Car Seat Challenge

What is a car seat challenge?

A period of observation in a car seat before hospital discharge to monitor for possible apnea, bradycardia, or oxygen desaturation.  

All infants meeting any of the following criteria requirements at the time of discharge will receive a Car Seat Challenge.

1. Gestational age less than 37 weeks.

2. Weight less than 2500 grams.

3. Requires oxygen supplementation at discharge.

A car seat challenge is performed in the car seat that he/she will be discharged home in.

An infant is evaluated in the car seat for the length of time required to drive from the hospital to the baby’s home destination or a minimum of 90 minutes, whichever is determined to be longer. 

How is a car seat challenge performed? 

• The infant will remain on his/her Cardiorespiratory and Pulse Oximeter monitor(s).

• The bedside nurse will monitor his/her heart rate, respiratory rate, oxygen saturation, as well as skin color, respiratory effort, and activity level.

• Infant is positioned in an upright 45 degree angle.

A car seat challenge will be marked as “FAILED” if any of the following parameters are observed:

1. Apnea/bradycardia spells or desaturations.

2. Persistent labored respirations (tachypnea, grunting, retractions, nasal flaring, etc.)

3. Duskiness/patient turns blue or pale

What happens if an infant fails a car seat challenge? 

• Discontinue the test and notify the provider and parents.

• Important note: The test can be performed a second time; HOWEVER, if the patient fails a second time, the infant is required to go home with a car bed.

Want to join the team of over 43,000 nationally certified Child Passenger Safety Technicians and get your National Child Passenger Safety Certification? Click here now: https://cert.safekids.org

Blood Pressure

Blood pressure is one of the first signs that your infant may be getting sick. That’s why obtaining accurate and reliable blood pressure measurements is essential to the neonate. It is absolutely necessary to use the correct size blood pressure cuff that corresponds to the size of the infant. In the NICU, blood pressure cuffs typically range from size 1-5 depending on your facility and product/brand that they use!

A standard protocol for blood pressure measurements in preterm infants includes:

♥ <24 weeks gestation: Systolic 50-65. Diastolic 24-40. MAP 24-30.

♥ 24-28 weeks gestation: Systolic 50-60. Diastolic 22-35. MAP 24-35.

♥ 29-32 weeks gestation: Systolic 50-60. Diastolic 24-35. MAP 30-40.

♥ 32-36 weeks gestation: Systolic 50-60. Diastolic 24-35. MAP 30-50.

♥ >36 weeks gestation: Systolic 50-90. Diastolic 28-40. MAP 35-45.

Let's Talk: ASD

What is an ASD?

An atrial septal defect is a hole in the atrial septum (muscle wall) that separates the upper chambers of the heart. Because of the low pressure in the right atrium, this hole typically allows oxygenated blood from the lungs to shunt from the left atrium to the right atrium. This blood travels to the right ventricle, which then pumps it back to the lungs rather than the body. An ASD may be single or multiple, can vary in sizes, and may occur anywhere on the atrial septum. The severity of the symptoms depends on all of those factors. 

The following are some examples of signs and symptoms that you may see in an infant with EITHER an ASD or VSD due to increased blood flow, fluid overload, or congestive heart failure:

• Brisk pulses 

• RDS

• Murmur

• Edema 

• Poor growth & development

• Tachypnea and/or tachycardia

• Increased WOB and fatigue

• Sweating

• Restlessness and look of panic 

How is an ASD treated?

Surgical correction is the first line of treatment. They may be closed by patching or suturing during open heart surgery. It is a very common procedure and most babies recover very well! 

What Is An APGAR?

The APGAR test is a standard procedure that is administered for every infant. Your baby’s score is very important because it will determine their medical care during their first few days at the hospital. Every baby gets an APGAR score, but as a parent, it can be a completely foreign topic that leaves you worried and confused, especially if your infant ends up getting a low score. Keep in mind that most babies RARELY get a perfect score.

Generally speaking, the “APGAR Scoring System” is a method to quickly summarize the health of a newborn. In short, it is a baby's first assessment. It was developed in 1952 by Dr. Virginia Apgar. Every baby is scored at one minute of life and then again at five. Your baby will continue to be scored in five-minute increments until he achieves a 7 or higher.

What Does APGAR Stand For?

• A stands for Appearance (skin color, pink or blue)

• P stands for Pulse (heart rate or beats per minute)

• G stands for Grimace response (reflexes and crying)

• A stands for Activity (muscle tone and flexion)

• R stands for Respiration (breathing rate, effort, and pattern)

What Does An APGAR Score Mean?

A score between 7 and 10 is considered normal. A score between 4 and 6 indicates that breathing assistance may be required. A score under 4 means that prompt, life-saving resuscitation measures are necessary. 

To get the overall score for an infant, a score of 0 to 2 will be assigned for each of the 5 categories.

• Heart rate: 

  • 0 means there is no heart rate

  • 1 means there are fewer than 100 beats per minute (not very responsive)

  • 2 means there are more than 100 beats per minute (baby is vigorous)

• Respiration: 

  • 0 means there is no breathing

  • 1 means there is a weak cry

  • 2 means there is a strong cry

• Muscle tone: 

  • 0 means the baby is limp

  • 1 means the baby has some flexion

  • 2 means the baby has active motion

• Reflex Response: 

  • 0 means no response to their airways being stimulated

  • 1 means there is a grimace during stimulation

  • 2 means there is a grimace and cough/sneeze during stimulation

• Color:

  • 0 means the baby's entire body is blue/pale

  • 1 means the baby has good color except on their hands/feet (acrocyanosis)

  • 2 means the baby is completely pink and has good color

What Happens If My Baby Has A Low APGAR Score?

Medical staff will first focus on getting your baby into a stable condition and then they will seek to find answers to the questions that will be weighing on your mind, like what has caused your baby’s low score.

As medical staff works to discover if there is an underlying condition or another cause of your baby's low score, they will keep you updated throughout the process. More importantly, they will keep you informed about your baby's current state of health and what to expect in the coming days.

More information can be found at: https://www.birthinjurysafety.org/birth-injuries/apgar-scoring-system.html 

How I Became a Nurse

I first became passionate about health and wellness at a young age. Throughout high school, I volunteered at the local hospital and worked alongside many nurses. My daily responsibilities included attending to the patients’ bedside needs, answering call lights, and delivering meal trays. While interacting with the patients and staff, I became very interested in nutrition. I chose to attend the Didactic Program in Dietetics at California Polytechnic State University, San Luis Obispo because of its rigorous quarter system and “Learn By Doing” approach. However, as I went deeper into my classes, I desired to learn more about the care and wellbeing of others than just nutritional status.

During my sophomore year of college, I welcomed the opportunity to work for an Alzheimer’s Center as a Volunteer Caregiver. The first moment that I stepped onto the floor, the smells and sights of the deterioration that aging causes overwhelmed me, and I questioned whether or not I was meant for this line of work. However, my perspective immediately changed once I interacted with the patients. While assisting the elderly residents suffering from moderate to severe Alzheimer’s disease, I gained a wealth of knowledge and experience that simply cannot be obtained in the classroom. For instance, I was given the responsibility of feeding the residents who suffered from hand tremors due to Parkinson’s disease, along with those who were physically unable to manipulate utensils. In addition, I worked alongside many nurses making sure each resident consumed proper medications while providing a safe and comforting environment.

While volunteering at the Alzheimer’s Center, I discovered my talent of providing care and reassurance to the patients. I felt comfortable putting the residents at ease, gaining their confidence and empathizing with them. It is important to me that patients receive quality care when they are at their most vulnerable. By providing hands-on care to the residents, I saw just how big of a contribution that nurses and caregivers make not only in the lives of the patients but also the patient’s families. Possessing a career that enabled me to have a positive impact on the health of others was something that I was determined to pursue. 

I aspired to further augment my caregiving experience by branching out into the hospital setting. I quickly became a volunteer at the local Medical Center, where I worked on-call for each hospital department. I was responsible for admitting and discharging patients, transporting patients to and from radiology, as well as assembling oxygen tanks and delivering prescriptions to the pharmacy. By working in the different hospital departments, I was exposed to professionals and patients from all ages and backgrounds. It was easy for me to integrate myself into the team of nurses, physicians, volunteers, and food service workers. I enjoyed the one-on-one interactions that I had with the patients while caring for them when they needed it most. My passion for caregiving was confirmed when I was hired as a Dietary Aide, where my primary responsibility involved meeting one-on-one with patients to help them choose appropriate meals based on their food preferences, medical diets, and allergies. 

My genuine desire to care for others and to become a nurse was further enhanced during my junior year at Cal Poly. I was selected for an internship through the Women, Infants and Children (WIC) Breastfeeding Program where I helped to provide breastfeeding education and support to low-income postpartum women. Since a major goal of the WIC Breastfeeding Program is to improve the nutritional status of infants, possessing a strong nutritional background helped me to succeed as an intern. I learned how to ease the suffering of mothers in pain while guiding them toward healthy practices. It was easy for me to quickly establish nurturing and trusting relationships with the new clients and motivate them on the right steps toward lead long, healthy lifestyles. It is here where I discovered my passion of investing myself fully into the health and wellbeing of others.

My experiences working alongside nurses and many healthcare professionals helped to solidify my desire to become a registered nurse. Through the breastfeeding clinics and the Medical Center, I discovered my innate ability of providing a sense of safety and comfort while caring for patients. While exposing myself to the medical needs of the elderly population and the special care they required, I recognized that empathy and compassion are an integral component of healing the mind, body, and soul. Possessing a nutrition background enables me to have a positive impact on the health of others by using a well-rounded approach. I am passionate about making a positive impact in the lives of others, and  nursing is the career that best fulfills this ambition for me.

What motivates you as a nurse? Why did you become a nurse? What attracted you to nursing? COMMENT BELOW :)

What Babies Need NICU Care?

Most babies admitted to the NICU are preterm (born before 37 weeks gestation), have low birth weight, or have a health condition that needs special care. In the U.S., nearly half a million babies are born preterm. Babies with health conditions such as trouble breathing, heart problems, infections, or birth defects are also cared for in the NICU.

Below are some factors that can place a baby at high risk and increase the chances of being admitted to the NICU. 

BABY FACTORS INCLUDE:

• Born <37 weeks gestation or >42 weeks.

• Low or high birth weight (SGA or LGA)

• The need for emergency medication or resuscitation in the delivery room

• Birth defects/congenital anomalies (cardiac, dysmorphic features, intestinal malformation, etc.)

• Respiratory distress (apnea, fetal distress, birth asphyxia) 

• Infection from an STI such as herpes, syphilis, group B streptococcus, chlamydia

• Neurological disorder (seizures, hydrocephalus, IVH, etc.)

• Low blood sugar (hypoglycemia)

• Breech or other abnormal positioning 

• Meconium aspiration 

• Umbilical cord wrapped around the baby's neck (nuchal cord)

• Forceps, vacuum-assist, or cesarean delivery injury

MATERNAL FACTORS INCLUDE:

• Being younger than age 16 or older than age 35 (AKA advanced maternal age)

• Drug or alcohol use

• Diabetes

• High blood pressure (preeclampsia)

• Bleeding / placental complication

• Multiple pregnancy (twins, triplets, etc.)

• Too little or too much amniotic fluid

• Premature rupture of membranes

NICU community, any other factors that I’m missing???

Information retrieved from 

https://www.stanfordchildrens.org/en/topic/default?id=the-neonatal-intensive-care-unit-nicu-90-P02389 

What Is a NICU Nurse?

A neonatal nurse is a registered nurse (RN) that works in a Neonatal Intensive Care Unit (NICU) and assesses, monitors, and cares for medically fragile newborns. Some NICU RNs are licensed with an ADN, BSN, or advanced degree. In some cases, NICU nurses may care for medically complex infants up to one year of age. 

Like other critical care areas of nursing, this department is highly specialized, fast paced, and yes, stressful. These infants are born with a variety of health challenges including prematurity, birth defects, chromosomal anomalies, infections, cardiac malformations, surgical problems, etc. NICU nurses will typically care for infants from birth until they are discharged home from the hospital. They care for newborns who need around-the-clock attention. In order to provide such expansive and dedicated care, NICU nurses typically work 12-hour shifts that include nights, weekends, and holidays. We can legally care for one to three babies during our shift depending on their complexity and acuity. Contrary to popular belief, it is SO MUCH MORE than just “cuddling with babies all day.”

The reality is, being a NICU nurse is HARD. We DON’T just work “3 days a week.”

You get drained easily. No, you’re not physically lifting and turning heavy patients like on the “floors” or adult ICU units. The NICU is mentally and emotionally exhausting to the point where sometimes you need to just step away, take a vacation, and enjoy some time for yourself.

You miss birthdays, holidays, weekends, sleep and sanity. But on the flipside, it’s very rewarding. Knowing that you are making a HUGE impact on the lives of others is such an incredible feeling. The benefits definitely outweigh the cons that this profession might have. All of the sleepless nights and draining assignments are so worth it because you get to nurture, heal, and be a part of a wonderful collaborative team whose main priority is to save babies! How cool is that?! I may be biased, but neonatal nursing is honestly the best! 

What do you do? Why do you do it? How did you choose your specialty? 

When Can My Baby Go Home?

A question every parent will ask is, "When can I take my baby home from the NICU?" This is such a loaded question, and NICU nurses hear this question everyday. Although we don’t have a crystal ball and cannot predict the future, there are a few factors that help us determine the answer to this question.

For the most part, the length of stay will vary for every baby, but a general rule of thumb is that a baby will be discharged around his/her due date. In other words, if a baby was born three months too early, he will typically stay in the NICU for three months. Yes it’s true that some go home much sooner than their due date, and some stay months-to-years past it. Nonetheless, here are a few conditions that usually need to be met before discharge. 

TYPICAL NICU DISCHARGE CRITERIA:

• A baby's ability to maintain his/her temperature in an open crib (thermoregulation) without any support.

• A baby's ability to feed by mouth (though some babies can go home with NG tubes or G-tube feeds).

• A baby's ability to breathe without assistance (although some babies may be sent home with oxygen support via low flow nasal cannula or a tracheostomy).

• When a baby is titrated off caffeine and outgrows apnea/bradycardia spells (A/B spells).

• When a baby is weaned off methadone d/t intrauterine drug exposure & has consecutive neonatal abstinence scores of zero.

• When a baby is infection free!

• When a baby is consistently gaining weight.

• When a baby’s lab values & electrolytes have normalized.

The bottom line is that your baby drives their care, and their discharge date is dependent upon them. Much of the decision making is based on the baby’s ability to eat, breathe, grow, and display signs of readiness for a successful discharge home.

Questions? Comments? I’d love to hear your feedback :)

Diapers!

Did you know?

In the NICU, we have many diapers specifically-designed to protect the delicate and fragile, still-developing skin of premature infants? These diapers range from nano preemie size to about three months! 

♥ Nano preemie diapers are intended for infants who weigh less than 2 pounds

♥ Micro preemie diapers are intended for infants who weigh less than 4 pounds

♥ Preemie diapers and so forth are intended for infants >4 pounds

Using the correct size diaper for our neonates is optimal for healthy growth and development. Diapers should provide soft, gentle protection for the most delicate babies. This allows for desired positioning, because we know developmental positioning and being in the fetal tuck position is critically important for ELBW infants.

Babies can easily be positioned into a comfortable fetal tuck to mimic conditions in utero. Often preemies aren’t even allowed to wear clothes except for maybe a knit hat or mittens, since some babies are still learning to regulate their temperature. Sometimes getting to put a diaper on a baby is one of the few ordinary tasks that parents get to do. 

Diapers may seem like an insignificant component of the NICU, but they can actually make a huge difference in the lives of NICU babies and their parents! 

Powerful Precepting

Who is a preceptor?

An experienced practitioner who provides transitional role support and learning experiences to new staff. A preceptor serves as a role model who leads by example in addition to being a socializer, educator and coach, competency evaluator/validator, and protector.

Being a successful preceptor can be quite the challenge. Not only are you teaching your orientee ALL THE THINGS but also teaching yourself the invaluable role of a preceptor, communication techniques, theories of learning, and so much more! In addition, you are not only showing them the “ropes” of their new job but also providing them with the tools to use that rope safely and efficiently! 

As a role model, you are leading by example by adhering to the standards of your facility. You model professional behavior, resolve conflict, provide constructive feedback, and engage in active listening. Remember that your orientee is always watching you!

As an educator and coach, you assess your orientee’s learning needs and style. This helps you to plan appropriate learning activities and determine how much support and guidance/independence your orientee needs. By providing as many opportunities and experiences as possible for learning, this will help to develop their critical thinking and time management skills.

As a socializer, you help your preceptee settle and integrate into their new role in order to become a part of the team. You are introducing them to the culture and environment of the unit.

As a competency evaluator/validator, you ensure competent practice and adherence to all of the organization’s policies & procedures. You work within your scope of practice and help foster delegation and competent nursing skills. Lastly, discussing any performance issues and communicating with management to work through any limitations is imperative during the orientation process.

As a protector, you protect the safety of both the patient and the orientee by eliminating errors. You provide a safe and therapeutic environment conducive to learning and support the development of skills needed to safely care for patients. 

Fun Fact: On my very first day with my preceptee, it is very important for me to establish their love language and style of learning. This tells me how they best obtain information and how they like to be valued and acknowledged! There are all sorts of online tools used to determine your preceptee’s Love Language and Style of Learning, all easily obtainable through a simple Google search :)

Did you have a preceptor or preceptee that stood out to you? Either in a good way or not-so-good way? What happened/what did they do that was so noteworthy? Comment below!

Interview Tips & Tricks

Interviewing for the first time is INSANELY stressful. Especially when it’s for your dream job! I’ve had my fair share of opportunities to sit on both sides of the table, not just as the interviewee but also the interviewer. One of my favorite perks about my current role is serving as a member of the interview committee where I get to help management find the perfect candidate for open RN positions in the NICU!

Here are a few questions that I have been asked when interviewing for NICU jobs and some I would consider asking my future candidate in an interview:

1. Tell us a little about yourself. Why this unit, and why this hospital?

2. What are your 3 strengths? What are 3 areas that you can improve on?

3. How would your last manager/instructor describe you?

4. What does family-centered care mean to you?

5. Describe your ideal preceptor.

6. We all make mistakes. Can you tell us about a situation where a mistake was made or you observed one and what you did about it?

7. Scenario question: You find out that a colleague has been gossiping about you to other nurses on the unit. What would you do?

8. Have you ever been faced with an upset customer/patient/family member/parent and how you handled that?

9. The NICU can be a very stressful environment. We treat very sick babies who sometimes don’t survive or get to go home. Do you have experience with death and dying?

10. What do you perceive your biggest challenge will be in your new role?

11. What are your long term goals? Where do you see yourself in 5 years? 

12. Why are you the right person for this job? Why should we hire you?

13. Do you have any questions for us?

Want to hear examples of answers to these questions? CLICK HERE!

NICU: Where You're Never Too Young For Caffeine

Did you know?

Caffeine is the most commonly prescribed medication in the NICU setting for the treatment of apnea of prematurity! 

Neonatologists prescribe caffeine ON THE DAILY to neonates & infants (22-34 weeks gestation) to help prevent “apnea spells” which are the cessation of breathing lasting more than 20 sections. Caffeine is a respiratory stimulant used to help preemies (with immature lungs & respiratory drive) remember to breathe. This also helps to reduce the episodes of heart rate drops (brady dips) that can cause a decrease in perfusion.

Preemies are weaned off caffeine—usually around 34 weeks—based on their improving clinical status, age, and weight. Before a baby can be discharged, it is important to ensure that he/she is “spell free” and off caffeine for at least 5 days! 

And no, we are not giving babies cups of coffee! It is administered in a form called Caffeine Citrate, either PO (by mouth) or IV (intravenous).

#EstablishingHealthyHabits #WeDontDoDecaf

Referenced from the World Journal of Pediatrics (Caffeine Therapy in Preterm Infants)

Website: https://www.wjgnet.com/2219-2808/full/v4/i4/81.htm

A Note to NICU Parents

Congratulations on the birth of your baby! You have experienced one of life’s greatest miracles, but unfortunately things didn't go as planned. Your new baby has been born early or needs specialized NICU care. As neonatal nurses, we know that this can be an overwhelming and very stressful time for you and your family. The excitement you feel about the birth of your newborn can quickly change to fear about what may lie ahead. You may feel many emotions or have many questions about why your baby needs NICU care. You may feel anger, guilt, or sadness. Remember, whatever you are feeling is completely normal. It is not your fault that your baby is in the NICU.

Neonatal nurses are here to provide support and care to you and your newborn during his/her stay. You will notice lots of foreign equipment, wires, monitors, flashing lights, and sounds that can be scary and intimidating. You may wonder how you will be able to contribute to your baby’s care. As a parent, you are a very special and very important part of your baby’s care team. The comfort and love that you give to your baby is vital to his/her growth and development. We encourage you and welcome you to be present any time that you are able to be with your baby. When you cannot be at the bedside, please call us for updates! 

We also encourage you to confide in others going through the same journey. Talk with and get to know other parents. There are so many support groups and resources that your hospital will have to offer. You are not alone! I know that you have a lot of questions and are concerned about your baby. This blog is designed to help answer some of those questions. Be encouraged by the smallest successes you and your baby have. Your baby has tiny feet and will make tiny steps along his/her journey. Celebrate all of their victories and milestones because although they might not seem like it, they are EXTREMELY important. 

I encourage you to read through my blog posts and write to me so that I can help you in any way that I can!

The Struggle to Sweet Success

During my freshman year as an undergraduate nutrition major, I struggled academically. I did not know the best way to study, how to utilize resources such as tutors, professors and study groups, and I felt vulnerable asking for help. After a few poor grades and a drop in my GPA, I quickly became more inclined to seek out help. From personal experience, I understand when an individual needs help even if he/she is not willing to ask for it. Through my academic challenges, I developed the desire to help people and care for them in times of need. I learned the importance of teamwork and collaboration with my fellow classmates as well as the benefits of support and guidance that peers can offer. Where I lacked in the classroom, I made up for in personal and professional experience on my nursing applications. Don’t get me wrong, I still paid the consequences in nursing school, but the experience taught me how to be more focused on my academics by retaking classes, meeting with professors one-on-one, and always going that extra mile. 

When I graduated from nursing school, I had no job lined up (hospitals weren’t hiring new grads). I was studying miserably for hours on end for the NCLEX. I paid for two top review courses, was frantically putting together portfolios, cover letters, resumes, practicing (over and over and over) for interviews, applying for jobs all over the state, spending hours researching hospitals and jobs and had absolutely NO clue where I would end up!

A few months later, all of the puzzle pieces fell into place and my hard work finally paid off. I passed the NCLEX with 75 Qs (on my first try) and landed my dream job as an RN in a Level IV NICU in my hometown. I literally hit the ground running! Today, I have worked bedside for 3.5 years; I work 3 shifts a week, absolutely LOVING the neonatal population more and more everyday, and am now passionately sharing my nursing journey to my fellow followers! I have cared for some of the sickest and tiniest humans alive. I have seen things most people will never experience in their lifetime and felt things most will never feel. 

I was told "NO" and "Sorry, you’re just not good enough" so many times I can't remember. As an undergrad, I worked two jobs, completed my major, two concentrations, and a minor ALL in four years (which is unheard of), and faced so many rejections to count trying to get into nursing school. I had to find serious inner strength to keep going. But you know what? I am thankful for the fight! Because it has made me the most passionate yet humble person and nurse that I am today.

Through my undergraduate struggles, I learned how to be responsible for my own academic success and how to commit myself through hard work, motivation and passion for the field of nursing. If you know you are meant to be a nurse, NEVER GIVE UP! Keep going even when you’re physically, mentally, emotionally, and spiritually exhausted. Keep studying, doing research, making your plans and back up plans, asking questions, getting involved, taking the initiative, and going that extra mile! Some words of wisdom that I would tell my former self would be to trust in the process! I am a firm believer in my faith, and I know that God is good! Never doubt yourself, and always have trust in Him! Hard work + self-determination + prayer = sweet success! You have to hustle everyday and network wisely in order to achieve your goals! Trust me, it will pay off!

Questions? Comments? Concerns? Let me know below :)