itsybitsy

itsybitsy specializes in NICU.

itsybitsy's Latest Activity

1. 

   Slow flow nipple?

   itsybitsy replied to RNLAC's topic in NICU

   We typically don't feed on high flow. We regularly feed on low flow as long as that's the only issue. We don't feed if respirations are greater than 70 breaths/minute.
2. 

   Slow flow nipple?

   itsybitsy replied to RNLAC's topic in NICU

   Slow flow nipples are not all that?? What is that suppose to mean? That they don't work or what? If you're trying to say the practice is being outdated, you're sorely mistaken. Slow flow nipples are very heavily supported by evidence, and continue to be. You mention your SLP using a premie Dr. Brown nipple, which is a slower flow nipple than standard. So you would follow the MD orders to use a standard flow, because it's risker to use a slow flow than a standard flow in a baby with mild PPHN? What?!? It's risker to slow the flow of milk, than it is to possibly aspirate, stress the baby out, and worsen the PPHN? Where is the thinking that a baby will become stressed by eating from a slow flow nipple?! And really, you really should feed every baby left-side down for two reasons. One being that if they are on their side, the milk will not pool in the back of their throat but their cheek, lessening the chance of aspiration. The second reason for specifically left-side down is the anatomy of the stomach. The larger part of the stomach plunges to the left side of the body, meaning that intake will collect at the very bottom of the stomach if left-side down, rather than the flat part of the stomach on the right side. This allows a baby to continue eating without feeling full faster and will reduce reflex. You want them upright as well to reduce reflex.
3. 

   Slow flow nipple?

   itsybitsy replied to RNLAC's topic in NICU

   I'm sorry, but this is so wrong. This is just asking for aversion after aversion. "Spilling milk out of her mouth" is anterior loss. It's showing that the baby is not tolerating the flow of the feeding. The feeding is coming out of the nipple too fast, the baby is pushing it out. It's also a sign that that feeding should cease. If it continues, the baby is eventually going to get worn out and aspirate, because it will be too exhausted to push it out any longer. Secondly, arching, crying, pushing away from the nipple, falling asleep, etc., with a feeding are also signs that the baby is done eating. That baby is cueing that the feeding is no longer wanted... I wonder why. The faster flow is probably stressing the baby out more, probably exasperating the PPHN. This is a 25 weeker, who is 42 weeks, on oxygen, and have mild PPHN. If we are even going to orally feed this kid, it BETTER be slow flow, probably with a thickener. ALL of our premature babies are fed with a slow flow nipple, and most term kids are as well, all the way to discharge, and we send parents home with a slow flow bottle and nipple, to continue using. ALL of our premature babies are held in a left-side lying position, elevated. Many of our kids are paced, if it's needed. The order needs to be deleted from use. The kid is in the NICU for a reason, and doesn't need to aspirate, in which case they are at higher risk for if they have had any respiratory problems. The few kids that could probably use standard flow nipples are the chorio kids that just need some antibiotics and haven't had any respiratory problems. The SLP is not educated on neonatal feedings, obviously. I'd rather not have a kid that has mild PPHN to aspirate, thanks. Slow flow nipple is NOT harder to get out of the nipple, it's to literally SLOW THE FLOW. These kids SHOULD eat slower, so they DON'T aspirate. If the baby is worn out, then the feeding is done. If the baby isn't meeting their full feeds, then you need to tube feed, to meet those requirements. Obviously this is an ongoing problem, seeing as the baby is 42 weeks, in which case, I wouldn't be surprised if the baby needs a button to go home. My suggestion - Lobby for a SLP full-time in the NICU that knows what they are talking about.
4. 

   Thinking about getting a gun for safety

   itsybitsy replied to MotoRN34's topic in Home Health

   I would do whatever you feel is right for you. Whether that be having a concealed carry or not. Whether you want to leave it in your car or carry it on your person. I understand you when you relay that you aren't worried about your patients, rather the areas where your patients live. Which is why you might want to just leave it in your car. I wouldn't worry about it getting stolen unless you are leaving it in plain sight, in your vehicle. So many "what ifs" could happen and none of them justify limiting your ability to protect yourself where you feel is a threatening area. Pepper spray and blunt objects won't do you any good if a gun is pointed at you. Carrying on your person, into a patients home, is legal, as long as the patient/owner of the home doesn't have signage posted that firearms are not allowed. Yes, your employer probably doesn't "allow" it, if it's even discussed in your employee handbook. Your employer probably also doesn't allow many other things, such as cell phone use in patient homes. Obviously the latter wouldn't get you fired, while carrying concealed probably would, but it's not against the law. The point of concealed carry is that no one knows you have it, so your employer shouldn't and wouldn't know, even if you did, properly. The only time they SHOULD find out, is if you had to use it, in which case, if you saved yourself and your employer fires you for protecting yourself, within the limits of the law. In which case, I wouldn't want to work for said company. If you are found out to conceal carry, by accident (as in a patient saw it, as it wasn't concealed properly, and reported you), and you are fired, that is a risk you must decide if you want to take, in which you can mitigate that risk by concealing properly, 100% of the time.
5. 

   NP jobs that work 3days

   itsybitsy replied to Guest1059175's topic in NP

   Neonatal NP's work 3, 12 hour shifts. Some even work 24 hour shifts.
6. 

   Should I email the manager?

   itsybitsy replied to AnnieOaklyRN's topic in NICU

   I'm not an expert on job seeking, but I would maybe wait until I have secured an interview before e-mailing the manager. It might be awkward if you e-mail and are not called for an interview. However, I bet you will be, as you passed HR inspection last time, so I would just wait for the interview set-up, then e-mail.
7. 

   Removal of NG/OG tube

   itsybitsy replied to JThieman's topic in NICU

   We don't expect 100% from the babies. 80-90% for the past 24 hours is usually sufficient. It's also not a policy, it's a order. I can't remove the tube unless it's okay-ed by the provider. If the kid pulls it out themselves and eating 70%ish, they might let them try to fly. If not, then it goes back in obviously.
8. 

   Discharge after weaning to Crib

   itsybitsy replied to JThieman's topic in NICU

   Whoa, you went DOWN to 74F?! We only go to 28C (~82F), for at least 24 hours. We can go lower if the baby is hot, but if not, we leave it at 28C. We also start weaning at 33 weeks and about 4 pounds. Once they meet that criteria, we wean to a crib. So in our unit, they rarely even have a chance to even be close to discharge when we wean, as we also don't start feeding until 34-35 weeks, cue based. However, there are those rare times you get that extreme IUGR kid that goes home before reaching 4 pounds and is 37 weeks. Those are the few exceptions that may have to wait. But not longer than 24 hours. Why are term babies in isolates, given that their weight is sufficient?
9. 

   Working Holidays? 5 Ways to Make It Work for You

   itsybitsy replied to jeastridge's topic in Nursing

   Whenever someone is like this, I usually think they need to get off their high horse and stop acting like everybody needs to be as cheerful as themselves. I don't believe you or I have to be a grouch, but don't expect me to be overly excited to work. The last holiday (non-federal) I agreed/was nicely forced to work, I was told, it will be fun! The first issue was we were horribly understaffed that day. The second issue was that there was going to be a party with families throughout the day. Not that that's a bad thing, but just makes the unit a whole lot more busy and families will most definitely be showing up and needing assistance, hence more work. The glimmer of hope this was going to be "fun" was that there were multiple volunteers from the unit to come host and run the party, assist families/siblings, etc. Well, ONE volunteer showed up. ONE. In an already short-staffed unit, the working few of us were being called to hand out candy and participate in crafts with families who were arriving. Excuse me? I already have 2 more patients than I should, and now you are calling me to entertain? Needless to say, the day was anything but fun and I was not happy. Anyone who acted like that, I probably would have wanted to punch. So sure, if I have a quiet, nice assignment all day during a holiday, I can be as happy as I am any other day. But I won't be extra cheerful because I'm at work, I would still rather be somewhere else, everyone would.
10. 

    your admission routine

    itsybitsy replied to tinybbynurse's topic in NICU

    - Get respiratory support initiated. - Get your initial vitals and a quick assessment. - Get labs drawn, as they need to be drawn before any initiation of fluids. As you said, a blood culture needs to be obtained by sterile venous draw, and you can get all other labs, if able, with the same blood draw. Or if starting lines, blood can be drawn from the umbilical lines, which would kill 2 birds with 1 stone. Or get all other labs, other then the blood culture, from a capillary stick. If a blood culture is your difficulty, you might start the PIV, after getting other labs from a capillary stick, if labs are critical, as in a low blood sugar, and get the culture after. This is not ideal as antibiotics should be started within an hour of birth if it is a suspected chorioamnioitis, but you'll need to prioritize based on the baby. - If no lines are started, then start the PIV. If it's a difficult stick and someone else needs to try, move on to the next step when you get a few minutes between tries. - Get your meds - erythromycin, vitamin K, antibiotics, etc. If others are looking for PIV sites, go ahead and give the erythromycin and vitamin K. All other meds will then be set to go once the PIV is in and cultures are drawn. Ideally, that would all be done in 30 minutes to an hour.
11. 

    Post Op vitals frequency

    itsybitsy replied to JThieman's topic in NICU

    Q15m x 4 Q30m x 2 Q1H x 4 Q2H x 6 Is what we do.
12. 

    NIMV settings question

    itsybitsy replied to Ladybug777's topic in NICU

    I might add to my statement that if a PIP is higher than the PS + PEEP, it may read that because the baby took a larger breath. The ventilator wouldn't give the baby a higher PIP, only the baby would be able to do that on its own.
13. 

    NIMV settings question

    itsybitsy replied to Ladybug777's topic in NICU

    Correct me if I'm wrong but pressure control doesn't mean the PIP can't go any higher than the set pressure support + PEEP. This is what I interpret what you are saying... The PIP can go higher than PS + PEEP. If you just watch the ventilator, every breath reads a different ultimate PIP and if you have PS of 9, with a PEEP of 5, you can see PIPs higher than 14, when the baby initiates their own breaths. Usually it's only 1 or 2 higher as in 15 or 16, but it doesn't cut off at 14. The same is true for volume guarantee, except there is a pmax. Which is around 25 for most settings. Plus, a pressure control of 14 wouldn't really do any baby justice. You would be under-inflating the lungs and not giving adequate breaths.
14. 

    What do you think of 12 hour shifts

    itsybitsy replied to RNattie's topic in Nursing

    Best thing since sliced bread. However, I do work days. Honestly, I'd rather work two 18 hour days. THAT would be the life!
15. 

    Do you consider it helpful or not to be given a Pt’s attitude during a report?

    itsybitsy replied to DesiDani's topic in Nursing

    I always appreciate any type of report on interactions. It lets me know what I'm in for and who I need to be extra conscientious about. Whether I can ask them to wait a few minutes if they call and they wouldn't mind at all or if even asking them to wait would instill a full blown meltdown. I always say my interactions with parents whether it's, "Everyone [the nurses] have been writing narrative notes on all interactions with parents, as they have been threatening staff" to, "these people call every 5 minutes" to, "this family is so nice, they brought cookies which are in the back". I like the same in report. I hate being blindsided. On the flip side, nurses can have vastly different experiences within 24 hours. I've have parents who I didn't mind at all and were very appropriate. Then next shift comes, I tell them just that and they are flabbergasted as the experiences they had with the family were horrible. So it can vary nurse to nurse.
16. 

    What is the hardest shift you ever had?

    itsybitsy replied to vxxen's topic in Nursing

    Second worse shift. Four baby assignments for everyone. I had two scheduled discharges. Ended up discharging three. Fifteen minutes after the first discharge, I got an admission - that I did by myself, no help from anyone. The new baby was going into the same room as the one I just discharged, but it hadn't been cleaned yet, so I had to clean the room. Needless to say, the shift was a mess of just teaching and discharging, plus taking care of my last original baby and getting my admission tucked in while teaching the new parents. I got my last discharge out about an hour before shift change. Was talking to a co-worker for a second as I had cares on my last baby in 5 minutes. Another nurse was walking out her ONLY discharge at that time and also had cares. She wanted someone else to do cares and feed. I was asked and said I couldn't as I have cares now. I was then practically made to feed the other nurses baby. I was already upset at this point because I ran my *** off all day, with no help and now was being made to do someone else's work instead of my own. Finally got to my room to do cares 10 minutes late and I was approached and asked, "What makes you think you can say no to me?". ***** WHAT?!? At that point, I just shut my mouth because if I started, I wasn't going to be very nice. Still makes me extremely PO'ed to this day.