Tiki_Torch

How long does your unit generally leave UAC's in? Do you ever use radial artery lines? My previous NICU left UAC's in for no longer than 5 days and then the baby got a radial artery line if they still needed arterial blood gases. My new place keeps the UACs in until they are no longer needed for ABGs or until they stop working well... can be up to 3 weeks sometimes... and I've only seen two babies with radial artery lines in the past 3 years. We don't have a high incidence of infection or injury related to keeping the UACs in place for so long as far as I can tell. Just wondering what other units do. Also, does anyone know of any research articles that speak to a safe length of time to leave UACs in place? Thanks, Tiki

Prmenrs, as always you bring up a good point! You are correct about the "smart" that alcohol on a cut can cause. This is another reason for quickly wiping the site with a gauze pad. The sucrose and swaddling are already on board. The quick, one swipe with an alcohol wipe is not a method to be applied every time a heelstick is performed, but in the case that a few more drops of blood are needed, my experience is that the alcohol smart is much, much less painful than another lance stick would be.

I don't think a lot of people know this tip, but along with the swaddling, sucrose pacifier, raising the head of the bed, certainly warming the heel for 5 to 7 minutes, sticking in the appropriate place on the heel, and allowing the foot to fill with blood beween "squeezes" (watch for the skin to change from pale to pink--full of blood), you can also wipe the site again with an alcohol swab when the blood begins to stop flowing well. The clotting mechanisms begin as soon as the injury occurs so after about 2 minutes or less the blood will stop flowing well because clot formation is beginning; alcohol will break up the fibrin network at the site which makes the heelstick site bleed again. The blood will not flow as fast as it did with the initial stick, but you will certainly get another good round of drops to hopefully finish filling your tube. If you do use the alcohol trick, be sure to wipe the first drop with a gauze pad (like you do after you stick the heel) just in case the alcohol might cause a problem with the lab test (I don't know if it matters; being safe rather than sorry here). The alcohol trick is a really good one and one I love to share. By the way, one of my pet peeves is to see medical people draw labs or fingerstick blood sugars and then place an alcohol wipe over the site. For crying out loud, I want a gauze pad placed on my arm or finger... I don't want the site to continue bleeding. :-D LOL.

Oh My Stars!!! I adore Dr. Polin!!! How fortunate you are to have been able to work with him!!! I've seen him at some nursing conferences and find him absolutely wonderful. Once I attended a conference on my birthday and for my present to myself I took along my "Fetal and Neonatal Secrets" and "Workbook in Practical Neonatology" for him to autograph. It was a wonderful birthday present I will never forget. My favorite books for nuts and bolts are: Core Curriculum for Neonatal Intensive Care Nursing, 3rd Edition by Verklan & Walden; Neonatal Medications & Nutrition: A Comprehensive Guide, 3rd Edition, by Zenk, Sills and Koeppel; and Manual of Neonatal Care, 5th Edition, by Cloherty, Eichenwald, and Stark. I keep these three in my tote bag I take to work and refer to them all the time. I also like the Neofax for a quick drug reference. There is a book similar to Cloherty's Manual of Neonatal Care but it is written by Gomella which is very good. For beginning NICU nurses I also agree with the Merenstein & Gardner book and I also recommend Physical Assessment of the Newborn: A Comprehensive Approach to the Art of Physical Examination, 3rd Edition by Tappero and Honeyfield... it's also good for seasoned nurses too. :-D Tiki

I'm not sure whether you must have worked in the NICU for 2 years or have worked in the NICU for a certain number of hours, or both. What I DO remember is that the number of hours pretty much added up to a person working full time for 2 years. It's been several years since I took my test from NCC, so I don't remember exactly. Hopefully their web site can tell you; if not, I'd imagine that if you request information (download it from the web site or ask them to mail it to you) the information will be found there. :-D

I agree that "Gastric Residuals" and "Gastric Aspirates" are basically the same thing in that they are both indicating that the contents of a stomach have been retrieved by aspirating the NG/OG tube with a syringe. If the baby is receiving feedings, I believe the term "Gastric Residuals" would be most appropriate since this is explaining how much "residual food" is left in the stomach at feeding time. "Gastric Aspirates" could mean the amount of "residual" food left in the stomach but coulc also mean any type of gastric contents aspirated with a syringe from the stomach. Babies who are NPO can often have gastric aspirates of things like cloudy mucus or yellow, green, bloody, brown or other colored aspirates depending on their health condition. Our flowsheets have "gastric residuals" as a top heading and under that we include the total amount of gastric residuals, the amount refed and the amount discarded. We often receive orders to "refeed _____ ml of clear/cloudy/or partially digested food". Whenever we get back something that is not normal (green, yellow, bloody, etc.) we report it and discard it and include it under the "Gastric Aspirates" area of our flowsheet. I certainly agree that the two terms are interchangable and the only difference would be how your hospital intends them to be used... how your physicians and nurse practitioners use the information to evaluate the babies progress.

I'd suggest obtaining your RNC from NCC because this credentialing organization is mostly focused on maternal-child nursing. It seems to be the standard for NICU nurses and nurse practitioners to get their certification from NCC. Check out their web site at http://www.nccnet.org. Good luck to you wherever you go for your certification; I'm glad you are interested in doing so!

We dilute our Gent to 5 mg/ml and give it over 30 minutes on a pump. We never push it. We give Amp over 15 minutes on a pump (100 mg/ml dilution). Our near-term and term babies start Gent at q18h and get Peak and Trough around the 3rd dose. Our preemies start at q24h and get Peak and Trough around the second dose if they need Gent; we start them on Claforan first since it is less toxic and easier on their kidney function than Gent and then start Gent if a culture shows the baby really needs the Gent.

Working in the NICU has not changed my opinion on the issue of abortion. I am pro-choice because I believe that every situation and circumstance is different as well as that every person deserves to make up their own mind about their own lives. Most women who make the decision to abort have given it much thought and do not do so without realizing the gravity of their situation. (I have a medical condition which has left me unable to become pregnant so I've never, thankfully, had to deal personally with such a decision in my own life.) My heart goes out to anyone who has had to make such a decision and I support them completely whether they choose abortion or not. Just my 2 cents... I will say, however, that working in the NICU has made me much more aware of the poor outcomes babies born at less than 25 weeks often must endure (if they survive). I also have thought that if I ever did have a baby born at that gestation, I'd very, very seriously consider comfort/pallative care over "doing everything medically possible to save the baby". This is a heavy subject and it's bringing me down. I think I'll go over to the humor area to see if I can lighten up my mood a bit.

Threre is a regional methadone clinic in our area so we see our fair share of methadone babies. Just as the others mentioned, we see the same symptoms with the most common ones being very tight muscle tone, irritability, sneezing, loose stools, excoriation to knees or other areas that come in contact with the bedding, high temperatures, and sometimes feeding difficulties. The babies sometimes act very "frantic" at feeding time. It's like they know they are hungry and are trying to eat but the minute the nipple hits their mouth they don't have the patience to latch on and suck at first. We seem to notice that the symptoms begin to appear when they are 2 or 3 days old. Depending on the mother's dosage, the symptoms can last for several days to a few weeks. The longest we had a baby with symptoms was about a month. We do Finnegan scoring every 4 hours and generally give tincture of opium to the babies which helps a lot. Other helpful things are to keep the room quiet, be very attentive to their stirring and cries and then intervene immediately, don't rock them too much and don't talk to them while they are eating. Seems like they get overloaded with stimulation much easier than other babies and this only makes matters much worse. Over time they need less and less medication and usually get to go home after they have been off medication for a few days. We encourage the mom to visit often so she can learn the best ways to care for her baby. We also work very hard at not being judgemental since this does nothing to help the baby or it's family. Granted, these babies can be a real handful when they are in the worst part of their withdrawl, but at least it's better than heroin or whatever...

I agree about using this time to ask questions and for help as much as you need to. The longer time goes by and your coworkers see you are not asking as many questions, they will be more likely to think you don't have questions and are getting along better than the average newbie. We all expect questions and to repeat our answers, etc with you for the first few months when you are out of orientation. It's very true that it takes about 2 years to begin to feel "comfortable" in the NICU. Take advantage of your newbie status and milk it for all it's worth. Spend time with your books reading up on the conditions of the patients you take care of each shift and that will probably be helpful too. In the NICU (and really, all areas of nursing) education is a continuous process... fo the rest of your career. You'll do fine!!! Oh yes, and when you begin to feel overwhelmed, try this: Close your eyes, take a deep breath, and count to three. I read this in a nursing journal once and it really works great for helping to calm and center yourself. Works like a charm!

Thank you soooo much obnursesteff! Your post really did help an awful lot. We are doing these tests on Tiki

I have a question for all of you who take care of well babies along with their moms. When the baby is a healthy near-term (35 or more weeks gestation) who spends their admission without requiring special nursery care, do you do a car seat test on the ones born before 37 weeks gestation (AAP Guideline)? If you do perform a car seat test: Who performs the test (RN, Respiratory Therapist, etc.)? If the test is performed in a Well Baby Nursery setting, who watches the baby during the test? (Well Baby Nurseries are often too busy for one nurse to care for babies and watch a car seat test properly.) How long is the baby in the car seat? How low do you allow the O2 sat to drop and still consider the test passing? How long can the O2 sat be down and still consider the test passing? If they fail the car seat test, do you test them in a car bed and make them go home in a car bed if they pass the car bed test? Any other information would be very much appreciated! Thanks, Tiki

There is an article titled, Resuscitation of the Extremely Preterm Infant: A Perspective from the Social Model of Disability written by Teresa A. Savage, PhD, RN and Karen Kavanaugh, PhD, RN in the June 2004 issue of Newborn and Infant Nursing Reviews , Volume 4 Number 2: 2004: pp 114-120 which is a good one. The journal is published by Elsevier, Inc and they have a web site "www.nainr.com". You can probably get a copy of the article through your school librarian via CINAHL. This is what the Abstract of the article says: The imminent birth of an extremely premature infant presents parents and health care professionals with difficult decisions regarding how aggressively to provide treatment for the infant. These delemmas exist because extremely premature infants are at risk for disabilities such as cerebral palsy, blindness, and other neurological disorders. Technology has facilitated improved survival rates, but outcomes are uncertain and cannot be reliably predicted. The essential questions with the birth of an extremely preterm infant are: should the infant be resuscitated, and who makes the decision to resuscitate? This paper will explore resuscitation decisions for the extremely preterm infant within the social model of disability. I hope this information is helpful to you. If I come across some others I'll let you know. Be sure to ask your librarian about serching CINAHL for journal articles relating to your subject. Most colleges have access to them through CINAHL. (CINAHL means Cummulative Index of Nursing and Allied Health Literature.... I think.) Welcome to the AllNurses NICU board, and good luck with your paper! Tiki

I'm just a bit curious. At your hospital, when you attend c-sections, do you transport the baby (not preemie or requiring oxygen support) to your well baby nursery or NICU in: (1) a prewarmed transport isolette (2) a regular newborn open bassinet (3) in your arms? Thanks!

Sounds like a really great plan Elizabells!!! Let us know how it goes! I'm sure we would all be interested to keep up with you as you progress over the next few years!! Tiki

I've worked with a few male RN's in NICUs over the years and enjoyed all but one of them. (The one I didn't enjoy was there simply to earn "critical care nursing time" in order to apply to CRNA school. It was totally obvious that he didn't want to be there. After a few months he found out that the CRNA schools preferred adult critical care experience, so he left to go to the Medical ICU and we were all very glad.) I don't know whatever happened to him after that because I moved away from that hospital not long afterwards... I've noticed that the babies fathers enjoy having a male nurse for their baby. It's someone they can talk sports and "guy" stuff with and the often model their own behavior by observing the male nurse work with the baby. Male nurses are great in the NICU!

Honesty is always the best policy. The only way to begin to fix a problem is to admit that a problem exists. Congratulations on admitting the problem. Now, lets fix it. Go to your boss and tell them what you did and why. I think if I were your boss I'd respect you more for admitting to something before I had to find out about it and present the facts to you. Put yourself in your bosses position... If you had someone working for you who did the things you did, how would you feel about that person? Now, if that person came to you to tell you they have made a mistake because felt overwhelmed with too much work, that they are very sorry and realize the seriousness of their errors, I'm sure that if you were that boss you would be a heck of a lot more understanding than if your coworkers went to the boss to complain about your serious mistake first. The boss should then be able to realize that you had too much work put upon you. A first clue to the boss that there was too much work put on you was that people were calling you "superwoman", because only a "superwoman" could be expected to get that much work done that fast. Tell the truth. Get if off your chest. You will feel sooooo much better!!! Be aware at how very, very important your work is and how much the doctors and nurses depend on you to get accurate vital signs and O2 sat results!!! (Often a person's vital signs are the first indication that their body is about to crash!! Just because a normal O2 sat is 96% doesn't mean that every person will register a 96%. There are no "right" answers with vital signs... the result for each person is as individual as each person.) I think you know deep in your heart how important this is. If you feel you still want to continue working at this palce, let the boss know what has happened, the sooner the better too. Also, be aware that whether you fess up or not, lots and lots of eyes will be watching you now, and you might hear whispers sometimes too. This is why I say own up to your mistakes, learn from them, take the punishment like a person with integrity would, and go on with life as a better person who can hold her head up with dignity. Wishing you only the best.

Hi Elizabells, One plausable option is to work as a bedside NICU RN for 2 or more years (preferably one where you can get lots of experience with lots of different types of patients) before doing the Nurse Practitioner classes. After you have been working in the NICU for 6 months or so you could take some classes towards your Masters program (if you have any left to take), one class each semester or so. This way you can see for yourself by watching the seasoned nurses and the NNPs you would be working with as they go about their daily work. You may be amazed how difficult performing procedures and making critical thinking decisions can be some times when you are actually working in the NICU. A lot can be said for finding a mentor on the unit too. I honestly believe hands on experience first will make you the kind of practitioner you truly want to be. You seem to be a very caring, motivated person and I'm sure you will make the best decision for yourself. Wishing you only the best!!! Tiki PS I received the same information from NCC about the NNP test requirements, etc. in a mailing from them a few weeks ago. I have my RNC certification from NCC in Intensive Care Neonatal Nursing. The information presented in the post about Vanderbilt's NNP program is accurate.

My two cents: My sister-in-law is a forensic psychiatrist. Before that, she was an internist but got tired of constantly pronouncing people dead...very depressing job. She fulfilled her father's wishes and became a MD. She told me a couple of years ago that she envys the nurses she works with (staff nurses and nurse practitioners) because of the patient interaction and being able to connect with the patients in a very human way. I asked her once what she would have liked to do if she hadn't become a doctor; she thought for a moment and said, "An archeologist." Do what you want with your life... the operative word being your . If your Dad wants to sew up some guy's cheek, maybe he can go back to school and learn how. There is an Emergency Room physician at University Hospital in Las Vegas who went back to school to be a doctor when he was 45 years old. He had been a policeman, worked for the Secret Service, and even owned a business but after having an injury he decided he wanted to become a doctor and said to himself, "It's now or never." and he is very happy being an ER doctor. Our parents generally only want the best for us but sometimes their idea of what's best is not what ours is too. Their job is to support us and let live the life we were born to do. Your Dad obvoiusly loves you very much. Stick to your guns and do what you want with your life. Sometimes saying, "Thank you Dad for your love and guidence over the years; now trust me to do the best I can with the knowledge you've given me as I make the decision which will make my life a happy one for me." Good luck in your future endeavors!

although i believe there is more than one certification organization for nicu nursing, the national cerification corporation for the obstetric, gynecologic and neonatal nursing specialties (ncc) is the most popular among nicus in the usa. http://www.nccnet.org they only specialize in areas of womens's health and neonatal nursing including nurse practitioners. they have tests for low risk neonatal nursing as well as the high risk (nicu) nursing, labor & delivery nursing, telephone nursing, women's health nursing, breastfeeding, and fetal monitoring. please see their web site for full information. all of our nurse practitioners where i worked when i took the test were required to pass the ncc neonatal nurse practitioner exam and they placed the credentials "rnc, nnp" behind their names. i took the test in 2000 and passed on the first attempt. i had worked in a level iii nicu for 2 1/2 years and on a mother-baby (mostly ante- and post-partum) for 6 years before that. the main book i studied was core curriculum for neonatal intensive care nursing . now they have a 3rd edition, by verklan & walden, 2004, saunders, isbn# 0721603947. my coworkers also studied this book. we would study together and on our own. i mostly studied alone though because of my lifestyle. the only nurses i worked with who had to take the test a second time were the ones who did not review at all the first time. i honestly believe that any nicu nurse who works full time for 2 years and cares for a variety of patients and keeps up with new knowledge (journals, conventions, ceus, etc.) should have no problem passing this exam. i will also recommend three other books: core review for neonatal intensive care nursing . there is a 2nd edition which is to be available this month (march 2005). i have the 2001 edition by watson, saunders, isbn# 0721696805. this book has 600 multiple choice questions similar to the ones on the nicu ncc exam. there are answers at the back along with rationales and references for more learning. it's fantastic as a preparation. it is a "companion" book to the "core curriculum..." above. if you feel you need more indepth study in a certain area i recommend: handbook of neonatal intensive care by merenstein and gardner, 5th edition, 2002, mosby, isbn# 0323014712. and comprehensive neonatal nursing: a physiologic perspective by kenner and lott, 2003, saunders, isbn 0721697178. i support certification fully. i renew every three years and get 50% off the renewal price when i use learning module ceus from ncc. i love the ncc continuing education modules because they are informative and relate fully to my every day work. i will pay $50 for my three year renewal at the end of this year. when i took the exam it was offered twice a year at the largest city in my state. i understand that now the tests can be taken many times each year and that places like sylvan learning centers are approved to give the tests there. if you have a bunch of nurses who want to take the exam at your hospital, the ncc will send a representative to your hospital and you can sit for the test there.... no traveling involved. cool. wishing the best of luck to everyone who takes the exam!

My computer won't let me access the vapotherm website (ancient computer). To those of you who use vapotherm, is it only for babies who would normally be put on CPAP or can it be used for chronic bronchopulmonary dysplasia patients as well? Thanks!

Hammouam, If you are studying for the NCC test in Neonatal Intensive Care Nursing I would suggest two excellent books. The first one is comprehensive and written in an outline format. I've read it forwards and backwards. I keep one with me all the time and I used it to study for my exam. The second book is probably exactly what you are looking for. It is like a "companion" book to the first book I mentioned. It is full of questions with multiple choice answers. The chapters are divided up into different areas. You read the questions, make a notation of your answer and then look in the back of the book to find the correct answer, the rationale, and the book or study/article where the rationale came from in case you want to look up more information to study. The first book is Core Curriculum for Neonatal Intensive Care Nursing, 3rd Edition Edited by M. Terese Verklan & Marlene Walden. It is endorsed by NANN, AWHONN and AACN. 2004. Saunders. ISBN# is 0721603947. It costs about $70. The second book is Core Review for Neonatal Intensive Care Nursing Edited by Robin L. Watson. It is also endorsed by NANN, AWHONN and AACN. 2001. Saunders. ISBN# 0721696805. It costs about $45. Both can be purchased on amazon.com and bn.com. Good luck!!

Thanks Gompers! Very good information from you, as always! The policy we are revising will also be in use for the Mother-Baby unit as well as our NICU babies; I'm hoping some OB nurses will be able to share some of their insight too. Thanks again Gompers, you're the best!! Tiki

We use them on all our babies and change them every 24 hours. I believe the company is named Ballard. At my previous NICU we did the two-person suction with the saline drops and all that. From my experience with these in-line suction catheters I've noticed the babies tolerated suctioning much better and it's a real plus not having to have another nurse come to help you. Sure, it can be done alone, but the chances of contamination and bagging with inappropriate pressures is much greater than with two people. We recently viewed a Sensorimedics video from the company concerning the oscillator and it said to suction only prn. It makes since because the oscillator is constantly pushing air and secretions too I suppose out to the periphery. I have seen this to be true because babies on oscillators usually have scant secretions until they come off the oscillator and go to a conventional vent which is when we see lots more secretions. I'm a fan of in-line suction catheters. Tiki