Someone answer me before I lose my mind

  1. Ok, I am new to the NICU and finding some things incredibly frustrating. Everytime I give report there is always something that I or a nurse before me has done completely wrong (according to the nurse accepting report). Then when I ask someone more experienced, they will often disagree. I feel like I am not providing good enough care because everyone (my preceptor, the docs, the other nurses, the team leader, etc) tells me something different. We also have primary nurses who know their babies very well, but that info does not get passed on and then they are understandably upset when they come back after their days off and the baby's "normal" care was done differently.

    So, my question is: Do any of you have a good system for passing on the care plan? Even a copy of the forms you use would be helpful.

    Also: what do you all feel about instilling NS with suctionning. Our policy is to go down dry, if still crackly or coarse, instill and suction 2 times. I am asking because a nurse told me that the newest research says not to instill, and she feels that is the reason her primary is not doing as well on the ventillator. But, the RTs tell me that isn't the case.

    Any help would be appreciated, I am going nuts
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    About fergus51

    Joined: Jul '00; Posts: 11,351; Likes: 384


  3. by   KayNICUchsd
    The hospital I did my preceptorship at had a pretty good system. Each nurse would use the same sheet and report off accordingly... See if this helps any!!!

    Name: Age: MD: Weight:

    Cardiovascular/A's and B's:
    Infectious Disease:
    Social/ D/C Teaching/ OT/PT Consults:

    Pretty much covered everything and made things consistent when all nurses were using it and reporting off in the same order... Makes sense...
  4. by   sweetdreams
    Sounds like you must be giving report to some nurses that have worked in the unit since it opened. Seems like ICU has a tendency to turn some nurses into Supernurse... a legend in their own mind. Yet, in my experience they are usually worthless in a code except to critique everyone elses performance afterward. Usually there are several ways to perform a task. Its hard to tell from your post if these nurses are (a) Ultimately interested in optimal patient care, (b) so ingrained in their way of doing things that your way seems inefficient, or (c) trying to establish a pecking order by using this behavior to initiate you to the unit.

    I would follow a standardized report much like KayNICUchsd mentioned above which also highlighted changes in the patient and new orders as well as your "gut" feeling about the patient. I always really appreciate the latter in report.

    If they get to picky in report over minor details, feel free to hand them the chart, its all in there.

    Hang in there, everyone in the unit was new at one time, even if it was the day after God made dirt for some.
  5. by   dawngloves
    I can help you with the suction question! We talked bout his before. Seems six of one, half dozen another.
  6. by   prmenrs
    I posted on that other thread re: suctioning, so will not repeat here.

    Try to develop a "report sheet" for yourself, w/info like the above. The one I developed for myself was 5x8, 2 sides One side for history. There is not THAT much variety in NICU, pts are USUALLY either term and sick [meconium, pneumonia, pneumothorax, tachypnea, IDM, heart problem, bilirubin, IUGR, etc] or premies [weeks @ birth, weeks today, rds, surf'ed, pda, rx'd, bilirubin, IVH gr?, NEC]. You can put all those acronyms on one side under 'baby history', and circle the ones that apply. Have a vertical line, on the other side of that is mom's hx: gr/para, age, vag/C-sect, prenatal care or not, perinatal risks like ROM, AB/O, diabetes, tocolysis, DRUG history, social hx if pertinent; if getting towards d/c, teaching needs and d/c testing, CRgram, PKU, f/u appointments, etc.

    All that is on the back. the front has name, today's date, today's WT and whether wt is + or - and how much. One side of this side has a vertical line, w/ the space divided into 12 sections and times written in the corners (12 hr shifts). Put scheduled meds, labs, treatments in the boxes. Check 'em off as you do them. The other side of this line goes by systems: RESP: settings, last gas, secretions, any x-ray reports; IV'S: list all lines, what's infusing, concentrations, when it needs to be changed; LABS: when they're due and any significant results, if any head or heart US are scheduled; FEEDINGS: what, how, when, and any special hints/techniques that work for that particular munchkin; the last section is for whatever you want, I would put stuff like if the baby had any off-unit proceedures or tests scheduled that day, or any therapies, AND, the dreaded A'S and B'S--anything that didn't otherwise have a home.

    The last thing I want to say is that if a baby has a primary RN, that RN should NOT depend on word of mouth to pass on any special instructions, and then get upset if those wishes are not granted. S/He needs to WRITE THEM ON THE KARDEX!!!!! (or whatever it is you use to document the 'plan of care').

    If you get scolded by someone, just ask where you should have looked to obtain the info; if it isn't written down, clarify what she wants done and write it down for yourself.

    Some of my co-workers had notebooks they used for their worksheets so they could keep babies histories in one place. Made for good documentation for evals, too. Only problem is that the info should be shredded at the end of the shift, or, at least, the name and DOB torn off so it's not identifiable. (then, of course, YOU don't know who it is, either.)

    Try to be patient, they're getting used to you, too; if you're getting conflicting info, talk to your preceptor, see if there is a policy regarding that issue. You might do a little "homework", too--look it up in your Merenstein or on the internet. Try to get written info: the word of the day is 'evidenced based practice'.

    Hang in there, ok?
    Last edit by prmenrs on Jul 28, '03
  7. by   fergus51
    Thanks all.

    We don't have any problems with reporting the assessment findings. The problems are with the "little things". Like for example, a nurse today told me her baby couldn't tolerate nasal cpap. Other babies only like certain positions for feeds, etc.. There is no real care plan to pass on those little things.

    As far as policies. It is the unit policy to instill (I am a policy book freak and all my reading says instill, but that's not current enough info according to some and is according to others), and that's what I've been doing since I started here.
    Last edit by fergus51 on Jul 30, '03
  8. by   glascow
    Listen to what everyone has to say. Then, with experience, you will form your own opinions. Try to emulate the nurse you most respect. Everyday is a learning experience. What one baby liked 12 hrs ago, they may not like anymore. That's why it's ICU, the nurse is constantly assessing and reassessing every action. The baby that ended up tubed probably was decompensating anway.
  9. by   pengland1965
    There has been alot of good advice here. I would only add 1 more idea. Read your unit policy! We keep our policies updated at least yearly. If there is something special that works well with an infant. The primary nurse usually writes it on the Kardex. Anyone can write special instructions on the Kardex. But we try to limit the number of people to the infant's primary nurse and associate nurses.
  10. by   ainz
    Good patient care policies and procedures keep everyone on the same sheet of music. An outline of what is to be included in report should be developed by your nurse manager and medical director, again, everyone on the same sheet of music.
  11. by   nurseiam
    We also use a Kardex with what is listed above. But each nurse still does things a little different. When I was new I found a few nurses whose practice I admired and always went to them. They were people that I knew I wanted to be like. It worked very well.When I was new I would also go over my chart after report and write other information in in a different colored ink. If you work in a stretch then keep your card and clip it to the next night that way when you are giving report to a person who has not had that patient ou have all the info you have gathered. This will also help you recognize trends in your patient.
    Good luck!
  12. by   NicuGal
    We too use a has all the pertinent info and we have a sheet that lists the systems and you just put down things like CNS...HUS on such and such date...results blah blah. Also, we have an area to put individualized care, such as the things that the supernurses want people to know. We also put dry eraser boards at all the kids beds and we put stuff like..I luv my belly, or don't forget to sx me before I eat.

    As for the lit is dry, but if a kid is known to have icky secretions, the saline goes down. Most kids with RDS really don't have many secretions unless something else is going on. I would go by your policy...can't get into trouble that way.
  13. by   fergus51
    Oh, people can get upset if I follow the policies. It covers me with the manager, but still can upset the primary nurse.

    The problem seems to be that we don't have a Kardex with the special instructions at the bedside. I like the idea of a dry erase board. The pertinent medical information gets passed on without problems, it's the individualized care that doesn't. I have no desire to change the care that the primary nurse has been doing, and I have no problem adapting my care to different babies and primaries. My problem is that I can't find the necessary information to do that.
  14. by   CatRN
    Hi there....
    First, don't get frustrated! Every nurse has a different way to do the same thing, and since our patients cannot verbally tell us what they like.....we like to think we know what they like. Most babies prefer prone to other positions, no left side postioning for reflux babies...etc. Also, NICU nurses are notoriously terroritorial...and sometimes are used the one way of doing things and don't like to learn different methods. NICU nursing is constantly changing and new literature and studies are constantly being published with different ways to feed, position, suction, etc. Developmental care is evolving, kangaroo care is more popular....but are still not being implemented in all NICU's. Just ask questions and like another poster suggested, if they want the history down to the apgars on a baby that's on Day 60 of life, pass them the chart and tell them to look it up. Kardex's are great....but unfortunately, I learned that some places are completely on computer now and the kardex no longer exists. As a travelor, I have learned so many different things from so many different NICU's and in turn, have taught some places new ways of doing the same things. It's a constant learning experience!
    As far as suctioning, use your judgement. If the secretions seem thin and are visible frothing up and down the ETT, than no saline necessary. But if you suspect a plug or your baby isn't moving air on ascultation, give a few manual breaths and if you still don't hear any air moving......consider the hx of the infant of is desat'ing, etc.....maybe a little saline is necessary....some literature supports saline, some doesn't. Such is the case with study suggests one thing, and another quickly suggests likewise. Just remember, each baby is unique and can change in an instant. Hope this helps a bit!