daily duties

New grads make what the hospital offers new grads. New grads usually transition easily...they have a clean slate LOL

A typical day depends on the unit, if you are in charge, on transport or have admits. Eves usually is visitor central, so you have to plan your activity around visitors. We come on at 3p, get bedside report, check orders, get out formulas for first feeds, sometimes do a bath at 4p if you have a Q2 hour kid, then from there you usually have a couple of Q3 kids that need to eat for 5p, maybe only one, and then the other will need to eat at 6p. Factor in parent teaching, baths, etc. Dinner is when you are in a lull. Then back to square one for the next 4-8 hours. Not a lot of down time usually. Then around 9p our HAL's come up, we check and hang those, start our charting, stock bedspaces and give report to the on coming nurse if we leave at 11p, otherwise you con't on until 3a. Sometimes you have admits, so you are taken away from those kids, admit someone, usually keep that kid and give up another to someone else, do all that paperwork and pick up where you need to on the other kids. On transport, if you get called, you hand off those kids to whomever is assigned to take them, get your transport stuff together, head out, come back usually a few hours from then, if the kid is for our unit then we hand it off, do all the paperwork, and then pick up the kids we had before.

There is no set routine as you can see LOL

As far as pay and new grad stuff - agree with above post - for pay it depends on the hospital as all units are usually paid equally, and it's fine to start in NICU as a new grad because it's a whole new world anyways. I'd say that 2/3 of the NICU nurses I know started as new grads.

The daily routine varies by unit. Everyone does something different. On my unit, it's like this:

charge nurse - She doesn't have any patients, helps anyone in need, makes assignments for the next shift, alerts nursing supervisor if there are staffing needs or problems on the unit, sets up admission beds, signs out all narcotics, and generally keeps the ship running!

admit/transport nurse - She has an easier assignment, and if there is a baby to be admitted from L&D or transported from another hospital, she does the honors, giving up her patient assignment for the rest of her shift (those babies are absorbed into other nurses' assignments), and focuses on the new baby.

high risk delivery nurse - She has an easier assignment, runs to any high risk deliveries with a doc and respiratory therapist, helps stabilize the newborn, helps transport it to the NICU if necessary, and the other nurses keep an eye out for her babies while she's off in L&D.

staff nurse - It really depends on the assignment. If the baby is very very sick, it's one nurse to one baby. That will include lots of IVs, medications, transfusions, labs, etc. Extremely busy at times, other times it's more monitoring a baby who is on maximum life support and has the potential to go bad. If the babies are more stable then it's usually 2 babies per nurse, and maybe it'll be one stable ventilated patient and one other baby, usually some sort of IVs and medications going on, usually some NG or oral feedings as well. "Feeders and growers" are very stable babies getting ready to go home, learning to bottle feed, no IVs, maybe a little oxygen. These kids are usually three or four per nurse, or maybe one of these kids paired with a sicker baby. So it all depends. The main thing is that you have to chart on each baby hourly, check IV sites at least that often, and coordinate your schedule so everything happens on time!

Days is busy by us, because the docs do their rounds and then put in all kinds of new orders. Also days is when most testing is done, both on and off the unit, and most surgeries whether on the unit or in the main OR. Evenings is when when hang all our new IVs and have lots of families visiting. Big time for teaching parents whose babies are nearing discharge, and for emotionally supporting those whose babies are very sick. Nights is when a lot of our busywork happens - charting, audits, stocking, cleaning, etc.

Each unit will be different in how they run, though. The thing is, I often don't know when I get to work if I'll have a handful of adorable babies to cuddle and feed...and feel like I'm on a hamster wheel going round and round and round...or if I'll have a single critical baby who is very unstable and requiring the most intensive care possible. That's what I love about NICU, especially ones that keep their babies until discharge (rather than sending to a step-down nursery) - you never know what you're going to get because they do it all. Plus, some days you look at those "feeder growers" and remember that you took care of some of them on some of those critical days, where they were really unstable, and now you're giving them tubbie baths and feeding them bottles. VERY rewarding!!!

I just started as a new grad in a NICU in the fall, so I can give you an account of my duties. At the place where I work, new grads spend the first several weeks in class part-time and working one-on-one with a nurse on the floor part time, then we spend the remainder of the first 6 months working with a partner-- which means that you have your own patients and they have their own patients, but they are in the same room with you and they are there to be a resource for you and to check over your documentation.

So..

I come on at 7 am or pm depending on the month as my shift rotates each month (more on that later).

I'll describe a typical day shift first.

1. Come on at 7am, get report on my babies and get organized. Report includes double-checking IV rates/ vent settings/ and any orders given on the previous shift. My unit consists of an intensive care nursery (icn) and a special care nursery (scn)-- the special care nursery being where the kids go when they are less acute and closer to going home. If I am in the scn, I generally have three patients (rarely, four) who are usually on a Q3 schedule-- which usually means you need to take their vitals, change their diapers, and feed them every three hours and give medications as ordered (we try to time the meds, especially PO meds to fall in line with the rest of their care, but that's not always possible). With three kids, their schedules are usually staggered by 30 minutes or so. In the icn, I usually have 2 patients who are on either Q1, Q2, or Q3 schedules, or 1 patient that is on a Q1 (possibly Q2) schedule-- a patient has to be pretty darn acute to get their own nurse and usually new grads don't get assigned these patients. I figure out which baby is due first and start there.

2. Safety first-- the first thing I do when I get to each bedside is the safety checks-- what are the alarms settings on the monitors (are they what they are supposed to be?)? is there an ambu bag/ anasthesia bag at the bedside and is it working? is the suction canister and tubing hooked up and working and is the pressure set at the right level?

3. Vitals and Assessment-- write down HR/BP/respirations/O2 sat/CO2 levels and continue with assessment-- take temp, auscultate HR (check to make sure it's correlating with the monitor), breath sounds, and bowl sounds, palpate pulses/ abdomen, change diaper and while you're there measure abdominal girth, palpate head (special attention to sagittal suture and fontanelles), while you're doing all that, you look at the baby's skin and assess any IV sites/ wounds and monitor their tolerance to handling.

4. Feeds-- via NG/ OG/ bottle (nipple) or assisting moms with breastfeeding or nippling their baby-- or often a combination of different techniques. Feeding often includes defrosting and fortifying breastmilk-- and making sure there is enough ready to go for the next shift's first feed.

5. Hanging IV fluid-- where I work the day shift mixes and hangs new IV fluids and changes IV tubing if needed. HAL comes up at around 6pm-- as a courtesy, the day shift usually checks and hangs the HAL, though it is technically a night shift responsibility so if you don't get it don't have time to get it done, it should be no big deal.

6. Medication administration- IV/ IM/ SQ/ PO/ PR .... and so it goes. In our unit, all meds are checked with another nurse before administration to assure that the right pt. is getting the right dose at the right time, etc.

7. Blood work/ IV placement- in my unit IV placement and arterial sticks are considered "advanced skills" and not taught until after the first 6 months, if I have a baby who needs an IV or an arterial stick done to draw labs, I get the admit, charge, or my preceptor to do it while I assist. I can do bloodwork via heel stick or an arterial line if that is already in place.

8. Assessment and suctioning of ventilated patients, at least 2X per shift (often times more) with the help of an RT or another RN.

9. Off-unit procedures-- you need to prep your patient and get together the appropriate equipment and paperwork if you need to take your patient off-unit for an MRI/ surgery/etc. You also need to make sure that someone else is assigned to cover your other patients while you're gone.

10. Admissions/ Discharges-- as needed, both involve a lot of paperwork. Admissions involve getting all the equipment set up, getting IV fluids ready, getting IV access if needed, sending off bloodwork, giving meds, etc. Discharges involve a lot of patient teaching.

10. Communicate with the rest of the medical team about the patient-- ie notifying doctors re: abnormal findings, concerns, suggestions, etc.

11. Psychosocial stuff-- do parent/ patient teaching, talk with parents, offer family support and refer them to appropriate resources (social work/ lactation consultants/ etc) when needed.

12. And let us not forget DOCUMENTATION.

Night shift includes most of the above, but also:

Hanging HAL (though, as I said before, day shift often does this)

Weighing and bathing

Measuring head circumference, length once a week

Doing AM labs

Stocking drawers

I think that's most of it, though I'm sure I forgot some things.

What I was going to say about rotating shifts is that yeah, it kind of sucks, but there are really plusses and minuses to both the day and night shifts-- days are busier and there's more going on so you get exposed to more things (procedures/tests/etc), but nights are quieter and you have more time to look stuff up and more time to get stuff done.

As far as the "transition" goes, it really helps if the unit has a really good and structured orientation program. That said, it is A LOT to learn in a realtively short time and can be *very* stressful. Starting pay depends on where you work-- you're more likely to make more $ in a large metropolitan area, public hospitals generally pay less, etc.

Any other questions :-) ?

Wow! Thanks mischievium for a great synopsis of a day in the life of a NICU nurse! P.S. What's HAL?

"HAL", is short for hyperalimentation, also known as "TPN" (total parenteral nutrition). It's an IV fluid made specifically to order for each baby based on their nutritional needs and contains electrolytes, dextrose, vitimins, and protein. Babies who are not taking breastmilk/ formula for whatever reason, are generally on HAL.