Thursday, June 14, 2007

Technology. Gotta love it.

NICU nursing is very much about the technology. We have a machine for just about everything. OK, nobody has perfected the baby-butt-patter yet, but pretty much everything else.

I've been a NICU nurse for over 25 years, so I've seen lots of changes in the technology. IV technology, for example. When I started in NICU, nearly all the IV's were started in the scalp with a steel needle called a butterfly. It has little plastic "wings" to help stabilize it, hence the name. Now, we almost always use a tiny flexible catheter. It has a stylet (special hollow needle) in the center, but we take that out once the catheter is in place.

Scalp veins are still the largest, most stable veins in a newborn, but if the baby has hair, you end up shaving and that's disturbing to the parents.

Also disturbing to the parents is the thought that the baby could be injured by the catheter. They know we use a needle to place it, and some of them either forget or don't know that the needle comes out and only a flexible tube is in place. More than once, I've been asked about the risk of "that needle" getting into the baby's brain. That wasn't a problem when we DID use needles, and it certainly isn't a risk with the catheters. Scalp vein placements don't bother the babies, but they do bother parents, so we try to avoid them if possible.

New babies who are seriously ill or very tiny may have a conventional IV, but they will also have some sort of central venous catheter as well. The easiest to place are the umbilical catheters. It's not exactly a simple matter, but when things go well, it's possible to have a catheter placed in the umbilical vein and one of the 2 umbilical arteries fairly quickly. Those give central venous and arterial access without making any incisions or even puncturing the skin.

We use the umbilical arterial catheter(UAC) to measure blood pressure and to take blood samples to measure oxygen and carbon dioxide content in the blood as well as acid-base balance. We also get the majority of our blood counts and blood chemistry samples from the arterial line.

The umbilical venous catheters (UVC) are used primarily to provide fluid and high calorie IV feedings. One of the most important advances for the UVCs is the double-lumen catheter. It has 2 separate tracks and that allows us to give 2 totally different fluids at the same time. When there isn't a UAC, we can get blood samples from the UVC, but this is much less common. UAC and UVC have been around NICU's longer than I have, but the technology has been upgraded.

Another huge step forward was the development of the neonatal-sized PICC - percutaneously inserted central catheter. This is a longer, flexible catheter placed through a fairly large peripheral vein. It is long enough to reach the large blood vessels in the chest that flow into the heart. It can be left in place for weeks, unlike the conventional IV catheters which usually have to be replaced after a few days (when we're lucky). Those come in single-lumen and double-lumen catheters as well. The physician or nurse practitioner decides based on the length of time the baby is likely to need the PICC and the reason she needs it.


Bohemian Road Nurse... said...

Wow--I had no idea they'd put PICCs in babies. Very interesting post.

Judy said...

PICCs are pretty much routine in our unit for babies who need long-term IV fluids and medications. We occasionally have a broviac if the NNPs can't get a PICC placed, but that's fairly uncommon.

chris and vic said...

I realize I'm responding way-late to this post. I am an NICU nurse, too, who has freqently reflected on the role of technology in the NICU (and in healthcare in general) and on the meaningfulness of technology vs other skills and values in healthcare.

Here is my current state of thinking:
1) I have noticed that over the years, most inservices are around new technology---learning how to operate the monitors, IV infusion pumps, and other "new products". Proportionately, there are very few inservices on ethics or the role of patient teaching or advocacy or developmental care . . .
2) Adding this together with the task-orientedness of nursing, I come up with a strange definition of nursing care---something like this . . .

"The bedside nurse in this critical care area will show evidence of her ability to be detail-oriented, keeping a checklist of the details of various patients needs---such as recording vent settings hourly, administering exact mls of fluids, and exact mls of output. Exact weights, to the gram, will be recorded. A dollop of hand gel the size of a quarter will be used to sanitize her hands, at least 8x/hr. Exact, to the tenth of a gram, formulations of formula or breast-milk additives will be measured. Checking exact, to the tenth of an ml, doses of meds is necessary to ensure the prevention of med errors.

"Other examples of details include keeping the babies on schedule for feedings, cares, vital signs---beginning their cares 15 min. ahead of completion time. Keeping track of weekly dates for changing isolettes, and marking date and time on any opened bottle of sterile water, Tylenol drops, powdered formula or liquid formula is necessary. Dates and times for fresh and frozen breast milk and its thaw-times is expected as well.

"Interdiscipliary plans of care need to be reviewed, with dates of review noted. Yellow out expired items.

"Wipe down surfaces at the bedside, check emergency equipment and monitor alarms at the beginning of every shift. Clean out sinks with attention to flushing the drains and traps with OSHA-approved bacteriocidals.

"Progress notes must include DAR--data, action, response of the patient. Admission, change in status, discharge require such a progress note. Notification of a physician requires a note. Date and time in all cases."

OKAY, you get the point . . .
Somewhere, further down the list is the need to partner with the family in the plan of care and keep contact via a daily phone call with them if they don't visit.
Record their visits and phone calls in a log. Be sure they feel included and comfortable with the cares they assume as the infant becomes more stable. Teach them to read their baby's cues. Teach the developmental needs of the infant. Tell them about changes in condition in a timely way; and tell them about changes in the plan of care. Arrange for a weekly or bi-monthly care conference. Facilitate their communication with the physician. Translate 'medicalese'. Encourage breastfeeding. Monitor bonding behaviors or the lack thereof. Accomodate their concerns, their anger, their avoidance. Investigate if visiting is not regular and frequent or if visiting falls off. Shift emphasis from the meds, monitors and oxygen to the signs of improvement or worsening condition of the baby. Explain 'two steps forward and one step back' to the parents with examples. Acknowledge their joys and their fears. Prepare them to care for their infant post hospitalization. Ensure follow-up in a follow-up clinic or with their peds or Birth-to-Three programs. Do not give false reassurances. Mediate between family and medical team, if necessary---for example, translate 'medicalese'.

I also belong to the preemie lists online, Narof and Preemie-Child. I read some of the medical blogs re: neonatology. I participate most often on The Preemie Experiment blog. I have been doing this for 8 years. I have an adopted 12-year-old ex-preemie at home. I was his nurse before I was his adoptive mom. I think I see many angeles and perspectives re: preemies. I have learned a lot. I think there are quite a few missing pieces in neonatology, in nursing, in our view of prematurity. For example, the whole "miracle" outlook is a trap. The consequences of what we start, how we care for and what we teach the parents of preemies does not begin to prepare them for the struggles they will have in the future. My son is one of the 40% who will never live independently. The consequences of prematurity are daunting for families and society.

There are many missing pieces in neonatology and neonatal nursing. Technology is the rote part, the detail---but what is the big picture? Are we honest about the long-term outcomes---do we even want to know how it all turns out in the end?

These are the questions that now influence my practice the most . . .

Chris and Vic

Anonymous said...

How long do you typically leave the UAC's in your patients?

Judy said...

There really isn't a 'typical' because it very much depends on the baby's condition. In term or near-term babies, it's out pretty much as fast as we can get the baby stable. We'll keep it in longer in very sick babies with persistent pulmonary hypertension, for example and may not ever place one in babies who are not so sick. With a really tiny baby who needs a lot of respiratory support, it might stay in 2 weeks. That's pretty unusual, though - and pretty close to the upper limit.