When I was first starting out my NICU journey, I found it difficult to find reliable information on the NICU and the types of tasks NICU nurses were responsible for. In this blog, I’ve collaborated with NICU nurses from different facilities around the country to identify common shift patterns, workflows, and patient care duties. Here, I’ll answer some NICU nursing FAQs, explain some NICU nurse basics and review what we do on a daily basis. Let’s dive in!
What do NICU Nurses Do?
NICU nurses care for premature or critically ill newborns during their first few moments of life. We support their organ systems while they adjust to life outside of the womb and ensure they develop and mature appropriately. The complexity of care a facility offers depends on their NICU acuity level (Level I units provide the simplest interventions, and Level IV NICUs deliver the most intense).
In simple terms, we’re in the business of growing & healing the world's tiniest humans.
What are some concepts I’ll need to be familiar with?
No matter your NICU unit’s size or acuity level, there are certain concepts and terms you’ll need to be familiar with:
Measurements: Our patients are measured in grams & centimeters. We frequently measure head circumference, abdominal girth, length, and weight to ensure our patients are growing appropriately.
Gestational Age: In the NICU, the baby’s actual age isn’t the only factor that drives the care plan. We also consider their gestational age, meaning how old they are from the moment of conception. A baby that was delivered at 24 weeks would require completely different care interventions (feeding plan, respiratory support, medications, "touch times") from a baby that was delivered at 40 weeks (term), even if they were born on the same day.
Medications: NICU medications are often measured in tenths of mLs, so we have to be very careful about medication safety to ensure we don’t provide too much or too little medication.
Respiratory Support/Oxygen: 2L of oxygen is considered “high flow" because our babies noses and lungs are incredibly small. Also, don’t panic if you see a patient with oxygen saturations in the high 70s. In the NICU that might be acceptable for that patient, depending on their cardiac status, level of maturity, or secondary diagnosis.
Diet: We measure our feedings in mLs as well, sometimes only giving a few drops. Most NICUs will provide infants with mother’s milk, donor milk, formula, or parenteral nutrition (TPN), depending on their diagnosis and nutritional needs.
Extra-Small Sizing: We use the smallest blood pressure cuffs, diapers, IVs, nasal cannulas, and breathing tubes you have ever seen. NICU nursing is delicate work.
What types of patients will I care for?
♡ NICUs usually care for infants from birth - one year old. Infants that still require intensive care after one year will transition to a pediatric intensive care unit (PICU) setting for developmentally appropriate interventions.
♡ Most babies are admitted directly from L&D, postpartum (mother/baby), or are transferred from other facilities for a higher level of care.
Common NICU diagnoses include:
Sepsis (Maternal Fever, Pre-Ruptured Membranes for several days/weeks, etc.)
Multiples (twins, triplets, etc).
High-Risk Deliveries (drug-related births, STD exposure, unknown pregnancy)
Medical Conditions (cardiac issues, GI/GU, IUGR, etc.): some are pre-diagnosed, some are unknown until the time of delivery
Traumatic Delivery (body cooling)
Premature Birth (22-37 wks) a.k.a “preemies”
Congenital Defects and Chromosomal Abnormalities
Necrotizing Enterocolitis (NEC)
Feeding Issues
What is the Typical NICU nurse workflow?
While each unit has unique schedules and care practices, the following NICU nurse schedule outlines general timelines and duties for a nurse who begins work at 0700 or 1900.
0645 or 1845
Before our unit meets for a safety huddle, we "scrub in." Huddle usually involves a meeting between the oncoming nursing team, respiratory therapists & unit leadership. During this meeting, the charge nurse will give a "brief" on any safety events, pending deliveries, or staffing updates for the upcoming 12 hours. It allows you time to prepare for any patient safety concerns while also letting you bond with your team.
It’s important to remember to leave your jewelry and watches at home, as your arms will need to be bare from the elbows down. Be sure to scrub with soap and water and clean under your fingernails. This ensures that you don’t bring any outside bacteria, germs, or dirt to the vulnerable patients in the NICU.
0700 or 1900
After attending huddle, you’ll head to the bedside to get a patient report from the offgoing nurse. NICU handover report looks a lot different than report in other units.
Typical Patient Report Topics:
HISTORY OF PREGNANCY & DELIVERY
Age (gestational age and current age)
Weight (review gain/loss trends)
Head circumference
Length of the patient from head to toe
VITAL SIGNS
Temperatures (normal range: 36.5-37.5 C)
Heart rate (normal range: 100-200)
Respiratory rate (normal range: 10-100)
Blood pressures (normal range: MAP 20-70)
Apnea/bradycardia/desaturation episodes
DIET
NPO or PO eating
Type of nutrition (donor milk, mother’s milk, formula, or TPN)
OG or NG tubes and their sizes (normal size: 5-6 Fr)
Necessary feeding support (slow flow nipple, positioning, feeding rate, history of emesis, etc.)
GI/GU
Urine output (all diapers must be weighed)
Most recent stool (size and consistency)
Ostomy, if present (most recent bag change date & skin care plan)
Foley catheter, if present (french size, reason for placement, date of placement, catheter placement measurement, & recent output)
GI surgical tubes (size & type: Salem Sump or Replogle)
IV OR CENTAL LINE ACCESS
Umbilical lines
PICC lines
Peripheral IVs
IV fluids (location, rate, and fluid type)
Broviac
TPN and lipids
D10W, NS, or other TKO
Any replacement fluids, like sodium acetate?
Many units require nurses to “walk the line” together with the off going RN during handover report. No matter what type of line the patient has, whether it’s a feeding tube, IV access, or ET tube, you should confirm proper placement, proper infusions/settings and appropriate connections at the start and end of the shift.
ETT size
Placement of ETT
Ventilator Settings (HFOV, SIMV, BCPAP, NIMV, etc)
Suctioning needs
Nasal Cannula size and O2 flow rate
FiO2 Requirements
How to respond to baby “spells” (desaturations, apnea, bradycardia, etc.)
CARDIAC
Hemodynamic stability
Review recent blood transfusion requirements
Pulses (goal: +2 in the brachial, femoral, and distal)
Color (pink, pale, appropriate for ethnicity, etc.)
Review cardiac medications and infusions (dopamine, epinephrine, atropine etc).
NEURO
Neuro baseline (sedated, somnolent, active)
Sutures and fontanelle status
Reflexes (sucking, moro reflex, ability to console)
Head ultrasound status
MRI review when necessary
PAIN
Pain is assessed with the NPASS pain scale (Neonatal Pain, Agitation, & Sedation Scale)
Pain treatment regimen (what scheduled and PRN medications are available, when/how often they can be given, etc.)
SKIN
Last bath
Products to use (Mepitel, Mepilex, gauze, sterile water, etc.)
Skin tears, bruises, wounds, rashes
LABS:
Recent lab trends (bilirubin levels, H/H, chem panels, CRP, INR, etc.)
DIAGNOSTICS:
Chest x-rays
Head ultrasounds
Echocardiograms
Any pending procedures or diagnostic testing
ORDERS:
Finally, we take a look at all of the physician/NNP orders that have been completed within the last 24 hours, as well as those that have been scheduled for the upcoming shift.
How you spend the rest of your shift depends on the acuity of your patient assignment. To give you clarity, we’ll review a common shift schedule for a critical 1:1 assignment and one for a 2:1 feeder/grower assignment.
1 to 1 ASSIGNMENT
Example diagnoses for this type of assignment include: pre-op cardiac surgery, body cooling, micro preemies (22-26 weeks), pre- & post-op surgical patients, complex chronic patients, etc.
Let’s say a nurse is caring for a baby that was born at 23 weeks gestation. The bed area is going to have the following (most likely): a high-frequency oscillating ventilator (these things are BEASTS but are SO gentle on little lungs), multiple IV pumps and syringe pumps infusing a variety of medications, a vital signs monitor (displaying heart rate, oxygen saturation, respiratory rate, and BP level) and possibly a Bili-light to assist the body in breaking down bilirubin (increased levels cause jaundice).
0730 or 1930
After you finish getting report, you’ll want to prepare for your first round of “cares”. After assessing the safety of the bedside, checking orders, and assessing lines, you would sanitize the bedside. Be sure to clean the isolette/warmer, buttons, IV pumps, work areas, and charting areas. After touching base with the RT (Respiratory Therapist) we would establish a plan for our assessments & care interventions.
Example: While listening and counting the heart rate and respiratory rate, the nurse is working on their head to toe assessment as well. Additional tasks include changing the infant’s diaper, taking their temperature, feeling their pulses, assessing the baby’s vigor, and re-swaddling the infant. This is called “clustered care”.
If the nurse knew they had a scheduled chest x-ray & labs to draw, they would time them together. They could help the RT draw labs, perform the chest x-ray at bedside, AND make sure the neonatologist knows about the “touch time” so they can assess the baby during this period.
0800 or 2000
The neonatal assessment is possibly the most important part of your shift. If you’ve never taken care of this baby before, you’ll want to be extremely thorough. If you’ve cared for the infant for a few shifts in a row, it’s important to identify changes since your previous assessment.
Example: When assessing a NICU patient, a nurse asks themself questions like:
What does the baby’s head feel like? Are the sutures separated or overlapping?
Do I hear a murmur?
What do the lungs sound like? Any crackles or wheezing?
How are the bowel sounds? What’s the color of the baby’s abdomen? Is their belly soft or distended? Are there any bowel loops visible?
How is the patient’s muscle tone? Does the Infant have full range of motion with their limbs?
Is the patient vigorous and “fighting” me, or are they flaccid?
After obtaining blood pressure measurements and an axillary temperature, the nurse will work on several other checks from head to toe. They’ll perform oral care with any colostrum available, check the OG tube to remove any air from the stomach, suction out the ETT tube and make a mental note of the secretions. Finally, before closing up the isolette, the nurse would change the infant’s diaper. We weigh diapers from admission to discharge.
In a few minutes, the nurse should have their ABG results back along with the x-ray image, which may result in changes to the HFOV settings. As the bedside nurse, you are actively managing the patient’s oxygen concentration to keep their saturations between the ordered parameters. Too much oxygen for too long can be detrimental to the infant’s developing retinas, and not enough starves the body of much needed oxygen. You’ll be monitoring the oxygen levels all shift.
0900 or 2100
Once you’ve completed your assessment, you’ll want to weigh in on rounds. During bedside rounds, the interdisciplinary team (neonatologist, NNP, RN, RT, PT, OT, SLP, social work, the unit charge nurse) discusses the plan of care and changes necessary to meet clinical goals. Be sure to include parents whenever possible.
1000 or 2200
Around 1000, vitals are recorded and charting begins! Most units require nurses to chart hourly vitals for 1:1 assignments. These would include the infant’s heart rate, respirations, blood oxygen levels.
1100 or 2300 - 1900 or 1900
For critically ill 1:1 assignments, assessments and touch times would vary based on the patient’s stability and gestational age.
Example: A 23-week neonate might have “touch times” every six hours at 0800/2000 & 1400/0200. A more stable infant might have a touch time every three hours at 0800/2000, 1200/0000, and 1600/0400.
In addition to scheduled touch times you may need to provide interventions like blood product transfusions (blood, FFP, cryo, platelets), medication administration, new IV initiation, or assisting family members hold their baby.
Bedside procedures may also need to be performed at the bedside. These could include PICC line insertion, lumbar puncture placement, chest x-rays, and head ultrasounds to name a few.
Of course, all of this is dependent on the acuity of the patient. Vitals may be collected more often or the RN may have to assess the infant more frequently to keep them safe and free from harm.
As the bedside RN, the only time you leave the bedside is for a rest or meal break. You’ll be continually watching the patient’s vital signs, reporting changes in status to the neonatologist or NP, explaining changes to the parents, and charting EVERYTHING.
2:1 Assignment
Example diagnoses for this type of assignment include: mild prematurity (30+ weeks), multiple gestation (twins, triplets, etc.) or well-developing infants who previously presented with complex problems but are currently doing well.
Just like with a 1:1 assignment, for 2:1 assignments, you’d get report, clean the bedside, and prepare for touch times. The main difference, besides having to juggle care times for more than one baby, is that these infants will require cares/feeding more often.
Infants that are close to going home are usually cared for and fed on a 3-hour schedule:
Example:
Baby A Touch Times: 8, 11, 1400, & 1700 / 2000, 2300, 0200 & 0500
Baby B Touch Times: 9, 12, 1300 & 1800 / 2100, 0000, 0300, & 0600
*** Sometimes, a baby may require care “Ad Lib,” meaning they are allowed to eat and get held whenever they want! This could potentially throw your whole shift in a tizzy, but it’s ultimately a sign that the baby is almost ready to go home.
Managing 2 or more babies usually involves additional tasks like:
Coordinating care times with speech or occupational therapy.
Assisting parents with feeding skills.
Completing discharge teaching with family members (car seat education, baths, diaper changes, feedings, follow-up appointments, well-baby care, etc.).
Conducting hearing screens.
While caring for three infants may not seem as stressful as caring for 1 critically ill baby, juggling multiple babies can be just as busy and hectic. Some days feel as if you are just moving from baby to baby; feeding one patient, vital signs, diaper changes, linen changes, then to the next, and the next, and finally charting it ALL. Then, doing that on repeat until 1900/0700.
NICU LIFE
Life can change in the blink of an eye in the NICU. One minute the unit is calm, the next, a crash c-section is performed and a 24-week gestation baby is being admitted and your team comes together to make it as smooth as possible. Quite often, those of us familiar with the NICU call this a “feast or famine”! We slow down a lot to discharge babies home and then all of a sudden L&D wants to hand the NICU multiple high-risk admissions. No matter where you work, you’re sure to witness that phenomenon!
When I tell people that I am a NICU nurse, they often respond by saying: “How sad, seeing all those sick babies!” or “How do you do that?” Quite simply, seeing babies get healthy enough to go home is addicting! You get to help families through some of the hardest times of their lives & see the tiny babies you cared so much for turn into “line-backer” toddlers! Lots of happy tears and sad tears, but in the end, most of us NICU RNs think the NICU is the most magical place to be a nurse.
Ready to Start Your NICU Journey?
Now that you know what a day in the life of a NICU nurse could look like, you’ll have to decide if NICU nursing is the right path for you. If you’re ready to take the next step, we’ve got tons of resources, educational materials, and bedside tools to make your transition to the NICU a positive and rewarding experience. Check out the latest merch on NICUity and be sure to subscribe to our free newsletter to get the inside scoop on the latest NICU happenings.
HEAD OVER TO THE PODCAST!
Another great resource for you BELOW. I was featured on The Morning Rounds and talked all things NICU Nursing. Dynamics, my personal journey, NICU Nurse Tips & Tricks!
NICU Nurse Essential Resources
March of Dimes! Resources for parents & providers
Tori Meskin MSN RNC-NIC. Nurse. Blogger. Content Creator. Tori has been a clinician since 2012, works in acute care/inpatient NICU & Pediatric settings in southern California. She is a blogger, content creator (@nurse.tori_), NICU & Pediatric Critical Care RN, Sponsored Capella University MSN graduate, a Barco Uniforms Ambassador & Brave beginnings Ambassador. She has obtained her National NICU Nurse Certification (RNC-NIC) & has previously worked as a travel nurse, pursuing bedside experiences in several NICU settings. Follow her as she shares her NICU journey married life & juggles work, school, content creation, & brings you top notch Tips & Tricks along the way. Find her at www.tipsfromtori.com or info@tipsfromtori.com