"Never trust a 35 weeker"

[prmenrs]

What in the world does she mean????

I get asked that a lot.

35 week gestation premies (either newly born, or finally after 4-5 weeks of nicu stay) frequently act like they know what they're doing. They stay warm in an open crib, they've learned how to eat, they've even learned to breathe on a regular basis. They're gaining wt., and they're cuter than just about anything on the planet. Mom and dad are bonded, providing care, breastfeeding. (Well, maybe not dad.)

Don't trust them! and try not to let anyone send them home!

In a heartbeat, they can remember that they're only 35 wks, and, by rights, they don't have to know how to do any of the above. They can get cold, have residuals and have apnea of prematurity, get septic, even die.

As long as you remember they're not trustworthy, you won't completely relax around them.

Gompers, dawngloves, krvrn, and all the other experienced nicu nurses--what do you think?

[grlgid]

Wow. You keep them until 40 weeks. That is amazing. Our situation is similar to Gompers. If they are PO feeding well, maintaining temp, and gaining weight consistently then they are out the door and the insurance companies are keeping a watchful eye on their progress and if they meet the criteria then they are asking when are they going home. I've never seen a baby go home on gavage feedings though unless PO feeding was not an option for the baby. I'm not sure at what gestational age we allow them to go home, but I think it is about 35 weeks and sometimes 34 weeks.

That sounds like us for the most part but we have a new policy now where if the baby has met all the discharge criteria but has a "spell" (apnea/bradycardia/desaturation) they have to wait out 7 days before they can go home. If they have one in that time frame the clock reset and they start the countdown all over again.

[prmenrs, RN]

That sounds like us for the most part but we have a new policy now where if the baby has met all the discharge criteria but has a "spell" (apnea/bradycardia/desaturation) they have to wait out 7 days before they can go home. If they have one in that time frame the clock reset and they start the countdown all over again.

Seems like they need to go back on Caffeine and go home on a monitor.

[Music in My Heart]

Great thread and right on the money with that tag line, prmenrs. I'm planning to appropriate it as my own once I make it to the NICU.

I actually have a great example on video. My daughter was a 27 weeker. By 36 weeks, she was just cruising along, looking cute, eating, growing...A-OK.

One day my wife and I are in there with the video camera, chatting, relaxing, thinking all is grand. In the background, you start to hear one beep louder than all the others. Next thing you see is the nurse's hand come into the scene to stroke her back and remind her that she does need to breathe.

It was a good wake-up call for us before we brought her home.

Boy did I have a love/hate relationship with that O2 saturation monitor.

[viccar82]

I have to say I haven't been in the NICU long enough to experience a whole lot of feeder/growers getting really sick and coding . . . however what I find a little surprising, we do not admit 35 weekers unless there is another issue. As a standard 35 weeks + does not buy them an automatic ticket into our unit. It is likely because we are filled with 24/25 weekers, d-hernias, NEC, surgical, etc babies that we often do not have room for a 35 weekers who appears to be doing well just after delivery. However, hearing others stories I just wonder about those little 35 weekers who are sent to newborn nursery because we just don't have the room for them.

[RainDreamer, BSN, RN]

I have to say I haven't been in the NICU long enough to experience a whole lot of feeder/growers getting really sick and coding . . . however what I find a little surprising, we do not admit 35 weekers unless there is another issue. As a standard 35 weeks + does not buy them an automatic ticket into our unit. It is likely because we are filled with 24/25 weekers, d-hernias, NEC, surgical, etc babies that we often do not have room for a 35 weekers who appears to be doing well just after delivery. However, hearing others stories I just wonder about those little 35 weekers who are sent to newborn nursery because we just don't have the room for them.

We don't routinely admit 35 weekers either. Even 33-34 weekers. If they're big enough and have no respiratory issues, then they're usually sent to the continuing care nursery. They do keep a close watch on them though and will keep them until they are ready to go home.

[elizabells, BSN, RN]

We've recently had a spell of 34-weekers getting sent to WELLBABY. Can't wait for that to bite us in the backside.

Uch, we do that too, as long as they make weight. I mean, come on, the kid came out early for a REASON, let's figure out what that is before we send them off to either a) mom's room, where they may get checked on once every few hours or b) WBN, where you've got one nurse for twenty babies, and they aren't even on monitors. Great plan.

NB: Not knocking WBN nurses AT ALL, that's just a lot of kids to keep track of. I could never do it; I'd go mad. I like my 1-3 patients, thanks very much.

[Elvish, BSN, DNP, RN, NP]

Oh, I completely agree with you, elizabells. No offense taken at all!

Last night at the end of my shift, I (along with two other nurses) had 31 babies to keep track of, ON TOP OF two withdrawing methadone kids (one consistently scoring 16-22), a 35-wk feeder-grower, a bilibed kid, and a kid whose mom is in ICU after almost bleeding to death during her c/s (undxed HELLP). If they'd tried to send a 34-weeker in on top of all that, I would have been, um, less than thrilled.

I know NICU can get very hairy, but when I do go over there, I'm always amazed at the lack of chaos that seems to reign in my corner of the woods.

[RainDreamer, BSN, RN]

Right after I graduated I started working in a well-baby nursery ..... we didn't do couplet care, so no moms, just babies. Normally we'd have 6-8 babies. I'd get frustrated when I'd call NICU for a grunting baby or a baby with constant hypoglycemia ..... and they'd treat us like incompetent idiots! I wasn't totally stupid and incapable of watching a baby through transition, but please take into consideration that I have all these other babies that need my attention too, so I don't have time to focus on a baby that needs closer monitoring.

Needless to say, I ended up leaving that place. The place I'm at now, I think we do a pretty good job at bringing babies up to the unit that need closer monitoring. When I go over to look at a baby for them, I just feel more comfortable bringing the kid up to the unit ..... a lot of times they just need a bit more time transitioning, but I feel safer in having them on a monitor and on the unit where we can watch them closer.

Well-baby nursery is incredibly chaotic, I totally agree Arwen! Of course I still have some nights in the NICU where it's crazy and the unit is a busy place. But I NEVER in my life ran my butt off more than when I worked in well-baby. A few weeks ago I had to float to couplet care ..... I got a 20 minute lunch break for that entire shift ..... reminded me of those old days, whew!

[Jolie, BSN]

echomoon,

I appreciate your post more than you'll ever know. The last place I worked had a group of "renowned" perinatologists who all seemed to forget that the goal of pregnancy is a healthy mother and baby. Their answer to everything was to deliver IMMEDIATELY.

I'm not talking about moms with life-threatening conditions like HELLP syndrome, or babies with TTTS. I'm talking about moms with multiples who were "not expected" to carry to term (not allowed to try, either) babies with a single U/S showing delayed growth, one mom was recommended to have a section at 32 weeks because her older children had genetic abnormalities. HUH? Thank goodness she was smart enough to refuse, because when she delivered spontaneously at 37 weeks, her daughter experienced mild RDS. How bad do you think it would have been 5 weeks earlier?

It just seemed to me that these people completely lost sight of the second patient.

[elizabells, BSN, RN]

I went to a conference a few months ago that had a lecture on the near-term infant... I'll see if I can dig up the notes. Basically the hope is to make purely elective c/s prior to 39wks a "never event". The problem is that the OBs who allow/encourage this to happen don't have to deal with the consequences. As one said to the group "My expertise ends at the five minute APGAR". Apparently, for some, their sense of responsibility does too.

[preemieRNkate, RN]

So I've been taking care of the dreaded 35 weeker for the past couple of days. You all know, the kid born at a community level I hospital that comes out and then starts grunting and acting all silly. Came to us, and wound up intubated with a big ol' pneumo. Bought himself some chest tubes and he's got some mild PPHN. He's on HFJV, weaned off of INO today. He's starting to make the turn-around (I pray!) to getting better. I totally thought of this thread when I talked to the parents the other day. I told them that I don't fear admitting a baby born at 24 weeks, cause I know (more or less) what to expect- intubated, on a vent, probably with pressors, blood transfusions, etc. It's the 35 weeker with some "mild" RDS coming in on a transport from a community hospital that I fear. The ambulance ride could cure them, or they will wind up needing everything we've got. Oh, and of course, they are THE nicest people around. Although these kids are scary at times, they are my favorite to take care of. The micropreemies are exciting to me at first, but it's the kids that I can take care of for a week or so and I can see them go from death's door to almost out the door that I really like. Cross your fingers for this little guy (and for his nurses!). Oh, and NEVER TRUST A 35 WEEKER!!!

[prmenrs, RN]

We've had a supposedly 36+6 weeker for a week or so. He's an IDM. Had problems initially and needed respiratory support, umbi lines, then bili lights. Now he's just a poor feeder, but the monitor shows periodic breathing w/HR and Sat dips.

In other words, he ACTS like a 35 weeker! Which goes right along w/the IDM bit. He worries me some, cuz I haven't quite convinced the neo that he acts so immature.