Cardiothoracic Stepdown to NICU

adventure_rn, MSN, NP · Aug 9, 2017

To address several of the topics you bring up:

Turnover: You may still see issues with high turnover depending on the hospital, staff, and management. That said, most people who go into NICU stay there (whether it's on that given unit or another NICU); you'll likely have at least some coworkers who have literally worked on your unit for decades. One of my coworkers started on my unit in her 20s, and she's still working full time at age 75 because she loves it (not because she needs to). Seriously. It's awesome, but it can make gaining seniority tricky.

Appreciation: While I think nurses in general don't always receive much useful feedback from management (since they're removed from the bedside), I believe that NICU nursing is very gratifying because of the parent interaction. True, NICU parents can be really stressed out, and they can occasionally displace that anxiety onto staff. However, most parents are sincerely very appreciative that you're caring for their baby, and they'll frequently tell you how much they appreciate your work. Very different from the adult world.

Experience: Realize that you're going to feel like a new grad again. That said, NICU 'new to specialty' programs recognize that most nurses have very limited NICU exposure, and therefore provide extensive orientation. You'll probably have several months of supervised orientation as well as classroom time. They'll start you out with the 'well-ish' kids before moving you to the sicker kids so that you feel comfortable with well baby assessment first.

Typical day: Unless a kid is seriously critical and the plan of care is constantly changing, NICU care tends to be pretty regimented. We generally practice clustered care by doing 'care times' every 3 hours or so, during which we assess, take vitals, do a diaper change, draw labs if needed, and do a feed (either bottle, breast, or gavage). That way, the baby can get 2.5 hours of uninterrupted sleep in between cares. It's kind of like having an adult total care patient who needs to be fed, turned, and taken to the toilet on a regular schedule. Most kids will be on an 8/11/2/5, 8:30/11:30/2:30/5:30, or 9/12/3/6 schedule. Therefore in a 3 baby assignment, you'd do your first cares on baby A at 8:00, cares on baby B at 8:30, and cares on baby C at 9:00, then chart in between and repeat the process at 11:00, 2:00, and 5:00. If you've got a higher acuity baby (i.e. ventilator or CPAP), they'll probably be in a 2 baby assignment, but still on a predictable schedule. If a baby is really sick then you might be drawing labs every hour, transfusing, adjusting ventilator settings, etc., in which case you may be 1:1.

So hourly with a 2 baby assignment might be:

7:00--report

7:30--checking orders, checking safety equipment

8:00--first care Baby A (assess, vitals, diaper, feed; care may take a long time if infant is on high level respiratory support)

9:00--first care Baby B

10:00--rounds, charting

11:00--second care Baby A

12:00--second care Baby B

1:00--lunch, charting

2:00--third care Baby A

3:00--third care Baby B

4:00--stringing fluids, charting

5:00--fourth care Baby A

6:00--fourth care Baby B

7:00--report

A 3 baby assignment would be identical, but slip a third kid into the 8:30, 11:30, 2:30, and 5:30 slots between Baby A and Baby B.

In addition, we also do certain activities as needed (labs, med admin, baths, hourly IV checks, parent education). I like to lay eyes on each baby at least once an hour to make sure they haven't maneuvered themselves into a face plant position or catapulted themselves down to the bottom of the incubator. Some kids, especially those who are NPO or continuous feeds, may have care times less often (i.e. q 4 hours). We're also moving away from the 'care time' concept because we want to respect babies' natural sleep-wake cycles, but we do still try to practice clustered care when kids are awake.

Typical Assignments: Depends on your unit approach. When you first start out, they may give you 3-baby 'feeder-grower' assignments (former preemies learning to eat) to get comfortable with well babies. A two-baby might be a CPAP and a vent. One 1:1 is critical; body cooling, vasoactive drips, oscillator, inhaled nitric oxide, etc; frequent assessments, frequent labs, potential to code. With ECMO, you may have 2 nurses to one baby.

Telling you what's wrong: They will. You just have to learn their norms and their language. You learn to asses with a different set of parameters. Some NICU nurses with decades of experience can just look at a kid and know that the baby is on the verge of getting septic; it's pretty remarkable.

I'd ask if you are able to shadow; that would probably give you the best sense of the work. I'd also read through the prior posts in the NICU forum; several of your questions have been discussed before with some very helpful responses. Best of luck.

vintage_RN, BSN, RN · Aug 15, 2017

Haha my NICU is crazy. We have 3 cpaps on an assignment, all the 1:1 assiments you described are 1:2 except for ECMO and dialysis. We pretty much never have 1:1 lol