Problem with respiratory team!!!!!!!! Arghhhhhh!

[NICU_Nurse, BSN, RN]

Okay, here's the deal. Most of you know by now that I graduated in Jan. and started right away in the NICU. I have worked very hard trying to learn as much as possible, but I'm running into a problem with some members of our respiratory team. In my hospital, the RT's are on the unit 24-7 with their own assignments. We are supposed to work together, and they basically handle all the vent settings, cpap, nc's, and drawing/interpreting blood gases. The past couple of days (an example...this is a daily occurance) I have worked with 'Sam', an RT on night shift. Sam is..well...a bit of a character, but I had never doubted for a minute that he was experienced and capable. I had a baby on an oscillator, who was tolerating the settings well and was being weaned down from 70% fiO2. The baby was on the second day of a three-day course of Dexamethasone, and had been weaned down to 40%. He was satting high, nearly 100, and appeared to be quite comfortable. No flailing, jitteriness, etc. Relaxed, sats high. Sam was doing blood gases q4 hours, and each time they came back, he would tell me how they were and give me a printed report. I am still learning to interpret these effectively, and so am somewhat reliant on the RT's expertise to assist and guide me in my decision making. If all else fails, I ask another nurse or three, but opinions vary, etc. Sam tells me all night that the gases are good, no problem. I look at the reports and everything was good, except the pCO2 seemed to be sloooooooooooooowly rising. I ask him about this, he says it's not bad, nothing to worry about, not high at all. Because this infant appears calm and comfortable, I used minimal sedation- q 4-6 instead of q2 hours (Versed was the only thing ordered). I was also concerned about over-sedating this baby, an ELBW infant who was three weeks old (gest. age 24 3/7). At about mid-shift, I became a tad bit concerned that the baby wasn't moving at all (had gotten three doses of Morphine on day shift) and decided not to sedate for the rest of the shift unless I had to, and would report all to the incoming RN, who could then use her own judgment regarding additional sedation. Okay, day shift, here comes the day RT, and he literally *****es me out for not sedating the baby q2 hours, telling me very loudly that I am trying to kill the baby, I am making him have to work harder during the day shift, etc. He asks about the gases, and I say that they were not bad all night, and look to Sam to back me up. Well, dontcha know that Sam decides to do a bit of hemming and hawing, and he says, 'Oh, the gases were crap all night long, the PCO2 was horrible, etc.' and my jaw just hit the floor. I mean, I LOOKED at each and every gas, but I do admit that I am still learning, and I'm wondering if I missed something!!! I would never EVER do anything to the detriment of these babies, and so I now look to you nursing goddesses for some advice! If I am wrong, I humbly stand corrected! Of course, the second the day RT comes to the bedside, the baby begins to move around a bit and opens his eyes. I decided that it was the noise of all the shift change brouhaha, etc., and the fact that the sedation from earlier in the day had finally begun wearing off, but of course the day RT starts wailing about how active the baby is and how could I let him get this way etc. Explaining was pointless, because as he said, Look at him! Doesn't matter what happened all night, the baby is moving his legs for three minutes and all of a sudden I'm the angel of death! Okay, that's situation number one. Second one is this: I had Sam last night again, same baby, and I suggested that we turn the baby and reposition his head. Sam says okay, and then decides he can't turn the baby without jostling the tube yadayada, so I finally say, okay, let's just reposition using positioning rolls and we'll explain it to day shift. Well, the new day RT comes on, this time a very crabby woman, who proceeds to curse at me and accuses me of trying to break down the entire right side of the baby's face by not turning him overnight. I tried to explain, looked at Sam yet again for back up, considering that it was SOLELY him who decided not to turn the baby, and he hems and haws. I walk away, turn around, and hear him saying to the day RT that every time we turned the baby on his stomach he desatted and didn't tolerate it, so that's why he didn't turn the baby all night. WHAT? That was a blatant lie!! He told me that oscillator babies don't like the stomach, he couldn't check for chest wiggle that way, etc. and here he is just telling her this and basically making me look like the wicked witch who lives to torture innocent children! For the second day in a row, I got a drop-dead look from the RT and I got so frustrated I was about to scream and rip Sam's hair out at the roots. Anyone? Please tell me what I'm doing wrong here! The ONLY thing I am concerned about is the baby's health and well-being. I need advice. Thank you!

[NicuGal, MSN, RN]

Sounds like you need to go to the unit manager and do some high complaining. First, in our unit, if the gases are bad, it is RT's responsiblity to call the HO or fellow. Second, if you did good charting, I would have thrown that in his face. Third, tell him that if he ever speaks to you this way again, you will not only right him up, but go to human resources and report him for slander. You tell them that their job is to take care of the respiratory side, you will take care of the nursing aspect. There are some kids in our unit that we don't move for DAYS! Nope, they like how they are, we leave them there!

Geez...what a bunch of crabs!!! And do all these things with a BIG grin on your face..makes it so much more effective!!!

Hang in there! :) :) :)

[prmenrs, RN]

Sam is very dangerous. Document every thing you decide jointly, and double check gas values w/another nurse or an RT you DO trust.

It's OK to look astonished, say (and look wide-eyed and as innocent as possible), "But, Sam, YOU said we shouldn't turn the baby because...(whatever). Look, I even documented it right here!"

What an a**w*p*!!!

[kids]

Originally posted by prmenrs

Sam is very dangerous. Document every thing you decide jointly, and double check gas values w/another nurse or an RT you DO trust.

It's OK to look astonished, say (and look wide-eyed and as innocent as possible), "But, Sam, YOU said we shouldn't turn the baby because...(whatever). Look, I even documented it right here!"

What an a**w*p*!!!

DITTO!

Cover your own a$$ and hang his at the same time (or rather show him you are on to his game).

[NICU_Nurse, BSN, RN]

Thank you for your replies. Another thing I'm wondering is how you handle sedation with your vented babies, particularly babies who are on oscillators? How often do you use sedation? Assuming it is ordered q2-4, do you typically sedate every two hours, every four, just now and then? Is there ever a situation where you wouldn't sedate the baby, despite the existence of a PRN order? I know that your first response would be to use judgement, but my judgement is a bit limited by my lack of experience, so feel free to answer and know that I am not relying on any of you to directly answer these questions...I am responsible for this baby, but I am curious what more experienced nurses think. I was very upset that the day shift RT was so angry about the 'lack of sedation'. He has twenty years of experience on me, and I know he's not a nurse, and I KNOW he shouldn't have spoken to me that way, but the thing I'm wondering is SHOULD I have been sedating that baby more? I mean, is there a general protocol regarding sedation while on a vent? I want my babies to be as comfortable and calm as possible, but I don't want to sedate just for the sake of sedating, you know?

[NicuGal, MSN, RN]

We don't use sedation just to because it is there. The kid has to show us he needs it...poor sats, restless, things like that. If they want it straight, it should be a staight order, not PRN. I have not given sedation because it drops their Maps, or they aren't MOVING at all, unless that is what they want. I don't think that their is any protocal for it.

[ICUBecky]

i'm not in NICU...so i can't tell you about sedating a baby. but, i have had some bad experiences with RT too. i once had to go off on one, because she was questioning my nursing judgements, the key word here is NURSING, all night. turning/repositioning, "shouldn't you do something about that blod pressure", "he should be sedated" (even though ALL ABGs were WNL, and he was just about comatose)...stuff like that. everytime she went into the room, she would make a comment about my nursing care. what the heck, who is the one who went to nursing school for 4 years? i finally said, "listen you are supposed to handle pulmonary, and I am supposed to handle nursing care. you worry about the vent, and i will worry about everything else" i said it somewhat *****ingly and she backed off. she never said a thing since. well, i quit that job and moved to another where i am also the respiratory therapist for my patient, and i can criticise my own nursing judgements!

please kristi, stand up for yourself...don't let these RT's intimidate you, especially when it is your nursing judgement (such as sedation, and turning). if they keep bothering you, discuss this with your unit manager. CHART, CHART, CHART!! don't get in trouble for something the RT told you to do. and ultimately, the decisions are up to you, b/c these babies are your ultimate responsibilities. if you disagree with what the RT says, you follow your own judgement!

good luck!

becky

[prmenrs, RN]

I believe a baby on oscillation is critically ill; fighting the ventilaor WILL have lethal consequences--sedated and paralyzed, please. That means paralytic q2h, MS alternate q2h, ~?ativan q3-4hr; additional doses of paralytic if he even thinks about moving.

Gently tilting side to side [with a blanket roll] can help w/edema, and lung aeration. Turning prone is good; premies, esp. can have better lung function on their tummies. If you go prone, it may be easier to turn head to foot rather than rolling over--lines and chest tubes tangle less that way. Also make sure there's help around when you turn, just in case....

ASSUME that a baby that sick needs sedation and pain meds--he has no way of telling you other than changing VS, which may not be good.

Also cover their eyes and ears to protect from noise and light. keep the environment QUIET!

Remember your good positioning from nsg fundamentals--don't leave arms and legs hanging off and not supported. If the baby doesn't look comfortable, he probably isn't and won't rest and heal as easily.

Just in case I didn't mention it, this is a pt who needs a 1:1 nurse.

It's easy to dismiss all this kind of "little" stuff as silly when you're trying to figure out blood values and drips, etc., but I believe it makes a big difference, not only to the baby but to his parents. Sometimes using a toy to rest an arm on helps remind Mom and Dad that you know it's a baby. Soft, gentle music can also supplement pain meds.

Kristi, I really admire the effort you're making to provide the best and most comprehensive possible care for these babies. You will be a great NICU nurse, and will not forget these lessons when you are mentoring a younger nurse someday.

God Bless, baby girl!!

[KRVRN, BSN, RN]

Yes, Sam was inappropriate, and I agree with what everyone else has said regarding that.

As for the question of sedation, I agree with prmenrs. A HFOV baby shoud be quite sedated. There's an arguement for not sedating if you want the baby to breathe more in an effort to extubate soon. A HFOV pt is NOT supposed to be breathing by himself. Sedate. I've found that babies will sometimes sat better if they receive sedation, even if they are not wiggling or fighting. But ultimately it's your choice to give sedation or not because they can't give drugs right?

Something else to remember... Just because they SAY it doesn't mean YOU are wrong for disagreeing. An exampe: I've had experienced RT's question me as to why I wanted to flip the baby to assess the abdomen. Well, my unit states I have LOOK and FEEL and measure the abd at least q6hrs if it's warranted (which is basically every baby that's not full term r/o sepsis). Well, it had been 6 hours, and yes, we will be turning for the CXR 3 hours from now but that's too late. CYA right? This is a sick preemie on pressors that probably shouldn't even be getting feedings (but that's another arguement). Was already having some residuals...could be an early sign of course. Truthfully I would rather have assessed the abd q3hrs. but that's too often to be messing with the baby. So guess who wins? Me. I'm sorry but I HAVE to turn the baby. Either help me or go away. The RT didn't like it but oh well, there's more to a baby than a pair of lungs and I'm responsible for the rest of it.

So don't feel bad if you disgaree. Same goes for other nurses. They don't know what was going on with the baby if they weren't there, so don't feel bad if they criticize your reasoning. We've all had the situation where you sedate the baby left and right for being crazy then the next shift doesn't do it at all and they wonder why you did. Then you get the baby back again and you have to sedate left and right again.

[NicuGal, MSN, RN]

Do you guys really keep them that quiet? We only snow the ones on high high settings and the others we let wake up as we extubate straight from the ocillator many times. We rarely paralyze now...there have been studies that show that it is very hard on the gut and the fluid shifts are hard on these kids. A few of our attending believe that this also can help precipitate an IVH because of the dramatic fluid shifts....the decrease in BP then means you need vasopressors and pushes and these can increase the capillary load and lead to IVH in some cases.

I always find it interesting how each place does things so differently!

[KRVRN, BSN, RN]

We consider HFOV high settings. We only use it for the sick kids. So we would never extubate straight from HFOV. We use paralytics as a last resort also.

[prmenrs, RN]

Ditto what KRVRN wrote. If HFOV isn't high, high settings, what is?

I would consider anyone on HFOV sick enough to warrant paralyzation as well. At that point, you want as much control over their breathing as possible. Keeping them paralyzed and ni-ni [as my son used to say] is the only way to maintain that control.

You don't want them in pain, you want them as relaxed and asleep as possible. If they're paralyzed, they should automatically be getting the good drugs--it's not nice to paralyze them, and leave them awake, feeling everything you do to them, good or bad.