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karnicurnc, MSN, APRN, CNS 3,906 Views

Joined Oct 20, '09 - from 'Virginia'. karnicurnc is a Neonatal Clinical Nurse Specialist. She has '19' year(s) of experience and specializes in 'L/D 4 yrs & Level 3 NICU 15 yrs'. Posts: 173 (30% Liked) Likes: 81

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  • Oct 27

    I am a neonatal CNS who graduated in May of last year. My hospital paid for me to go to school as the state requires a CNS in a Level III or higher NICU. I am 1 of 11 CNS's in my hospital (a large teaching/tertiary regional facility) and we are well-utilized in the system. I have received offers from other centers looking for a neonatal CNS, so maybe it depends on what your focus is on. I am lucky to have quite a bit of autonomy in my role, and for that I am grateful. When I went to school I was 1 of 2 neonatal CNS students and our plan of study was a hybrid - taking classes with NNP students and adult CNS students. This year that school opened up a dedicated neonatal CNS track.

  • Oct 26

    I am a neonatal CNS who graduated in May of last year. My hospital paid for me to go to school as the state requires a CNS in a Level III or higher NICU. I am 1 of 11 CNS's in my hospital (a large teaching/tertiary regional facility) and we are well-utilized in the system. I have received offers from other centers looking for a neonatal CNS, so maybe it depends on what your focus is on. I am lucky to have quite a bit of autonomy in my role, and for that I am grateful. When I went to school I was 1 of 2 neonatal CNS students and our plan of study was a hybrid - taking classes with NNP students and adult CNS students. This year that school opened up a dedicated neonatal CNS track.

  • Sep 17

    The healthcare team should stop asking the parents if they want everything done to save their baby. The team should tell the parents that all that can be done is to provide comfort care and let the parents hold. Choices such as coding with chest compressions, bagging, and meds should not be offered. Until the team steps up and offers a humane and dignified scenario, we, the NICU nurses, will have to continue to fight this battle for the babies.

  • Jun 9

    Research has established that the mother's dose of medication does not directly correlate with the severity of the infant's withdrawal symptoms. In other words, if the mother's dose is high, you can not expect that the infant will experience severe symptoms. Conversely, if the mother's dose is low you can not assume the infant will be fine and not experience severe symptoms. See research citation below.

    Pizarro, D., Habli, M., Grier, M., Bombrys, A., Sibai, B., & Livingston, J. (2011). Higher maternal doses of methadone does not increase neonatal abstinence syndrome. Journal of substance abuse treatment, 40(3), 295-298.

  • May 27

    We do not check abd girths as they are useless as stated previously.
    Here are two articles that helped to provide evidence to change our practice from checking residuals to NOT checking them unless there are other signs of feeding intolerance (abd distention and emesis). Residuals alone are not a useful tool and actually lead to increased TPN days, increased central line days (and all inherent risks), increased LOS and costs.
    Dilemmas Surrounding Interpretation of Gastric Residuals in the NICU Setting
    The value of routine evaluation of gastric residuals in very low birth weight infants. - PubMed - NCBI
    I am happy to email the articles directly to you if you are not able to access them.

  • Apr 3

    We encourage consistent breastfeeding if the mother can produce a UDS that is negative for street drugs. Most of these mothers are not able to maintain a supply because they do not visit and therefore breastfeed often enough, so in a few days it becomes a moot point.

  • Dec 29 '15

    I agree, good idea to apply. All they can do is decline to interview, but you will never know if you don't try.
    Good luck!

  • Dec 27 '15

    We do not check abd girths as they are useless as stated previously.
    Here are two articles that helped to provide evidence to change our practice from checking residuals to NOT checking them unless there are other signs of feeding intolerance (abd distention and emesis). Residuals alone are not a useful tool and actually lead to increased TPN days, increased central line days (and all inherent risks), increased LOS and costs.
    Dilemmas Surrounding Interpretation of Gastric Residuals in the NICU Setting
    The value of routine evaluation of gastric residuals in very low birth weight infants. - PubMed - NCBI
    I am happy to email the articles directly to you if you are not able to access them.

  • Dec 26 '15

    I wanted to share our newly developed feeding protocol related to gastric residuals. This is a section taken from our staff education presentation and explains the evidence behind our decision to no longer check residuals.

    • Gastric residuals are a sign of poor gastric emptying and gastro-duodenal hypomotility or reflux common in the preterm infant and thus do not reflect pathology.
    • Gastric residuals are influenced by feeding method (continuous vs. bolus), infant position, and feeding tube placement and size. Continuous feeds compared to bolus feeds increase the rate of gastric emptying. Position can influence gastric residual volume by as much as 25% . Prone or right lateral position following feeds decreases gastric residuals.
    • Current evidence does not support that checking gastric residuals improves care or that gastric residuals are a predictor of NEC, sepsis, or feeding intolerance.
    • Discarding gastric residuals may cause loss of essential gastric enzymes and/or acid and aspirating gastric residuals may damage or irritate the gastric mucosa.
    • Although not statistically significant, in the study by Torrazza et al infants who did not receive evaluation of gastric residuals at every feed reached 150 ml per kg of enteral feeds six days sooner and required central venous access for six less days.
    • Although infants who develop NEC have larger gastric residuals, a volume to guide practice has not been defined. In the study by Cobb there was an overlap between control infants and infants who developed NEC limiting the clinical utility of gastric residuals as a predictor of NEC.
    • Bloody residuals were another marker in the study by Bertino et al but were not a risk factor by themselves.
    • Gastric residuals in the absence of other clinical symptoms should not slow down enteral feeding advancement.

  • Dec 25 '15

    I wanted to share our newly developed feeding protocol related to gastric residuals. This is a section taken from our staff education presentation and explains the evidence behind our decision to no longer check residuals.

    • Gastric residuals are a sign of poor gastric emptying and gastro-duodenal hypomotility or reflux common in the preterm infant and thus do not reflect pathology.
    • Gastric residuals are influenced by feeding method (continuous vs. bolus), infant position, and feeding tube placement and size. Continuous feeds compared to bolus feeds increase the rate of gastric emptying. Position can influence gastric residual volume by as much as 25% . Prone or right lateral position following feeds decreases gastric residuals.
    • Current evidence does not support that checking gastric residuals improves care or that gastric residuals are a predictor of NEC, sepsis, or feeding intolerance.
    • Discarding gastric residuals may cause loss of essential gastric enzymes and/or acid and aspirating gastric residuals may damage or irritate the gastric mucosa.
    • Although not statistically significant, in the study by Torrazza et al infants who did not receive evaluation of gastric residuals at every feed reached 150 ml per kg of enteral feeds six days sooner and required central venous access for six less days.
    • Although infants who develop NEC have larger gastric residuals, a volume to guide practice has not been defined. In the study by Cobb there was an overlap between control infants and infants who developed NEC limiting the clinical utility of gastric residuals as a predictor of NEC.
    • Bloody residuals were another marker in the study by Bertino et al but were not a risk factor by themselves.
    • Gastric residuals in the absence of other clinical symptoms should not slow down enteral feeding advancement.

  • Dec 24 '15

    We have used the Medela warmer for years, but only had 1 per pod of 12 infants, so it was not very useful except for the one person who got to it first for that round of feedings. We have also used warm tap water in Styrofoam cups for years (a horrible practice, I might add.) We will be installing 60 Creche Penguin micro-fridges and individual well warmers in January. There is a fair amount of literature to support banishing the cup of water warming method and to support storing and warming infants feedings in a precise and controlled manner. Eliminating 1 case of surgical NEC per year would pay for the fridges and warmers for a 60 bed unit like ours.
    From the Pediatrix STOP NEC Collaborative: "NEC is also associated with greatly increased healthcare costs, estimated at $200,000 during the 1st year of life."
    References
    Ganapathy V, Hay JW, Kim JH, Lee ML, Rechtman DJ. Long term healthcare costs of infants who survived neonatal necrotizing enterocolitis: a retrospective longitudinal study among infants enrolled in Texas Medicaid. BMC Pediatr. 2013;13:127.
    Bisquera JA, Cooper TR, Berseth CL. Impact of necrotizing enterocolitis on length of stay and hospital charges in very low birth weight infants. Pediatrics. 2002;109:423-428.

    Want to read more about contaminated hospital water?
    "Contamination of Hospital Tap Water
    For 40 years, hospital tap water has been identified as a potential source of nosocomial infections from bacteria and other contaminants including Cryptosporidium parvum,
    Legionelle spp, E Coli and Pseudomonas aeruginosa. 25-29 Patients at high risk of infection due to waterborne pathogens include AIDS patients, organ transplant recipients, oncology patients and neonates. 30 Healthcare-associated infections from
    water supplies have been identified in hospital nurseries. As recently as 2009, 23 strains of Pseudomonas aeruginosa were found in the water supply of a children’s hospital in the US. 31 In another report Buyukyavuz, et al, 26 identified Staphylococcus and Klebsiella pneumoniae in hospital tap water used to heat infant milk. These bacteria were determined to be directly responsible for an outbreak of septicemia in the hospital’s
    neonatal intensive care unit.
    Squier 28 and Angelbeck 30 have explained the process of microbial contamination of hospital tap water. A slime layer or biofilm containing microorganisms adheres to the lumen of pipes and fixtures in municipal and hospital plumbing systems and in hospital water tanks. Patient exposure to waterborne microorganisms can occur through any exposure to tap water including bathing, drinking, contact with medical equipment wet
    with water or health care provider hands rinsed in water. When tap water is used to warm infant feedings, there is potential for contamination of not only the container and the milk but also the nurse’s hands. Squier recommends using dry-warming devices to
    heat fluids that come in contact with patients. In concurrence, the CDC in their 2003 Guideline for Infection Control in Health-Care Facilities, 32 suggested facilities remove sources of contaminated water whenever possible. These guidelines clearly recognize that moist environments and water-based solutions can serve as reservoirs for waterborne microorganisms in hospital settings."
    Reference
    http://www.nicmag.ca/pdf/NIC-25-3-MJ...Supplement.pdf



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