Handoff Report

After huddle, report begins. A NICU report looks much different than the adult world and includes ALL (if not MOST) of the following, depending on your facility:

GENERAL

1. Baby’s name

2. Code status (Full, DNR, partial code, etc.)

3. Social history (CPS involvement, custody issues, etc.)

4. Any transmission precautions?

PREGNANCY AND DELIVERY 

1. Age. Birth date + gestation, corrected gestational age, day of life.

2. Weight. Birth weight, current weight, gain or loss from the previous day. 

3. Location of birth (hospital name, precipitous delivery in ER, homebirth, etc.).

4. APGAR scores.

5. Head circumference.

6. Length of the patient.

7. Events/complications during delivery (resuscitation measures needed + duration).

8. Primary diagnosis & reason for NICU admission.

MATERNAL HISTORY

1. Maternal age.

2. GTPAL.

3. Complications and health status (preeclampsia, IVF, etc.).

VITAL SIGNS 

1. Temperature (36.5-37.5 C).

2. Heart rate (100-200).

3. Respiratory (10-100).

4. Blood pressure (MAP depends on age).

5. Apnea/Bradycardias/Desaturations.

6. Pain management (N-PASS).

GI/DIET

1. NPO, tube feeding or PO eating 

2. Expressed breast milk, donor milk, or formula 

3. Quality of oral feedings (nipple preference, pacing, timing, positioning, etc.). 

4. Last BM (stool).

5. Abdominal girth.

6. Voiding type (diaper, ostomy, etc.).

7. Tube tube (OG, NG, Replogle, Anderson, or G tubes).

8. Tube purpose (decompression, feeding, intermittent/continuous suctioning).

9. Tube french size, length out, placement date (& when it’s due to be changed).

10. Last swallow study + results.

11. Last upper GI + results.

GU 

1. Urine output (all diapers are weighed until discharge).

2. Foley (french size, reason for placement, date of placement, length out, & output).

IV ACCESS

1. Umbilical lines.

2. PICC line.

3. Peripheral IV.

4. TKO IV fluids

5. Broviac (sometimes). 

6. TPN and Lipids.

7. D10W.

8. Any replacement fluids, such as albumin or sodium acetate?

RESPIRATORY SUPPORT 

1. ETT size, placement on X-ray, number marked at gum, date of last intubation, date of last retape.

2. Ventilator type, mode, & settings (HFOV, SIMV, Bubble CPAP, Non-Invasive, HFNC, etc.).

3. Suctioning needs & characteristics of secretions.

4. FiO2 requirements.

5. Spell history, description, and management.

6. Last chest/abdominal X-ray + interpretation.

CARDIAC 

1. Pulses (goal is +2).

2. Color (Pink, Pale, Mottled, Jaundice, etc.). 

3. Cardiac meds (PGE, Dopa, Epi, Atropine etc.).

4. Last echocardiogram + interpretation.

NEURO 

1. Tone of infant & neuromuscular status.

2. Last cerebral ultrasound (hydrocephalus, IVH, etc.).

3. Last MRI.

4. Last EEG.

5. Seizure history and management.

6. Last head circumference.

7. Neonatal Abstinence Scoring System scores over 24 hours.

INTEGUMENTARY

1. Last bath and products to use.

2. Skin tears, bruises, wounds.

LABS/HEMATOLOGY

1. Review lab trends (bilirubin, H|H, CMP, CRP, etc.).

2. CBGs.

3. Last blood transfusion.

OTHER DIAGNOSTICS

1. Last eye exam. 

2. Last ultrasound (renal, abdominal, scrotal, etc.).

3. Last bone survey.

ORDERS: 

1. Review all of the most recent lab results, shift medications, and look through all of the orders together.

2. Lastly, walk to each of the babies’ bedsides (or just one bedside if you’re assigned a 1:1) together and look at everything. This includes double checking pumps, infusion rates, IV access, tube placement, settings, and connections.

Common NICU Diagnoses

In the NICU, we see infants born with a wide variety of health challenges, and the way we treat one baby with a certain condition may be entirely different than the way we treat another baby. It’s true that we see almost anything and everything; however, not every baby can be admitted to our unit.

NICU patient population admissions range from birth to one year of age. MOST of our babies (about 99.9% of them, in fact) are admitted directly from L&D, Mother/Baby, or are transferred to us from other facilities (in order to receive higher level NICU care). In other words, if your child is older than one year old and is in need of intensive care, they would be admitted to the Peds ICU rather than the NICU.

Listed below are just a few of the reasons a baby would be admitted to a NICU:

1. Respiratory Distress Syndrome

2. Rule Out Sepsis (Maternal Fever, UTI, Premature Rupture Of Membranes, GBS +)

3. Rule Out Bowel Obstruction (Volvulus, Perforation, Imperforate Anus)

4. Digestive Disorders

5. Hyperbilirubinemia/Jaundice

6. Multiple Gestation (Twins, Triples, etc.)

7. Blood Disorders (Incompatibility)

8. High Risk Delivery (drug related, STI exposure, unknown pregnancy) 

9. Medical Issues (Cardiac Defect)

10. Traumatic Delivery/Birth Injury (Shoulder Dystocia, Hypothermia Therapy) 

11. Premature Birth (22-37 wks) “Preemies” 

12. Postmaturity 

13. Disorders of CNS

14. Congenital Defects (Chromosomal, Genetic, Cardiac, Rare Syndrome) 

15. Intrauterine Growth Restriction (IUGR)

16. Infant of Diabetic Mother (IDM)

17. Necrotizing Enterocolitis (NEC)

18. Feeding Difficulties

19. Infection

20. Low or Very Low Birthweight

21. Substance Abuse

22. Small for Gestational Age

23. Large for Gestational Age

NICU nurses & NICU parents: Any that I’m missing? Let me know!

Let's Talk: PFO

Before birth, the fetal circulatory system includes three open structures through which blood moves. These pathways normally close soon after birth and include:

1. Ductus arteriosus

2. Ductus venosus

3. Foramen ovale

The foramen ovale allows the shunting of oxygen rich blood from the placenta via the ductus venosus into the left atrium. 

IN UTERO

The umbilical vein brings oxygenated blood through the ductus venosus to the inferior vena cava and right atrium, where it is directed across the patent foramen ovale into the left atrium. This allows the left ventricle to pump the most oxygenated blood to the coronary arteries (heart) and carotid arteries (brain).

Deoxygenated blood returning via the superior vena cava is directed across the tricuspid valve and into the right ventricle. The right ventricle pumps this blood into the pulmonary arteries, across the patent ductus arteriosus into the descending aorta.

AT BIRTH

The lungs inflate when the baby takes his/her first breath. This decreases pulmonary vascular resistance and increases the flow of blood from the right ventricle. The resultant increase in pulmonary blood flow leads to an elevation in left atrial pressure, which causes the septum primum flap to seal the foramen ovale, closing this hole and separating the two atria. This also increases blood flow to the lungs, as blood entering the right atrium can no longer bypass the right ventricle and is now pumped through the pulmonary artery into the lungs.

In premature infants, sometimes the septum primum flap fails to seal the foramen ovale after birth and the shunt remains open. This is termed a patent (or open) foramen ovale (PFO). As the heart grows in size, the PFO also increases in size.

The PFO opening offers the potential for the shunting of blood between the left and right atria. In most cases, however, there are no associated symptoms and no treatment is prescribed. Eventually, the opening will close on its own.

Essentials to Know

In the NICU, life can change in the blink of an eye. One minute the unit is calm and “q-u-i-e-t,” and the next, a crash C-section is performed and a 26-weeker is being transported to you and your entire team comes together in order to make the admission as smooth as possible. It’s safe to say that the NICU is either feast or famine. The unit slows down a lot during the winter and discharges more babies home than they are admitting. Then comes summer and L&D is popping out high risk babies left and right.

The job of a NICU nurse is so rewarding and unlike any other. You get to help families through quite possibly the hardest time in their lives and see the fruits of your labor grow into “line-backer” toddlers!

As a new nurse starting out in the NICU, here are a few essentials that you should know:

THE BEGINNING OF YOUR SHIFT

After clocking in to work, you meet for morning huddle. Huddle consists of the nursing team and charge nurse who meet together for roughly five minutes to give a “briefing” on the unit. This is when the team discusses general hospital and unit updates, and the plan of care for the day. This includes announcing “hot spots”—which are the sicker, more unstable babies on the unit that we need to keep a VERY close eye on. It is both a safe precaution and a time to bond with your team before you start your day.

After you meet for morning huddle, NICU nurses "SCRUB IN." Leave your jewelry, watches, rings, etc. at home. Your arms will be bare from the elbows down as you scrub with soap and water (for the duration of time that your NICU requires). NICU is "bare arms" in order to keep our little ones safe and healthy.

GENERAL NICU BABY BASICS

• MEASUREMENTS: Our patients are measured in grams & centimeters. 

• GESTATION AND CARE: Baby age (in gestation) drives the care plan. How old they are determines their day to day care.

• MEDICATIONS: Our medications are often measured in tenths of mLs. And a bolus might be 3mLs!

• OXYGEN: 2L of oxygen is considered “high flow” in the NICU. Don’t panic if you see a patient with oxygen saturations in the high 70s, that might be acceptable for that patient depending on his/her underlying condition (Cardiac defect, Prematurity, PPHN, etc.) 

• DIET: We measure our feedings in mLs, sometimes only giving drops. 

• SIZING: We use the smallest blood pressure cuffs you have ever seen and sometimes those are too big! NICU nursing is delicate work.

Sample NICU Head-to-Toe Assessment

• What does the baby’s head feel like?

• Are the sutures separated or overlapping?

• Are the fontanelles flat, soft, sunken, bulging, etc.?

• Do I hear a murmur?

• What do the lungs sound like? Crackles? Wheezing? Clear and equal?

• How are the bowel sounds? 

• Is the abdomen soft? Firm? Distended? Bruised?

• Is my baby’s skin ruddy (red)? Pink? Pale? Mottled? Yellow?

• Is the skin warm?

• Centrally cyanotic or acrocyanotic? 

• Are there any skin tears or breakdown?

• Can I visualize bowel loops? Any discoloration?

• How is the patient’s muscle tone?

• Does the infant have full range of motion with their limbs?

• Is the patient vigorous, crying, and “fighting” me? Or are they flaccid and do not arouse with my cares?

Questions? Comments? Concerns? Anything I’m missing, let me know in the comments below!

Sample 1:1 Assignment

NICU PATIENT CARE FOR YOUR 1:1 ASSIGNMENT

Some patients are so medically complex, unstable, and incredibly fragile that they cannot safely be paired with another baby. This means that one nurse is responsible for one baby ONLY. That said, oftentimes these babies are the absolute smallest ones on the unit and require care tasks that take up every second of your 12-hour shift. The nurse may not even have time to sit down and chart or take a break until the late afternoon. If you were caring for a very high acuity 1-to-1 patient, here is a rundown of what a typical shift may look like for you:

Sample diagnoses that may require 1:1 care: 

• ECMO

• Pre-op Cardiac Surgery

• Unstable vent (Jet, High Frequency Oscillator, VDR4, etc.)

• Hypothermia therapy

• Micropreemies

• Pre/Post-Op Surgical patients

• Complex chronic lungers

Let’s say that the nurse is caring for a baby that was born at 23 weeks gestation. The bed area is most likely going to have the following equipment:

A High Frequency Oscillating Ventilator (these things are BEASTS but are SO gentle on the lungs)

Multiple IV pumps + poles with a variety of medications running

A cardiopulmonary monitor displaying heart rate, oxygen saturation, and respiratory rate

An isolette with humidity

Possibly a Bili-light used to assist the body in breaking down bilirubin (increased levels cause jaundice).

0700

After scrubbing in and removing all jewelry per your NICU’s policy, you will start your report around 7:00 (AM or PM). Report typically finishes around 7:30 (AM or PM), and shortly after that you would begin your first round of care on the infant. After assessing the safety of the bedside (i.e. ensuring your suction works, your bag & mask inflates, and visualizing your emergency drug sheet), you would start your shift by sanitizing the bedspace and everything that you plan on touching throughout the day at your baby’s bedside. Remember: you are working in the ICU, and this patient population is extremely susceptible to getting sick and acquiring infections. Wiping down all of the high-touch areas (isolette, IV pumps, stethoscope, work area, charting area, work phone, etc.) is so important to prevent the spread of germs and bacteria.

Next, you would double check your orders, assess your lines, drains, & airways, and touch base with your respiratory therapist (RT) to come up with a game plan for the day. More than likely, your patient is considered to be “minimal handling” (AKA min stim) meaning you will perform cares every 6 hours (twice a shift) in order to promote sleep, reduce hypothermia & hypoglycemia, and decrease the risk of intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP). 

For example, your “touch times” would probably be 0800/2000 hours and 1400/0200 hours. You will group or “cluster” your cares with the RT in order to minimize disrupting your baby’s sleep. On the off hours, only monitor vitals are obtained to allow the patient a chance of having a period of uninterrupted sleep. Of course, all of this is dependent on the acuity of the patient, vitals may be needed more often, or the RN may be disturbing the infant more frequently in order to keep the patient safe and alive.

0800

After devising a game plan for the shift (i.e. what times you and the RT are going to perform your cares simultaneously), you would gather all of the supplies that you need so that you’re ready to go. Your first round of cares will include a head-to-toe assessment, diaper change, temperature check, pulse check, eye care, and so much more. It is important to be thorough but also quick in order to save time, decrease heat loss (since the isolette doors will be open for a period of time) and provide containment to foster proper development. For example, while auscultating and counting the heart rate and respiratory rate, I am working on my head to toe assessment. While feeling the fontanelles, I am performing a neuro check. And while obtaining my girth, I am assessing abdominal quality and checking residual. 

When reviewing orders in the morning, if there was a scheduled chest x-ray at 0800 and labs to draw, I would time these tasks together. If my OG tube was due to be changed at a certain time, I would wait to perform my cares until that point in order to minimize disturbances. In addition, most procedures are done at the bedside in the NICU: PICC line placement, lumbar punctures, ultrasounds, to name a few. So I would work my day around the time that these procedures are ordered, or I would schedule these procedures during my “touch” times. I would also let my doctor know when we are doing touch time so he/she can examine the baby during this time as well. 

After obtaining blood pressure measurements (with the tiniest blood pressure cuff you have ever seen!) and an axillary temperature, I work on several other checks from head to toe. I perform oral hygiene with any colostrum that we may have available from mom, check the OG tube to remove any air from the stomach, suction out the ET tube and make mental note of the secretions, and lastly change the infant’s diaper. Diapers are weighed from admission to discharge in order to measure intake and output.

If you performed a morning blood gas, and chest x-ray, this may or may not have resulted in some ventilator setting changes. As the bedside nurse, you are actively managing the patient’s oxygen concentration to keep their saturations between the ordered parameters. Too much oxygen for too long can be detrimental to the infant’s developing retinas, and too low is starving the body of the needed oxygen. 

Bedside rounds (0900)

Depending on the facility, the neonatologist may round on your baby by himself/herself OR with the entire interdisciplinary care team. If all specialties (MD, bedside RN, RT, PT, OT, ST, SW, case manager, charge nurse, pharmacist, dietitian, etc.) present to the bedside, they will collectively discuss the plan of care and changes that need to be made to the neonate’s daily needs. Then, the doctor will explain this to the parents if they are present at the bedside. If not, they will try to contact them by phone for a daily update. After the plan of care for the day is discussed, you won’t change anything until your orders are written.

1000

Around 1000, charting begins! Every hour, monitor vitals, isolette temperatures, and IV pump rates + volumes must be recorded and documented. Some babies may be on one, two, three, IV drip medications that should be titrated based on monitor data (e.g. dopamine, morphine, etc.) and may require more frequent charting (Q15 minutes, for example). It is practice in my unit to obtain hourly vitals including heart rate, respirations, pain scores, oxygen saturation, and arterial BP (if your baby has umbilical lines).

As the bedside RN for a critically ill or premature infant, you really are not ever leaving that bedside. You will be constantly and closely watching the patient’s vital signs, reporting changes in status to the neonatologist, explaining changes to the parents, and charting EVERYTHING. When it’s time for you to take your break, another nurse will cover your assignment and watch your baby. 

If your baby is “stable” enough to be held, another job of yours is assisting parents with kangaroo care. NICU nurses promote family-centered care and encourage family involvement when performing care tasks. This includes teaching parents how to change a diaper, educating them about your assessment findings and if anything has deviated from the baby’s baseline, helping them with feeding techniques, and providing information about pumping and breast milk. 

In addition, product transfusions (PRBCs, FFP, Platelets, exchange transfusions), administering medications, starting new IVs (with a 24 gauge catheter), drawing labs, or requesting assistance with repositioning your patient may occur several times throughout your shift. 

By now, it’s probably your next “touch” time, and you will do everything that you did in the morning all over again! 

It is on days like this when your brain is working in overdrive and going a million miles an hour. All of your critical thinking skills are used and abused. It is such a rush in the beginning of the shift which then transitions to alarm fatigue from the loud noise of the ventilators and the monitors and pumps constantly beeping. I come home on these days and everything hurts: my brain, eyes, feet, and bladder. My ankles are swollen, and it takes everything in me to muster up the energy to shower, pack my lunch for the next day, and then wake up and do it all over again.

NICU Parents

As a NICU nurse, parents instill their trust in me to keep their little ones safe and alive. ME! Someone they don’t know from Adam. Someone they’re probably meeting for the very first time at their baby’s bedside. It’s both an honor and a huge responsibility.

Parents do not intentionally sign up for this, nor did they ever imagine in their wildest dreams that they would end up here. The majority of NICU mamas feel robbed of their pregnancy & gypped of the “normal” experience. They experience a mix of emotions… sometimes all at the same time. They feel anger, guilt, sadness, fear, even grief. They feel guilty for not being able to come visit their baby as much as they would like due to other personal obligations. Many parents have other kids at home, a job, transportation issues, housing problems, or financial hardships. A mother’s body may be in excruciating pain from the traumatic birth. She’s probably suffering the “loss” of her baby, who was whisked away to the NICU and taken from her arms.

Most mamas are attached to breast pumps; they pack their milk in a plastic baggy and slap a hospital label on it. Some mother’s don’t get to experience a baby shower or make that cute Pinterest-inspired pregnancy announcement. Sometimes NICU parents leave the hospital without a baby to take home. Parents may not have had the opportunity or chance to take maternity photos, or even begin to set up the nursery.

However, the majority of NICU parents also say that their NICU experience made them stronger not only as individuals but also as a couple & FAMILY. It brings parents together in ways that one couldn’t possibly fathom. I always say that my NICU babies are my heroes, but let’s not forget the PARENTS. You guys are true heroes! Always remember: Your feelings are totally valid and DO NOT have an expiration date!

Typical Day in the Life of a NICU Nurse

Parts 1 + 2 Combined!

3-to-1 Assignment

0700: Arrive on the unit & participate in morning huddle.

0730-0800: Get report on all 3 patients.

Room 1: Former 28 week preemie, now a 38-week feeder/grower, has some meds & on a 3L HFNC requiring 21% oxygen.
Room 2: Hyperbili term baby who came from home, has a peripheral IV for fluids + nutrition & an NG tube used intermittently when he doesn’t finish his bottles. Has some labs, stable on room air.
Room 3: NAS baby withdrawing from IUDE, requiring methadone Q3H & frequent consoling. 

0800-0830: Scrubbing in & removing all jewelry per my NICU’s policy. Next I assess the safety of the bedsides (i.e. check suction, bag & mask inflation, & visualize emergency drug sheets). I sanitize each bedspace + everything that I plan on touching throughout the day. Wiping down high-touch areas (cribs, IV pumps, stethoscopes, bedside tables, charting area, work phone, etc.) is so important to prevent infections.

Next, I double check orders, assess lines, drains, & airways & organize my day. NICU babies eat every 3 hours at my facility (9, 12, 3, 6 AM/PM), meaning I wake up & assess each baby 4 times during my shift. Cares for each baby should take NO LONGER than 30 mins or else you will fall behind!

0830-0900: Start rounding on my patients & introducing myself to any families present at the bedside. I start with the baby who’s already awake, crying, & hungry (example: Room 1). I collect vitals, perform my nursing head-to-toe assessment, complete my ADLs (diaper change, oral hygiene, eye care, measure abdominal girth, etc.), & feed the infant. I administer morning meds & ensure all cares are complete before I exit the room & move on to my 2nd baby.

0900-0930: I complete all of the above tasks for the baby in Room 2. I touch, look, & compare the IV site, flush the line, & check the dressing. I draw labs such as serum bili or glucose (as needed), check NG tube placement, patency, & aspirate residual, then put him to sleep before moving on to my final baby.

0930-1000: Administer morning dose of methadone to the baby in Room 3 in addition to all of the prior care tasks (See previous post). This baby may take longer to console & might need to be held/comforted for quite some time after all of my cares are complete.

1000: Charting begins on all of my patients. This includes documenting ALL. THE. THINGS. that I did in the morning such as my assessments, vitals, education, provider notifications, etc.

1100-1130: My first (& sometimes only) lunch break.

1130: Round 2 starts!
Assessments, vitals, feeds, diapers, medications, labs. Then charting everything on round 2!

1330-1430: Catch up on any charting or any missed tasks from the morning/early afternoon.

1430: Round 3 starts!

1600: Pharmacy delivers TPN + lipids to the NICU around this time. If any of my babies have a PICC line with caps + tubing due to be changed, this is when I would perform that task. If any of my babies are on IV fluids or require respiratory support, I check their capillary blood sugar and/or blood gases.

1630: I take my second (& final) break.

1700: Update my report sheets & organize the information needed for my hand-off report at the end of the shift.

1730: Round 4!

1900: Give report on all of my patients to nightshift!

1930: Byeeee!

This would be considered a smooth day. Most of my shifts include all of the above PLUS dealing with unexpected situations that arise such as responding to critical labs, changes in patient status, talking with MDs, providing education to parents, admitting + discharging patients, starting new IVs, processing new orders, transporting patients down to radiology, comforting inconsolable babies, hunting down volunteer cuddlers, teaching + educating a nursing student or new orientee on everything & anything, etc.

Hopefully this helps to give you a glimpse into a typical day in the life of a NICU nurse!

Let me know in the comments if you want a rundown for a sample 1-to-1 assignment!

Hypoplastic Left Heart Syndrome (HLHS)

Hypoplastic left heart syndrome (HLHS) is a severe congenital heart defect characterized by a small (underdeveloped) and functionally inadequate left ventricle. In a normal heart, the left side pumps oxygenated blood to the aorta, which then carries the blood to the body. In a baby with HLHS, the mitral valve and aortic valve are too small (atretic) or completely closed and nonfunctioning. As a result, the blood flow to the body is severely restricted. 

Initially, a baby may present with little-to-no symptoms due to the presence of the PDA. However, when the PDA closes, this could be very serious and life threatening for the infant. The following are some symptoms associated with HLHS:

• Blue or purple lips, skin and nails

• Cool extremities

• Difficulty breathing/increased work of breathing

• Difficulty feeding

• Diaphoresis/clammy skin

• Lethargy (excessive sleepiness)

• Low oxygen saturation reading on the CR monitor

 Diagnosis may require some or all of the following tests:

• Echocardiogram

• Electrocardiogram

• Cardiac catheterization

• Cardiac MRI

HLHS is often fatal without early intervention and immediate treatment. Medications may help stabilize the baby initially, but surgery will be absolutely necessary and vital for survival. Open-heart surgery is performed in order to redirect the oxygen-rich and oxygen-poor blood. The end result is that the right side will take over the role of the left and pump oxygenated blood to the body. The deoxygenated blood will flow from the veins to the lungs without passing through the heart. 

A series of three reconstructive operations will be performed to repair the heart; these include the Sano Modification of the Norwood Procedure (immediately after birth), Glenn repair (around 6 months of age), and Fontan (3-4 years old). These three stages are referred to as “Staged Reconstruction.”

After the baby is discharged, pediatric cardiologists will continue to follow him/her well into young adulthood, coordinating care as needed.

Let's Talk: PDA

What is a PDA?

In short, a patent ductus arteriosus is the vessel that connects the aorta to the pulmonary artery. This vessel is necessary to support the fetal circulation while in utero. It is termed a PDA when it remains open later than the newborn period. The persistence of the PDA after birth may cause difficulties depending on its size, and the magnitude and direction of blood shunting through the PDA will depend on pulmonary and systemic vascular resistance.

Because the pressure is higher in the aorta than the pulmonary arteries, this causes excess pulmonary blood flow. In some congenital heart defects (e.g. tricuspid atresia, TGA, HLHS) it is actually beneficial and imperative to maintain the PDA as it allows the necessary mixing of blood to sustain life prior to surgery. This is achieved through medications such as prostaglandin (PGE). 

In term infants:

The flow of blood through the PDA allows blood to flow from the left to right, increasing pulmonary blood flow. High pulmonary blood flow causes increased pulmonary vascular resistance, pulmonary hypertension, and right ventricular hypertrophy.

In preterm infants:

The ductus arteriosus in utero is not as responsive to an increased oxygen environment and does not close after birth. That’s because the smooth muscle of the heart has a diminished response to oxygen. Decreased pulmonary resistance causes blood to shunt from left to right and reenter pulmonary circulation. This leads to increased pulmonary congestion, decreased lung compliance and stiff lungs. The baby may have trouble with weaning from ventilator support.

Clinical manifestations of a PDA:

• Increased WOB

• RDS

• Moist lung sounds

• Murmur

• Tachypnea and/or tachycardia

• CBG that indicates metabolic acidosis due to decreased cardiac output and tissue perfusion

Treatment:

• CPAP to increase pressure on the lungs

• Diuretics to decrease pulmonary congestion

• Tylenol to work against the body’s natural prostaglandins to close the PDA

• Surgical ligation if pharmaceutical treatment does not work or is contraindicated (renal disease)

Is Being a New Grad in the NICU Hard?

Is being a new grad in the NICU hard?

Yes. 100%. Without a doubt. Being a new grad registered nurse in general is very difficult. Now add the NICU on top of that and you’ve got yourself one challenging yet INCREDIBLY rewarding career.

You may find yourself asking, “Did I take on more than I can handle?”

You work your booty off in nursing school studying for exams, prepping for skills labs, putting your social life on hold, and completing hundreds if not thousands of clinical hours (probably with nurses who didn’t want you there). Then came the daunting job search and application process where you felt like you would never get hired. Fast forward to now and BOOM you’re a brand spanking new nurse in a completely foreign environment and you feel like you know absolutely nothing.

I’ve been there. We’ve all been there. The best advice I can offer you is to trust the process and to have faith in yourself. There is a lot that you don’t know and you will never learn everything that there possibly is to know. It’s going to take some time. You will not catch on and become an expert right out of the gate.

Ask a TON of questions. Even if it feels like it’s something that you “should know.” Never assume anything because that is when mistakes happen and patient safety gets compromised.

Lastly, STAY POSITIVE!!! There will be good days and bad. Some shifts are more difficult than others. Sometimes we are too hard on ourselves and forget about the huge impact we’re making in the lives of our patients. It’s easy to feel intimidated by other nurses. I can’t tell you how many times a coworker has been rude to me. Don’t take criticism personally. Learn from it. You DESERVE to be where you are, and don’t let anyone tell you otherwise. Remember how far you’ve come in your nursing journey. You earned that right to wear “RN” on your badge!

Will I Lose My Skills?

Some of you may find yourself asking, “Will I lose all of my skills if I work in the NICU?”

Well, honestly, the simple answer is YES! However, you will GAIN so many others! Let me break it down for you…

As a new grad RN entering the NICU, you will definitely lose many “nursing school” skills that you (kind of) learned throughout your clinicals and practicums. Point blank. In general, any specialty that you decide to pursue will cause you to strengthen one skillset and lose another.

However, there are SO MANY more skills that you will learn in the NICU world compared to the three measly PowerPoint slides that nursing school gave you. Working with the neonatal population is very different from any other unit. (We don’t do “BIG people”). Our vital signs, medications, labs, and what we consider to be “normal” is SO different from the adult world or even the rest of the hospital. The NICU is such a unique place, and there is no way to keep up with every skill that you (kind of) learned in nursing school. 

However, the funny thing is that most NICU nurses will tell you that they gladly gave up skills they may have “lost” because of how much they love working with neonates.

But the beauty of nursing is you can always try something else if you decide you want to move on! Just because you "lost" your skill doesn't mean you can't relearn it. Nursing is like riding a bike. You just get back on and try it again.

My Personal Journey

In my personal journey to becoming a NICU nurse, I found it difficult to find resources and information about NICU nursing. So, in order to help others, I have tried to compile as much information as I can on the basics of a NICU nurse and what we do on a daily basis. 

That being said, there are SO many different aspects to being a NICU nurse. I mean, when the word “intensive” is used in your job title and tiny lives are in your hands, it’s safe to say that this role is no joke.

Working in the NICU is both thrilling and scary at the same time. To some it may sound amazing, and to others it may sound like a cake walk, but many don’t actually know what really happens during our day-to-day shifts. My blog + Instagram are dedicated to providing you all with more information and insight about a typical day in the NICU and what it is that we nurses do on the regular. I hope to help give you a glimpse into our unit and why I love it so much. Welcome to our world!

For starters, let’s address the most important question… What Do NICU Nurses Do?

We take care of the tiniest and often sickest humans in the hospital. It is important to understand that premature infants are not only small, but their entire bodies are extremely underdeveloped. All of their vital organs are incredibly immature and fragile. We are in the business of “growing humans.”

A typical day could range from feeding babies and educating parents that are close to going home, all the way to shifts holding a mother’s hand, as we explain that it’s time for her to hold her baby for the last time while we remove life support as the baby passes.

Every day in a NICU looks completely different from the last. Every shift in the NICU looks different from the one before it. Every NICU baby looks different than the next. And every NICU looks different from one another.

There is so much variety and diversity on the unit. You will never become bored as a NICU nurse. You will never stop learning as a NICU nurse. And you will never stop growing as a NICU nurse, just like our babies! 

If you are looking for a high risk, high reward nursing specialty, the NICU is definitely the place for you!

Surgeries

Have you ever seen the NICU turned into a personal mini OR? Me either, until recently!

Some of the surgeries that are performed at the bedside in my NICU include:

• PDA ligations

• Hernia repairs

• Repairs of intestinal perforations

• Drain + chest tube placement

Although every surgery is very different, the pre/post op care is essentially the same.

PRE-OP CARE:

Ensure that all of your consent forms are signed and that the surgical team has answered all of the family’s questions.

Have the most recent labs, images and diagnostics pulled up for the surgeon to see.

Flush your IVs and make sure you have access for the anesthesiologist to administer medications.

Grab a set of pre-surgery vitals (the OR team will perform the rest during the surgery).

Ensure that a pre-op bath has been given.

Complete your pre-procedure checklist! (NPO status, time of last void, etc.).

Prepare for the family for what to expect following the surgery (i.e. will the baby be intubated, edematous, etc.).

Last but not least…the TIME OUT. This is where you state two patient identifiers (baby’s name, medical record number, birthdate, etc.) and the name of the procedure. Then once you all agree, it’s time to begin!

POST-OP CARE:

Monitor vital signs every 15 minutes x 4 sets, every 30 minutes x 2 sets, and then hourly.

Manage pain! Surgery is extremely painful, and you want to ensure your baby is properly medicated and sedated AROUND. THE. CLOCK.

Monitor for signs/symptoms of infection or a possible complication.

Monitor for bleeding, drainage, odor or basically anything coming out from the surgical site.

Notify the surgeon if the dressing becomes soiled, saturated, or starts lifting.

Update the family and keep them well-informed.

NCLEX Updates

Unless you’re living under a rock, you know that COVID-19 has impacted virtually everything—including the NCLEX-RN. 
Effective March 25, 2020, the NCLEX resumed testing RN candidates at a 𝐥𝐢𝐦𝐢𝐭𝐞𝐝 𝐧𝐮𝐦𝐛𝐞𝐫 of testing centers across the U.S. Recently, however, 𝐀𝐋𝐋 NCLEX test centers have officially reopened!
Adjustments have been made to enhance the safety of those taking the test. This ensures social distancing measures are in effect + increases the number of candidates that can test daily. All of these changes follow the CDC guidelines and recommendations. 

HERE IS A REVIEW OF THE IMPORTANT CHANGES MADE TO THE NCLEX-RN:

• The minimum number of test questions decreased from 75 to 𝟔𝟎.


• The maximum number of test questions decreased from 265 to 𝟏𝟑𝟎.


• The maximum testing time decreased to 𝟒 𝐡𝐨𝐮𝐫𝐬.


• The difficulty level and passing standard have 𝐍𝐎𝐓 changed (meaning you’re just as likely to pass as you were before).


• The pretest and Next Generation questions have been 𝐝𝐢𝐬𝐜𝐨𝐧𝐭𝐢𝐧𝐮𝐞𝐝.


• These changes will be effective until 𝐒𝐞𝐩𝐭𝐞𝐦𝐛𝐞𝐫 𝟑𝟎, 𝟐𝟎𝟐𝟎.


ATTs have been automatically extended for candidates whose appointments were cancelled due to COVID-19. They are currently valid for 6 months or more.

Candidates will still be given the opportunity to take scheduled breaks after 2 hours and again after 3.5 hours, as well as any unscheduled breaks.

Candidates are required to bring and wear their own face mask 𝐝𝐮𝐫𝐢𝐧𝐠 𝐭𝐡𝐞 𝐞𝐧𝐭𝐢𝐫𝐞 𝐭𝐞𝐬𝐭. You will be turned away & unable to test if you do not bring PPE.

Additional information can be found on the Pearson Vue and NCSBN websites.

Airborne Precautions

Let’s Talk: Airborne Precautions

• These organisms will enter your respiratory tract and are spread through airflow from one person to another

• These evaporated droplets can remain suspended in the air + can survive for long periods of time

• The CDC recommends placing these patients in a single room known as an airborne infection isolation room (AIIR). These are negative pressure rooms that provide air filtration and 6 to 12 air exchanges per hour to reduce the risk of transmission.

• Examples of organisms: anthrax, tuberculosis, measles, chickenpox, disseminated herpes zoster, Coronavirus

COVID-19 is a new disease and we are still learning how it spreads as well as the severity of illness it causes. So far, we have learned that the virus is thought to spread mainly from person-to-person through airborne transmission. There are several ways that a person can be infected with this virus:

• Between people who are in close contact with one another (about 6 feet).

• Through respiratory droplets produced when an infected person coughs or sneezes.

• These droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs.

Donning PPE:

• Optional: Bouffant + booties

• Hand hygiene 

• Gown

• Approved N95 mask (that was properly fit tested)

• Face/eye shield

• Gloves

• Optional: 2nd pair of gloves

Doffing PPE:

• Top pair of gloves

• Hand hygiene

• Gown + gloves simultaneously

• Exit patient’s room

• Perform hand hygiene

• Face shield/goggles

• Hand hygiene

• N95 mask

• Hand hygiene 

• Bouffant + booties (if you wore them)

Contact Precautions

In the hospital, transmission-based precautions are used to help stop the spread of germs from one person to another in order to protect patients, families, and healthcare workers. If your baby has been placed on transmission precautions, it is important to understand what this means and what to expect from us, the staff. Knowing the methods in which a disease is transmitted is important for implementing proper infection control measures.

There are three different types of transmission-based precautions, and it can be confusing trying to differentiate between them:

1. Airborne

2. Contact

3. Droplet

Let’s Talk: Contact Precautions

• Defined as direct or indirect contact with a patient or the patient’s environment. This includes everything in the baby's room or objects in contact with the baby infected with an organism.

• Used for infections, diseases, or germs that are spread by touching the patient or items in the room.

• Examples of organisms: Clostridium difficile, MRSA, VRE, diarrhea, open wounds, skin infections (varicella zoster, HSV, impetigo, scabies, etc.), RSV and other respiratory infections.

Required PPE:

• Gown

• Gloves

Remember to use water + soap for C.diff, otherwise hand sanitizer will suffice!!!

Droplet Precautions

In the hospital, transmission-based precautions are used to help stop the spread of germs from one person to another in order to protect patients, families, and healthcare workers. If your baby has been placed on transmission precautions, it is important to understand what this means and what to expect from us, the staff. Knowing the methods in which a disease is transmitted is important for implementing proper infection control measures.

There are three different types of transmission-based precautions, and it can be confusing trying to differentiate between them:

1. Airborne

2. Contact

3. Droplet

Let’s Talk: Droplet Precautions

• Transmittable by tiny, infected, air droplets contacting the surfaces of the eye, nose, or mouth.

• Can be acquired by coughing, sneezing, talking, breathing, or during certain medical procedures (bronchoscopy)

• Can be acquired by bodily fluids (urine, feces, saliva, sputum, semen, sweat, vomit, breastmilk) that enter your mouth, eyes, nose, or through a break in your skin.

• Necessary when a patient infected with a pathogen is within three to six feet of the patient.

• Examples of organisms: pneumonia, influenza, whooping cough, bacterial meningitis, plague, Ebola, SARS, diphtheria, rubella, mumps, etc.

Required PPE:

• Gown

• Surgical face mask

• Eye shield/goggles

• Gloves

Feeding a Preemie

Feeding a premature baby is harder than you think. It requires a lot of patience and skill.

Before I fed my first preemie, I didn’t realize there was a special way to feed them. I assumed that all babies were fed the same, but boy was I WRONG!

In the NICU, we teach parents to feed their preemies in the “side lying” position. This enables the baby to regulate the flow of milk into his/her mouth. The milk pools in the cheek pocket, allowing the baby to swallow the volume of milk that he/she can tolerate.

I’m sure this position is the opposite of what you would think, but it’s actually the safest and most effective technique for these little ones. Because premature infants have underdeveloped airways, pharynges and might still be experiencing respiratory distress, they have a hard time coordinating sucking, swallowing, and breathing. Therefore, when the baby is turned onto his/her side and the parent supports the head and neck, this is the most optimal position for the baby. Some of the more uncoordinated babies may even require cheek & chin support to help them latch onto the nipple better to form a tighter seal. 

Bottle feeding is a form of exercise for a preemie and can make them extremely tired and fatigued. Therefore, frequent burping and breathing breaks are essential for a successful feed.

In addition to educating parents about positioning their baby, we also teach them how to hold the bottle horizontally in order to fill the nipple halfway with milk. If the baby drinks too much milk at once, this can lead to coughing, choking, aspirating, spelling, etc.

ATTENTION NICU PARENTS

It is important to not get discouraged if your baby does not drink all of his/her milk initially. It is a learning experience for the both of you. You want this to be a positive, safe, and enjoyable experience so that they want to do it again, and again, and again! Do NOT force your baby to take the whole bottle and stress him/her out. The goal is to help your baby to achieve competent feeding skills for a lifetime! 

Why Does Flow Matter?

Why Does Flow Matter to the Preemie in the NICU?

Imagine drinking milk through a straw versus from a firehose. Talk about a difference! Can you even begin to fathom how hard this would be? Would you choke? Cough? Potentially aspirate? Lose some (if not most) of the milk? You would be inundated by more milk than you could handle, and it would be pretty darn difficult to manage your food with how fast that flow is. 

Now imagine a 34 week preemie learning how to coordinate sucking, swallowing, and breathing all at the same time. Most preemies have some form of respiratory distress, and when they can barely breathe to begin with, this makes eating on top of that extremely challenging.

 Infants start showing hunger cues around 33-35 weeks gestation. These are signs that the baby is interested in bottle feeding and include:

·       Rooting around (moving head side to side and searching for the breast)

·       Opening their mouth

·       Crying and fussing due to hunger

·       Bringing fists to mouth and sucking on hands

·       Aggressively sucking on the pacifier

Typically, we will start with the slow flow nipple when feeding by mouth and gradually work our way to the regular flow as the baby gets bigger and more coordinated.

In the NICU, we use various types of nipples and bottles when feeding our babies. Some of these include Dr. Brown’s bottles, regular flow nipples, slow flow nipples, Pigeon nipples, and orthodontic nipples. Finding the appropriate bottle/nipple for your baby depends on his/her condition and whether or not they are experiencing any feeding difficulties or challenges. Consideration of the infant’s oral motor abilities and neurologic maturity must also be taken into account when choosing which bottle to use. An occupation therapist and/or speech therapist will work with your baby to determine which bottle/nipple is the right fit for him/her.

The Dr. Brown’s bottle helps to reduce colic or excess gas.

The pigeon is a specialized nipple for cleft lip/palate babies.

The slow flow nipple is designed for the breastfed baby.

The regular flow is the standard nipple for most term newborns.

The orthodontic nipple is specifically designed to support the shape of a baby’s developing palate and jaw and reduce pressure on the gums and developing teeth.

Face Shield Calligraphy

New PPE, who dis?!? ;)

I call this look: “Face shield, but make it fashion.” ♥

In the healthcare world, frontline workers are not wearing face shields merely as a fashion accessory but rather as a necessity to care for very sick, vulnerable, and highly contagious patients. It’s safe to say, though, that this piece of personal protective gear does take up quite a bit of space on our faces... So why not make it look a bit more aesthetically pleasing? 

Since face shields have become a daily staple in my workplace, I decided to have some fun with it and really embrace the new PPE guidelines by including my own personal flair & twist.

Thank you to the amazingly fabulous & incredibly talented Tia from https://www.dottheicrossthet.net for beautifying my face shield and helping me to not feel like a sad dog with an “E-collar cone” on my head. Tia is a local calligrapher who went above & beyond to make the face shield that I wear when I take care of my NICU babies super unique and creative. 

Not only is this face covering cute and stylish, but it’s also FUNCTIONAL! I am so in love & cannot wait to wear this bad boy to work!

Not gonna lie, it’s still pretty hard to #Smize behind this thing, but I’m doing my best, Tyra Banks.