XP: Fired my first nurse. :/ *vent/long*

The nurse we had today, who we've had once or twice before, also had an intern with her, who provided most of the care when we were there for 11am Hands On.  We've had students/interns with our nurses before and we've never had a problem.  I have NO problem with a student/intern, but as a preceptor myself for pharmacy students, I know that ultimately I am responsible for what my student does.

So, we go in at 7:45pm for Adalyn's 8pm Hands On.  I had called twice this afternoon, around 230pm and 6ish to get an update.   They told me that Adalyn had been having a good afternoon--no bradys or anything--and that her oxygen requirement had been between 28-30%. Yay!

So, I had planned to go in and Kangaroo her for an hour after her 8pm Hands On (again, don't want to stress her too much with the outside environment). Well, when we got there, she was crying pretty loud and was moved all the way to the side of the incubator on her tummy.  She was arched back/sideways.  I opened the side to try to soothe her, and that is when I noticed that the entire bed was soaked! It had reached all down her body and the blanket on the mattress and underneath her was damp.  I told the nurse (who had just come on shift at 7pm) and she came in, said "Oh, my god! Let's get that changed immediately! I'm so sorry--I didn't notice it when I first got here!" 

She said that after report, she came in the room about 7:30pm or so and heard her crying a little.  She opened the isolette (from the other side) and calmed the baby.  She said that if she had noticed that she would have immediately changed it and not waited until the 8pm Hands On.  

We determined that the connection from the feeding tube to her NG tube must not have been done correctly, because it was indeed the formula feed that she gets twice a day.  The nurse does not believe that there would be anyway for her to vomit up that much and not have a brady or desat episode.  The nurse was mortified that I found her like that and was starting to change it, and I told her that she could change the bed when I kangarooed her after her 8pm Hands On and that we could just put a clean blanket under her while we changed the diaper, etc. 

Well, when we turned her over, we also saw that she had some massive, dry boogers around her cannulas and that the tape that held the NG tube was covered in dried up/caked formula.  She had dried formula around her eye (very small specks, but there nonetheless) and one of her heartrate probes were damp and barely hanging on to her skin.  The nurse (again, horrified) got some stuff to give Adalyn a mini-sponge bath and get her cleaned up and got her new leads for the ones hanging off. 

So, we got her squared away, did her diaper change, etc, and I noticed that on her monitor that denotes her oxygen saturation, the range had been set "85 to Off".  Basically, the monitor is SUPPOSED to be set "85 to 95" so that it beeps/alerts/flashes when the oxygen is below 85% saturation or over 95% saturation.  If it is higher than 95%--ie, 96% or 97%, for at least a few minutes, the nurse is supposed to wean her down a smidge on her oxygen.  This is very important because at this gestational age, too much oxygen is bad for her eyes and, hello, she already has retinopathy (ROP)--we don't want to make it worse.  The only time it is to be set at "85-OFF" is when it is a term baby or a baby who does not have/not at risk for having ROP and/or is not on supplemental oxygen or is at 21% oxygen, which is room air. 

Never in Adalyn's 7 weeks (man, it's been 7 weeks already!) has Adalyn ever been as low as 21% that I can recall.  And, ESPECIALLY because of her episode last night, I KNOW that she has not been consistently lower than about 30%.  So, there is absolutely NO reason why it should have been set like that.  The night nurse said that it wasn't supposed to be set like that.  She said that the nurse may have set it since Adalyn was always maybe 96% but if she was turned down she would desat, so even though it was off, she kept an eye on it. However, it should not have been set to OFF and she couldn't really explain why.  

So, at this point, I'm starting to get pretty ticked off. However, I tell the night nurse that I would like for her to tell the Charge Nurse that I don't want students/interns ever again for Adalyn.  She said that she totally understands and that she will make sure to tell the Charge Nurse when she comes around.  She apologizes again for what happened, etc.  She changed the settings on the monitor and set me up with Kangarooing Adalyn. 

She goes to set the food pump, and as it starts going I see that she only put to feed Adalyn 24.5ml instead of 31ml.  I ask her if there was a change or something because it's supposed to be 31ml, and she said that in Report (that is when the nurse tells the next nurse about what has happened, etc) he told her that.  I ask her to check in her chart if 31ml has been charted and if he just got confused when talking to her.  She came back and said that it was 31ml and that she is sorry that she didn't double check.  (At this point, I'm wondering where the &*$# the training nurse is when the intern is giving report!)

As I'm Kangarooing Adalyn, she is making the bed and sees that the mattress is wet and decides to disinfect and wipe it all down.  I'm getting more and more convinced that my daughter did not get any of her 5pm feed and did not eat for 6 hours and completely missed out on 24 VERY IMPORTANT calories, not to mention all the calories she must have burned crying because she was hungry. Oh, and don't forget all the calories she burned from being uncomfortable with her drama from last night, getting multiple heel pricks, and getting an IV put in for her transfusion.

So, you must think that I fired the night nurse, right? WRONG! The more that I sat there with DH and we discussed what happened, the more upset we got at the training nurse and the intern.  I'm actually more upset at the training nurse than the intern!

DH and I decided that we no longer want to have ANY students/interns assigned to Adalyn, and that we no longer want this particular nurse to care for our daughter.  In the 7 weeks that we've been there, I've never felt uncomfortable about the care that she received.  I knew that we were going to have to talk to the Charge Nurse ourselves.

So, after about an hour, I asked the night nurse to put Adalyn back in the bed.  I asked her that we wanted to talk to the Charge Nurse.  Keep in mind that during this whole time I let her know how unsettling all this was and how uncomfortable I felt about the care she received from the day nurse.

She called her, told her what had happened, and then she told me that it would be like 10 or 15 minutes because the Charge Nurse was finishing up with an Admission.  The nurse was almost scared to tell us that we would have to wait (am I really that intimidating?) and I said that it wasn't a problem at all.  

Once the Charge Nurse arrived, I explained (and showed) why we were concerned about the care she received today.  I started off by saying that we were concerned about her feed, since it looked like she didn't get any of her 5pm feed, and how no one noticed it in 3 hours.  Do they not check the baby at all? What about when they went back in her isolette to disconnect the tube from her OG tube??  I told her that obviously the student didn't check the connection, but that the responsibility also lies with the trainer for not checking up on her student. 

I also told her about the Monitor settings and how it makes me feel like the nurse just didn't want to be bothered with my daughter's high-satting.  And that even if she did it and "kept an eye on it", she didn't let the night nurse know that she had changed the parameters. Who knows how long she would be high-satting and the night nurse not notice it? Especially after all her MDs and other nurses harp on the importance of not having too much oxygen, for me to find this, it is quite unsettling, frustrating, and upsetting.

I told the Charge Nurse that I no longer want any students/interns assigned to Adalyn, and that I also do not want the nurse that we had today to ever take care of my daughter again.  I'm sure that she is a great nurse, she is a trainer and all, but she was not a great nurse to my daughter today, and that is something that I just won't be able to get past.  

The Charge Nurse apologized for everything and said that she appreciates the feedback, because it could be that the trainer thought that the intern was pretty much trained, and that obviously that is not the case.   She said that she knows that we've been very accommodating with students since she was admitted, but that she understands that once you get burned, you never want them again.  She said that she will note it, as well as the nurse, from being assigned to Adalyn. 

She tried to say that the Monitor could be if she was at 21% Room Air, and I stopped her explanation right there when I told her that our daughter has never been at 21% in her entire life.  She then said that it was also the responsibility of the incoming nurse to check to make sure that all the parameters are correct, but that the monitor should not have been set at "85-OFF". 

She said that after making sure the baby is ok, our next concern is to make sure that the parents feel that their baby is being well taken care of.  They don't want us to worry about the kind of care that our baby is receiving.  She told me that all of my concerns were valid and would be addressed, and that she will make a note regarding not placing that nurse, or any other students/interns, with our baby again. 

I told her that I'm not trying to be nit-picky or difficult and that these were not life-and-death situations, but that it was my child, and it was just too many balls dropped.  It made me worry about what else could they drop.  Even though she is in the Step Down unit, it is STILL the NICU.  She said that it isn't as if we were upset about a blanket not being tucked in--all that happened should not have happened.  

I'm so glad that I'm such an observant mom and that I question all that is happening in my child's care.  What if I never said anything? What if this intern isn't as nit-picky as he should be, and/or this trainer isn't as observant, and something happens to someone's child when the matter IS life-and-death? When you are taking care of preemies, you can't just be blase about it--you can't be "ish" about it.  You've got to be OCD/anal retentive ALL THE TIME.  If you don't want to, then don't be a NICU nurse!

You can't mess with the care of someone's baby.   Perhaps when she was training him, things just got missed, because they're talking about something else.  I'm sure that's why my daughter was covered in dried boogers on her cannuals. Missing little things can add up to big things.  Also, when I see that you're missing little things, I don't trust you, and therefore you give DH and I more stress, which after last night, WE DO NOT NEED! We've got enough stress--we sure as hell don't need more!