. Document it and take mom’s temperature- mom may have a fever but baby is fine. - Low Baseline Variability is bad! The FHR stays the same/ does not change. You also do LION. - (L)eft side, (I)ncrease IV, (O)2, (N)otify the Dr. (And if Pit was running, stop it.) - High Baseline Variability means that the baby's HR is always changing- that is good! Document it. (Think opposite of stable VS in an adult- constant not good!) - Late Decelerations are bad! The HR slows near the end or after a contraction. You do LION. - (L)eft side, (I)ncrease IV, (O)2, (N)otify the Dr. (And if Pit was running, stop it.) - Early Decelerations are fine. The baby’s HR is slowing before a contraction or at the beginning of a contraction. Just document it. - Variable Decelerations are very bad. This is a prolapsed cord. Push, Position. This is the most unique and very bad- that’s why you push the cord and position the pelvis high to reduce pressure. - REVIEW FHT- If it starts with an L it is bad, treat it with LION. If it doesn’t, you’re good and just document, EXCEPT Variable- That is VERY bad. You push and position. - Variable Decelerations (Cord compression) - Early Decelerations (Head compression) - Acceleration/High FHR (Okay) - Late Deceleration (Placental Insufficiency) - If you do not know the answer, choose CHECK FETAL HEART RATE. No matter what happens, this always persists. L&D Stage 2: Delivery of the baby: 1. You deliver the head/cephalic (unless they say breech). 2. Then you suction the mouth, then nose. 3. Check for a nuchal cord (around the neck). 4. Deliver the shoulders and the body. 5. The baby must have an ID band on before it leaves the delivery area. L&D Stage 3: Delivery of the placenta: 1. Make sure the entire placenta is there. 2. Check for a 3 vessel cord. Think AVA (2 Arteries, 1 Vein) L&D Stage 4: Recovery: - First 2 hours after delivery of placenta. 4 things you do, 4x per hr, in 4th stage. 1. Vital Signs: Assess for ss of shock: pressures down, rates up, pale, cold, clammy. 2. Check the fundus: Boggy- massage it. Displaced- have mom urinate/catheterize. 3. Check the pads: Bleeding excessively? She will saturate a pad in 15 minutes or less (we are checking her 4x per hr which is q15m. Change the pad each time. 4. ROLL her over. Check for bleeding underneath her. Not safe to only check pads. Postpartum Assessment: - Usually every 4 hrs or every 8 hrs based on mothers stability. - Breasts - Uterine Fundus: - You want firm and midline. Massage if boggy, urinate/cath if displaced. What is the height of the fundus related to the belly button? Fundal height=day postpartum, choose midline! - Bladder - Bowel - Lochia (Vaginal Drainage): - Rubra (1st): Red. - Serosa (2nd): Pink. - Alba (3rd): White. - 4-6” on a pad per hr okay. Excessive if 1 pad is saturated in 15 minutes. - Should never move from alba back to rubra, indicates a major problem! - Episiotomy (incision) - Hemoglobin/Hematocrit - Extremity Check: - Looking for thrombophlebitis. Check bilateral calf circumference. Don’t do homans, it isn’t as accurate. - Affect (Emotions) - Discomforts - Variations in the Newborn: Know that milia, epstein’s pearls, mongolian spots, Erythema toxicum neonatorum, Telangiectatic nevi - Stork Bites, Nevus flammeus - port wine stain, hemangiomas, - - - - - Cephalohematomas, Caput Succedaneum, and hyperbilirubinemia are all normal- must document! (1st) Telangiectatic nevi, or “Stork Bites” are blanchable pink/red spots. (2nd) Nevus flammeus, or “Port Wine Stains” are red to purple, not elevated, sharply demarcated skin that does not fade or blanch. Cephalohematomas - Swelling caused by bleeding between the osteum and periosteum of the skull. It does not cross suture lines. Caput Succedaneum - (Crosses Sutures/Caput Symmetrical) - Edematous swelling on the scalp caused by pressure during birth. Usually disappears in a few days. Hyperbilirubinemia: Normal, physiologic jaundice - appears after 24 hours of age and disappears at about 1 week of age. Pathologic jaundice - Not normal, is caused by or related to disease. OB Medications Tocolytics: Given to women threatening prematurity and you need to stop labor. - Terbutaline- Can cause maternal tachycardia - Mag Sulfate- You can cause hypermagnesemia if you give too much. So not only do contractions decrease, but also ↓HR, ↓BP, ↓reflexes, ↓RR, ↓LOC. M for - - - Mag lowers BP. - As long as RR above 12, you’re fine to give mag. If lower, mag needs to be lowered. - As long as reflexes are +2, you're fine. If +1, mag needs to be slowed. If +3, mag needs to be sped up. - (Review- 12 and 2 are good, 11 and 1 are bad!) Oxytocics: Stimulate and strengthen labor. - Pitocin- can cause uterine hyperstimulation (contractions longer than 90 seconds or closer than every 2 minutes- if you see that, back off of Pit). - Methergine- causes high BP. it contracts blood vessels and uterusvasoconstriction- increase BP. M for Methergine raises BP. Fetal Lung Maturing Medications: Medications to help fetal lungs mature faster. - Betamethasone- Steroid. This is given to mom. It is given IM. It is given before the baby is born. It can be repeated as long as the baby is still in utero. - Survanta- Surfactant. It is given to the neonate. It is given transtracheal (blown in through the trachea). It is given after the baby is born. Halidol: The only antipsychotic tranquilizer that can be given to pregnant women. FURTHER REVIEW/BASIC FACTS Medication Helps and Hints - - - - - - - - - Humulin 70/30 is a mix of insulin (Insulin R and Insulin N). It is 70% N and 30% R. Take a number and multiply x 0.7 for 70% and 0.3 for 30% ( for 1 unit, you would be giving 0.7 units of N and 0.3 units of R. For 2 units total, you’d be giving 1.4 units of N and 0.6 units of R). Can you mix insulin in the same syringe? Yes. Clear first, then cloudy. You put air in cloudy (N) , air in clear (R) and draw up (R), then draw up cloudy (N). Injections- what needles you use for particular injections - IM: 21 g, 1” (think of IM as 1M and pick the answer with two 1s) - SQ: 25 g, ⅝” ( think of SQ as 5Q and pick the answer with two 5s) Heparin is given IV or SQ. Works immediately. Cannot be given for >3 weeks (except Lovenox). The antidote is Protamine Sulfate. Lab test is PTT. Can be given to pregnant women. Coumadin is given only PO. Takes 2-7 days to work. Can be given forever. The antidote is Vitamin K. Lab test is PT/INR. Can’t be given to pregnant women. Does the diuretic waste K or spare K? If it ends in X, it X’s out K, it wastes it (plus Diuril) Examples include: Chlorothiazide (Diuril), chlorthalidone (Hygroton), hydrochlorothiazide (Esidrix, HydroDiuril, Microzide), bumetanide (Bumex) and furosemide (Lasix). Baclofen, Flexeril: Boards test muscle relaxants as a class. The two side effects are fatigue and muscle weakness. The things to teach include don’t drink, don't drive, don't operate heavy machinery. Pediatric Teaching 0-2yo: Sensoriomotor thinking- totally present oriented, not past or future. You have to teach them while you do it/ what you are doing because they understand the present. Just tell them. 3-6yo: Preoperational- Fantasy oriented, illogical. You cannot reason with them. If they can think it, it can happen. They understand the future and the past. You can teach them shortly before (the morning of, the day of, a few hours before). You teach them what you are going to do (now future tense). You teach them via play. You can play with dolls and show them what will happen the day of. 7-11yo: Concrete operations- Rule oriented, they live and die by the rules. They are rigid. There is no abstract. There is one and only one way to do things, and everything else is wrong. Teach them days ahead, so it isn’t until 7 that you can teach a child a day ahead. They need to be taught what you are going to do as well as skills. A 7-11 year old will do the skill exactly the same every time, because they are rigid. Use age appropriate reading and demonstration. 12-15yo: Formal operations- They can abstract and think about cause and effect. As soon as they reach 12, they can be taught like an adult. 12 year old is the first age that can manage their own care because they can plan accordingly. Principles Regarding How To Take Psych Tests: 1. Make sure you know what phase of the relationship you’re in. 2. 3. 4. 5. 6. 7. 1. 2. 3. 4. - Pre Interaction - Introduction - Orientation Don’t give gifts in psych. Don’t accept gifts in psych. Don’t give advice. Reflect back: “What do you think?” (you can give advice in peds, med surg, etc. but not psych. Don’t give guarantees in psych. Immediacy: If the patient says something, the best answer is the one that keeps the patient talking. “Let's talk about it” Even if appropriate- don’t refer! Concreteness: Don’t use slang. “You feel rotten?” “You should chill out”- They take things very seriously and may think that they are rotting or need to go to the freezer. Empathy- They will not like a nurse who is not empathetic. It shows that the nurse acknowledges that the patient’s feelings are acceptable. How to answer empathy questions Recognize that it is an empathy question. These always have a quote in the question and each answer choice is a quote. Put yourself in the client’s shoes. Read the choices as if you really mean them. Ask yourself “If I said those and really meant them, how would I be feeling?” Go and choose the answer that reflects that feeling or anything close. (Not the answer that reflects their words- Empathy ignores what is said and follows what is felt).
