TheMiss 3,258 Views
Joined: Feb 17, '09;
Posts: 48 (42% Liked)
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Thermometers, I mean. These babies act like you're setting them on fire when you put the thermometer in the axillary pocket. I've decided that, from now on, I'd I need to stimulate a baby during a b&d, I'm gonna just poke a thermometer under his arm. Babies are silly.
While I don't agree with the harsh criticism of the other posters in this thread...neither do I agree with the harsh criticism of the OP and his/her post. The OP may genuinely not know what is involved in this specialty. The OP may think that because babies are involved that it must be a piece of cake, or maybe the OP is confusing nursery nursing with NICU.
Though I do agree with two things.
First, the NICU is definitely not easy--I know I can't do it for many reasons. Then again, very few specialities meet the definition of "easy" that the OP is looking for
Second, and I say this to the OP with all kindness: I know you mean well, but let your mother decide what specialty is best for her. I'm sure you'd feel ire if your mom tried to pick out your speciality for you. So let Mom find her own path.
I actually wrote a research paper about the superiority of single rooms for NICU after becoming curious about them when another hospital in town opened up such a unit. All the nurses in my unit were positive it was a horrible idea, doomed to fail, nightmare for the nurses, horrible parents that create roach havens and never leave, you get the idea.
The research I uncovered showed that once nurses actually worked in such a unit, they found they were the preferred way for NICU infants to be managed and the vast majority felt that even intubated vent patients were safely managed in this environment. Other research shows that infants managed in this environment and with good developmental care have a shorter length of stay (compared to same hospital infants also receiving good developmental care).
From a developmental viewpoint, what better way to provide a perfectly individualized developmental environment than with a private room?
To more directly answer the OP's question, I spoke with one of the nurses who works in that unit about moving day. This nurse stated that moving day for them found them with about 40 infants. They used about 60 nurses to quickly move all the infants. There were many extra neonatologists on hand as well as a double complement of RT's. They also called in all the available transport teams to help out. The move itself went flawlessly with that approach.
Knowing what I know now after working in the field (and I don't want to ever be in this situation, believe me), I think my criteria have changed for at what point I'd want my infant resuscitated. It surely wouldn't be at the 23-week mark, and probably really not until about 26-27 weeks. That may sound cruel, but not more cruel than poking and prodding and intubating and oscillating and brain bleeding and even then there are no guarantees? Not to me it isn't. This isn't an indictment of anyone who has chosen/would choose differently, but it feels way more cruel to me to keep a tiny baby alive like that than to just hold them and let them go peacefully.
There is a reason the 23-24 weekers that go on to have no deficits are called miracles....because they don't happen much.
I'm a vanilla NICU nurse.
My twin and I were born at 23 weeks gestation in 1984. We both survived and are completely healthy. My twin unfortunately developed ROP and now is completely blind. She has had her right eye removed due to severe glaucoma and can't see anything out of her left eye. She was in the NICU for the 4 months after birth and sent home with o2, I was in for 3 months after birth. Other than her having the ROP, we are both completely healthy..it's weird actually, I can see scars on both of our wrists from all the ABGs they did in the first few months of life. So think positively...things always turn out okay
My statements might not be well-received, but I firmly believe in them, so here goes...
Many physicians will not tattle on each other unless the circumstances are extenuating, even if a wrongdoing was clearly committed. However, many workplaces cultures encourage nurses to snitch, sell each other out, backbite, and sabotage their coworkers.
In addition, the nursing profession sometimes attracts more than its fair share of people with low self-esteems. Persons who suffer from low self-esteem crave validation and need ego-boosting in order to feel better about themselves. Therefore, we see the two-faced, backstabbing, passive-aggressive behaviors emerge.
Some nurses with low self-esteem get temporary thrills by treating their coworkers like monkey poop. For some reason, their egos are temporarily boosted when they insult their colleagues behind one's back.
You must always remember that a person does not feel the need to be two-faced and passive aggressive toward another human being unless his/her own self esteem is missing something.
One solution is to improve the working environment of bedside nurses. Overworked and underpaid nurses are likely to feel powerless and lash out at each other, so I feel that we would see less hostile behavior if working conditions were improved. Also, bad behavior rolls downhill from management to staff nurses, so I think that every manager needs adequate training on how to boost the morale of the nurses that they manage.
These nurses had to pass the English proficiency exam and NCLEX. Ask them to speak slowly and clearly. If necessary, ask them every time you speak to them. If the patients have a problem understanding them, tell them to call the administrators.
Is your manager difficult to understand? That may be difficult to get around.
Have these nurses been here in the U.S. very long? If so, then they are aware of the language barrier.
BTW - - when I worked in New Orleans, I was told I talked too fast and was asked to slow down!! And I felt they all talked to slowly! And then there were the Cajuns - a language all to themselves, American born and bred, families here longer than mine!
Bearcub - - everything isn't perfect in Canada, either. You will be an unwelcome American to many people there. Best wishes to you, I hope you find the happiness there that has apparently alluded you here.
And weren't most of us from immigrant families only 3-5 generations ago? Only one of my grandparents was born here - how about yours?
This is why I don't have colleagues to my home because you never know what people are going to say once they get back to work. Women have a way of judging each other based on cleaning. I once took care of a 400 gram 23 weeker that circled the drain for my entire 12 hour shift. When my relief came on all she could do was complain about how untidy the area was! Excuse ME I was busy coding an embryo for the last 12 hours. Some times you just have to prioritize.
Even on a vent baby, wouldn't that seem somewhat counter-productive....I realize those are short acting meds, and the baby is vented, but how would you get a good idea of the baby's actual pain status if you're medicating them before you touch?
I am posting to share something with you all, in hopes that you could learn from my growth and in my hope, that I can learn from you as well.
I have taken classes recently, about palliative care practice, read the books, the articles. Watched fellow "senior RN's" all in the hopes of finding a way to grasp the method of withdrawl of support.
I have learned, I guess....the "hard way". As I have grown in this practice, I am becoming known as the "palliative care" nurse by default.
Last year, I had my first loss. A 35 weeker corrected, had been in the NI for about 3 weeks. The shift before mine had put her on low wall suction due to gastric residuals and the beginning of what we all know and hate...NEC. Long, painful story later....she passed away after a good 45 minutes of great efforts to save her...with the parents in the room...on the floor screaming and crying.
That day. I wanted to quit the NICU.
I ended up in a palliative care class about 6 months later, crying the whole time, and found that I may be suffering from some sort of post traumatic stress. It became blatently clear, even more so that I had a problem a week or so after the class. Running the high risk clinic that week, in came "Diana's" mother. "Dear God, maybe she doesnt recognize me" I thought, selfishly. She looked in my eyes, half way between the developmental assessment of her older child, and said "Christine, I know you tried to save her." I started balling, I had to stop and get another nurse because I was just so distraught. 35 weekers are not supposed to die....especially under my hands.
Feeling completely un-proffessional, and heartbroken...I realized that day that I had to do one of two things. Quit, or cope.
So, I chose to cope. I had worked long and hard to become a confident, competent NICU RN, transport nurse, head of parent support, one of the team leaders for high risk....I kept going and going, without really stopping to take care of Christine. I had realized how far I had come, in only a year and a half out of nursing school...however, realized just how far I had come everywhere else but within myself.
I started by forgiving me. I did what I was trained to do, and it didnt work. In the beginning I prayed, and I cried, just trying to figure it all out. I went back and forth with de-briefing counselors, on whether or not I should take care of the really sick ones....but I knew, that if this was the choice, than I would surely have to leave the NICU. I forgave myself for being so hard on me, for being what I considered "selfish".
Once I got this together, I knew the best way to go from here on was to become not only skilled, but emotionally stable too. The way I did this, was by giving parents peace, and calm in the storm.
I now find myself sitting on the parents side when the M.D. gives the aweful news of the head ultrasound, offering them a hand, tissue, and comfort. And when it is decided, I give them all the time they need. I explain everything I am doing, and why. I recently went to the head of neonatology and demanded a morphine drip for continuous sedation during extubation procedures, I encourage skin to skin while the baby is alive, and dressing their tiny ones, bathing them etc.....
Yesterday, 650 gram "Amanda", went to heaven on the chest of her mother. Skin to skin with nothing more than the morphine drip line, a darkened room with a single light on in the corner. The monitors were muted, and I threw a blanket over the red alarm on the top...turning the monitor towards me...the last thing I wanted them to see was the blaring heart rate of 30 and sats of 25.... Before I withdrew the ETT, I shared with the mother how I felt that this was the way any baby should go to heaven...surrounded in the love of her family, held by her mother, her father and in such a way, her face was so relaxed in calm peace and comfort, and how her heart rate had never looked so good...and before removing the ET, cleaned her face gently with baby oil to remove that sticky tape, and asked parents once more if they were ready....wiped the tears from her mothers face, placed my hand on her fathers hand and slowly withdrew the tube....allowing even, this nurse to drop a few tears too. The rest of the family in the background of the room, in silent calm. I realized yesterday, that I had arrived in this place of peace...one that I had been longing for, for such a long time.
It was 5 pm. I never left the family except for the last hour, after baby was wrapped and family was holding, giving the parents quiet, and told them I would be right outside the glass doors if they needed me. The grandmother of the baby, mother of the mother, brought me a water and said to me, holding my hand "you must have been doing this for a long time, you are such a blessing to your profession, to our family, to my daughter, to my first grand-daughter, to the patients that you serve."
"A long time"
Is this not one of the greatest compliments one can recieve from a patient or their family?
I decided to take a few hours PTO time once I had finished up my charting, I rode my bike home, and I thought about my day. I was saddened for this new mother, I thought about how hard she worked to pump the 6 mls of breast milk that I forgot to take out of the breast milk freezer before I went home. I thought about how she came into the hospital, with hope that we would have the expertise and knowledge to save her 25.3 weeker, how she hung upside down for 4 days trying to keep a fully dilated cervix from having any pressure on it, how the father and her had just gotten married.....
I used to tell myself, "its not about you." I excused my placement in the situation of a parent losing their child. I was just the nurse afterall, and most of the nurses I have seen, would not have done the photos, the memory box, the skin to skin...as a matter of fact, babies have been taken off the vent lying in their beds...and to me, none of that made sense...I had grown and found a way for not only the family to go in peace, but to let myself also be in peace...which I now know is so important. Fellow nurses, we are not the center of loss....the babies are not our own children....however we are a part of the process, and once we realize this.....things can change dramatically for not only ourselves but our patients as well. When we see what we do, as giving a gift....then we know that we have come to a very, treasured place in our careers.
I continue to grow each time I experience grief and loss in the NICU. I have found that loss does not always include the death of a baby. I see now, that loss starts the second a baby enters the unit...be it a full term baby for 3 days of antibiotics, or a 25 weeker with a grade 4 bilat hemorrhage.....a loss of the "dream" delivery, the television perfection of birthing balls and swimming newborns, was not given to them....there will be grief and sadness...it is how we, as their nurses handle these emotions, that will make all the difference in their hospital stay.
I hope in some way that my own loss, of the perfect "Real nursing in the NICU" where all the babies live, smile and parents smiling in joy with the hopes of spending the next 4 months traveling 3 times a day with pumped breast milk, half the time missing a feeding because we had to chose which baby to change on the half hour...I hope that this loss has helped you in some way too. Please remember that grief is a profound human experience and grief and loss is not always pulling the ETT.....it is much, much more than that, and yes.....you are part of the circle too.
I look forward to reading your stories and learning from you, how you have handled compassionate support withdrawl, and your ideas on how to make this tough situation, easier for the famalies and the staff.
I pray that you are able to find peace in giving of your compassion...every time you give of you, truly you are giving back to yourself.
When I think about PPHN, it helps me to think about it's other name- persistent fetal circulation- because that really does describe what is going on. In utero, the baby's blood supply comes in through their umbilical vein, up to their right atrium, and the majority goes through the foramen ovale, into the left atrium and out to the body through the ductus arteriosus. After the ductus, the blood circulates out to the body and back to the mother via the umbilical artery. Very little blood flows to the lungs via the pulmonary artery because the pressure in the artery as well as pulmonary vascular resistence is very high. So more simply, the blood comes in, bypasses the lungs, goes out to the body and back out to the placenta- round and round and round. When a baby is in utero, this is no big deal because the placenta does the oxygenating for the baby. This is another reason the pO2 of a fetus is so very low- like 20-25.
PPHN occurs when the baby's body doesn't figure out it has to switch from being a fetus to being a "big kid" now. Normally, with the first few breaths, the pulmonary vascular resistance (higher blood pressure in lungs) goes down, and the systemic vascular resistance (blood pressure in the body) goes up. When the higher blood pressure in the lungs goes down, blood can flow to the lungs easily and be oxygenated there. This change, as well as the raising of the systemic pressure helps close the foramen ovale and ductus arteriosus, so blood flows through the heart in what we think of as a normal pattern- right atrium to right ventricle, out to lungs via pulmonary artery, back to left atrium via pulmonary vein, to left ventricle and out to body via aorta. Several things cause the changes in blood pressure I talked about- the raising of the baby's pO2, the mechanical forces of the first breaths, the loss of certain substances from the placenta, even fluid shifts in the body- all normal processes at birth. When the newborn's body does not undergo this transition- boom! You have PPHN.
Babies in certain situations are more likely to have PPHN- those with hypoplastic lungs, meconium aspiration, hypoxia/asphyxia at birth, sepsis, diaphagmatic hernia all come to mind. This is because there are already factors impairing their oxygenation/ventilation/acid base status, etc, so their normal transition does not occur.
Books will tell you the signs and symptoms of PPHN include cyanosis, tachypnea, low pO2 with normal-ish pCO2, possible cardiac murmur, and often a notable difference in their preductal (right hand) SpO2 and their post ductal (either foot) SpO2. From practice, I can say that these kids are often the term/near term kids that were born through mec, normal appearing for the first few hours. Then they seem to crash and burn, requiring way more O2 per hood or cannula, etc. than you would expect for their GA. Their work of breathing increases significantly and they just look crappy!
Treatment often includes placement of UA/UV for good access and careful BP/ABG monitoring- you often end up with multiple drips (sedation, pressors, etc) to run on these kiddos- as well as intubation and ventilation with an oscillator for oxygenation and to help reduce CO2 retention. Nitric oxide, a pulmonary vasodilator, is often used to help promote relaxation of the pulmonary vessels. Minimal stimulation is recommended, with carefully controlled light/sound and sedation, as a stressed or struggling infant can reverse any progress that is being made in relaxing those vessels. We always treat with antibiotics to rule out any possible septic causes. Occasionally, these infants need ECMO to provide their oxygenation until their own body can adapt to the task- finally switching from fetal to regular newborn circulation.
I hope this makes sense! If it doesn't, please PM me and I'll try to help you. I'm doing a study on PPHN for my NNP program right now, so this is a favorite topic of mine.
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