Being an NICU nurse sounds like a pretty amazing job! I mean you get the word “intense” in your title and there are little babies. While it sounds amazing, many don’t know what NICU Nurses do in a typical shift. This guest post offers a glimpse behind the curtain.
What Do NICU Nurses Do?
Welcome to the Neonatal Intensive Care Unit! We take care of the tiniest, and sometimes, sickest humans in the hospital. It is important to understand that premature infants are not only small, their entire body is premature and underdeveloped- their brain, their heart, their lungs, the GI system, their skin.
Ninety-eight percent of our days are great, but the 2% that are bad are really bad. Some days are feeding and cuddling babies that are close to going home, some days are holding a new mom’s hand as the team explains that it’s time for her to hold her baby while he dies. I love my specialty and wouldn’t trade it for anything.
There are several different levels of nurseries, ranging from a Level I (which is a well baby nursery) to a Level IV (which are the most advanced, usually part of a large children’s hospital or academic medical center). I work in a level III NICU that does not perform surgeries.
Every day in a NICU looks different from the last. Every shift in the NICU looks different from the one before it. And every NICU looks different from another.
Remember that everything in NICU is smaller. Our patients are measured in grams and centimeters. Our medications are often measured in tenths of mLs. 2L of oxygen is considered high flow in here, but don’t panic if you see a patient with oxygen saturations in the high 80s, that might be acceptable for that patient. We measure our feedings in mLs as well, sometimes only giving drops. We use the smallest blood pressure cuffs you have ever seen and sometimes those are too big. NICU nursing is delicate work.
I’m going to lead you through 2 scenarios, one featuring a nurse 1:1 with a critically ill or premature infant, and another with a nurse caring for 3 feeder-grower infants.
Regardless of the assignment, NICU nurses are usually the first in the hospital doors. Before our unit meets for huddle (where the off-going charge nurse gives updates on the status of the unit, who the Neonatologist and Neonatal Nurse Practitioner are for the day, and any other important updates), and we scrub in. Leave your jewelry and watches at home, your arms will be bare from the elbows down as you scrub with soap and water, clean under your fingernails, and use a no-rinse surgical sanitizer.
After huddle begins report. A NICU report looks much different than an adult world one.
- History of the pregnancy and delivery
- Weight (gain or loss)
- Head circumference
- Length of the patient.
- OG or NG tubes
- How well the infant takes oral feedings
- Last stool
- IV access
- Umbilical lines
- PICC line
- Peripheral IV
- Is the baby on TPN and lipids? (We run TPN and lipids separately)
- Or D10W?
- Any replacement fluids, like sodium acetate?
- Respiratory support
Specific settings are covered and discussed, placement and size of the endotracheal tube is covered if the patient has one, how often the patient is being suctioned (and what it looks like!), and what the patient’s oxygen demands have been. If there have been any recent radiology studies, like chest x-rays, head ultrasounds, or echocardiograms, we review those as well as any that might be scheduled for that day. Finally, we review the most recent lab results and go over all of the orders together. It is practice in our unit to “walk the line” together with the off going RN. No matter what type of line the patient has, a feeding tube, IV access, ET tube, we confirm proper placement and proper infusions/settings and connections at the start/end of our shift.
Caring for the 1-on-1 patient
Let’s say this nurse is caring for a baby that was born at 24 weeks gestation. The bed area is going to have the following (most likely): a High Frequency Oscillating Ventilator (these things are BEASTS but are SO gentle on little lungs), multiple IV pumps and syringe pumps with a variety of medications running, a cardiopulmonary monitor displaying heart rate, oxygen saturation, and respiratory rate, and possibly a bili-light used to assist the body in breaking down bilirubin (increased levels cause jaundice).
Report should’ve finished by 7:30, and shortly after that you would begin your first round of cares on this infant. Let’s say an ABG is ordered as well as a blood glucose level for 0800, along with a chest x-ray. Because the infant has an umbilical arterial catheter (UAC), we can draw a blood gas (and the rest of our labs) directly from that line. Extreme caution should be used when doing so in small infants. Even withdrawing 1-2mLs of blood can be a large enough change to cause hemodynamic instability.
After calling the respiratory therapist to confirm that they can run the ABG, I would draw my ABG off of the UAC, obtain my blood glucose, and start recording vital signs. While listening and counting the heart rate and respiratory rate, I am working on my head to toe assessment as well.
A NICU Head-to-Toe Assessment Example
- What does the patient’s head feel like?
- Are the sutures separated or overlapping?
- Do I hear a murmur? (Actually, while the piston is running on a HFOV, you cannot hear heart sounds!)
- What do the lungs sound like?
- Clear and equal?
- What about bowel sounds?
- Is the abdomen soft
- Bowel loops visible (they look like sausages under the skin)
- How is the patient’s muscle tone?
- Does the infant have full range of motion with their limbs
- Does one stay still?
- Is the patient vigorous and “fighting” me
- Or are they flaccid?
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 care with any colostrum that we may have available, check the OG tube to remove any air from the stomach, suction out the ET tube and make note of the secretions, and finally change the infant’s diaper. We weigh diapers from admission to discharge. Hopefully, all of that can be completed before the x-ray techs arrive. You would shield yourself with a lead apron and position the infant for the x-ray. After the x-ray is complete, you position the infant in a comfortable way, close the doors to their isolette, turn down your bedside light, pull the isolette cover down, and let that baby sleep.
By now you should have your ABG results back along with the x-ray image, which may result in some HFOV setting changes. While waiting for new/changed orders, it’s time to chart your heart out before bedside rounds begin at 0900. As the bedside nurse, you are actively managing the patient’s oxygen concentration to keep their saturations between the ordered parameters. Too high for too long can be detrimental to the infant’s developing retinas, and too low is starving the body of needed oxygen.
During bedside rounds, the offgoing Neonatal Nurse Practitioner (NNP) gives report on the past 24 hours and suggests a plan for the next 24 hours to the oncoming NNP. This is all in medical speak first and then our Neonatologist explains it to the parents if they are at the bedside for rounds.
During rounds the people present at the bedside include: the Neonatologist, the offgoing NNP, the oncoming NNP, the bedside RN, Respiratory therapy, PT, OT, SLP, Social Work, the unit manager, and the parents. The plan of care for the day is discussed but you won’t change anything until your orders are written.
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At 1000, monitor vitals are recorded. It is practice in my unit to obtain vitals on patients receiving oxygen support every 2 hours. Every 4 hours, at 8/20, 12/00, and 16/4, the RN performs hands on cares: a full head to toe, diaper change, oral care. On the off hours only monitor vitals are obtained to allow the patient a chance of having a period of undisturbed sleep. Of course, all of this is dependent on the acuity of the patient, vitals may be needed more frequently, or the RN may be disturbing the infant more frequently to keep the patient safe and alive.
The whole morning repeats again starting at 1200, except for rounds. As the bedside RN for a critically ill or premature infant, you really are not ever leaving that bedside. You will be continually watching the patient’s vital signs, reporting changes in status to the Neonatologist and NNP, explaining changes to the parents, and charting EVERYTHING. You could have to transfuse multiple blood products, administer pressors or other medications, or request assistance in repositioning your patient. It is on days like this, when your brain is going a million miles an hour, that all of your critical thinking skills are used. It is such a rush.
During all of this, you or your coworkers might be working on placing another peripheral IV in a baby… using a 24 gauge catheter!
Most procedures are done at the bedside in the NICU as well: PICC lines, lumbar punctures, chest x-rays, and head ultrasounds to name a few.
Caring for the 3-to-1 patients
On the complete other end of the spectrum from caring for one critically ill baby, is managing the care of three! Report would look similar to that of the critical baby, but information on discharge planning would also be shared.
Infants that are close to going home are cared for and fed on a 3-hour schedule:
- 8, 11, 2, and 5
- 9, 12, 3, and 6 (to avoid having to feed a baby at shift change)
- Or may be on an ad lib schedule: getting to eat whenever they want
Managing these 3 patients might involve coordinating care times with speech or occupational therapy, assisting parents with feeding skills, having parents complete parts of discharge education, administering car seat screens or hearing screens, or simply just care for the three patients and getting some snuggles in.
While caring for the three infants may not seem as stressful as caring for the 1 critically ill baby, the days where you have 3 patients are stressful. Some days feel as if you are just moving from feeding one patient, to another, to the next, charting it all, and then repeating all day long, but other days you feel like a chicken with their head cut off attempting to run around the unit while keeping all your patients organized.
Life can change in the blink of an eye in the NICU. One minute the unit is calm, the next, a crash c-section is performed and a 24-week gestation baby is being admitted and your team comes together to make it as smooth as possible. Quite often, when it rains it pours in the mother-baby world and the NICU is no stranger to that phenomenon.
When I tell people that I am a NICU nurse, they often respond by saying: “I could never do that!” While I think NICU is a sometimes scary specialty, it is addicting. You get addicted to helping these families through the toughest part of their lives and seeing these tiny babies eventually grow into roly-poly toddlers.
If you are looking for a high risk, high reward nursing specialty, the NICU might be the place for you.
Charlotte Minnema, BSN, RN, CLC is a registered nurse in a Level III Neonatal Intensive Care Unit in Michigan. In addition to being a wife, momma, and nurse, Charlotte is pursuing her Doctor of Nursing Practice degree to become a Primary Care Pediatric Nurse Practitioner.
In her free time (HA! Free time…) Charlotte enjoys going for walks with her husband and son, knitting, reading, and trying new recipes.
Follow her journey of juggling married life, mom life, nurse life, and student life on Instagram @drnursecharly
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