012 Mark Klimek

The lecture emphasizes the importance of prioritization, delegation, and staff management in nursing exams. Prioritization involves determining the sicker or healthier patient among multiple cases. Rules for prioritization include "acute beats chronic," "fresh post-op beats medical or surgical," and "unstable beats stable." Words indicating stability or instability in patient descriptions are crucial for accurate prioritization. The lecture provides examples and explanations to help understand and apply these principles effectively in nursing practice. Page 54, this is the most important lecture in the whole review. Everyone will get at least 15 questions on this. You'll think this is all your test was, sometimes. Most people just dead guess on these ones. I don't want you dead guessing. And if they don't dead guess, they use ABCs. I don't want to use an ABC in this. So let's talk about how you prioritize. Prioritization, delegation, and staff management. The first skill is prioritization. They will be testing to see how you prioritize four different patients. Number one, you are deciding which patient is sickest or healthiest. Now be sure you know which one you're looking for, because sometimes they have you looking for the sickest, highest priority, and sometimes they have you looking for the lowest, healthiest priority. For example, if they said there's been a disaster in your town and you have to discharge one of the following people to make room for incoming wounded, who would you discharge? Would you be looking for the highest priority client or the lowest priority client? Lowest. But if they said to you, you receive reports on all of the following four patients, which patient will you check first when you get out a report? What would you pick? Highest. So the point is, sometimes you're picking the highest, sometimes you're picking the lowest. Make sure you keep that in your mind, because sometimes you can start out looking for the lowest, and halfway through the question, start looking for the highest. So don't get turned around in the middle of the question. Okay. Exams. Now, four rules for prioritization. That's that. Sorry, that's the right thing to do. Sorry, that's the right thing to do. I just wanted to be more open and transparent, please. What they will do in the answers, the answers will always have four parts. They'll have an age, a gender, a diagnosis, and a modifying phrase. So the answers will always be, a 10-year-old male with hypospadias who's throwing up bile-stained emesis. Well, the age is the age, the gender is the gender, the diagnosis is hypospadias, and the modifying phrase was, who's throwing up bile-stained emesis. You got that? They always have an age, a gender, a diagnosis, and a modifying phrase. Two of those are totally irrelevant, and you do not use them in your answer. Which two are irrelevant? Age and gender. When you're prioritized, completely get rid of the age, completely get rid of the gender. Do you understand, though, in pediatrics, in a pediatric question, you got to pay attention to the age, but in a prioritization question, you don't pay attention to the age, because a two-year-old is not more valuable than a 90-year-old. They're both humans. Do you understand what I'm saying? So age is not a criteria whereby you prioritize. Gender is not a criterion by which you prioritize. Women are not more valuable than men, and men are not more valuable than women. It's irrelevant. Okay, the diagnosis is important, and the modifying phrase is important. Which one is more important? The modifying phrase. The modifying phrase is always more important. So if the patient had... Sorry. I'll get rid of this. Okay, if the patient had angina pectoris versus myocardial infarction. Angina pectoris versus myocardial infarction. Who's the higher priority person? The heart attack, the MI. However, look at this. With unstable BP, with stable vital signs, I added a modifying phrase. See that? Now, who's the higher priority? The angina, because he has what? Unstoppable blood pressure. The myocardial infarction, they told me, was stable because he has stable vital signs. So here we have low priority, high priority, high priority, low priority. We always pay more attention to which one. Modifying phrase, so he's the higher priority, he's the lower priority, regardless of this. Do you see that? That's why you can't use ABC. That's one of the many reasons why you can't. So this person is more stable, this is more unstable. Here's your higher priority, here's your lower. So always break the tie in favor of the modifying phrase. All right? Now let's go to the four rules for prioritization, the four rules. Rule number one, acute beats chronic. Acute beats chronic. What do I mean by beats is, is a higher priority than. In other words, an acutely ill person is a higher priority than a chronically ill person. Now let's look at this, how this works out. If you had the following patients, a COPD, a CHF, and an appendicitis, who would be the higher priority? Exactly, why? Because what are the other two? Chronic illnesses, the appendicitis is acute. If you used ABCs, who would be your highest priority client? COPD and you'd be dead wrong. Are you seeing what I'm talking about? So acutely ill, would you agree with me that an acute gut is a higher priority than a chronic lung? Absolutely. So acute beats chronic, it's not ABC. Okay, next one, rule number two on the next page. Rule number two. Fresh post-op, fresh post-op. Now how fresh would fresh be? How many hours? Twelve. Twelve, not twenty-four, twelve. So any post-op in the first twelve hours is a fresh post-op. Fresh post-op beats medical or other surgical. Fresh post-op beats medical or other surgical. Okay, so what about this? Of those people, who is your highest priority? A COPD-er, a CHF-er, an acute appendicitis, a two-hour post-coli systectomy, and a second to post-op day coronary artery bypass graft. Who's your highest priority? The two-hour post-coli, why? They're a fresh post-op. They're a fresh post-op, and that beats what? Medical and other surgical. What about this? And a radical neck dissection. Who would win? Two-hour post-coli. And a bilateral above-the-knee amputation. Who would win? Two-hour post-coli. And a right frontal craniotomy. Who would win? The two-hour post-coli. What's my point? It doesn't matter how bad the surgery is or how involved the surgery is, if you aren't twelve hours in, you aren't high-risk. You're recovering. That fresh post-op is much more unstable than this guy, no matter what was done. So don't go on all of this stuff. Go on the timeframes. Are you seeing that? Okay. Rule number three. This is my favorite rule. I use it. I didn't use it. I use it. This is the one I use. And that is unstable beats stable. Unstable beats stable. So that means unstable people are a higher priority than stable people. Duh. Who knew that before you went to nursing school? Who knew that in seventh grade? So then why don't you get these questions right all the time if you knew that? Why? Because you don't get them right. Why don't you get them right? You know this, then why don't you get it right? The word stable. Yeah. In the question, there's all these words, and you were never taught what words count for stability and what words count for instability. No school teaches that. I'm going to teach you that right now. It's Peterbilt. I always tell the faculty when faculty meet, we've got to teach the students what stable and unstable means. Oh, we do. We do. No, they don't. In my classes, I listen and they talk in platitudes. You know, if it's life-threatening, it's high. Well, then tell me what's life-threatening, guys. I mean, you can't just be. I need concrete, specific things to look at. So we're going to generate some concrete, specific lists here. Words to look for in an answer. Do you see the two lists? One of them says things that make a patient stable, and the other says things that make a patient unstable. What do I mean by things? Words. Words in an answer or modified phrase that makes a patient either what? Stable or unstable. So you can actually take this to a question and use it, and you'll know what you're talking about. Okay, let's go through the list of things that makes a patient stable. Let's start there. What makes an answer stable? Number one, let's start real easy. Use of the word stable. No, I'm serious. People, I don't know how many people will say, well, it says they're stable, but you know, they could just like, you know, a second later, they could just like decompensate, and they could herniate, and then they could die, and that could happen in seconds. So while it's saying it's stable now, they're really like a ticking time bomb, so I'm going to put them high priority. No! They said they were stable. They're stable. People, don't argue with the fact that they said they were stable. You have to answer it at this moment in time for this patient. If they said this patient was stable right now, what are they? Stable. And if they destabilize in one second, we're not talking about that. Do you understand what I'm saying? We're talking about right now when they're talking about this patient. So let's go across to the other list. Things that make a patient unstable. What do you think number one is there? Use of the word unstable. And don't argue whether you think they would be unstable or not. They said they were. Okay, next. Go back to stable. Go back to the stable column. We're going to bounce back and forth between stable. Do you see what we're going to do here? Okay, stable. One thing that makes a patient stable. Number two, chronic illness. Chronic illness makes you stable. So go to the unstable side. Number two, what makes a patient unstable? Acute illness. What rule is that? That was rule number one, wasn't it? The reason why I like this rule is because it's grandfather's rule number one into it. Okay, go back to the stable side. A phrase that makes you stable. Post-op greater than 12 hours. If the patient is post-op greater than 12 hours, they are stable. So what makes a patient unstable? Post-op less than 12 hours. Now what rule is that? That was rule number two. So I use rule number three because it includes rule number one and rule number six. Okay, go back to something that makes you stable. Go back to the stable. Local or regional anesthesia. If you had a procedure with local or regional anesthesia, you are stable. So what makes you unstable? General anesthesia, but only in the first 12 hours. Go back to stable, things that make you stable. Lab abnormalities of an A or B level. Lab abnormalities of an A or B level. What am I talking about? Remember this morning? If you've got a lab abnormality, yes it's abnormal, but it's an A or a B, guess what the patient is? Stable. Okay, then what makes you unstable? Lab abnormalities of a C or a D. So who's unstable? A client with a creatinine of 17.8 or a client with a potassium of 6.1? Potassium of 6.1, because that's a D versus an A. Right there. Go back to things that make you stable. The phrases, ready for discharge. And don't argue, oh I don't really think they'd be ready for discharge that soon. I really don't think they would be. They said they were, they are. But don't argue it. Okay, ready for discharge. Well, to be discharged, to be discharged, or admitted longer than 24 hours ago. Admitted longer than 24 hours ago. So if the patient has been here longer than 24 hours, we assume they are what? Stable. And don't say, well I don't think it would take that long to stabilize them. They said it. You go with it. So what makes a patient unstable? What phrases? Not ready for discharge. Newly admitted. Newly diagnosed. Or, or what? Admitted less than 24 hours ago. Yes, admitted less than 24 hours ago. Stable. Another one. Stable. Unchanged assessment. Unchanged assessment. Meaning the assessment is unchanged. It's the same as it's been. There's nothing new. Okay, what makes a patient unstable? Changing or change the assessment. There's something new. There's something different. Okay, we're almost done. Go back to stable. This is a long one, so get it down word for word. A patient is stable, don't write it down. A patient is stable if they are, here we go, experiencing the typical expected signs and symptoms of the disease with which they were diagnosed. Experiencing the typical expected signs and symptoms of the disease with which they were diagnosed. A patient is stable if they are experiencing the typical expected signs and symptoms of the disease with which they were diagnosed. Go to unstable. The patient is unstable if they are, and get this down now, experiencing unexpected signs and symptoms. Unexpected. Signs. And. Symptoms. The mistake that most students make when they prioritize patients is they prioritize based on symptoms, severity, rather than symptoms, symptoms expectedness. In other words, if somebody has severe pain and somebody has mild pain, they will always prioritize the severe pain higher than the mild pain. And that's wrong. If somebody has kidney stones and they're having severe colic pain, are they stable or unstable? Stable. Stable, why? Because you expect severe colicky pain with kidney stones. Right, yeah. But somebody's having mild pain with a chest x-ray. Should you have mild pain with a chest x-ray? You should have no pain with a chest x-ray. So who's unstable? The mild pain with the chest x-ray is unstable. The guy with the severe pain with the kidney stone is stable. Did you hear what I'm saying? Okay. Um... All right, let's look at how we apply this. How do we apply this? I want you to tell me who the highest priority patient is here. And I want you to use the rules I taught you, okay? You have a 16-year-old female with meningococcal meningitis. All right? Who has had a temp of 103.8 since admission three days ago? That's your first patient. 16-year-old girl, meningococcal meningitis. She's had a temperature of 103.8 since she was admitted three days ago. The next patient is a 67-year-old male with irritable bowel syndrome who's spiked a temp of 100.3 this afternoon. I want you to talk to your buddy and decide who, on the basis of the rules I gave you, not guessing, but on the basis of the rules I gave you, I want you to cite who is higher priority and why. I don't know what you said, but I would have picked the other one if I would have been in a tent. Now there's a change. One hour. How many would say, what would you guys say, A or B? B. B is the answer. Now, what do we rule out right away here? A. Okay, so we can rule this out. And we can rule that out. Okay, now, meningococcal meningitis, high or low priority? High. High because it's what? Acute. Irritable Bowel Syndrome, high or low? High. Because it's? High. Okay. Now that's our diagnosis. Let's go to our modifying phrase, which are going to be more or less important? More. More important, okay. Who has had? What kind of language is that? Who has had? But what criteria are we talking about in your list there? Unchanged. Who said it? Unchanged. Unchanged. Who has had? Who has had? So automatically that puts her what? Up or down? Down. Down. A temp of 103.8. Now, when you get a symptom, when you get a symptom on these questions, do not look at how bad it is. Look at whether it is what? Expected or not. Remember that? Typical expected. Do you expect kids with, do you expect anybody with meningococcal meningitis to have a fairly high fever? Yes. So is this expected? Yes. So does that make her high or low priority? Low. Low. And to put the nail in the coffin, what phrase comes next? Three days ago. Three days ago. And that puts her what? Never admitted more than 24 hours ago. So she's low. So how many highs does she have? How many lows does she have? Two or three. Two or three. And all the lows are in what area? Modifying phrase. So we're thinking she's what? Low priority. Okay. Who's spiked? Changing. Changing. High. Okay. Temp of 103. How do you deal with that? What do you say to yourself? Is it expected for an IBS? No, not low. Don't say low. I told you it's not severity. Don't be talking high and low. Ask, is it expected for an IBSer, irritable bowel, to have a temp of 100.3? No. Actually, for them it's high. It's not low. 100.3. So that's unexpected. So does that make him high or low priority? High. High. Unexpected. And then to put the nail in the coffin, what did it end with? This afternoon, which means it was new, changed, not been happening. So how many highs does he have? Two or three. How many lows? One. The highs are all in the modifying phrase, who's your higher priority be? Now let me ask you that. Does that make sense to you? Now in real life, I said this was low and this was high. Low priority, high priority. High priority, right? So who could go home? If it's true that this one's low, she can go home, this one's high, he cannot go home. Is that true? Yes. It is absolutely true. Why? If she goes home, do we know what's happening with her? Everything? Yes, we know the symptom, we know why she's got a 103.8, we know what it is, it's been that way, we're going to send her home with a home health referral for what? IV, antibiotics, and she's good to go. She can go home because she's stable. Can I send this guy home? Why can I not send him home? You don't know what's going on. Do you know what this is? It's not that. So what is it? You don't know. Do you know what this is? Yes. Do you know what this is? Yes. Yes, it's a symptom of that. Well, I knew she had that. Tell me something I didn't know. I can't send this guy home. This guy could probably, probably ruptured an ulceration, probably is developing septic peritonitis, and we're just catching his temperature on the way up. If I send him home, he's going to come in dead because he's going to go into septic shock and fade out during the night, and no one knows it. Do you see why this guy, you can't send him home. He may die. This way, you can send home. How many of you would have picked the meningitis an hour ago? How many would have picked the irritable bowel an hour ago? Nobody? Nobody would have picked it? Do you see what I'm saying? But does it make sense? And do you see why it's true? Okay. Do you see where it says always unstable? I want to give you four things that are always unstable regardless of whether it's expected or not. Remember I told you, when you get a symptom, don't qualify how bad it is, but ask is it expected or not? Well, there are four things that, just because they're there, makes you unstable. Number one, hemorrhage. If you are hemorrhaging, even if I expect it, you're unstable, right? For example, if I said a client had DIC and hemophilia, which would be rare, but let's say they did, and I said he's hemorrhaging, I don't want you to say, well, you know, hemorrhaging, I would expect a client with DIC and hemophilia to hemorrhage, so since it's expected, it's low priority. Do you see the absurdity in that? There are certain things that, even if they are expected, are what? Serious. Serious and bad. So hemorrhaging is always bad, even if you expect it. Does that make sense? Now, do not confuse hemorrhaging with bleeding. Those are two different things. Board thinks bleeding, hemorrhaging, you know, so that is, there's a huge difference between bleeding and hemorrhaging. So if you see bleeding, high or low? No, it depends on whether it's expected or not. I gotcha, I gotcha. Hemorrhaging, high or low? High, because it's one of those things. Okay, second one. High fevers over 105. 105 and over. Why? Even if it's expected, what will a person with a fever of 105 and over do? Cease. So that's high priority. Now, what could I have done to this meningitis girl to make her a high priority? Made her temp 105, and then she's there. Okay. Hypoglycemia is the third one, a low blood glucose. A patient has hypoglycemia, their blood glucose is 8. Don't do this. Don't say, well, you know, I would expect a low glucose with hypoglycemia. So an 8 is stable. You see how stupid that is? If you got a low sugar, it doesn't matter if it's expected or not, you are in trouble. Okay, so hemorrhaging, high fever, hypoglycemia. So far they're all H's, right? And the last ones are pulselessness or breathlessness. If you are pulseless or breathless, even if it's expected, you are a high priority. Now, how would that ever happen? Well, could you imagine a question like this? The patient has B-fib, ventricular fibrillation, or A-systole, and you don't get a pulse. High or low priority? High. Well, you know, if they had A-systole, I would expect them not to have a pulse, so they're okay. You see how stupid that is? You can't take this to the absurd. You see what I'm saying? I'm trying to show you where the line is drawn. So, with pulselessness, breathlessness, hypoglycemia, hemorrhaging, and high fevers, what are they? Unstable, regardless of expected or not. But everything else obeys the rule of expectedness or not. Do you understand that? That's the way to go with it. Hey, just a real quick question. When is pulselessness and breathlessness actually the lowest priority? At the scene of an unwitnessed accident. At the scene of an unwitnessed accident. If you find anyone who is pulseless or breathless, guess what? They are what? What did you say? They're dead. They're the lowest priority. But if you witness the problem, who's the highest priority? Pulseless, breathless. So, knowing whether to prioritize pulselessness and breathlessness as highest or lowest depends on witnessed or not. Was it witnessed? Was it not witnessed? By the way, what are the three things that result in a black tag in an accident at an unwitnessed accident? What are the three things that result in a black tag? You know what I mean by a black tag? Tag them black and ship them last at an unwitnessed accident. Pulselessness. Breathlessness. Fixed and dilated pupils. Even if they're breathing and have a pulse. Those are the three things. You can have any one of those. They're black tags at an unwitnessed. And the hardest one is someone who has fixed and dilated pupils who's still breathing. You know, that's the hard one to leave alone. You know what I'm saying? But you've got to go to somebody else. Somebody else needs your help more. Alright, rule number three. No, rule number four on the next page. Rule number four. This is a tiebreaker. This is a tiebreaker. Caution. Only use this as a tiebreaker. I'm trying to be totally honest with you. A lot of times when you use those previous rules you end up with about two or three that could be it. So you need a tiebreaker. The tiebreaker says the more vital the organ the higher the priority. The more vital the organ the higher the priority. Now just a caution here. The organ we're talking about is it the organ of the diagnosis or the organ of the modifying phrase? The organ of the modifying phrase is what we're talking to. When you do your tiebreaker do the tiebreaking with the organ in which the modifying phrase is happening not the diagnosis. The modifying phrase is happening not the diagnosis itself. You got that? Okay, now what I need to give you is the order of organ vitality. So here it is. The most vital organ in your body is your brain. The second most vital organ is your lung. The third most vital is your heart. The fourth is the liver. The next is the kidney. And the next is the pancreas. After that no one agrees. But that's good enough. That'll get you what you need. Brain, lung, heart, liver, kidney, pancreas. In that order. So you have a 23-year-old does that matter? Male. With CHF. High or low priority? Low. Low because it's what? Chronic. With potassium of 6.6. High, why? It's a CD. It's one of those CD levels. Okay? And no EKG changes. What would that do? Increase his priority or lower his priority? Lower. Lower because they're saying at least he's not affected the what yet? The heart. Okay. A chronic renal failure with a creatinine of 24.7. High or low? Low. High or low? It's high. No, I mean high priority, low priority. Oh, low. Why? For two reasons. It's an A-level plus it's expected. And this is really not expected with that. And pink brothy sputum. Why high priority? Is a classic symptom of chronic renal failure pink brothy sputum. So this person is unstable. This guy's unstable but asymptomatic. This guy is unstable and having unstable and having symptoms. So this guy could be beating this guy. We'll see. Alright? A patient with acute hepatitis high or low priority? Acute hepatitis? High. High. With jaundice. High or low? Low. Low. Why? You expect jaundice with hepatitis. An increased ammonia level. Expected. Food is high. Who you cannot around? Expected or unexpected with hepatitis? Unexpected. Unexpected. Okay, so that's it. Unexpected. So that's what? High. So we got an unstable here an unstable here and an unstable there. We got three unstable people, right? Okay. Who's our highest priority? Okay. Potassium. What organ system are we worried about? Heart. So we got a heart. Number one is a heart. Number two we got a what? Lung. No, we don't have a kidney. Lung. We got a lung. Remember you go with the modifying phrase you don't go with the disease. So we got a lung. Right? And then number three we got a what? Liver. Don't say liver, right? We got a brain. Okay. So I go to my tiebreaker. Correct? And who wins? He wins. Are you seeing this? Does that help you? Can you replicate that? Can you actually do that when you go to take the boy? Okay. Does this change some of the ways you might do things? Does it make sense to you why you do it that way? Do you see why it's valid? Just tell me if they're stable or unstable. Angina pectoris. Why? Chronic. Okay. With crushing substernal chest pain. Stable. Because that is expected with angina. Not relieved by rest or free nitroglycerin. Unstable. Because the definition of angina is chest pain relieved by rest and nitro. So if it's unrelieved, it's not angina anymore. It's MI. Now they're not angina. Okay. Does everybody see what I'm saying on that? Okay. Delegation. Do not delegate the following responsibilities to an LPN. An LPN, you're not allowed to assume the following responsibilities if an RN delegates it to you. Now don't yell at me, I didn't write the list. Okay? I'm recording. So don't shoot the messenger. I know that 99% of the hospitals in Ohio don't do this, but this is what the book says. Okay? Do not delegate the following to an LPN. Starting an IV. And you say, but what if they have IV certification? It didn't say they did, so you're not allowed to hang or mix IV meds. They're not allowed to hang or mix IV meds. Number three. Pushing IV push meds. So what can they do in regard to an IV? Maintain. Maintain and document the flow. That's what they can do. D. Do not delegate the following to an LPN. D. They cannot administer blood or mess with central line. They cannot administer blood or mess with central line. So no central line flushing. If I had to go down to the wire on it, I would say they're not allowed to change a central line dressing. But if that was the only thing they could do, you know, I'm going to really seriously not let them do that unless it's the only option. The next one. They're not allowed to plan care. The RN makes the care plan. The LPN can implement it, but the RN does the care plan. The next one, they're not allowed to perform or develop teaching. What they can do is reinforce teaching. What's the difference between performing and reinforcing? Yes. So if somebody needs to talk about their diabetes, who should do the patient teaching regarding diabetes? The RN. But can an LPN reinforce the necessity of doing an Accu-Check to give insulin to a patient? Yes. They're not allowed to take care of unstable patients. So LPNs, that's why you need to know this stable unstable thing, because you're supposed to know what you're allowed to accept and what you're not allowed to accept. You'd have taken the meningococcal meningitis kit, but you wouldn't have been allowed to do that. If you remember that illustration. They're not allowed to do the first of anything. If they're doing the first, I mean, if there's something that's being done for the very first time, who should do the very first? The RNs, because what are they going to do? Assess and care plan. Can they do the first tube feed after a G tube was inserted? No. Can they change post operative dressings? Sure. Should they change the first post op dressing the day of surgery? No. Can they feed stroke patients? Sure. But they shouldn't do the first feeding of the stroke patient after surgery. Should they get the patient out of bed the very first time after surgery? No. Can they take vital signs? Should they take the first set of vital signs after a patient came back from surgery? No. And that's one that nobody ever does. But I do it as an RN. I even have an RN who is a stroke killer. Somebody's waiting for a lawsuit to happen on that one. You won't stand up five minutes before if that happens. Yes? Does adjusting mean that you're allowed to do the first dressing change? That is it. Boards would allow an RN to do that kind of thing. A more assertive kind of thing. And are you with the last one now? They're not allowed to do the following assessments. They're not allowed to do the following assessments. Admission. Discharge. Transfer. Or, the last one is the first one after a change. The first assessment after there has been a change. Who has to do the first assessment after there has been a change? The RN. Because they have to assess, plan the whole thing. So what about this? In a report, a nurse says, I think I heard crackles on that floor. I think he has had them. I think I heard them. Who would be the person that should go assess that person? The RN. Something may have changed. Okay. So who should the LPN check? Who would you send the LPN to check? And LPNs, who would you go check? A patient who has been three days ago and is on nitroglycerin. A patient with a subtotal thyroidectomy two days ago who says, why are they washing elephants in the parking lot? Who should the LPN check? Who should the RN check? A for the LPN. B for the RN. Why B for the RN? What's going on, man? Subtotals, subtotals get? Storm. And what's a symptom of storm? Malaria. It could be that that person's going into storm. We don't know. But the angina with the substernal crushing chest pain in the neck, that's a symptom. But why are they doing that? Why do they always give you the crushing substernal chest pain versus why are elephants in the parking lot? They know that people, including nurses, when they hear crushing substernal chest pain, they go what? But don't go low. It's no big deal. They don't call it an aid. They call it a UAP. Unlicensed assistive personnel. When they talk about a UAP, it's an aid, a test. Here's what they're not allowed to do, charting. Now, they can chart what they did, but they can't chart about the patient. So, call light and reach, bed, bath, give. But they chart patient less anxious today, tolerated, ambulation well. No. Secondly, they're not allowed to give meds. Except for what? What meds can they give? Topical, over-the-counter barrier creams. Aids can independently apply topical, over-the-counter barrier creams. So, can they give nitroglycerin ointments? It's topical, over-the-counter barrier creams. And they can't give meds. They can't give meds over-the-counter. But it's not over-the-counter. Okay, good job. Can they apply Neosporin ointment? Technically what? Because it's what? Not a barrier. You see what I'm saying? What about hydrocortisone cream? Probably not. What about A&E ointment? What about Elay ointment for the skin? H. Sounds like a what? Enzyme. It's probably not over-the-counter. Okay, don't get bogged down on that, because that's the one that least tested different states are somewhat different from each other. Why do I think that's stupid? Why do we delegate the measurement of something called vital signs and AccuCheck, which can go to brain damage? Why do we delegate those two things to each other? I know what's going on. I'm on top of it. Nothing surprises me. Nothing hits me at 6 o'clock when I look at the sheet and I go, oh, my goodness, the blood pressure is 90 and my heart is beating like crazy. I know what's going on. Here's the deal. If somebody comes back from surgery and I do a set of vitals and the vital signs are unchanged from the first day of surgery, I know what's going on. Okay. Enough said on that one. Next thing, they're not allowed to do treatments except for enemas. Figure that out. Doesn't take a rocket scientist. If you can pick any other answer other than catheterize, pick the other answer. But if it would say catheterize the patient, give an IV push medication, intubate the client, and irrigate the T-tube, what would you have them do? Do you see what I'm saying? But if there's one aid on, I know there's one big question on ATI that was talking about what would you let an aid do? And you were between having them empty the bag on an ileal conduit continent pouch and versus somebody or versus evaluating the effects of range of motion. And everybody was freaking out between this emptying this bag they never heard of, let alone, you know, an aid doing it versus range of motion. But that question was not about that. The question was about doing versus evaluating. You see? And people missed it. So look at your verbs, not just verbs. Can they do a med bag? Can they evaluate if no? So sometimes that verb can get you off the hook on that one. All right. Did we cover all that? What an aid is not allowed to do? Well then what is an aid allowed to do? You may delegate ADL, Med Bag and LTN. Why? Who does the first? All right. Now, why in an extended care facility, why are LTNs allowed to do a lot of these things I said that they cannot do? Why could they do them in an extended care facility? What is assumed about the patient clientele and LTN can do many of the things that I said you can't do in those settings. So keep that in mind. All right. Staff management. Turn the page. Do not delegate to the family safety responsibilities. Do not delegate to the family that's on the next page. Safety of the patient. So what do I mean by that? Who's responsible for the safety of the patient? You are. So if a family member says, would you leave the restraints off my dad while I'm here, I'll watch and make sure nothing happens and I'll call you when I leave and you can put the restraints back on and I'll call you when I leave. I'm telling you no. The book is wrong. You cannot delegate safety to a non-hospital caregiver. What about a sitter? Yes, why can you delegate to a sitter? What has to happen for them to do what you teach them to do? So if you decide and the doctor says that the mother can give this three year old kid the insulin shot, okay, can you do it? Yes, as long as you what? Document in the chart that you taught the infant that you would do with any new grad, new hire, on competency for insulin injection. And then you put that in the record and you're good to go. But you can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their ability to do it. You can't just let them do it without documenting teaching and their