SteveNNP

I agree with the others... try looking for the major academic center in your area. I work as an NNP in a large RPC Level IV+ECMO+open heart NICU, and we are constantly overloaded with acuity haha. On my average shift, I have a few preop cardiac, a postop open heart, maybe an ECMO, and a smattering of convalescing preemies. I am not sure anyone else is seeing this where they work, but we have seen a dramatic decrease in extremely preterm infants, where we used to get 23-26 weekers all the time...now most preemies are in the 28-33 range. I credit this to our OB colleagues doing great things to keep babies in, such as lady partsl progesterone. By not having the really extreme pretermers, we avoid a lot of the sequel, which decreases overall daily acuity, which is a good thing! I will say we have seen more and more IUGR kids, which is probably related to keeping micros in longer until the placenta gives out.

How old is this baby? The nice thing about fetal hemoglobin is that it holds onto a LOT more oxygen at lower saturations than our blood. So you can rest assured that even if sats are in the 70s, she's still probably not getting too hypoxic...as long as she's not staying there for too long. In my unit, if this baby were less than 14 days old, we would consider her symptomatic, and use either indomethacin or ibuprofen lysine to attempt to close the duct. If greater than 14 days, we would consider a PDA ligation.

This is why any warmer or isolette manufactured in the past 5 or so years has a built in scale. Unless a child is on ECMO (and sometimes we weigh those kids too...) or is a comfort care, babies should be weighed at least every other day. As a NNP provider in the NICU, I rely on frequent weights in order to fight against the growth curve slump by making adjustments to total calories, fluids, electrolyte components, etc on a daily basis. We've seen that every baby loses weight...and that by stopping that weight loss tumble, we can discharge healthy babies that are actually ON the growth curve instead of way below. I don't think doing a simple bed scale weight should be any more "harmful" than a diaper change. Micros are more likely in my opinion... to get a head bleed from inappropriately titrated fluid balances than a simple lift, zero and hold weight check.

We do not do call shifts in my unit. IMHO, call shifts are an excuse by management to not hire or adequately staff a unit. Part of it here is that we are unionized, and have set patient ratios. Hell would break loose if management tried to mandate extra shifts above what our contract states.

The role you are describing can be done by several different nurses, including L&D, Newborn Nursery, and NICU. It's typically an assigned role for the day, not a "hired-into" position. You would also likely need some solid newborn experience before they cut you loose running deliveries. In my hospital, we have experienced NICU nurses who attend all high risk deliveries, update parents, etc...with one of us NNPs or PAs. They are all experienced in transport, resuscitation and neonatal care. This might be something you can transition into once you have some experience!

Hi RN.amour- my recommendation would be to sift through the threads on this forum. All those questions have been asked and answered many times. Good luck!

When I was a bedside RN, we used pink water jugs with warm water. The unit then used the Penguin for awhile, and then in a push to avoid contact with tap water, we now have a Medela waterless warmer at every bedside. I believe at the time it was a risk for contamination with waterborne pathogens that an immunocompromised preemie might contract. There also was concern for uneven/overheating causing breastmilk component damage.

Albuterol ABSOLUTELY causes tachycardia, especially when given frequently and in higher doses. This is why a lot of units used to (and some still do) give Xopenex instead. Sounds to me like you properly assessed pain, and found that the infant didn't require anything at that time. We have found that neonates become rapidly opioid-tolerant and dependent after only a day or two of narcotics. Fentanyl especially, being 1000x more potent than morphine with a much quicker onset of action. Unless the baby is showing true signs of pain, and not just agitation, we avoid narcotics in all our patients except surgical ones. And even babies who have open heart surgery via sternotomy are often off narcotics within 96 hours if they can tolerate Tylenol and it's well controlled. IMHO we shouldn't be giving out narcotics just because...especially since we don't know what it does to the plastic neonatal brain.

Absorb the bounce? This is the most ridiculous thing I've ever heard The chest wiggle that is seen with HFOV use is from the lungs expanding and contracting using tiny tidal volumes at a steady MAP. If the theory were true, neonatal chest wall compliance would allow for "extra bounce" on the anterior chest wall to make up for loss on the back. But since Z-flo mattresses are soft, you "should" have more "bounce" on the back anyway! For us, the biggest issue with Z-flo mattresses is that they can often contain micro bubbles in the gel, which confound xrays. We actually got rid of them due to their prohibitively high cost, and lack of observed benefit vs standard nurse-made blanket mattresses. We do use head positioners however.

I am from the NYC area, and it's true that the number of schools offering NNP degrees have decreased recently, including Columbia University, my own grad school. The NNP market is a bit oversaturated here on the island of Manhattan, and even in NJ and the rest of NY. You can find the occasional NNP position on Long Island or upstate. My personal opinion is that it's just not profitable for schools to pay for an NNP program, which involves hiring a director, doctorally/masters prepared professors, clinical sites, etc when there are only 3-5 applicants per year, which was the case at Columbia. That program closed because of low demand, and transition periods within the school of nursing. Stonybrook has a large and popular NNP program, which a lot of RNs gravitate to, because most NNPs are working as FT NICU RNs and prefer the distance option, AND it's a third of the cost of Columbia's program. To answer your question about PNPs...my hospital no longer hires PAs or PNPs for the NICU. We have a few left from before the new rule, but now our directors only want board-certified NNPs, which helps with Magnet and US News & World Report status. A lot of our NICU RNs got their PNP only to get screwed out of a job in our unit. It's a shame because they would bring such a wealth of needed knowledge.

Well, this is what we have today: Prematurity Transient Tachypnea of the Newborn Presumed sepsis r/t maternal chorioamnionitis Sepsis Congenital heart disease (pre/post/periop) Congenital autoimmune myocarditis Gastroschisis Omphalocele PPHN/pulmonary hypertension Meconium aspiration syndrome Choanal atresia Pierre Robin Sequence Hydrocephalus Neonatal seizures Hypoxic-Ischemic encephalopathy (head cooling) ECMO Sirenomelia (Mermaid) Posterior urethral valves/UPJ obstruction Anal atresia Tracheoesophageal fistula/Esophageal atresia Spina Bifida Congenital viral infections

Can I ask how there is any antibacterial activity left if it's been irradiated? Isn't it just then a topical sugar application?

In my unit (Level IV) routine VS and cares/feeds are at 8-11-2-5. Fluids are done by day shift, and routine labs are done at 0400.

We don't sedate or give pain meds for simply being intubated, EXCEPT if they are pulmonary hypertension patients who are having spells, our cardiacs who can't tolerate increased SVR, and/or our postops. That being said we are a huge bubble cpap center and the vast vast majority of our non surgical patients are not on vents.

I'd recommend applying to every hospital with a NICU position in NYC and the burbs. We hire several new grads here in our NICU. Most managers I feel actually prefer new grads over seasoned nurses from other departments, because there are no bad habits to unlearn, and let's face it...NICU is unlike any other floor or unit.

Wow this situation sounds ghastly for an NNP. Frankly I wouldn't work for a place that put so many restrictions on me as a practitioner. Where I am now, while I of course involve the fellow and attending in my decision-making, I am fully functional in terms of coming up with a plan of care, consulting my subspecialty colleagues, admitting/discharging, performing complex procedures...etc without any input or oversight from an attending. I *do* have a collaborating physician who acts as a mentor and an intermediary between the practitioner team and the attendings. I am the one entering orders under my name, interpreting my own studies, transporting patients to CT/MRI, providing deep sedation for bedside open chest closures...I am the primary person managing our critically ill post op open heart CT patients from day one through DC. I know this isn't the case everywhere, but I would shrivel up and die as a practitioner in that kind of environment where I'm being babysat by an attending.

I agree with everything else EXCEPT this quote. I sure hope this isn't the standard practice. At my facility (Level IV with ADC=75 including open hearts, ECMO, head cooling, and one-lung ventilation) and we rarely get daily CXR on stable intubated babies. Unless its a postop cardiac on a Lasix drip who we're trying to dry out, or a preemie who is acting funny. It's just not clinically indicated. And all these xrays add up to a significant dose of radiation by the time they go home.

There is no way they can mandate that NPs be doctorally prepared until they decide that the BSN is the entry degree to nursing... and that hasn't happened yet, over a hundred years later haha. There's nowhere near the amount of faculty available to train every NP as DNP. I think in the sense that the (at least current) goal is to have DNP graduates take a national board exam similar to the USMLE Step exams is an example of how the DNP really hasn't become that attractive to NNPs. There's no way they can make us take a national exam on subject matter that is across the lifespan when our entire clinical experience and knowlege is from 23 weeks gestation through age 2... and most of us haven't care for an infant past 1 year. For me, there is no financial or personal incentive to take on 30-45k in debt, and spend 2-4 years in school for a degree that gets me nothing but a title. It does nothing to expand my scope of practice. I do see some attraction to the research and science side of it, which now that I have been practicing as a NP for 5 years...has me wishing I had paid more attention to stats, research, etc back in school to apply to practice today, vs just surviving grad school. In any case, good luck with whatever you choose...who knows- I may go back for my DNP someday but not until some benefits are seen to offset the costs.

As a general rule, we make babies NPO 4 hours before, during, and 4 hours after transfusion. We start an additional line to deliver IVF/TPN during the transfusion. We currently have research in progress looking at the age of donor blood at time of transfusion in relation to NEC development. Another thought to consider is a chicken/egg issue. If the baby is so anemic that oxygen delivery is compromised, ischemia occurs leading to NEC, maybe it's that and not the transfusion itself?

"If it's just neo CICU, at what age will you transfer them to the "regular" peds CICU?" We almost always discharge to home from our current NeoCICU section of our NICU now. It's the rare kid who's waiting for transplant or on a 6 wk course of ABX for endocarditis that we send to the floor. Once the new unit is open, if we are over capacity in the NeoCICU, we plan to transfer them back to the general med/surg NICU.

We do not use double lumen lines for our UACs. We only use double-lumen UVCs in certain situations - ONLY on our pre/postop cardiac patients that require pressors, PGE1, Flolan, etc... The vast majority of our patients only need a single lumen UVC, and have a PICC placed the day the 48hr sepsis rule out is complete.

BabyNP offers some great advice, so I won't add too much... but I think with that much bedside experience by the time you enter clinicals is great. My added advice is to seek out learning opportunities. Take care of the sicker babies...get used to interpreting labs and Xrays, how to adjust vent settings for gases, putting in IVs, attending deliveries if you do that at your hospital, as well as doing transports. In my opinion, an RN who is confidently caring for all kinds of patients and has a mind to absorb the nuances of neonatal patho makes for a great new NP

As an NNP who has worked in NICU for 10 years, nearly 5 as an NNP, I can tell you there are never enough NNPs to go around. Especially as you said with units expanding rapidly, some even with 100+ beds. We are fortunate to be a NNP friendly unit, with many of us having been RNs on the unit who went back to school. The vast majority of our team is in their early thirties. Only 4 are older than that. Unfortunately the NCC no longer requires NICU experience to take the certification exam, which is ridiculous in my book. We were one of the last specialties to require 2 years of bedside practice in a Level III+ NICU for certification. We have seen many applicants with ZERO practical experience in NICU. Luckily all our in-house NNPs were smart about it and worked as RNs first. The market is only going to expand. It's true that we are a higher paid specialty due to our shift work, intensivist practice, transport, and some of us rotating. It's also sometimes lacking the perks of our primary care colleagues who work bankers hours, no nights/weekends/holidays etc. But as for me I don't mind. Love what I do. We are building the nation's first Neonatal Cardiac ICU, to care for pre/postop congenital heart disease and cardiac patients, run by neonatologists and NNPs along with cardiologists. We already do it, just not in a dedicated unit, and this will be very exciting for us.

Congratulations!

^Yeah we do too... we had our very first neonatal CVVHDF/CRRT via ECMO circuit patient recently. Very interesting case, as we had to learn very quickly how to manage one more machine at the bedside