NICU duties

SteveNNP, MSN, NP · Dec 13, 2005

Wow.....no short answer to that one. But in attempt to boil 12 hours of chaos down into a paragraph, here's what I do......

It's usually like walking in front of a moving bus, since all hell seems to break loose at shift change. After getting report on my 2-3 patients, I check my patients, then sit down to check my orders from the last 24 hours and sign my MAR's. I usually sedate/medicate my pts before performing my assessments, which usually come next. If I have first admit, I make sure I have an admit bed set up with a vent and ready to go. I then do a complete head to toe assessment on my babies, while at the same time changing their diapers, repositioning, changing linens [to cluster care] I also give any meds that are due. VS are usually q2 or q3. If I have a feeder, I need to check residuals, warm breast milk, etc. they are usually fed q3. Most nights I also need to weigh my kids, even when on the vent. This can take quite a bit of time. Early in the am, I draw any labs, either heel stick or arterial/venous, and reposition the babies for am XRays. I recheck them every 2-3 hours if not less to reposition, change diapers, etc. Around 6:15am I usually medicate them for the next shift coming on. NOW.....in addition to all this, I have to respond to multiple alarms [spo2, bradys, etc], give scheduled & PRN meds around the clock, start and restart IV's, maybe code a baby, suction, adjust respiratory settings with the RT's help, deal with parents arriving at the same time, discharge teaching, going to all high-risk deliveries and C-sections until I get an admission, maybe code the admission, admit a baby, do more paperwork, chart,chart,chart...manage cardiac and BP issues, call the MD's for orders, transfuse with blood/platelets/FFP/Albumin, start Dopamine/Dobutamine, manage arterial lines, maybe perform multiple blood draws, etc:uhoh3: .......

THis isn't all I do, it's just all I can fit in one lengthy post. I love it, and it comes with challenges and a lot of rewarding experiences. Hope this helps!

SteveRN21

BlaineCM · Dec 14, 2005

Wow! Thanks so much for the very informative reply. Sounds like your day is action packed!!

Finallyat40 · Dec 15, 2005

breastfeeding, holding, bathing, updating on progress, and when you have three babies, that's X 3....oh yeah and arguing with the resident on call to come look at your baby whose tummy is hard and has a residual!

Just curious, you mentioned sedating your babies before performing an assessment...what do you use? Sweeties? We don't sedate our babies, but we do cluster our care and use a great deal of developmental positioning for their comfort....just curious.

Jamie

SteveNNP, MSN, NP · Dec 15, 2005

Sorry, I just realized that I was a little vague about the sedation. That only applies to my vent babies. All others will only get repositioned/swaddled, or sweet ease if a painful procedure is being done. I usually give a Morphine/Versed cocktail about 30 min before touching my vent babies if pressures are stable. They tend to remain more stable that way when I mess with them. Clustering care really can't be emphasized enough.

Finallyat40 · Dec 15, 2005

Even on a vent baby, wouldn't that seem somewhat counter-productive....I realize those are short acting meds, and the baby is vented, but how would you get a good idea of the baby's actual pain status if you're medicating them before you touch?

In our unit, we use sedation when necessary on our patients, usually on our high frequency kiddos so they won't fight (and in my mind, that has to be a miserable feeling), and on our PAH kids for relaxation, but rarely on our standard SIMV kids....we also extubate as quickly as possible, so that might have something to do with it....In my experience, it's the CPAP'ers that need sedation more than the vented ones....they can be so agitated!

sorry, didn't mean to hijack.

Jamie

Gompers, BSN, RN · Dec 15, 2005

Even on a vent baby, wouldn't that seem somewhat counter-productive....I realize those are short acting meds, and the baby is vented, but how would you get a good idea of the baby's actual pain status if you're medicating them before you touch?

We have a policy that every baby on the vent needs to be on some type of narcotic for pain relief. Either a morphine or fentanyl drip, or bolus morphine around the clock. Unless we plan on extubating in less than four hours, we have to give something for pain. We start with "half doses" and go from there, as much as the baby needs. Even babies on drips, we'll give them bolus fentanyl when we handle them if they're prone to desaturation during stimulation. Not medicating them just to see if they have pain doesn't make sense. You don't want them to ever have pain. Our goal is to have their hourly pain scores at 0, even during handling. If we handle a baby once and they go nuts, we make sure that the next time, we premedicate so it doesn't happen again.

We're real sticklers for pain control, as one of our nurse practitioners developed a pain tool that is now used nationwide.

Gompers, BSN, RN · Dec 15, 2005

Okay, back to the original question!!!

Let me review my last three nights at work, as they show different sides of the NICU world...

Night 1:

Four grower-feeder babies, which means that they have no IVs and are just learning to eat from a bottle and gain weight before they go home. Two had nasal cannulas with small amounts of oxygen, as they were tiny preemies and had some lung damage. Three of the four babies still had feeding tubes, while the other was taking everything by bottle. The ones with the tubes, they'd alternate taking one feeding by bottle, the next by tube, etc. The babies ate every 3-4 hours. All had several oral medications that I'd mix in with their formula at feeding times. The two with oxygen also had inhalers that the respiratory therapist had to give once a shift. Three were in basinettes or cribs, the last was still in an incubator and was still too small to handle room termperature. So basically, I came on, got report on the babies and made a schedule for the night - when all four babies had to eat, when they had medications, etc. I gave them all sponge baths, weighed them, dressed them, changed their linens, fed them, medicated them, held them, and spoke with their parents when they visited and called. If the parents where on the unit, I tried to do some discharge teaching. If any of the babies had problems, which luckily none of them did, I'd have called the docs for an update and new orders. It was kind of like being on a hamster wheel - I ran around all night caring for these babies, and as soon as the last one was fed, the first one was due to eat again! It wasn't too stressful, as they generally did very well overnight, and they were cute as can be - it was just busy is all.

Night 2:

I had two babies - one former preemie, who was now several months old, and a week-old preemie that was about 2 pounds. The former preemie recently had surgery and was not yet feeding, so I had to monitor his central line and IV fluids. He was on IV antibiotics for an infection, and he had a NG tube in his stomach to suction out any secretions to let his bowel rest after surgery. He was a little cranky, as he had recently been weaned off a narcotic drip and was hungry. I basically monitored him all night, gave him his antibiotics, and comforted him when he was upset. The second baby was pretty "new" still, and didn't yet have a central line. Her peripheral IV came out, so I had to insert a new one. She was getting small amounts of breastmilk by feeding tube every 2 hours, but most of her fluids and nutrition came from her IVs so it was vital to get the IV started ASAP. She was under the bilirubin lights for jaundice, and was not happy about having her eyes covered! She had come off the vent earlier in the day and was on Vapotherm, which is a high pressure, high humidity nasal cannula. She did forget to breathe a few times that night, so the doc increased the amount of pressure the cannula was at. Her only medication was IV caffiene, which was given to stimulate her brain to breathe. If she kept having apneic episodes, the doctors were going to have to put her back on the ventilator. Luckily this didn't happen! I also had the high-risk OB pager, and once was paged to go down to a delivery with the docs and respiratory therapist. It was a 30-week preemie, so after we got him breathing well we brought him to the unit and another nurse admitted him, while her previous patients got absorbed into other nurses' assignments.

Night 3:

I took care of a baby that had come back from surgery about 6 hour prior to my shift. She was on very high ventilator settings and her blood gasses were horrible. Every two hours I had to poke her heel with a lancet to obtain small amounts of blood to do the gasses. Twice the docs wanted me to stick her artery in her wrist to get an arterial blood gas to better monitor her progress. She was on one kind of ventilator, then we changed to another type, then back to the first one. We tried all different ventilator settings, and I had the doctors and respiratory therapists at my bedside on and off all night. I drew 6 or 7 poor blood gasses, and finally at 6:30am I drew a gas that was perfect. She was on 100% oxygen, so no where to go if her oxygen saturations fell. We finally found the correct support for her! She was very pale, so I asked to draw a blood count. It was fine, so no transfusion for her. She was also on a paralyzing IV medication every 1-2 hours. The surgeons wanted her on it so she wouldn't move and disturb the surgical site, but with the way her blood gasses were, we'd probably have started her on it anyways to stop her from fighting against the ventilator and improve her lung compliance. It's scary at first giving this medication, because honestly your patient looks dead when you do. They can't move a muscle, not even they eyes, so they hang open sometimes and you have to put ointment on them to keep them from drying out. I also gave her three kinds of IV antibiotics, IV steroids, and IV diuretics. She was on morphine boluses but by the end of the night we started a fentanyl drip to keep her constantly comfortable. I checked her vital signs once an hour. She didn't have a central line so I had all her IV fluids running through a peripheral IV line, and had another to give her medications through. I monitored her skin so it wouldn't break down while she was immobile. I talked to her parents several times when they called, and explained everything that was going on. It was a very stressful night, as she was doing so poorly, and I rarely left her bedside except to pee and take a 20 minute dinner break. I was just glad that she was doing better when I left, weaning on the oxygen and color improving. On my way out, I asked a nurse practitioner who just came on shift to please ask the docs if she could start a central line on the baby for her IV fluids and meds, and an arterial line to draw blood gasses from.

So there you have it - my work week!

:rolleyes:

SteveNNP, MSN, NP · Dec 15, 2005

Even on a vent baby, wouldn't that seem somewhat counter-productive....I realize those are short acting meds, and the baby is vented, but how would you get a good idea of the baby's actual pain status if you're medicating them before you touch?
In our unit, we use sedation when necessary on our patients, usually on our high frequency kiddos so they won't fight (and in my mind, that has to be a miserable feeling), and on our PAH kids for relaxation, but rarely on our standard SIMV kids....we also extubate as quickly as possible, so that might have something to do with it....In my experience, it's the CPAP'ers that need sedation more than the vented ones....they can be so agitated!
sorry, didn't mean to hijack.
Jamie

I know....this is often a hotly debated issue on our unit, with people taking both sides. Personally, I look at Spo2 stability, HR, mean arterial pressures and facial expressions, such as brow furrowing, squinting, and nasolabial furrowing. Alterations in these have been found to indicate pain, whether or not accompanied by physical agitation. Often these little guys are so weak, they couldn't fight/move if they wanted to. I'll let them move a little, to keep their 3rd spacing down, But they will get sedated at least q4 unless on a fentanyl drip. We use a pain scale, and are trying to implement standard orders for fentanyl drips on all vent babies. I know that I'd want LOTS of drugs if I was ever intubated, and underwent all the procedures they do. There is also some research out there that points toward a decrease in IVH, due to a more stable BP [less fighting/agitation, stress hormone release] Often day shift hasn't medicated them in hours, because they didn't "seem" to be in pain, but I'd rather give it and play safe. Sometimes it takes all night to "catch up" on analgesia, but when their levels are high enough, they will usually be much more stable, o2 requirements will go down [100% to 35% after drugs in one of my babies cases] There are certain instances in which I'll hold it, such as uncontrollable low BP, planned extubation

Finallyat40 · Dec 15, 2005

very large teaching hospital, so we're at the whim of interns, residents, NNP's, fellows and attendings.....and one of our attendings is adamantly against sedation...even for the high frequency kiddos. It makes me crazy sometimes! We do use fentanly and versed drips as needed, and if one of my kids would benefit from some sedation, in my opinion....I'm the first to go toe to toe with the docs.....I've even been known to page the Resident, get the to agree to sedation and be sure and have it piggy-backed before the attending comes in the next day....then we have the opportunity for a little "history" in terms of lowered Fi02 requirements, etc. Thanks for sharing the information.

Jamie

vegnurse21 · Dec 18, 2005

We have a policy that every baby on the vent needs to be on some type of narcotic for pain relief. Either a morphine or fentanyl drip, or bolus morphine around the clock. Unless we plan on extubating in less than four hours, we have to give something for pain. We start with "half doses" and go from there, as much as the baby needs. Even babies on drips, we'll give them bolus fentanyl when we handle them if they're prone to desaturation during stimulation. Not medicating them just to see if they have pain doesn't make sense. You don't want them to ever have pain. Our goal is to have their hourly pain scores at 0, even during handling. If we handle a baby once and they go nuts, we make sure that the next time, we premedicate so it doesn't happen again.
We're real sticklers for pain control, as one of our nurse practitioners developed a pain tool that is now used nationwide.

Okay, I'm a student that is hoping to go into NICU in about 6 months when I graduate. I haven't been able to buy any books yet about it, so I'm still very uneducated about the specifics. Can I ask why you would use a narcotic for babies on vents? Is it painful or just irritating?

I only spent one day in NICU observing so I really haven't had much experience whatsoever. I spend a lot of time in this forum just trying to soak up as much information as I can lol!

Gompers, BSN, RN · Dec 19, 2005

Okay, I'm a student that is hoping to go into NICU in about 6 months when I graduate. I haven't been able to buy any books yet about it, so I'm still very uneducated about the specifics. Can I ask why you would use a narcotic for babies on vents? Is it painful or just irritating?

Being on a ventilator is uncomfortable for anyone, even babies. I've never been awake and intubated myself, but I can't imagine it's comfortable at all. You can't move any which way you want because of the tube, and it's pretty large in proportion to your throat. So yeah, probably irritating and a little painful too. There is also suctioning, where you pass a suction catheter down the tube and suck the secretions out of the lungs. That is VERY irritating. There is also the issue of sedation - it's natural to want to pull that tube out - it's like a basic reflex, I think. So if you sedate the patient, adult or baby, they're less likely to be trying to pul the tube out.