05.09 The Nurse Routine

All right, we are going to talk about the nurse routine, and I am really excited about this one because I think it's going to help you tremendously in your career. This isn't just one of those school things, but this is going to help you immensely in your career, so I want you to watch this one, pay attention, and draw what you can from it.

Start your shift right. Set yourself up for success at the beginning of your shift instead of fumbling through when something goes wrong. The first five minutes will determine the rest of your shift. You're going to be there 12, 13, 14 hours, getting those first five minutes right is so crucial to having a great shift. So, we're going to talk about those first five minutes on the floor, and the first five minutes with your patient, and I think that that's going to set you up tremendously for success, all right?

So the first thing you do is the safety check, and what we're talking about here, guys, is when you walk into that patient's room, where do your eyes go? Where do your hands go? What do you say? What do you do? What do you check? All right, so when we're talking right here, I want this to help you understand what to do the second you walk into that patient's room, and we're going to use the mnemonic MADLE, M-A-D-L-E.

When you walk into your next patient's room I want you to think MADLE, monitors, alarms, drips, lines, emergency equipment. Monitors, alarms, drips, lines, emergency equipment. I want you to keep that in mind, and this is going to help you massively when you walk into the room, MADLE.

All right, so the first thing is monitors. Are the monitors working? Are they plugged in? Do they need servicing? When you walk in, one of the first thing to do, I look at my patient, and then my eyes go directly to the monitor, all right?

Notice, on some of these monitors you're going to have a biomed sticker on top of it. On top of each of those there's going to be an expiration date. You need to check that expiration date, make sure it's accurate, and your eyes need to glance directly to this monitor.
Are we getting waveforms? Are those waveforms accurate? Is there an expiration date? Is this monitor going to work for our patient? Okay, this is going to be on your pumps, on your IV machines, on your ventilators, on everything that your ... on your feeding tubes.

Everything that your patient uses, make sure it's on, it's working, it's plugged in, all right? Are things like ventilators plugged into the red outlets? All right, make sure that everything is working as it needs to be working, and that it's plugged in.

All right, then alarms. So, we walk into our patient's room, we look at our patient, we look at our monitors, then we look at our alarms. Every monitor should have an alarm set. This would be for your art lines, for your ventilators, for your EKG rhythms, everything should have an alarm.

What we recommend is we recommend setting the alarm 25% above and below your patient's baseline. So if your patient's normal heart rate is 100 BPMs, beats per minute, I would set an alarm at 125, and I would set an alarm down at 75. That means if my patient goes down to 74 I'm going to hear an alarm, my patient goes up to 126 I'm going to hear an alarm. Your facility may differ a little bit, so make sure you check your facility with that.

Now, think about it, this is when you want to be notified, so you got to use some judgment here. Some people just set their high alarm at 100 and they walk out, but if your patient's heart rate is at 50 baseline, and you're not notified until 100, that could be a big concern. Or do you want to be notified when it's 75, 85? There's a pretty significant jump here to get to 100, so make sure that you use some critical thinking, and you can always adjust these based on what you notice your patient's baselines to be.

But you're going to see those trends when you show up, and your off going nurse should report to you what that patient normally it, so set it base to that. As a new nurse you're going to definitely be seeing these EKG ones, and you need to be setting your alarms based on that.

If you have a COPD patient, we might have a little bit lower O2 set, then we might have it set maybe a little bit lower, maybe at 90 or something, but for a normal patient maybe we have it 92, maybe we have it at 94. So, really use some critical judgment, and make sure you set those alarms right when you get there.

Next I'm going to be looking at my drips, right? So I've looked at my patient, I've looked at my monitors, I've set my alarms, now I'm looking at my drips. Do we have the correct bags hanging, all right? If I'm told that my patient's on 0.9% NS, I walk in the room and they're on 3%, man, I got a problem. I need to get that switched out immediately, or I need to find out if there was an order that changed that.

This happens, okay, I want you guys to know that this happens. Sometimes orders don't get changed. Sometimes nurses hang things without saying that it was hung, or sometimes they forget. So, if you're told, if the orders say the patient should be on .9 NS going at 75 mL’s an hour, you go in there and they're on 3% going at 200, boy, we got a problem coming up quick.

Make sure your pumps are set correctly. If you're told it's 75 and it's at 200, you need to verify that quick. You need to stop it until you notice and find where that order is written, all right? So, do that very, very quickly, especially with your weight based drugs. Make sure that you check those against the pump and against the MAR, and make sure you have the patient's weight available so that you can set it appropriately.

Then you check your bags, okay? If you have Propofol, if you have nitro, if you have other medications that are very, very specific, make sure you check those bags. Make sure it's labeled appropriately. Make sure you have this label on there. Make sure you have this tag on here. A lot of times you'll have a little sticker here on the line as well, make sure that all those lines are clean.

Make sure you pull out the MAR, triple check with the nurse there, especially if you have these drips going like nitro and stuff like that, make sure you have the other nurse there saying this is what it's set at, this is what it's running at, and you both can sit there and verify it. That's really important.

Now lines, this is one of my pet peeves, do not let the other nurse leave until you flush the central line and make sure it's a clean, patent line. Here's why, if your patient has a central line, and the nurse says it's open, it's working just fine, just checked it, they go home, then you go in there three hours later to give a med, and that line's clogged, man, you don't go in there and you don't flush it really hard trying to clean it open, and the last thing you want to do is go and call the provider and say, “Hey, central line's clogged.” “Well, when did that happen?” “I don't know. This is the first time I've used it.” Man, you need to check.

This is one of those CYA things, cover your ass things, but it's also for the patient's safety. We want to make sure they have a clean, patent line in case something happens. Let's say they start to code, you go in there, going to push your drugs, and you can't get access, well, you need to know that as soon as you can. So, go in there, check those lines.

Then you need to check change dates. What does your facility say? How often do you need to change these lines? For maybe an IV, might be every 96 hours. That's going to be based on your facility. For a PICC and a central venous, maybe it's Q7 days. Check with your facility, that should be written and initialed right here on the dressing, all right?

Make sure you're checking this quickly. If you notice that you can't get a line, if you notice the line's late, you need to add that to your to-do list that I need to be changing these, okay? Check lines.

All right, MADLE, now we're on to emergency equipment. M-A-D-L-E, we're on emergency equipment, make sure you have emergency equipment at the bedside. You need to have O2 available, you need to have an ambu bag, and you need to have suctioning equipment available. All these things need to be there.

You also need to make sure you have a Christmas tree. That's what we call these little things here are Christmas trees, because when you turn it the other way it's kind of shaped like a Christmas tree. So, make sure you have those at the bedside, that's so you can give oxygen, you can suction, you can have the ambu bag available if needed.

Even if the patient's trached or intubated, make sure you have that stuff available. Patients can pull those things out, they can stop functioning, so make sure you have them all available.

Make sure you have a crash cart available, and you have suction, clean, in the sterile tubing if you need to, and available to use with your patient. These things should be checked daily by an RN. This stuff is usually by, like, an ICU circulator to make sure it's all working, and functioning, and each drawer has everything it needs to have. There is nothing worse than having a patient code and not having what you need available at the bedside, all right? So, make sure you're doing those things.

Again guys, that is our M-A-D-L-E, MADLE. Make sure you do those things when you walk into your patient's room, that can all be done in just a matter of a couple minutes. So, don't think that this is going to set you back in time. This is going to save you an enormous amount of time, and heartache, and pain, and disaster for your patient, if you do those things right away.

Now we do our head to toe assessment right away. This should be done within the first 30 to 40 minutes of your shift, preferably even earlier. This is one of the first things I would do. I'd walk in there, look at my patient, start talking to them. I'm kind of getting my neuro assessment. As my patient's talking to me I'm doing my MADLE stuff. I'm looking around the room, checking monitors, checking lines.

Now I'm rolling right into my quick head to toe assessment to get my baseline. I want to get the baseline. I want to see, what's my patient at at this moment? What's their skin at? What's their head at? What's their heart rate at? What's everything at right away when I first get there so I know if any slight changes happen.

Now, working on a neuro ICU unit, these changes could happen fast, okay? So I want to know where my patient's at. Even if you work med/surg, even if you work ED, get this baseline as quickly as you can. Compare this to the report. If I get report and I say a patient's alert and orient times three, times four, I walk in there and the patient doesn't have a clue what their name is, doesn't know where they're at, uh oh, I got a problem. Either they just changed in the matter of those five minutes, or I didn't get an appropriate report.

So I'm checking neuro status as I'm just talking to them. I'm looking at their skin as we're talking. I'm feeling pulses when I'm checking name badge and stuff. So I'm getting all these things, I'm listening to heart, I'm listening to lungs, I'm listening to breathing. I'm doing all these things as I'm talking to them. When I'm checking IV sites I'm doing some of this stuff.

Is anything new? What do I need to be concerned about? Does anything need to be intervened with? What's the worst thing that could happen to this patient? What could happen based on where the patient is right now, and what's the worst that could happen?

So, the patient has a big stage four ulcer right here, what's the worst that could happen? Well, that could get worse. That could start oozing out. If my patient has a central line right here, what's the worst that could happen? They could pull it out. Or if my patient ... based on their medical diagnosis, what's the worst thing that could happen? It sounds bad, maybe, but as a nurse we need to be thinking what's the worst that could happen with this patient, okay?

Now I start drawing a mental time tape. I start saying, what's going to happen during this shift? Okay, I've assessed my patient, I've checked for safety, my meds are due at these different times, so procedures are scheduled right here, I know that maybe they have an MRI here, or they're going for surgery here, and I start thinking about these things. Here's all the stuff that I need to do. Here's all the points where I need intervention, or I need somebody to help. Maybe there's a CT scheduled right here.

So I start laying this out. This is what my 12 hours are going to look like with this patient. Does my patient need to be NPO starting here? Do they need to drink their contrast for an x-ray right here? So I start really looking at these things. Are consents signed?

And I start laying all this out in my mind, and I start comparing between different patients. Is it a busy hour? Maybe I have another patient right here who's also got a procedure planned, so maybe I need to do something here with this patient, there with that patient, and you just start kind of laying these things out, and you start planning your care.

Then you start saying where can I cluster things? If these are both meds, I can do all these meds at one time. I can do all these meds at one time. So, this is called creating a time tape, and also clustering your care, and making sure that you can start doing things together.
All right, guys, this is a lot of stuff here. I want you to come back, I want you to think MADLE, I want you to think how do I do my head to toe assessment, and I want you to be thinking about time tape, so you need to develop a routine. You need to say do the same thing every time so that nothing gets missed. If you know how you're doing things, following the MADLE, and having a routine, showing up at the same place, doing the same things, you know when things start to deviate from norm and you can bring it back to the normal.

Then your safety checks, MADLE, machines, monitors, alarms, drips, lines, emergency equipment, head to toe assessment, get a baseline, compare it, start thinking about your concerns, what could go off from my patient? Then you create your time tape, you plan ahead, anticipate needs, and start scheduling your shift out, comparing it to everything that one patient has in these 12 hours, and then what different patients have going on in the same 12 hour time.

Then you really focus on those first five minutes. Those first five minutes mean so much when you're working in a hospital. Have a first successful five minutes, you'll have a successful 12 hours.
All right, guys, that's a lot, but I do want you to come back to this lesson. I want you to come back and use all the resources in this lesson, because as you start working, please, please, I beg you, come back to this lesson and start realizing having a standard routine, doing your safety checks, doing your assessment, and then doing all these different things, is going to help you immensely.

Creating the time tape, doing your head to toe assessment, having a routine, your safety checks, is going to make such a different in your shift. I know you guys can do this. I know you'll be successful. We love you guys. Thanks so much for listening to this, and go out and be your best selves today. Happy nursing.