Basic Usual Routine:
0700-0730 Get report.
0730-0800 Update my boards (name, phone number, doctor, NNP, date, etc.), wipe down/clean my high touch areas (counter, refrigerator, feeding pumps, IV pumps, crib sides or incubator doors and handles, etc.), check my alarms limits (HR, RR, sats), and make sure I have my emergency equipment set up and ready to use (Neopuff, suction) - I do this in each room.
0800-0830 Start my first care time. I usually get my feeding prepared before I start with the baby. Luckily, our unit is pretty good about fortifying breastmilk for the next ~12 hours for the next shift so you have your milk ready. So I will measure out the ordered volume if not ad lib or if ad lib then about what the baby is eating the past couple feeds. I'll throw that in the milk warmer (if it is going to be fed within an hour) and that usually takes about 6-8 minutes. Within that time, I get vital signs (I usually get my blood pressure the first care time so I don't have to the rest of the day if they are stable), do my assessment, check my feeding tube placement, check my line placements (UVC, UAC, PICC, etc.) and/or check my PIV site and flush it if it is only a saline lock, change my pulse oximeter site, change the diaper, reposition, draw any labs needed, complete x-rays, and do my oral cares last (positive reinforcement saved for last). At some point during about this time, the doctor, NNP, and slue (sp?) of students/residents come by to look at the baby. Weigh the baby (when changing the diaper) if it has not already been done and if appropriate, redress the baby. By time I have done that, my feeding is warmed and ready/ready to be hooked up. I either hook it up to the pump and connect it to the baby if they are gavage fed only or have it in a bottle if they are po-ing. Feed the baby and if necessary, gavage the remaining amount that is ordered if they are not ad lib. Feeding them usually takes between 10-15 minutes and then gavage over about the time that you have remaining in 30 minutes or depending upon how much milk/formula you have left to feed. Then I tuck them back in. Then charting, which I usually have between 5-10 minutes to do until my second set of cares.
0830-0900 Second set of cares. Same process as my first set of cares.
0900-0930 Third set of cares. Same process.
Between all of these times, if parents are at the bedside, I encourage them to change the diaper, breastfeed if wanting and baby is able, and/or to hold the baby. Get them set up and move on.
Usually you will have between 2-4 babies so you might have one more or one less care time depending on your assignment. Most commonly though you will have a combination of 3 babies.
Around 0930-1100 is rounds. Usually only takes about 10-15 minutes. So you'll sit through that, review any morning x-rays, labs drawn, etc. and receive your new orders for the day.
If any of them are on respiratory support, I take note of oxygen needs, pressures/volume receiving, means, etc. I also alternate my devices if it is that type of support as in a mask versus prongs. Suction their mouths if they are having a lot of secretions or suction my ETT tube if lung sounds are course. It depends on who you talk to, but some say only suction if indicated and some say to suction every time you reposition because things shift around. The lines get blurred most of the time because when secretions do move around after repositioning, you are more than likely going to have indications to suction anyways. So use nursing judgement.
You will repeat this process 3 or 4 more times for each baby. Three times if the baby is on continuous feeds as breastmilk/formula is only good for 4 hours not refrigerated. Four times for any other feeding variety. Or whenever the baby wakes up if the baby is ad lib demand. Usually the Q3H schedule runs like: 0800, 1100, 1400, 1700 - 0830, 1130, 1430, 1730 - or - 0900, 1200, 1500, 1800. Q4H are usually 0800, 1200, 1600 - 0830, 1230, 1630 - or - 0900, 1300, 1700. For a critical baby, sometimes care times will be every 6 hours to further decrease stimulus at which point care times can really be anytime because you only have to do them twice and more than likely they are NPO if you are doing Q6H cares.
Throughout the day, you'll give meds PO/gavage/IV. Just depends when they are due. We hang new IV fluids/TPN/lipids around 1600-1700. So the evening care times take a little bit longer if you have IVs so I always start 5-10 minutes early if I do. We check our lines/PIV every hour along with accurate intake every hour if we are running fluids so I clear my pumps on the hour. If it is only a saline lock PIV, I just check them every care time with a flush. With running IV's we also weight our diapers.
You might have eye exams, ultrasounds, MRI's, echoes, etc. needing to be completed throughout the day, so things sometimes get shifted around, as in you might complete care times 15 minutes early because they showed up and we woke the baby up and doing cares after, since the baby is already awake and being stimulated, is the most developmentally appropriate. Gavage feedings can wait since you don't need to wake them up to start it.
Usually around the 1700 mark, I begin to restock my rooms for diaper and feeding supplies. I fortify my milk if ordered for the next shift. Finish any charting I may need to do and wait around to give report at 1900.
Rinse and repeat.
Hardest thing to deal with? Death definitely. Always is and always will be. Whether you show it or not, it is definite.
More commonly though? NAS babies, mostly annoying, not just that I can't help them much but that it was caused by the mother. Sort of a touchy subject since the mother may be on methadone or some variety of drug to prevent being on a different street drug or a lot of times for chronic pain. Most feel incredibly guilty, but it is what it is. Furthermore, I do have a hard time with some parents in general. You are caring for the most or one of the most important person in their lives and they don't realize and probably don't care that their baby is not the only baby you care for. I get it, their baby is in the NICU, but many times the parents who call or need you the most are they ones whose babies are the healthiest. Not the critical 23 weekers' parents but the parents of the 36 weekers' who might need a feeding tube. Sometimes, I feel like I lay my eyes more frequently on those babies than the sick ones who I need to be looking at. Those are definitely hard for me. Mentally and physically. I always have a superb bedside manner, but when I'm really working my brain for that 23 weeker and I'm being called every 15 minutes for simple tasks you can perform (i.e. swaddling, putting back to the crib, getting the pacifier), I get a little testy in my brain.
Most fulfilling? Getting to see so many babies go home. That little 23 weeker above becoming one of the healthy kids. Yea, she might be chronic, but off oxygen, eating everything, and going home fairly scot free aside from maybe needing glasses and a little PT/OT. Seeing so many of those babies make it, its incredible, as 10-15 years ago it was not common and 20-30 years ago a lost cause before it began.