Floating to NICU... how to be helpful?

wjf00 · Sep 27, 2006

Sorry you are being floated with not enough orientation. The manager who approved that should be fired. I would demand an assigned resource nurse before taking any assignment, and if you are unfamiliar with the diagnosis or not sure of the Plan of care, refuse the assignment. You are the patients voice, NICU patients deserve a strong advocate.

I don't understand how a Hospital system can be so uncaring towards patients and staff. NICU is one of the most highly specialized areas in any hospital, floating should be limited to well oriented float nurses. Only nurses who volunteer should be floated.

Gompers, BSN, RN · Sep 27, 2006

Okay, let me see if I can help out a bit here. We also have float nurses trained to work in the NICU when things are busy for us. Usually they're from Peds, PICU, or OB and we don't really give them an orientation - more like a tour of the unit to see where things are, a review of the flowsheet, standard NICU schedules and procedures, etc. But we've had adult float nurses want to help out, too, so we've given them 2-3 week orientations 1:1 with a NICU nurse and then they're able to work with us and take care of stable patients on their own. They seem to enjoy having the opportunity!

My question is what are some really important things for a float nurse to know/look for? Of course usually we have 3 feeder-growers but sometimes it can be a little more intense. I never know when someone else's baby's alarm is going off whether to do something or not, usually end up going over there looking useless b/c I don't know what to do to help, the kids are so different from our pts. I know this probably isn't specific enough, but maybe if you start talking I will be able to come up with something more. Right now I am not too fond of working in the NICU, and not too good at even the tiny ones. I had the hardest time getting enough blood for a heel stick the other day, another nurse ended up having to do it for me. (We only do Accuchecks and draws from central lines on our floor, or if we get blood w/an IV start, as far as labs go).

About the alarms - I'd ask right off at the beginning of the shift what they expect you to do about them. Generally, you will go over to the baby and assess the situation. First, look at the baby. If the baby is obviously cyanotic, generally they're apneic and need to be stimulated to breathe. We do this by rubbing their backs or flicking their heels if they're exposed. Look at the monitor - if the baby is bradycardic (generally under 100 beats per minute in neonatal patients) they need to be stimulated to breathe. If they're desaturating (generally under 85%) you need to investigate why. If they're apneic (no movement on the respiratory monitor or obviously not breathing) they need stimulation. If they're breathing, check to see if they have a nasal cannula and if it's actually IN their nose! They also might be vomiting, and in that case just get their heads to the side so they don't aspirate and use a washcloth to help clear the area. If the baby is laying there, breathing, not vomiting, not bradycardic, but just desaturating - again, assess the situation. Make sure the wave form is picking up well from the pulse ox and that the cannula is in. If all seems well, look and see if there is a nurse around and ask if they just want you to increase the baby's oxygen flow. But like I said, ask the nurses at the beginning of the shift what they expect of you, and let them know you work in general peds where they aren't always on monitors. They should be able to help you out.

For the heelsticks - make sure their heels are warmed. Ask if they have heel warmers - these are little packs that you crack and they heat up, then you wrap them around their heels for about five minutes. This increases bloodflow to the area and gets lots of perfusion to the capillary beds. If they don't have heelwarmers, you can wet a washcloth with warm (not HOT) water and wrap that around the foot and ankle, securing the whole thing with a disposable diaper to keep the heat and wetness inside. Then make sure to stick the sides of the heel near the back - not the bottom or back of the heel. They should have a chart somewhere on the unit to show the optimum area to stick. Hold the baby's calf in your palm and use your thumb to bend back their foot while letting the blood flow. Don't pump the leg - just let it rest a bit here and there. If the blood is starting to slow down or the whole heel is messy, use a sterile 2x2 gauze to wipe it clean and the blood should flow better.

The feeding makes me nervous too... whether they are really eating enough or whether I'm pushing them and they are gonna puke, any tricks to getting them to eat better...

If they're on PO AD LIB feedings, look at how much and how often they've been eating for the NICU nurses. Use that as a guide. Also, unless told to, don't wake a baby to feed it - they generally don't eat as well if they're still sleepy. Swaddle the baby firmly and hold it on your knee, facing you. Trying to feed a smaller baby in the crook of your arm isn't the best plan - they end up getting lost in your elbow, their chins smoosh down to their chests, and they get warm and sleepy. Plus you can't really see their faces and how well they're sucking, swallowing, and breathing.

Also the parents in the NICU, usually being in a much much different situation than the parents on my home unit, act and react in very different ways and any tips for that would also be appreciated.

Remember that these parents have never had these babies at home - we have always done most of their care, so they need a lot of guidance. In Peds, the parents can often take over a lot of the care and while that is our goal in the NICU, it's a challenge, especially with first-time parents. We start them slow with caring for their babies and if we're doing the work in front of them, we often explain what we're doing and why so they are always learning. We wouldn't expect a float nurse to do any discharge teaching, so don't worry about that. Just ask the parents - have you changed a diaper/fed/bathed the baby? They'll let you know what point they're at and where they feel comfortable.

As far as things NOT to do...

Like I said, no discharge teaching. NICU babies are unique and have special needs at home.

I wouldn't rock the boat too much - don't try and change anything unless there is really something crazy going on. Just go with the flow and follow the routine.

Look at the flowsheet for that day and previous days. You will see how we chart. That's the biggest problem we seem to have with floaters and agency nurses is their charting - which we can't figure out because they have our previous flowsheets to look at for guidance. If we chart things like color, oxygen sats, activity, and position every hour...why are they not doing the same when it's right there in front of them??? Or if we do vitals on a particular baby Q3 hours, why are they doing them EVERY hour? Just follow what we've been doing and you should be fine.

Thank you for wanting to help out a busy NICU!!

Gompers, BSN, RN · Sep 27, 2006

Sorry you are being floated with not enough orientation. The manager who approved that should be fired. I would demand an assigned resource nurse before taking any assignment, and if you are unfamiliar with the diagnosis or not sure of the Plan of care, refuse the assignment. You are the patients voice, NICU patients deserve a strong advocate.
I don't understand how a Hospital system can be so uncaring towards patients and staff. NICU is one of the most highly specialized areas in any hospital, floating should be limited to well oriented float nurses. Only nurses who volunteer should be floated.

I don't see what's so bad about floating that someone should be fired! These are similar areas - in our hospital, we float between maternal-child areas. We don't get an orientation, but another nurse will give us a run-down of the unit and flowsheet, stuff like that. On other units, our resource is the charge nurse. In my unit, we have leaders in each room, and those are the assigned resource people.

We're not talking about giving float nurses sick babies!!! We would never give a float a baby that is vented or otherwise sick. We're talking about giving float nurses "grower-feeder" babies which are babies that used to be sick who are now transitioning to home. They are learning to eat from a bottle and might just have an NG tube. Sometimes they're on a nasal cannula too. We'd never give a float nurse a baby with an IV or anything like that, unless they were from newborn nursery and dealt with that on a regular basis.

Floating isn't a volunteer thing if it's within the same area - like maternal-child. The hospital must be staffed, and if one unit is dead slow and another is hopping, there will be some floating. If you don't float your nurses at all, you don't GET float nurses either- this is called a "closed" unit. Problem with that is that there is often mandatory overtime which is something that most nurses will not appreciate. Or there is mandatory downstaffing, which means the nurses are using up all their paid time off or going without pay. Floating isn't just to benefit the hospital - but also the nurses in this way.

The nurses that come to us from adult areas DO get an orientation and are volunteering to cross-train/float, same as if we wanted to spend some time on their units.

LisaRn21 · Sep 27, 2006

We get pulled all over the hospital too. I have been arguing this for over a year now. I"m not a icu/ccu/nicu nurse .. I am a general floor nurse! I was acctually pulled to the ccu one time and the girl who started with me was still on orientation and here I am off orientation and in the critical care area by myself.. I said I feel like this is so wrong. Apparently we always get the most stable patients..but you know what? that doesn't always happen... and their opinion of stable is not my opinion of stable. I once was pulled to the nicu and in report and I said.. Are you sure this person is ok for me to take? and they kept saying yes yes. So like a dummy I took it. The kid ended up on a ventilator (which I know nothing about) and they the nurse coming in was the rudest person I have ever met!!! She came in for report took one look a tthe kid and said I'll figure it out myself... you probably have no clue what just happened to the kid. It really made me mad. I said fine. took my stuff and ran out of there I hated every second of it! lol We have a lot of nurses in the units that thinkthey are God in training lol They think they are so much better than any floor nurse.. its discusting. I've learned to call them out on certain things when they try and degrade me .. but a lot of the times they are right.. I don't know certain things...and thats because I don't work there everyday and see what they see!!!

cathys01 · Sep 27, 2006

In our hospital the NICU nurses do sometimes get floated to Newborn nursery, but nobody else ever floats to our unit. We use PRN nurses, overtime regular nurses and agency nurses if we are short and desperately need somebody.

perfectbluebuildings, BSN, RN · Sep 28, 2006

Thanks for the suggestions Gompers!! To everyone else I am not always sure it is quite enough orientation but after the first time I did a whole shift there on my own, I realized it was not so bad. They do NOT give us anyone on a vent, at all; usually they don't even have any IV access but occasionally we get one with a Broviac or IV, but the babes they give us have been stable. I just wanted to add that no one is oriented to float anywhere until they've been off orientation x6months, that is a very new policy.

Gompers, we do have heel warmers and I did use one, I think what I did though like you said, the "heel got really messy" and I didn't think to clean it up before trying to get more blood, and this was a term baby who was already mad at the world anyway kicking and screaming for dear life.

The feeding... I did not realize that would be a better position, but when i think of it, the tiny ones I've fed "in the crook of my elbow' do seem to fall asleep!! That definitely helps.

And it sounds like the breathing/O2 sat thing is similar to what we would do on our floor, stimulation and checking probe placement, etc; I just wasn't sure b/c the patients are so much more fragile a lot of the time. I'll take your suggestion to ask the nurses around me next time, esp. because it seems like some of them can go to the 70's regularly and go back up and the nurses are pretty nonchalant, which I'm not used to unless it's a chronic kid. So I guess every babe is different.

The charting is pretty straightforward, I haven't really had a problem with it... a lot is on computer except for these flowsheets for VS, I/O's, O2 sat, etc.; and is assessments just like I'd do on any kid.

I guess one thing I wonder, maybe I should ask the policy- about bathing the kids? How often do you all usually do it, and is there a general rule or does it vary place to place?

The parents... I think one difference is that the bedspace for the pts in NICU is so much smaller than the rooms on our floor, which only makes sense, so while I'm used to parents watching me, it's usually not at such close range so I guess that is what has made me nervous. I would never try to do D/C teaching, usually the only thing parents want to know is the baby's weight and how they have been eating, and if anything has come up with them that day. I can answer those pretty easily!!

Gompers thank you for all the concrete suggestions outlined for me, that must have taken quite a bit of your time but it is so very helpful. I thank you all for your suggestions and concerns and if you think of anything else PLEASE pass it on, it will be greatly appreciated.

Gompers, BSN, RN · Sep 28, 2006

Gompers, we do have heel warmers and I did use one, I think what I did though like you said, the "heel got really messy" and I didn't think to clean it up before trying to get more blood, and this was a term baby who was already mad at the world anyway kicking and screaming for dear life.
The feeding... I did not realize that would be a better position, but when i think of it, the tiny ones I've fed "in the crook of my elbow' do seem to fall asleep!! That definitely helps.
I guess one thing I wonder, maybe I should ask the policy- about bathing the kids? How often do you all usually do it, and is there a general rule or does it vary place to place?

You're welcome for the suggestions!

I actually prefer to use the warm washcloth method with full term babies. Their feet are so big that the heelwarmer only really heats a part of their heels, and sometimes the rest of their feet remain cold. So by using the wet washcloth and wrapping it in a diaper, I'm able to provide warmth to the whole foot from the ankle through the toes. Then when I'm doing the lab, if the heel gets all messy and sticky - which will induce faster clotting - I will use the wet washcloth to wipe the heel up and then I do seem to get a better, more managable bloodflow again after that. It's easier to scoop a nice fat drop of blood into a micro-container than scraping "loose" blood off the entire surface of the heel. Again, make sure the water used to wet the washcloth is very warm but NOT HOT because they can get burned.

Yes, feeding a preemie is definitely a challenge. Watch the other nurses next time for tips and see what they do. Many of us like to do that position where they're swaddled - hands IN so they're not distracted by their own arms waving around - and on our knees so we can really watch the baby well. Lean the back of their head/neck against your non-dominant hand and hold the bottle with the dominant one.

Time of day and frequency of bathing, weighing, and routine linen changes are something that will vary from unit to unit, so definitely ask about that.

Good luck!

RainDreamer, BSN, RN · Sep 28, 2006

Great advice already!

I just wanted to add a few things:

baths

We really have no set policy for baths. We just give them when they're needed. We'll write in the kardex the last time they had a bath, and we just give a bath when we think it's needed. Usually the bigger chronic kids will get baths every night or every couple days ..... more often than the littler ones. With each round I always get a sterile wipe and wipe their faces, eyes, mouth .... and just clean them off a bit. But I would just ask what the policy is, if there is one.

alarms

I would do like Gompers said and just ask the nurse. That's what I do if it's not my baby. If my pod partner is busy and their baby's alarm is going off I ask them if they want me to silence the alarm (always ask before silencing! it drives me NUTS when someone silences my alarm and I don't know it) and then I'll ask what (if anything), the baby needs. Do they need to be suctioned? Do they need manual breaths? Do they need stimulation? Or do they just come back up on their own? Their nurse knows how their baby is and what usually needs to be done.

heelsticks

When I worked in the newborn nursery this was the HARDEST thing for me to learn!! It was really a challenge for me and I must say it just takes a lot of practice to get a good technique down. I used to have these big term babies that would scream the whole time I was getting blood. I remember sweating through the whole thing too! I'd get exhausted .... my arm would hurt ..... it was a nightmare for me and the baby. It just took a long time for me to figure out how exactly to get that blood flowing without milking and hurting the baby's foot. Even when I would put the heelwarmer on, it was still a nightmare sometimes. Definitely make sure the foot is nice and warm. Wrap the baby up TIGHT, just leaving that leg out. Give the baby some sucrose and a pacifier. When the blood starts slowing down, do like Gompers said and wipe it off with a 2X2 ... that really helps it to start flowing again. Before long you'll get a good technique down and it'll be no big deal .... but I remember having the hardest time with heelsticks, even with accuchecks.

parents

Normally I just ask the parents what they are comfortable doing. That, or I ask the nurse I get report from. I ask if the parents will be in that night .... so I know if I need to wait for them to get there before starting the baby's round. If a baby has been there for a while and is now a feeder/grower, the parents like to do pretty much everything. They'll change the diaper, change the clothes, take the temp, feed the baby, etc. If I don't get that information from the nurse beforehand, then I just ask the parents when they come in.

Good luck to you!!

perfectbluebuildings, BSN, RN · Sep 28, 2006

thanks so much, again! keep the suggestions coming :)

texas2007, BSN, RN · Sep 29, 2006

I must say that as a student who wishes to land a job in the NICU next year, this thread has been VERY informative! Thanks to everybody who has responded!

Gompers, BSN, RN · Sep 29, 2006

I must say that as a student who wishes to land a job in the NICU next year, this thread has been VERY informative! Thanks to everybody who has responded!

Don't worry - they'll teach you everything you need to know on NICU orientation which will last a few months. Float nurses don't get an orientation like that when they come by us so it's overwhelming for them. Good luck!