Love_2_Learn

Thanks for your reply and thoughts! I'm thinking of microscopic amounts of undiluted powder though. The filter needle filters out particles that are 5 microns in size; actually quite microscopic. It seems like the filter would only take out the teensy microscopic bits if there were any, similar to how it removes the teensy microscopic bits of glass shards from ampules. I'd absolutely hate to think I was filtering out too much of the medication and causing the patient not to receive the full dose!!! I guess I'm over thinking this. I only got started thinking about it when seeing a nurse draw up her reconstituted (diluted powder with sterile water) ampicillin and her saying, "I always filter medications that are powder that I've mixed up." Again, I think too much I suppose. Thanks again for your thoughts! They are good ones! I wonder if I should ask a pharmacist?.....

I know very well that the filter needles are always to be used when drawing up any medication from a glass ampule. Fully understand about microscopic glass shards and how they can cause problems. Now I am wondering if I should be using one to draw up a reconstituted powder medication before administering it. Example: We place sterile water in (flat rubber topped) vials of powdered ampicillin and then draw up the liquid ampicillin after it has become clear and fully mixed. Once it's mixed do I need to use a filter needle to draw it up into a syringe and then remove the filter needle before connecting it to the IV medication tubing to give to the patient? I guess my main question is: Could there be microscopic blobs of unmixed powdered ampicillin which needs to be filtered before administering? I'd love to know the correct answer and would be ridiculously happy if someone has a reference I could use to share with my coworkers if this is true. I want to do what is best for my patients and realize that new evidence occurs daily and changes can be good. Thanks in advance for any information or thoughts you have on this subject!

Working part time at a hospital will get your foot in the door and if you are a good employee (dependable, friendly, hard worker) you will probably get extra points when they decide to hire the recent new grads. Lots of student nurses work as secretaries on the nursing units. This is a good way to learn the routine of the unit, common lab and other orders, how to work the computers, etc. Later once you are in your actual nursing classes they might have positions specifically for nursing students, similar to nursing assistants the first year and then with some expanded duties the second year. If you are fully certain OB is the area you want to be in, try to aim for that area (labor & delivery, antenatal floor, postpartum, well baby nursery, mother-baby unit, special care nursery, NICU, etc). If you end up on med-surg that is not a minus because you will realize that all kinds of women have babies and many of them have conditions which are treated in a med-surg area (asthma flare ups, heart conditions, strokes, sickle-cell, kidney stones, gallbladder problems, etc.) so you can learn a lot and be prepared for when later as an OB nurse a mother comes in pregnant and in distress for something unrelated to her pregnancy. I always knew I wanted to work with babies and I asked my OB instructor if it was truly necessary for me to work 2 years of med-surg first (I had worked med-surg for on year as a student nurse every Friday & Saturday night for the last year of my nursing education) and she said that if I knew for certain in my heart that I wanted to work with the little ones that she would rather see me go straight to the nursery rather than force myself to do a 2 year med-surg stint and end up leaving the profession because I was unhappy. I started in a well baby nursery, then did mother-baby (learned postpartum moms & some stable undelivered moms). I appreciate her advice and am happy with my decision. My only drawback is that I realize that today (20 years later) I know very little about adults. I still subscribe to two general nursing journals along with all my neonatal ones but I would feel lost on a med-surg floor or any floor except postpartum at this time in my career. Keep that in mind as you make your decisions. Any experience is good experience and sometimes life puts you in places you don't think you want to be but in hindsight you are ever so glad you were put there because of the learning experience it gave you. Enjoy your education, study hard, remember the basics are incredibly important as everything else builds on them (A&P, Micro, etc) and remember that nursing school is intense but you will make it through just like so many of the rest of us did. Good luck in your schooling and career! One last thought, go ahead and join AWHONN the main nursing organization for OB nurses. You will probably get the student's rate to join and will get journals and loads of other information access concerning OB nursing. It would be good side reading to get your feet wet, but don't neglect your nursing studies. http://www.awhonn.org

We nurses are the last line of defense our patients have. Look up medication information, question doctor's orders, question the pharmacist, do whatever you need to in order to be your patients advocate. And like others have said, little Miss Priss who is so overly-confident, blows off pharmacology, and takes false pride in doing everything like lightening will just as quickly find herself in a heap of trouble! Keep your integrity, smile, and always strive to do your best. I'm proud of you!

Wonderful article! Thanks for sharing! I hope subee gets a chance to read it especially since anesthesia specialists recognized the problem first.

I don't know if its true, but I've heard that at the end of life people do not feel hungry like we do when we are healthy. It was explained to me in reference to my pets (no offense meant!) in how when they are at the end of their life they "go off their food". I've had lots of pets over the years and always noticed that at the end, in old age, they would suddenly turn very gray in their face quickly and then stop eating to the point of refusing food, and then within a couple of days they would leave our Earth. It seems kind of natural that our bodies would not be feeling the need for food when our body realizes that the calories needed to sustain life are not going to be needed. It's late, I'm kind of tired & having random thoughts. Guess I'll go to bed. :zzzzz

I'm honestly not familiar with the kangaroo pumps; don't think I've ever seen one but I've never worked in a pediatrics unit. Anyway, just wanted to say that when we put our breast milk on pumps we always make sure the syringe is in a horizontal position so the fats will enter the tubing in a more constant fashion. If the syringe is placed with the plunger on top and the tubing down below, ALL the fat can be seen collecting just under the plunger. When placed horizontally the fats can be seen all along the syringe. It really doesn't take but about an hour to see the separation occur. This is also why we make sure we put exactly the 4-hour amount of feeding in the syringe so we don't waste any of the precious fats.

I agree with NICU_babyRN's suggestion. You might also want to consider consulting with the dietitian for your unit since they probably would have some good evidence-based information and articles to share. I believe the American Dietetic Association has lots of guidelines and I'm sure they have some which would apply in this situation; your dietitian might have that information at their fingertips. Good luck, take a deep breath, and as I can see you already know...continue to speak and act as the professional you obviously are when coming up against difficult situations.

I really learned a lot from the book, Newborn Intensive Care: What Every Parent Needs to Know Edited by Jeanette Zaichkin. The newest edition was published in October 2009. It's about $30 on Amazon. You may recognize Jeanette Zaichkin's name as she is one of the leaders in NICU nursing. Her name is big for her contributions to the Neonatal Resuscitation Program books. Anyway, it's written in such a way that helps me explain things to parents in words THEY can understand. It's way too easy to use medical jargon without realizing it and this book has helped me a lot through the years. As far as admissions go, I agree with you getting report on the patient now that you have gotten better at performing the routine admission procedures. Where I have worked, the admitting nurse takes report and all the other nurses gather around to help. When you are the one to receive report it puts you in the driver seat to think critically about what is wrong with the baby and the expected plan of care the doctor or nurse practitioner will implement. Of course you will dive in and work on the baby too, but knowing where the baby's "been" helps you know where you will be "going" with the baby over the next few minutes and hours. It will all come together with time, and don't be discouraged if it takes at least 2 years to begin... yes begin.... to feel a bit comfortable. Never stop learning, seeking, and caring with all the empathy your heart can hold for your patients, families and coworkers. Wishing you the best nursing career possible!

Every 2 weeks. We don't use humidity. We have little sheets of paper which also have the NTE based on birth weight which is taped to the isolette and gives appropriate NTE for age as they grow...it's on this paper that we write the date to change the isolette. We also include it on our computer-charting kardex.

We use the Medela waterless breast milk warmers. They also can turn frozen milk into thawed milk or warm milk depending on what you want. It holds bottles and syringes of all sizes. We really like them a lot.

I've not worked on a med-surg floor for almost 20 years but remember how hectic it was. I have nothing to offer to help you but simply want to say how much I admire all of you and will be sure to send extra prayers and good wishes your way. It takes my breath away to see how busy you all can be!!!!!

Sounds like you have everything going in your favor. Honestly I can't think of a thing to share with you other than to be yourself. I'd hire you in a New York second. Keep your compassion and energy. Say your prayers and as you mentioned, God will place you where you need to be; I have a feeling it will be the NICU. Get a good night's sleep, have a healthy breakfast, and take a few deep, slow breaths before your interview. Be sure to look the interviewer in the eye, smile politely and be the kind of personality you would like to hire. I have confidence in you!

Just for clarification, if one of our babies has an og or ng tube in place and are allowed to bottle feed, we do check for residual before the feeding. This would be the case when the doctor orders something like, "Enfamil Premature 20 calorie with iron, 33 ml po/og q3h". If the baby does not have a tube at all and is bottle feeding we would not place a tube to check for residual before bottle feeding. We only check residual if there is a tube in place.

I can't imagine you being fired for crying. As you mention you tend to be strong during emergencies like resuscitations this is true for pretty much all of us. In the heat of the moment we are all strong, level-headed, thinking hard and acting fast. It's often after the incident that we tend to break down a bit and we often do it among ourselves. It's ok to shed a little tear with a family but you must remember they need you to be strong too. When babies pass away they are usually in the arms of their Mother and Father; the parents are usually crying and often the Mother lets out a cry that will bring you to your knees. Generally we pull the curtains around them to let them have their privacy and we walk away and wipe our tears and hug each other. After the family has felt they are ready to leave the unit, this is when we often will truly cry together. A really hard thing to do is assist parents who want to give post-mortem care to their baby like bathing the little one and dressing them, bundling them, etc. Now, that is hard but again, you somehow suck it up because you know they need this for their grieving and they are allowing you into one of their most intimate moments of their lives and will appreciate you for helping them. Sometimes the hospital minister will have a prayer with us nurses and I remember once when we had a bunch of deaths occur in a short time our nurse manager brought in a psychologist to help us with our grief. So, it's ok to cry and be emotional in the right place and somehow you will be able to manage this like the rest of us crybabies do. I'm one of the worst crybabies I know and I've managed to remain professional although I have cried a tear or two with a family (the kind of tear that comes when you look at the parent in the eye, your eye fills with water and you gently wipe it away as you give them a hug). Your compassion will make you a great nurse for working with Mothers and Babies!

I may be wrong but my understanding that both the CNS and NNP (Clinical Nurse Specialist and Neonatal Nurse Practitioner) have Master's Degrees in Nursing. In most states they are both considered Advanced Practice Nurses (APNs). I have heard only a few states do not recognize the CNS as an APN. So, before you can get your Masters in Nursing (MSN) you need to have a BSN (unless you are doing some sort of fast track ADN-to-MSN program I suppose). Being Master's prepared the Clinical Nurse Specialist would make about the same salary as a Nurse Practitioner. A BSN working as a bedside nurse makes a regular staff nurse's salary with usually a little differential of about $1 per hour for having their BSN. I once heard that the nurses in a Master's of Nursing program start together and then about mid-way through their program they split off and the NNPs learn more about managing and giving care and the CNSs learn more about teaching and research. It reminds me of when I took A&P and Micro... we had a bunch of students studying with us who went on to become Dental Hygienists.... we all started studying similar things and then "split-off" into other areas. Am I making any sense? I can pretty reliably say that the smaller hospitals will not have a CNS as Unit Educators as often as the main mega-center type hospitals do. They just don't have the money to spend on their salary and that is so very, very unfortunate for the nursing staff, physicians, NNPs, managers, patients and families. A good CNS is worth her/his weight in gold as they can help all the people I've mentioned to do better work, more effectively and more efficiently and with better evidence-based outcomes. I'd imagine if you became a CNS you would also be qualified to teach in a nursing program but I'm not positive about that. The CNSs I've worked with did a little bedside care which mostly revolved around changing PICC and Broviac dressings. They spent a lot of time on policies, procedures, setting up protocols (like hypothermia protocols for babies at risk for HIE) and teaching everyone how to do it and being a resource person to us all, designing, implementing and evaluating research projects, keeping up with statistics about infection rates, etc, helping set up and prepare staff nurses for transport team, teaching classes to new NICU employees and updating the older nurses as well. They taught all kinds of continuing education classes too. The NNPs and MDs appreciated their knowledge and ability to find out answers to questions on all types of topics. They were respected by the staff nurses because they really knew their stuff, respected by the NNPs, MDs and Management on all levels for their education and abilities. They did not act as managers and had no real input into employee evaluations so they stayed neutral with the nurses and the nurses could feel comfortable talking with them and sharing their educational needs without feeling "stupid". I love CNSs and feel each and every NICU should have one. I guess that's obvious from my post. There is a much higher demand for Neonatal Nurse Practitioners these days though. I believe NNPs are also supposed to be "teachers" as well and are certainly in a perfect position to teach some continuing education classes as well as doing some kind and gentle bedside teaching when they see the need. I would love to see a dual NNP/CNS degree but I suppose to to either job most proficiently they really can't be combined... a person can only do so much! You mentioned your love of bedside nursing and patient/family teaching. As a staff nurse you would do a lot of bedside teaching as such moments occur all day and night. You could also consider being a Discharge Planning Nurse who helps the babies get ready for final discharge by teaching the parents and caregivers CPR, help them get used to using home oxygen or monitors, set up follow-up appointments, help them understand the road ahead concerning the next 2 years of follow-up care and things like that. The Discharge Planners I have worked with had Associate Degrees or Bachelors Degrees and did not need a Masters Degree. NNPs often work in the Follow-Up Clinics seeing the babies after they have been discharged. They do exams on them to see how well they are doing with their developmental skills and health and help by intervening as needed by setting up appointments with specialist doctors or interventions with specialists in hearing, physical therapy, etc. This is something where lots of family teaching would be involved and you would not necessarily work in a NICU but in a clinic near the hospital and you would see babies from discharge age up to about 2 to 3 years of age. You would get to know them well because they come for follow-up visits every few weeks or months depending on their needs. Just a thought.... Good luck with your decision. I'm sure you have a great career ahead of you! I look forward to hearing what other posters have to say about this topic.

We have those comment codes on our glucometers too. If we don't put in the comment right away we have never been called on it. Like you said, once it turns off you are toast. Fortunately we have an intervention in our computer charting called "critical report" where we can put things like the labs, blood gases, x-rays, and "other" items that are considered critical and then in that screen we can say what the test was, the result, who was notified, any new order, if we followed a protocol for the critical lab, etc. and there is a comment box where we can write more information. We can also change the date and time of when the Dr. was notified up to about 24 hours in the past. I think it is about the same as doing the glucometer comment code thing. The Joint Commission visited us within the past year and said nothing about our glucometers lacking comment codes; so maybe the critical report area was enough to make them feel we did what was needed based on the blood glucose result. Good luck!

I suggest getting a job doing something like unit secretary or other clerical work at the hospital where the NICU is that you want to work. Just work part time like one or two shifts a week. I know lots of people who were given first choice when jobs came open because they were already "in the system" at the hospital so much less hiring paperwork had to be done, and they had already proven themselves as good employees (not tardy, hard worker, gets along with others, etc.). A little note about "certifications"... The word is sometimes uses when it really should not. For example in NRP, PALS, and BCLS you actually are not "certified" you are considered someone who has "completed the program". (I read that in my NRP book too.) True certifications require generally longer term experience and a very difficulty exam to prove that you have expertise in an area of knowledge. For example I have my certification in intensive care neonatal nursing from NCC (http://www.nncnet.org) and it required I have at least 2 years of full time experience in the NICU and then I had to take a test that took about 2 hours after studying for several months for it. I have to do continuing education in the specialty to maintain my certification too. Just a little side note... Good luck in your endeavors! Sounds like you are going to be a wonderful asset to our profession!

Thank you all for your replies. I agree with everything you all have said. I just can't find any information showing how the chemistry of the breast and formula milks actually change for the worse when blended together. I honestly don't think there is any evidence proving this but am hoping someone will be able to enlighten me on this. Thanks again!

I'm hearing something I've never heard of and need to know if there is research out there to support this issue. The issue is this: Does mixing formula and breast milk together in the same bottle or syringe change the composition of the milks and therefore should not be done? For example a baby is to eat 20 ml each feeding. Doctors orders say, "Feed 20 ml breast milk or Premature Enfamil 20 calorie, po/og every 3 hours". You have 15 ml of breast milk left in the fridge, none in the freezer. Should you not mix the 15 ml breast milk with 5 ml formula in the same bottle or syringe for feeding because it "changes the formula composition"? I can understand that if a baby likes the taste of breast milk better than formula then to feed them in separate bottles because mixing them could make the feeding taste icky to them, but what if you are doing only OG/NG tube feeding? I think it would be great to keep aside a drop of breast milk in an oral syringe to place on the baby's tongue with a pacifier during the tube feeding, but then why would you not mix the breast milk and formula in the syringe for tube feeding? Am I making any sense? I mean, they are going to get mixed in the stomach at the same time anyway, right? Do stomach acids make a difference? What else could the reason be? Share your knowledge with me. This is something I've never heard of in all my 20 years of NICU nursing... I've done a little research this morning after coming home from work but was wondering if there are some new studies about this topic.... Thanks in advance!:)

I can't speak to the ethics of your question; however, I remember working on a postpartum unit and mothers took Tylox and Percodan for pain and were sent home on these medications to use as needed for postpartum pain. The OB doctors said that the amounts that pass through the breast milk are so small (when Mom's take the ordered doses) that an effect, if any, would me quite minimal and really insignificant. I know that there are some drugs that do cross over into the breast milk and some that don't. There is a book on our NICU unit that our neonatologists consult in such situations. It seems that the drugs that are super strong antibiotics, heart drugs, and chemotherapy drugs are the ones that stand out in my mind as the ones that mom's have to pump-and-dump until they are off of them. I also have heard the same information about the methadone as mentioned in a couple of posts above. We often test the breast milk of our methadone moms to look for drugs other than methadone... HIV positive Moms are not allowed to breast feed as the virus passes through the breast milk.

My state accepts continuing education credits that are accepted by other states. I think most stare boards of nursing also do as well.

We use cows. I'd give my right eye tooth fo a hand held device!! Each patient needs their own computer for meds in my opinion. Not only for infection control but because hauling cows everywhere you go slows you down in a very major way and makes you clumsy looking. Not very professional looking!

Oops, there must have been an inadvertent misunderstanding of my post. We only use sterile water as test bottles to let a a baby show they can swallow a few sips before giving formula or breast milk po. Giving water with any sugar in it would defeat the purpose as any sugar water that is accidentally aspirated could set up the baby for pneumonia. I apologize if my post was not clear on that point. :)

If it's a PIV we generally heparin lock them. Lately we had a big baby who had difficult IV access and needed 10 days of antibiotics. Our neonatologist placed a PICC line and we ran UAC fluids (1/2 normal saline with 1 unit Heparin/mL) at 0.4 mL/hr until the antibiotics were finished being given then the PICC was discontinued. I have noticed over the years that heparin locks don't seem to last nearly as long as PIVs that have a little fluid running though them. I wonder if the fluid dilutes the medications and helps cause less irritation to the vein from the medications or maybe the fluid running helps in some other way. Wish I knew the answer. By the way, we heparin lock our PIVs and flush every 3-4 hours with a 2 unit/ml heparin solution prefilled syringe from our pharmacy.