Tips for Clinical Observation in NICU

Jolie, BSN · Jan 12, 2007

First of all, practice normal newborn assessments on your well-baby patients.

Then, prepare a cheat sheet to bring with you containing the following information: normal vital signs for neonates, norms for common lab values such as CBC, electrolytes, and glucose.

Prepare drug cards for a few common meds such as Ampicillin, Gentamycin, Surfactant, and Caffeine.

Read up on the pathophysiology of the most common admitting diagnoses: Prematurity, Respiratory Distress Syndrome, Possible Sepsis, and Glucose Instability.

Prepare a brief (1 or 2 nursing diagnoses) careplan for each of the above.

No one can (or will) expect you to have any experience with NICU infants. But as a preceptor, I can tell you that nothing is more frustrating than trying to guide a student who lacks even the most basic foundation needed for further learning. Students who have not prepared for their NICU observation will learn nothing, frustrate the staff, and probably find themselves sitting in the breakroom. The only thing worse than an unprepared student is a "know-it-all" who oversteps his/her bounds and does things without asking.

In 11 years of OB and NICU nursing, I was fortunate to encounter only one such student. I informed her instructor that she was not welcome back in my unit. Turns out, I was not the first one to complain, and I believe she was dropped from the program.

Thank you for asking. Given your conscientiousness, I am sure you will do fine! Please post and let us know how it goes!

zahryia, LPN · Jan 12, 2007

Wow, Jolie! Great post.

llg, PhD, RN · Jan 12, 2007

I would start with a basic understanding of the different types of patients that you are going to see. Be familiar with the basics of gestational age assessment and the characteristics (and common problems) associated with different gestations. Then I would start adding on the stuff that Jolie discussed.

Having taught neonatal nursing -- both as a staff development instructor and as a nursing school instructor, I find it easiest to start with the gestational age characteristics and common problems of the newborn at different gestational ages. That gives the student a basic foundation, a way of looking at babies for the first time. Then specific details about specific babies and conditions can be added on to that basic framework.

pooperscooperrn0624 · Jan 12, 2007

Remember developmental care on these infants. Be organized and do what you need to do quickly then get out of their bed. Do not talk over the infant when you are assessing it. I will IM you a good website video on newborn assessments. This is more detailed than what you will need to do but it is very good. The unit should have several neofax's lying around so nab you one to look up meds your infant is on.

RNin2007 · Jan 13, 2007

You were given very good advice. I was in the NICU for 11 weeks last term (2, 12 hour shifts per week). We were expected to know EVERYTHING that Jolie said...our clinical instructor gave us those directions. Whenever we passed medication, I wrote down all the calculations on a piece of paper and showed my preceptor beforehand (even if it was the same medication, 5 weeks later). You can never be too careful. I also found resources on the unit in the neonatologists office (after asking my preceptor) and used the time between my assessments by reading about neonatal nursing care. Core Cirriculum in Neonatal Nursing is a great resource. I also reviewed what I would document on the baby's chart before writing it, and had my preceptor double check all my charting. Whenever I did an assessment (usually q 3 hrs) I summarized my findings with the nurse so she knew that I was being thorough (or if I forgot something, she would remind me).

Definitely don't overstep any boundaries...ask questions, when it is an appropriate time.

I loved my NICU clinical days....!

BittyBabyGrower, MSN, RN · Jan 13, 2007

Is this just strictly observation or are you hands on? We get both, the obs ones usually have things they have to observe and need to know. What gets us is when they have certain things that they need to look up and they ask us to basically do their work for them...nope, not happening....we will help you out, but we aren't going to feed you the answers. Did your instructor talk to the UM, if she, she should be able to guide you as to what the nurses really mean. If you are hands on, Jolie's post says it all.

kimsnothome · Jan 13, 2007

This is strictly observation only for one day during our peds rotation. It's all done very casually on the school's end (i.e.: "go to NICU today and observe"), so I think that traditionally students have shown up without a clue what to do or expect.

Thank you!

Is this just strictly observation or are you hands on?

llg, PhD, RN · Jan 13, 2007

This is strictly observation only for one day during our peds rotation. It's all done very casually on the school's end (i.e.: "go to NICU today and observe"), so I think that traditionally students have shown up without a clue what to do or expect.
Thank you!
Is this just strictly observation or are you hands on?
My hospital provides a lot of those 1-day observational experiences for nursing students. For such experiences, I recommend reviewing:
1. Gestational age and the common characteristics of babies at different gestational ages.
2. Common problems of the newborn and common problems of prematurity.
3. Needs of the parent of the NICU patient.
Those 3 things should give you the foundation you need.

kimsnothome · Jan 13, 2007

Thanks to everyone for all the great advice, I really appreciate it!

Kim

Gompers, BSN, RN · Jan 14, 2007

If it's just an observation day, the nurses shouldn't expect you to be all that prepared, I don't think that's quite fair. We all know that they don't teach you much NICU-related stuff in peds and OB during nursing school. That's why they're sending you to check it out! When we have students come to observe, we just try to show them what NICU nursing is about and what kinds of patients and conditions we deal with. If it was a preceptorship, that would be different since it's a long-term hands-on experience. But everyone here has given good advice on some things to bone up on before you go to the NICU, and that will help you have an even better experience because you'll know a bit more about things already.

Here's some Top 10 lists to help you out:

Reasons infants are admitted to the NICU:

1. Prematurity (23-36 weeks gestation)

2. Respiratory distress

3. Congenital birth defects

4. Jaundice

5. Hypoglycemia

6. Surgical issues

7. Birth trauma

8. Infection

9. Drug withdrawl

10. Feeding intolerance

Equipment used in the NICU:

1. Ventilators - conventional, high frequency, jet

2. CPAP - continuous positive airway pressure

3. Nasal cannulas - regular and high flow/high humidity

4. IV pumps

5. Syringe pumps

6. Radiant warmer beds

7. Isolettes

8. Cardiac and oxygen monitors

9. Suction machines

10. Accucheck

Labs drawn on NICU babies:

1. Blood gasses

2. Glucose

3. Electrolytes

4. CBC

5. Coags

6. Bilirubin

7. Medication levels

8. Blood cultures

9. Liver function tests

10. Renal function tests

Common acronyms heard in the NICU:

1. NEC - Necrotizing enterocolitis

2. IVH - Intraventricular hemmorhage

3. PDA - Patent ductus arteriosis

4. PVL - Periventricular leukomalacia

5. BPD - Brochopulmonary dysplasia

6. PIE - Pulmonary interstitial emphysema

7. ROP - Retinopathy of prematurity

8. AOP - Apnea of prematurity

9. PFC - Persistant fetal circulation

10. TEF - Tracheal esophogeal fistula

Typical nursing duties in the NICU:

1. Performing and charting assessments and vital signs

2. Feedings - NG, OG, NJ, GT, PO

3. Medication administration - IV, IM, oral, topical, rectal

4. Labs - via umbilical or peripheral lines, heelstick, venous stick, or arterial puncture

5. Bathing, weighing, and measuring babies routinely

6. Obtaining new IV access as needed

7. Reporting patient observations and labs to the doctors and nurse practioners

8. Carrying out orders written by the doctors and nurse practitioners

9. Assisting with procedures like intubation, line placement, x-rays, u/s, chest tube insertion

10. Supporting the families of our patients!!!

Common NICU medications:

1. Antibiotics (ampicillin, gentamicin, cefotaxime, vancomycin)

2. Antifungals (amphotericin, fluconazole, caspofungin)

3. Antacids (Zantac, Prevacid, Prilosec)

4. Analgesics (morphine, fentanyl, acetaminophen)

5. Sedatives (Ativan, Versed, chloral hydrate)

6. Vasopressors (dopamine, dobutamine)

7. Cardiac (epinephrine, atropine, prostaglandins)

8. Sodium bicarbonate

9. Surfactant

10. Caffiene

I remember one evening I was assigned three students who would be observing me for 4 hours. Two of them weren't interested in NICU as a career and one of them was like me - she went to nursing school in hopes of becoming a NICU nurse someday. All three listened and watched intently as I explained what kind of patients I had that day and what my duties were. At one point, I was going to weigh this little peanut - probably about 1-1/2 pounds or so, off the ventilator and doing well, just tiny. I could have easily weighed him myself, but I asked if one of them would like to volunteer to help me. Of course the NICU-hopeful jumped in, and I had her put her hands into the isolette, palms up. I placed the baby in her hands while I changed his linens and zeroed his bedscale. She carefully set him down on his clean bed and just stood there staring at him. I swear, she had tears in her eyes she was so happy. She gave me the biggest hug when she left that night, telling me how amazing it had been to hold that little guy even for a minute and thanking me for the experience.

(Yes, quite a long post. I'm waiting to go to bed until the baby wakes up for her next feeding...and she's reeeeeeaaaaalllllly sleeping right now. It's been almost 6 hours! Just watch, she'll sleep through the night the one time I'm waiting up for her!!!)