NICU nurses in my hospital are responsible for putting IVs in our neonatal patients. We don’t have an IV team to do it for us, and often, our nurses are called to other units when other units have difficulty putting IVs in babies. Regardless, IV placement is an essential nursing skill, and putting IVs in infants is different than putting IVs in adults. For adults, I can usually see or palpate (feel) veins. For babies, it can be difficult to see veins, and I’ve never been able to palpate them. It had been a while since I placed an IV in a baby, so I asked and volunteered to do it for a colleague needing to replace an IV in her patient on my last shift.
I placed the IV in the patient, but not without almost giving myself a needle stick (I dropped the needle, and it rolled away from me before I could retract it) and having some blood splash from quickly releasing a used hub on a bedside table. I’ve never come close to giving myself a needle stick, nor have I created such a mess from attempting to place an IV. Senior nurses were present to help me hold down the baby and hold up a vein finder. I felt like I was fumbling through the process with an audience. I hadn’t worked with these nurses before to place an IV because I was still new to the night shift. And while I eventually got the IV in, I felt foolish with how long it took and how I splashed blood on the table. I’m embarrassed that this is the first impression I’ve given these nurses on my IV skills. In a way, however, it was confirmation that I needed the practice.
While I was placing the IV on my colleague’s patient, the IV on my patient stopped working and needed replacement. As soon as I placed the IV on my colleague’s patient, I hurried to my patient’s isolette. I attempted to put a new IV on my patient, got it during my second attempt (the vein blew during the first attempt), but then accidentally pulled out the catheter as I tried to remove the tape and Tegaderm to retape the IV. It had stopped flushing smoothly, and the other nurse and I thought we could retape it to prevent it from getting kinked or occluded. As a guideline, a different nurse should take over the IV placement after two unsuccessful attempts. I stopped with further IV attempts on my patient beyond my two tries but got the lesson to remove tape individually so as not to pull out an entire catheter when retaping. (I had initially tried pulling off the tape before the Tegaderm, but it was hard to separate it from the Tegaderm). My colleagues eventually got a new IV in my patient. I appreciate the teamwork, but I still feel embarrassed by how I kept “messing up.”
I wanted IV practice on my last shift, and the universe gave me multiple chances! As humbling as my previous shift was, I realize the only way to improve my nursing skills is with experience and practicing essential skills: I will be more consistent and successful at putting in IVs only by putting in more IVs. Luckily, NICU nurses support each other and help and assist one another during IV placements. However, there are times when the unit is busy, and nurses may not always be available to help each other. I want to feel more confident with doing IV placement alone. I will have to request to do IVs whenever there is a chance.
Sometimes, it feels weird to be older and yet so new in work experience. I must remind myself and give myself the grace that I am still relatively new to my profession. There’s a lot I’m still learning to do that senior nurses do effortlessly and automatically. And even the most experienced nurses make mistakes or are sometimes unable to get an IV placed on the first try. I can’t expect perfection, but I can at least aim for improvement.
When I had my baby, my husband and I struggled to feed our newborn. I wanted to breastfeed my baby exclusively, but she would not breastfeed well. Influenced by various sources and committed to breastfeeding, I refused to pump or bottle-feed my baby while in the hospital. My baby and I roomed in together while I tried to breastfeed. My husband recalls having to travel with my baby somewhere for light therapy. I vaguely remember this too, but I was tired, delirious from lack of sleep, and recovering from a C-section. I only remember sleeping while my husband and baby were out of the room. In retrospect, my baby most likely went to the NICU because she was jaundiced. She may have been there for only a few hours because I remember waking when my baby and husband returned from wherever they went. Thankfully, the hospital did not admit my baby to the NICU, and we could leave the hospital together. However, our struggles to feed our newborn continued when we got home. Looking back at our experience as new parents, I wish I had known some things about feeding our baby that I know now as an experienced mom and NICU nurse.
Photo by Helena Jankoviu010dovu00e1 Kovu00e1u010dovu00e1 on Pexels.com
Fed is Best
As a NICU nurse, I see term or late pre-term infants (born at 34-37 weeks gestation) who come to our NICU for hypoglycemia (low blood sugar) or hyperbilirubinemia (seen as jaundice/yellowish skin). Often, these term babies come to our unit because they are not eating well. For some babies, parents refuse to feed baby formula while postpartum, and the mom may not have established her breastmilk supply yet. This description reflected us as newborn parents and a likely reason why my baby needed phototherapy.
A build-up of bilirubin in a baby’s body can cause jaundice. Bilirubin is usually processed by the liver and leaves the body as waste. A newborn’s liver may not yet efficiently function, but the baby should be eating/drinking something to produce waste and encourage processing out bilirubin. A newborn baby drinking breastmilk or formula helps curtail jaundice. If a baby is not feeding well or is still jaundiced despite attempted feedings, however, hospitals can treat elevated bilirubin levels (hyperbilirubinemia) through light phototherapy.
Jaundice is normal in newborns, but the hospital monitors bilirubin levels and treats when levels rise above certain thresholds. If the baby’s bilirubin is too high, brain damage can occur. In our hospital, if a postpartum baby needs phototherapy, the baby is admitted to the NICU. Phototherapy in the NICU only happens after multiple attempted feedings and when bilirubin levels exceed treatment thresholds.
Frequent feedings are how parents can reduce bilirubin levels in otherwise healthy babies (and hopefully prevent hyperbilirubinemia that requires NICU care). However, frequent feedings can also help prevent another common condition in our NICU: hypoglycemia, or low blood sugar. If an otherwise healthy baby born to a non-diabetic mom takes enough breastmilk or formula, the baby can usually avoid hypoglycemia. However, if the baby is unable to feed adequately, the baby can develop low blood sugar.
Before a baby goes to the NICU for hypoglycemia treatment and monitoring, the mother and the postpartum staff will attempt to feed the baby. If the mother consents, the baby can be offered formula. If bottle-feeding is still insufficient, a sugar gel is given to the baby orally. The postpartum unit will attempt several feeding and sugar gel administrations before the baby goes to the NICU. If the NICU admits a baby for hypoglycemia, we will place an IV to deliver sugar to the baby as IV fluids. Once the sugar levels in the baby are sufficient, and the baby is drinking adequately, we can reduce the IV fluids and eventually remove IV fluids if the baby can orally consume the needed calories and fluids while maintaining healthy blood sugar and hydration. In the NICU, we try feeding our babies breastmilk if it’s available and not contraindicated (i.e., substance-abusing mother). If breastmilk is unavailable and we need to feed a baby orally, we will give provider-ordered formula to our babies.
For babies admitted for hyperbilirubinemia or hypoglycemia, I sometimes hear the baby barely drank anything because the baby was unable to breastfeed from a mom who wanted only to breastfeed exclusively. Before doctors send the baby to the NICU, the nurses can offer the baby formula if the mom consents or requests it. However, by this time, the baby may have worn themselves out or be too tired to drink from the bottle. It makes me and other NICU nurses wonder, “If the parent or nurses fed the baby from the bottle sooner, would the baby still need to go to the NICU? Is the mother promptly informed of her options if her milk supply hasn’t come in or the baby cannot latch or breastfeed?”
While I’m glad my husband got to go with my baby and accompany her for phototherapy, I would have preferred that my baby not leave my postpartum room at all for treatment or tests. To prevent my daughter from needing to leave our room, I would have pumped sooner to encourage my milk supply and produce milk that my husband or I could bottle-feed my baby. We did not learn until weeks later that my daughter was tongue- and lip-tied, which may have initially made it difficult for her to breastfeed. From my perspective, it’s better to feed a newborn some formula to keep the baby with mom and out of the NICU than to rely solely on breastmilk that may not be available yet or difficult for the baby to access.
Pumping is Okay
I was offered to pump in the hospital but refused, thinking I would breastfeed. My doula recommended not to pump until after the first month, so I tried holding off on pumping in an attempt to have my baby latch, help establish our breastfeeding rhythm, and set my breastmilk supply.
I didn’t want to feed her from a bottle because I didn’t want to cause nipple confusion and have my baby prefer the bottle over breastfeeding. When we got home, I thought I was doing okay breastfeeding, but when we brought our baby to her 1-week checkup, she wasn’t gaining enough weight. We brought her to her 2-week checkup, and her pediatrician still didn’t think she was gaining enough. My daughter fell in the 2nd percentile on the growth chart. (I did not discover until months later that my husband and his siblings were so small as newborns they were not even on the growth chart). We were strongly encouraged to start bottle feeding her formula.
Wrought with guilt, we decided to feed her some formula, and I began to pump. By this time, I had developed mastitis (Mastitis is a painful infection in the breast caused by bacteria introduced by breastfeeding. It also caused me to have body aches, a high fever, and chills. Imagine dealing with this while trying to care for a newborn!) My supply was woefully insufficient, and most of my daughter’s caloric intake was formula once I started to pump while battling mastitis.
Formula is Okay
It is okay to use formula if you are not producing breast milk or enough breast milk/colostrum to feed your baby. I wanted to exclusively breastfeed because I learned about the benefits of breastfeeding and how it’s the best, natural, and easiest way to feed my baby. It’s great for baby bonding and helps provide passive immunity to the baby. However, I got mastitis TWICE within the first month or so of my daughter’s life. We also learned my daughter was tongue-tied, making it difficult for my daughter to breastfeed. Not until later did I meet other mothers who breastfed AND bottle-fed their babies or moms who exclusively pumped. (Moms who exclusively pump only feed their babies breastmilk from a bottle). Had I not been so attached to exclusively breastfeeding, I could have adapted and explored these other options earlier as a new parent.
Do What’s Best for You and Your Family
Aside from taking antibiotics, the way to clear a mastitis infection from the breast is by breastfeeding or pumping. My daughter preferred the bottle by this time, so I relied on pumping to clear my infection. Pumping (and antibiotics) eventually relieved the pain and released the mastitis in my breasts, but the repeated infections impacted my supply. Encouraged by my doula, I remember three days where I spent about 9 hours pumping (diligently pumping 45 minutes every 2 hours, per her recommendation) only to produce about 1 ounce of breastmilk daily. I was so exhausted and upset by the results of my efforts. I also felt cut off from my daughter while I pumped (Because I couldn’t figure out how to safely hold her with all the pumping tubes hanging from my body, my husband or parents would take her while I pumped). After the three days dedicated to pumping round-the-clock, I decided it was not worth it to continue to pump. It was more important for me to be with my baby than to try giving her my pumped breastmilk.
I still held out hope for breastfeeding. Once my infection cleared, I tried to breastfeed my daughter using an SNS (supplemental nursing system – a tube placed on the breast but connected to a bottle to measure and ensure the baby has adequate intake). She was already used to the bottle nipple and did not take to the SNS. I attempted multiple times, but she would refuse to feed through the SNS, and I would end up with formula spilling all over my chest.
I share a bit of my breastfeeding journey to emphasize that there are many ways to feed and nourish a baby. In the end, so long as the baby is healthy and safe, parents decide what works best for them and their family. The caregivers’ mental health and well-being are as important as the baby’s. The way you choose to care for your baby may not resemble how other families do things, and that’s okay. I was ashamed for not breastfeeding my daughter for as long and in the way I hoped, but I felt my attachment to breastfeeding distanced my baby from me and caused so much anxiety and distress. Parents should not be ashamed of doing what is best for them and their families.
In the NICU, I meet moms who feel nervous they cannot directly breastfeed, yet they can pump and produce enough breastmilk to meet their baby’s needs. I meet parents who are ashamed they don’t have a separate nursery for their baby. We live in Los Angeles – not every family can afford to pay for a home with different bedrooms for each of their children! Many of our parents rely on WIC because they can’t afford to purchase formula. Getting formula from WIC is better than diluting formula or not feeding the baby enough nutritious calories. I try to assure the parents I see they can do what works for their family – it doesn’t need to match other families.
I felt defeated when I finally gave up pumping and breastfeeding. I wish I gave myself a little grace as a newborn mom and wasn’t so hard on myself. I felt so much grief over my inability to mother and feed my child as I thought I should that it made me feel inadequate as a mom. I was separated from my baby while I pumped, trying to salvage any breastmilk I had. I cried every day when I was pumping or trying to breastfeed. Ultimately, I fed my baby adequately, thanks to formula, and my child is now a healthy school-age girl. She still falls on the low end of the growth chart, but her father and I are not tall, so my daughter’s standard is the tenth percentile or less.
As I reflect on my experience as a new mom, I hope to impart grace and support to other new parents now that I’m a NICU nurse. If a caregiver is feeding their baby adequately, caring for and bonding with them, and keeping them safe, I want them to know they are doing a great job! I also want them to know it’s okay to make adjustments as needed or change their minds about how they want to do things. Parents can adapt their plans according to the family’s needs.
I originally wrote this post to give insight on how to lower the likelihood of hyperbilirubinemia or hypoglycemia (and admission to the NICU) through frequent feedings. If this information helps reduce NICU admissions and prolong in-room bonding between caregiver and baby, I would be ecstatic. Ultimately, I hope this post reassures parents (and serves as a reminder to myself) that there are many ways to care for a baby. There are no perfect parents; there are no perfect children. We’re just doing our best with the information and resources we have. Good luck to you on your journey!
Mother’s Day coincided with my 3rd consecutive day working in the hospital. I get pretty exhausted after three-in-a-row shifts, even working on dayshift. Knowing how tired I get, my husband thoughtfully ordered food for us to have dinner at home last night. After dinner, I finally opened my daughter’s Mother’s Day card/gift she made at her school. (She’s been eager to have me open it since she brought it home on Friday – I insisted on waiting until Mother’s Day)
A portrait – part of my daughter’s Mother’s Day gift
My shift was hectic yesterday, but I didn’t mind working on Mother’s Day in the NICU. For our babies who have parents that visit them, I get to be there to comfort and support the parents and to celebrate the mothers on their special day. Some parents have difficulty being separated from their babies while their babies heal or recover in the NICU, especially on days like Mothers Day. NICU nurses often provide emotional support and assurance for patients’ caregivers. Some parents don’t yet feel comfortable handling or caring for their babies. As nurses, we educate and guide caregivers in their new roles.
All the NICU nurses made Mother’s Day cards using our babies’ various handprints or footprints on Saturday. I don’t usually have much downtime to craft cards for parents, but I enjoyed making memorable print keepsakes for our patients and their caregivers. Some of our babies have no parents visiting them and are awaiting placement in foster care or adoption. We still made Mother’s Day cards for them – their future families may appreciate their teeny baby prints!
Until this past weekend, I’d never seen these cards or prints on our unit. At my children’s hospital preceptorship in nursing school, I often saw footprint cards made by nurses in the NICU. However, those patients were at higher acuity, so 1) had longer stays and 2) had 1:1 nurse-to-patient ratios. Still, I want to try making more of these cards for our NICU babies in the future. It’s a great souvenir for caregivers, and it allows me to practice my beginner calligraphy skills!
Since I worked on Mother’s Day, my family decided to celebrate Mother’s Day with my parents on Tuesday, May 10, when my Mexican friends celebrate Mother’s Day / Dia de la Madre. (Cultural Awareness Tip: El Salvador and Guatemala also celebrate their Mother’s Day on May 10). We have many patients from immigrant families at work, so I told some nurses to keep displaying their Mother’s Day cards/signs until Tuesday.
Wherever or whenever you happen to celebrate it, I hope you have (or had) a “Happy Mother’s Day”!
I spent last Friday morning at work crying. I was in my new job at my new hospital and in training. The training I took Friday morning was a mandatory two-hour computer-based session about the Commercial Sexual Exploitation of Children or CSEC. I cried with the testimonials and the trauma described by survivors and experts in the field. I felt a combination of rage and helplessness while I watched and listened to the videos. Luckily, I was in an area where no one else was sitting around me, so I felt I could express my grief and despair without too much concern.
I think this is part of what scares me about being a pediatric nurse. I worry if I can emotionally regulate myself when working with abused or neglected children. I also wonder and hope I can recognize and report abuse should I ever encounter an abuse victim. As difficult as it was, I appreciated completing the training and felt it was valuable. As a nurse, I am a mandatory reporter and must report child abuse when I suspect it. However, I think the general population should also take the introductory training about the Commercial Sexual Exploitation of Children to increase awareness, recognize and reduce risks, and maybe correct misconceptions about victims.
It is unlikely that the public would voluntarily take a two-hour training about the Sexual Exploitation of Children. Despite this, I hope to educate my readers and others who come across my blog or social media posts, because I think it’s important and is something I can easily do to help victims of CSEC. Some of the things I learned from the training are found below:
I can cry and grieve for these children, but I also want to take action. Let me know if you learned anything new from this post or if you found it helpful. I’m also curious to learn and hear from others about ways they support victims of the commercial sexual exploitation of children.
I have not posted in a while because I have been busy with some life changes. I recently resigned from my new grad RN job and accepted an offer to work at another hospital. What could have possibly taken me away from my #1 choice hospital and my highly pursued new grad program? A spot in my dream unit, the NICU!
It was tough for me to leave my program since I felt like the people were supportive overall. I truly appreciated the environment, community, and staff. I was learning a lot and growing as a nurse. However, my experience as a new grad RN working in the Float pool with adult patients also affirmed that my ultimate goal is to work with babies in a NICU.
My hospital has a NICU, which was a big reason I applied to their new grad program – I had hopes to move into their NICU eventually, especially after having a NICU preceptorship during nursing school. However, after working as a resident, I learned that the NICU at the hospital where I was employed does not accept inexperienced NICU nurses. The NICU manager recommended I apply to an L&D fellowship after my Float Pool residency, and maybe I could transfer to the NICU afterward. That would mean the earliest I could go to our NICU would be 2023, and that’s with the caveat that I would get accepted into a competitive year-long L&D fellowship. I would be competing with other nurses whose ultimate goal is to be an L&D nurse and other more experienced nurses previously rejected from the L&D fellowship.
After learning all this, I had the opportunity to interview during a mass hiring event for another hospital. The hospital already had my application from earlier in the year, one of the 70+ positions I applied to before starting my new grad program. I shared I only wanted NICU positions – there was no other reason I’d leave my new grad program since it was a great program in a good hospital. I interviewed with the NICU manager at the new hospital via MS Teams in between scheduled night shifts. At the end of the interview, she shared she’d like to hire me. I gave my job three weeks’ notice once I passed the background check and received a target start date. I started orientation for my nightshift NICU position at the new hospital on Oct. 1, last Friday.
I know it’s customary to give two weeks’ notice, but I felt obligated to give my old hospital three weeks. I ended up working four more shifts than if I had only given two weeks’ notice. During those four shifts, I had the most brutal shift I’ve had since coming off preceptorship and working solo. If I had left sooner, I could have saved myself from experiencing the most horrendous shift I’ve had so far. Luckily, my last shift was smooth and helped build my confidence after feeling torn down and broken from the week before – I met my patient’s needs promptly, charted everything on time, gave good shift reports, and my patients had no incidents. At my last job, I ended on a good note and had valuable learning experiences. My horrible shift in the week leading to my final shift taught me that when I’m overwhelmed, not only should I delegate, I should escalate to the charge nurse or nurse leaders. I will remember how awful my experience was on that shift to remind me in my nursing practice: “When Overwhelmed, Delegate + Escalate!”
I will remember this lesson as I start my new job. I am excited to have the opportunity to be in a NICU again. The children’s hospital where I precepted during nursing school opened its new grad program about a month after starting my previous job. Various cohort-mates encouraged me to apply, but I decided I needed to give my program and hospital a fair chance. I passed the opportunity to apply to the children’s hospital NICU new grad program before learning that my hospital would not hire me into their NICU for at least two more years. I don’t regret not applying to that NICU program because I’m grateful for my experience and feel more confident as a nurse because of what I’ve learned working with adults. I gave my program a chance and put forth my best effort, and concluded that I wasn’t willing to wait years to reach my goal to be a NICU nurse.
The earnest pursuit of career goals is somewhat new to me. For years, I didn’t know what I wanted. I knew that I was comfortable but not necessarily excited or passionate about my previous career as an engineer/scientist. During performance reviews, I would dread when my manager would ask what 5-year plan was because I wasn’t inspired by what was around me. I didn’t want my manager’s job, and other than becoming more skilled, building my expertise, and gaining more leadership experience, I wasn’t sure what else to say. Now, it’s nice to have a goal (dayshift NICU nurse) and work towards it.
It’s still a little terrifying: “What if I don’t like it?” “What if the staff is mean at the new hospital?” “What if it’s not what I thought?” “What if I’m not good at it?” “What if I can’t handle the long commute?” “What if I can’t last long enough on nightshift to make it to dayshift?”
Sometimes, you don’t know if you’re going to like something or will be able to handle it until you give it a try. I also have to be open to the possibility of failure or making mistakes with this new job – it’s those moments where real growth occurs, however. That’s how I became a better engineer or scientist. I made a mistake and remembered not to do it again. It’s like doing something wrong a couple of times before you figure out how to do it right, or in the most efficient way.
I think a terrifying part of being a novice nurse is mistakes in healthcare can have a profound and permanent impact on a patient and patient’s family. If I made a mistake as an engineer or scientist, many processes and people were in place that ensured no one would get hurt or injured. Delays or mistakes I made may cost hundreds of thousands of dollars, but they would never hurt someone. As a nurse, I no longer have that sense of security or protection. It’s anxiety-provoking. I’ve met many nurses with high blood pressure, anxiety, or depression due to the stresses of this profession. I don’t want to develop health issues because of my chosen career. I went into this profession to help people, so I try focusing on how I can help or improve care vs. contemplating the many ways I can injure someone or how someone may injure me (a genuine consideration with adult patients).
I’m still a recent grad with less than a year of acute care experience and still developing. Fortunately, my employer views me as a new grad and is willing to train me as a NICU nurse. I consider my new position as an opportunity to learn, grow, and be a better nurse. I’m going to try to focus on that and becoming the best NICU nurse I can be. Wish me luck!
The Mature Student Nurse 