attn: experienced NICU RNs---

[prmenrs]

Like Bortaz, NICUGal, babyRN, etc.

We are in need of a current "Day in the Life" thread. The stickies are so old, they don't work because they rewrote the code (or something techy like that).

If any of you feel so inclined, I would really appreciate your help!

[Bortaz, MSN, RN]

With a sick/premature baby, you can add:

*Management of ventilators (Conventional, High Freq Jet, Oscillator) and other respiratory equipment, which with a sick/preemie can be a constant, every couple of minutes chore. If the baby is really sick/acting up, you can expect frequent CBG/ABGs and ventilator setting changes.

* Management and titration of 6-10 drips (Dopamine, Dobutrex, Fentanyl, Versed, TPN, Lipids, etc). With a central line, God bless you if it's your day to change out all the tubing setups. Sterile procedure that can be quite a chore when there are many drips.

* If things go south, coding of the infant. For less severe cases, frequent rescue of the infant that is about to code. Bagging/Neopuff/Manual Vent Breaths/Titration of O2.

* Suctioning of infant's ETT, oral, nasal, etc. Q1 hour vital signs. If parents involved and present (and if baby stable) encouraging kangaroo care/parental participation. Q whatever-hour position change of infant, as tolerated.

* Education of the parents, and more frequently, correcting the information they found on Google.

* Caloric or Trophic feeding protocols. Checking for residuals/distention of abdomen/other signs of NEC. (I abhor NEC!)

* Medications galore! Lasix, Vanco, Gent, Ampicillin, the list goes on and on and on.

* Being a guardian of your baby, protecting him/her from other staff and the baby's parents. I am known as the guy that won't let just anyone touch my infant without an explanation of what they're doing and why they are doing it.

*Strict I/O recording.

*Maintaining minimum stimulation.

*Blood transfusions.

*Radiology, quite frequently. Being a Nazi in enforcing the use of gonadal shields...why must I ALWAYS have to enforce this? Just DO IT! Grr... (Pet peeve, sorry)

*Maintenance/observation of central lines/PICCs/Umbilical lines. Infiltration? Catheter toes? Fluid compatibility? I'm always surprised by how many nurses think their PICC line is ok, just because there's no swelling at the site of insertion!

*Lots of labs to be drawn, frequently through an art line. (Here, only the nurses draw the art line draws...capillary sticks are done by RT/Lab).

*If the worst happens, and your baby dies, you have to do post-mortem care. This is where we get down to brass tacks, and you learn whether you're really cut out to be a NICU nurse. Dealing with the family is hard, for me, but nothing is harder than bathing that dead baby, cutting off that lock of hair, wrapping that precious child in that shroud, and placing the sweet baby into the refrigerator in the morgue.

I could go on for hours, because sometimes it seems an endless list of tasks to be completed. I can tell you, I've had one-baby assignments that have worn me out, physically and mentally, far worse than an 8 pt adult M/S assignment would have.

I started in the NICU straight out of school, knew nothing when I walked in the door. If you're like me, as a new NICU nurse you'll spend many, many hours outside of work, reading books and the internet, teaching yourself about NICU patients. 4 years in, I still spend a lot of time studying, reading up on new stuff or learning the latest/greatest new things.

I am one of those NICU nurses that truly feels that this job is NOT for everyone. I always hate it when I ask new nurses to our unit, why they wanted to work in NICU, and they respond "I heard it was easier, and I'm tired of heavy med surg assignments!" I want to make those nurses leave my unit immediately...That is the WRONG answer.

Also, this might not be the unit for you if you dream of snuggling cute little pixies. The NICU can be an ugly, ugly place. You will likely see things that horrify you. You will likely have your ethics challenged. You WILL have your heart broken. I'm a big old gnarly dude with many years of law enforcement experience, and I will freely admit I've shed some tears on the drive home...tears of frustration, tears of grief, and tears of joy.

Having said that: I'll never do anything else, as long as I have a choice. This job has changed my life, and I have made lifelong friends here. When you see a former preemie at Wal-Mart, and the parents hug you and thank you for saving their baby's life, or when you get the invitation to that former 24 weeker's 1st, 2nd, 3rd birthday...well, it's a point of pride that your hard work, dedication, and compassion made that birthday possible. I have parents that bring my former babies back to the unit regularly, to see me. It makes my day.

It's the best job I've ever had.l hope you all (especially you new nurses) benefit from the information in this thread, and I pray that you all do your best, work with compassion, and become outstanding NICU nurses.

[prmenrs, RN]

Thank you, Mr. B!

[prmenrs, RN]

There is a former pt. I follow on FB--s/he took @ least 10 yrs off my life and scared the crap outta me a LOT. But s/he's an awesome teenager now w/a great family. Warms my heart to see him/her grow.

[Bortaz, MSN, RN]

Keeping late hours, prmenrs? :)

[MegginJ]

With a sick/premature baby, you can add:

*If the worst happens, and your baby dies, you have to do post-mortem care. This is where we get down to brass tacks, and you learn whether you're really cut out to be a NICU nurse. Dealing with the family is hard, for me, but nothing is harder than bathing that dead baby, cutting off that lock of hair, wrapping that precious child in that shroud, and placing the sweet baby into the refrigerator in the morgue.

I could go on for hours, because sometimes it seems an endless list of tasks to be completed. I can tell you, I've had one-baby assignments that have worn me out, physically and mentally, far worse than an 8 pt adult M/S assignment would have.

I started in the NICU straight out of school, knew nothing when I walked in the door. If you're like me, as a new NICU nurse you'll spend many, many hours outside of work, reading books and the internet, teaching yourself about NICU patients. 4 years in, I still spend a lot of time studying, reading up on new stuff or learning the latest/greatest new things.

I am one of those NICU nurses that truly feels that this job is NOT for everyone. I always hate it when I ask new nurses to our unit, why they wanted to work in NICU, and they respond "I heard it was easier, and I'm tired of heavy med surg assignments!" I want to make those nurses leave my unit immediately...That is the WRONG answer.

It's the best job I've ever had.l hope you all (especially you new nurses) benefit from the information in this thread, and I pray that you all do your best, work with compassion, and become outstanding NICU nurses.

Thank you Bortaz for showing us some of the heartbreaking moments. The only NICU experience that I have is my baby being in there, I didn't know that the nurses had to do that part of it. At least now I can be more prepared mentally. I loved all of my NICU nurses, they were always very nice and I felt good knowing they were taking care of my baby for me. My experience is what made me want to go to school for nursing (I was 18), I swore I would never want to work in that stressful place with someone else's baby in my hands, but here I am! Call me crazy but I just feel like that's where I belong, like I'm being pulled toward the NICU. Lord help me!

[MegginJ]

I was 18** where did that smiley face even come from? Lol oops...

[prmenrs, RN]

Keeping late hours, prmenrs? :)

I think we're in different time zones, Bortaz! But, yes, I do wake up in the middle of the night and 'surf'. Not as bad as some other things I could do @ such hours....

[aerorunner80, ADN, BSN, MSN, APRN]

I wish there were a simple "day in the life". There are so many variables. You could start off your day with two stable babies and before you know it, one is in emergency surgery.

[Encast, BSN, RN]

Thank you so much for this post!! I start my new job in the NICU in a couple of weeks. Thank you for giving us (New Nurses) and idea of what to expect.

[aerorunner80, ADN, BSN, MSN, APRN]

OK, Now that I'm home, I'll try to write a day out.

0645 Arrive at work, leaving extra time to walk in and clock in at 0653.

Be at bedside and ready to get report at 0700.

Report is usually done by 0730. At that point I log into the computer, open my charts and double check my orders and my meds(dosage, time, route). Then it is time to do environment checks. Making sure alarm parameters are set correctly and also checking suction (sometimes these aren't even set up at a bedside..a SERIOUS pt safety issue) and bags.

I usually start in with cares between 0730 and 0800, depending on the baby. Do assessment, feed baby, etc. Sit down and chart, if I have time. Around 0900, it's time for the second baby.

Typically I take my morning break around 0930, but again that all depends. There have been some mornings I've taken it early and some mornings I have not gotten one at all. Especially if I am an admit and get a sick one.

1000-1030 is catching up on charting time.

Rounds are also going on at this time so I try my hardest to be there for that. If I have a sick kid, I will make it a priority to be at the bedside when the team is there so I an catch all the new orders and ask questions, etc.

1100 starts round 2 of care times.

I try to go to lunch around 1300 if possible.

1400-1500 is catching up on charting time.

1600 depends on the babies you have. Sometimes there are routine labs due and sometimes not. This can be a little bit of a downtime for us.

1700 starts the last round of cares.

1830-1900 is catching up on charting time, making sure the carts are stocked (techs don't stock our carts for some reason....it would be nice), your bedside is in neat working order for the next shift. This is also the time we play musical babies and move them either to another bed space in the unit or to our setpdown unit. It can be hectic and loud sometimes.

0800-1830 parents can come in and now we are open to siblings coming in as well. When parents are at the bedside, it can get especially busy with updating, teaching, and just answering thier questions or talking to them in general. Especially when you have two very busy families.

I think this gives a very generaloverview of a typical day for me. Keep in mind that this ALL depends on the acuity of your babies, if you are an admit, going to deliveries, etc. Always keep in mind that this is an ICU and things can change at the drop of a dime. You could have a kid NEC out, develop respiratory distress, go into DIC, extubate themselves/need intubated, have lines placed, need a new PIV (this can be super time consuming if the kiddo is a hard stick), have a trach baby decannulate (this just recently happened to me........no bueno!), discharge a baby (which is more work than one would think at first), etc. The list goes on.

[champagnesupeRNova]

Bortaz's post describes pretty much everything I deal with on a day-to-day basis.

There are also a LOT of unexpected things than can occur during your shift in the NICU, for example:

-Infant's abdomen starts to look distended. He may or may not throw up. Depending on other factors/history/vitals he has bought himself a septic work up. (Blood cultures, CBC, CRP, X-ray, etc.). Based on X-ray, they decide to make infant NPO. You now have to start an IV, get fluids, hang fluids, start antibiotics, etc. This will take time and you might get totally thrown off your original "schedule" that you planned at the beginning of shift.

-Your baby that was extubated to CPAP early in the day starts to get tachypneic, you keep having to go up on his oxygen. Blood gas comes back bad. He has bought himself a re-intubation. Get equipment and everything ready, assist with intubation.

-Intubated infant on ventilator has had 2 bad blood gases in a row (showing acidosis). Docs continue to make ventilator setting changes. You draw a third blood gas. Gas comes back bad again. Infant now has to be switched to oscillator or jet. Close monitoring and frequent blood gases ensue.

-You get report on your intubated infant who has had an exploratory laparoscopy earlier in the day and was previously on room air, but was intubated for surgery and remains so. He is considered stable and they plan to extubate later that night. Report is not even over yet and infant codes. You spend the next 1-2 hours at the bedside stabilizing him and getting everything in order. Another nurse has gotten report on the other baby you were supposed to have. (OK, OK THIS IS ISN'T COMMON, but it happened to me).

-You do a routine Accucheck on your micro-preemie. It turns out to be 286. You'll be starting drips, getting frequent accuchecks, and doing some close monitoring.

-It's time to change out a baby's isolette. Baby is on the oscillator. You need 4 people and maybe 40 minutes to finish the process. By the time you've changed it out and assessed the baby, it's an hour and a half later.

-You hear the pulse ox alarm go off on one of your feeder/grower babies (who is being discharged tomorrow). You go to the bedside, the baby is turning blue and o2 saturation is dropping. PPV/Bagging. Baby won't be going home soon.

-You go to turn off the feeding pump that has delivered a feeding to your baby through the NG tube. You glance in the isolette to see the NG tube that your baby has pulled out lying neatly next to the baby. You have fed the bed.

And there are many, many more. NICU is an interesting place where the learning never stops! I love it.

[prmenrs, RN]

I just LOVE feeding the bed. Baby lying there perfectly content in a pool of formula or breast milk. Even better if the feeding had MVI or Fe in it.

On the same theme, I once busted a baby who had been on a running IV of D10. The t-connector had become disconnected from the IV--nothing was going into his IV, but he was happily sucking up the D10 po.