During my first week I attended phlebotomy clinic that work with the nursing team. I asked my team leader if they allowed students to perform venipuncture in this trust and they do.I was working with two phlebotomist in clinic. I observed for the first few times making sure I understood and was confident in what I had practiced at school and how it is done within this practice. The team here were very supportive and welcoming. In the clinic, I was helping cleaning the arm to keep the field clean as possible before the needle goes into the vein as most children have numbing cream/ Ametop/Elma so its important to wipe it off once its done its job. Then attaching the tourniquet to be able to feel the vein and I soon observed that not every being can be seen by your eyes.

Also learning what blood bottles we needed so the most common is gold which is biochemistry/microbiology and immunology analysis- urea&electrolytes, bone profile, liver function tests, thyroid function tests, troponin, lipid profile, immunology, serology. We also used a lot of purple which is for a full blood count. We also used grey for glucose analysis and blue for coagulation.

The phlebotomist are very good at reassuring and talking to the children as this can be very scary for them. They show the parents the best way to safely hold their children in a blood test. At the end of the day I approached the person I was working with and asked if it was okay if I did the blood test. This was an older child which i thought was probably better for my first experience as younger children get very distressed and move a lot. With a lot of support I got into the vein and successfully got the blood test completed. After the blood test I double checked the patient was okay and didn’t feel funny after.

I spent the morning with the dietician. We spent the first ten minutes of her explaining her role and showing me how the different system works ( System One). We then saw patients that attended the clinic for a number of reasons. We discussed how patients have specific types of feeds or supplements that are suited best to them. Then they use guidelines from gosh to calculate feeds by weight and it also specifies for girls and boys how much they need every 24 hours. This varies due to age and weight however it may be altered if the Childs weight is higher or lower than what is for their age. The dieticians will decide what the maximum is for the child. The patients seen in clinic are either due to enteral feeding and need a review or their weight is under the acceptable rate and is altering their growth. I learned a lot about how you can add more calories into a Childs diet by adding yoghurt with honey or jam. Nuts to snack on. Or even adding cheese or olive oil to get extra calories into a meal. They also advise the patients to take vitamin D to reduce tiredness and promote energy. All extra calories and taking vitamin D is for to boost the patients energy.

Then I spent the day with Dietician and Speech and language therapist. They provide a clinic together to see patients with eating difficulties, not meeting nutritional needs, aspirations, dysphasia (swallowing difficulties) and falling under the centiles on growth charts.

We saw many patients and I learnt the importance of reassuring parents and teaching how to explore food through play to encourage children to put it into their mouth. I also learnt that children diagnosed with Down syndrome have a different growth chart as it’s calculated differently. The parents need to keep a record of feeding if with food to keep a week diary of food and water intake, if the baby is on breast milk or formula feed to give a number of volume for intake. Also I asked the speech and language therapist what she is looking out for when they observe the feeding in clinic. They are looking at the breathing and making sure the patients are taking breaks if needed, any change in colour of skin, any noises when swallowing, any nostril flaring, coughing, increase secretions and signs of chocking.

I spent the day with the tissue viability nurse in clinic. I had exposure to many leg ulcers and background on how it started. The tissue viability nurse took her time to sit down with me and explain how to determine if the leg has the ulcer due to the arteries or the veins or sometimes both. We then talked about how if it is a mix or venous then compression can be applied, this is decided by the tissue viability nurse. I learnt how to effectively clean, apply silver, medi honey or aquacel then wrap the leg and add compression bandages to promote healing. Most of the patients were so experienced with how to deal with there legs and can even do the changing othe dressing and applying epiderm at home! I learnt so much and went home feeling more confident on how to dress the legs if needed.

The SHO asked me if I would like to help after a baby has been delivered by caesarean section. I had to quickly get changed into scrubs. We then waited by the resusitaire ready for babies arrival. When baby had arrived we had to wait one minute after they were delivered to allow the cord to turn white meaning that all the nutrients and haemoglobin has gone to the baby. The SHO informed me after that if the baby hadn’t cried or something was wrong the cord would have been cut straight away.

Then once mum got to have a look at her baby they were passed straight over to the SHO and me. We used the newborn life support by resuscitation council uk. We stimulated baby and kept them warm whilst assessing colour, tone, breathing (nostril flares and work of breathing) and heart rate. Once we were happy with our assessment all wet towels were removed and baby was wrapped in dry towels. Then given back to the parents.

Promote professionalism and trust

In this placement, I have seen how quickly a patient can deteriorate.This is about building a professional relationship by caring for your patient, I think it’s all about what you can do to benefit the patient. Some of these patients on this particular ward take a while to warm up to you and build trust as they have been having treatment for a long time. They can be very apprehensive towards you and need time to gain their trust.

This could be something as simple as grabbing them some water or fruit juice from the kitchen to encourage their drinking. Or going to different wards to look for some crackers and cheese. Making sure the patient and their care giver are comfortable is essential. You can find so much out from a patient from just doing their observations or even walking them down to x-ray. Then you can complete a full history for this patient and even giving their care giver someone to talk to because it can be stressful and lonely for them too.

Final reflection

Knowledge-

Learning from my biology and pharmacology lessons and lots of revision on conditions in neonatal ward I can update parents on baby’s progress and answer any questions that parents may have. When checking vital signs, I can identify normal and abnormal values for patients on neonatal (preterm and term babies) to be able to escalate care as necessary. Whilst on placement I have a greater understand routes of treatment-IV, topical, IM,oral(NGT,PEG,NJ) and why we give it.

Throughout my placement I was allocated a patient to look after this allowed me to build a repour and maintain health and safety to promote health and wellbeing and prevent deterioration of symptoms. Being able to have one patient on respiratory support to look after for a full shift with minimal supervision showed my growth as a student nurse. A patient on respiratory support needs constant monitoring because they can desaturate quickly. I can notice this by understanding my normal ranges of saturation. Whilst on placement I have been able to familiarise myself with admission and discharges on the ward. On admission the patient needs their vital signs and weight done immediately to fill out admission paperwork and calculate medications based on the child’s weight and fill out a WETFLAG.  A WETFLAG is required to be completed as it is used in emergency protocols. On discharging a patient, parents must come in for teaching of safe sleep, drawing up medications and providing patient education by giving leaflets and showing videos. As well as giving emergency first aid training to all parents leaving the neonatal unit with their baby.

During my time at neonatal I have observed the importance of safeguarding vulnerable patients and working alongside the discharge co-ordinator and attending safeguarding meetings for the paediatrics of the hospital this includes neonatal, A&E and Children’s unit.

Once a week in the neonatal ward provides training for all staff and students. Attending these sessions I have been able to understand blood gases and check abnormalities. As well as having practice with the blood gas machine which I have never seen before. Another session we were shown different safety equipment and daily checks that need to be done to ensure emergency equipment is ready for any situation and setting up equipment ready for an admission. Lastly, being able to attend the set up of the new incubators being brought to the unit as well as the checking of the rescusataire kept in neonatal. A rescusataire needs to be checked regularly as it keeps all emergency equipment in such as intubation kits, oxygen, it warms the baby up and can suction if the baby needs it.

Skills-

During my time in neonatal ward I feel as though I have built positive professional relationships and being able to build on my experience as a student nurse. On my night shifts as a nurse I was able to attend one emergency c-section and observe the importance of getting a baby out by emergency c-section safely but quickly. Watching this has made me understand what a mother goes through in childbirth and being able to support them as much as I can after. Childbirth can be amazing and positive but it can also be scary for mothers for multiple reasons such as prematurity, meconium aspiration or babies not feeding. All reasons for admission on neonatal ward. I have also attended a blue call on the labour and delivery and seen the importance of inter-professional working is neonatal senior nurses and doctors are constantly running back and forth from neonatal to labour and delivery to ensure patient safety.

On every shift, I have been able to support parents with breastfeeding by ensuring the baby is latching properly, helping the mother to get the baby out safely from the cot, providing a screen for privacy of the mother to feed her child. Also providing reassurance as it can be stressful for mothers who haven’t had their milk production come in as quickly as they would like. A few other ways babies are fed on neonatal are via nasogastric, where I have learned how to aspirate the stomach ph before feeding and checking the levels of aspiration and knowing on the ph strips what is a normal and abnormal colour of ph. We do this to reduce risk of aspiration and to check the NGT is in the stomach. Another way of feeding is bottle or cup which seems easy but babies can get very tired from sucking very easy. I have learned how to position a baby when feeding, stimulate them if they need it and bring wind up to reduce the air in the stomach. Also when a mother is expressing knowing where the equipment is kept, how to sterilise the equipment and date and store the expressed milk safely this could also be donor milk. I have also had the opportunity to have conversations with parents on my shifts to ask how feeding is going , making sure they know I am there to support them, update them on progress and answer any questions. On neonatal, the nurses have to prepare feeds for the baby this is done by measuring the milk which is calculate at the start of the shift by weight and the amount of mls, checking if the milk being given is in date , defrosting and warming milk with a milk warmer and labelling and dating milk warmer bags.

Every shift I have been able to practice routines by receiving hand over from staff and working out my schedule for the day, looking at how many times the baby is being fed this could be hourly, two hourly or three hourlies. Then looking at what time medication is being given and being able to prepare it and fitting that around feeding time and 4 hourly cares such as nappy change, bedding change, and doing two blood pressures on the shift. During the day I have been able to attend doctors’ wards round and have them ask questions to me about the patient I am looking after I found this very scary for the first few weeks as a doctor had never asked me much before. During this placement I have had to ask many questions and do lots of research to be able to familiarise myself with conditions and medications I have not had before and being able to answer questions that I’m able to and know when I’m unsure about something it’s okay to ask a nurse to answer.

As a result of this experience, I have understood that if you don’t further research and understand the place you are working at you won’t progress further. Being able to gather your own knowledge through research and experience will enable you to feel confident in yourself and build trust with the patient and their family. Also I feel with more practice I won’t shy away from doctors and feel confident enough to escalate to them or have a conversation with them during ward rounds and update them clearly on my patient.

Attitudes and values-

I feel as though i have learnt practising effectively on this placement. Knowing how to manage time and working out how to fit all cares being given into the shift. Being able to give a detailed thorough handover to staff using the a-e assessment. Using the structure and order used on the ward in handover. Being able to let staff know what is needed during break with patient whilst i am gone. Making sure i am doing things correctly if i’m unsure to ask a nurse to walk me through it and then next time i will try. Knowing my limits and what i am able to do has enabled me to practice effectively and work with a multidisciplinary team. Clear understanding and the ability to recognise potential changes of babies needs urgent interventions and when to alert someone. Making sure staff get there breaks and if they need me to help them with anything.