NICU pearls

labordude, BSN, RN · Mar 28, 2015

Never trust a 35 weeker. Doubly so if they are white and have a member.

labordude, BSN, RN · Mar 30, 2015

But in all seriousness, here's a few.

If you get a kiddo who ends up with a dusky foot after umbilical line insertion, try putting a heel warmer on the OPPOSITE foot. You'd be amazed how frequently that works.
When drawing a heel stick CBC, wipe with your gauze pad after every 3 drops to remove the microclots that are forming at the site of your stick. Also, do not SHAKE the tube. Invert gently and you can actually roll the tube around the get as much of the blood in contact with the EDTA in the tube as possible.
From a pain and discomfort perspective THREE venous sticks are still preferable to one heel stick. Learn how to do them. You will also get more accurate lab results.
Talk to your NNP/MD team about infant driven feeding and get it implemented in your unit. No more of this PO q shift, PO every other feed bull...crap. If you actually follow the infant's cues, they do better. Funny how that works.
If you have a kiddo on CPAP (whether NCPAP or BCPAP) and they are prone, do not lay them directly on a Freddy Frog. They have this nasty tendency to faceplant and increase the pressure of the prongs on their nares. See pictures below.
- Picture 1 = GOOD positioning with blanket roll:
- Picture 2 = POOR positioning:
[*]If you don't do Bubble CPAP...why are you not doing Bubble CPAP?!
[*]Draw your blood cultures BEFORE placing the IV for the most accurate results.
[*]Learn how to calculate Glucose Infusion Rate (GIR) and know it for your babies on IV fluids/TPN. Make sure you understand the implications of this number.
[*]If your baby is on servo mode and suddenly requiring a much higher or lower air temperature, something is not right. It may be as simple as a probe cover falling off or they are laying on it, but they might also have a high temp for other reasons. Be vigilant!
[*]If you have choice things to say about the mother of an NAS baby, don't take care of that baby. They don't need your negativity.
[*]NG tubes are often misplaced. Research has shown that Nose-Ear-Xiphoid(NEX) results in a too shallow an insertion the majority of the time and that Nose-Ear-MidwaybetweenxiphoidandUmbilicus (NEMU) is better. Better yet are the regression algorithms that have been invented. One is (for NG) 3*wt in kg + 13. For the statistically interested, that particular formula identified 100% of misplaced NG tubes in the study.
[*]Get more comfortable drawing labs in the room with mom or even with the baby skin to skin. There is a huge amount of research demonstrating the negative effects of mother-infant separation with regards to stress hormone production, distress behaviors, and poor feeding following return to mom. Just don't do it while she's breastfeeding, that poor little bugger will start thinking he's going to get stuck every time he latches.

Okay, I'm done. I'm in an exercise induced high right now so I'm going to enjoy it.

mrscreixell · Apr 8, 2015

Thanks ICUGUY, great tips. They have been added to the list.

mrscreixell · Apr 8, 2015

Hi, would you mind sharing with me via PM your unit's police on feeding? I'm quite interested in how it is being implemented. Thanks.

tinkerbell419 · Apr 8, 2015

Taking blood gases has been a bit of a nightmare but a tip is to roll the capilary tube in the palm of your hand to stop it clotting and take your time when feeding it into the machine. And use a clot catcher. And dont use too much vaseline on babies heel when collecting the blood and it sticks to the bottom of the tube.

tinkerbell419 · Apr 8, 2015

What is a freddy frog?

tinkerbell419 · Apr 8, 2015

And does anyone has any really good tips on how to bleed a baby for taking bloods, and what size lancets (heel pricking devices) to use. Do any of you have a policy or guide for which lancet to use?

Coffee Nurse, BSN, RN · Apr 9, 2015

But in all seriousness, here's a few.
If your baby is on servo mode and suddenly requiring a much higher or lower air temperature, something is not right. It may be as simple as a probe cover falling off or they are laying on it, but they might also have a high temp for other reasons. Be vigilant!
NG tubes are often misplaced. Research has shown that Nose-Ear-Xiphoid(NEX) results in a too shallow an insertion the majority of the time and that Nose-Ear-MidwaybetweenxiphoidandUmbilicus (NEMU) is better. Better yet are the regression algorithms that have been invented. One is (for NG) 3*wt in kg + 13. For the statistically interested, that particular formula identified 100% of misplaced NG tubes in the study.

I always get suspicious when I see the probe temp and air temp are reading the same or nearly the same. Check to make sure the probe hasn't come off and is just reading the air temp.

Our policy is also NEX for NGTs, but that's just never made sense to me from an anatomical point of view. I measure NEX then add a cm or two -- basically whatever will get me to that NEMU point that you describe :yes:

Coffee Nurse, BSN, RN · Apr 9, 2015

And does anyone has any really good tips on how to bleed a baby for taking bloods, and what size lancets (heel pricking devices) to use. Do any of you have a policy or guide for which lancet to use?

-Make sure the foot is warm -- wrap it, use a heel warmer or warm compress. The perfusion (=flow) will be better, plus your results will be more accurate.

-Be firm in your stick -- I see a lot of new nurses/students trying to be gentle with the lancet, but if you don't press firmly and do it too shallow you'll probably end up having to stick again anyway.

-Try to keep the baby's foot below his/her heart. People tend to lift the leg to give themselves easier access, but they're really working against themselves with that.

-Release the foot/leg regularly and nearly completely to let the foot refill.

-Remember it's a baby, not just a leg!! The number of times I've come across people taking blood and the leg is twisted at the most unnatural angle to the body...ow. (Same thing goes for peripheral cannula insertion.) Position the baby supine if he'll tolerate it, or sidelying and use the uppermost foot.

-Swaddle if possible, and use a pacifier if okay with parents. It's kinder to the baby and makes your job easier too.

labordude, BSN, RN · Apr 9, 2015

What is a freddy frog?

Frederick T. Frog - Philips

It's a positioning that is a bean bag. Many hospitals have discontinued using them because they are an expense that is hard to justify.

labordude, BSN, RN · Apr 9, 2015

-Make sure the foot is warm -- wrap it, use a heel warmer or warm compress. The perfusion (=flow) will be better, plus your results will be more accurate.
-Be firm in your stick -- I see a lot of new nurses/students trying to be gentle with the lancet, but if you don't press firmly and do it too shallow you'll probably end up having to stick again anyway.
-Try to keep the baby's foot below his/her heart. People tend to lift the leg to give themselves easier access, but they're really working against themselves with that.
-Release the foot/leg regularly and nearly completely to let the foot refill.
-Remember it's a baby, not just a leg!! The number of times I've come across people taking blood and the leg is twisted at the most unnatural angle to the body...ow. (Same thing goes for peripheral cannula insertion.) Position the baby supine if he'll tolerate it, or sidelying and use the uppermost foot.
-Swaddle if possible, and use a pacifier if okay with parents. It's kinder to the baby and makes your job easier too.

When it comes to picking a lancet, I always choose the smallest appropriate size. There is almost never a reason to use the full-term size lancet just to do a point-of-care glucose. For positioning of the lancet, take your finger to the pad of the heel and slide toward you until you hit the bone. Position the bottom edge of the lancet on the bone and roll it forward. You will end up in a spot okay for use as seen in this image.

Be careful in using the medial side as the medial plantar artery is much closer to where you are sticking. You are usually better off working the lateral side.