Lecture twelve- MOC Flashcards
4 rules of prioritization
#1 acute beats chronic; acute is the higher priority #2 fresh postop (12hrs) beats med/other surgical #3 unstable beats stable #4 more vital the organ the higher the priority (the organ in the modifying phrase
unstable pt characteristics
- acute illness
- general anesthesia
- postop <12hrs
- lab abnormalities of c/d lvls
- “not ready for discharge”
- “newly admitted/dx”
- admitted less than 24hrs ago
- changing/changed assessments
- experiencing unexpected s/s of a disease
stable pt characteristics
- chronic illness
- postop >12hrs
- local/regional anesthesia
- lab abnormalities a/b lvl
- “ready for discharge”
- admitted longer than 24hrs ago
- unchanged assessments
- experiencing typical/expected s/s of disease
4 things that are ALWAYS unstable
- hemmorhage
- high fever >105
- hypoglycemia
- pulseless/breathless
three things that result in a black tag in an unwitnessed accident triage
- pulseless
- breathless
- fixed/dilated pupils
organ vitality order
- brain
- lungs
- heart
- liver
- kidneys
- pancreas
what should the rn NOT delegate to the lvn
- starting an IV
- hanging/mixing IV meds
- Pushin IV meds
- blood admin
- central line care
- planning care
- form/dev teaching
- unstable pt care
- the first of ANYTHING
- assessments
- can only maintain ivs*
what should the rn NOT delegate to the UAP
- charting about a pt; they can only chart what they did
- med admin; the can only give barrier topical OTC meds
- assessments; only vitals/accuchecks
- treatments; only enemas
- evaluation
UAPS only
implement
when handling staff ask
- is it illegal
2 is it causing harm - is it just simply inappropriate
heart auscultation APETM
Apical 2nd R Pulmonic 2nd L Erbs point 3rd L Tricuspid 4th L Mitral/Bicuspid 5th midclavicular "try before you buy"
Psych when you have no clue
“the nurse will examine own feelings”
“Establish a trusting relationship”
Nutrition when you have no clue
- chicken
- fish
- no meds in food
Pharm when you have no clue
SE
if you know the drug but dont know the side effects pick the side effect in the same body system!
Never push K+ ___
IV
if you have no idea what the drug is (PO)
choose a GI SE
never tell a child a drug is ___
candy
OB when you have no clue
check FHR
MEDSURG when you have no clue #1 assessment
LOC
MEDSURG when you have no clue #1 intervention
estb an airway
PEDS growth/dev always give the child
more time to grow
PEDS norm, older, easier
Norm- always say its normal when in doubt
Older- if you narrow it down to two ages go with the older
Easier- when in doubt pick the easier task
rule out
absolutes
if two answers say the same thing,
neither is right
if two answers are opposite,
one is probably right
umbrella; look for
the answer that is more global
suspension meds shake well before
giving
sesame street rule LAST RESORT
” 3 of these things belong together on is just not the same” pick the outlier
if there is an answer you’ve never seen before
DONT PICK IT
