Unsure of boundaries

NICU_Nurse, BSN, RN · Sep 9, 2003

I'm working night six of a six-night stretch tonight and promise to come back to this tomorrow when I have more time, but I know that in my facility usually if the baby is asymptomatic they'll wait what seems like an awfully long time to transfuse.

What I'd be concerned with is the huffing- was she receiving any supplemental O2 when you had her? (Nasal cannula, etc.?) I would definitely check her blood gases to see where she's at because of the huffing, especially if that was new for her.

When you say she was green, do you mean green all over? I've seen babies who are developing NEC turn green, and it starts in the abdomen and sort of radiates after a while. These babies go bad FAST when that happens, so I'd also have been looking at her feeds- is she being fed? How long has she been eating? How old is she? How much is she getting, and how aggressively have they been increasing the amounts? Etc.

I hope that others with more time available can come answer this, but as I said, I have GOT to get to sleep. :)

Welcome to the boards, BTW! Good luck on nights. I'm with you in spirit.

llg, PhD, RN · Sep 9, 2003

What do the senior members of your nursing staff say? ... your preceptor? charge nurse? unit educator? etc. While a general bulletin board such as this one can give you information about common practices nation-wide, your relationship with your local docs is more location-specific.

Have you established relationships with some of the more experienced nurses in your unit that you can discuss this sort of thing with? If not, that is something you should consider a high priority for your career.

As far as this specific case goes ... I, too, worry about this baby's "huffiing." Exactly what do you mean by that and how long had it been going on? Did this "huffing" represent a change in the patient's condition or had the baby been doing it all along and the docs were well-aware of it? This is the type of information that is crucial to an analysis of the situation.

Also, what exactly about the baby was green? That's not a common term used to describe a baby's color. Baby's are usually described as pink, pale, dusky, cyanotic, blue, jaundiced, etc. ... but green is not a usual skin color (though abdomens often become green after bowel perforation). So ... again, what does this "green" represent -- oxygenation? Are you using the term "green" to signify decreased oxygenation? How long had the baby been green? Does the green color represent a recent change in the baby's condition?

Perhaps "huffing" and "green" are the terms your nursery commonly uses to describe certain phenomena -- so, I don't want to criticize you for using them. But they are not commonly used throughout the neonatal profession. If those terms are not the ones commonly used by your physicians, it would help you to "present your case" to the physicians to use the clearest terms possible to describe the baby's condition and to be sure to communicate all the information that the doc might need, such as the answers to my questions above.

In general, docs don't like to treat things in the middle of night unless there is a change in the baby's condition. The night doc may not be the baby's primary phyisician and he's going to leave the ongoing management of the baby to the baby's primary doc unless there is some change that needs to be addressed for the patient's safety. So unless your assessment findings indicate a significant change in the baby's condition and/or some newly identified threat to the baby, the doc would probably wait until rounds the next day. The "trick" to getting what you want from a doc in the middle of the night is to give them all of the information they need to assess the baby's status -- in particular, what has changed and what seems to be dangerous. Be clear about why you are worried and have concrete evidence whenever possible to back up your concerns, showing them how the baby's condition has deterioted to the point where you are concerned and they need to act.

Good luck with your career! .... and welcome to the world of neonatal nursing! :-)

llg

KRVRN, BSN, RN · Sep 9, 2003

Those values are usually low enough to transfuse even if the baby is asymptomatic. You said the baby's labs were going down all week... that may be why he dismissed you. Was the H/H fairly close to 6/19 the day before?

The huffing... was this new for the baby? If it was new then he was probably starting to be symptommatic and maybe should have been transfused. Was he feeding well (or as well as normal for him)? Tachypneic? My experience is that intermediate feeder/grower types will be allowed to have a lower H/H than more acute babies, esp if they're asymptommatic their retic count is high.

As far as the green color... does he have a high direct bili? I agree also that NEC babies can turn greenish pale colors... did he have any other S/S of sepsis?

lily0004us · Sep 9, 2003

I agree 6.9 hgb is low, but had they checked a retic earlier? If the baby is a STABLE FEEDER GROWER, asymptomatic and the retic is fine, our Docs do not routinely transfuse. Transfusion can suppress the babies ability to make his/her own red cells.

When was the lab drawn? Had the physicians ordered it that evening or was is drawn with A.M. labs the previous morning? If it was ordered that evening, then you had every right to notify the physician, however if it was drawn the previous A.M., they probably already knew about it. Now, had the baby become symptomatic during the night (inc. A/B's, inc. desats, acidotic (with a.m. CBG), etc.), it would have warranted notifying the Doc.

I never felt alone in the NICU. I hope you have resource people around to share thoughts and concerns with. Nightshift can be frustrating especially when you've been fretting over something all night and not getting any response out of the on-call Doc, and all of a sudden dayshift arrives (nurses and Docs), and the ball starts rolling!

Good luck, and remember you're at the bedside to be the patient's caregiver and advocate. If you are truly worried about something, it never hurts to ask. (You can discuss it with your co-workers first.) Frankly, I don't remember the times I've been rebuffed by doctors, but believe me, those times when I thought I should have been more aggressive are permanently etched in my memory!

nicudaynurse · Sep 9, 2003

I agree with everyone else's post. I too have dealt with physicians that react the way yours did. It sometimes seems to depend on what mood he or she is in. If you hadn't notified him about the labs the doc probably would have come in the next day and yelled at anyone who would listen "why wasn't I notified about these labs?", but when you do tell them they don't really seem to care. Doc's can be so confusing sometimes! I think it's funny how different the doc's styles can be. We have one doc who will come in and yell "why are all these babies intubated" and write orders to extubate, pull lines, etc... Some doc's are definitley more conservative than others.

Anyway back to the original subject. Of course it's hard to give you a straight answer without knowing the whole clinical picture. I was concerned with the platelet count myself. I understand all the reasons as to why the H&H can be low and why sometimes it isn't treated, but the platelets being that low seems worrisome (NEC, sepsis, etc...). Has the low platelets been an ongoing problem? Was the differential ok??

Goldenearring1 · Sep 10, 2003

Bear with me as I will try my best to give some more info:

this infant was born at 28 weeks now 30 weeks getting HAL/IL and OG'd q3h with 12cc EPL24 with Fe and on Amino and Fe. Her labs were funky all week with Hgb/Hct going downhill everyday as well as her RBCs and Platelets. To me she looked green all over her head looked green she was not vigorous her bp was low a couple of times the day before on the AM shift but for me her bp was fine, she was a little tachy and the huffing had just started on my shift her temp was good, when I did her heelstick she did not even move, not like the rest of my babies I had for that shift. I have resources on the unit, but I really didn't like the answers that I received. I am very new to this and I am trying to bring the whole clinical picture together not just what one result says. When I gave report to the nurse coming on the shift she says well I guess I will have to start a PIV (she had a PICC). I understand what happens with prematurity and anemia, but I just don't understand why would a doc let an infant needlessly suffer like that, maybe I am still naive to this profession and with time and experience I hope to get better. When I came back that night she was vigorous had pinked-up and looked really different. Thanks for your responses, I am sure that I will be back with more questions.

Melissa

dawngloves, BSN, RN · Sep 10, 2003

HGB/HCT 6.9/19 plat 88 :eek: :chair:

cindylouwho · Sep 10, 2003

where abouts in S.C. are you?