Posted in Med Surg

One of the most useful skills you will utilize as an RN is organization. In fact, if assessment is your King-Daddy skill, then organization is a close second. An organized, orderly room is a much safer (and more pleasant) place to be than a chaotic mess. One of the things I like to do is something I call “idiot-proofing” my patient. This has nothing to do with the intellectual capacity of my patient, but more to do with setting things up so that anyone (ANYONE) could walk into my room and know what’s what. Here are a few things I do to make sure that if someone walked into my room while I was away, they would know what they need to know:

Label label label
When you go into your room to do your initial assessment, take some masking tape and a sharpie with you. You will want to trace each med from the bag, to the pump, to the patient. You will label each IV pump. “But wait,” you say. “Doesn’t the pump display the name of the drug?” Yes, it does…but the scrolling takes several seconds and I don’t have several seconds to stand there and try to figure it out. Just label it. You will also label each IV just above the Y-site. Why there? Because the Y-site is where you will be attaching an IVP or another primary line…so that’s where you’ll want your label.

So, what should you label your lines? It depends. If it’s a drug, that’s easy…label with the name of the drug (insulin, levo, fentanyl, neo, nitro, etc…). If it’s IV fluids that you are also running your piggybacks through, label it “NS w/IVPB” or “LR w/IVPB” whatever…so that anyone walking into your room knows where they can hang your clindamycin or whatever.

If you’ve got a flush line running (more on this in a bit), label it accordingly. The last thing you want is someone to piggyback your antibiotic into a line flushing insulin, for example. I always label my flush lines with the drug they are flushing “Insulin Flush” or “Levo Flush”. That way anyone (even an idiot) knows RIGHT AWAY that this particular line is mixing with insulin or levo at some point and they probably want to steer clear. If you had just labeled this line as “NS”, then chances are someone could easily come along and “help you out” by hanging your Flagyl and piggybacking it in. No bueno.

Clear up compatibility confusion
There is nothing I love more than an IV compatibility conundrum. Oftentimes your patient will have three lumens and 7 or more gtts. This is where things get fancy. Run your IV compatibility report with every IV drug your patient is getting…people will often just run the continuous infusions and forget about the piggybacks. Run those, too…sometimes you’ll be surprised what you can Y-site together (or what you can’t!). Print two copies of this report…one for the bedside and one to put with any patient paperwork (if your facility still uses paper!). If the puzzle is particularly complex, I will write on the report what I have Y-sited together…if they have three lumens, then I’ll label them A, B, C and write out what is running together. For example: A= proposal, levo, fentanyl; B=Lasix, Acyclovir, Cefazolin; C=NS w/ IVPB (disclaimer: please consult a pharmacology reference at your facility before infusing these particular drugs together!).

Along those lines, if you have something that you absolutely DO NOT want to run with anything else EVER…cap off those ports somehow. Cover them with tape and label them DO NOT USE. Remember, we are ‘idiot-proofing’ our patient with the goal that anyone walking into the room would know the score immediately and not have to spend half an hour figuring things out.

Ins/Outs
If your patient has multiple suction canisters, it is a nice idea to label each as well (OGT, ETT, Yankauer, etc…) This way it’s easy to see which should be on intermittent LWS and which should be on continuous. Also, don’t forget to mark the canister level at the end of your shift…if you don’t then the next shift can’t accurately do their I/Os.

As for measuring the intake, this is easy if your patient is NPO and just receiving IV fluids. If they are drinking it gets trickier to keep track. One easy way is to put a piece of masking tape on their water pitcher and just mark off  how many times they empty it. If they are on a strict fluid restriction, then one method is to pre-label the paper cups and put them in the room. For example, let’s say your patient is on a fluid restriction of 1200 mls for 24-hrs. Make sure you account for his antibiotics, and then determine what his PO intake can be…let’s say it’s 900 ml…which is about 4 of those paper cups. Label them #1 of 4, #2 of 4, #3 of 4 and #4 of 4. I’d also put the date on there as well (IDIOT-proof, remember?). This way both the patient AND the next nurse knows how much fluid he can have and help ration it out over the 24-hr period.

Titrating gtts to protocol
Some gtts you will titrate according to a specific protocol. Insulin and heparin are two that come to mind. Do yourself and your buddies a favor, and put a copy of the protocol AT the bedside. This way as you check your blood sugar, you have the information right in front of you and know exactly how to titrate the gtt, without having to walk out of the room to go look at it. We usually tape these to the sides of the IV pumps, but you place anywhere, as long as its accessible.

A word about flush lines
Flush lines are often overlooked and it drives me bonkers! You will want to use a flush line in the following instances:
– you are infusing a drug at a very slow rate (less than 5-10ml/hr)
– you are infusing a drug that you will likely be turning on/off

If you are infusing a drug at a very slow rate, it’s probably not enough to keep the line open. A flush line ensure the line stays open and that the drug you are dripping in is carried in to the patient effectively. The most common drug in this scenario is insulin or maybe a vasopressor that you are weaning off.

If you are infusing something that you will probably be turning on/off, a flush line ensures you don’t have to manually flush and lock the line each and every time you turn the infusion off. Flushing a line that is running a powerful drug is a pain in the neck because in order to do it SAFELY you should withdraw any drug that is sitting in the line, and then flush and lock it. A common drug in this scenario is insulin, heparin, or any vasoactive gtt such as levophed. If your line is persnickety and refuses to allow withdraw, then you are in a pickle, aren’t you? A flush line avoids this and helps keep your line open to boot. (Along those lines, if your line ever acts up and won’t allow blood return, this is a sign you need to TPA it…don’t wait for it to become so sluggish it clots off…no fun!).

I hope these tips help you keep your patients safe and happy regardless of who follows  you or walks into your room to help while you’re off on a much-needed break!

Be safe out there!

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