RN's who work in the NICU

JoniL&DRN · Nov 17, 2004

might get more response if you move this thread to the NICU section...

sparkyRN · Nov 24, 2004

I'm glad you are interested in becoming "one of us!" People ask me all the time."how do you work with those sick babies, it must be so sad?" Well, sometimes it real is. And sometimes it is maddening especially when you notice a problem that the resident docs don't take seriously-staff docs and NNPs are usually better. And sometimes it's like the movie "Groundhog Day" where everyday is exactly like the day before and time seems to never end. This most likely happens in a Special Care setting (Image taking care of 6 feeder/growers all eating q3h during a 12 hour shift. Thats 24 bottles averaging 15min /baby- if they are good eaters. You barely finish one set of feeding before it is time to start again. The math works out to 6 solid hours of sitting feeding babies. And you haven't assessed, changed diapers, done VS, charted, talked to family on the phone, done bedside teaching or actually cleaned the baby up!) But, mostly it is very rewarding. Most of the babies do get better and most of them do go home without major delays or disabilities. If you stick around long enough you can see major breakthroughs, be a part of research trials and take care of the babies of some of your first patients!

Obviously all units are different for numerous reasons. Some are at teaching/university hospitals that generally have Level III (highest acuity) units and are a regional referral hospital with a transport program for outlying hospitals. Some are set in a children's hospital. Others are in private maternity hospitals. Some units have 4 beds, ours has 80. Each of these settings, along with type of patients will dictate different approaches to care. I work in an urban university affilated teaching hospital that trains residents, neonatal fellows and NNPs. It was one of the first NICU in the country. Because many of our pts are poor and uninsured or underinsured we don't have the resources for some of the things many other private units take for granted.

But you asked about a typical day...

My 12 hour shift will start with getting an assignment. Because the census can fluctuate greatly and we are chronically understaffed, I will usually have 2-3 pts. and an admit in ICU, 5-6 pts. and an admit in our step down unit, and 6-7 babies in Special Care hopefully with a nursing student to help out. (I understand the more typical setting would have a max of 1-4 pts. for every nurse depending on pt acuity.)The off-shift nurse will give me report at the bedside, where we review significant history of mother and baby, resp., neuro, and cardio status, feedings, IV fluids, meds, recent and pending labs. We will review the bedside flow sheet that shows all the baby's blood gases, lab reports and nutrition profile. We talk about who's called &/or visited, how they're handling things. We'll also talk about the quirks...preferred positions, tolerance for suctioning, etc. It sounds like it would take forever, but report on each baby usually lasts just a couple of minutes. After report, I'll review the chart to make sure the Kardex is up to date, make sure my IV pumps are infusing correctly then hit the ground running-literally! A typical day in ICU will start with a pt assessment, VS, diaper or urine bag change with I&O, changing ng/og tubes and starting feedings. We manage all our own resp. care and will suction prn or on schedule as ordered, allow the baby to settle then draw morning lab incl ABG. The staff docs, residents, NNPs, nutritionists, social workers and charge nurse make rounds on every baby every morning. Nurses are expected to be at the bedside to voice concerns. Late afternoon they do quick sign-out rounds, which I usually do not hang around for unless my babies are sick. The on call docs often round on the sick babies around 2300 if necessary. Once a.m. labs are back the residents will write their orders for the next 24 hours. The nurse is expected to review everything ordered to make sure it's all accurate-often it is not, esp. at the first of the month. Baby's peripheral IVs (PIV) don't usually last very long especially if he is jaundiced. So. most shifts include at least one or more IV restart. Hopefully a baby will have a UAC & UVC or a PICC for IV access, but not all do. Sometimes intubated babies will need to be electively or emergently reintubated and the nurse is right there to assist with suctioning, bagging, and ET positioning and taping. IV fluids and tubing will be changed once or more/day. If a nurse is up for an admission, she will go down on any delivery under 28 weeks with the resident or NNP, otherwise she will take the transporter to delivery when the resident calls for it and bring the baby up to admit. She will assist in giving surfactant, and schedule follow up lab with the resident. There may be blood to hang and certainly any fragile baby might go through several fluid/med changes. Sometimes they go from conventional vent, to an oscillator and may in some cases require Nitric oxide therapy or transport to an ECMO unit. The nurse is in charge of understanding and maintaining all that. Then there are the parents. They usually will call or visit daily and the nurse is the one that they talk to first. I try to explain things as simply as possible trying to avoid medical lingo (most of our families are not very well educated) without sounding like I'm talking down to them. I always try to find something positive to say first. When the baby is not likely to make it, I start to lay the ground work to prepare them for the baby's death. ("He's not peeing which means his kidneys are not working and that's because his blood pressure is too low. A baby can't lives if his kidneys don't work." - kind of like that.) That's probably the hardest thing of all. You don't want them to give up hope when a baby first gets sick-some of them have an amazing ability to turn around, but you also don't want to create unrealistic expectations. I keep notes clipped on my nurses chart that I refer to when I do my computer charting which I try to do q2h. Whenever possible I try to take 2 short breaks and one regular lunch break during the 12 hours. The nurses are great about watching each others babies and helping out with admissions and when a baby crashes. Try to be helpful and it will be returned to you when you need it.

I hope this helps! I sure hadn't planned on writing this much, but I have a lot to talk about after doing this for 19.5 years!

kristylee · Nov 24, 2004

sparkyRN

Thank you for all the detail you provided. It was very helpful in understanding what it's like in the NICU. I like how you refer to them as 'your babies' :) I can tell you're a wonderful nurse! Thanks again!

t2000JC · Nov 27, 2004

SparyRN, i am surprised that your census seems high. On my unit it is usually 1-2 with admit ICU, 3-4 stepdown; occ. 5. I am running around with 4 usually, I admire you for being able to do it with more! t.

sparkyRN · Nov 28, 2004

We dream of those days! :)

It's hard to ever get the staffing where it needs to be when newly trained nurses work for 2 years to get their experience then move on to more exciting locations as travelers. Or they burnout because of the workload before the next group of nurses gets through hosp. orientation, classroom learning, clinical training and preceptorship (usually about 4 months). Plus, the shortage is really acute for our hospital because of several things. The city has a large medical center with constant need for nurses. And, quite frankly, our hospital's physical plant is not very appealing. Our particular building is OLD (1940's) and our unit just does not match up to the shiny, slick NICU's in town. Plus, we are downtown which can be a negative for commuters. Our babies are the sickest, our census the highest and our skills have to be the best. You can't survive here if you can't cut the workload.

Kind of a self-perpetuating problem...

lee03 · Nov 30, 2004

I am new to the forum but couldnt resist in commenting here....I am amazed at how you all have a 3-4 baby assignment with an admit!!!! I work at a level IV NICU (with ECHMO) and our census is usually around 35-50 kids give or take a few...in level III we always have 1-2 babies and the admit nurse only has a stable baby. The nurses who work on Level II ( or Special care nursery ) will generally have a 3 baby assignment unless we are REALLY busy then they might max out at around 4 kids.

sparkyRN · Dec 1, 2004

And where are you located....I might need to move there! :)

lee03 · Dec 2, 2004

im from Portland Oregon =) Where are you from?

sparkyRN · Dec 3, 2004

I'm 15 minutes from Graceland!