September 15th is National Neonatal Nurses Day! Below, nurse Meghan Gunning, BSN, RN, shares her experience as a neonatal nurse in the neonatal intensive care unit (NICU) in Baltimore, Maryland.
I start my shift like most of my nursing colleagues: unsure of what the next 12 hours will bring, but hopeful to end the day with a sense of accomplishment. In the NICU, our accomplishments usually come in the tiniest, smallest forms possible. For instance, an eight milliliter (mL) blood transfusion—a volume less than two teaspoons—can make a world of difference to a premature baby’s oxygen saturation and heart rate.
A common phrase in nursing is that there is no typical day, and that holds true in the NICU world as well. We see everything from full-term infants with an anoxic brain injuries, to neonates who may be withdrawing from maternal drug use, to the smallest of the smallest neonates. For a one-pound, one-ounce, 23-week neonate, every move must be delicate in order to prevent harm to his gelatinous skin, immature GI tract, and the blood vessels of the brain.
Today, I am starting with two patients. The first is an ex-31-weeker who is working on feeding and growing, and the second is a full-term infant recovering from a tracheoesophageal fistula (TEF) repair. Both patients are relatively stable compared with many of the other infants on the unit, but they both have important personal goals to achieve in order to eventually go home. My 31-weeker, for instance, has a history of being suppository dependent, but has finally started to stool on her own (with some belly rubbing assistance from her loving nurse). Rule number one in the NICU: Pooping is a big deal. My TEF baby, on the other hand, has to work on tolerating the volume of his feeds without vomiting. Additionally, when we check his stomach contents (by aspirating from his nasogastric tube), we need to see that his stomach is handling the feeds and that there isn’t too much leftover formula. He also must grow and prepare for his repeat swallow study next week, to evaluate whether he is still silently aspirating his formula. If the test shows that he’s aspirating, it will most likely buy him a trip to the OR for placement of a gastric tube. Any procedure poses the obvious risks, such as infection, but the surgery itself can be too large an undertaking for an infant. Many times infants can decompensate simply from the stress of a routine procedure.
After I check my orders and verify that all of my resuscitation equipment is at the bedside, I begin to care for my 31-weeker: obtaining her vital signs, measuring her abdominal girth, and changing her diaper. The charge nurse then approaches me and tells me about the impending delivery of a 33-weeker over in labor and delivery (L&D), and because I am triage and first admit (the first nurse slated to get a new patient today), I will be attending the resuscitation of the infant in L&D. At this point, I give report on my TEF baby to a fellow nurse, who will add this patient to her assignment while I attend to the delivery and admission of the new baby. Second rule of the NICU: Teamwork is crucial when you’re dealing with the tiniest of human beings.
I set up my admit bed, confirm that all of my equipment is functioning, and then I wait until we receive the delivery call. Once we do, the neonatology fellow, a nurse practitioner, a respiratory therapist, and I rush to L&D and wait some more. Finally, after 10 minutes, a baby boy appears in our resuscitation room. We dry and stimulate the baby, and ensure that his initial vital signs are within normal limits. Luckily, in this case, the baby was pink, crying, and overall very healthy despite being over a month early (he actually got a five-minute APGAR score of 10, which is the rarest of the rare). Many times, especially with micro-preemies, emergent intubation and central line access must be achieved prior to even leaving the resuscitation area in order for the child to be stable enough for transport to the NICU. Sadly, in those cases, a mother may have to wait to see her child until many hours after birth, as those first few minutes are so critical for the care team. But this time, we were lucky; mom was able to see and hold her son for a couple minutes before we traveled back to our unit.
The baby boy’s admission was very smooth, again, in large part, to the excellent teamwork and help from my coworkers. Without me even asking, my colleagues jumped in and assisted with obtaining vitals, measurements, and lab work. It feels really great to be part of such a well-oiled machine. I was able to complete all the necessary documentation and assessments without a glitch (I can honestly say that that’s the first time that has happened since beginning this job a year ago), just in time to take a quick break. I let my teammates know that I’m stepping off of the unit, and enjoy a brief five minutes of decompression time—enough to scarf down a granola bar before baby boy’s mom is calling from upstairs for an update. I assure her that everything has gone smoothly, and he’s now resting. I explain that I had to start an IV in her son’s hand, in order to run some maintenance fluids so that his blood sugar doesn’t drop, and that he will be on antibiotics for a 48-hour sepsis rule out. She says she’ll be down shortly to see him.
Before returning to my assignment, I take a quick stroll around the unit to check on some of the babies I’ve cared for in the past. I walk past the room of an ex-27-week infant who was transferred here for repair of his small bowel obstruction. His ostomy had not produced any stool in his first three weeks post-op, but was finally beginning to function on its own. I tell his nurse that when I had him last week, he let out his first gas from the ostomy all on his own, and that his parents were just beaming with pride. The father was actually mad at himself for not catching the act on video! Now that he was stooling, they were over the moon with happiness (again, refer to NICU rule 1).
I walk past the room of an infant with hydrops fetalis, and hear the whirring of the oscillator vent. This baby was born with bilateral pleural effusions, a pericardial effusion, and ascites, all at 32 weeks. To be perfectly honest, I was surprised that the baby had made it as long as she had. In her five short days on Earth, she’s already had a whole blood exchange transfusion, been under multiple phototherapy lights, and gotten multiple transfusions of platelets, plasma, and albumin (protein), all to help correct her fluid imbalance. I say a little prayer for her as I continue on back to my area of the unit.
Finally, I run into a mother that I’ve grown fairly close with, as I took care of her little girl in her first couple days of life. This mother had already gone through two miscarriages, and delivered this little peanut about eight weeks early, weighing a little less than two pounds. I was able to let her hold her baby one of the first nights after she delivered, and she silently wept the entire time. I could barely hold back my own tears, as well. I asked how my little rock star was doing today, and her mother beamed and proudly told me that she now weighs 3 pounds, 8 ounces—to which I responded, “Whoa, she’s getting so fat!”
I head back to my patients and continue the day performing cares every three hours—checking NG tube aspirates, changing linens, and recording daily weights, along with helping my teammates when they need assistance. I double check a 12-mL blood transfusion for an ex-23-weeker, silence alarms on a full-term infant post-cooling protocol for hypoxic ischemic encephalopathy (HIE), and help direct a hopeful grandparent toward her new grandchild’s room.
I finish the day by giving report to the next nurse, highlighting the big milestones achieved for the day: my 31-weeker’s feeds were advanced from 18 mL to 21 mL, and she tolerated the increase very well; my 33-weeker was stable and going to be just fine. These may seem like small changes in the grand scheme of things, but they can have a huge impact on the health and well being of the infant. This leads me to NICU rule number three: our work may be based on tiny little victories, but those tiny little victories are what leads to healthy, happy babies.
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