Thenursing profession is a vocation in which a practitioner`stheoretical and clinical knowledge, skills, and judgment During forthe protection and restoration of the human well-being. Clinicalevaluation skills can only develop through knowledge, experience,practice, and critical thinking. I have been working in Neonatal ICU(NICU) for the past ten years. The experiential knowledge I havegained over the years has helped me to offer excellent service topatients and their families as well as relate better with colleaguesand adhere to set professional and organizational guidelines.
Duringmy practice in NICU, I have admitted a 33-weeks-old, 1200gram, SGA(small for gestational age) baby for observation. Two days afteradmission, it was noted that the baby had self-resolving apneabradycardia and desaturation. The frequency of apnea, bradycardia,and desaturations gradually increased. Some of the episodes requiredstimulation (usually tactile). During one episode, the baby turneddusky and was also lethargic with temperatures dropping to 96.5oF.A physical examination showed an undistended and soft abdomen withhypoactive bowel sounds. Again, there were three bouts of vomitingthat revealed partially digested formula. These clinicalmanifestations co-related with early-onset sepsis. Using theSituation, Background, Assessment and Recommendation (SBAR)technique, I requested the doctor to examine the baby and orderdiagnostic and laboratory assessments such as chest and abdomen x-rayto rule out necrotizing enterocolitis or pneumonia and LumbarPuncture to rule out meningitis. Before the doctor arrived to make anexamination, I stimulated the baby with blow-by oxygen. I alsoperformed oral and nasal suctions to suck out any secretions andplaced the baby`s neck in a neutral position. I checked the urineoutput and observed that it was within reasonable limits. Icollaborated with a respiratory therapist to set up for oxygen byNCPAP as the baby had not responded to stimulation and blow-byoxygen. I administered a bag and mask ventilation with noimprovements. Hence, I administered NCPAP of 6 and 25% oxygen. Bloodculture, BMP, CBC, CBG, urine analysis and culture, LP, and chest andabdomen x-ray were done. The infant was put on medication comprisingof antibiotics (ampicillin and gentamicin) as the cornerstonetreatment of sepsis. In line with the pathophysiology of early-onsetsepsis, I embarked on collecting the medical history of the baby`smother. Ideally, early-onset sepsis is primarily acquired from themother perinatally. Thus, I noted that the mother had been diagnosedwith the premature rupture of membranes and but had no history offever during the pregnancy.
Again,in my stay at NICU, I have observed that administration of ExpressedBreast milk is a common practice. However, the practice facessignificant risks as I have noticed EBM bottles with no label, date,and time in one of the baby`s EBM box. I also saw EBM bottlesmisplaced in another infant`s box. I informed NCM and discussed inCOP meeting. The action plan was to check the EBM by two RN or oneRN and a HUC, sign the log paper kept at the baby`s bedside chart andtogether go to the EBM freezer/fridge, and keep EBM bottles in thecorrect box.
Ideally,nursing practice including the actions discussed above should beguided by evidence obtained through research so as to improvehealthcare outcome. "EBP has been defined as taking the bestavailable evidence from the literature and combining it with clinicalknowledge to care for an individual patient, it is a core competencyfor those who are completing an education in the health professions"(Long & Mathews, 2016). "Quality improvement is defined as aformal scientific approach to the analysis of performance and thesystemic efforts to improve it" (Wilson, 2016). "A researchstudy is meant to generate new generalizable knowledge or contributenew knowledge to what is currently known by using experimentalmethods that may be unproven instead of current standards of care"(Stausmire, 2014). Research study requires approval frominstitutional review board (IRB).
Long,Dennis M., & Mathews Eric (2016). Evidence- based practiceknowledge and
perfusionists`clinical behavior. Perfusionp.1. DOI: 10.1177/0267659115589400
Stausmire,Julie M. (2014). Quality improvement or research-deciding which roadto take.
Wilson,Denise (2016). Evidence-based care sheet. Quality Model forImprovement: Plan-Do-
Ihave admitted a 33-weeks-old baby with respiratory distress. Duringthe course of hospitalization, the baby developed NecrotizingEnterocolitis. Sepsis work-up was done, and dopamine started forhypotension. KUB revealed free air necessitating consultation withthe surgeon. The surgeon decided to do surgery at the bedside becauseof the grave condition of the baby. I called the parents, informedthem about the status of the infant. The neo fellow and the surgeonalso talked to the parents. They obtained consent from the baby`smother to start the surgery before she could arrive at NICU. Afteropening the abdomen, the surgeon saw that the intestines werenecrotic, and surgery would not benefit the baby in any way. Hedecided to close the abdomen. The neo fellow and I called the parentsand talked to them about the infant`s condition. They agreed with thesurgeon`s decision to provide comfort care only. By the time theparents arrived, the operation was over, and the baby was onventilator support, and dopamine, and IV fluid. The surgeon and theneo fellow discussed with the parents about the baby`s condition in aprivate room. The parents requested to hold the baby while still onthe ventilator support. They took a brief moment and discussedbriefly before asking to have the support removed. At that time, thechild was receiving oxygen through extubation and a nasal cannula. Icalled for the chaplain and a social worker to the bedside and left amessage for child`s life. I provided a comfortable sitting positionfor the parents so that they could hold the baby. The chaplain andthe social worker came to the bedside and talked to the parents. TheChaplain also baptized the baby as per the parents` wish. Given theweight of the situation, the parents requested to be excused and bealerted once death was confirmed. Once the baby was deceased, Isought their permission to transfer the body to the morgue. A fewdays after the funeral service, the baby`s mother called and thankedme for supporting them during the difficult situation.
Givensuch close interactions with patients and their families, one isguaranteed that while working in a multicultural community, one willencounter clients from different cultural, ethnic, and religiousbackgrounds. A nursing practitioner must respect such differences andoffer services accordingly. There is one particular situation I hadwith a Muslim family. The mother of a hospitalized patient was upsetbecause she was unable to read the Quran for her baby every day asshe had transportation problems. Therefore, I offered to read theQuran to the baby provided that she would let me and instruct me onwhat to read in English. She accepted my offer and was jubilant andgrateful that I had helped her.
Aterm infant was admitted to NICU with vomiting. The baby wasdiagnosed with the short gut syndrome. The plan was to graduallyincrease PO feeding while the baby was on TPN/intralipid and continuethe same plan at home upon discharge. According to the home healthagency, they would provide the supplies one day before the discharge.However, I needed to ensure that the mom was competent in using thetubing and pump at home before the patient was discharged. I used thechain of command to get the supplies to the unit at least two daysbefore discharge. To accomplish this, I had to involve the chargenurse, nurse manager, neo intern, neo fellow, and case manager. OnceI received the supplies, I trained the mother on the process. Thetask was challenging to her, but she mastered it in the end. Afterdischarge, the mother called me and said she was comfortable changingTPN and IL.
Inanother case, I admitted a 33-weeks-old baby with respiratorydistress. During hospitalization, the baby had developed NecrotizingEnterocolitis. Her treatment involved sepsis workup and dopamine forhypotension. KUB revealed free air movement and made it necessary fora surgery consultation. The surgeon decided to do surgery at thebedside because of the grave condition of the baby. I called theparents and informed them about the status of the baby. To get theprocedure done right, I had to collaborate with many people namely:the pharmacy in order to get the medications on time the lab to getresults ASAP the unit clerk to take sample to the lab theradiologist to do the x-ray Stat the parents to know the change incondition of the baby charge nurse to get additional help (baby wasin isolation room) surgeon to carry out the operation theanesthesiology to aid the surgeon and the department to set up forsurgery. At the same time, I sought input from the social worker andthe chaplain to attend the end-of-life support for the parents.
Nursesin NICU use appropriate resources to plan and provide nursing carethat is safe and efficient. They have to assess the infant and familycare needs and resources available to achieve desired the outcome andalso stick to organizational and professional guidelines. Thisenhances healthcare outcomes and increases patient satisfaction.
(S) Doctor, my name is Sue, RN, from level ll NICU, to inform you regarding Baby Z, had a bradycardic episode, desaturated to 75. Heart rate returned to 130 with stimulation and increased oxygen to 28%. He also had some regurgitation of formula.
(B) Baby Z, is a former 27-weeks gestational age, 3-weeks-old now. He was on CPAP for short period and remains in 24% flow support. His tube feeding is continuous. He had a couple of apneic episodes today, for the first time. Tachypneic with respiratory rate of 75. The day nurse reported that baby slept more today, and his mother felt he wasn’t as alert as usual.
(A)Assessment findings are diminished muscle tone, mottled skin, breath sounds clear and equal, abdomen soft and not distended.
(R)I recommend you to come and assess the baby now. I think the baby is septic. It would be great if you could order for chest X-ray and sepsis work up. So that, I can call for x-ray and set up for sepsis work up before your arrival to NICU.