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Miniature Miracles — A Day in the Life of a NICU Nurse

Tuesday April 10, 2007
Nurses in the NICU care for the tiniest babies. Here, a caretaker holds baby Brandon Dennison’s hand. Photo by Young Kim.
Nurses in the NICU care for the tiniest babies. Here, a caretaker holds baby Brandon Dennison’s hand. Photo by Young Kim.
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A miniature hand twitches as Shirley Valdivia, RN, pricks it with a needle, but there is no accompanying cry. The ventilator makes it impossible for this patient to make a sound. Luckily for Brandon Jr., who weighs just over one pound, Valdivia is an expert when it comes to interpreting subtle cues from patients who cannot rely on vocal chords, eyes, or muscles to communicate with caregivers.

Valdivia, a seasoned neonatal intensive care nurse at Alta Bates Summit Medical Center in Berkeley, Calif., works to insert a line that appears no thicker than a strand of hair into the baby’s artery. In the NICU, where doses, diapers, and drips are all miniature, having an eye for minutiae is essential, and is sometimes the difference between life and death.

Semi-private rooms mimic womb

As Valdivia does her rounds, she walks into rooms that are dim and quiet by design. The NICU at Alta Bates was one of the first in the country to create semi-private rooms for preemies. The goal was to mimic the calm environment of the womb to help preemies thrive.

Rather than stressing the preemies with loud monitors, bright lights, and cramped space for caregivers, the semi-private rooms are designed to give parents the privacy to bond with their infants. Also, the rooms — which hold two or three infants — separate these patients from the hustle and bustle of staff when another baby in the unit is unstable.

For Valdivia, the room design is only one of many aspects of NICU that have changed since she began neonatal nursing in 1978. When she first started as an Army nurse, the ventilators gave babies a breath at a programmed rate, but now the machines sense when the baby is breathing naturally and assist with the breath. There are also high-frequency ventilators that can give as many as 600 tiny breaths per minute to minimize lung damage.

Technology has also greatly improved her ability to give babies nutrition. In the past, nurses often placed butterfly PIVs in the scalp, but the vessels were too small to tolerate much dextrose and protein. Now the preemies get their nutrition through PICC lines that last longer and can be used to give more adequate nutrition.

“It’s easier to do my job now,” says Valdivia, a charge nurse. “We are saving babies now whom we couldn’t save before.”

She has seen some babies born at 23 weeks survive, whereas years ago, it was hard to save babies younger than 26 and 27 weeks. However, preemies born after 26 weeks still have better odds. Older babies typically have decreased chances of developmental disabilities, blindness, deafness, and cerebral palsy. The Alta Bates NICU sees about 1,000 babies per year, and roughly 200 of those babies are less than 1500 grams, or 3.3 pounds.

Even though the NICU is armed with the most advanced technology, Valdivia often relies on more subtle changes in a baby’s behavior or appearance to catch a problem. She was on duty once when a 2-month-old baby girl suddenly became cold, so the physician prescribed a common antibiotic. Later Valdivia noticed the baby had cellulitis of the neck. Valdivia suspected the cellulitis was caused by a staph infection, so the doctor changed the prescription to an antibiotic that treats staph infections, and the baby had improved within 24 hours.

“You have to be able to see what other people can’t see,” she says. “That made the difference for this baby.”

NICU nurses also watch for any signs of necrotizing enterocolitis (NEC), an infection of the intestines. Before they feed a baby, nurses check for signs of poor digestion. They look for residuals in the stomach, abdominal distention, blood in the stool, apnea, or bradycardia.

If there are any signs of NEC, the physician will order a white blood cell count, blood culture, and abdominal X-ray. If these tests confirm NEC, nurses will stop feeding the baby orally and administer antibiotics for 10 days while the baby is nourished with TPN. In serious cases, babies are transferred to Children’s Hospital in Oakland to be evaluated by a surgeon. They may have part of their intestine removed if the bowel appears compromised. If the entire intestine is necrotic, babies usually die, Valdivia says.

“The situation can change dramatically in a short period of time,” she says. “One baby was crying and crying, and I went in to see what was going on, and he had full-blown NEC and was in pain, but it hadn’t been picked up because he had seemed fine during his previous assessment.”

Valdivia’s decades of experience have given her a radar for signs of infection in other parts of a preemie’s body. These miniature patients are at risk of infection because they often miss out on the antibodies they would normally receive in utero from the mother during the final trimester.

“Their immune systems are also immature for fighting infection,” Valdivia adds. “There are a lot of bacteria on their skin, normal flora, and the lines we put in [them] give this bacteria a way to get into them.”

A baby who is not as active, looks a little grey, is getting cold, or who has more apnea might mean that the nurse should talk to the neonatologist about having lab work done. An infection that is not treated promptly could put a baby at risk of meningitis, which can lead to brain damage.

Bonnie Wong-Harano, RN at Alta Bates Summit Medical Center in Berkeley, Calif., cares for triplets who are “co-mattressed” to encourage body contact.
(Photo by Young Kim.)
Preemie language

Valdivia is well-known on her floor as an expert in interpreting a preemie’s subtle methods of communication, called developmental cues. For example, when preemies look away, become flaccid, thrust their tongues, cover their faces, or splay their hands, this is a signal that they need some time out. In other words, the parent or caregiver needs to stop what he or she is doing. If these cues are ignored, the baby’s heart rate could drop, and in the worst case, the baby could stop breathing.

In addition, Valdivia is one of the most trusted nippling experts on the floor. Preemies can have difficulty transitioning to bottle feeding because they have not yet developed the natural ability to suck, swallow, and breathe simultaneously. Some also have nipple aversion because they have been on ventilators and do not want anything in their mouths. Valdivia has honed the skill of assessing how to best help these babies successfully drink from a bottle.

“Other nurses know there is a problem, but Shirley knows the tricks to solve the problem,” says Annette Ravizza, RN, who has worked with Valdivia for 18 years.

Valdivia checks for malformations of the mouth, breathing problems, and muscle tone to determine what strategy to use. She discerns when to use a low-flow versus fast-flow nipple, when to feed with a syringe, and when to use a spoon. Sometimes it’s as subtle as changing the type of formula to successfully encourage a baby to eat.

Shirley Valdivia, RN, NICU charge nurse Shirley Valdivia, RN, NICU charge nurse at Alta Bates Summit Medical Center in Berkeley, Calif., with a patient. Photo by Young Kim.
Why she loves it

Although Valdivia is respected by nurses and physicians for her technical expertise, she knows that most parents need more than medical lingo to help them stay connected with their babies during the emotional intensity of a NICU stay.

“When I was younger, I liked the technical challenges more, but now I also really enjoy the emotional care I can give to families,” she says. “I like being able to help families really get close to their baby, because they are in a strange environment and a lot of times they are afraid and think there is nothing they can do for the baby.”

The fact that she is fluent in Spanish allows her to step in and translate for families who need an interpreter. Valdivia, who grew up in Peru, is often asked to translate during a case conference when a physician, nurse, and social worker all meet with Spanish-speaking parents.

One of the most delicate situations she navigates is when family members learn they will lose their baby.

“This is a special moment for them, and you want to give them memories,” she says, holding back tears. “I like giving them the opportunity to hold the baby, bathe the baby, or pass the baby around so they can have special memories to take with them.”

In these sad situations, Valdivia turns to her husband and other staff members to cope with her own grief at losing a patient. She also has known what it’s like to have a little one in the NICU. She was in labor with her second daughter when the doctor discovered that the umbilical cord was strangling the baby. To save the baby, the physician cut the cord before delivery. As a result, her daughter spent a couple of days in the NICU.

“She just needed some oxygen to stabilize, and I knew she was in good hands,” Valdivia says.

But most of the time Valdivia is the one in scrubs. Whether she is placing a PICC line, interpreting a preemie’s signs, or comforting a grieving family, Valdivia’s presence is noticed.

“Shirley is amazing,” says Amarjit Sandhu, MD, chief of neonatology at Alta Bates. “I’ve worked with her since the 1980s, and if I’m in any difficult situation, it seems we can handle it if Shirley is there. She doesn’t panic, and she understands what is going on with these babies.”

Heather Stringer is a freelance writer for NurseWeek. To comment on this story, send e-mail to editorca@nurseweek.com.