Updated: Jul 20
We take care of the tiniest, and often, sickest humans in the hospital. It is important to understand that premature infant are not only small, their entire body is premature and underdeveloped (including their brain, heart, lungs, GI system, skin etc).
The first thing to understand is there are several different levels of NICUs, ranging from Level I (which is a well-baby nursery) to Level IV (which are the most advanced, usually part of a large children’s hospital or academic medical center).
Basic NICU Level Breakdown
Level I (nursery level, community-based hospitals, birthing centers)
Level IV (most acute, Children's Hospitals, University Hospitals, Destination centers)
I have worked in Level III & Level IV NICU’s where & life-saving procedures happen daily. I have also worked in Level II NICUs where babies need a little support before going home.
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.
MEASUREMENTS: Our patients are measured in grams & centimeters.
GESTATION AND CARE: Baby age (in gestation) drives the care plan. How old they determine their day-to-day. (Ex: feeding plan, respiratory status, medications, "touch times" etc).
MEDICATIONS: Our medications are often measured in tenths of MLS.
OXYGEN: 2L of oxygen is considered “high flow," but don’t panic if you see a patient with oxygen saturations in the high 70s, that might be acceptable for that patient (Cardiac, Premature, different Diagnosis)
DIET: We measure our feedings in MLS as well, 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.
♡ NICU patient population admissions range from birth - 1 year.
♡ Most babies are admitted from L&D, or Mother/Baby, or transferred from other facilities (to a higher Level NICU).
♡ Listed below are just a few of the reasons a baby would be admitted to a NICU.
♡ (Keep in mind some of the Diagnoses would refer a baby to a Level IV NICU setting).
Sepsis Rule Out (Maternal Fever, Pre-Ruptured Membranes for several days/weeks
High-Risk Deliveries (drug-related, STD exposure, unknown pregnancy)
Medical Conditions (Cardiac issues, GI/GU,) are usually pre-diagnosed
Congenital Defects (Chromosomal, Genetic)
0700 or 1900
Before our unit meets for huddle we "SCRUB in." Huddle consists of the Nursing team, Respiratory therapists & Charge Nurse who all meet together to give a "brief" on the patient's and plan of care or updates for the day. It is a both a safety precaution & time to bond with your team of the day or night.
Leave your jewelry and watches at home, your arms will be bare from the elbows down as you scrub with soap and water (or the scrub your NICU requires: a no-rinse surgical sanitizer for example), clean under your fingernails. NICU is "bare arms."
After huddle, begins report. A NICU report looks much different than an adult world one.
HISTORY OF PREGNANCY & DELIVERY
Age (Birth Gestation & Current Gestation)
Weight (Gain or Loss, Daily)
Length of the patient.
Temperatures (36.5-37.5 C)
Heart rate (100-200)
Blood pressures (MAP 20-70)
NPO or PO eating
Breast milk or formula
OG or NG tubes (and their APPROPRIATE SIZES! 5-6 Fr)
PO feeding status
How well the infant takes oral feedings (nipple preference, slow-flow or regular)
Urine output (all diapers are weighed until discharge)
Ostomy (bag change & skin care plan)
Foley (french size, reason for placement, date of placement, placement cm, & output)
GI Surgical Tubes (size & type: Salem Sump or Repogle)
IV OR CENTAL LINE ACCESS
TPN and lipids
Any replacement fluids, like sodium acetate?
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
Placement of ETT
Ventilator Settings (HFOV, SIMV, BCPAP, NIMV, etc)
How to respond to baby “spells”
Review hemodynamic stability
Last Blood transfusion
Pulses (Goal +2) (Brachial & Femoral, Distal
Color (Pink/Pale/Appropriate for Ethnicity)
Review Cardiac Medications (Dopamine, Epi, Atropine etc).
Review Neonatal Neuro baseline
Sutures, Fontanells overview
Reflexes (Sucking, moro reflex, ability to console,
Review head ultrasounds as available.
Review MRIs as available
Pain is assessed with NPASS “Neonatal Pain, Agitation, & Sedation Scale"
Products to use (Mepitel, Mepilex, Gauze, Sterile Water etc.)
Skin tears, bruises, wounds
Review Lab trends
NICU tends to focus on Bili Levels, H/H, Chem panels, CRP, INR etc.
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.
Here are 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.
Examples: Pre-op Cardiac Surgery, Body Cooling, Micro Preemies (22-26wks), Pre & Post-Op Surgical patients, Complex Chronic Patients, etc.
Example: Let’s say this nurse is caring for a baby that was born at 23 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 finishes around 7:30 (AM or PM), and shortly after that, you would begin your first round of cares on this infant. After assessing the safety of the bedside, checking orders, assessing lines, etc. you would Sanitize the bedside. (Isolette or Warmer, Buttons, IV pumps, Work areas, Charting areas, etc. After touching base with the RT (Respiratory Therapist) we would combine assessments & care.
Example: while listening and counting the heart rate and respiratory rate, I am working on my head to toe assessment as well. Diaper changes, temperature taking, feeling pules, assessing baby vigor, all at the same time & providing containment. We also group or “cluster care”.
So, if I knew I have a scheduled chest x-ray & labs to draw, we time them together. I could help my RT draw my labs (from a UVC, or heel stick), (do a blood glucose along with the blood draw!) perform the chest x-ray bedside, AND make sure the Doctor knows we are doing “touch time” so they can assess the baby during this time.
What does the baby’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 do bowel sound & appear visually?
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 ETT tube and make mental note of the secretions, and finally change the infant’s diaper. We weigh diapers from admission to discharge.
By now you should have your ABG results back along with the x-ray image, which may result in some HFOV 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 needed oxygen. Oxygen keeps us busy to say the least!
During bedside rounds, all in medical roles discuss the plan of care and changes to the daily neonates needs. 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, NNP, the bedside RN, Respiratory therapy, PT, OT, SLP, Social Work, the unit Charge Nurse, and the parents. The plan of care for the day is discussed but you won’t change anything until your orders are written.
Around 1000, monitor vitals are recorded and charting begins! It is practiced in my unit to obtain hourly vitals, including heart rate, respirations, blood oxygen levels (other NICUs maybe Q2 for babies on respiratory support).
Vital signs & assessments vary based on the patient’s gestational age & stability.
For example: This 23-week neonate would have “Touch Times” at 08/20 & 14/02 (Head to toe assessment, temperature, diaper, blood pressure etc).
Other Post-Op Surgical patients
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.
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 or NP/NICU Fellow, explaining changes to the parents, and charting EVERYTHING.
In addition, product transfusions (Blood, FFP, Cryo, Platelets), administering medications, starting new IVs (24 gauge catheter!), or request assistance in repositioning your patient may occur.
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.
Lastly, 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.
On the complete other end of the spectrum from caring for one critically ill baby, is managing the care of three NICU babies! Report would look similar to that of the critical baby, but more information focusing 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, 1400, & 1700 / 2000, 2300, 0200 & 0500
9, 12, 1300 & 1800 / 2100, 0000, 0300, & 0600
Or a baby may be “Ad Lib,” and eat whenever they want!
Which could throw your whole shift in a tizzy.
Managing 3 babies might involve coordinating care times with speech or occupational therapy, assisting parents with feeding skills, having parents complete parts of discharge education, (car seat education, baths, diaper changes, feedings, follow-up appointments, well-baby care, etc.) hearing screens, or simply just care for the three patients and getting some snuggles in (especially on night shift J )
While caring for three infants may not seem as stressful as caring for 1 critically ill baby, the days where you have 3+ patients are stressful. Some days feel as if you are just moving from baby to baby; feeding one patient, vital signs, diaper changes, linen changes, then to the next, and the next, and finally charting it ALL. Then, repeating all day long.
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, NICU is feast or famine! We slow down a lot discharge babies home and then L&D is popping with high-risk NICU admissions. NICU is no stranger to that phenomenon.
When I tell people that I am a NICU nurse, they often respond by saying: “How sad, seeing all those sick babies!” or “How do you do that?” Quite simply, this unit is addicting! You get to help families through quite possibly the hardest time in their lives & see the fruits of your labor grow into “line-backer” toddlers!
If you are looking for a high-risk, high-reward nursing specialty, the NICU might be the place for you!
Another great resource for you BELOW. I was featured on The Morning Rounds and talked all things NICU Nursing. Dynamics, my personal journey, NICU Nurse Tips & Tricks!
Tori Meskin BSN RNC-NIC. Nurse. Blogger. Podcaster. Tori has been a clinician since 2012, works in acute care/inpatient NICU & Pediatric settings in southern California. She is a blogger, podcaster, NICU & Pediatric Critical Care RN, Sponsored Capella University MSN student, a Barco Uniforms Ambassador & Brave beginnings Ambassador. She has obtained her National NICU Nurse Certification (RNC-NIC) & has previously worked as a travel nurse, pursuing bedside experiences in several NICU settings. Follow her as she shares her NICU journey married life & juggles work, school, content creation, & brings you top notch Tips & Tricks along the way. Find her at www.tipsfromtori.com or firstname.lastname@example.org