Welcome to the NICU!The NICU is located in the Montreal Children’s Hospital on B-6 south. There are 52 single patient rooms which are divided into 3 zones- blue, yellow and silver. The NICU relies on several interdisciplinary teams made up of neonatologists, pediatricians, nurse practitioners, nurses, respiratory therapists, pharmacists, nutritionists, social workers, occupational therapists, and other consultants, to treat severely ill newborns (premature or term infants with serious medical or surgical problems). The nursing team consists of approximately 200 nurses including 8 RNA’s. Each shift, approximately 23 to 26 staff nurses provide care under the coordination of a team leader and assistant head nurse. The newborn patients arrive via the Birthing Centre as well as being transported from other centres throughout Quebec by the NICU transport team. A resuscitation nurse, as well as a neonatal transport team nurse is assigned on each shift. Below are the members of our NICU Leadership Team.

Role Name Local & ExtensionNICU Coordinator: Provides direction for organization of care and services within the MUHC neonatal program

Andreane Pharand B06 3822 66299

Nurse Manager: Manages the day to day activities in the department including management of staff

Lynn Lauzon B06 2839 23763 Mobile 66448

Assistant Nurse Manager: Scheduling, assignments and staff support Southida InthachitCassandre Marthone

B06 2843 25080 23762

Assistant Head Nurse: Transport Team/Outreach: Oversees the NICU transport activities and transport nurses

Diane Lalonde B06 3822 24905

Nursing Educator NPDE: Oversees staff education, training, orientation and ongoing staff development

Elissa Remmer B06-2831 22151

Clinical/Education Support: Supports staff with clinical practice Martine Chagnon B06 2831 22151

Lactation Consultant/Nurse Clinician: Provides teaching and support to mothers and staff/responsible for quality and efficiencies in the milk preparation laboratory

Mireille Bechard B06 2831 23159

MCH lactation consultant: Supports families within MCH for lactation

Linda Boisvert 35985

Discharge Coordinator: Works in partnership with members of the NICU team to facilitate/coordinate the discharge and transfer process

Lyne Boisvert B06 2108 22611

Administrative Technician: Payroll, vacations, and purchase of supplies

Linda Gendron B06 3822 23378

Nurse Practitioners ( 9):Advanced practice nurses work in partnership with the neonatologists

Linda MorneaultPhilippe LamerRose BoyleMartine ClaveauMarie-Eve MoreauM. Ribeiro de SalvaOlga KazantsevaAndrea Martel-BucciEmilie St-Germain

B05 2514 22294

Medical Director of NICUMedical Director of NICU Transport

Dr. Therese PerreaultDr Louis Beaumier

Neonatal Follow-up Clinic: Neonatal Clinic provides developmental assessment and long-term follow-up (until school age) of infants who are at risk neurodevelopmental delays

Trish GrierDiane Martin

NURSING ORIENTATION IN THE NICU

Nursing orientation for nurses starting in the NICU consists of:

o HR Welcome Day (1 x 8hr day)o MCH Pediatric Nursing Orientation (2 x 8hr days)o “Exploration Day” in the NICU (1x 8hr day)o Phase II Theory Days (2 x 8hr theory days)o 5-6 weeks of precepted clinical experience (may be shorter, depending on previous

experience).o Neonatal Resuscitation Program (NRP) is required in the NICU (1x 8hr day), and will be

scheduled at some point soon during/after your orientation.

The 5-6 week period of precepted clinical experience consists of being paired with an experienced nurse to learn some of our basic nursing/unit-specific skills and become familiar with patients, protocols, care providers, and the unit’s culture. This period can be divided into two phases (Phase I and Phase II), where in only stable babies would be taken during Phase I, and unstable babies would be taken in Phase II. Depending on your previous experience, your preceptor may choose to follow this pattern, or may choose to take a mixed assignment (Phase I and Phase II babies at the same time). You should discuss your preference and comfort level with your preceptor. Regardless of how you proceed, by the end of orientation, you are expected to demonstrate safe practice of basic unit-specific skills as outlined in the “NICU Phase I” and “NICU Phase II” documents that follow.

At the end of your orientation period, we will do a formal evaluation of your progress and set goals for the time to come (done with an Educator, a Nurse Manager, and/or an Assistant NM). This evaluation may be done earlier in the process if there are specific challenges that present themselves along the way. Your capacity to provide safe care for NICU patients alone will be evaluated. For some, prolongation of orientation may be necessary; for others, another setting may be suggested.

We expect that you take initiative in your learning and seek out opportunities to acquire the knowledge and skill needed to become a skilled NICU nurse. Your preceptor should be seen as a guide, but your own autonomy and independence as well as your personal investment are critical in your development (remember you will be on your one day!).

SHIFT HOURS

The hours for a:12 hour day shift are: 7:15-19:408 hour day shift are 7:15-15:30

8 hour evening shift are: 15:15-23:3012 hour night shift are: 19:15-7:40

Checklist for Starting in the NICU

***** (You are responsible for ensuring that you have attended or completed all of the activities below.)******

Activity Resource Person Date/time/location Completed

(Check if done)

Locker on B06S See nurse manager Lynn Lauzon

MCH orientation (2 days)

Pre-arranged by educators

Oacis Login See NICU Admin Agent (Linda Gendron)

VSign Once you have Oacis Login, you should be able to download VSign. Have your preceptor sponsor you and show you the app.

ADC Login NICU Admin Agent (Linda Gendron) to send request for access to pharmacy

Fingerprint by educators or superuser. Please set time with them.

Bloodbank/

Traceline access

NICU Admin Agent (Linda Gendron) to fax in request to bloodbank

Call blood bank (x22366) to activate your Traceline account.

Glucometer training

Organize with preceptor to do online training capsule if not done in MUHC already, then do practical demonstration with educator or preceptor

Once training capsule done & employee card available, educator to send in name/IUN to Point of Care.

Name tag If not done at time of HR welcome day, ask manager for form and calendar of picture days.

Updated July 2015 E.R.

Focus of Phase I – Safe care of up to 3 stable NICU patients:

Safety at the bedside (consistent practice of SAFE, medication calculations, initiation of first steps of NRP during acute deterioration, etc)

Consolidation of physical skills (physical exam and vital signs of newborn, recognition of deterioration, management of IV infusions, etc.)

Time management – planning out day ahead of time, anticipating obstacles Who to go to for help; when to ask for help; delegation of tasks Organization of day-to-day care (completing day/night-shift routine tasks without

gaps, taking breaks appropriately, maintaining a tidy bedside environment, etc) Theoretical knowledge –

Goal is independent reading of orientation manual (USB key) Focus on:

o Fluids and Electrolyteso Hematological Systemo Gastrointestinal Systemo Nutritiono Respiratory Systemo Developmental Careo Pharmacology

Read, understand and be able to apply protocols included on USB key:o NICU Admission Protocolo Skin Care & Temperature Regulation Protocolo Inifeed Protocolo NICU Bath Protocolo Kangaroo Care Protocolo Tracheostomy Care & Management Protocolo Sucrose Medication Administration Protocol and Collective Ordero Management of Breast Milk

NICU phase I

NICU phase II

Focus of Phase II – Safe care of up to 2 unstable NICU patients:

Consolidation of physical assessment skills and links to pathophysiology, with focus on anticipation of deterioration

Initiation of first AND subsequent steps of NRP during acute deterioration Organization during high-intensity care Consolidation of advanced skills (eg drip calculations and preparation, intubation

medication calculations, etc.) Application of critical thinking – playing an active role in team decisions

(initiating / questioning / bringing to attention concerns) Theoretical knowledge –

Goal is independent reading of orientation manual (USB key) Focus on:

o Cardiovascular systemo Renal and Genitourinaryo Hepatic systemo Metabolic systemo Neurologic systemo Geneticso Musculoskeletal systemo Immunology

Read, understand and be able to apply protocols included on USB key:o Ventilator-Associated Pneumonia (VAP) Protocolo Administration of inhaled NO in the NICUo Surfactant administration in the NICUo Clinical Guidelines for Analgesia/Sedation Weaningo Pediatric Opioid Therapy Guidelineso Concensus for Counselling re: Resuscitation at Limits of Viability

1. Introduction of the NICU roles & Tour of unit : oMDs & NNPs

NICU « Exploration

Day »

oRNs & RNAsoDischarge RNoLactation consultantsoRTsoPCAs & house keepingoDietician, Pharmacy, SWoUnit coordinators

2. Description of NICU population

3. Important information regarding:oNurses scheduleoRequest for days offoEmail, facebookoCommunication book

o Information that can be found on the portal (infection control manual, policies and procedures, med protocols, Logibec)

oGlucometer teachingoVSignoOACIS-Trace lineoPneumatic tube systemoADC machine

4. Mini NRPoWhat to do when a baby decompensatesoWhat to do for A & BsoBag & mask

5. Bedside of the babyo Different bedso Organization at the bedsideo Verification of the proper equipment & environment(SAFE)o Responding to alarms & setting proper limitso IV & kangaroo pumps

6. Physical exam of the newborno Head to toe assessmento “Check”

7. Feeding:o Frequency

o Formulaso Gavage vs bottleo Feeding schedule & protocolo Milk room and role of RNA

8. Documentation:o Medical charto Nursing charto PTI

o SunScaleo Sucrose

9. Fluids and medication exercises

10. “Treasure Hunt

GENERAL CONSIDERATIONS WHEN CARING FOR NEONATES

Vital signsHeart rate 120-160 bpmRespiration 40-60Blood pressure See tableBody temperature 36.5oC-37.5oC (Axillary)

Saturation – Oxygen With Love (OWL)

Alarm limits

ALL BABIES (preterm, term, PPHN) except cardiac babiesOxygen Room Air

HIGH Saturation Limit 95 100

LOW Saturation Limit 88 91

Babies with congenital heart defects

HIGH Saturation LimitTo be determined by the

Cardiology Team + ordered.Please write limits on care

plan.LOW Saturation Limit

Fluids Babies should have feeding or IV solution Fluid per days of life

Day 1 65 ml/kg/dayDay 2 80 ml/kg/dayDay 3 100 ml/kg/dayDay 4 120 ml/kg/dayDay 5 120-160 ml/kg/day

EquipmentBag Blender attached to bag should be set 10% higher than baseline need;

exceptions include babies on PGE, babies on NO, and cardiac patientsMask Mask should fit on the baby’s nose and mouth,

Ensure that mask is inflated to permit a good sealSuction Should be functional at each bedside, and set at 110 mmHgSaturation monitor Verify alarms at the beginning of the shiftCardiac monitor Verify alarms at the beginning of the shiftIV pump Adjust rate according to fluids order; set VTBI for 4 hours’ worthIsolette The mode should be on patient mode set at 36.5oC. Verify probe placement.

VITAL SIGNS REFERENCE VALUES

Clinics in Perinatology 26: 4; 989, 1999

Annex I

Visual description of four grades of IVH

Annex II

Different types of TEFs

Normal Heart

Congenital Heart Defects

Patent Ductus Arteriosus

The ductus arteriosus connects the main pulmonary artery to the aorta. In utero, it allows the blood leaving the right ventricle to bypass the pulmonary circulation and pass into the descending aorta.

Ventricular Septal Defect

A hole in the septum between the 2 ventricles. The size of the defect varies, from pinhole to complete absence of septum. Pulmonary vascular resistance (PVR) being less than systemic vascular resistance (SVR), it creates a left-to-right shunt, increasing pulmonary blood flow.

Atrial Septal Defect

Consists of a hole in the septum between the 2 atrium. As pulmonary vascular resistance (PVR) decreases, it creates a left-to-right shunt with right ventricular volume overload and hypertrophy.

Atrioventricular Canal Defect

An opening in the septum between the 2 atrium and the 2 ventricles which allows oxygen rich blood to pass from the left ventricle through the opening in the septum and then mix with the oxygen-poor blood in the right ventricle.

.

Double Outlet Right Ventricle

A congenital defect in which both the pulmonary artery and the aorta arise from the right ventricle.

Coarctation of the Aorta

A localized constriction of the aorta that usually occurs at the junction of the transverse aortic arch and the descending aorta in the vicinity of the ductus arteriosus.

Critical Aortic Stenosis

A lesion that results in obstruction of blood flow from the left ventricle to the aorta.

Interrupted Aortic Arch

It is the complete discontinuity between the proximal and distal portions of the aortic arch

Hypoplastic Left Heart Syndrome

A clinical spectrum that is characterized by hypoplasia of the left ventricle, severe mitral valve stenosis or atresia, or severe aortic valve stenosis or atresia, and hypoplastic ascending aorta and transverse aortic arch

Tetralogy of Fallot (4 defects)

A congenital heart defect including: VSD Right ventricular hypertrophy

(thickening of the muscle walls of the right ventricle due to the increased pressure in the RV). Causes a characteristic boot shaped appearance on x-ray.

Right ventricular outflow tract obstruction (pulmonary arterial stenosis or pulmonary atresia which creates an obstruction of blood flow from the right ventricle to the pulmonary artery)

Overriding aorta (the aortic valve is enlarged and appears to arise from both the left and right ventricles instead of the left ventricle only).

Truncus Arteriosus

Characterized by a single arterial trunk arising from the normally formed ventricles by means of a single semilunar valve (ie, truncal valve).

Total Anomalous Pulmonary Venous Return

Drainage of all the pulmonary veins is into the right atrium either directly or by way of the systemic veins.

Ebstein’s Anomaly

An abnormality of the tricuspid valve where two leaflets of the valve are displaced downward into the right ventricle and the third leaflet is elongated and may be tethered to the wall of the chamber

Transposition of the Great Arteries

Arises when the aorta arises from the right ventricle and ejects deoxygenated blood to the body; the pulmonary artery arises from the left ventricle and recirculates oxygenated blood to the lungs

Tricuspid Atresia

Congenital absence or agenesis of the tricuspid valve

Pulmonary Atresia

A complete agenesis of the pulmonary valve which prevents blood from flowing forward from the right ventricle to the lungs.

Less than or equal to 1000 grams

or

Between 23 weeks to 28 6/7 weeks gestation

(inclusive)

Day 0-7

Start isolette humidity level at 75%-85% the higher value reserved for the 23 week -25 week neonate & the lower value reserved for the neonate above 26 weeks gestational age).

Day 8 Gradually reduce isolette humidity level to achieve final goal of 50%. Proceed to wean over 20 hours by reducing humidity level by 5% every 4 hours.

To ensure tolerance to changing humidity levels, measure and document temperature every 3 to 4 hours. If axilla temperature unstable, check temperature every 2 hours.

Maintain 50% humidity until neonate attains 32 weeks corrected gestational age, and then stop.

1001 grams to less than or equal to 1500 grams

or

Between 29 weeks to 31 weeks gestation

(inclusive)

Day 0-7

Start isolette humidity level at 70%

Day 8 Gradually reduce isolette humidity level to achieve final goal of 50%. Proceed to wean over 20 hours by reducing humidity level by 5% every 4 hours.

To ensure tolerance to changing humidity levels, measure and document temperature every 3 to every 4 hours. If axilla temperature unstable, check temperature every 2 hours.

Maintain 50% humidity until neonate attains 32 weeks corrected gestational age, and then stop.

If temperature instability occurs repeatedly during weaning of humidity, advise Neonatal medical team.

Exceptions may occur in the ELBW infants. If the neonate does not tolerate the humidity weaning (hypothermia, weight loss, hypernatremia) the neonate could be left at 75% with weekly reassessment of humidity level, (a medical order is required).

In case of hypernatremia, and/or weight loss, the humidity, should be raised, (this requires a medical order).

Humidity above 85% is no longer recommended; it can increase risk of infection and prolong the skin maturation process in the ELBW infant. Maintain ISC* Isolette Servo Control mode while neonate in humidity. Monitor and document humidity, skin temperature (ISC *probe), and isolette environment temperature.

Recommended Isolette Humidity Levels

Preemie Care

Please respect the preemie's environment

1. Follow humidity guidelines in care plans.

2. When providing routine care, change linens if damp.

3. It is essential that the isolette dome remain closed, so please provide care via the portholes. If needed, use the "Boost Air" button and lower the side door. The Boost Air option provides a heat wall that lasts 20 minutes.

4. Follow bath guidelines closely! The preemies skin will absorb products and the soap/lotion may cause skin burns. Please do not rub skin, but dab gently.

5. Do not use 2% CHG wipes if the preemie was born at less than 1000 grams OR less than 4 weeks of age.

6. Try to position the preemie as if they were still in the womb! Positioning can make all the difference in motor development in later life.

7. Offer kangaroo care whenever possible!

ABBREVIATIONS

ABR Auditory brainstem response Réponse du potentiel évoquéASD Atrial septal defect Malformation du septum auriculaireBPD Bronchopulmonary dysplasia Dysplasie bronchopulmonaireCBC Complete blood count Formule sanguine completeCBG Capillary blood gas Gas sanguine capillaireCDH Congenital diaphragmatic hernia Hernie diaphragmatique congénitaleCPAP Continuous positive airway pressure Pression d’air positive continueCR Case room Salle d’accouchementC/S Caesarean section CésarienneCSF Cerebrospinal fluid Liquide céphalo-rachidienCVS Cardiovascular system Système cardio-vasculaired/c Discontinue; discharge Cessé; congeDIC Disseminated intravascular

coagulationCoagulation intravasculaire disséminée

DLMP Date of last menstruation period Date des dernières menstruationsDOB Date of birth Date de naissanceECG/EKG Electrocardiogram ÉlectrocardiogrammeECMO Extra corporeal membrane

oxygenationOxygénation par membrane extra-corporelle

EDC/EDD Expected date of confinement/delivery

Date probable d’accouchement

EEG Electroencephalogram ÉlectroencephalogrammeEGD Esophagogastroduodenoscopy OesophagogastroduodénoscopieENT Ear-nose-throat Otho-rhino-laringologie (ORL)ETA Endotracheal aspirate Aspiration endotrachéaleET tube Endotracheal tube Tube endotrachéaleFiO2 Fractional inspired oxygen Fraction d’oxygène inspireFLK “Funny looking kid” syndromeFT Full term À termeFUO Fever of underterminate origin Fièvre d’origine indéterminéeGE Gastroenteritis Gastroentérite

GER Gastroesophageal reflux Reflux gastroesophagienGI Gastrointestinal system Système gastrointestinalGPA Gravida-para-abortion Gravida-para-abortionGU Genito-urinary system Système génito-urinaireHBF Fetal hemoglobin Hémoglobine foetaleHBP High blood pressure Hypertension artérielleHC Head circumference Circonférence crânienneHCTZ Hydrochlorothiazide HydrochlorothiazideHDN Hemolytic disease of the newborn Maladie hémolytique du nouveau-néHR Heart rate Rythme cardiaqueIA Intra-arterial Intra-artérielIBD Inflammatory bowel disease Maladie inflammatoire intestinaleICP Intra-cranial pressure Pression intra-crânienneIDM Infant of diabetic mother Enfant d’une mere diabétiqueI & O Intake and output Ingesta-excretaIUFD Intrauterine fetal death Mort foetale intra-utérineIUGR Intrauterine growth retardation Retard de croissance intra-utérinIVF In vitro fertilization Fertilisation in vitroIVH Intraventricular hemorrhage Hémorragie intraventriculaireIVSH Intraventricular septal hypertrophy Hypertrophie du septum ventriculaireKVO Keep vein open Tenir veine ouverte (TVO)LBW Low birth weight Petit poids de naissanceLFT Liver function test Test de fonction hépatique

LGA Large for gestational age Gros pour l’âge gestationnelLIH Left inguinal hernia Hernie inguinale gaucheLP Lumbar puncture Poncture lombaireLVF Left ventricular failure Insuffisance ventriculaire gaucheLVH Left ventricular hypertrophy Hypertrophie ventriculaire gaucheMAS Meconium aspiration syndrome Syndrome d’aspiration méconialeMRI Magnetic resonance imaging Imagerie par resonance magnétiqueNEC Necrotizing enterocolitis Entérocolite nécrosanteNG Nasogastric NasogastriqueNJ Nasojejunal NasojéjunalNKA No known allergies Pas d’allergies connuesNT Naso-tracheal Naso-trachéal

OAE Otho acoustic emission Émission otho-accoustiqueOB Occult blood Sang occulteOOP Out on pass Congé medical temporaire (CMT)PAB Premature atrial beat Battement premature des oreillettesPAC Premature atrial contraction Contraction premature des oreillettesPDA Patent ductus arteriosus Persistance du canal artérielPFT Pulmonary function test Test de function pulmonairePPHN Persistent pulmonary hypertension of

newbornHypertension du nouveau-né

PRBC Packed red blood cells Culot sanguinPrem Premature PrématuréPTX Pneumothorax PneumothoraxPVC Premature ventricular contractions Contraction premature des ventriculesR/A Room air Air ambientRbc Red blood cells Globules rougesRDS Respiratory distress syndrome Syndrome de détresse respiratoireROP Retinopathy of prematurity Rétinopathie du prematureRR Respiratory rate Rythme respiratoireRS Reducing substances Substances réductricesSGA Small for gestational age Petit pour l’âge gestationnelSIDS Sudden infant death syndrome Syndrôme de mort subite du nouveau-

néTEF Tracheo-esophageal fistula Fistule trachéo-oesophagienneTGV Transposition of great vessels Transposition des grands vaisseauxTOF Tetralogy of Fallot Tétralogie de FallotTORCH Toxoplasmosis, rubella,

cytomegalovirus, herpesToxoplasmos, rubéole, cytomegalovirus, herpes

TPN Total parenteral nutrition Alimentation parentérale totale (IV)TTN Transitory Tachypnea of the newborn Tachypnée du nouveau-néVCUG Voiding cystourethrogram Cystouréthrogramme mictionnelVSD Ventricular septal defect Malformation du septum ventriculairewbc White blood cells Globules blancheswt Weight Poidsx-match Crossmatch Crossmatch

GUIDELINES FOR FEEDING SCHEDULESRational: To ensure that the patient receives an appropriate caloric distribution between carbohydrates, protein and fat during the weaning of parenteral nutrition and the progression of enteral feeds.

The following are proposed guidelines regarding the decrease of the amino acid solution and fat emulsion solution infusion rates. Please remember that these are GUIDELINES and should be adjusted based on the baby’s tolerance.

Feeding schedules should be ordered q 1 hour (continuous drip), q 2 hours or q 3 hours.

- For continuous feeds (q 1 hour): Feeds are usually initiated at 1ml/hr and are progressed according to the frequency and number of

days of the feeding schedule determined by the medical team (ie: increase by 1 ml/hour q day, q 12 hours or q 8 hours, etc.)

- For q 2 and q 3 hours feeds:.

Follow Feeding protocol to progress feeds according to the frequency, number of days of the feeding schedule, determined by the medical team.

.How to wean Amino acid and Fat emulsion solutions :

Fat emulsion infusion is decreased by one quarter once baby is at 25% of full PO. Fat emulsion infusion is decreased by half once baby is at 50% of full PO. Fat emulsion infusion is decreased again by half once baby is at 75% full PO. As feeds increase, adjust the amino acid and fat emulsion solutions rate accordingly.

When progressing feeds for neonates you should always keep in mind that the optimal daily fluids must be 150 ml/kg/day if the formula concentration is 67-68 calories/100 ml. This volume is required in order to provide the patient with their minimum calorie requirements. If the fluids cannot be increased to 150ml/kg/day for medical reasons, then the calorie density of the formula should be increased. Fortification of breastmilk or fortified formula should be tried only when the babies are up to at least 100ml/kg/day. ( Recommendation of feeding protocol 2013 )

If neonates are on an Omegaven and Intralipids infusions, the nutritionist will determine the progression of weaning for both lipids and Omegaven.

If neonates are receiving Vivonex, fat emulsion solutions should not be decreased.

Refer to the feeding protocol for guidelines regarding trophic feeds

We still need a medical order to initiate trophic or nutritional feeds. The table 2 of the initiation and progression of feeds is a guide that does not work for all neonates. For example neonates who have had intolerances, surgeries (especially abdominal), NEC, reflux, HIE,etc.

Horaire d’alimentationFeeding schedule

TFI : 150 cc/kg/day X 2.8 kg = 420 cc/day TOTAL

DATE(YYYY/MM/DD)

HOURS PO(ml/24hrs)

AMINOSYN(ml/24hrs)

LIPIDS(ml/24hrs)

3 days 5 days NPO 15.8 ml/hr 1.7 ml/hr

09 – 12 09 – 12 – 15 3 ml 15.0 ml/hr 1.7 ml/hr

15 – 18 18 – 21 – 00 6 ml 14.0 ml/hr 1.7 ml/hr

21 – 00 03 – 06 – 09 9 ml 13.0 ml/hr 1.7 ml/hr

03 – 06 12 – 15 – 18 12 ml 12.0 ml/hr 1.7 ml/hr

09 – 12 21 – 00 – 03 15 ml

(+/- 25% of full PO)

11.4 ml/hr 1.3 ml/hr

15 – 18 06 – 09 – 12 18 ml 10.4 ml/hr 1.3 ml/hr

21 – 00 15 – 18 – 21 21 ml 9.4 ml/hr 1.3 ml/hr

03 – 06 00 – 03 – 06 24 ml 8.4 ml/hr 1.3 ml/hr

09 – 12 09 – 12 27 ml

(+/- 50 % of full PO)

7.8 ml/hr 0.85 ml/hr

15 15 – 18 30 ml 6.8 ml/hr 0.85 ml/hr

18 21 – 00 33 ml 5.8 ml/hr 0.85 ml/hr

21 03 – 06 36 ml 4.8 ml/hr 0.85 ml/hr

00 09 – 12 39 ml

(+/- 75% of full PO)

4.2 ml/hr 0.43 ml/hr

03 15 – 18 42 ml 3.2 ml/hr 0.43 ml/hr

06 21 – 00 45 ml 2.2 ml/hr 0.43 ml/hr

09 03 – 06 48 ml 1.2 ml/hr 0.43 ml/hr

12 09 53 ml D/C D/C

Full PO = 53 cc q 3 hrs Type of formula : BM – Enf. 67

EXAMPLE

for babies > 1 800 grams

PTI (TNP) Examples

Example 1PTI NOT IN PTI NURSING NOTES

DAY 1: Reason for

admission: R/O choanal

stenosis Condition:

RA B/G

breastmilkDAY 2

Sedation for CT-scan

R/O choanal stenosis

Pain scale

Sedation and test (évènement ponctuel)

Pain score Condition of the

patient

Sedation and test. Condition during and after the test.

Example 2PTI NOT IN PTI NURSING NOTES

DAY 1: Reason for

admission: Bowel

perforation Prematurity

Condition: Intubated prem SIMV 20 30% O2

Unstable with low BP

Dopamine and Fentanyl

PICC line Replogle LWS

Bowel perforation Prematurity

Intubation O2 parameters Ventilator

parameters Pain score Central line Sedation Inotropes

Conditions of the patient

Lines ETT

DAY 1 (LATER) Bowel surgery Replogle Fentanyl

Coartation of the aorta

PGE PIV Insertion of the

Procedures Condition PGE

Dopamine ETT PICC line

lines Intubation

Example 3PTI NOT IN PTI NURSING NOTES

Reason for admission:

Coarctation of the aorta

Condition: Stable in RA PGE PIV Insertion of

UVL-UAL Intubation for

apnea

Coarctation PGE PIV Insertion of the

lines Intubation

Procedures Condition PGE

The day after admission OR then 9D coming back on 9C 15 days later

Condition: RA Feeding C.D.

with NG Pacer wires Infected chest

wound

Coarctation repair Infected chest

wound (with treatment plan) (green sheet attach to TNP)

Condition Feeding Pacer wires

Condition Feeding Pacer wires Wound care

NICU Nursing Staff InfoIn the NICU nurses work 12 hour shifts and 8 hour shifts. The following information has been created based on the collective agreement to help you navigate the administrative departmental rules.

1. Scheduling The NICU utilizes self-scheduling which means each nurse has the opportunity to create their own 6 week schedule following the scheduling guidelines below.

You must create your schedule in the template within the specified time period, typically 3 weeks. Note only one person can work on the schedule at a time.

How to enter your schedule:

Step 1: The AHN will open the self-schedule template located on the computer in the Blue Station. Open the folder called Self-Schedule. On the upper left corner click on is a button called Log-in as shown below.

A pop up grid will open asking you for your employee number, you use it to log-in and enter your schedule. Once the schedule is completed, click on log-out icon located on the left upper corner. The file will automatically save your entry and close.

Step 2: Nurses will have a period of 3 weeks to enter their desired schedule Full time hours is equal to 75 hours per two weeks. Part-time nurses should only fill the hours of their position at this step.

Legend

Shift Code to Place in TemplateDays 12 hours D 12Days 8 hours D8Evening 8 hours E8Nights 12 hours E2 & NNights 8 hours N 8Vacation VStatutory Holiday SHUnavailable shifts X

Step 3: After the first round (3 weeks) have passed and nurses have entered their schedules into the template, the AHN will close the schedule to review for 4 to 5 days. The schedule is then returned to the nurses for a second round. During this period the nurses are to look at the numbers of staff located on top of schedule and attempt to balance with the unit quotas.

At this point the part time nurses can add extra shifts up to full time hours. Also, all nurses can fill out an availability sheet if they wish to pick up extra shifts (straight time or over time), found in the availability binder. This sheet is to be submitted to the AHN for approval before being placed in the availability book.

Step 4: After the second round of schedule review (2 weeks) the AHN will adjust the final shifts to ensure a balanced schedule is maintained.

Step 5:The final electronic schedule is posted, emailed to the staff and a paper copy is available in the black binder. After the final schedule is posted, you have may exchange shifts using the procedure below.

Guidelineso Please ensure you have scheduled the required hours as per your position. Full time: 20- 12

hour shifts per a 6 week schedule and or 30- 8 hour shifts.o You are allowed to put one X per 2 weeks for a maximum total of 3 per 6 week rotation. We

will try our best not to schedule you on the days that are noted as X.o Weekend staffing quotas must be respected. You must schedule yourself 1 weekend out of 2

for a total of 3 weekends per 6 week rotation. You may replace a weekend with another but if the numbers are not balanced out, we will return you to your original weekend to balance them.

o Respect the 50% ratio of nights and days o We recommend no more than 3x 12 hours shift in a row, if this can not be avoided exceptions

will be evaluated o Do not place stats after a vacation to extend your time.o Maintain a minimum of 12 hours between shifts ( do not schedule yourself nights and then an

evening the day after)

For any question please email the AHN’s or call Sophie (25080) or Firas (23762)

2. Shift ExchangesAny exchanges between staff members once the official schedule is out must be authorized by the AHN. You must fill out a pink exchange form and submit the pink form to the AHN for approval. Once approved, the change will be indicated on the schedule. Please ensure the person you are exchanging with has a similar experience level, and the change fits into their schedule respecting the guidelines above. (Nursing Assistants should contact Mireille)

3. Sick CallsAll fulltime employees have 9.6 (8-hour days) paid sick days in their sick day bank per year. Part time employees do not have a sick bank. In order to ensure adequate staffing on the unit at all times, sick calls should be made at least 4 hours prior to the shift when possible. Calls should go to the AHN or the unit extension 514-934-1934 extension 22389 and or nurse in charge (25649) and you must also call the Nursing Resource Manager at extension 23097.

4. Overtime If you are required to do overtime (unable to take your coffee and meal breaks or you are required to stay beyond your working shift, you must notify AHN or Nurse in charge on nights prior to doing the overtime. You should fill out an overtime and additional work shift payment form found at the front desk and final approval will be done by the Head Nurse. This sheet is then given to the administrative technician who puts it into the payroll.

5. AvailabilityIn order to staff the unit adequately staff members can put themselves available to work additional shifts. If you are part time you can complete your hours up until full time hours at straight time. Any hours over fulltime hours will be paid at time and a half. Fill out the availability forms found in the schedule binder and the availability will be chosen according seniority and overtime is done on “tour de role” while privileging straight time shifts first.

6. Statutory HolidaysThe MUHC has 13 (8 hour) statutory holidays which can be accumulated to a maximum of 5. Note during popular vacation timeframes, vacation days will have priority over statutory holidays.

7. Vacations After you have worked for a year you are entitled to have paid vacation which is indicated on your pay slip. Twice a year you will be asked to fill out a vacation request slip and hand into the administrative technician (Claude) in room B06 3822. Questions should be directed to the administration technician at 23378.

8. LockerEach employee will be granted a locker that is shared with another co-worker. Locks will be supplied.

9. NRP: Neonatal Resuscitation ProgramCertification for NRP is required to work in the NUCU and would be scheduled every 2 years and is provided by the NICU instructors.

10. Mock CodesIn order to ensure ongoing training and practice for neonatal codes, Mock Codes will be held every Thursday with an interdisciplinary team. You will be notified the day before of your participation.

FLUID AND MEDICATIONS EXERCISES1. Baby A weighs 1.2 kg. He was born this morning. He is NPO. His fluids

are at 65 mL/kg/day. What type of maintenance should he be on and what rate?

2. BB B was asphyxiated at birth. His apgars where 0 (at birth), 5 (at 5 minutes) and 7 (at 10 minutes). He is 2 days old. He weighs 3.4 kg. He receives 170 mL/day of fluid. His maintenance is standard amino.

a. What should his maintenance be running at?

b. How many mL/kg/day is he receiving?

c. Is he receiving enough fluid?

3. BB C weighs 3.5 kg. He is NPO. He is receiving TPN via a single PICC line and is newly receiving Tobramycin Q24H and Ampicillin Q6H. His SMOF are ordered at 2.2 mL/hr over 24hrs and amino acid at 17.4 ml/hr. He is on 120 mL/kg/day. Should the SMOF really be running over 24 hrs? What should the amino acid be running at?

4. BB D has only 1 IV. He receives caffeine twice a day. Caffeine is given IV slow push, over 3-5 minutes, after the loading dose (which he has already received). He is NPO. He weighs 4.1 kg. He is on TPN and his fluids are at 130 mL/kg/day. Should you turn off the TPN (amino acid and/or SMOF?) to give the caffeine? His SMOF are ordered at 3 g/kg/day. What should his amino acid & SMOF be running at?

5. You have an order to start Lasix IV. The order is written as follows: “Please give 1 mg/kg Lasix Q12H”. Your baby weighs 2.7 kg. Lasix vial concentration is 10 mg/mL.

a. What information is missing from this order?

b. What is the actual dose of Lasix that your baby should be getting?

c. You are then asked to prepare the dose and administer it right away, how much Lasix do you draw up?

6. BB E born term was admitted for seizures. He is 3 days old and weighs 3.5 kg. Ampicillin was ordered at 100 mg/kg/dose Q8H, and Tobramycin was ordered at 5 mg/kg/day Q12H.

a. Is the dose and frequency of these medications correct?

7. BB F began to have seizures this morning; he was loaded with 20 mg/kg of Phenobarbital. Pheno vial concentration is 30 mg/mL. He weighs 3.1 kg and is not intubated. Find the recipes for dilution binder, and describe how the pheno would have been given. How would you program the pump?

8. BB G is on Hydrochlorothiazide 3 mg/kg/day and Spironolactone at 3 mg/kg/day. He weighs 3.1 kg. He receives both these meds Q12H. What is the dose that you are giving him in mg Q12H?

9. BB H weighs 2.7 kg, is 5 days old, and is NPO. He is being treated for a severe central line sepsis. The antibiotic is Vancomycin 15 mg/kg/dose Q12H. He has one line. His fluids are running at 130 mL/kg/day. He should be receiving 45.6 mL of lipids per day. Calculate the rate of your amino acid and lipids?

10. BB I is on TPN. His fluids are at 150 cc/kg/day and he weighs 2.8 kg. He will be started on a three day feeding schedule. Plan his feeding schedule given that the lipids are running at 1.7 cc/hr.

11. BB J is on Piperacillin-Tazobactam 75 mg/kg/dose Q8H. He weighs 2.3 kg. How fast are you going give the dose? What is the volume to be infused on your pump? Should you turn off the amino acid? And the SMOF?

FLUID AND MEDICATIONS EXERCISES - ANSWERS

1. Baby A weighs 1.2 kg. He was born this morning. He is NPO. His fluids are at 65 mL/kg/day. What type of maintenance should he be on and what rate?Standard amino (0/0) 3.3 mL/hr

2. BB B was asphyxiated at birth. His Apgars where 0 (at birth), 5 (at 5 minutes) and 7 (at 10 minutes). He is 2 days old. He weighs 3.4 kg. He receives 170 mL/day of fluid. His maintenance is standard amino.

a.What should his maintenance be running at? 7 mL/hrb.How many mL/kg/day is he receiving? 50 ml/kg/dayc..Is he receiving enough fluid?A 2 day old BB should be receiving 80 mL/kg/day, but because of the HIE the doctor will probably restrict his fluids

3. BB C weighs 3.5 kg. He is NPO. He is receiving TPN via a single PICC line and is newly receiving Tobramycin Q24H and Ampicillin Q6H. His SMOF are ordered at 2.2 mL/hr over 24hrs and amino acid at 17.4 ml/hr. He is on 120 mL/kg/day. Should the SMOF really be running over 24hr? What should the amino acid be running at? Lipids should be recalculated over 23.5hrs and it will still run at 2.2 ml/hr. Amino acid should run at 15.3 ml/hr.

4. BB D has only 1 IV. He receives caffeine twice a day. Caffeine is given IV slow push, over 3-5 minutes, after the loading dose (which he has

already received). He is NPO. He weighs 4.1 kg. He is on TPN and his fluids are at 130 mL/kg/day. Should you turn off the TPN (amino acid and/or SMOF?) to give the caffeine? His SMOF are ordered at 3 g/kg/day. What should his amino acid & SMOF be running at? His total fluids are 533 mL. SMOF and amino acid must be stopped for 3-5 minutes while the caffeine is pushed through the med port. So SMOF will infuse at 2.56 ml/hr (can be rounded up to 2.6) over 24hrs and the A.A. solution will infuse at 19.6 ml/hr over 24hrs.

3g/kg/day x 4.1kg (wt)= 12.3g/day12.3g/day x 5 (Lipids are 20%) = 2.56ml/hr

24

5. You have an order to start Lasix IV. The order is written as follows: “Please give 1 mg/kg Lasix Q12H”. Your baby weighs 2.7 kg. Lasix vial concentration is 10 mg/mL.

a. What information is missing from this order? Total mg per dose. The route: IV.

b. What is the actual dose of Lasix that your baby should be getting? 2.7 mgc. You are then asked to prepare the dose and administer it right away, how much

Lasix do you draw up? 0.27 ml

6. BB E born term was admitted for seizures. He is 3 days old and weighs 3.5 kg. Ampicillin was ordered at 100 mg/kg/dose Q8H, and Tobramycin was ordered at 5 mg/kg/day Q12H. Is the dose and frequency of these medications correct? Tobramycin should be at 5 mg/kg/day but Q24HThe ampicillin meningitis dose recommended is 100mg/Kg but Q6hrs

7. BB F began to have seizures this morning; he was loaded with 20 mg/kg of Phenobarbital. Pheno vial concentration is 30 mg/mL. He weighs 3.1 kg and is not intubated. Find the recipes for dilution binder, and describe how the pheno would have been given. How would you program the pump?

Max final concentration for pheno in binder is 10 mg/mL. To make a solution of 10mg/mL, you will first take 1 ml (=30mg) from the vial and mix it with 2 mL of NS (=30mg/total volume of 3 mL). From this solution, you will draw up 62 mg = 6.2 mL of medication. You will then prime your medication tubing and

administer over 30 minutes if your patient is not intubated, and slow push if your patient is intubated. If you give the medication by syringe pump, your VTBI is 6.2 + 0.5 mL = 6.7 mL, and your rate will be over 30 minutes (therefore 6.7x2 = 13.4 mL/hr).

8. BB G is on Hydrochlorothiazide 3 mg/kg/day and Spironolactone at 3 mg/kg/day. He weighs 3.1 kg. He receives both these meds Q12H. What is the dose that you are giving him in mg Q12H?4.7 mg of HCTZ and 4.7 mg of Spiro for each dose

9. BB H weighs 2.7 kg, is 5 days old, and is NPO. He is being treated for a severe central line sepsis. The antibiotic is Vancomycin 15 mg/kg/dose Q12H. He has one line. His fluids are running at 130 mL/kg/day. He should be receiving 45.6 mL of SMOF per day. Calculate the rate of your amino acid and SMOF?Total fluids = 351 mL/dayAmino = 12.72 mL/hrSMOF = 2.07 mL/hr (over 22 hrs), as SMOF not compatible with vanco and must be turned off for one hour each time (it is given over 1 hour)

10. BB I is on TPN. His fluids are at 150 cc/kg/day and he weighs 2.8 kg. He will be started on a three day feeding schedule. Plan his feeding schedule given that his SMOF are running at 1.7 cc/hr.See feeding schedule example.

11. BB J is on Piperacillin-Tazobactam 75 mg/kg/dose Q8H. He weighs 2.3 kg. The concentration is 50 mg/ml.

A.How fast are you going to give the dose? Over 30 minutes (rate = 8 mL/hr). B.What is the volume to be infused on your pump? 4.0 ml (3.5 ml + 0.5 ml for the tubing). C.Should you turn off the amino acid? No, it is compatible with amino acid. D.And the SMOF? Yes, it is not compatible with SMOF.

REVIEW QUESTIONS PHASE I

1. What is the maximum concentration of potassium (KCl) that you can infuse in mEq/L?

a. In a peripheral vein?

b. In a central vein?

2. How would you lock a PIV versus a UVL line.

3. What is the maximum concentration of dextrose you can give?

a. In a peripheral vein?

b. In a central vein?

4. What is the normal value for pCO2?

What is the normal value for pH?

What is the normal value for HCO3?

5. You have a baby with a blood gas of pH: 7.29, CO2: 69, HCO3: 23. What’s wrong?

6. Your baby is receiving a continuous drip gavage of Enf. 67 at 15cc/hr by NG. Suddenly your monitor alarms…the baby’s sat is 71% and his HR is 86. When you look at your baby he is slightly dusky and he has some milk coming from her nose. What do you do?

7. How often should you change a PICC dressing?

When do you draw a blood culture from a PICC line?

8. A doctor verbally tells you to do a CBC on a baby. What steps do you take?

9. How often should you change an isolette?

10. How long is FRESH breastmilk good for in our fridge?

FRESH fortified breastmilk?

Once thawed?

In the parent’s freezer at home?

11. How long is milk good once open at room temperature? How long is milk good once it is heated up?

12. Name at least 10 causes of Apneas?

1. 6. 2. 7. 3. 8. 4. 9. 5. 10.

13. How often should you check an I.V. site infusing?

14. When should the PKU blood be drawn?

When should the PKU urine be done?

15. How often should you change an NG tube?

How often should you change an NJ tube?

16. You have a baby on PGE who had TGV. What should your blender be set at to deliver oxygen through his mask? And why?

17. If your baby is on NO, what should your blender be set at?

18. At what level should your suction be set at for suctioning your baby’s nose, mouth and ETT?

What should the suction be set at for a replogle to LWS?

Can you use the same suction tubing?

19. Over how long would you give? Is it compatible with amino acid and SMOF?

a. Vancomycin?

b. Lasix?

c. Dilantin?

20. How often should you change the milk when you have a syringe on a continuous drip?

What about the tubing? ___

21. In what tube would you put your specimen to send for and what is the minimum quantity:

d. CBC?

e. BUN, creatinine?

f. PT, PTT?

g. Vancomycin level?

h. Liver function test?

i. Bilirubin?

22. What tests are included in LFT’s (there are 6 of them)?

1. 4. 2. 5. 3. 6.

23. Name three (3) essential things to review when taking a 1:1 report.

1. 2. 3.

24. How often do you change IV tubings & microclaves? SMOF tubing?

Solution with Heparin added (Hep ½ NS)?

Solution with nothing added (D5W)?

Kangaroo extension set?

25. When and where do we swab babies for MRSA/VRE?

26. What is the amount of Heparin you should add to prepare a heparinized solution?

j. Baby 1,500g

k. Baby 1,500 g

27. If baby A has seizures, what kind of bed should he/she be in? Why?

28. If baby B is on phototherapy (lamp), what important adjustment should you make?

29. What special care does the baby need?

30. What are 3 signs of reflux?REVIEW QUESTIONS PHASE I - ANSWERS

1.What is the maximum amount of potassium (KCl) that you can infuse in mEq/L?

a. In a peripheral vein? 60 mEq/L

b. In a central vein? 120 mEq/L

2.How would you lock a PIV versus a UVL line.PIV: 1 mL NS IV q6h + PRNUVL: Flush with 1mL NS, then lock with 1 mL 10u/mL heparin IV q12h + PRN to a maximum of 4x/day

3.What is the maximum concentration of dextrose you can give?

c. In a peripheral vein?12.5%

d. In a central vein?20%

4. What is the normal value for CO2? 35-45

What is the normal value for pH? 7.35-7.45

What is the normal value for HCO3? 22-26

5. You have a baby with a blood gas of pH: 7.29, CO2: 69, HCO3: 23. What’s wrong?Respiratory acidosis non-compensated.

6. Your baby is receiving a continuous drip gavage of Enf. 67 at 15cc/hr by NG. Suddenly your monitor alarms…the baby’s sat is 71% and his HR is 86. When you look at your baby he is slightly dusky and he has some milk coming from her nose. What do you do?1. Stop the gavage2. Suction + give O2 free flow3. Flow NRP guidelines4. Verify NG placement

7. How often should a PICC dressing be changed?PRN Max q 14 days

When do you draw a blood culture from a PICC line? Signs of infection

8. A doctor verbally tells you to do a CBC on a baby. What steps do you take?

Have physician enter order in to Oacis.Print label by “submitting”.Collect specimen Clear order by submitting again

9. How often should you change an isolette?q week

10. How long is FRESH breastmilk good for in our fridge? 48 hrs

FRESH fortified breastmilk?24 hrs

Once thawed? 24 hrs

In the parent’s freezer at home? 12 months for deep freezer; 3-6 months for regular fridge freezer

11.How long is milk good once open at room temperature? 4 hrs

How long is milk good once it is heated up? 1 hr

12.Name at least 10 causes of apnea

1. RDS 7. Seizures2. Hypothermia 8. Central hypoventilation (Ondine’s curse)3. Prematurity 9 On continuous PGE drip .

4. Accressory muscle fatigue 10. Brain injury (edema, bleed)

5. Reflux (gastric problems) 11. Brain malformation 6. Infection (meningitis, sepsis, etc) 12. Certain metabolic disorders

13.How often should you check an I.V. site infusing?q hr with pump level

14.When should the PKU blood be drawn? 24-48 hrs

When should the PKU urine be done? 21 ays

15.How often should you change an NG tube?

q month for long-term (the blue one), q 3 days for the green one and 1 day for the short-term

How often should you change an NJ tube?Never (to be removed with medical order)

16.You have a baby on PGE who has a TGV. What should your blender be set at to deliver oxygen through his mask? And Why?Maximum 30% (O2). High Fi02 concentration can promote the closure of the ductus arteriosus

17.If your baby is on NO, what should your blender be set at?Minimum 30% (O2)

18.At what level should your suction be set at for suctioning your baby’s nose, mouth and ETT?110 mmHg, as per VAP protocol

What should the suction be set at for a replogle to LWS? 40 – 60 mmHgCan you use the same suction tubing?No. You need three set-ups: one for the repogle, one for the ETT and one for the Little Sucker (to be changed daily by the bedside RN)

19. Over how long would you give? Is it compatible with amino acid and/or SMOF?

o Vancomycin?Over 1 hr, compatible with amino acid only.

o Lasix? Slow push over 5 to 10 minutes. It is important to give it SLOW push to prevent risk of hypotension and hearing loss. Stop amino acid for the time you give your dose. Compatible with SMOF.

o Dilantin?Over 30 minutes. Use the in line filter (001248) connected after your IV tubing. Only compatible with NS.

20.How often should you change the milk when you have a syringe on a continuous drip? What about the tubing?Syringe q 4 hrs and tubing q 12 hrs

21.In what tube would you put your specimen to send for and what is the minimum quantity:

o CBC?Lavender – 375 to 500 ul

o BUN, creatinine Yellow – 400 ul

o PT, PTT?Blue citrate tube – 1.8 mL (to the line) (mark with hepabsorb label if heparin in patient)

o Vancomycin level?Yellow – 400 ul

o Liver function test?Yellow – 400 to 450 ul

o Bilirubin?Yellow – 400 ul. *Protect from light; turn bili lights off prior

22.What tests are included in LFTs (there are 6 of them)?1. Bilirubin Total 4. ALT

2. Bilirubin Direct 5. AST3. GGT 6. Alkaline phosphate

23. Name three (3) essential things to review when taking a 1:1 report.

1. SAFE2. Medical orders in chart3. Oacis orders

24.How often do you change IV tubings and microclaves?q 96 hrs

SMOF tubing?q 24 hrs

Solution with Heparin added (Hep ½ NS)?q 24 hrs

Solution with nothing added (D5W)?q 96 hrs with tubing

Kangaroo extention set?q 24 hrs

25.When and where do we swab babies for MRSA/VRE?At admission; if patient is on antibiotics, repeat the swabs 1 week after stopping the abx.VRE: rectal swab or stoolMRSA: Nares, ETT aspirate, open wound, ostomy, urine (if foley or intermittent catheterizations), umbilicus (if 1 month old)

26.What is the amount of Heparin you should add to prepare a heparinized solution?

o Baby 1,500g0.5 u/mL

o Baby 1,500 g1 u/mL

27.If baby A has seizures, what kind of bed should he/she be in? Why?Isolette, not bundled, no pyjamas in order to see the patient doing abnormal movements. The same recommendation applies to any unstable patients.

28.If baby B is on phototherapy (lamp), what important adjustment should you make? Adjust by increasing fluids (to avoid dehydration) as per order.

What special care does the baby need?Cover eyes, change position frequently, put baby in isolette, do not apply creams or oil to skin.

29.What are signs of reflux?Vomiting, coughing, desats/brady with and after feeds, arching of back, irritability with and after feeds.

WARD TOUR – Treasure Hunt

OBJECTIVE: To become familiar with the ward's facilities

PLAN:

1. LOCATE THE FOLLOWING EQUIPMENT NEEDED TO SET-UP FOR AN ADMISSION IN NO ACUTE DISTRESS – FIND THEM IN THE PATIENT ROOM CART AND IN THE CSR:

• A clean Giraffe and an ISC probe• Linen, diapers, chix• White cribs, big cribs• A stethoscope• A thermometer• A wall suction canister• Suction catheters, sterile gloves• A small bottle of sterile water• Anesthesia bag and mask• Leads for cardiac monitor + probe for saturation• B-Braun pumps, syringe pumps • A blood pressure block + cable and blood pressure cuffs• An identification band + card• A chart; a medical chart and nursing chart• A scale• Measuring tape• Phototherapy light and biliblanket

2. LOCATE THE FOLLOWING EQUIPMENT NEEDED IN AN EMERGENCY:

• The emergency cart (in each section)• Wee light

3. LOCATE THE FOLLOWING ITEMS NEEDED FOR FEEDINGS:

• Breastmilk fridges (little, in rooms, and big, in milk room); freezer • Enfamil 67, 81, Enfamil lactose free, Enfamil premature 67, 81, Enfacare 74.• Pregestimil 67• Sterile water• Nipples, pacifiers• Feeding tubes #5, #8 NG tubes• Extension set for NG feeds• PO syringes• Breast pump (electric)• Breast feeding information for mothers• Breast pump kits• Blue pads

4. LOCATE THESE FOLLOWING MISCELLANEOUS ITEMS:

• Procedure carts• Formulary via Oacis; Neofax hard copy• Sterile/non-sterile urine containers• Blood culture bottles• The specimen fridge & specimen box• Pneumatic tube system – send something to someone!!• Nurse console phone• Special order cupboard (equipment ordered specially for NICU)• MRI tubing, pillow, and ear plugs• Code pink consoles in patient rooms• Items required to start IV • Sucrose• Carnet de santé• parents rooms and special family sleep rooms• fire cupboard – where Code Green Evacuation equipment is found• CSR procedure trays:

C.V. line – cut down tray umbilical lines & exchange transfusion tray for umb line insertion LP needles & trays chest tubes & trays exchange transfusion – disposable

5. Med Rooms:

• Individual patient boxes• Injectables – refrigerated• Injectables – not refrigerated• ADC machine• Location of heprinse syringes & NS posiflush syringes• Location of medication tubing• Supplies in med room drawers• Narcotic cupboard

6. LOCATE THE FOLLOWING ITEMS USED TO ASSIST WARD COMMUNICATION BETWEEN THE STAFF (THIS INCLUDES NURSES, DOCTORS, SOCIAL WORKERS, OTHERS) AND THE PARENTS:

• Procedure binders• Protocols on Intranet• Nursing communication book• Patient assignment board at each station• Patient checklist white board in conference room• PKU info – ask RNAs• General hospital telephone directory• List of commonly used phone numbers

• Lab book for phone results• Memento boxes and special gowns• Developmental care tools• PJs and blankets• Camera

7) There is a wide variety of stationary forms used on the ward. Expose yourself to them by going through an infant's chart. Note the different forms and check where such blank forms are kept.

8) COMPUTERS: The computers on the unit provide us with many services relating directly and indirectly to patient care. Find and open the following:

o Oaciso Tracelineo Infection control manual on portalo Policies and Procedures Page of portalo VSign

GUIDELINES FOR REPORT

1 : 1 REPORT: bedside RNs

- Complete head to toe report- Maternal history and reason for transfer- Resp.- C.V.S.- C.N.S.- G.I. / G.U.- Fluid management- Medications- Revision and initialing Md's orders (in paper and Oacis)- Plans and tests- Social- Special concerns

TL : TL REPORT:

- Detailed report required for new admissions- Changes and plans for babies already known- Discussion re: - elective transfers for the day/night

- reviewing staffing needs- patient population (O.R., tests, transfert to wards

return to reffering hospital etc.)

*** The baby is your responsability till the end of shift 07:38 or 19:38. If you need to leave before the end of shift with a justified reason, the charge nurse and or the team leader needs to be notified. It is also your responsability to make sure that a nurse in the room is covering your patients till the nurse coming on takes over. A 1:1 report needs to be given to this nurse by the one who is covering for you.

Revised Aug 2015

MEAL AND BREAK TIMESMeal and break times are given as follows:

• 8 hour day 30 mins. break45 mins. Meal

• 8 hour evening 45 mins. meal30 mins. Break

• 8 hour night 45 mins. meal 30 mins. Break

• 12 hour day 30 mins. break60 mins. lunch 25 mins. Supper (10 mins/supper & 15 mins/break)

• 12 hours night 25 mins. meal 60 mins. Meal (10 mins/supper & 15 mins/break)

30 mins. break• 4 hour (any shift) 15 mins. breakDAYS

Morning break times in the NICU are left to the team leader/bedside nurse's discretion according to the patient's needs.The TL and staff should determine break times according to the needs of the patients, and safe coverage of the room must be ensured at all times. NIGHTS Break times on evenings and nights are taken whenever it can be arranged according to the patient and ward needs. If it is a busy night, and some people will not be able to get their breaks, the charge nurse should contact the nurse supervisor as

early as possible (in case a float is available to help with coverage). Overtime owed to anyone missing all or part of their breaks must be authorized by the nursing supervisor.

ROUTINE - DAY DUTY07:15-19:40

1. When the nurse comes on shift, she/he should take report from night nurse caring for her/his patients. At this time, the infant's general condition is assessed.

2. The nurse is responsible for ensuring ALL equipment for the patient is working, ALL alarms are on and that the appropriate emergency equipment is available directly at the bedside. (ex. suction, mask and bag).

3. The RN leaving as well as the RN coming in should revise the doctor's orders for the last 12 hrs and countersigning these orders.

4. The RN leaving as well as the RN coming in should revise the doctor’s bloodwork orders in Oacis for the day. Orders that require cancellation, modification or countersignature will be brought up to the responsible physician/NNP by the day nurse.

5. Desinfect BB’s equipment with wipes.

6. Checks that all IV solutions at baby's bedside and rates on pumps are correct.

7. Plan nursing care for the day; coordinate all procedures, tests and examinations by others as much as possible in order to assure that the patient has as much rest as possible.

8. The nurse is responsible for changing the IV solutions and tubing q 96hrs for drips and TPN, and q24 hrs for lipids. When full line change performed, double checking policy is MANDATORY to ensure all clamps are open, rates and solutions are appropriate, and lines are placed as per protocol. The time of solution change and initials of both nurses must be written on the nursing flowsheet on page 6, below Parenteral Nutrition.

9. The nurse is responsible for changing suction tubings and little suckers for intubated patients q 24hrs (VAP protocol), and for non-intubated patients PRN (PCA will change q7days on Saturday). This is a shared duty between day and night to ensure that tubing change is done and marked with day-of-the-week sticker.

10.The nurse is responsible for changing the isolette q 7 days and the humidity bac q24hrs when in use. This is a shared duty between day and night to ensure that changes are done and marked with day-of-the-week stickers.

11.The nurse is responsible for changing the continuous-drip feeding set-up. The tubing must be changed every 12hrs for syringe tubings and every 24hrs for the Kangaroo tubings.

12.The nurse is responsible to up-date the Nursing Care Plan Worksheet AND the patient’s PTI she/he is caring for.

13.The nurse must ensure that the patient’s bedside area is tidy and well stocked for the

next shift (ie. diapers, suction catheters, etc)

ROUTINE - NIGHT DUTY19:15 - 07:38

7. 1-6. As listed in Day Duty responsibilities.

8. The nurse should then plan nursing care. This is very similar to daytime care as intensive care is around-the-clock care. However, ensure that the patients get (esp. long term pts.) as much sleep as is possible while delivering optimum care.

9. Follow standard of care for bath & “lingettes” as per protocol.

10. See 9-10-11-12-13 Day Duty

11. Patients are weighed and weights are recorded on the graphic sheet.

12. Cardiac monitor leads, temperature probes and saturation probes are repositioned or changed if needed (however, saturation probes need to be repositioned with every check on premature babies).

13. The nurse is responsible for changing suction tubings and little suckers for intubated patients q 24hrs (VAP protocol), and for non-intubated patients PRN (PCA will change q7days on Saturday). This is a shared duty between day and night to ensure that tubing change is done and marked with day-of-the-week sticker.

14. The nurse is responsible for changing the isolette q 7 days and the humidity bac q24hrs when in use. This is a shared duty between day and night to ensure that changes are done and marked with day-of-the-week stickers.

15. The nurse is responsible to calculate the 24 hr. differential fluid AND caloric totals and transfer them on the previous day's graphic record. (ie. on Nov. 7 you write the 24 hr. totals under Nov. 6). The 24 hour period used for charting and calculations is 00:01 hours to 00:00 hours.

16. The nurse is responsible for reset the volume of the pumps at midnight.

17. The nurse is responsible for maintaining blood work up to date. In the early morning, she/he is responsible to ensure that blood work ordered previously or routine blood work is done (ex. CBG, CBC, TPN blood work, etc.)

NICU INFECTION CONTROL POLICY - ISOLATION POLICY

The IC manual is available in cupboard at the front desk and on the Intranet

RATIONALE: Newborn infants (both preterm and term) do not have a fully developed immune system and are regarded as immunocompromised. All patients in the NICU are considered at high risk for infections and must be carefully protected from potential pathogens carried on hands or from the hospital environment.

GOAL: To prevent babies from acquiring infection;

• directly from each other (rubella, measles, etc..)• indirectly from each other (via staff, hands, equipment)• directly from staff (i.e. colds, gastroenteritis, etc.)

Each baby and its equipment (including the chart) are considered to be contaminatedwith organisms which could colonize and potentially cause infection in other babies.

1. HAND HYGIENE: Hand hygiene is the most effective way to prevent the spread of communicable diseases and other micro organisms from being transmitted to other human beings, equipment It can be defined as a vigorous, brief, rubbing together of all surfaces of lathered hands, followed by rinsing under running water.

a. BEFORE ENTERING THE NICU, ALL INDIVIDUALS MUST REMOVE THEIR RINGS, WATCHES AND BRACELETS AND WASH THEIR HANDS TO THE ELBOWS TO PREVENT THE SPREAD OF INFECTION.

b. Health care personnel assigned to the NICU (i.e. nurses, R.T., physicians) should wear short sleeved clothing or ensure that sleeves are rolled up above the elbows before entering the unit and when in contact with the newborn.

c. Keep fingernails clean and short (should not extend beyond fingertips). Do not wear artificial nails or extenders as they trap bacteria and are difficult to maintain clean. Nail polish should not be worn; if wearing nail-polish, you must wear gloves for all patient

contact and perform good hand hygiene prior to putting gloves on and after removing them. Do not wear jewellery (rings, bracelets). Forearms shall be uncovered to allow for proper hand hygiene.

If any individual has cold-like symptoms, she/he should wear a mask and gloves during patient care.

The mask should be changed when the mask is no longer dry (i.e., after sneezing, etc.) with attention to hand-washing after applying a new mask.

The routine use of gowns prior to entering the NICU is not necessary.

Food and drink (except water) is not permitted in the patient care area.

-INDICATIONS FOR HAND HYGIENE: FIVE MOMENTS See in Infection control manual on Intranet MUHC Portal

-CHOICE OF AGENTS See in Infection control manual on Intranet MUHC Portal

-HAND HYGIENE TECHNIQUE See in Infection control manual on Intranet MUHC Portal

2. GOWNING:

LONG SLEEVE GOWNS (ISOLATION GOWNS):

• Long sleeve gowns are used only for patients requiring isolation in which a gown is required (see appropriate infection control card for further information).

• In cases in which a long sleeved gown is required – every gown that has been worn once should be put in dirty laundry. Do not wear the same gown twice.

• Long sleeve gowns are not to be worn by staff to keep warm.

• Long sleeve gowns are kept outside of the isolation room. Only a minimum of gowns are stored here daily. When an infant is placed in isolation, in which a long sleeved (isolation gown) is called for, call the laundry daily for an adequate supply.

BLUE - SHORT SLEEVED GOWNS

• Blue gowns worn when holding an infant i.e. feeding a baby, only provide for protection against visible soiling of the caregivers clothing. These gowns have no benefit in the reduction of infections. The use of these gowns is not required by the hospital infection control committee.

• Staff should not be wearing gowns while walking around the unit or when there is contact involving other patients.

VISITORS:

Visitors are not required to wear a blue gown even if they plan on picking up the baby. If soiling of their clothing is very likely, you may offer them a gown but this is only suggested for rare cases.

3. ISOLATION TECHNIQUE:

When an infant is placed on "Isolation", an isolation card should placed on the patient’s door to identify what precautions need to be taken. The patient’s chart and his care plan binder should be kept strictly in the alcove. Theses documents are considered clean for all the isolation period. The isolation should be documented and followed through to the end of the isolation period.

NOTE: For tests off the unit, the receiving department must be notified regarding any patient who is on isolation.

ISOLATION ROOM VENTILATION (air flow)

There are three isolation rooms (66, 67, and 25).

A. For Positive Pressure– All three rooms can be used.

Positive Pressure is used for immunosuppressed patients requiring protective isolation.

• immune deficiency syndromes• pre-post transplants• other requiring protective isolation

B. For Negative Pressure – Only rooms 66 and 67 can be used.

Negative Pressure is used for airborne infections (known, suspected or contacts)

• chicken pox, pertussis, tuberculosis

4. EQUIPMENT

See protocol for cleaning equipment on unit in Infection Control Manual

5. VISITING POLICY AND INFECTION CONTROL:

Parents are welcome at all times. They should be informed regarding colds/diarrhea and precautions to take if they acquire such illness. Preferably, they should not visit if they present with an influenza-like1 illness during the Influenza season (December - April).

If they do come with a regular cold, they should be taught about using masks, handwashing, not touching face, nose, etc., and not to go near patients other than their own baby. When handling the baby, the individual should wear gloves and wash their hands after removal of the gloves.

Information about Books for Babies for staff members

Why read to a baby in an NICU? Babies recognize their parent’s voice from the womb, and reading to the baby can

reassure the baby that the parent is there. Reading may be something concrete and normal that the parent can do while the baby is

still ill. Reading may provide some intimacy for the family, and may help the parent feel closer

to their baby and involved in his/her life at this critical time. Reading may decrease the parental stress associated with an NICU admission. Reading is a high quality interaction and can stimulate neuron production in the brain, so

may be valuable to help with the baby’s development, especially for at risk neonates. Encourages the family to start a habit of reading, which has been shown to e extremely

important in improving future listening, language and reading skills.The intervention:

As soon as possible after the baby is admitted to the NICU, the nurse chooses a book in the family’s mother tongue from the library in the Developmental care tool’s room (in the Blue zone). Books are available in nearly 20 languages.

There is a bookplate inside the book and a letter to parents explaining the benefits of reading to the baby.

The nurse takes a Kleenprint Footprinter from the library, and imprints the baby’s foot print on the bookplate, fills tin the bookplate with the baby’s name and her name, and offers the book to the parent. She/he then makes a check mark in the box on care plan as a confirmation the family got the book.

The nurse suggests to the parent that she/he may want to read to the baby for a few minutes every day, and assists the family to do so, either reading at the bedside or port of the isolette, or holding the baby, as appropriate.

A new book is offered to the parent every month if the baby is admitted for a long period of time. The book goes home with the family at the time of discharge.

Revised April 2016

S:/Global-Share/MCH_NICU_Nursing/MartineChagnon/Nursing Performance Appraisal Form

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