Grunting baby...

[winter_green]

I'm a L&D new grad nurse...shy of 4 months to being a year. During my 4 months of orientation, I was oriented to our well baby nursery as well but was oriented to the nursery for ONE DAY. I feel so uncomfortable starting baby IVs, lab draw, even just monitoring.

I took care of a mom who delievered SVD and baby was 37 weeks, tachynpea intermittent with refraction. I took baby into the nursery to observe and another RN took over to recover my mom. Got MD's orders to observe for 2 hours. The last hour baby started grunting and O2 sat dec to 92%...I called MD and got orders for CRP, CBC, blood culture, IV for D10... boy, did this make my charge nurse mad.... it was 2 hours before change of shift and craziness begin on the floor. It changed the whole nurse patient ratio and my charge nurse was taking care of 4 patients and needed me back on the floor. Our scheduled induction had to be canceled because of we did not have enough morning staff to accomodate. I felt that everyone thought my baby was fine and should had not lab work up and an IV... I felt bad in a way, but my baby was grunting on and off... was I wrong? I was worried...

[tewdles, RN]

Here's the bottom line...you were thinking of the patient and outcomes for the patient before your were considering how your actions might affect staffing. THAT is YOUR job.

And it sounds like you did it well.

How your actions affect staffing is something your supervisor or charge must be concerned with. My guess is that she is experienced enough to know that you potentially saved her from a chaotic mess when that infant crashed later. Hopefully she will tell you how much she appreciates that at some appropriate time.

[FlyingScot, RN]

A little GFR in the beginning wouldn't get my knickers in a twist but a kiddo who was only tachypneic with intermittent retractions initially who then started grunting over an hour later is a whole 'nother animal as far as I'm concerned. The margin for error is too small in neonates to play around. Go with your gut...staffing issues be-damned. What do you think she would have said to you if you had sat on this kid and it later crashed.

[FlyingScot, RN]

Hopefully she will tell you how much she appreciates that at some appropriate time.

You know and I know she won't say a thing.

So let's do it for her.

GOOD JOB!

[klone, MSN, RN]

Where I work, a grunting baby that lasts past 2 hours buys a work up and CXR. I don't neccesarily agree about just getting an xray before the cultures, but unless the kid's glucose was off, it wouldn't get an IV where we work until 4 hours. And we would never transition a kid on blowby on mom.

And thus, the schism between L&D and NICU continues.Of course you would never transition a baby with blowby on mom. You're a NICU nurse.

[BabyLady, BSN, RN]

I agree that a CXR and blood gas are important aspects of a comprehensive work-up to make a differetial diagnosis of TTN vs. RDS vs. possible sepsis vs. possible cardiac abnormalities.

But it concerns me that (maybe I'm misinterpreting your post) that your unit would consider a "dose of surfactant...to help" a baby "transition" especially without having ruled out sepsis as a cause of the baby's symptoms.

Is easing transition an acceptable use of surfactant? If so, what would the criteria be? A particular O2 requirement? Would the baby be temporarily intubated solely for surfactant administration, then placed on a cannula?

I realize that I'm a relic, but I always understood surfactant to be reserved for infants with RDS requiring mechanical support.

You actually did not misinterpret my post. This is something we have been doing for the past few months with a huge amount of success. We have intubated, administered surfactant, then extubated and placed, usually on high-flow or CPAP, when a baby is in RDS and a CXR and blood gas demonstrates a need.

The purpose is to keep the infant OFF of ventilator support and they will even administer a second dose in 24 hours, if warranted.

[Jolie, BSN]

You actually did not misinterpret my post. This is something we have been doing for the past few months with a huge amount of success. We have intubated, administered surfactant, then extubated and placed, usually on high-flow or CPAP, when a baby is in RDS and a CXR and blood gas demonstrates a need.

The purpose is to keep the infant OFF of ventilator support and they will even administer a second dose in 24 hours, if warranted.

Thank you for clarifying. We were talking apples to oranges, to an extent.

A baby with RDS as verified by a CXR, needing high-flow O2 or CPAP post surfactant is quite different than what I evisioned by your earlier mention of helping a baby transition.

[BabyLady, BSN, RN]

Thank you for clarifying. We were talking apples to oranges, to an extent.

A baby with RDS as verified by a CXR, needing high-flow O2 or CPAP post surfactant is quite different than what I evisioned by your earlier mention of helping a baby transition.

Ah!!! .

Yes, we were talking about two different things. If they are still not transitioning after going through everything to help them transition (which you know doesn't take long), they will draw all of those labs and start the baby on AB's until a clearer picture can be given.

I was just really referring to the OP, who had a newborn in well-baby, I couldn't imagine a Peds drawing all those labs before trying anything less invasive.