NICU new grad help with assessment/time management

[Chloe713]

I started working in a level 4 NICU as a new grad this past month. I am having trouble with time management. It takes me around 25 min to assess, get vitals, change and weigh their diaper, and get their feeding ready. I heard it should only take me 15 min. I usually start by trying to count respirations by placing my hand on them, I’m not sure if there is a better way to count them? Then I measure their head circumference and feel their fontanels and sutures. Then I take their temperature, which usually makes them cry so when I try to count their HR and listen to their lungs, I can’t get it because their HR is too fast and I can’t hear it. I then listen to their stomach, change their diaper, measure their abdominal girth. I also have a hard time getting their abdominal girth because I don’t know if I’m laying the tape measure correctly or if it’s too low or high. I get the BP and change the pulse ox when they’re calmer. Does anyone have any tips to be able to assess better and quicker? I feel like I’m drowning and I get so behind every day.

[babyNP., APRN]

I don't have any specific tips (hard to assess if I don't see you in person) but I will tell you that what you are experiencing is 100% normal. Be kind to yourself. Although is it required to get an apical heart rate and manually count their respirations and do a head circumference every single care time? I would clarify that with your preceptor because that seems unnecessary and excessive.

As a new grad in Level IV, you are in a highly niche unit taking care of very sick babies. It is hard (I cried a few times). It will take time. Eventually I went from not being able to remember a single thing about my kids and constantly looking at my report sheet throughout the shift to not writing anything down and just listening to report because I had my own mental plan in place and was comfortable with the electronic medical record guiding me if my brain had questions (just the way my brain worked, nothing wrong with writing things down on a report sheet for anyone regardless of experience). Nowadays, I don't have that luxury of doing that with sometimes 25 babies on my service as a NNP, lol, as there is only so much my brain can process.

[Coffee Nurse, BSN, RN]

Agreed that it is a totally normal thing to feel like you're taking forever compared to people who've been doing this for a while. My biggest tip for time management, especially at your stage, is to start everything early and give yourself plenty of time to do a good thorough job. If it takes you half an hour to do a full assessment, give yourself the half hour, starting early enough that you're still starting your feed (if applicable) on time. This will keep you and the kiddos on schedule. As you get more efficient, it'll take you less time, and you can start a little later.

As far as your actual assessment, it sounds like you've got things pretty much in the right order. I like to go from least invasive to most invasive, so I'd start with counting resps (yes, using the hand method, or just watching the chest if it's visible enough) and doing a BP, then a temperature so they don't have much of a chance to drop after opening the incubator doors or unwrapping. I agree that the thermometer almost inevitably causes crying, but a pacifier or some containment holding should settle them down well enough for you to proceed with auscultating.

[prmenrs, RN]

Start w/observations: position, color, activity, O2 sat, what equipment, what drips, IV site(s). Resp status and support. Then tactile: gently place your hand on their back to count resp; place stethoscope to listen for breath sounds, move to front (preferably w/o waking the kiddo) listen for murmurs, count heart rate, listen for bowel sounds; feel fontanels and sutures, pulses. Turn the baby over, slip the measuring tape under the baby; take the abd girth @ the umbilicus, that's standard. Check NG tube placement, note measurement. Diaper change, skin integrity. Close your diaper up completely to prevent urine evaporation. Change your gloves. If there's a bath, give it now. Dry and re-diaper. Meds and feeding.

Until you develop a routine, it will take take as long as it takes. You will speed up as time goes on. If you have a routine, you will not miss stuff, and have to bother the baby again. If any of your findings are not normal, it will slow you down--a lot.

I wish you all the best. I know you will do well.

[Leader25, ASN, BSN, RN]

Seems excessive for a stable neonate,remember you should be able to follow NRP guidelines in an emergency,you will not have that much time. So is it girth ac or once a shift,? depends,sometimes we keep doing something because the order was not updated,like daily HC instead of HC mon,wed,Fri.

[Coffee Nurse, BSN, RN]

3 hours ago, Leader25 said:

Seems excessive for a stable neonate,remember you should be able to follow NRP guidelines in an emergency,you will not have that much time. So is it girth ac or once a shift,? depends,sometimes we keep doing something because the order was not updated,like daily HC instead of HC mon,wed,Fri.

She's talking about a beginning-of-shift assessment, not a delivery room assessment.