RM-RN 898 Views
Joined: Sep 26, '09;
Posts: 18 (22% Liked)
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If I have 2 at the same time, I also start with the less time-consuming patient. It might be because they're a faster eater, their parents aren't in for that feeding, they're all NG, they have less on-going issues, etc. Otherwise, this is kind of how it goes...
As soon as I'm done with report, I verify my orders and make sure that I know what I'm doing at my initial assessment. (My inclination is to chit chat, but I have to remind myself that I'll regret that choice later!)
Wipe down their bedspace with our cleaning wipes.
Gather all the supplies I'm going to need for both babies and place them at the bedsides, or make sure they're stocked already. This is another place where I'm confirming what I'm going to do before I touch the baby. I find that if I set out the things I know I'm going to need, I'm much less likely to have to backtrack or have things I've forgotten. This would include any medications I might need to give.
Confirm that whatever everyone is eating is available for immediate use. (This is something that has hung me up on several occasions! The right formula not available, breastmilk not thawed, etc). Then I prepare #1's feeding and I'm ready to go by 1945 at the latest. My goal is to be on to the next baby by 2015.
If there's something more time-consuming that anyone needs, I'll see if I can save it for the less-involved time. Say baby #1 needs a bed changed, or a bath and linen overhaul and they can have that done any time...I'll do it at a time when I'm not also trying to fit in 3-4 head-to-toe assessments.
The actual hands-on assessment rhythm will come with practice. Generally, it's not the time-consuming part. I would not skimp on RR or HR. Our policy is 1 full minute, but follow whatever your unit policy is. Palpating pulses and abdomens will get faster with practice. I move from head-to-toe once, completing assessment and cares on the way down. Something like...
-temp and inspection of all lines....clean/dry dressings, infusing appropriately.
-Auscultate lung sounds and count RR
-HR, sounds, PMI...if I haven't annoyed the baby into screaming like a banshee, yet. For bigger babies, I sometimes do this before I return them after feeding....when they're full and sleepy. You can spend a long time trying to comfort a larger baby in order to complete your assessment, when all they want is food.
-Bowel sounds. We can't chart absent until we've listened for 5 full minutes. If they're absent, it's probably not a 4:1 assignment and feeding in a timely fashion isn't an issue.
-B/P (moving to something else while it's reading)
-Eye and mouth inspections and care
-Confirm NG placement, aspirate residual, confirm secure dressing
-Any daily measurements that are needed.
-Visual inspection of everything else outside the diaper.
-Assessment and diaper care.
-Clean-up the mess I've made in the bed.
-Old gloves off, wash hands, new gloves. (this is when I'm doing that mental checklist of anything I might have forgotten.)
If they're all big babies, and they don't require as much hands-on cares, they can probably also stand to start eating sooner. So....Ill start my hands-on at 1930, and start nippling at 2145. We have a 30-minute rule on feedings, so I know I'll be done no later than 2015.
Most of it is just practice. Don't feel down about being slower than some other people. If something goes south, the other babies might have to wait a little. There's nothing you can do to change that sometimes. I certainly wouldn't cut back on your assessment.
It'll get better.
Auscultation/aspiration on initial placement. Confirmation of position by number markings on the tube, as well as aspirate every feeding/assessment. Also confirm on each x-ray that's taken.
For the most part, you'll get better with practice. If anyone is expecting you to reposition without any guidance or help, they're looking for some extubations. That's just not reasonable. Be confident in advocating for your baby. That includes asking for help when you're unsure of how to proceed.
After some practice, a "stable" vent is a one-person event for me. New/unstable vents are me plus RT. HFJV or HFOV are me, another RN and RT....especially if I'm doing something else like linen changes.
I also suction before and after the repositioning to get whatever might be tossing around in there. Sometimes it's much easier to disconnect and reconnect as much as you safely can, rather that trying to untangle it all, so you can avoid making big knots of your tubes and wires. Just be careful to protect the exposed ends from coming in contact with any other surface. The stuff you can safely disconnect for a second are leads (from the cable, not the baby), suction tubing (from the distal end), and POx (cable, not baby).
So...I get everything ready and call for some assistance. I'll ask RT to secure the tube, and I'll do everything else. I reposition the body of the baby first, and rearrange all of their wires/tubes after that. I try to go in a positioning order that makes sense, and makes the whole ordeal less traumatic for everyone. Vented kids are usually in Omnibeds, so their tubing comes into the bed right down the middle. It makes it easier to move from side-to-side.
We don't disconnect vent tubing unless it's absolutely necessary. Breaking into the circuit leads to an increase in VAP and tracheal infections. Not to mention, that you loose whatever pressures you've been trying to gain.
Frankly, I couldn't care less if people think I'm an idiot for asking for too much help. IMO...there's no such thing. The worst case scenario? I've asked them for 5 minutes of their time so they can stand around and do nothing. I'm okay with that.
70% for 1 week. 50% for the second week. Off after 14 days since even the ELBW's skin is mature by then. Then the bed is changed out and they start fresh. All O2 is humidified.
We use the Tegaderm that's made especially for securing IV's. It comes with two extra medipore strips for chevroning the hub and securing the tubing. They're small enough that they don't extend beyond the Tegaderm edges. With the babies that nothing sticks to, we sometimes will picture frame the edges of the Tegaderm with transpore.
We use Neobars for everyone. I have a little bit of a love/hate relationship with them. When they work, they work very well, adhere nicely, stand-up to a lot of movement and secretions, etc.....but when they don't (or are used/measured incorrectly), they're a pain in the rear. I don't know that I'd be less annoyed by any other method, though.
The answer really depends on your course content. No two nursing programs offer all of the same information. Some offer core component classes that refresh the information, and some push you right out of the gate.
In general...yes, a working knowledge of basic A&P is the foundation you'll be working on. Terminology won't really help you unless you know how it fits into the whole picture. In the very least, I'd try to brush up on the information and understand how the main systems work.
For us, strict I/O is the standard on admit. We'll continue it by order for anyone NPO, with cardiac/renal/glucose issues, or really any baby who might remotely need it. Once the baby is stable, we might continue doing it just because the nurses think it's a good idea. Every baby still has their number of voids and stools counted.
We do have Foleys in 3.5 and 5fr, but we rarely use them. If anything, we end up sending them to the ER since they don't stock them.
Our hospital doesn't require a BSN to work in the NICU, and our unit is probably fairly even with both ADN and BSN nurses. Whether or not it would help, in my opinion, depends on the individual educational programs and what type of work history you bring with you to the workplace. Similarly, the nursing experiences that would help you for a future in the NICU depends on what level NICU you're looking to work in, and what types of services they provide. I would call or e-mail the nurse manager of the NICU at your hospital and ask him or her.
There was a nice recognition from the administration and several other units in the hospital, we had some of our equipment set up in a main lobby so people could see what we do on a daily basis, and we had a potluck on both shifts. So...nothing expensive...but rewarding.
We try to keep the layers down, and are aware of the recommendations from Giraffe. The developmental positioning/containment trumps the mattress benefits for us, though. So.....
After a layer that covers the mattress, there's a gel pillow for all babies in any incubator-type bed. For the E/VLBW babies, they're large enough that they go from head to sternum.
Then it's the Snugli, with some kind of cloth liner for the inevitable soiling. Snuglis can be a hot commodity, so we protect them.
If they're old enough and stable enough to be prone, we support them with folded, smooth cotton infant t-shirts under their belly. The only part left touching the mattress is their lower leg.
We very rarely see skin breakdown from pressure. Also, we don't usually start to consider transitioning the babies to clothes until they're 1700g or so. I dislike blanket swaddling anyone smaller, and won't do so if they have any kind of lines. If I swaddle someone in an incubator, it's for that champion leg bracer who is determined to jump ship.
I would completely echo many of the sentiments already given. These are my personal requests....
I don't mind people who telecommute at the bedside....work on their NICU diary in a digital format....or upload baby's current round of pictures to their blog (as long as they wash their hands!!!). Most of the time I prefer it over people who sit and watch the monitor all day. It allows them to be present in as much care as possible, without letting some of the natural panic/boredom take over.
I also LOVE IT when parents write down terms they don't understand and keep a handy list of questions. Sometimes we forget that parents don't speak our language.
Please remember what time your baby's feedings/cares are (assuming you've made it to a regular schedule...YAY!)...and give me a little time to get everything done before you call. If I absolutely cannot get to the phone, please be understanding. The same goes if you come for the 2100 feeding at 2000, and I have 2 other babies before yours. I can't imagine a parent wanting me to rush through their own baby's feeding/assessment/bathing because someone else is waiting....so please don't expect me to rush through someone else's cares.
And yes....KEEP PUMPING!!! The 3cc minimal feeds your baby gets today will be 100+ cc's before you know it.
Skip the gossiping about other nurses, or trying to ask questions about other babies. It's hard in our tight-knit community, but it will serve you well in the long run.
If there's something you don't understand or you didn't like, just ask the nurse who did it. Sometimes you don't catch everything someone does, or you see something that doesn't make sense. Instead of guessing the worst thing....ask. I don't mind. You are your baby's very best advocate!
I think last....and most importantly....the answer to almost all of the "When will my baby...." is....when he or she is ready. I can tell you what things we're waiting to see...and what readiness cues I'm looking for, but as for when it actually happens....no one knows but your baby. They're clever that way.
We provide parents with their baby's medical labels, and they write the date and time of collection on each label before placing it on their syringe/bottle. When it comes to retrieving the milk from the freezer/fridge we double check independently, the same as routine medications. If the milk is transferred to a syringe or bottle...we place an additional label on it for verification.
We do have a formula prep room. We're not supposed to prepare any feedings at the bedside.
For additives, we use the Enfamil HMF at either 1:25 or 1:50, beneprotein, and Prolacta. If we fortify with formula, we typically use the ready-to-feed and mix per ratio. If we do use the powdered to fortify, each baby gets their own measuring cup/spoon that's sterilized or disposed of when finished. We seem to be hot on the high protein stuff lately, too.
I've never seen anyone doing the "rinsing" with formula. We routinely use donor breast milk. We don't use formula for anyone under 34 weeks. We do start with minimal feeds, but it's not for mom's milk supply.....it's to allow the baby's gut some time for adjusting to feeding. Mom's milk supply just usually falls right into place.
We do have some people who are very anti-formula. They tend to be the "birth plan" crowd, who hasn't yet accepted that their baby has a different plan. We try to accomodate their wishes, if at all possible.
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