24gaDalek

BabyNP, Thank you for your detailed and thoughtful response. I feel somehow like I have to defend my question based on some of your answers as it feels like from your answer you think maybe I don't understand the implications of having premature infants as patients (developing brain, risk of addiction, etc.). I am not trying to step on your toes, just expressing how I felt at first blush reading your response. I didn't give full information on the particulars of the actual situation because I was just curious in general what nurses have available to them in their unit. I can assure you that I attempted all non-pharmacologic interventions. I have a full complement of tricks up my sleeve for quieting agitated infants. I work night shift and I don't like to rouse the on-call Doc out of his or her bed for any old reason out of courtesy to them and they know that based on our working relationship. We also have two docs in house so if one is busy with a sick baby they can defer to the other doc. As far as using the charge or ANM to help me advocate, while I understand that in some cases that may be necessary the idea that I would even need to go that far makes me extremely sad. I have used that route once when a NAS observation baby was intermittently screaming, vomiting, and vibrating off the bed and the on call doc refused to start medicating until the primary doc did rounds in the am. I don't think there would be such a hesitation to treat pain in the adult world. I also know that there used to be very old-school ideas about premature infants and pain. Conversely, pain medication should not be used as a crutch to "snow" an infant into oblivion. But I do think there is something to be said for nursing judgment in the case of PRNs.

Hi there, I have been mulling this over for quite some time now. I started NICU nursing at a Level IV NICU that was very well regarded clinically and considered the best in the area. When we had infants on HFOV, HFJV, and sometimes just vented we always had analgesia like fentanyl (occasionally drips for really sick kiddos) available PRN as well as ativan if the babies were really restless. Every infant had these as a standard order if they were intubated. It was up to nursing judgment to use them. I am now at a Level III NICU in the same city. Not as well regarded clinically but part of a large, well known HMO that is trying to change its status to be considered more competitive. We get a lot of Neos that are just off of residency or are at our hospital for other reasons. "Gunner" NEOs don't typically work here. Anyway, I have noticed a deep reluctance among the Neos to provide what I feel is adequate analgesia or sedation for intubated infants. Last night I had to practically beg for PRN fentanyl for a former 24 weeker (now corrected to 30 weeks) on the HFJV who is extremely ill and was literally jumping off the bed in agony. This is very typical for our hospital and this usually seems to come to a head on night shift with the on call (they stay in house for 24 hours) Neo reluctant to step on a primary doc's toes by ordering pain meds. So I ask you, what do your docs do for your intubated kids? Do you have a standard protocol for PRNs like my previous hospital? This is weighing really heavily on my mind as I had a rough night last night with a kiddo who was obviously in pain. It was a long night.

I have been night shifting for 4 years. I do not sleep well during the day without medication. My problem is that if I wake up to use the restroom or for any reason (noises outside, etc.) after having 4 or more hours of sleep my body thinks I was taking a nap and there is no more sleep after that. I have tried everything to get adequate rest (adequate for me would be 7-8 hours) but what it boils down to is that I cannot override my circadian rhythm. The people I work with who handle night shift the best are the ones who do not flip flop between sleeping schedules. The longer they have held the night shift ritual the better they adjust. Having children, this would not work for me so I flip flop back and forth and cope with feeling varying degrees of tired/exhausted 99% of the time. There are couches and blankets and pillows in our break room for night shift. Many people choose to take naps during their lunch break which helps them get through the shift. Not adjusting well to night shift is a bummer for me because it really does work best for our family schedule. I also enjoy the more laid back feeling to the shift and my coworkers. I am going to suffer through it for a few more years and then figure out how to get off of it.

Omnomnom makes me want to kick kittens Not a fan of pannus or lochia either

Our policy is to use a gel pillow for just the head when on HFOV. I have heard from a snarky nurse that I gave report to that gel pillows should be avoided all together because it impedes the action of the HFOV. I always figured if you see good wiggle/jiggle in the chest area why would the gel pillow be impeding anything? I also couldn't see any sound research one way or another.

Agreed. This is the crux of the issue. There is a disconnect somewhere and the end result can be poor outcomes for infants. The sweet little infants are the ones that suffer the decisions of others.

Just got out of the shower and had to get a few more points in, lol We NICU personnel are the end of the line for the birth trauma/bad baby scenario. When the questioning begins from the parents it is typically, "Why can't you save my baby?" instead of, "Where did this all go wrong?" We are the bearers of bad news and wholly the advocate for the baby and the baby alone. We can look like the bad guys. It is hard not to get angry when parents who choose to forgo a hospital birth because of the big, bad medical establishment suddenly want us to do "everything medically possible to save my baby" regardless of how detrimental it is to the infant and in some cases completely futile. The hospital is spending millions of dollars to put their baby on ECMO and body cooling for a baby that is, without a doubt, going to be dinged (a NICU term) and possibly unsaveable when perhaps a few quiet conversations and some different choices could have resulted in a 2-3 day hospital stay and a healthy infant. We get frustrated because we see what could have been and are only left picking up the pieces of what is.

I am a NICU nurse and as part of my job I also work up in L&D as an NRP rapid response personnel. I attend all deliveries typically, but mainly the high risk ones, so I have seen a lot of births and resuscitated my share of infants. At my facility, Midwives typically deliver low risk infants and OB/GYN deliver high risk. I respect someone's decision to have a baby at home as long as people are fully aware of the risks behind it and the willingness to accept the blame if there are complications due to their choices. Unfortunately, I have seen many infants that end up in the NICU due a mistrust of "medical establishment" and a fear that anything associated with a hospital means aggressive and unnecessary treatment for mom and baby. Sometimes this misinformation comes from misguided practitioners with their own agendas. Sometimes the misinformation is from countless hours of "research" by the parents from Dr. Google and/or countless blogs dedicated to using homebirth as a big middle finger to the "medical establishment." I would respect the decisions of these parents more if their information came from rational sources and sound consideration of both the pros and cons. Generally, this is not the case in my experience. Yes, bad outcomes can happen anywhere. I have witnessed semi-questionable actions by both midwives and OB/GYNs at deliveries (aggressively delayed cord clamping and placental birth resulting in severe maternal hemorrhage, TOLAC of 10.5 lb baby where the uterus ruptured). But none (yet) that have resulted in a preventable insult to the infant. And most of these choices by the practitioners were in deference to parental preference. The sticking point for me is the preventable insult, whether at home or in the hospital. There seems to be this chain of responsibility that just goes absolutely haywire in these cases. SOMEONE at some point in this process should have been the emergency brake before the train went off the rails. It is the supervising practitioner's responsibility to present all of the pertinent information and sufficiently lay out the worst case scenarios. It is the parent's responsibility to put aside their own agenda and listen to all information presented and make the choice that is the best for the baby. Yes, your birth may end up less than your ideal if you have had complications. But I personally believe that a healthy baby and mom is the best outcome. I don't think that in birthing the journey is the end all, be all. All that matters is being able to take your little one home. The problem is that labor and delivery is so fraught with emotion that I think it is hard for both parties to see clearly. I completely understand the frustration of the OP. We NICU RNs see so many messed up babies due to just sheer horrible luck (incompetent cervix, CMV exposure, genetic factors, etc.) that it boggles our minds that anyone would play roulette with a perfectly healthy baby. I personally ended up with two c-sections and had both babies before being a NICU nurse. My first due to cpd and failure to progress. My son ended up being 9.2 pounds and having a nuchal x4. I boo-hooed the fact that I didn't have the natural labor that I originally wanted because then I don't think I really grasped what really was going on. Now I'm grateful that I kept an open mind to any outcome that resulted in my son being born alive and healthy. Today I get to come home after a sad night in the NICU and I get to hug and kiss both my babies before they head off to school. The trade-off of ideal birth vs. actual birth was worth it to me for that very reason. I could blah blah about this all day but I won't.

Did you go to a public or private university? Private University If you chose a private university what advantages did you expect over a public university? Well, the city and state I live in having community college programs that are so impacted that the wait for an ADN program is 2-5 years long. Because of a budget crisis, state colleges and universities put a block on any Bachelor's Degree students with a previous Bachelor's Degree from entering any 4 year program. Because I already have a Bachelor's Degree it was either wait 2-5 years for a space in an ADN program or pay 60K at a private university for an ABSN program that I finished in 1 year after I completed my prereqs. Did cost play any role in selecting what university you went to? No, not really. I wasn't thrilled about the price tag of my private education but it was the fastest route to getting my BSN. What was the cost of tuition per year? My ABSN program was only a year long and it cost about 60K total Did you use the student loan money for anything other than tuition, books or school fees? Yes, tuition, books, school fees, and also child care because I was a full time stay at home mom with two young kids before I committed to nursing school full time. When you signed for the loans, did you have any idea how much the payments per month would be?I sat in a very long financial department presentation during orientation that spelled out exactly how much the typical payments would cost given a few different scenarios. If you are a working RN, what percentage of your monthly take home pay goes to servicing your school loans? This is such a joke and this is the reason I had to respond to this thread. I make >100k per year where I work, just my base salary, not including an annual bonus plus yearly raises. I also got through nursing school and working a full 2-5 years faster than other people in the same track as me. My school loan payment is less than 1/10th of what I pull in per month. Because we lived modestly in the years I was a stay at home mom, we were not saddled with debt other than a mortgage that we were already paying on one salary alone and anything I made as an RN starting out was icing on the cake (after making my student loan payments, obviously). Balk and judge away at large student loan debt, but it has been worth it for me. Every last cent. If you are a working RN, knowing what you know now what if anything would you have done differently to keep the debt to a minimum? Eh, there are some scholarships I should have applied for in school to lessen the debt. I guess I just figured working my butt off for a $1000 scholarship was not worth it when I was paying $60K for my total education. If I were not living where I live with the highest paid RNs in the country and in a sought after specialty that increases my earning potential this school would have been a bad idea. But I knew roughly how much I would make before I started nursing school so it was a win/win.

We typically don't give travellers sick kiddos as a courtesy at first. After one week of hospital orientation that goes over EMR and general hospital policies, our travelers get only two shifts of orientation. You are expected to hit the ground running. I don't think it would be fair or safe for you to take over complicated cases without having the opportunity to fully delve into the policies and procedures for our unit. Yes, some things are the same no matter where you go. But many things are not. You can't teach/learn everything in two shifts. I have seen some travelers that have stayed for multiple contracts get complicated patients. But it always depends on the skill mix that is available that shift, etc. There are permanent staff who need certification and training on certain equipment that will take priority. In addition, our hospital got burned by litigation that involved a patient injury that occurred because of a traveler. I think everyone is a little gun-shy because of this now.

Did you find it was hard to adapt to a completely different career or was it a seamless transition? Starting out as the bottom of the totem pole was the worst part for me, because it can be an ego blow. The learning curve for nursing is very steep and the first year out of nursing school was rough. It is true when they say that it takes years to become truly proficient as a nurse, sometimes more, sometimes less depending on where you specialize. But you really are learning something new every day, regardless. The feeling of perpetual learning for some is energizing and for others is unsettling. Did you find nursing school difficult coming from a non science background? I did not come from a medical science background, but did have some training in the sciences waaaaay back in my career before my career before nursing. But as others have said, nursing school is difficult if not for the concepts but for the volume of learning required. I graduated with my BSN in 1 year because I have a Bachelor's Degree in something else and did all my prereqs first. The ABSN program is one of the hardest things physically I have ever done. It was exhausting. Do you feel great job satisfaction as a nurse? I feel a great amount of pride in the fact that I worked my tail off to become a Registered Nurse. I also was fulfilling a dream I had since high school. I love helping people. I love my patients (most of the time). But being a nurse is also very physically and mentally draining. I give 100% at work then sometimes come home and feel all used up. I love my job, that is true. I get paid very well and I work with some nurses that just astound me with their skills and ability. Every so often I will pick my head up during a shift and feel very privileged to be doing what I do. However, I work night shift, which abuses my body. I work every other weekend, every other Christmas/New Years, and any holidays that fall on my regularly scheduled shift day so I miss a lot. It is a give and take. I feel like it is worth it. Some don't.

We usually put a restriction on siblings by age during flu season but wait until the county health department tell us to do that based on an uptick in flu cases. Flu season so far this year has been mild so we are still allowing siblings of a certain age to come in to the unit for visits.

I had a similar situation with a preceptor. I didn't curse at her, but after she embarrassed me by berating me multiple times in front of our colleagues for weeks I had had enough and I made a very snarky remark to her face. After what I said left my lips, I immediately regretted it. I finished the shift and was off for a couple of days. When I came back, the first thing I did was apologize profusely to her. She said everything was cool. At the end of the shift I was bombarded by her and a Nurse Manager stating how inappropriate my behavior was and how I could not respond appropriately to "constructive criticism." I was devastated. I stuck it out and explained to the Nurse Manager, after the preceptor left, that I was reacting to weeks of belittling, etc. Unfortunately, this woman made my life a living hell for the next few months. She spread rumors about me, turned her friends against me, and generally made me feel like the scum of the earth. Being a new nurse and dealing with the emotional fatigue and stress of just trying to find my way was hard enough, but add to that the feeling that at any minute you could be left twisting in the wind by your colleagues and it was enough to almost kill me. I put my mind to working hard and being the kind person that I normally am, but I was fighting an uphill battle. After about 6 months of constant stress I finally made a friend at work and she kind of took me under her wing. If it hadn't been for her vouching for me I probably would have quit. Things got better, but everything was tainted by that first impression. After two years, I left. What I realize now is that any unit that would have a preceptor who treats orientees in that manner is a broken unit. Something in that unit is not right. Either there is no one appropriate who will orient, which is a problem, or there are managers that turn a blind eye to poor treatment of their employees, which is an even bigger problem. Run as fast as you can away from this place. Yeah, you screwed up cussing your preceptor out. But it never should have gotten to that point to begin with. If shoddy treatment of new employees is going unreported or unnoticed by management how can you trust them to ever have your back? If they give you another chance prepare yourself for butt-kissing and groveling for months. Humble yourself. Stroke their egos by acknowledging their superior knowledge and experience as often as you can but as genuinely as you can. Your life is going to suck while doing this. Mine did. You may never get their respect but they may leave you alone. If you are okay with that. I wasn't. Good luck to you.

Yes, agreed. I even had a protective surgical jacket and shoe covers on and I am just there for the baby. All it took was one improperly clamped cord slithering across my arm x1 and I now try to wear the jacket to every delivery.