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670 | NPN addendum
4. Completed 21day course of amp/cefotax. Continues on day
[**6-22**] vanco course. Last BC [**12-14**] ntd.
Continue to monitor for s+s sepsis and administer antibx as
ordered.
5. Temp 97.4ax post CXR/cares this am--warming lights
applied, temp resolved and stable thereafter. Active
w/cares. Req 2 doses prn fentanyl in addition to fentanyl
infusion @6mcg/k/min (conc. 500mcg fent in 50cc D5W).
Sucrose on pacifier used in addition w/good effect. AFSF.
Continue to support [**Last Name (un) 103**] needs.
7. Mom in majority of day, sitting at bedside w/infant.
given update. [**Last Name (un) **] on phone this am, given reassurance.
Continue to support and update [**Last Name (un) 32**] regularly.
8. Continues on [**Last Name (un) 406**] neoblue. Sl jaundiced. For [**Last Name (un) 33**] and
lytes in am.
Continue to monitor.
| Overall Positive Note |
671 | Nursing NICU Note
Pt required frequent bag and mask venitilation for
desaturations noted to high 70s-low 80s despite 100% FiO2,
combivent puffs and increase in HFOV settings.
Poor perfusion noted; delayed capillary refill and
extremities cool to touch despite stable temp. [** 13**] attempted
arterial sticks for arterial line without success. Upper
extremity BP means did remain stable. Pt received platelets
as ordered. Attending MD ordered not to obtain further blood
samples this shift following VBG.
Abd. appeared distended and very firm. No drainage noted
from abdominal drains. Repogle was to low wall suction
draining dark bilious drainage.
Pt received one dose of Pavulon. Pt's fentanyl drip
increased to 9mcg/k/hr. Pt received one bolus of fentanyl
prior to coming off [** **] and being placed on convential vent
to be held by [** 32**]. Pt appeared comfortable.
Family team meeting held. Decision to redirect care. [** **]
supported by team during redirection of care. Mother held
infant. [** **] spoke lovingly to their baby. [**Name (NI) 117**] crying
and clearly upset. Pt baptized per [**Name (NI) 32**] request. Memory
box started: Baby footprints and lock of hair obtained.
Pictures taken with 35mm camera and film placed in memory
box. Other personal belongings placed in memory box. Media
Services contact[**Name (NI) **] and message left requesting photos be
taken of infant if possible. Message left for Social work.
Neonatal Demise checklist and Neonatal Bereavement Follow-up
form initiated.
| Overall Negative Note |
672 | Nursing NICU Note
1. resp. O/Pt remains on [** **]- please see flowsheet for
settings. FiO2 62-85% this shift, with a need for increase
in FiO2 to 100% with cares. Brief sat drifts noted to around
84-86%. Please refer to CBG from this shift. A/No changes in
[** **] settings thus far this shift. Pt appears present at
these settings at this time. P/Cont. to monitor. Cont. to
supply and wean FiO2 as pt needs/tolerates.
3. F/N. O/ Remains NPO. TF remain at 130cc/k/d. IV TPND12/IL
running as ordered. Please refer to flowsheet for
examinations of pt from this shift. Voiding. No stool
passed. A/Alt. in F/N. P/Cont. to monitor I/O. Cont. to
monitor dstick stability. Cont. to monitor for s/s of NEC.
4. sepsis. O/Remains on Ampicillin and Gentamicin as
ordered. A/Treatment for potential sepsis continues. P/cont.
to monitor.
5. Dev. O/Pt remains nested in sheepskin with good firm
boundaries. Temp stable on servo control on a warmer. Brings
fist to mouth/face. Pt resting well in between care times.
Active at care times, but settles quite easily with
decreased intervention and hand containment. Remains on a
continuous Fentanyl drip at 6mcg/kg/hour. A/Alt. in G/D. Pt
appears comfortable and settled on cont. fentanyl infusion.
No fentanyl boluses required this shift thus far. P/Cont. to
support pt's growth and dev. needs. Cont. to monitor pt's
stress and comfort level.
7. social. O/No contact from [**Name2 (NI) 32**] this shift thus far.
A/Unable to fully assess parental involvent at this time.
P/Cont. to support and educate [**Name2 (NI) 32**]. Keep updated with
family meetings.
8. [**Name2 (NI) 33**]. O/Remains under mini neoblue light. Skin
palish-pink. A/Treatment for hyperbili. P/Cont. to monitor
effectiveness of phototherapy.
| Overall Neutral Note |
673 | Nursing progress note
#1 O: [**Known lastname 1140**] maintained on [**Known lastname **] ventilation as documented
without changes made for shift, lungs continue tight and
squeeky with slight increased aeration noted in upper bases
at [**2185**] evaluation, FiO2 63-84 for shift increasing to 100%
for cares, without secretions noted via ET tube, moderate
oral secretions noted A: maximum support cont. P: monitor
closely and monitor gases, wean as indicated
#2 O: BP stable as documented with perfusion good with equal
pulses, percordium quiet A: stable P: monitor closely
#3 O: [**Known lastname 1140**] started on 10cc/kg/day(8.5cc Q 3 hours)via ng
feedings at 1400 and continues on 130cc/kg/day via
PN/IL/Fentanyl with abdomen softly full, at 0800 evaluation
without BS evident with BS hypoactive at [**2185**] evaluation,
AG-17cms., without residuals noted, d/s-97, u/o-2.4cc/kg/hr
for 16 hours, without stool passed as yet A: feedings
initiated slowly P: wt. daily and close monitoring of
tolerance, monitor I&O's, monitor labs as ordered
#4 O: O: Pre [**Year (4 digits) **] level 1.3 with gentamicin discontinued
with cefotaxime started as ordered, infant active with cares
but sleeping/resting through cares A: sepsis treatment
coarse cont. P: cont. with plan
#5 O: [**Known lastname 1140**] remains on a fentanyl drip as ordered with [**Known lastname 1140**]
quiet and tolerating cares well, moved into isolette with
[**2185**] evaluation and settling nicely into nest A: quiet and
comfortable for shift P: cont. with plan, wean as indicated
#6 O: slight abrasion noted on left cheek after tape removed
for tube retaping at [**2185**], cleansed and left open to air,
without other breakdown noted A: sensitive skin P: vigilant
skin care and monitoring
#7 O: [**Year (4 digits) **] in this a.m. and p.m. to visit [**Known lastname 1140**], mom
changing diaper and washing face/eyes, [**Known lastname 32**] updated at
bedside A: Involved P: support, teach and keep informed
#8 O: Remains under neo [**Doctor First Name **] with eye patches on A&P: check
[**Doctor First Name 33**] in a.m.
| Overall Positive Note |
674 | NP NOTE
Procedure Note: [** 1876**] removal
Time out observed.
[** 1876**] shut off, suture removed and line pulled back to 1 cm , afte which it was discontinued with out any difficulty, No blood loss, Infant desaturated during procedure, and was hand bag ventilated to increase O2 saturations. Infant has been stress intolerant most of day.
No observed complications from [** 1876**] removal.
Mother present at bedside.
| Overall Neutral Note |
675 | NP NOTE
PE: samll critically ill preterm infant on radiant warmer, orally intubated on HFOV. Pale pink, warm, well perfused. Very intolerant to caregiving with desaturations during handling.
AFOF sutures approximated, eyes closed, oral ETT, clear secretion.
Chest with improved excursion with manual ventilation, continues with squeakt, tight bs, fair exchange, though improved.
CV: RRR, no murmur, pulses+2=
Abd: soft, hypotonic bs
GU: immature
EXT: PIV in foot for TX.
Neuro: sedated but responsive, symmteric grasps, tone
| Overall Neutral Note |
676 | 0700-[**2115**] ADDENDUM TO NPN
FEN: NPO, TF 130cc/kg/d based on a weight of 800gms per
order. IVFs PND10w, IL and Fentanyl drip infusing via PICC.
Electrolytes sent at 1300 today, see lab for results.
Dsticks 195, 218, 161, 75 in subsequent order (see flowsheet
for exact times that dsticks were obtained). Infant has
received a total of 5 NS boluses as of this writing,
treatment for poor perfusion and hypovolemia. Infant has
voided a total of 2cc this shift and thus an indwelling
urinary catheter was placed at 1830. No stool. On initial
exam this a.m., infant's abdomen was noted to be slightly
firm with absent BS. Infant had a 2cc bilious aspirate at
that time and was having bilious spits. NGT was D/C'd
replaced with a repogle to LCWS. Repogle has been draining
small amounts bilious fluid. Infant had multiple abdomimal
x-rays today in order to be evaluated for NEC and intestinal
perforation. TCH surgery was consulted and at approximately
1730, two drains were surgically placed in the abdomen.
Large amounts of stool drained from abdomen immediately
after initial incision was made indicating that a
perforation had occurred. Two drains are in place at this
time. Surgical dressings placed around base of drains. No
drainage noted at this time.
[**Year (4 digits) **]: Remains under NeoBlue photothx however photothx has
frequently been turned off today for exams, x-rays, surgery,
etc.
PARENTING: [**Year (4 digits) **] were called by team this a.m. and
informed of concerns over infant's clinical status. They had
a family meeting with M.D. shortly after arriving to the
NICU (this RN was not present). Surgery also met with
[**Year (4 digits) 32**] prior to placing the drain. [**Year (4 digits) **] remained at
bedside throughout most of the afternoon and received
frequent updates. They are appropriately very worried.
| Overall Neutral Note |
677 | Cont. of Nursing Progress Note
#4 cont.- P: Complete abx course, monitor for s/s of
infection closely.
#[**5-21**] O/A: Infant remains on servo warmer, nested with tent
in place with stable temps. Servo setting decreased by .1
for warm temps. Eyes are bilaterally fused. Receving
Fentanyl infusion to maintain comfort, infant appears
comfortable and received PRN Fentanyl prior to last set of
cares and xray. Infant is active but settles nicely. Skin
is intact, patches of errythema to right knee and thigh
noted. Meptotac intact to area below umbi. Last head u/s
showed grade [**1-17**] bleed on right side and grade 4 on Left.
P: Continue to monitor infant comfort, skin, and support
infant's development, F/u head u/s scheduled for today, will
obtain lytes/bili this a.m.
#7- O/A: no contact with [**Name2 (NI) 32**] thus far this shift. P:
Support family, keep informed, and have team meet with
family.
#8- O/A: Infant remains under neo blue mini with eye shields
in place for a bili yesterday a.m. of 2.5 (0.5). P: Cont.
phototherapy as ordered and will obtain bili this a.m.
| Overall Neutral Note |
678 | Nursing NICU Note
1. Resp. O/Pt remains on [** **] vent settings: MAP of 16,
Delta P 39. FiO2 primarily 80-90% this shift (RT and [** 13**]
aware), but FiO2 ranging from 60-90%. Desaturations noted as
low as 77% usually requiring adjustment in FiO2. See
flowsheet. See lab results for CBG obtained this shift (RT
and [** 13**] notified of results). A/Requiring high concentration
of FiO2 and [** **] support to maintain adequate oxygenation.
P/Cont. to supply and wean FiO2 as pt needs/tolerates. Cont.
to monitor pt's resp status on present settings.
3. F/N. O/TF remain at 130cc/k/d. IVF adjusted for dstick
results per orders. Please refer to flowsheet for dstick
results ([** 13**] and Attending MD aware of results). Presently
D5W running at 30cc/k/d and TPN D12.5/IL running at
100cc/k/d via intact DL PICC. Please refer to flowsheet for
examinations of pt from this shift. [** 13**] is aware of
abdominal/testicular discolorations noted. U/O still at
4cc/k/hour. No stool passed. NGT remains vented.
5. Dev. O/Temp stable on servo control in an isolette. Awake
at care times and appears to be sleeping well in between. PT
sensitive to stimulation and needs increase in FiO2 with
intervention. Appears to tolerate prone position better than
side-lying. Brings hand to face. A/ Alt. in G/D. P/Cont. to
support pt's growth and dev. needs.
7. [** 32**]. O/No contact from [**Name2 (NI) 32**] this shift. A/Unable
to fully assess [**Name2 (NI) 32**] involvement at this time. P/Cont. to
support and educate [**Name2 (NI) 32**].
8. [**Name2 (NI) 33**]. O/Reinitiated phototherapy last night. Skin pink.
A/Treatment for increased [**Name2 (NI) 33**] level. P/Cont. to monitor
effectiveness of phototherapy.
| Overall Neutral Note |
679 | Nursing progress note
#1 O: [**Known lastname 1140**] remains on [**Known lastname **] vent with settings as documented,
FiO2 for shift 87-100% with one episode of drifting to 79-80
requiring bagging to resolve for shift, lungs tight and
coarse thru/out with slightly diminished fields noted on
right at 1400 evaluation A: significant support required for
oxygenation/ventilation P: close monitoring and
interventions as indicated
#2 O: BP remain stable as documented, color slightly ruddy
pink with pulses equal and slightly bounding, slight 1/2cm.
round raised pulsating area noted on R upper arm with 0800
evaluation (question brachial artery), [**Known lastname 13**] aware, perfusion
good without mottling noted A: stable CV status at present
P: cont. with close monitoring and assessment
#3 O: Abdomen soft without BS audible, no loops with slight
distention, AG-16.5cms, remains on PN as ordered with plan
to resume IL this evening with TF to advance to 130cc/kg/day
with new fluids this evening, u/o-2.7cc/kg/hr for shift A:
FR as ordered P: close monitoring of I&O's, wt. daily, and
monitor labs as ordered/indicated
#4 O: [**Known lastname 1140**] remains on antibiotics as ordered A&P: administer
meds and monitor for overt/subtle signs of sepsis
#5 O: [**Known lastname 1140**] needing increase in sedation secondary to trouble
settling and increase agitation noted after a.m. care even
with bolus of fentanyl given, [**Known lastname 1140**] calming with mom's
containment and soft spoken voice, bringing arms to head
with hands going to face area, increased comfort noted with
[**Known lastname 1140**] on side A: without reserve, requiring increased
intervention with sedation P: monitor and intervene as
indicated, maximize intervention to enhance rest periods
#6 O: skin intact without breakdown noted A&P: close
monitoring
#7 O: Mom in at 1030-1730 with [**Known lastname **] in at 1600-1730, mom
participating in [**Known lastname **] care at 1400, taking temp., changing
diaper and washing face and eyes, mom also
calming/containing son at 1100 when [**Known lastname 1140**] agitated, [**Known lastname 32**]
updated at bedside A: mom participating with son's care P:
support and encourage, teach and keep informed
| Overall Positive Note |
680 | 0700-[**2115**] ADDENDUM TO NPN
PARENTING: Mom came in to visit at around 1p.m. today and
[**Year (4 digits) 370**] was in at about 3p.m. Prior to [**Year (4 digits) 370**] coming in, M.D. sat
down with Mom at bedside for a meeting to discuss the twins'
clinical status' and the plan of care for each. When [**Year (4 digits) 370**]
visited later, he requested to meet with the M.D. as well
for an update. This RN, RN [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2531**], and [**First Name9 (NamePattern2) 13**] [**First Name8 (NamePattern2) 589**]
[**Last Name (NamePattern1) 473**] were also present at that time. Mom was pumping and
not present for the 2nd meeting. After M.D. reviewed what
she had reviewed previously with Mom, [**Name (NI) 370**] informed the team
members present that Mom had called him after the earlier
meeting very upset. He stated that Mom had been "hysterical"
as she related the information that she had received
regarding [**Known lastname **] clinical status. [**Known lastname 370**] expressed that Mom's
concerns were primarily related to the plan to consider
initiation of steroids and her worry about possible
side-effects. The team members informed [**Known lastname 370**] that we were
unaware that Mom had been so upset after the meeting and
asked him what we could do to help her the next time we
share information with her. [**Known lastname 370**] requested that he be present
the next time a meeting is held so that he can be a support
to his wife. Team assured [**Known lastname 370**] that we would make an effort
to do so and encouraged him to keep us informed as to how we
can be most supportive during this difficult time.
| Overall Negative Note |
681 | NPN Noc
#1 Resp: HFOV MAP 17 AMP 39, Fi02 65-78% o/n. LS tight and
coarse, [** 842**]'d sm cloudy secretions from ETT/mouth. Will
check blood gas this AM. P: Cont to monitor resp status.
#3 FEN: TF=130cc/kg/day, infant cont to be NPO. PND7.5, IL,
and Fent infusing via DL PICC. Primary port to PICC line
with blood backup in tubing noted, flushed and patent, cont
to have blood backup with PN running through. [** 13**] aware,
port not flushable at this time, clotted. Primary port was
heplocked and cont fluids via secondary line. Left foot PIV,
infusing PRBCs o/n without diff. Infant receivied 2nd
alloquot of 10cc/kg. CW 881 (+9 from previous noc), using
weight 750gm for calculations. Abd soft, round, and pink, AG
19.5-20. Hypoactive BS noted, no stool, uop 4cc/kg/hr. Will
recheck lytes, BUN/Cr in the AM. P: Cont to monitor FEN
status.
#4 Sepsis: COnt with Amp and Cefotaxime. Will draw Vanco
trough this AM. Infant acting appropriate, temp stable. P:C
ont with abxs, f/u with Vanco trough-dose accordingly,
moniotr for sx of sepsis.
#5 G&D: temp stable in servoisolette, nested on sheepskin.
[** **] and active with cares, sleeps well in between. Cont on
Fent drip at 5.5mcg/kg/hr, received one bolus so far this
shift prior to repositioning. P: Cont to monitor and support
G&D, cont with Fent drip, monitor pain.
#7 [** **]: [** 370**] called x 1 o/n, updated by this RN. P: Cont
to encourage parental calls and visits.
#8 [** **]: Infant cont on neoblue [**Last Name (LF) 406**], [**First Name3 (LF) 31**] recheck [**First Name3 (LF) 33**]
level this AM. P: Cont phototherapy, f/u with [**First Name3 (LF) 33**] levels.
See flowsheet for further details.
| Overall Neutral Note |
682 | NPN addendum
5. Infant nested on sheepskin and water pillow in isolette.
Temp stable 97.9-98.4ax. Req fentanyl prn dose prior to
cares w/fair effect. Active w/cares, settled well after.
Continues on fent drip (500mcg in 50ccD5W) at 5.5mcg/k/min.
Skin appears dry but in fair condition. Rpt HUS done today
given poor increment on crit following PRBC tranf'n on
sunday.
Continue to support [**Last Name (un) 103**] needs.
7. Mom and [**Last Name (un) **] in visiting today, mom here for cares and
participating in temp/diaper change. Attended family mtg
today. This RN unable to attend--pls see [**Last Name (un) 13**]'s note
regarding mtg. [**Last Name (un) **] appeared satisfied w/mtg. Remain
appropriately guarded re infant's status.
Continue to support and update [**Last Name (un) 32**] regularly; family
mtgs provided on wkly basis.
8. Continues on neoblue phtx. For [**Last Name (un) 33**] check in am w/other
labs noted in FEN.
Continue to monitor.
| Overall Neutral Note |
683 | npn 7a-7p
1.) SEPSIS: ABX amp/gent dc'd today after day 7. began
oxcicllin for 3doses today. FOR CT changes. bc-, LP-.
continue to monitor for s/sx of infx.
2.) RESP: Infant remains intubated with settings of 16/5
rate 26. 5 of peep. no changes made today. 02 sats 86-100%.
ls very diminished-course. rr=20's-50's. ic/scr. occ
increase wob. suctioned more frequently for cloudy to yellow
secretions, from ett. cloudy orally. CT changed this am
without difficulty. pneumo appears smaller by
transilluminator, confirmed by cxr. CT-continuous LWS.
fentanyl gtt continues for pain management. prn mso4 given
x1 after ct change, with gd effect. received first dose vit
A today, continue to monitor resp status closely.
3.) FEN: TF decrease to 150cc/kg/d. Currently pnd6 infusing
via dluvc at 2.5cc/hr each. with IL at 0.5 and FENT gtt at
0.3cc/hr. abd is soft with hypoactive bs. ag=18cm. no stool
this shift. uop for 12hrs =4.6cc/kg/hr. no spits. no asp.
ngt position checked. plan to obtain lytes this evening and
in am. continue to monitor fen.
4.) DEV: Infant is nested on sheepskin on radient warmer.
temps 97.6-99.4 adjusted warmer. a/a with cares. lethargic
inbetween. fentanyl gtt continues for pain management with
gd effect. maew. afsf. brings hands to face for comfort.
continue to support dev needs.
5.) SOCIAL: Parents in to visit frequently and have been
upated by myself and team at bedside. loving and concerned
parents. ask appropriate questions. continue to support and
update.
6.) HYPERBILI: Infant continues under single phototherapy
for bili level 4.8,0.4, plan to recheck in am. is pink and
sl jaundice. continue to monitor for s/sx of hyperbili.
| Overall Neutral Note |
684 | NPN 1900-0700
ID: Infant now day 7 of 7 with abx Amp and Gent. Meds
admin as ordered. Temps sl elevated on servo warmer.
Warmer therefore weaned. BC and LP negative.
RESP: Infant remains intubated on conv vent settings 16/5,
R26. Rate weaned x2 thus far this shift per CBG. Most
recent CBG 0200: 7.31/55/39/29/0. FiO2 25-29%. LS
coarse/diminished. Sxn'd Q2-4H for lg amt cloudy secretions
via ETT & PO. IC/SC retractions. RR 30-60s. CT LUQ to
cont LWS, actively evacuating air. Pressure incr to 20cmH20
at 2400 [**Name8 (MD) **] [**Name8 (MD) 13**] for incr WOB and reaccum as verified by
translumination. To monitor CT patency closely. Fent drip
at 2mcg/kg for discomfort, with good effect. No spells thus
far this shift, occ drifts. Pt is on caffeine. To start
Vit A today. Continue to monitor.
FEN: BW 940g CW 905g (up 70g). Pt remains NPO. TF
160cc/k/day via DLUVC; PND6, IL, + Fentanyl drip. DS
stable: 169, 123, 102. Abd soft, round, no loops, no
audiable BS noted. AG= 17.5cm. 12hr UO= 3.4cc/k/hr, no
stool since [**12-18**]. Lytes 2100: 135/4.3/100/25 via hand drip.
At 0400, lytes sent via UVC line: 124/6.1/91/22/17. [**Month/Year (2) 13**]
aware. Lytes to be repeated this am for verification.
Trig: 87.
DEV: Temps warm this shift (99.1-100.1) while nested on
servo warmer. Warmer temp was therefore decreased.
Alert/drowsy with cares. Fent drip at 2mcg/kg for CT pain.
Morphine 0.1mg PRN for breakthrough pain. None required
thus far this shift. Moving hands to face. [**Last Name (LF) 194**], [**First Name3 (LF) 105**].
SOC: Parents in to visit x2 thus far. Updated at bedside
by this RN. Asking approp questions. Continue to support
and update parents as needed.
BILI: Rebound bili sent at 2100: 4.8/0.4 (up from 3.6/0.3).
Pt relit under photoRx bank at 2300. Eye mask in place.
Pt appears sl jaundiced. NPO, no stool since [**12-18**].
Continue to monitor.
| Overall Neutral Note |
685 | npn 7a-7p
1.) POT FOR SEPSIS: DAY [**4-26**] ON AMP/GENT. BC PENDING. CBC
WNL. LP-. CONTINUE TO MONITOR FOR SEPSIS.
2.) RESP: received on vent settings. of 16/5 rate22.
increased to rate of 30 at 2pm after capgas of 7.16, pco2
94, po2 22, c02 35 and base-0. fio2 28-48 %. increase with
cares. ls course amd diminished. large pneumo on left with
transilluminater. cxr taken several times today for new ct
and manipipulation. needle aspiration 35cc. later asp of
80cc. ct is to continuous LWS, with intermittent bubbling.
plan to repeat cbg this evening. infant is on caffeine daily
and will begin vitA Tomorrow. received mso4 x2 this am for
procedures and fentanyl bolus. at 1330 fentanyl gtt started,
with good affect. continue to monitor resp status closely.
3.) FEN: Infant NPO. TF 160cc/kg/d OF PND6 INFUSING VIA
DLUVC. 2.8cc/hr through each port. IL infusing at 0.5cc/hr.
fentanyl gtt is at 0.3cc/hr for total of 6.2cc/hr. plan to
have picc line placed this evening, consents signed in
chart. abd is soft, with + bs. no spits. no asp. no stool
this shift. up for 12hrs. is 5cc/kg/hr. plan to obtain lytes
and bili with first evening cares. trig level in am.
continue to monitor fen.
4.) DEV: infant remains nested on sheepskin on radient
warmer weaned for temp 99.1-99.3. infant was placed on right
side to keep left side up most of day, position changed only
with cares. infant is quietly a/a with cares. sedated with
fentanyl gtt. continue to monitor dev.
5.) PARENTS: Mom and dad both in throughout day, updated at
bedside. by this rn, and team. asking appropriate questions.
loving and concerned parents. continue to update and
support.
6.) HYPERBILII: Plan to obtain bili level this evening with
other labs. off phototherapy since [**2186-12-19**]. pt is jaundice.
follow plan after results. continue to monitor s/sx of
hyperbili.
| Overall Neutral Note |
686 | NPN
#1 Sepsis: infant remains on amp/gent, plan to repeat CBC
tonight with 24h labs d/t low WBC on initial labwork. stable
temps, active, alert. cont to closely monitor and complete
abx course as ordered.
#2 Resp: remains on NCPAP +6 FiO2, 28-34% with sats 89-97%.
BBS sl coarse/=. no desats or bradys so far this shift. on
caffeine. plan to draw cap gas this afternoon. cont to
closely monitor.
#3 FN: NPO, TF 80cc/kg/d, currently receiving D10 @30cc/kg
and Starter PN @50cc/kg via DLUVC. plan to start PN tonight
and increase fluids to 100cc/kg if indicated. voiding, no
stool yet this shift. plan to draw 24
lytes,bili,triglyceride tonight. Infant enrolled in lipid
study. cont to closely monitor.
#4 Dev: infant remains nested on warmer, stable temps.
active, alert, irritable at times but settles with
repositioning and containment. cont to provide dev support.
#5 Social: Dad in with multiple family members throughout
the day, updated on infant status. Asking appropriate
questions, invested, loving family. cont to provide updates
and support.
| Overall Neutral Note |
687 | Cont. of Nursing Progress Note
#5- O/A: Mom up this am, updated at bedside by this RN.
Asking approriate questions. Dad up this pm with
grandparents, then mom and other visitors. Again updated at
bedside by this RN. Stated that they would be returning for
next set of cares. Very loving and invested parents who are
approriately concerned. (mom in house for htn) P: Cont. to
support and inform parents. Encourage parental visits and
phone calls.
#6- O/A: Phototherapy dc'd this am for a bili of 2.0/0.2.
P: Check rebound in am.
| Overall Neutral Note |
688 | npn 7a-7p
1.) SEPSIS: Infant continues on amp/gent for 48hr R/O. BC
pending. continue to monitor for s/sx of infx.
2.) RESP: infant continues in nasal cpap prong 6. fio2
34-36% most of shift. lscl/= with ic/scr. no desats or
bradys thus far this shift. rr=50's-70's. 02 sats 87-96%.
bulb suctioned mouth with cares for cl secretions. continue
to monitor resp status closely.
3.) FEN: TF advanced to 120cc/kg/d IVF currently PND10
infusing via DL UVC at 4.3cc/hr, 2.2 through primary, and
2.1 through secondary. will add IL with new PN this evening.
began enteral feeds today of bm/ssc20, at 10cc/kg/d or 1.5cc
q4hrs. tol well. min bilious asp. no spits. abd is soft with
+bs. pink and full occ soft loop noted. passed first
meconium stool today. uop for 8hrs=3.8cc/kg/hr. plan to
repeat lytes in am. continue to support fen.
4.) DEV: Infant nested on sheepskin on radient warmer. temps
stable. A/A with cares. sl irritable at times but settles
quietly. afsf. maew. HUS is scheduled for this Friday.
continue to support dev needs.
5.) SOCIAL: Mom in this am updated at bedside and helped
with temp and diaper change. asking appropriate questions.
dad in later this afternoon updated as well. parents both
loving and concerned. family meeting scheduled for Monday.
continue to update and support family.
6.) HYPERBILI: Infant under double phototherapy, eyeshields
in place. infant is ruddy and sl jaundice. bili level today
4.9, 0.4. plan to repeat in am. continue to monitor for s/sx
of hyperbili.
| Overall Neutral Note |
689 | [** 13**] Progress Note
Infant had very unstable night with intermittent re-ecumulation of right pneumothorax and left atelectasis. Required numerous boluses of NS, Sodium Bocarbonate, PRBC as well as hand bagging and ventilator manipulation. HR have ranged from 185-200 with sats 65-85%. Phenobarbital given to help R/O seizures. Combivent given for tight BS with some improvement. By morning HR has come down into the 140's, improved perfusion, and sats in the high 90's. Will need close monitoring. [** **] have been at the bedside for much of the night and are up to date.
| Overall Neutral Note |
690 | NPN continued:
Tibial arterial line NS + 1u hep/cc. DS 70, 52. Abdomen
round, firm, taut when palpated, appears mottled. No loops.
Girth stable. Bilious aspirates obtained throughout night-
Infant examined by [** 13**]. Please see flowsheet for details.
Air also aspirated via NGT. NGT left open to vent. BabyGram
obtained- showing no compromise in abdomen. Urine output
.62cc/kg/hr. Generalized edema noted. One medium meconium
stool this shift. Lytes obtained this am- see flowsheet for
details.
A: Abdomen poses concern for compromise.
P: Cont to monitor abdomen closely. F/U d-sticks. Monitor
f/e balance.
DEV:
O: Infant temps stable at present- weaned x2 on open warmer.
Infant is nested with sheepskin. Font s/f. Infant alert with
cares; opened eyes intermittently throughout night. Tone
WNL; MAE. Infant fent drip increased slowly overnight from
2mcg/kg to 5mcg/kg d/t increased interventions. Infant also
given Fent bolus x1 and Morphine bolus x1. Pavulon given x1.
Phenobarbitol also given this am. Please see flowsheet for
details. Infant appears comfortable at present.Infant
responds well to hand containment and firm boundaries.
A: Infant appears comfortable at present.
P: Cont to support development and promote comfort.
SOC:
O: [** **] in frequently throughout night. Went home for
short period of time, calling frequently, and updated over
phone. [** **] currently at bedside with infant, providing
hand containment and speaking to her. Updated by [** 13**] [**Name6 (MD) 1047**] and MD. [**First Name (Titles) **] [**Last Name (Titles) 1048**] concerned about
infant, and are tearful. [**Last Name (Titles) **] planning on staying
throughout day, as mom was d/c'd yesterday. [**Last Name (Titles) **] have
family room reserved for stay. Mom continues to pump and is
freezing BM.
A: [**Last Name (Titles) **] [**Last Name (Titles) 1048**] concerned for infant.
P: Cont to support educate and keep informed.
BILI:
O: Bili this am 2.2/0.7. No phototherapy.
A: Resolving hyperbili
P: Cont to follow clinically.
| Overall Negative Note |
691 | Nursing Progress NOte Cont.
CV- Infant started on dopamine and then dobutamine for
unstable CV status, including frequent low HR's and blood
pressures. Doses manipulated multiple times with the goal
of maintaining MAPS >25. Infant completed 8cc of 2nd ordered
aliquot at approximately 1100. Infant pale to dusky as
perfusion declined throughout day.
[**Name (NI) 1049**] Mom and Dad at the beside throughout the day,
touching and speaking to their baby. Had friends with them
for support. Mom and Dad [**Name (NI) 1050**] sad and crying, very
concerned with infant's status througout ordeal. Very aware
of infant's status. Updated and consulted frequently by team
members and RN's. After code situation in am and frequent
bagging being required [**Name (NI) 32**] decided to redirect care at
about 1230. At this time mom and dad held infant while
intubated and at about 1250 infant was extubated while in
mom's lap. Mom and this RN dressed infant. [**Name (NI) **] continued
to hold infant and mourn with friends surrounding them
(infant pronounced by attending at 1300). [**Name (NI) **] and
friends remained with infant after demise. Team, RN and SW
spoke with [**Name (NI) 32**] before they left floor. Please see
attending noted for further details regarding redirection of
care.
Please see flowsheet, RRT and attending notes for further
information.
| Overall Negative Note |
692 | NICU NPN 1900-0700
RESP O: Baby remains orally intubated on settings of HFOV
MAP17, DELTA P 36. FIO2 during the night has been 44-67%,
increased to 80-100% with cares. O2 sats 90-97%, with
occasional drifts to the 80's. Lungs are coarse, suctioned
x2 for scant to small amount of secretions from ETT and
mouth. Baby has mild ic/sc retractions. rr 30-50's.
FEN O: Tf remain at 140cc/k/d. Enteral feeds are at 10cc/k,
tolerating well. IVF of d12.5PN, and IL are infusing through
PICC line without difficulty. Weight 796g, up 52g, basing wt
on 750g. U/O 2.6cc/k/hr. Abdomen is round and soft, bs are
hypoactive, no stool to time this shift. Minimal ngt
aspirates.
Pot for sepsis O: Remains on antibiotics.
DEV O: Temps are stable, nested on sheepskin, in servo
isolette. Baby is [**Name2 (NI) **] and active, opening eyes with cares,
settles with containment. Fontanells are soft and flat.
Parenting O: Mom was in to visit with her sister during
evening cares, took baby's temp. Asking appropriate
questions.
[**Name2 (NI) **] O: Baby remains under neoblue, wearing eye shields.
| Overall Neutral Note |
693 | NPN 0700-1900
#1 RESP O:Infant remains orally intubated on [** **] 70-100%
02, desats easily with any stimulus, requiring Fentanyl
boluses and hand bagging with 100%02 during procedures. BBS
equal, tight,coarse and diminished. ABG done today, wnl. A:
Alt in RESP P: Cont to assess for increased resp distress,
monitor blood gases as needed, provide 02 as needed.
Decrease touch an stimuli when possible.
#2 CVR O: Infant remains pink and well perfused, No audible
murmur, pulses normal and nonbounding, precordium quiet,
MAPS >28. A: Alt in CVR P: Cont to assess for changes in CVR
status, monitor blood pressure.
#3 FEN O: Infant remains on TF 160cc/k/day of IVF infusing
via [** 1876**]/UVC as charted in flowsheet. D/S stable, remains
NPO, good urine output, no stool, abd flat, no bowel sounds.
A: ALt in FEN P: COnt to maintain IVF as ordered, wt q day
or when stable, maintain NPO status.
#4 SEPSIS O: Infant remains on Ampi and Gent. Temp stable,
VSS, Blood cultures neg to date. LP attempted this afternoon
but no specimen obtained. A: r/o Sepsis P: cont to assess
for signs of sepsis, cont with antibiotics as ordered.
#6 SKIN O: Infant remains pink, dry and well perfused, no
flaking noted, no abrasions or open areas, skin overall
intact. A: ALt in SKin P: cont to assess closely for
irritations in skin, provide comfort measures and soft
surroundings.
#7 SOCIAL O: Mom and Dad in to visit today, asking
appropriate questions and updated on infant's progress. MOm
appears very anxious, sitting by bedsides watching both
infant's monitors today. Provided comfort and info to mom.
A; Involved and concerned family P: Cont to inform and
support family as needed.
#8 BILI O: bili sl elevated today, remains under single
phototherapy. P: Plan for bili on Monday.
| Overall Neutral Note |
694 | NPN
#1 #2
Infant remains on [** **] with present settings of Delta P=34;
MAP=15; FIO2~81-100% to maintain sats low/mid 90s. (most of
shift was spent in 100%-- at times able to wean down to 80%,
but usually not for long periods). Please see flow sheet
for all ABGs and changes made, but most recent at ~0200-
7.24/59/48/27/-3. CxR obtained at ~0100 and was reported
without change from previous film. BS course
initially--became "tighter" as shift progressed. Infant
suctioned for mod amounts of cloudy white secretions down
ETT and orally. Color is pink; well perfused. Murmer not
audible. BP means >29.
#3
NPO status continues. TF=160cc/k. Wt is up 29gms=650. [** 1876**]
with half NaAc/sterile water; DUVC with PN D9.5W/Lipids and
Fentanyl infusing as ordered. Abd is soft and flat; BS not
audible. Voiding well ~5cc/kg/hr over past 24 hours
(3.7cc/kg/hr over past 12 hours); no stool. DS=114.
#4
Infant remains on antibiotics day #8/?. Infant will need
repeat LP at some point.
#5/#6
Infant remains on an open warmer nestled in sheepskin with
tent to cover. Temp has been stable. Infant remains very
sensitive to touch and will desat quickly with handling.
Infant is receiving Fentanyl 3mcg/kg/hr, and is also
receiving 1.3mcg Fentanyl boluses prn. Infant does appear
comfortable for the most part. Eyes remain fused. Skin is
dry and intact without any areas of breakdown noted.
#7
No contact thus far tonight from [** 32**].
#8
Infant remains under mini neoblue phototherapy with eyes
protected. Bili level to be checked in a few days.
| Overall Neutral Note |
695 | Nursing NICU Note
1. Resp. O/PT remains on [** **] settings of: Map-17, Delta
P-37. FiO2 primarily 68-81% this shift. Increase in FiO2
needed with cares, sometimes as high as 100%. Combivent
puffs given once this shift thus far. Please refer to
flowsheet. A/Requires [** **] support to maintain adequate
oxygenation. P/Cont. to supply and wean FiO2 as pt
needs/tolerates. Cont. to monitor for s/s of resp distress.
3. F/N. O/TF remain at 130cc/k/d. TPN D9.7/IL running at
120cc/k/d via intact PIV in Left foot. Some dependent edema
noted in left leg. PIV flushed without difficulty. Left leg
elevated while on side. Enteral feeds remain at 10cc/k/d
pngt over 5 min. Please refer to flowsheet for examinations
of pt from this shift. [** 13**] in to examine pt for sm amt of
duskiness noted over right side of abdomen. See urine out.
No stool. A/Appears to be tolerating present feeding
regimen. at this time. P/Cont. to monitor for s/s of feeding
intolerance. Monitor I/O.
4. sepsis. O/Remains on Cefotaxime, Ampicillin and
Vancomycin as ordered. Most recent blood culture neg to
date. A/Treatment for potential sepsis/menigitis. P/cont. to
monitor.
5. dev. O/Temp remains stable on servo control in an
isolette. Awake and [** **] with cares. Pt on Fentanyl drip as
ordered. Aggitation and increase in FiO2 noted following 180
degree rotation. Pt required one Fentanyl bolus ([** 13**] aware)
and appeared to settle well afterwards. A/Discomfort and
stress well controled with Fentanyl drip and occasional
boluses. P/Cont. to support pt's growth and dev. needs.
Cont. to monitor for s/s of discomfort and stress. Strive to
keep pt comfortable and stress well managed.
7. [** 32**]. O/No contact from [**Name2 (NI) 32**] this shift. P/Cont. to
support and educate [**Name2 (NI) 32**].
8. [**Name2 (NI) 33**]. O/Remains under NeoBlue [**Name2 (NI) 406**] phototherapy. Skin
remains pink. A/Treatment for hyperbili. P/Cont. to monitor
effectiveness of phototherapy.
| Overall Neutral Note |
696 | NPN 0700-1500
Received infant on HIFI vent-MAp-9, Delta P-23, FIO2 59%. breath sounds very diminished left worse than right. ABg at 0800-7.3/33. Acute episode of pneumothroax at 0830 resulting in hypotension, bradycardia and desaturation. Hr 76-95- chest compressions done x 5minutes. Received Epi x 1. Chest needle aspirated for large amounts of air and manual evacuation of air continued for >4hrs ( as infant remained stable as long as aspiration was performed). parents have decided not to have chest tube placed and make infant as comfortable as possible. Infant has received fentanyl q 1hr for comfort.
CV: Color was ruddy- Head paled out during resuscitation. HUS- small Grade 1 bleed. On Dopamine gtt at present at 20mcgs/kg/min to maintain BP until parents are ready to withdraw support.
Parents have been in all morning- updated by Dr. [**First Name (STitle) 202**] as to the gravity of [**Doctor Last Name 2649**] status. Parents have decided to not continue with aggressive measures and make [**Doctor Last Name 1447**] comfortable. They have called in family for support. Both infants were baptized this afternoon. Both Mom and Dad have done kangaroo care with [**Doctor Last Name 1447**] and pictures have been taken. Awaiting mom's father to arrive. Parents are appropriately sad and tearful. gransparents seem very supportive of them and their decision.
Currently infant is being held by Mom. [**Name (NI) 687**] fentanyl given at 1425.
| Overall Negative Note |
697 | NURSING DEATH NOTE
At parents' request, infant was removed from the ventilator at 1610. Infant had received Fentanyl qhr for comfort. Baby was held by both Mom and Dad. [**Name (NI) **] was pronounced dead at 1655. Parents were with their very supportive family at this time.
Post-mortem care was done by myself and NNP-[**Doctor Last Name 45**]. Per parents' wishes, no autopsy will be done. Infant was transfported to the morgue as per protocol.
Bereavement papers and memory box complete. Social Work- [**First Name4 (NamePattern1) 352**] [**Last Name (NamePattern1) 353**] to follow up with family tomorrow.
| Overall Negative Note |
698 | NPN
1. RESP: Infant was received on HFOV vent settings: MAP 14,
delta P 34, FIO2 61%. Self extubation during cares,
reintubated, in gd position by CXR. Infant was agitated,
unabe to settle despite 3 fentanyl boluses, and increasing
in 02 to 100%, requiring bagging. Infant was given 1 dose of
Pavulon and fentanyl drip was increased to 6.5mcg/kg/hr.
Infant started to decrease02 requirement to 40%. At 3am,
CBG 7.24 41 61, MAP was decreased to 13.
A/P; Requiring pavulon and increased sedation to stabilize
worsening resp. status. Monitor oxygenation/ventilation, may
need CXR to further assess expansion, closely follow adjust
02 requirement, evaluate sedation and further need for
pavulon. Continue on hydrocortisone taper for significant
lung disease.
3. FEN: WT .824kg, up 37gr. NPO overnight due to resp.
instability/pavulon. TF at 130cc/kg, PN 10 via non-central
PICCL, with IL and fentanly gtt. DStix 239, s/p stressful
event. Abd soft, no loops, body with pale/mottled
appearance, [**MD Number(3) 736**]. UOP decreasing to 1.3cc/kg/hr so far,
no stools. AG 19cm, active BS prior to sedation.
A/P: Feedings on hold due to resp. status, follow DSTix ,
lytes and UOP, wt.
5. Dev: Infant was received nested in heated isolette. Unble
to return to baseline quiet state after self extubation,
fentanyl boluses did not provide relief, continued to be
inconsolabe/agitated with worsening resp.state. Infant
starting to move s/p pavulon. Quiet state, lower 02
requirement with increased fentanyl gtt/pavulon.
A/P: Unable to wean fentanly gtt, requiring more sedation to
stabilize infant. Monitor sedation needs closely, presently
at 6.5mcg/kg/hr of fentanyl gtt, assess need for
boluses-will need sedation prior to stressful cares-[**MD Number(3) 842**]/wt
times.
7. Social: [**MD Number(3) **] and GM visiting prior to extubation. Mom
stayed and was and bedside for evening events. Mom stayed at
the bedside for most of the time, but became [**MD Number(3) 236**]/upset as
he worsened. [**MD Number(3) 370**] came in again to be with mom. R. [**Name2 (NI) **] spoke
with mom.
| Overall Negative Note |
699 | NPN cont'd
7. Social: [** **] left as infant became more stablized.
A/P: Cont. to support and update, encourage mom to take
breaks from bedside.
8. [** **]: Remains on neo blue photox with eye shields. will
need to recheck [** 33**].
| Overall Neutral Note |
700 | NPN 7a-7p
#1: [**Known lastname 1140**] conts orally intubated on [**Known lastname **] vent. Settings: MAP
16 and delta P 39. FIO2 70-100% most of the day. BBS very
coarse and tight. This afternoon had sign. desat with apnea
and bradycardia, needing PPV to recover. Slow to recover.
Infant was started on Combivent inhaler. FIO2 now down to
50's. Sx'ed x2 for sm amt cloudy secretions from ETT and lg
thick cloudy secretions PO. CXR done. A: sign O2 req
P:Cont with Combivent inhaler as ordered. Sx as needed.
Will check blood gas.
#3: TF: 130cc/k/d. NPO. KUB this afternoon revealed no gas
pattern per Team. Infant noted to have very faint
hypoactive [**Last Name (un) 218**]. Abd soft, and full, no loops. AG
unchnaged. Did have small spit x1- benign. NG tube vented.
U/O: 4cc/k/hr in 12hrs. No stool despite glycerin supp. x1.
Double lumen PICC patent. Primary port infusing PND12.5, IL
and Fentanyl and secondary port infusing PND12.5. SOdium
Bicarb. given x1 as ordered. A: NPO P:Cont with PN & IL as
ordered. Check d/s. Follow wt and exam.
#4: Blood culture negative. Infant with appropriate
behavior. Temps stable. Ampicillin and Cefotaxime given as
ordered. A: day 16/21 P:Cont with antibiotics as ordered.
#5: Temps stable while nested on sheepskin in servo
isolette. Infant is [**Last Name (un) **]/active with cares. Very sensitive
to touch and stim. Mom brought in dark blanket, now
covering isolette. Attempting to limit touching, noise and
light. Fonts soft/flat. MAE. A: stable P:Cont to support
dev needs.
#7: [**Last Name (un) **] in today. Both updated by Dr. [**First Name (STitle) **]. Both aware
of infant's sign desat today. Aware that infant is getting
blood transfusion. Asking appropriate questions. A:
Involved family P:Cont to support and educate.
#8: Phototherapy remains off. Plan to check rebound [**First Name (STitle) 33**] in
am.
Infant is being transfused 2 aliquots of PRBC's for Hct 32.
1st aliquot finishing. Infant tol'ing well. Consent in
chart. 2nd aliquot to start at 1830.
| Overall Negative Note |
701 | NPN 7p-7a
#1: [**Known lastname 1140**] remains on [**Known lastname **] vent. Weaned settings x1 this shift
to current settings: MAP 16 and delta P 37. FIO2- mostly
70-78%, into the 90-100% range after PICC placement and
adjustments, several x-rays, retaping, and care. BBS
coarse/tight. CXR improved [**Name8 (MD) **] RRT. 2nd dose of
Hydrocortisone given. Breathing with IC/SC retractions. A:
stable P:Will give 3rd dose of Hydrocortisone at 0630.
Will be checking blood gas this am. Cont to monitor and
provide support as needed.
#3: Wt 906, up 19gms. TF: 130cc/k/d. PICC placed by [**Name8 (MD) 13**]-
non-cnetral on x-ray. Currently on IVF at 120cc/k/d.
PND9.7, IL and Fentanyl infusing via patent PICC. Enteral
feeds at 10cc/k/d. 21 feed held r/t PICC placement.
Resumed at 01care. Infant thus far has tol'ed 1.3cc BM20,
gavaged over 30mins. No spits thus far. Min benign asp. Abd
soft and full. No loops noted. AG stable. U/O: ~3.1cc/k/hr
in past 24hrs. No stool. P:Cont with current feeding
plan. Will check lytes and d/s with next care.
#4: Blood culture from [**12-14**] remains negative to date.
Infant is [**Month/Year (2) **]/active with cares. Temps stable. Conts on
antibiotics as ordered. A: stable P:Cont with antibiotics
as ordered. Will check Vancomycin levels with next dose.
#5: Temps stable in servo isolette. Infant is nested within
boundaries, on sheepskin with water pillow under head. Room
light off as much as possible. Infant MAE. Fonts soft/flat.
Brings hands to face. Conts on Fentanyl drip as ordered
with good relief. Did get bolus dose x1 prior to PICC.
Small scab noted on left toe. [**Month/Year (2) 13**] assesed. Cont to monitor.
A: stable P:Cont to support dev needs.
#7: No contact with [**Name2 (NI) 32**] thus far.
#8: Remains under [**Name2 (NI) **] Neoblue phototherapy. Voiding. No
stool. Min amt of enteral feeds. A: hyperbili P:Will
check [**Name2 (NI) 33**] level with next care.
| Overall Neutral Note |
702 | NPN 7a-7p
#1: [**Known lastname 1140**] conts on [**Known lastname **] vent. Weaned this am to current
settings: MAP 16, and delta P 36. FIO2 50-77%. Infant sats
better when prone. BBS coarse/tight/=. CXR this am stable.
Sx'ed for sm amt secretions from ETT and mod-lg amts PO. A:
weaned vent settings P:Cont to monitor and provide support
as needed. Blood gas in the am.
#3: TF: 140cc/k/d. Infant made NPO this am s/p 0.2cc benign
asp, ^'ed ag to 19cm, full soft abd with slight dusky hue on
right side and small benign spit. [**Known lastname 13**] Rivers assessed. KUB
revealed no gas pattern per Team. No stool despite rectal
stim x1. U/O: 2.2cc/k/hr in past 12hrs. Conts on PND12.5
and IL. PND12.5 infusing via both lumen of double lumen
PICC, and IL piggybacked in 1ary port along with Fentanyl
gtt. D/S stable. A: NPO P:Cont to monitor. KUB in the
am. Follow wt and exam. Check lytes in am.
#4: Blood culture negative. Temps stable. Infant with
appropriate behavior. Ampicillin and Cefotaxime given as
ordered. A: day 15/21 P:Cont to monitor for s&s of
infection. Antibiotics as ordered to complete 21day course.
#5: Temps stable in servo isolette. Weaned x1. Infant has
been [**Known lastname **]/active during care. Does settle after cares and
sleeps well in btw. Infant is nested on sheepskin, within
boundaries with water pillow in place for comfort. Also
conts on Fentanyl gtt at 6mcg/k/hr with good pain/stress
control. Both knees slightly reddened today. Tegaderm
applied to protect them when prone. Fonts soft/flat. Lg
bruise noted on left cheek. Team aware. Opened eyes during
care. A: stable P:Cont to limit stim. Support dev needs.
#7: Mom in for most of the day. [**Known lastname 370**] joined her by late
afternoon. Both updated and asking appropriate questions.
A: Involved family P:Cont to support and educate.
#8: Infant conts under min Neoblue. Slightly jaundice. NPO.
Voiding qs. No stool. A: hyperbili P:Check [**Known lastname 33**] level in
the am.
| Overall Neutral Note |
703 | NPN 0700-1900
#1 RESP O: Infant remains orally intubated on [** **], settings
as charted, 02 90-100% most of shift, unable to wean, infant
having frequent desats and needing 100%02 and handbagging
with procedures. 1800 ABG was good this evening, Delta P
decreased but MAP increased to 17 with improvement in
infant's oxygenation. A: ALt in Resp P: cont to assess for
increased resp distress, provide 02 as needed, cont with
comfort measures and Fentanyl.
#2 CVR O: Infant remains pink and well perfused, no audible
murmur, pulses normal and nonbounding, B/P stable, [** 1876**]
infusing well. A; Alt in CVR P: Cont to assess for changes
in CVR status.
#3 FEN O: Infant decreased to TF120cc/k/day and increased to
TPN D12 and IL infusing via UVC, at present time now
infusing via PICC line. UVC to be d/c'd this evening. UOP
4cc/k/hr, no stool, no bowel sounds, d/s 61. A: Alt in Fen
P: cont to maintain IVF, wt when stable. Check d/s.
#4 SEPSIS O: Infant remain son AMpi and [**Name (NI) **]. P: Cont with
antibiotics as needed.
#6 SKIN O: Infant's skin intact, pink and drying. No open
areas. P: cont to assess for skin integrity.
#7 PARENTSO: Mom and Dad in today, mom remains very anxious
at bedside, Dad asking many appropriate questions. A;
Involved and concerned family P: cont to inform and support
as needed.
#8 BILI O: Infant remains on single phototherapy. Plan for
bili in am.
| Overall Neutral Note |
704 | Nursing Note
1. O/A Recieved [** **] on HiFi settings of delta P17 Map of
9. Weaned from these vent settings to delta P15, MAP of 8
after good gas. Gas after wean at ~1430 of
7.28/52/50/25/-2. Pls see flowsheet for trends. Received
3rd dose of surf at 11am. BLS course/=, sats >90%. Sats
stable with all cares. No spontaneous bradys thus far. P/
Cont to monitor gases and wean from vent as tolerated.
2. O/A No murmur by auscultation. Started on indomethacin
for presumed PDA. BP means (by peripheral art line) >28 with
occassional decreases to low 20's. Continues on
dopamine(60mcg/50ccD10W) at 22mcg/kg infusing via peripheral
line without incident. [** 20**] is pink, well perfused, has
appropriate cap refill, +pulses, quiet precordium. Tot
blood out at this time =3.4cc. Calc HCT=48 today. P/ Cont
to monitor. Wean from dopa as tolerated.
3. O/A recieved [** **] on TF of 100ml/kg/d. TF now ^ to
150ml/kg/d for elevated Na=148. D5W infusing without
incident via PIV @ 1.3ml/h, D10W infusing without incident
via PIV @1.3ml/h, [**12-20**] NSw/ [**12-20**] u hep. via Periph Art line @
1.0ml/h without incident. Tol IVF well with stable D/S, v/
no stool thus far. UOP= 1.4ml/kg/h, abd flat and
unremarkable. Refer to flowsheet for lytes and other lab
values for exact trends. P/ Cont to support FEN needs.
4. O/A Currently on warmer with plans to transfer to servo
iso. Nested on sheepskin, with tent in place. Occasional
movement, startles then has limited movement with cares,
AFOSF, PFOSF, AGA. P/ Cont to support GD reqs.
5. O/A Parents called several times today for updates. In
this afternoon x1. Updated at bediside with family members.
[**Name (NI) 263**] states she is overwhelmed. Dad and Mom [**Name (NI) 236**] at
bedside. Offered emotional support. P Parents will meet with
NNP in Mom's room for review of infants course in NICU, and
updates. P/ Cont to update, support, and educate family.
6. O/A Cont on amp and gent for sepsis r/o. No s/s of
infection. P/ Cont to assess for s/s of infection.
Refer to flowsheet for details.
| Overall Neutral Note |
705 | [** 96**] ON-Call
Both [** 26**] in to visit last evening. Father has returned from out of town. He reports having done a lot of internet research regarding Trisomy 18 and feels that [**Known lastname 536**] chest and heart anomalies should be treated surgically. I stated that consultations could be obtained from specialists at [**Hospital3 48**], that I was not knowledgable about the surgical interventions that would be required nor would the surgery be done at the [**Hospital1 **]. I did state that they might encounter some resistance due to her diagnosis, with questionable benefit given her diagnosis, but we would support their inquiries as advocates for their child. Both [**Hospital1 26**] held [**Known lastname **] and mother gave her a bath and used A/D oinment on the dry areas of her skin. I confirmed the family meeting planned for Monday [**5-15**] at 2 pm with Dr. [**First Name8 (NamePattern2) 537**] [**Last Name (NamePattern1) 165**]/NICU team.
| Overall Negative Note |
706 | NICU nursing note 7p-7a
1. Resp: Infant remains intubated on IMV settings 21/6 Rt
24. FiO2 21-26%. BSC/=, no retractions. No bradys. Occas
labile O2sats with drifts to high 70's. Sxn'd scant amount
via ETT. Appears comfortable. Cont to monitor.
2. CV: Loud murmur ausc. Brisk cap refills. + peripheral
pulses. Infant pink, BP 59/26 (38). Cont to monitor
closely.
5.Malformations: Diagnosis of Trisomy 18. Hyperactive
percordium d/t absent sternum. Polydactyly present. Extra
digit to right hand slightly cyanotic. Cont to monitor.
Infant noted with tremors at start of shift. Versed and
Morphine given for comfort. Cont to manage.
5. FEN: CW= 1975g up 40. Remains on TF=110cc/kg/d of
Neosure 22 gavaged every 3hours over 120minutes. Abd soft,
soft loops. + bowel sounds. Small spits x1. Voiding,
stooling heme(-). Cont to monitor.
6. G&D: Temps stable under off warmer. Clothed and covered
with blankets. Drowsy, alert at times. Active, MAEW.
AFOF. Sedated. Cont to support needs associated with
anomalies.
7. [** **]: Mom and [** **] visited. Updated on condition and
plan. [** 72**] performed diaper change and other cares. Mom
held infant during feeding. Anxious and loving. Cont to
support.
| Overall Neutral Note |
707 | Nursing Progress Note
#1-O/A- Received infant vented at 21/6x24. Infant remains
vented at those settings. FIO2 21-27% so far this shift.
No resp distress. P- Cont to assess for Resp needs.
#2-O/A- Cont with audible murmur. Known large VSD. HR and
BP wnl. No current CV distress. P- Cont to assess for CV
needs.
#4-O/A- Trisomy 18. Cont with multiple anomolies. Remains
vented for absent sternum. R hand extra digit remains
dusky. P- Cont to assess for changes or needs related to
malformations.
#5-O/A- TF=110cc/kg/d of Neosure22 via NGT. Abd soft, int
soft loops. Two larger aspirates this shift most likely
related to almost continuous feeds. [** 96**] aware. Voiding and
stooling. P- Cont to assess for FEN needs.
#6-O/A- [**Known lastname **] [**Known lastname 533**] cont to be mostly sedated but active
with cares. Tremors at times. MSO4 and Versed given as
needed for comfort. Temp stable on off warmer with clothes
on and blankets covering her. Not swaddled related to
fragile chest. P- Cont to assess for G&D needs.
#7-O/[**Name (NI) 251**] [**Name (NI) 72**] called with updates given. [**Name (NI) 72**] asked multiple
questions about possible surgeries to fix [**Known lastname **] [**Known lastname 549**]
chest and heart. He stated he had been researching on the
internet. [**Known lastname 72**] encouraged by RN that he was exploring all
his options. No matter what the outcome he will feel better
knowing that he did explore all options. [**Known lastname 72**] reminded by RN
that [**Known lastname **] [**Known lastname 550**] issues also involve her brain. [**Known lastname 72**]
instructed to speak with [**Known lastname 96**] or MD the next time he calls or
visits. P- Cont to enc parental calls and visits.
See flowsheet for further details.
| Overall Negative Note |
708 | Case Management Note
Discharge options are limited for this little infant with Trisomy 18, endotube, vent,NGT feeds, IV Mso4 and Versed. I have called [**Hospital 541**] Hospital for Children ([**Telephone/Fax (1) 542**]) and they are not able to manage an endotracheal tube and would not be able to consider admission for infat. I have called [**Hospital1 543**] Pediatric unit ([**Telephone/Fax (1) 544**]) and they are not able to do endotracheal tubes either. I have placed calls to several skilled nursing facilities ([**Hospital 545**] Pediatrics in [**Location (un) 546**] and [**Hospital3 547**] of [**Location (un) 548**] Mass) today. I await return calls, but endotube will also be a barrier for admission as well. Given absent sternum , a permanent trach/airway not an option per team. We can offer hospice/bereavement services to family for coping with this catastrophic dx, if family amenable. If family were to consider home w/hospice, they would have to provide care for infant at home 24 hrs/day , but would have some back up w/hospice nurses. I would need to ascertain if endotube at home a possibility with home hospices. I will cont to explore d'c options and discuss w/team and family as indicated
| Overall Negative Note |
709 | [** 96**] On-Call
Please see Dr.[**Name (NI) 407**] note for overall summary and plan.
Physical Exam
General: infant on open warmer, intubated on vent support, under phototherapy
Skin: warm and dry; scattered petechiae; pink
HEENT: orally intubated; anterior fontanel open, level; sutures opposed
Chest: breath sounds equal fair aeration; no visible sternum
CV: RRR, murmur audible; precordium very active with visible heart just below skin surface; pulses +2
Abd: soft; no masses; + bowel sounds; cord on/drying
GU: normal female
Ext: polydactaly with primitive digits, overriding thumbs
Neuro: calm during exam; moving all extremities; + grasps; increased tone when disturbed
| Overall Neutral Note |
710 | NPN 0700-1900
1. SIMV 21/6 rate24, 21-26%FiO2. No vent changes made
today. rr30-50's, sats88-94%. LS clr/=, sm airleak
audible. Sxnd for mod-lg cldy from ETT. Of note, sm [**Doctor Last Name **]
of blood noted at one catheter passing, none seen
thereafter. Team aware. Continue to monitor resp status,
plan on gas in am.
2. Infant with known PDA/VSD, loud murmur heard, pulses nl.
BP 74/31 M46. Continue to watch for CHF, perfusion.
4. Infant with known Trisomy18, examined by genetics today.
Genetics spoke with mom at length via phone interpreter.
Explained chromosomes, Trisomy18, statistics/probabilities.
Mom asked [**Name2 (NI) 206**] questions, had flat affect during meeting
but was tearful at bedside when visiting infant. COntinue
to support infant with Trimsomy18 dx.
5. TF increased to100/k today. Ent feeds @30/k, SC20 pg, no
advancement plan. IV @70/k, PND10 adn IL infusing via PIV.
No spits, 3cc asps today benign in appearance and refed (but
subtracted from vol due). Belly soft, soft lops visible
good BS. u/o 2.3cc/k/hr adn passing sm mec. Continue to
feed as tolerated, monitor I+O.
6. Temp 97.7-98.2ax , set temp on warmer increased. Given
fentanyl q3hrs or so for sl agitation. Infant has tremors
of extremeties. Settles with paci and often times needs ETT
sxng. Continue to support [**Last Name (un) 86**] needs.
7. Mom had flat affect during genetics mtg but tearful at
bedside. given photos of infant to take home. SHe will be
staying with sister in [**Name (NI) 214**], phone #'s available in
chart. Attending had tried to contact dad who is currently
in [**State 521**] for unknown length of time--unsuccessful. Continue
to support and update non English spkg mother.
8. Under neoblu bank, for lytes/bili check in am. Continue
to monitor.
| Overall Negative Note |
711 | Neonatology - [** 96**] Progress Note
Infant sleeping with exam. Blunted response to stimuli. AFOF. MCA noted. She is pale pink, well perfused, grade III/VI murmur auscultated. She remains on conventional vent, breath sounds clear and equal. Abd softly distended with large visible loops. Stable temp on open warmer. Please refer to neonatology attending note for detailed plan.
| Overall Neutral Note |
712 | NURSING PROGRESS NOTES.
#1 O: BABY REMAINS INTUBATED AND VENTILATED. VENT SETTINGS
INCREASED TO MAP 13, DELTA P 24, HZ 15. OXYGEN REQUIREMENT
IN 30 TO 40% RANGE THIS MORNING, BACK AT 60 TO 70% RANGE
THIS AFTERNOON. BREATH SOUNDS COARSE AND DECREASED. ETT
RETAPED TODAY. SUCTIONED FOR MODERATE SECRETIONS FROM ETT,
LARGE WITH OLD BLOOD FROM MOUTH. A: INCREASED VENT SETTINGS
REQUIRED TODAY. P: CONTINUE TO MONITOR AND PROVIDE SUPPORT
AS REQUIRED.
#2 O: NO MURMUR HEARD. PULSES NORMAL, CAP REFILL BRISK.
PACKED RED BLOOD CELL TRANSFUSION COMPLETED AT 1000.
HYDROCORTISONE COMPLETED THIS MORNING. DOPAMINE
DISCONTINUED AT 0730 AND RESTARTED THIS AFTERNOON AT 1330
FOR BP MEAN DROP TO 26. DOPAMINE RANGE 4 TO 14 MCG/KG/MIN.
BLOOD OUT 1.8CC. A: NO MURMUR, OFF DOPAMINE FOR 6 HOURS
TODAY. P: CONTINUE TO MONITOR AND PROVIDE SUPPORT AS
REQURED.
#3 O: TOTAL FLUIDS INCREASED TO 140CC/KG/DAY. BABY REMAINS
NPO. D/STIX 134 AND 129. URINE OUTPUT GREATER THAN
7.3CC/KG/HR. NO STOOL, NO BOWEL SOUNDS. ABDOMEN SOFT AND
FLAT. UAC WORKING WELL AND INFUSING WITH 1/2 NACL WITH 1/2
UNIT HEPARIN PER CC. DOUBLE LUMEN UVC WORKING WELL.
PRIMARY PORT INFUSING WELL WITH D10W WITH 1/2 UNIT HEPARIN
PER CC. SECONDARY PORT INFUSING WELL WITH D10PN, IL AND
DOPAMINE. POTASSIUM DECREASING FROM 7.1 THIS MORNING TO
5.7. CALCIUM GLUCONATE GIVEN FOR IONIZED CALCIUM OF 1.05.
A: D/STIX AND POTASSIUM BETTER TODAY. P: CONTINUE TO
MONITOR AND PROVIDE SUPPORT AS REQUIRED.
#4 O: CONTINUES ON IV ANTIBIOTICS. A: SEPSIS POSSIBLE CAUSE
OF SEIZURES. P: CHECK LP BEFORE STOPPING ANTIBIOTICS.
#5 &8 O: TEMP STABLE ON WARMER NESTED ON SHEEPSKIN AND
COVERED WITH OXYHOOD. BABY SEEMED COMFORTABLE TODAY AND NO
FENTANYL WAS GIVEN. BABY TOLERATED PLACEMENT OF EEG LEADS
WITH HAND CONTAINMENT. A: BABY SLEPT WELL TODAY. P:
CONTINUE TO SUPPORT BABY.
#6 O: PARENTS UP SEVERAL TIMES TODAY AND WERE UPDATED BY
FELLOW. PARENTS CONCERNED AND CARING. MOTHER ASSISTED WITH
DIAPER CHANGE. A: INVOLVED FAMILY. P: CONTINUE TO KEEP
INFORMED.
| Overall Neutral Note |
713 | NPN Days
#1 ID: Temp stable on servowarmer, infant MAE, alert and
active with cares. Day [**5-30**] of Amp and [**Last Name (LF) **], [**First Name3 (LF) 31**] forgo LP
at this time r/t patient instability. Bld cxs NTD. P: Cont
to monitor for sx of sepsis, cont [**First Name3 (LF) 622**] for 14 day course per
team.
#2 Resp: HFOV, currently MAP 11 AMP 20, weaned MAP following
CXR showing hyperexpansion. F/u ABG drawn (see labs), no
changes made. LS cl/=, mild SC retrac, sxn Q4-6H for small
cloudy secretions. Infant with more frequent desats to 80's
this afternoon requiring increased Fi02 for recovery. Infant
given Fent for comfort, no Pavulon so far this shift. P:
Cont to monitor resp status.
#3 CV: No murmur appreciated, 130-150's, infant appears
pink/jaundiced/purple in color, cap refill approx 3 sec,
+PPP. Infant has generalized edema, TBO=0.5cc at this time.
Dopamine currently running at 11mcg/kg/min, MAPs 26-40, goal
is >25. Cuff BPs are correlating with UAC. P: Cont to
monitor CV status, wean Dopa as tolerated.
#4 FEN: TF=140cc/kg/day, infant receiving PND12.5, D12.5,
Dopamine, and Fent via DL UVC, infusing without diff. UAC
infusing sterile water with Na Acetate and Hep, without
diff. Abd is edematous, taught, AG 18.5. V/S, no stool.
Dstick 75. P: Cont to monitor FEN status, Q24H lytes,recheck
triglycerides in the AM (will restart IL this eve).
#5 G&D: Temp stable on warmer, infant is alert and active
with [**Last Name (LF) 1904**], [**First Name3 (LF) 105**], o/w appears calm. Neuro consult this
AM, no new recommendations at this time. P: Cont to monitor
and support G&D, cont daily HC, HUS repeat in the AM.
#6 Parents: Parents in this AM, updated by this RN at the
bedside, asking appropriate questions. FM scheduled for this
afternoon. P: Cont to encourage parental calls and visits.
#7 Pain/Comfort: Infant generally appears comfortable, cont
Fent gtt at 2mcg/kg/hr, 3 boluses given today for
intermittent agitation and desats. P: Cont to monitor pain.
#8 Bili: Cont mini neoblue. P: Cont phototherapy, f/u with
bili levels as ordered.
See flowsheet for further details.
| Overall Neutral Note |
714 | Family Meeting Note
Family meeting held with both parents, Dr. [**First Name (STitle) **], RNs Tierny and [**Doctor Last Name 3532**], RT [**Doctor Last Name 2791**], myself. Review of pre/perinatal events, current clincal status by systems including IVH. Respiratory and nutritional plans over the next 1-2 weeks and close monitoring of Head Ultrasounds conveyed. Potential for Post-hemorrhagic hydrocephalus and treatment options explained. All questions answered. Checklist completed and placed in chart.
| Overall Neutral Note |
715 | Admission Note
NICU Nursing Admission Note
Infant admitted to NICU after precipitous delivery in triage room of L&D. Please see Attending MD note for maternal history and infant's physical exam.
He was intubated in L&D and brought to NICU.
RESP: Infant intubated with settings of 24/5 X25. FiO2 40-60%. Survanta given at 0500. Lung sounds coarse and dim. IC/SC retractions. No spells noted. ABG at 0530 was 7.24/50/53/22/-6.
C/V: No murmur heard. HR 140-160's. Infant is ruddy with perfusion improving. NS bolus given at 0645. Extensive head and facial bruising noted.
F/N: BW 675g. NPO. TF 100cc/k/d. UAC and DLUVC inserted by NNP Rivers. UAC has 1/2NS with hep infusing at 0.8cc/h. DLUVC has D5W with hep infusing at 1cc/h each. D/S 85. Abd soft and flat. No void and no stool noted so far.
[**Month (only) **]: CBC and blood cultures sent. CBC benign. Blood cultures pending. Ampi and Gent given as ordered.
DEV: Boy [**Known lastname **] is active and alert. Skin is gelatinous and ruddy. Extensive bruising noted on his face and head. Initial temp was 92.4. Infant was placed upon infant transport mattress with warm gel and warmign lights applied. Temp warmed up steadily and was 97.5 at 0700. He is feisty and puts his hands to his face. Vitamin K given. Erythromycin held as eyes remain fused.
PAR: Parents in to visit on their way down to postpartum. They were appropriately teary at bedside and asked appropriate questions. Dr. [**Last Name (STitle) **] spoke with them at bedside. They were briefly oriented to NICU.
| Overall Neutral Note |
716 | NPN 0700-1900
RESP: Rec'd [** **] on HFV- Delta P-21, MAP-10, FIO2 ~60%.
0745:[** 20**] had several desats and sats remained in 60-70's
despite 100% FIo2, also noted Hr dropping to 60-70's- all
qsr. Poor perfusion noted w/ BP MAP-16-20(on 20mcqs
Dopamine). Team called to bedside. ABg just prior to
event- 7.25/52/43/24/-4. Dr [**Last Name (STitle) 118**] spoke to parents, who came
to bedside- updated on critical status of [**Last Name (STitle) **]. Asked to
hold [**Last Name (STitle) **]- [**Last Name (STitle) **] changed to conventional vent(settings of
35/6 x 50- 100% FIO2). Both parents held- care not
re-directed at this time. [**Last Name (STitle) 20**] kept on conv vent as BP
and perfusion improved. Abg at 1400 on conv vent- 35/6 x
45=7.36/36/50/21/-4. Have been able to wean FIo2 as low as
40%, however, that is short lived. Bradys have
dramatically increased to every few minutes, hr drops to
30-60's, all qsr. He then desats to 60-70's(needing
increased fio2), w/ slight drop in Bp as well. ? seizure
activity w/ these episodes. Having spoken to the parents,
who are aware of the increased spells, no extraordinary
measures are to be taken- DNR order in front of chart. No
further blood draws, blood gases.
CV/Heme: No murmur is audible. Color is pale-pink/jaundiced.
+ 3rd spacing throughout body. Legs/groin are stiff w/
edema.
BP has improved since changing vent support but still
ranges 20-28 on Dopmaine gtt at 20 mcqs.
[**Last Name (STitle) 20**] rec'd 1 aloquot of PRBC"s this am for a HCT of 19.7
( down from 31.2 at 11pm last night). Plt down to 76,
Pt-33.3, PTT70.5, INR-3.6,Fibrinogen-187
F&N: TF increased to 160cc/kg/d for lytes- 157/6.0/115/19.
Lytes 6hrs later=158/7.4. U/o=.7cc/kg/hr x 12hrs. No stool
out since birth. UAC infusing [**2-13**] NA Acetate w/ .5u Hep at
.8cc/hr. UVC- #1port=D5w w/.5u Hep at 1.6cc/hr,
#2port=Starter PN at 50cc/kg/d=1.4cc/hr + Dopamine at
.68cc/hr. D/s- 80 + 69.
S/p replacement overnight- IC=1.02.
A/P: MAintain fluids as ordered.
ID: Blood cx is negative to date. Gent d/c'd w/ trough
level of 1.9. Cefotaxime started.
| Overall Negative Note |
717 | Nursing Progress Note 0700-1900
SEPSIS O/A: Infant continues on Abx of Ampi & Gent. Day 3 of
7. P: LP to be done this week. Cont to monitor on current
regime.
RESP O/A: Infant received on HFOV: MAP 10, AMP 23, weaned
MAP to 8 & AMP to 21 @ after good ABGs (see laboratory for
results). CXR done @ 0945. ETT re-taped @ pushed to 6.5cm.
FiO2 44-85% throughout the day. Sxn mod white secretions
from the mouth x1 (some old blood present). P: Cont to
monitor ABG's. Wean Fio2 as tolerated.
CV O/A: No murmur audible by team today. Cap refill slightly
delayed. Moderate generalized edema present. Continues on
Dopamine drip; received on 15mcg/k/h, weaned to 8mcg/k/h
this afternoon, requiring 15mcg/k/h @ the end of the day to
maintain MAP >25. Unable to get a cuff pressure today.
Infant pale this a.m.; color improving throughout the day.
Hct 34.5 @ 1030; 6cc PRBC given @ 1200, Second aloquot of
6cc PRBC's hung @ 1700 (to infuse [**Doctor First Name 400**] three hours). P: Cont
to wean dopamine as tolerated. Monitor closely.
FEN O/A: TF @ 140cc/k/d. NPO. PAL Na Acetate w/ 0.5u hep/cc
infusing @ 1cc/h. Primary port of DLUVC: D5W w/ 0.5u hep/cc.
Secondary port of DLUVC: TPN D7.5 w/ hep & lipids. Dopamine
(30mg/50ml D5W) & Fentanyl drio (250mcg/50ml) piggybacked
into secondary port of DLUVC. D-sticks 107 & 120. Abdomen
flat/pale, AG 17cm. Voiding 2cc/k/h (12h). Lytes @ 1030:
139/4.8/107/19. P: Cont to monitor I&O, electrolytes and
d-sticks.
G&D O/A: [**Known lastname 3527**] is nested on sheepskin on a servo warmer.
Gel pillow under head. Temps 97.7-98.4 today. Eyes remain
fused. Infant is sedated. Infant head position not changed
today d/t unstable resp & CV status [**Name8 (MD) **] MD. P: Cont to
monitor. Keep comfortable.
PAR O/A: Parents in throughout the day with visitors.
Updated by this RN @ infant's bedside. Family verbalizes
that they "don't have any questions yet". P: Cont to update
& support NICU family.
COMFORT O/A: Continuous Fentanyl drip infusing at 2mcg/kg/h
for pain management. PRN Fentanyl dose given x1 prior to
CXR. No Pavulon given today.
| Overall Neutral Note |
718 | continued NPN
6. Parenting: Mom called at MN, briefly updated by this RN
and Dr. [**First Name (STitle) 202**]. Parents then came up to see baby due to his
fragile state. Parents were both updated by Dr. [**First Name (STitle) 202**],
discussed how sick baby was, need for parents to think about
re-direction of care with his unstable condition. [**First Name (STitle) 370**]
stated, that "baby was in our hands". Mom quiet,listening,
touching baby. Also, encouraged family supports and
religious/spiritual support. They expressed they did want
infant baptized but their priest was [**Name2 (NI) 1066**]. Very
loving parents, would be back to talk about their decisons.
This RN spoke to them in Spanish and understood
information-parents very fluent in English. [**Name6 (MD) 370**] is MD [**First Name (Titles) **]
[**Last Name (Titles) **] [**Name (NI) **], mom has family here in Mass.
7. Hyperbili: Under double phototx, eye patches on. Bili
1.7. Extensive bruising present especially head and trunk.
Cont to monitor, bili levels.
8.Skin: Thin, gelatenous like skin, areas of erythema, no
broken down areas, aquaphor to body. Increasing edema,3rd
spacing fluid. Eyes fused. Monitor for areas of breakdown,
aquaphor as ordered.
| Overall Negative Note |
719 | NPN 1900-0700
SEPSIS: Infant continues on Amp & Gent. Blood culture
remains negative at this time. Will continue to monitor.
RESP: <Please see attending and RT's note for details>
Infant received on HiFi. Had a significant respiratory event
requiring hand bagging with several failed attempts to
return to HiFi. Conventional vent attempted as well. Infant
was placed on a Fentanyl drip and got a dose of Pavulon.
Infant eventually placed back on HiFi where she remains at
this time. LS remain course and diminished with IC/SC
retractions. Several blood gases obtained this shift, see RT
note for details.
CV: No murmur appreciated. Infant received 2nd dose of
Indocin for 3mm PDA via echo ([**Name8 (MD) **] NNP). Infant remains on
Dopamine, cuff BP's remain stable with means mostly between
30-50. Infant finished blood transfusion this shift of
15cc/kg for Hct 29.9. Repeat Hct this shift was 30.0 - MD &
NNP aware.
FEN: Infant remains NPO with DLUVC in place. PAL placed by
MD this shift. PND5, D5W, Dopamine & Fentanyl infusing via
DLUVC. 1/2NS infusing via PAL. Abdomen soft/flat, bowel
sounds not audible. D/S 131, 105 thus far. Voiding
(5.7cc/kg/hr), no stool ever thus far. Lytes drawn x2 thus
far. NaCl bolus given for low sodium. Plan to recheck lytes
in AM.
G/D: Temp remained stable throughout shift nested in
sheepskin on radiant warmer. Eyes remain fused. Quite
irritable at times, Fentanyl PRN given x2 then Fentanyl drip
started. Pavulon given x2 thus far as well. Aquaphor ordered
to skin PRN. Skin translucent, but intact. Small bruises
noted on ankles. Plan to repeat HUS on Friday ([**Name8 (MD) **] NNP, last
HUS WNL).
PARENTS: Mom in with visitors at beginning of shift. NNP
spoke with Mom during respiratory event and Mom and her
sister came to visit. Mom updated at bedside by RN, NNP &
MD. Dad came in from home and was too updated by team. Once
infant started to stablize, family went back to Mom's room.
Encouraged parents to call and visit. Have not heard from
them since returning to room this AM.
| Overall Neutral Note |
720 | NPN 1900-0700
1 Infant with Potential Sepsis
2 Alt. Respiratory
3 Alt. Cardiovascular
4 Alt. FEN d/t prematurity
5 Alt. growth and development
6 ALt. Parenting d/t NICU stay
#1: O: Infant continues on Amp and Gent for a rule out. BC
pending. P: Conitinue to give abx as ordered, monitor for
further s/s of sepsis.
#2: O: Continues on HFOV, current settings MAP 11, deltaP22.
VBG at 9pm was 7.26/58, went up on delta p from 20 to 22 at
this time. MAP was increased from 10 to 11 this shift for
desats. Last VBG was 7.24/53/56/24/-5. No changes were made.
FiO2 69-100%. LS clear/diminished with ic/sc retractions.
Infant has been labile in O2 sats, requiring 100% frequently
to bring sats up. Sx with cares for sm-mod. cloudy/white
secretions. VitA will be started today.
#3: O: No murmur audible. HR 130's-150's. Infant is ruddy,
well perfused. Infant started on Dopamine at 5mcg/kg this
shift. BP MAPs have been 32-40 since. Blood out 4.7cc. P:
Continue to monitor.
#4: O: Infant not [**Last Name (LF) 3528**], [**First Name3 (LF) **] current weight is still
birthweight of 575g. Infant is NPO, TF 140cc/kg/day. Infant
has a double lumen UVC. Through the primary port D5 with
1/5U hep is running at 2.5cc/hr. Through the secondary port
infant has PN D5 running at 50cc/kg/day or 1.2cc/hr with
Dopamine at 5mcg/kg or .14cc/hr piggybacked in. Abdomen soft
and flat, hypo BS. Girth 17cm. Infant is voiding, no stool.
U.O. 0.9cc/kg/hr this shift. Dsticks 120, 167. Infant is
having lytes checked q6hrs, see laboratory for results. P:
Continue to monitor I&O, electrolytes and dsticks.
#5: O: Infant remains on servo warmer. Adjusting temp as
appropriate. Alert and active with cares, sleeps well in
between. Eyes remain fused. Infant is nested in sheepskin
with a waterpillow. A: AGA. P: Continue to support growth
and development.
#6: O: Parents in at beginning of shift. Asking appropriate
questions. A: Loving family. P: Continue to support parents
in the care of their infant.
REVISIONS TO PATHWAY:
1 Infant with Potential Sepsis; added
Start date: [**2148-1-19**]
2 Alt. Respiratory; added
Start date: [**2148-1-19**]
3 Alt. Cardiovascular; added
Start date: [**2148-1-19**]
4 Alt. FEN d/t prematurity; added
Start date: [**2148-1-19**]
5 Alt. growth and development; added
Start date: [**2148-1-19**]
6 ALt. Parenting d/t NICU stay; added
Start date: [**2148-1-19**]
| Overall Neutral Note |
721 | NPNOte
#1.On AMP+ gent given as ordered, gent pre level 1.2 cont
with gent,infant alert,active. A; asymptomatic P; cont
antibiotics as ordered.
#2. Remains orally [** **], on HFOV, currently at Delta
P=24, MAP10, Fio2 52-100%, labile with o2, BBS diminshed,
equal, checked for Pnuemo for having desat episode to 50's
needed hand bagging at 12.30pm,chest xray done changes made
on the vent~2pm for hyperinflation,,venous gas at 3pm,
7.35/40/35/23/-3. no changes made on the vent.cloudy et and
oral secretions suctioned in small amount.spont resp present
with mild subcostal retractions,A;labile on HFOV support. P;
cont vent support as needed.
#3.Pink, well perfused, murmur heard by Dr [**First Name (STitle) **], started
on Inomethacin, given as ordered,BP means 26-43, cuff
measurement,cardiac echo done,HCt 29.9,p cell transfusion
15cc/kg/day, over 4hrs infusing at secondary port of DLUVC.
Dopamine infusing at 2mcg/kg/minute infusing at primary port
of DLUVC.A; unstable hemodynamics P; cont to monitor,
maintain BP means 25-28.
#4. TF=120cc/kg/day, NPO, IVF PND5 with heparin infusing at
primary port at 50cc/kg/day, IVF D5 with hep infusing
~67cc/kg/day, BS not audiable, no loops, abd pink, d'stix88,
lytes 136/4.6/106/21,mag 2.2,BUN 20, Creat0.9,team aware,
urine dip stick results MD aware. voided 3.9cc/kg/hr for
last 12hrs, no stool.A; NPO, mainatined d'stix P; cont
current nutritional plan, lytes Q8h, triglycerides with next
blood draw.
#5.Infant alert, active, fentanyl x1 given for comfort,temp
stable in a tent, nested in sheepskin, mae, aquaphor
applied, skin intact,gelataneous, bruised heels,head u/s
done. A; AGA P; cont dev support.
#6. Parents visited, inbetween care,updated by DR [**First Name (STitle) **] at
mom's bedside. A; loving P; cont update and support.
#7. Mildly jaundiced, started on mini Neoblue light with
bili 4.0/0.3,alert,active.A; mildly jaundiced,P; bili in am.
| Overall Neutral Note |
722 | Nursing Progress Note
#1. O: Infant remains on day [**10-30**] of treatment of presumed
sepsis with ampicillin/gentamicin/ceftazdime. Blood cultures
neg thus far. A: Sepsis. P: Continue to follow.
#2. O: Infant remains on HiFi vent, settings increased
tonight per ABG of 7.24/78. Currently on delta P 18, MAP 12.
FiO2 overnight has been 85-100%. ABG now 7.35/52. Right
upper chest tube with constant bubbling. Ct has put out
~14cc's SS fluid. CT dressing site changed by NNP this
evening. CXR this evening with unresolved right pneumo. A:
Unstable. P: Continue to monitor.
#3. O: BP tonight with MAP's 25-34. Dobutamine d/c'd this
a.m. Dopamine weened to 20mcg/k/[**Month/Year (2) **]. Infant continues with
poor perfusion. Mod generalized edema. Continues with [**Month/Year (2) **]
color on trunk, groin, upper legs and arms. Skin taught.
Blood out currently 3cc's. Hct this evening 35.6/ plt 156.
Infant not taken off HiFi to ausciltate murmur. A: Weening
pressor support.
#4. O: Infant remains NPO on TF's of 150cc/k/d. 1/2NS with
hep infusing via PAL. D16PN infusing well via primary port
of DLUVC. D10W with hep, dopamine, fentanyl and IL's
infusing well via secondary port. D/S 97-119 tonight. Last
elec's at 0400 143-3.1-108-25. Abd [**Month/Year (2) **] and taught, no
loops. Voiding 6.5cc/k/hr. No stools. No new wgt tonight. A:
NPO. P: Continue to monitor FEN status.
#5. O: Infant remains on radiant warmer with stable temp.
She is unable to tolerate cares - desats to 50's-60's with
activity. On fentanyl drip 5mcg/k/[**Month/Year (2) **] plus fentanyl bolus
given prior to cares. Gel pillow under head. Lambswool
placed in neck roll. Some lip smacking noted occaisionally
during shift, not associated with desats. NNP aware. HC
22.5cm. Fonts firm and full. A: Pain/stress controlled. P:
Continue to assess and support developmental needs.
#6. No contact from family thus far.
#8. O: Infant remains under double phototherapy. Eye [**Doctor Last Name 39**]
in place. Bili this a.m. up to 4.1/0.4. A:
Hyperbilirubinemia. P: Continue to follow.
| Overall Neutral Note |
723 | NPN con't
G&D/Neuro: Temps stable nested on servo warmer. Skin intact
except for small area on left side of neck cracked and has
mod white/yell drng. Cleaned w/ sterile water and open to
air. Infant is lethargic and hypotonic especially in arms.
No reflexes. Has little spontaneous movements, although is
responding more during cares and when bothered. Sucks on ETT
occasionally. Very "jumpy" when touched. No signs of pain,
no fentanyl given, ordered for prn. No seizure activity
noted this shift. Recieving phenobarb and phosphenytoin as
ordered. Con't to monitor.
Family: Dad called x1, Appropriate on the phone. Asked for
update on [**Female First Name (un) 2517**] and wanted to make sure [**Known lastname **] was
comfortable. Con't to support and update as needed.
Bili: Infant jaundice under double phototherapy. Level sent
at 0600, pnd. See flowsheet
| Overall Neutral Note |
724 | NURSING PROGRESS NOTES.
#1 O: BABY REMAINS INTUBATED AND VENTILATED. BABY WAS
INITIALLY ON CONVENTIONAL VENTILATOR, CHANGED TO HI FI AT
NOON. BABY INITIALLY ON MAP OF 11, GRADUALLY INCREASED TO
12 AND THEN WAS ABLE TO WEAN OXYGEN FROM ABOUT 70% TO 35%TO
40%. BREATH SOUNDS COARSE, MILD RETRACTIONS. BICARB GIVEN
ONCE FOR ACIDOSIS THIS MORNING. THIRD DOSE OF SURFACTANT
GIVEN THIS MORNING. A: CHANGED TO HIFI TODAY AND ABLE TO
WEAN OXYGEN. P: CONTINUE TO MONITOR AND PROVIDE SUPPORT AS
REQUIRED.
#2 O: NO MURMUR HEARD. PULSES NORMAL, PRECORDIUM QUIET.
BLOOD OUT 5.9CC. DOPAMINE AT 30MCG/KG/MIN AT 0700. STARTED
HYDROCORTISONE AT 0730. DOPAMINE WEANED TO LOWEST OF
4MCG/KG/MIN BUT HAS SETTLED AT 10MCG/KG/MIN. 2 X ECG'S DONE
FOR HIGH POTASSIUM LEVELS THIS AFTERNOON. A: NO MURMUR,
HIGH POTASSIUM LEVELS REQUIRING TREATMENT.
#3 O: TOTAL FLUIDS INCREASED TO 120CC/KG/DAY. IV FLUIDS
INITIALLY D5W WITH 1/2 UNIT HEPARIN CHANGED TO D10W WITH 1/2
UNIT HEPARIN AFTER D/STIX OF 34 AND 43 BOTH OF WHICH WERE
TREATED WITH D10W BOLUS. AT 1830 BABY CHANGED TO D10PN.
PERIPHERAL IV REMOVED AS IT WAS NO LONGER WORKING THIS
AFTERNOON. UAC AND DOUBLE LUMEN UVC CONTINUE TO WORK WELL.
ABDOMEN IS SOFT AND FLAT, URINE OUTPUT 3.3CC/KG/HR, NO STOOL
PASSED. POTASSIUM AT 1500 WAS 8.1 AND WAS TREATED WITH
BICARB AND CALCIUM GLUCONATE , REPEAT 8.8 WAS TREATED WITH
BICARB AND LASIX. A: UNSTABLE ELECTROLYTES AND D/STIXS
TODAY. P: CONTINUE TO MONITOR AND TREAT AS NEEDED.
#4 O: BABY REMAINS ON IV AMPI AND GENT. A: CULTURES
NEGATIVE TO DATE. P: COMPLETE 48 HOUR R/O.
#5 O: TEMP STABLE ON WARMER WITH OXYHOOD. BABY HAS SLEPT
FAIRLY WELL NESTED ON SHEEPSKIN WITH BOUNDARIES. CLUSTERED
CARE AND DECREASED NOISE PROVIDED. A: SICK INFANT. P:
CONTINUE TO PROVIDE SUPPORT.
#6 O: PARENTS UP TO VISIT SEVERAL TIMES TODAY AND WERE
UPDATED AT BABY'S BEDSIDE. BOTH PARENTS TOUCHED BABY. A:
INVOLVED CARING FAMILY. P: CONTINUE TO KEEP INFORMED.
| Overall Neutral Note |
725 | NPN 0700-1900
#1 RESP O: Infant remains on HIFI Ventilation, 02
requirement 30% most of day. Weaned on vent today,please see
flowsheet for details. ABG's with good results. No spont
resp effort today, BBS equal with poor aeration. No spont
desats or bradys today. A: Alt in RESP P: cont to assess
closely for changes in 02 requirement, monitor vent settings
closely and wean as tolerated. ABG's as ordered
#2 O: CVR O: Infant remains pink, fair perfusion, jaundiced
and bruised. B/P stable today on 8 mcg/kg/min of Dopamine.
NO murmur audible, pulses full. 10cc/k of PRBC's infused
well. A: ALt in hemodynamic status P: cont to assess b/p
closely, Dopamine as needed. Monitor for signs of murmur,
cont to monitor HCT and blood out.
#3 FEN O: Infant remains on TF 140cc/k/day of TPN D10 at
75cc/k/d via UVC, 1/2 NS via UAC, D5W with Heparin via UVC,
Dopamine in D10W and IL infusing via UVC. D/S 136-230. UOP
decreased this shift, plan for BUN/Creat with next labs.
ABd. soft, nondistended, no bowel sounds audible. A: Alt in
FEN P: cont to assess strict I&O's, wt when more stable,
monitor blood sugar, plan for Lytes this evening.
#4 SEPSIS O: Infant remains on Ampi and Gent as ordered.
Temp stable. BLood cultures neg. A: R/O Sepsis P: cont with
antibiotics as needed, LP when infant more stable.
#6 PARENTING O: Parents in to visit throughout day, asking
appropriate questions and updated on infant's progress.
Family meeting held today with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **], parents and
this nurse. Dr. [**Last Name (STitle) **] spoke with parents regarding
Neurologist'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 166**] of EEG results and about the concern
of infant's low brain activity level and continuing to have
seizures on the EEG (although unable to see any clinical
seizures). Parents very concerned and asked mainly questions
regarding future outcome. Dr. [**Last Name (STitle) **] stated that we need
more information in the next few days including CT scan of
his brain, further EEG readings, therapeutic sz medication
and infant's phyisical exam. A; Concerned family P; cont to
inform
| Overall Neutral Note |
726 | NPN 7p-7a
Resp: Infant remains intubated settings unchanged today.
17/5x18. Fi02 23-27%. Abg this am 7.29/49/65/25/-3. On above
settings. RR 40's. Ls coarse to clr with sxn. Sxn x1 by RT>
Ic/Sc retractions. Cont to wean as [** **].
CV: Infant is mottled slightly jaundice. Conts with soft
murmur. Recieved last dose of indocin this afternoon. Conts
on dopamine 5mcg/kg in d10w. Bp means today 34-40's. to keep
means >32. Precordium active. Pulses full. Rec last dose of
hydrocortisone today as ordered. Rec prbc's. 16cc in 2
aloquots infused over 2hrs. Refill brisk. Cont to titrate
doapamine.
Fen: Infant remains on tf 120cc/kg. Rec ns with 1/2 unit of
heparing at 1cc/hr via uac. Pn with IL and dopamine infusing
via dluvc. Dstick today 189. Abd full but soft. AG 19.5cm.
Abd slightly dusky. Unchanged from previous. No bs
auscultated. Cath in situ voiding dk urine with lg blood per
test strip. lytes to be checked at 1800 with triglycerides.
Cont with current plan.
Sepsis: Infant conts on amp and gent. No new signs of sepsis
noted.
Dev: TEmp stable on servo warmer. Responding to verbal and
tactile stimuli. Occasional spontaneous movements. Sucking
on et tube this afternoon. Nested in sheepskin with
boundries in place. Cont to support developmental
milestones.
Parenting: Mom and Dad both in this afternoon. Mom dc'd this
afternoon. Family meeting this afternoon with Neourology
attending and resident. [**Doctor First Name 3459**], fellow, [**First Name4 (NamePattern1) 352**] [**Last Name (NamePattern1) 353**] SSw
and this RN also present. Parents given poor prognosis on
this infant. Parents expectedly upset, appear at this time
to be coping well with each other's support. Plan per team
to discuss redirection with family. Cont to support and
update.
Bili/: Infant conts under double phototx. Eyes covered. bili
this am 5.7/.6/5.1. Skin intact. No broken ares noted at
this time.
Pain: No signs of pain noted at this time.
Neuro: Infant conts on phenobard and fosphenotyin. No overt
sz activity noted. EEG not performed today. Neurology in
today and discusse
| Overall Neutral Note |
727 | NPN Days 7am-7pm
#1 O: [** 20**] remains orally intubated on vent settings of
32/6 BR 40 and remains in 100% FIO2. Breath sounds are
coarse. Very occasionally with have a few of his own
bresthes but chest movement is usually "in sync" with the
vent. Sxn orally for small amts tan/old blood secretions. A:
no chnages made on vent. P: Continue to moniter.
#2 O: HR remains regular with rates in the 80s during most
of this shift - over last several hours has had occasional
drifting of the HR to the 60s but mostly holding 69-74. No
murmur noted. Precordium active/visible. "Severe"
generalized pitting edema noted over extremities, trunk,
head and neck. Also signif bruising noted over extremities
and especially head, face and neck. Cuff pressures with
means 23 snd 24 - see flow sheet - was unable to obtain a
cuff pressure later this shift. Dopamine continued to infuse
at 20mcgs/k/minute until ~ 1720 pm. A: continued low HR and
b/p throughout the shift, continued poor perfusion with
severe edema. P: Continue to moniter.
#3 O: Remains on TF of 160cc/k/day. Has NaAcetate infusing
via UAC. Currently has D5W and starter PN infusing via
DLUVC but will switch to D5W into secondary port as well
this evening. Continued genralized edema as noted above.
U/O is approx 2.7cc/k, but urine is probaly mixed with
extravascular leaking fluid (did "see" [** **] actually void
X 1 this shift).No stool. Abd remains firm and edematous, no
bowel sounds heard. A: severe edema as noted, is making some
urine. P: Continue to moniter fluid, edema, urine output.
#4 Blood cultures were negative at 48+ hours and antibiotics
were d/c'd.
#5 O: [** 20**] remains on heated open warmer this shift when
not kangarooing with [** 32**]. [** 20**] spent many hours
kanagrooing with mom and [** **] held [**Name (NI) 3679**] for awhile this
evening. [**Name (NI) 20**] temp noted to be cool after kangarooing
(low to 94-95 axillary) and then increased when on warmer.
[**Name (NI) 20**] with minmal activiy - some arm movements noted when
on warmer.
| Overall Neutral Note |
728 | NPN Days continued
#5 continued.... Fentanyl given q 3-4 hours for presumed
discomfort r/t edema and immobility. Eyes remain fused.
[** 20**]'s posotioned side>back while on warmer, is on
sheepskin. A: 25+ week [** **] with edema, history of
concerning head u/s. P: Continue to moniter, continue to
give PRN fentanyl.
#6 O: Both [** 32**] in at beginning of shift and at end of
shift with mom visiting for several hours by herself during
the day. Mom's OB was in to visit as was [** **]'s maternal
grandmother. [**Name (NI) **] content to hold [**Name (NI) **] and sit quietly
with each other at the bedside. RN in to check on them
freqeuntly and updated them on plan of care and plans to
keep [**Name (NI) **] as comfortable as possible. MD [**Name8 (MD) 118**], NNP [**Doctor Last Name 1047**] and this RN met at the bedside with [**Doctor Last Name 32**] -
discussed changes in [**Doctor Last Name **]'s status (HR , blood pressure,
edema, etc) and possibility of discontinuing the dopamine -
[**Doctor Last Name 32**] discussed this possibility with each other and then
expressed that they would be comfortable stopping the
dopamine. [**Doctor Last Name **] asking appropriate questions but mostly
sitting and holding [**Doctor Last Name **] at the bedside. A: [**Doctor Last Name 32**]
updated and are aware that dopamine has been stopped. P:
Conitnue to support [**Doctor Last Name 32**]. [**Doctor Last Name **] are staying in [**Location (un) 2944**] parent room tonight and also have a cell phone number
listed in the chart.
#7 Phototherapy had been d/c'd prior to shift change this
morning and remains off.
#8 O: Please see description of edema and bruising as noted
in above problems. [**Location (un) 20**] has multiple, small scabs noted
over extremities. Also has severe pitting edema with areas
of "oozing" clear (?extravascular) fluid. [**Location (un) 20**]'s positon
changed side>back, skin cleansed with sterile H20,
extemities support with "facecloth" rolls as needed. A:
skin integrity as noted. P: Continue to moniter.
| Overall Negative Note |
729 | NICU NPN 1900-0700
POT FOR SEPSIS O: Baby remains on ampi, [** **], and
ceftazadime, day [**9-29**]. BC neg to date.
RESP O: Baby remains on HFOV MAP12,AMP 16. Art gas at 2200
7.46/48/38/35/+8. NNP aware. No changes made. Fio2 has been
68-100% during the night. O2 sats 87-99%, with drfits to the
80's, and she desats to the 70's with cares, requiring 100%
fio2. Upper right CT remains to suction, with air
evacuation, constant bubbling. Lower right CT, remains to
H20 seal. Lungs are diminished, and coarse. Suctioned x2 for
moderate secretions from ETT, mod from mouth. CXR obtained
at 0300.
CV O: HR 140-160's, Baby has overall bruising, cap refill
improved, pulses are normal, no murmur audible. Baby remains
on Dobutamine gtt, weaned to 10mcg/kg/[**Month/Year (2) **], also on Dopamine
gtt at 25mcg/kg/[**Month/Year (2) **]. Plan to wean dopa now as tolerated. BP
maps 24-43. Plt 252, HCT 36 awaiting other coag results. She
has moderate generalized edema.
FEN O: Per team, baby is to be weighed today when [**Month/Year (2) 32**]
are here. Tf increased to 150cc/k/d. Lytes at 2200 were
146/4.4/104/27/19. Repeat lytes sent at 0400 are pending.
IVF of .45%ns with hep infusing through PAL well. IVF of d5
with hep and PN and IL are infusing through DLUVC. D sticks
90, 154. U/O 5cc/kg/hr for this shift. Abdomen is taut, no
loops, bs are hypoactive, no stool.
DEV O: Temps are stable, nested on sheepskin, on servo
warmer. Baby drowsy, active with cares requiring increased
fio2. Fontanells are soft, full. Baby repositioned during
the night. She remains on a fentanyl gtt at 5mcg/kg/hr.
Received bolus x1 prior to CXR, otherwise, she seems less
irritable than she was last night.
Parenting O: No contact thus far this shift.
Bili O: Bili 4.4/0.5, remains under double phototherapy,
wearing eye shields. Difficult to assess jaundice due to
generalized ecchymosis.
| Overall Neutral Note |
730 | NICU NPN ADDENDUM
Baby was noted to have some intermittent jerking motions of upper and lower extremities, and what appeared to be some lip-smacking also, around 0430am correlating with desats. NNp aware and examined baby. [**Name (NI) **] continue to monitor. Per lab, coag results on careview have to be re-run. Results are pending.
| Overall Neutral Note |
731 | npn 7p-7a
1 alt resp
2 alt cv
3 alt FEN
4 alt sepsis
5 alt dev
6 alt parenting
7 alt bili/skin
admission note and care plan 7p-7a
#1 Infant recieved from L+D intubated with 2.5 ETT. Placed
on convent vent and given first dose of Survanta with good
FiO2 wean effect. CXR done and ETT high, no tension to be
put on tube. LS coarse and tight, second dose of Survanta
given at 0300 but FiO2 remains at 50-70% to maintain Sat
>92%. Mouth continues to have fresh blood draining from
difficult intubation. Infant boarderline low platelets
noted. ABG's obtained and vent appropriately weaned and one
dose bicarb given with good result. Will cont to monitor
and wean vent as tolerated.
#2 Infant noted to have stable BP upon admission then
quickly needing NS bolus x 3 total of .45% NS then started
on Dopamine 60mg/50cc started at 5mcg then needing to be at
max 20mcg so far at this time with order to maintain MAP
>35. Appearing very bruised but good cap refill noted and
no murmur audible at this time. Will cont to monitor BP and
titrate Dopamine as needed.
#3 TF 100cc/kilo/d of IVF infusing thru DUVC and UAC.
Currently UAC .45% NS w/hep infusing at 1.0cc//hr with
tempermental wave form noted and easily drawn off. UVC has
primary D5w/hep infusing thru it. Secondary has Dopamine
and D5 w/hep infusing for total of 4.2cc/hr. Abd flat with
+BS and no void yet. D/S stable x 2. 6h of age lytes and
bili drawn, pending. Will cont to monitor lytes and
maintain fluid balance.
#4 CBC and BC snet then antix started ampi and gent given.
Will monitor for sepsis and cont with antibx tx. Monitor.
#5 Infant is lethargic and nonresponsive at this time. On
sheepskin with boundaries. cont to support dev needs.
#6 Parents up to visit around 2300 and update given. Happy
with the infant and aware of current problems and what to
expect for now. Mom going to try to pump and decide to
breastfeed later. Support and inform.
#7 Infant noted to be extremely bruised from extraction.
Feet and legs are noted to be black from bruising, as well
as hands and areas on head and trunk.
REVISIONS TO PATHWAY:
1 alt resp; added
Start date: [**2158-11-9**]
2 alt cv; added
Start date: [**2158-11-9**]
3 alt FEN; added
Start date: [**2158-11-9**]
4 alt sepsis; added
Start date: [**2158-11-9**]
5 alt dev; added
Start date: [**2158-11-9**]
6 alt parenting; added
Start date: [**2158-11-9**]
7 alt bili/skin; added
Start date: [**2158-11-9**]
| Overall Neutral Note |
732 | NPN/0700-1900
#1 RESP: Infant remains orally intubated on settings 17/5
r18. FiO2 21-30%. No spells. LS sl. coarse to clear;
diminished on R side x1. Sxn ETT for small amts clear to
old blood tinged secretions. No spontaneous resp. effort
noted.
#2 CV: No audible murmur heard on exam. Repeat ECHO done
this afternoon. HR 120-130's. Full pulses; + palmar
pulses. Active precordium. Hct today=34.8. Transfused
with 20cc/k of PRBC's (two aloquots); receiving first
aloquot this shift. Platelets ^ to 124. Remains on Dopamine
(60mg/50Ml D5). Ranging from 18-22mcg/k/min to maintain
means >30 (have been running ~32 this shift).
#3 FEN: Received infant with TF at 120cc/k/d; ^ to 140cc/k/d
this afternoon sec. to decreased urine output. 0.45NS w/hep
infusing thru UAC. PN(D7), IL, and Dopamine infusing thru
DUVC. D5 w/hep ^ (piggybacked thru DUVC) when TF ^'d;
infusing at 20cc/k/d. Received one NS bolus of 10cc/k sec.
to urine ouput; 0.4cc/k/12hrs. No stools. Abd. soft, full,
no BS. Abdomen pink; sl. dusky. Girths=18-19cm. DS=120
and 156. Ordered for lytes, BUN/creat in AM.
#4 SEPSIS: Remains on Amp and Gent (Q36hrs). CB benign.
Blood cx from yest eve. pending.
#5 DEVELOPMENT: Infant nested on sheepskin on open warmer.
Temps 98.2-100.3; warmer weaned accordingly. Hypotonic;
moving extremities when touched; quiet at rest. Not opening
eyes. Bruising noted on head and torso. Reddened/pussy area
noted under neck folds; area washed with sterile water and
dried (left open to air).
#6 PARENTS: Mom and dad visiting at bedside this afternoon.
Updated by team members. Very loving and appropriate with
infant. Mom changed infant's diaper and checked temp
independently. Grandparents visiting later in shift.
#7 BILI: Remains under double phototx with eye shields in
place. Bili check in AM.
#8 PAIN: Ordered for Fentanyl 1mcg PRN for comfort.
Administered x1; able to wean FiO2 after given.
| Overall Neutral Note |
733 | NICU NPN 1900-0700
POT FOR SEPSIS O: Baby remains on ampi, [** **], and cef, day
[**8-30**].
RESP O: Baby remains critically ill, orally [**Month/Year (2) **] on
HFOV settings at MAP12, AMP 16. Fio2 has been 80-100% during
the night. Amp increased from 14-16. Last abg at 0230 was
7.32/57/61/31/0. She has ic/sc retractions, suctioned for sm
to moderate cloudy secretions. Baby has 2 chest tubes in
right chest, upper and lower, with air evacuating from upper
chest tube continously, both are to continous
suction.Serosang drainage from upper. Baby did have some
bleeding noted under the dressing after cxr at 0300, nnp
aware, and examined baby. [**Name (NI) **] new drainage noted since then.
Pneumo was smaller [**Name8 (MD) **] NNp on cxr at 0300.
CV O: Baby has generalized brusing, and severe edema over
entire body, with delayed cap refill. BP maps ranging from
18-40. She remains on Dopamine gtt at 25mcg/k/[**Name8 (MD) **], and
Dobutamine gtt at 20mcg/kg/[**Name8 (MD) **]. She is also receiving
hydrocortisone as ordered. HR are 150-170's.
FEN O: Decision was made not to weigh baby due to
instability. Tf remain at 120cc/k/d. IVF of D16PN, and IL
are infusing through DLUVC well. .45%ns with heparin is
infusing through PAL well. D sticks 80,77. Lytes at 0300
138/4.7/101/27/15. BUN 48, Creat 1.1. U/o 3.4cc/k/hr
overnight. Baby remains npo. Abdomen is firm, no bs, no
stool.
DEV/COMFORT O: Temps are stable, nested on sheepskin, on
servo warmer. She continues on a fentanyl gtt at 5mcg/k/hr,
and has received boluses overnight for increased
irritability. In addition to irritability, twitching noted.
NNp aware and assessed baby ?seizure activity therefore,
baby started on phenobarbital. No generalized, or
tonic/clonic movements noted. Fontanells are soft, and full.
We were going to attempt to turn baby at 0300, but she began
bleeding at CT site, and was desating at the time.
Parenting O: Mom and dad were in and left at [**2140**]. Updated
at the bedside by nnp.
Bili O: Baby remains under double photo, wearing eyeshields.
Bili this am 4.5/0.5.
| Overall Neutral Note |
734 | NPN 0700-1900 cont'd
BILI: Under double phototherapy w/ a bili at 1400 of
3.0/0.3/2.7.
DEV: HUS- significantly more bleeding, increased bradys, Bp
instability.? seizure activity. Labile w/ any intervention.
Fentanyl given x 2 ( less agitation noted off HFV).
Eyes remain fused.
Temp=97.8 ,nested on open warmer.
A/P: Keep comfortable w/ Fentaynl as needed
Skin: Gelatinous, Aquaphor applied x1. Extensive bruising
noted over head/face.
PARENTS: Mom and [** 370**] called to bedside this morning due to
[** **]'s instability. Mom and [** 370**] each were able to hold
[** **]. Rec'd updates from Dr. [**Last Name (STitle) **] they seem to
understand the gravity of their son's status, but have not
decided to withdraw care.
Parents returned to [**Location **]-partum but were called back this
afternoon after HUS was done. They were informed of the
dramatic increase in the bleeding and how this was and would
affect their son. They were informed also of the increase
in bradycardic episodes and that despite all our efforts, we
would not be able to "fix" the bleeding and most likely,
[**Known lastname 2704**] would not survive. [**Known lastname 2704**] was baptized this
morning. Parents feel they can not redirect care at this
time and would like to have "things progress naturally". A
DNR order is in chart, no further vent changes, blood gases,
medication, transfusions will be done.
Sw- [**First Name4 (NamePattern1) 352**] [**Last Name (NamePattern1) 353**] [**Name (NI) 1079**], in on family mtg.
A/P: WIll continue to update and support parents.
| Overall Negative Note |
735 | Neonatal NP-Note
Parents at bedside. Mother currently holding. Myself and bedside RN [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **] with parents current plan of care to include: comfort measures only, no blood work, no blood products. I also discussed the possibility of [**Known lastname 2704**] having a decompensation without them present and that leading to his ultimate demise. Both mother and father voiced that they are aware that that could occur. Father asked to see a copy of a Pediatrics text book. I asked if he had specific questions that I could address and he stated that he wanted to read some info on basic pathophysiology of extremely premature infants. I was able to provide a text for him to review.
| Overall Negative Note |
736 | NICU NPN 1900-0700
POT FOR SEPSIS O: Baby remains on ampi, [** **], and cefotaxime
now day [**7-30**] of antibiotics.
RESP O: Baby remains critically ill, orally [**Month/Year (2) **] on
HFOV current vent settings of MAP11, AMP 14. Both were
weaned during the night. Fio2 has been mainly 43-70%, but
has increased over the past hour to 85%. CXR at 0300, showed
some residual air, so head was repositioned up to help
evacuate air. Baby has 2 chest tubes in upper, and lower
right lung, lower has no bubbling in chamber, upper has
continous bubbling in air chamber, and drained approx 15cc's
of serosang fluid. Dressing [**Known lastname 3536**] are intact. O2 sats have
been 88-96%, with drifts to the 80's. Last abg at 0400 was
7.33/57/25/31/0. Please see flowsheet for other abg's during
the night. Mouth suctioned x2 for large cloudy secretions.
CV O: Baby remains on dopamine gtt, now at 25mcg/k/[**Last Name (LF) **], [**First Name3 (LF) **]
attending. Baby was also started on Dobutamine , and is
currently at 8mcg/k/[**First Name3 (LF) **]. There has really been no
improvement in her bp's during the night, with maps ranging
from 17-30, but mostly remaining in mid 20's. Color is
[**First Name3 (LF) **], with extensive bruising over body, and severe
generalized edema, with delayed cap refill. HR 120-150's.
Baby received 6cc's of Cryoprecipitate, 6cc's of PRBC's, and
6cc's of FFP overnight. Repeat hct at 2200 was 34. and Plt
129 at 2200. Plt from this am are pending. Sample obtained
for coags, but lab reported that sample was clotted, which
was a full 2.7cc sample. Incident report filed. NNp and
attending are aware.
FEN O: Tf remain at 120cc/k/d. IVF of PN, IL, and .45 ns
with hep, and infusing through DLUVC, and PAL well.(see
flowsheet). D sticks are stable during the night(see
flowsheet). Baby remains NPO, abdomen is firm, no bs, no
stool. U/o 1.6cc/k/hr. Lytes at 2400 was 134/3.3/99/24/14.
Lytes are pending from 0430. BUN 46, creat 0.8. Decision was
made by team not to obtain weight overnight, due to baby
being so unstable.
| Overall Neutral Note |
737 | NICU NPN 1900-0700
PARENTING: Mom and dad arrived to the NICU at 0630 this am, and spoke with NNP at the bedside. They are aware that it has been a difficult night for [**Known lastname 3527**], and that she is maxamized on her BP meds.
| Overall Neutral Note |
738 | NPN con't
will be ready on [** 461**]. Parents anxious to get CT scan
results. A: Involved and concerned family P; cont to inform
and support family as needed. Plan for family meeting
tommorow.
#7 BILI O: Infant remains under double phototherapy with eye
shields on . Bili today 5.0. P; cont with present managment.
CHeck bili level as ordered.
#8 PAIN O: Infant remains mostly lethargic today however is
moving to stimulus with occ. spont movement. Patient does
not appear to be in discomfort. P; cont to assess closely
for pain .
#9 NEURO O: Infant remains asleep/lethargic most of shift,
however was noted to have spont movement at times, and
reacted to touch more today was noted to be sl. more active.
Did not open eyes today. Muscle tone symmetrical and normal
tone. NO overt seizure activity noted however seizure
activity noted on EEG per Neurologist. Infant bolused with
Phenobarb and Fosphenytoin today. Phenobarb level 41 today.
Plan for a Fosphenytoin level in am. Remains on
Phenobarb/Fosphenytoin maintenance doses. A: Alt in Neuro P:
cont to assess closely for seizures activity, plan for EEG
this evening and report abnormalities to Neurological
fellow. Cont with meds.
| Overall Neutral Note |
739 | Neonatology NNP note
PE:
NEURO: Infant nested in open crib, on pavulon and fentanyl, AFOS, sutures sl [**Month (only) 120**].
RESP: infant remain orally [**Month (only) **] on HFOV, breath sounds = sl coarse with hand bagging.
CARDIAC: color pink/jaundice sl mottled on exam, mild generalized edema on exam, no audible murmur on exam, pulses palp = x4, cap refill ~4secs, mucous membranes pink and moist.
SKIN: intact, gelanteous, no rashes, lesions or bruises on exam.
GI: abd soft and round, no bowel sounds on exam, no HSM, no palpable masses on exam.
GU: voiding in diapers, normal extremely preterm female genitalia.
| Overall Neutral Note |
740 | 1. Resp: O: Infant continues on the vent at settings of 21/6
X 24. FiO2 has been 21-27%-- FiO2 more than RA when infant
is moving around. Ls are clear. RR 20-40s. She was sxned X 1
so far for a small amt of cloudy secretions. She is on no
resp meds. A: Stable on the vent. P: Monitor. Continue as
per plan.
2 & 4: O: Infant has a loud murmur as per baseline. HR
130-150s. BP not checked this shift. Infant is active w/
cares and is being medicated for comfort. She is being fed q
3 hours for hx of spits but full cares are done q 6 hours.
She has her diaper changed q 3 because a wet diaper seems to
bother her. A & D ointment has been applied to her butt and
baby magic lotion is being applied to her dry skin. A/P:
Continue w/ comfort measures.
5. F/N: O: Infant is on 110cc/k/d of Neosure 22, q 3 hour
feeds, gavaged over 2 hours each feed. Abd is benign. Infant
is voiding well. No stool so far this shift but she does
stool. No spits, min asps. She was not weighed tonight as
she will now be weighed each Sunday and Thursday nights
only. A: Tol feeds. P: Continue w/ plan.
6. G/d: O: Infant is nested on a sheepskin on an open
warmer. She is on an orthopedic mattress and has a gel
pillow. She is turned q 6 hours and has lacrilube applied to
her eyes. A/P: Continue to support infant needs.
7. [** **]: O: [** **] stopped by briefly after going to an
appointment in Labor and Delivery for Mom. They [**Name2 (NI) 553**]'t
stay tonight but will be in later today. They brought some
clothes for [**Known lastname **]. A/P: Continue to support.
| Overall Neutral Note |
741 | NPN 1900-0700
1. RESP: Infant received on CPAP 5 with FiO2 >50%. CBG
was 7.17/80 and infant was intubated with 3.0ETT at [**2163**] and
given survanta X2. Initial vent settings were 18/5 X30.
CBG's done throughout this shift (see flowsheet for details)
and vent settings increased to 22/6 X33. CBG on these
settings were 7.30/56 at 0400 and no vent changes were made
at this time. RR 30-70's. IC/SC retractions improving.
Sxn X 1 for small cloudy via ETT and large clear oral
secretions X2. Goal sats are 85-90% per cardiology from
TCH. No spells noted. Will monitor.
2. C/V: Murmur heard. HR 130-160's. BP stable with Map
in low 40's. 61/30 X41. Heart movement easily visible
subcutaneously. Pulses slightly full. 4 ext BP's done and
given to tean and cardiologist form TCH. Echo and EKG to be
done later today. Will monitor and call cardiology if any
blood pressure issues occur.
3. [**Month (only) **]: Infant remains on Ampi and Cefotaxime. CBC was
benign and blood cultures are pending. Will monitor.
4. BIRTH MALFORMATIONS: Genetics consult from TCH at
bedside to eval at start of shift. Blood for FISH and
karyotype to be sent later today. She is SGA and
microcephalic. Her sternum has a 3-5 cm gap with heart
movment easily visible subcutaneously. Polydactyly noted on
both hands. Rocker [**Last Name (un) 523**] feet and prominent labia minora
and clitoris noted.
5. F&N: TF remain at 60cc/k/d of D10W via PIV in right
hand. NPO. D/S 115-111-114-96. Abd soft and flat. A/G
22cm. No spits noted. U/O 0.22cc/k/h since birth. No
stool noted. BW 1870g.
6. DEV: Temp stable nested on sheepskin on servo-radiant
warmer. She is receiving fentanyl Q 4 hours per Dr.
[**First Name (STitle) **] to tol cares. HUS to be done later this am.
7. PAR: [**First Name (STitle) **] in to visit briefly. Dr. [**First Name (STitle) **] spoke
with them at bedside. Dad speaks [**Name2 (NI) 343**] well and
translates for Mom who speaks Creole only. They asked some
questions and took pictures of their daughter.
| Overall Neutral Note |
742 | Neonatology - NNP Progress Note
Infant is active with good tone. AFOF. She is pale pink, well perfused, soft murmur audible. She remains vented on moderate settings, breath sounds clear and equal. She remains NPO. IV fluids infusing via intact PIV. Abd soft, active bowel sounds. Congenital anomalies of absent sternum, bil polydactyly, clinodactyly, low set ears noted. Chromosome studies pending. Of note FOB flying to [**State 521**] this weekend. Please refer to neonatology attending note for detailed plan.
| Overall Neutral Note |
743 | Nursing Progress Note
Remains on SIMV, no vent changes this shift. FiO2 28-35%.
Breath sounds squeaky this am, noted diminished breath
sounds on left at 1630. Transillumination neg.Sx'ed x1 mod
blood tinged secretions.
#3 TF decreaased to 150cc/kg/day. DS 108x1. voided
10cc/kg/hr.
#4 Baby appeared comfortable and pain well managed most of
shift. Received Fentanyl x2. Temp elevated due to temp probe
becoming dislodged.
#5 Dad in this pm, spoke with Dr [**Last Name (STitle) 118**]. Stated that he was
tired today. HIs wife did not come with him because she is
also very tired. Dad opted not to hold baby today. Dad seems
to understand the severity of baby's illness and our
concerns about ther condition.
#6 No breakdown noted. Aquafor not applied.
#7 Remains under phototherapy.
#8 Remains on Dopamine 14mcg/kg/min. BP means 26-35. Color
more mottled this pm than the am. No murmur heard.
#9 Continues on antibiotics. Abd appears more distended and
shiny this pm. [**Last Name (STitle) 4789**] not draining, 6cc of air pulled back
from tube.
| Overall Neutral Note |
744 | Nursing NICU Note.
2. Resp. O/Received pt on [**Last Name (LF) **], [**First Name3 (LF) 1045**] P of 12, MAP. FiO2
primarily 47% today. Occasionally requiring increase in FiO2
noted as high as 67%. Please refer to flowsheet. Pt switched
to conventional vent, SIMV settings of 21/5, rate 26, 100%
FiO2 initially (when held by mother). Pt remains on these
settings per Attending physician. [**Name10 (NameIs) 3392**] refer to all blood
gas results from this shift- Team made aware of all ABG
results. Pt remains on 1/4NS with 2meq Bicarb/100cc at
.8cc/hour via intact UAC (infusion stopped while mother held
pt per Attending physician). A/Alt. in Resp status.
P/Monitor. Wean FiO2 as tolerates.
2. F/N. O/NPO. TF remain at 180cc/k/d. TPN (D10) and IL
running via an intact UVC line. [**Name10 (NameIs) 13**] made aware of dstick
results from this shift and is aware of electrolyte results
from this shift. Abd remains distended, firm-soft. Abd
remains dusky. Duskiness also noted to extend from abd up
left side of chest. No loops noted. Babygram obtained this
morning. Please refer to results of babygram. [**Name2 (NI) 4789**] to low
wall intermittent suction remains intact. A/Alteration in
F/N. P/Cont. to monitor closely.
4. G/D. O/Pt remains nested in sheepskin/bendybumper. OT in
this am; pt given a head pillow. Pillow placed under pt's
head when put back on warmer following being held by mother.
Please refer to flowsheet for temps noted this shift. Team
aware of occasional elevation in temp. Aquaphor applied.
Held by mother; pt appeared comfortable while being held.
Fentanyl given X3, see flowsheet. A/Alt. in G/D. P/Cont. to
decrease stress and treat pain as needed.
5. Parents. O/Mother and father in today. Mother met with
this nurse, [**Name (NI) 13**] and SW at bedside. Mother verbalized some of
her feelings. Mother given verbal support. Mother stated
that she would not want her son to be present if one of her
girls was dying. Family meeting held with parents, this
nurse, Attending and [**Name (NI) 13**]. Parents updated on pt's status.
A/Parents are actively involved. Alt. in parenting r/t
having a critically
| Overall Neutral Note |
745 | Nursing Progress Note
#2 Remains on HIFI vent, weaned to 14 on Amplitude. Sx'ed x1
sm cloudy secretions.
#3 TF at 170cc/kg. PN and lipids infusing thru UVC. Ds 87.
voided 3.3cc/kg/hr.
#4 Quiet most ofday. Became somewhat agitated when placed on
back. Appears mor comfortable on abd. Temp stable when probe
positioned properly.
#5 Parents in, met with Dr [**Last Name (STitle) 118**]. Informed of concerns about
inttestinla perforation. Mom [**Name (NI) 236**], asking a few questions.
Parents seem to understand the seriousness of baby's
condition. Mom was discharged home today. Dad will be back
to visit this pm.
#6 Lower back remains red but no breakdown noted. No
breakdown noted on other parts of body.
#7 Remains under single phototherapy.
#8 Received 3rd dose of Indocin. No murmur heard. Pulses
normal. Color pink with slight jaundice. Dopamine weaned to
12mcgs/kg/min. Weaning based on cuff BP"s on Dinamap rather
than ABP.
#9 Free air noted on KUB. Amp dc'ed and Vanco and Clida.
started. CBC and blood culture drawn this pm. No obvious
signs of sepsis noted. BP stable .
| Overall Neutral Note |
746 | NPN 0700-1900 cont'd
5. [** **]: Mom and Dad and MGM in to visit from 1100-1300.
Updated at bedside on infant's condition and plan of care by
this RN and attending [**Doctor Last Name 46**]. Asking appropriate questions.
Appropriately concerned about HUS results tomorrow. Mom
very quiet and distant today. Dad [**Name (NI) 203**] at bedside but
coping ok. SW and team aware. Will be back tomorrow am.
Loving, involved [**Name (NI) 26**]. P: Cont. to support and update
[**Name (NI) 26**].
6. Resp: Received infant orally intubated on HFOV settings
of Delta P 19 with a map of 11. Her current settings are
Delta P 15, Map 9. Recent ABG at 1400 was 7.41/35/47/23-1.
Chest x-ray obtained - please see above note for details.
FiO2 requirement this shift has been between 21% and 27%.
Infant was sxn x 2 for bloody secretions from ETT. Lung
sounds clear/=. Mod IC/SCR noted. P: Cont. to monitor resp.
status, follow BG and wean settings as tolerated.
7. FEN: Weight today was 460 down 55 gms. TF remain at 180
cc/kg/day. UAC has 7.5 meq of Na acetate and .5 unit hep/cc
running. DUVC: through primary port is D5w with 3 mEQ of
NaCl and 1 mEQ of KCl with IL. And through secondary port
is D5 with heparin. D/S 141/120. UO 10 cc/kg/hr for past
12 hours. No stool noted. Abd soft, round. There is an
area that remains dusky just over umbi - team aware. No BS
noted. Lytes will be drawn at 1700. At the time of the
writing of this note a PICC line attempt is being made.
Fluids will change in DUVC (or PICC) to PND5 at 1800. P:
Cont. to support nutritional needs.
| Overall Neutral Note |
747 | NPN 0700-1900
Received infant orally intubated on HFOV settings of [** 1195**] p 13, map 8. FiO2 requirement this shift has been between 21-30%. No murmur appreciated. B/P stable, arterial maps between 35-45. Infant was pink/well perfused (s/p transfusion). DUVC and UAC in place and running fluids. D/S 53. Infant had completed 7 day course of ampi/gent. HUS done this am (#4). A LP was done with follow-up HUS after. HUS continued to show extension of intracranial bleeding. Parnets in to visit at 1000. Team (This RN, MD [**Last Name (Titles) 46**], [**Last Name (Titles) 96**] [**Doctor Last Name **], SW [**Doctor Last Name **]) met with [**Doctor Last Name 26**] to discuss HUS results. [**Doctor Last Name **] made decision to withdraw support. Infant was switched to conventional [**Doctor Last Name **] and family members were able to hold infant on [**Doctor Last Name **]. Fentanyl was given for comfort. At 1430 infant was extubated and IV fluids were discontinued. Mother held infant until time of death. Dr. [**First Name (STitle) 46**] pronounced infant's time of death at 1602. Postmortem care done with [**First Name (STitle) 26**]. Memory box given to [**First Name (STitle) 26**]. [**First Name (STitle) **] left unit at 1730. Infant was brought to morgue with ID bands in place at 1750.
| Overall Neutral Note |
748 | NPN 0700-1900
1. Hyperbili: Infant remains under double photo with eye
shields in place. Bili drawn - results pending. P: Cont.
to monitor bili level and draw next level in am.
2. Parents: Mom and Dad in throughout day. Udpated at
bedside on infant's condition and plan of care by this RN,
[** 96**], and attending. Asking appropriate questions. Mother
was discharged today. Parents are staying in parent room
overnight. Loving, involved parents. P: Cont. to support
and update parents.
| Overall Neutral Note |
749 | NPN
ADDENDUM: P= keep strict I&O, monitor lytes closely, keep Ca
Gluconate at bedside, follow DS's, cont per plan
NPN#5 O= remains on warmer on servo under plastic tent..T
97.5 x1 with loose probe..reapplied..temp stable since, ^
fiesty/ active, MAE, tone appropriate for GA, nested in
shhepskin with boundaries in place..infant more settled
since positioned prone, AF soft & flat..HUS for Mon., eyes
remain fused A=very preemature infant, ^ temp sensitivity,
^risk for IVH..HUS Monday, q6hr cares, decrease stim
NPN#6 O= remains under double phototherapy as ordered, am
bili pnd, mult bruising noted A= hyperbili P= cont to max
skin exposure to lights, monitor levels
NPN#7 O= infant's skin very friable with mult bruising/
abrasions noted...Aquaphor applied x1..no leads applied to
skin A= fraigle skin P= cont close monitoring & meticulous
skin care
NPN#8 O= parents up at begining of shift..mom asking very
good questions..dad states overwhelmed..updated by
JPN/NNP/RN at bedside..Dr. [**Last Name (STitle) **] spoke with parents in room
s/p pulm hem..aware Indocin treatment..mom up later in shift
by herself and called for update x1 A= very involved parents
of critically ill infant P= cont to keep updated & supported
| Overall Neutral Note |
750 | NPN addendum
Parents: Mom and Dad and extended family have been up to visit throughout day. Dad and mom [**Name (NI) 203**] at bedside. Parents have been updated on infant's condition and plan of care by this RN and NNP. Asking appropriate questions. Parents were given sibling #2's memory box. A: Loving, invested parents grieving for the loss of their son. P: Cont. to support and update parents.
| Overall Negative Note |
751 | 1900-0415 NPN
RESPIRATORY: RECEIVED BABY ON 32/6 X35. FIO2 50-100%. BS COURSE. RESP RATE 30-50 WIHT IC/SC RETRACTIONS. MULTIPLE GASES OVERNIGHT WITH CONTINUED ACIDOSIS DESPITE VENT CHANGES AND BICARB GIVEN.~3AM BABY BEGAN TO DESAT--FIO2 INCREASED TO 100% WITH MANUAL BREATHS GIVEN AND THEN PPV STARTED. NNP/MD CALLED TO BEDSIDE. INTUBATION CONFIRMED, NO PNEUMO, BABY SUCTIONED.
CV:BABY RECEIVED ON DOPA 5MCG/KG WITH MBP >42. INCREASED TO 7.5MCG/KG FOR PERFUSION [**Name8 (MD) **] MD ORDER. JUST PRIOR TO DESAT EPISODE ABOVE, BABY STARTED TO DRIFT BP AND DOPAMAINE WAS INCREASED TO 10MCG/KG. BABY RECEIVED MULTIPLE BLOOD PRODUCTS OF THE SHIFT FOR HCT 19. REPEAT PLT COUNT 204. DURING RESUSCITATION BLOOD PRODUCTS FINISHED. DURING DESAT EPISODE ABOVE, HR BEGAN TO DRIFT, EPI GIVEN SEVERAL TIMES AND CHEST COMPRESSIONS STARTED. MD/NNP AT BEDSIDE THROUGHOUT. COLOR PALE/WITH PETECHIAE OVER ENTIRE BODY. SEVERE EDEMA THROUGHOUT 3+PITTING. ECHO THIS SHIFT
F/E/N:BABY ON D15W WITH HEP AT 80CC/KG WITH DS 149-197. TO HELP WITH ACIDOSIS IVF CHANGED TO D12.5 WITH SODIUM ACETATE AND HEPARIN. ABDOMEN FULL/FIRM WITH BLUE HUE AND DISTENDED WIHT AG 26.5CM. BELLY TENDER TO TOUCH. BABY ABDOMINAL TAP BY NNP ~230 FOR 60CC YELLOW COLORED FLUID. ABDOMEN SOFTER, ROUND WITH AG 24 AFTER TAP. BABY OOZING FROM SKIN, PUNCTURE SITES ALL OVER BODY. UNSURE IF SHE HAD VOIDED, NO STOOL. TRACKING OUTPUT BY WEIGHING CHUX (SEE FLOWSHEET)
G&D:MULTIPLE FENTANYL BOLUS DURING SHIFT FOR COMFORT AS ORDERED. FENTANYL DRIP STARTED 0130 AT 3MCG/KG. LIMITED SPONTANEOUS MOVEMENT NOTED. DID OPEN EYES AT TIMES. HEAD BOGGY.
SEPSIS:BABY ON [**Name2 (NI) 2348**]/AMP AS ORDERED. REPEAT CBC THIS SHFIT (SEE FLOWSHEET). BLOOD CX PENDING. ABD FLUID SAVED FOR ID CONSULT.
PARENTS:MOM AND DAD IN WITH MGM LAST EVENING. SPOKE TO DR [**First Name (STitle) **]. DR [**First Name (STitle) **] CALLED PARENTS AND WENT TO SEE THEM DURING ACUTE EPISODE. MOM CALLED LATER TO FIND OUT IF BABY HAD PASSED. NO FURTHER CONTACT WITH THIS RN BUT HAVE BEEN SEEN/SPOKENT TO BY ATTENDING
BABY PRONOUNCED BY MD. POSTMORTUM CARE COMPLETED
| Overall Negative Note |
752 | 1 RESP
2 CV
3 FEN
4 SEPSIS
5 G&D
6 FAMILY
Nursing Admit note:
See attending note for maternal and delivery room history.
Infant arrived to NICU at approx 11:15am - for prematurity
32 weeks and hydrops with ? viral etiology.
RESP: Intubated and surfactant given x2 today. Currently on
settings of 32/6 rate of 35. FIO2 (53-100%). RR (30's).
Lungs coarse. Mild subcostal retractions. Lungs tapped on
arrival for 24cc's from left side and 18.5cc's from right
side. Last arterial gas ~1500pm - 7.35 - 24 - 59 - 14 -
(-10). Weaned rated at that time from 38 to 35.
CV: Infant with loud murmur. HR 138-154. Very Pale. Inital
Hct 23.6. Plt 35. Coags unstable. Platlets given. PRBC being
given currently. FFP to be given after blood transfusion.
Dopamine 60mg/50cc's D10W infusing at 5mcqs for majority of
shift. MAPs 34-50. Infant grossly edematous. 3+ pitting
edema over entire body.
FEN: TF increased from 60cc/kilo to 80cc/kilo due to low
dsticks. IVF currently D15W - Infusing into DLUVC. Dsticks
0 - 43 today - given 5 D10W bolus's. Abdomin softly
distended secondary to fluid retension. Large amount of
fluid loss from edematous body. No true void thus far. NGT
and repoggle in briefly initially to decompress abdomin. No
stool.
SEPSIS: CBC and blood culure sent. WBC 1. ABX started. Amp
and Cefotaxime given as ordered. Infant with noted
"blueberry muffin spots" over body - more on lower
extremities.
G&D: Initally cold when arriving to NICU - 96.2 Rectally.
Warmed up with double warming lights. On warmer. On
sheepskin and chucks pads. Changing pads Q1-2 hours. No
notable movement of extremities. Contracture of elbows, hips
and knees noted from edema. Unable to fully straighten.
Eyes hazy. WIll need follow up by opthomology. Baby cares
given.
Family: Father in for update this afternoon. Updated briefly
at the bedside. Mother due to be in after change of shift.
Planning to baptize baby tonight.
REVISIONS TO PATHWAY:
1 RESP; added
Start date: [**2135-8-27**]
2 CV; added
Start date: [**2135-8-27**]
3 FEN; added
Start date: [**2135-8-27**]
4 SEPSIS; added
Start date: [**2135-8-27**]
5 G&D; added
Start date: [**2135-8-27**]
6 FAMILY; added
Start date: [**2135-8-27**]
| Overall Neutral Note |
753 | Nursing Progress Note:
2 Alteration in Perfusion
4 Birth Malformations
9 Alt in cardiovascular status
#1 Resp: O: Infant remains on prong CPAP of 4, 28-33% FiO2.
O2 sats stable. Lung sounds cl/=. Moderate IC/SC retractions
noted. Infant suctioned q 3hrs for mod. amount cloudy oral
secretions. Occasional drifting noted. No spells. A: Infant
breathing moderately comfortably w/ resp. support. P:
Continue w/ CPAP through the night awaiting [** 26**] decision
regarding placing infant on NC.
#5 FEN: O: Total fluids remain @ 120cc/kg/day, Neosure 27. Q
3hr feedings, PG, gavaged over 1hr 30min r/t hx of spits. No
spits. Minimal aspirates. Infant's abdomen is soft w/ soft
loops. +BS. Infant voiding well. No stool thus far this
shift. Nystatin powder applied x2 to groin area. A: Infant
tolerating feedings well. P: Continue to support infant's
nutritional needs.
#6 DEV: O: Infant remains nested on an off warmer w/
covering blanket to maintain infant's temp. Temps stable.
Infant recieved morphine x2 and versed x2 this shift for
comfort. Sucrose also given w/ cares. Infant sleeps
moderately well between cares. A/A w/ cares. Irritable at
times. Infant w/ low tone. A: Alt in G&D. P: Continue to
support infant's developmental needs.
#7 [** **]: O: Mom, [**Name (NI) 72**] and big sister in this afternoon
inbetween cares. Mom held infant x2hrs. Family meeting held
at bedside w/ MD, [**Name (NI) 96**], SW, interpreter and this RN regarding
infant's status. A: [**Name (NI) **] seem comfortable caring for
infant. Appear loving at bedside. P: Continue to update,
support and teach [**Name (NI) 26**]. Social work following.
#9 CV: O: Infant w/out sternum. Infant appears very pale.
Fairly perfused. Infant w/ loud murmur. HR's 170-180's. BP
stable. P: Continue to monitor infant's cardiovascular
status closely.
REVISIONS TO PATHWAY:
2 Alteration in Perfusion; resolved
4 Birth Malformations; resolved
9 Alt in cardiovascular status; added
Start date: [**2141-6-5**]
| Overall Neutral Note |
754 | Nursing Note 7a-7p
Baby girl [**Known lastname 524**] was rec'd this morning on a HiFlo NC, 4L at 100%. During change of shift she had her first episode of apnea and bradycardia (HR 56/59%) requiring BBO2 for an extended period of time, attending, [**Known lastname 96**], RRT and this RN in to evaluate. Infant weaned briefly to 2L 100% but quickly returned to 4L where she remained. [**Known lastname **] continued to have significant episodes of apnea and bradycardia throughout the day that required signficant interventions, bag/mask x15 minutes in addition to 10 min of facial CPAP for a HR 50 and sat of 12%. Please see flowsheet for further details regarding all episodes and interventions. Orally suctioned frequently for lge amts of cloudy secretions. Infant continued on 4L for duration of shift for comfort.
Several attempts made this [**Last Name (NamePattern4) 567**] [**Last Name (NamePattern4) 96**]'s, resource RN, this RN and attending to contact family. The first time [**Last Name (NamePattern4) **] returned call, spoke with Dr. [**Last Name (STitle) 165**] who explained [**Known lastname 536**] status, stated they would try to be in. Upon returning our calls the second time and speaking with Dr. [**Last Name (STitle) 165**] about [**Known lastname 536**] grave condition, [**Known lastname 72**] stated that he would be here in 30-60min. [**Known lastname 72**] in updated at bedside by this RN and Dr. [**Last Name (STitle) 165**] multiple times. [**Last Name (STitle) 72**] held infant throughout her passing. Mom in briefly with [**Last Name (STitle) **], sat next to them. [**Last Name (STitle) 72**] requested that we change her meds back to midazolam rather than ativan and requested that we no longer resuscitate her. Gave [**Last Name (STitle) **] a box of mom[**Name (NI) 568**] prior to them leaving.
[**Known lastname **] [**Last Name (NamePattern1) 569**] her Morphine and Ativan as ordered, also rec'd one extra dose of Morphine in between to maintain her comfort. Upon [**Last Name (NamePattern1) **]'s request midazolam restarted, given x1.
[**Known lastname **] passed at 1637 in [**Known lastname **]'s arms. Post-mortem and memory box completed.
| Overall Negative Note |
755 | NPN 7p-7a
Nursing addendum -
DEV: Infant recieved swaddled on off warmer. Temp @ 2100 - 100.3ax; unswaddled and blanket loosely placed. Last temp taken as of this writing - 98.9ax. Infant appeared agitated after ETT taken out; received one dose of midazolam with very good effect. Currently, infant is very calm and appears comfortable. A&D ordered for dry skin and lacrilube given to OU. Protruding nodule noted on scalp; team aware. Continue to support growth and development and assess for stress/discomfort.
| Overall Neutral Note |
756 | Nursing Progress Note
#1-O/A- Received infant on prong CPAP 6cm. Infant
decreased to CPAP of 5cm. FIO2 23-30% so far this shift.
No A's or B's so far this shift. P- Cont to assess for
Resp needs.
#2-O/A- Cont with loud murmur. Lg VSD. HR and BP wnl. No
CV distress. P- Cont to assess for CV/perfusion needs.
#4-O/A- Trisomy 18 and multiple anomolies. Absent sternum,
Lg VSD, Polydactyly- R extra digit dusky, no change. Rocker
bottom feet. P- Cont to assess for changes.
#5-O/A- TF=120cc/kg/d of Neosure27 via NGT. Abd exam
benign. Voiding, no stool so far this shift. Min asp, no
spits. Tol feeds. P- Cont to assess for FEN needs.
#6-O/A- [**Known lastname **] [**Known lastname 533**] cont to be awake and active with
cluster cares q4hrs. Sleeps well between cares. Temp
stable on off warmer covered by blanket. MSO4 and Versed
given as needed. Pain/stress well managed. P- Cont to
assess for G&D needs.
#7-O/A- No parental contact so far this shift. P- Cont to
enc parental calls and visits.
See flowsheet for further details.
| Overall Neutral Note |
757 | 0700-[**2040**] NPN
RESP: Current vent settings 26/7 r48 (received on vent
settings of 20/6 r30). Vent changes made based on blood gas
values, see lab. Sodium Bicarbonate given x2, tx metabolic
acidosis evidenced by blood gas values. Most recent blood
gas at 1530 7.15(pH)/70(pC02)/63(p02)/26(tC02)/-5(BXS). PIP
increased from 26 to 27 in response to this value. Fi02
requirement 41-66%. LS course, diminished; suctioned x1 for
small amount of cloudy secretions. Plan to continue close
monitoring of blood gases; consider initiation of sodium
bicarbonate drip.
I/D: Continues on Ampicillin and Gentamicin, tx for r/o
sepsis. BC remain pending, see lab for most recent CBC.
FEN: TF goal 100cc/kg/d (PN maintained at 50cc/kg/d when
titrating other fluid rates, per order). Na Acetate
currently infusing via [**Year (4 digits) 1197**] at 0.9cc/hr. DLUVC with PND10w
infusing via primary port at 50cc/kg/d. Dopamine,
concentrated to 120mcg/50cc D10w, infusing via secondary
port of DLUVC at 30mcg/kg/min. Fentanyl, concentrated to
500mcg/50cc D10w, infusing via secondary port of DLUVC at
2mcg/kg/min (increased from 1.5mcg/kg/min). PIV placed in
right foot. Dsticks 134, 107, and 138. Most recent
electrolytes 150/7.1/105/24, M.D. aware. Calcium gluconate
given at 1215, follow-up ionized calcium 1.01. See lab for
previous values. Abdomen increasingly firm and distended, no
BS, M.D. aware. Abdominal U/S performed. UO 0.4cc/kg/hr for
the past 8hrs, no stool, M.D. aware. Urine dipstick with
+protein, large blood. Plan to continue close monitoring of
FEN status.
PARENTING: [**Year (4 digits) 96**] telephoned father this a.m. to obtain consent
for transfusion of blood components. Father was in to visit
shortly thereafter and was updated by [**Last Name (NamePattern4) 3564**] RN, M.D.,
SW, and Greek interpreter met with both parents in Mom's
hospital room in the MICU at approximately 1345. Infant's
clinical status was reviewed as well as plan for infant's
ongoing care. Mom visibly upset and tearful.
| Overall Neutral Note |
758 | 0700-[**2040**] ADDENDUM TO NPN
....CONTINUED FROM ABOVE...
PARENTING: ...Dad expressed that he and Mom remain shocked
about the unexpected, early arrival of their twins and they
are very worried about this [**Year (4 digits) **]. Both parents expressed
understanding of what was explained to them in the meeting.
Dad and Mom plan to visit this evening after Mom is D/C'd
from MICU to the floor. Team will continue to support
parents and keep them informed.
BILI: Infant is jaudiced and has extensive bruising. Most
recent bili 3.4/0.3, remains under single photothx. Continue
to monitor.
| Overall Neutral Note |
759 | NPN 7a-1330
Received [**Doctor Last Name 846**] this am being hand bagged s/p right chest needle and chest tube placement for pneumothorax and decompinsating resp status. Several CXR's done and chest tube placement adjusted by [**First Name9 (NamePattern2) 96**] [**Last Name (un) 322**] as needed. Chest tube was connceted to cont low wall sx and was functioning well, occassional bubbles in water seal chamber. Only scant amt of serous/sang fluid noted in tubing and in collection chamber. Throughout the morning infant cont'ed to be hand bagged with no improvement in sats, including discrepency in pre/ post sats, and blood gas levels despite trials on several different modes of ventilation, 1 dose of Na bicarbonate, and re-intubation by Dr. [**First Name (STitle) **]. Along with failing resp status infant had poor perfusion and difficulty maintianing BP means 40-45. Infant tx'ed with dopamine to max of 20mcg/kg/min, brief dobutamine- max 5mcg/kg/min, and NS blous x1. Peripheral pulses nml, but capillary refill was always delayed. Overall color, pale/[**Doctor Last Name **]/cyanotic color. No murmur ever noted, but cardiac echo was done and revealed duct. See above notes for details. Blood out this am ~2.6cc. Repeat CBC with diff done- shifted. Blood culture remains negative to date. Infant given Ampicillin dose as ordered. TF: 80cc/k/d. UAC, and double lumen UVC all infusing well. Fluids were as noted on flowsheet. Abd soft, no [**Last Name (un) 113**] noted but difficult to assess with bagging,no loops. D/S stable 129 and 142. Infant passed trace and small mec stools. U/O: ~4.6cc/k/hr in 13.5hrs. Infant was started on Fentanyl drip this afternoon and did receive a total of 3 PRN doses for pain/stress control. Infant did open eyes briefly, but no movement on his own. Fonts soft/flat. HUS done. Temps stable nested on sheepskin on open warmer. Small bruise noted on left hip. [**Last Name (un) **] in several times and spoke with Dr. [**First Name (STitle) **] regarding serious condition of their son. [**Name (NI) **] did decide to have infant baptized by [**Last Name (un) 3673**] and were present for it. After last blood gas Dr. [**First Name (STitle) **] went to Mom's room and spoke with [**First Name (STitle) 26**]. [**First Name (STitle) **] decied to redirect care of infant and did not want to be present. When Dr. [**First Name (STitle) **] returned to NICU resp status cont'ed to worsen with falling HR's- 50's-80's. Dr. [**First Name (STitle) **] stated [**First Name (STitle) **] decided to redirect and infant was extubated. [**First Name (STitle) **] changed their minds about being with their baby and did come to see infant. Mom held infant for few mins and Dad for a few seconds. Photos were taken of infant, but [**First Name (STitle) 26**] declined to have a family photo taken. Infant was held by Rn until he passed and post-mortum care was done accordingly and infant brought to morgue. Dr.[**First Name (STitle) **] and [**Doctor First Name 561**],SW each spoke with [**Doctor First Name 26**] after infant's passing. Memory box started and placed back in bereavement cart.
| Overall Negative Note |
760 | Neonatology - [** 96**] Progress Note
Infant sleepy with exam. Responds to tactile stimulation with movement of extremities. She is pale pink, well perfused, loud murmur audible. She is comfortable on prong CPAP, breath sounds somewhat diminished to bases. Abd soft, active bowel sounds. Monilial rash in diaper area. miconozole powder ordered. Please refer to neonatology attending note for detailed plan.
| Overall Neutral Note |
761 | NICU TRANSFER NOTE
Baby Girl [**Known lastname 644**] [**Known lastname 641**] ready for transfer to TCH for PDA ligation. Transfer Consent signed. [**Known lastname 8**] at bedside. ID bands on.
Resp. Orally intubated with 2.5ETT. 20/5 x35. FIO2 21-25%. LS clear and equal. RR 40-50's. IC/SubC retractions. No bradys. On caffeine. Last ABG at 1300 50/7.32/49/26/-1. No vent changes made d/t pending surgery.
CV. Loud murmur. Color pink--mottled. Recieved 20cc/k PRBC tx today for hct 32. Tx completed at 1445. HR 150-160's. Dopamine currently at 8mcg/k/min to keep BP means 32-38. (Dopa mixed 60mg in 50cc D10W). Peripheral A line in place with 1/2NS and 1/2u hep/cc at 1cc/h.
FEN. NPO. BW 725g. Wt last noc 765g. TF at 130cc/k/d. PN D11 and IL via Central PICC in right arm. Dopa also piggy-backed into PICC. UO 4.6cc/k/h. No stool. Abd exam benign. No loops. Last Babygram today at 1100--wnl. Last ds at 1300--159.
Sepsis. CBC and Blood Cx sent yest eve when needed to be restarted on dopa. WBC 10.5/38N/0B. Hct 32. Plts 413. Blood cx pending. Temps stable in servo isolette. [**Known lastname **] and active. On vanco and gent. Next doses due at 0100 and 0200.
G&D. [**Known lastname **] and active. MAE. Nested on sheepskin. Servo isolette. Choroid plexus cyst on HUS.
[**Known lastname 8**]. Mom and dad involved. [**Name2 (NI) **] family in crisis d/t hospitalization/pending surgery. Appropriate.
Infant was baptized this am.
| Overall Neutral Note |
762 | NPN 7a-7p
Resp: HFOV MAP 13, DP 21, Hertz 15. ABG at 1130 was
7.38/46/48/28/0. No vent changes made. FiO2 24-38%. LS very
course, IC/SC retractions, No CXR done. No bradies. Stable
on current vent settings, con't to monitor closely.
CV: No murmor heard. HR 150s. Pink, well perfused. Keeping
MAPs 28-35. Required 16-20mcg most of day, but has weened to
9mcg in last 2hours. Recieved 2nd of 3 hydrocortisone doses.
Ordered 20cc/k of PRBCs for blood out of 9cc. Recieving
first 10cc/k at this time in PIV. Hct was 34 and plt 72.
Con't to administer blood and ween dopamine as tol.
Bili: Under single phototx w/ eyes covered. No plan as to
when next level will be checked. This am was 3.0/0.3.
FEN: TF 150cc/k/d. 1/2NS w/ hep in UAC and PN D5 running in
DUVC w/ IL. Was recieving PN D7 but had DS 268 and primary
UVC changed to D5. Subsequent DS 140/124/141. Abd flat, BS
absent. Abd soft but appears shiny and mottled at times.
Girht 17cm. No stools, UO; 6.1cc/k/hr. Stable, con't as
planned.
G&D/Pain/Skin: Alert w/ cares, moving around. Recieving
fentanyl drip (250mcg/50cc D5) at 2mcg/k/hr. Arousable and
active, but settles easier. Less tense when touched. Nested
on sheepskin w/ water pillow. On warmer, temps stable servo
controlled. Eyes fused. Skin dry, cracked, and peeling. No
open or bleeding areas although does have scabbing on feet,
legs, and abd. Con't to support dev needs, and manage pain
and stess as much as possible. OT consulted today.
Family: No contact so far this shift. Con't to support and
update as needed.
ID: Temps stable, alert w/ cares. BP not as labile today,
although doesn't respond well to noise or cares. WBC
increased from 14 to 23 at 0330. Diff added to that CBC. 60N
20B 8L. Shift ratio 0.25. Recieving vanc and gent per
orders. Vanc levels done, will report to NNP to adjust
dosing as needed. Con't to monitor.
| Overall Neutral Note |
763 | 1900-0700 NPN
#3CV
O:HR 130-160. COLOR PINK. SKIN WARM AND DRY/PEELING.
DOPAMINE 60MG/50CC INFUSING AT 9-11MCG/KG THIS SHIFT TO KEEP
MBP 28-32. SECOND ALLOQUOT PRBC'S GIVEN THIS SHIFT WITHOUT
INCIDENT. NO MURMUR. GOOD PULSES AND BRISK CAP REFILL..
FINAL DOSE HYDROCORTISONE GIVEN
A:STABLE
P:CONTINUE DOPA TO KEEP MBP 28-32, MONITOR PERFUSION,
MONITOR FOR MURMUR
#4HYPERBILI
O:REMAINS UNDER SINGLE PHOTOTHERAPY W/BILIMASK IN PLACE.
LAST BILI FROM TUESDAY AM 3.0/0.3
A:HYPERBILI
P:CONTINUE PHOTOTHERAPY, CHECK BILI AS ORDERED
#6G&D
O:ON OPEN WARMER WITH STABLE TEMPERATURE. ACTIVE/REACTIVE
WITH CARES AND SLEEPS WELL BETWEEN ON BELLY. ATTEMPTED
SIDELYING/SUPINE POSITIONING WITH AGITATION/ICNREASED FIO2.
BOTH RESOLVED WHEN BABY PLACED PRONE. NESTED ON SHEEPSKIN
W/WATER PILLOW. FONTANEL SOFT AND FLAT; SUTURES SMOOTH.
REMAINS ON FENTANYL DRIP 2MCG/KG MANAGING COMFORT WELL
A:AGA
P:CONTINUE TO SUPPORT AND MONITOR, CONTINUE FENTANYL FOR
COMFORT
#8SKIN
O:SCABS ON ANKLES/LEG. NO OPEN AREAS. SKIN DRY/PEELING.
EDEMA/DISCOLORATION NOTED TO NECK AREA--MD/NNP EXAMINED. U/S
TO BE OBTAINED IN AM
A:ALT IN SKIN INTEGRITY
P:CONTINUE TO MONITOR CLOSELY, OBTAIN U/S
#9PARENTING
O:DAD IN LAST EVENING. UPDATED AT BEDSIDE. PICKED UP MORE
BOTTLES, CAPS AND LABELS FOR HIS WIFE. ASKING WHEN BABY WILL
EAT.
A:INVOLVED, INVESTD [** **]
P:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TO DATE
#10SEPSIS
O:BABY REMAINS ON VANC/GENT AS ORDERED. VANC DOSE INCREASED
BASED ON PEAK LEVEL OBTAINED ON PREVIOUS SHIFT. PRE AND POST
GENT LEVELS 1.8/7.9. CULTURES NGTD. DUE FOR CBC,DIFF WITH AM
LABS
A:SEPSIS
P:CHECK LABS, CONTINUE ANTIBIOTICS, FOLLOW CULTURES FOR
GROWTH
| Overall Neutral Note |
764 | NPN: continued
9 Parent
8. Skin (Cont) Use of sheepskin and gel pad under head.
Plan: Continue with pressure reduction and auquaphore as
ordered. Monitor potential areas for breakdown closely.
9. Parents: Mother called early in shift and both parents
down to see baby. [**Name (NI) 7**] touched baby, asked [**Name2 (NI) 5148**]
questions. Discussed brief plan of care. Naming baby
[**Name (NI) 337**]. Preliminary discussion re: family meeting around
mother's D/C. Parents live in [**Location (un) 1182**]. Mother discussed
cultural time of confinement and that she is unsure of her
freq of visits. Supported parents with answering of
questions and encouraged them to call for updates. Mother
[**Name (NI) 5149**] that her sister will be able to help her but that
sister has no children. Parents speak Mandrin dialect. Plan:
Continue support of parental bonding. Facilitate parental
learning with support of interpreteur services.
REVISIONS TO PATHWAY:
9 Parent; added
Start date: [**2141-8-28**]
| Overall Neutral Note |
765 | Nursing Admission Note
Pt was admitted from L&D at 1645. Please see Attending
MD/NNP note for history and physical. See flowsheet for
additional details.
1. RESP: O: Pt was intubated in the OR and brought back
and placed on hifi vent. Survanta given at 1700. Lung
sounds were very coarse. IC/SC retractions. No spells
noted. Vent weaned at 1800. Gas pending. A: Hifi vent.
P: Monitor.
2. F&N: O: Pt is NPO. Bluish area noted on upper aspect
of pt's abdomen. NNP at bedside to eval. UAC and DLUVC
placed. Inital D/S was 78. D/S at [**2125**] was 30 and D10
bolus was given. UAC has 1/2NS with hep and DLUVC has D5
with hep infusing. Voided small amount X1. No stool ntoed.
A: Unstable D/S. P: Monitor closely.
4. DEV: O: Initial temp was 95.1. Pt warmed up nicely on
warmer. Very active. Erythromycin ointment held due to
eyes fused. Pt is nested on sheepskin. Vit K given. A:
AGA. P: Continue to support infant's needs.
5. SEPSIS: O: Pt will begin Ampi and Gent. CBC and blood
culture pending. A/P: Abx as ordered.
6. PAR: O: Parents in to see [**Known lastname 644**] on Mom's way down to
postpartum floor. They asked appropriate questions and
spoke lovingly of pt. A: Loving, vested family in crisis.
P: Continue to support parents.
| Overall Neutral Note |
766 | NPN 0700-1900 Correction from [**2195**]
[**Name6 (MD) 25**] above MD note, flowsheet, and labs for further
information.
1. O: Received pt orally intubated on vent [**Name6 (MD) **] 23/5
X30. Currently 28/6 X40 FiO2 increased from 40-100% by 1100.
No resp effort from pt. Ls crs. [**Name6 (MD) 187**]'d for lg yellow
[**Name6 (MD) 656**]. 2 CXR obtained. Mult ABGs. Bicarb given X3, then
Bicarb drip started at 1830. A: Increasing needs for resp
support. P: Cont to closely monitor resp status.
2. O: Tf approx. 100cc/kg. Pn d/c'd secondary to elevated K.
D10 hung infusing well via PICC. Changed to d20 at 1830.
Mult lytes obtained. 63cc total given of NS as boluses
throughout the day to increase Na. Dstix 70's. At 1900,
dtsix 21. 3 cc D10 bolus given. Mod edema over entire body
increasing as shift progressed. No UO. Urinary catheter
placed. AG increased from 17cm to 22cm. Abd firm with min to
no bs. A: Increasing edema. No OU. P: Cont to monitor I&O's,
lytes, Dstix, abd, and wt.
3. O: Hr 180-200's. Bp means 20-30's. Poor perfusion-sl
increased during shift. Dopa started at 1300. Currently at
35 mcg. Epi drip also started at 1830. 40cc/kg of PRBCS
given. FFP also given. Murmur present from 1500 on. Good
pulses. A: Increasing requirment of BP support. Now with new
murmur. P: Cont to closely monitor CV status.
4. O: Lethargic. Min response to painful stimuli. Temp
elevated during 1st blood transfusion, otherwise stable on
warmer. Fontanelle sl bulging, not tense. A: Decraesed
activity and response. P: Cont to monitor temp. Cont to
monitor activity and response. Reduce stimulation.
6. O: Mom called X1. Updated by RN. Mom and Dad in at 1700.
Asking appropriate questions. Updated by entire team.
Appropriately concerned and upset by infant's status.A:
Invested [**Name6 (MD) 118**] [**Name6 (MD) **]. P: Cont to support and educate.
10. O: Ceftaz added to antibiotics. Sputum cx sent. 2nd
blood cx sent. CBC shifted. Poor perfusion. Decreased
activity. A/P: Cont to monitor sepsis. Cont to follow cx.
| Overall Neutral Note |
767 | NPN DAYS
Alt Resp Status: Remains on vent [** **]: 18/5 rate 18 with
FiO2 25-31%. LS coarse to clear after sx. Sx q2-4hrs for
large amounts white [** 656**]. RR 30's-40's. Baby with mild
IC/SC retractions. No episodes of bradycardia so far today,
does have occasional drifts to the 80's%. Remains on
caffeine. Will check blood gas in the am. Continue to follow
closely.
Alt F&N: TF 150cc/kg/day. Enteral feeds of BM20 are
currently at 30cc/kg/day. IV fluids of PND9 and lipids are
at 120cc/kg/day via PIC line. Heplock intact to left foot,
flushes easily. Belly benign. AG 17-18cm. Urine output
8.1cc/kg/hr for the past 8hrs(baby received lasix between
alloquots of blood during the night). No stool. No loops
noted. No spits or aspirates. D/S 112. Will continue with
current plan of care. [**Month (only) **] increase feeds to 40cc/kg/day
tomorrow.
Alt In CV status: HR 130's-160's. Color pink and well
perfused. No murmur noted. BP stable. Will follow.
Alt in G&D: Temp stable in servo isolette. Awake and active
with cares. Nested on sheepskin with boundaries in place.
Calms easily with hand containment. Needs increased O2 with
cares. Will continue to provide for developmental needs.
Pot for Sepsis: Baby continues on gent and vanco q24hrs.
[**2197-5-28**] LP results are negative so far. Will continue with
antibiotics until 48hr r/o is complete.
Alt Parenting: Mom called this am. [**Month/Day/Year 8**] will be in this
eve for family team meeting and to kangaroo. Will continue
to update [**Month/Day/Year **] and provide support.
| Overall Neutral Note |
768 | NICU NSG NOTE
#1. Resp. O/ Conts on Conventional Vent. Rate weaned x2
today for adequete gases as documented on flow sheet.
Current [** **] 16/5 x19. FIO2 21-25%. Last gas on theses
[** **] at 1600 7.31/42/22/-4. RR 30-50's. LS clear. Sx'd
x2 for mod secretions. A/ Weaning vent support. P/ Cont to
monitor resp status closely. Monitor for increased
effort/support. Follow gases.
#2. FEN. O/ NPO. TF at 150cc/k/d. UAC: 1/2 NS with 1/2u
hep/cc at 2cc/h. UVC with PN D11 and Il. Dopa "y'd" into
blue port. UO 5.2cc/k/h. No stool. Abd soft and flat. No BS.
NO loops. DS 106-144.A/ No change in abd exam. Alt in FEN
r/t prematurity. P/ Cont to monitor I&O's. Monitor ds.
Monitor abd closely.
#3. CV. O/ Received infant on dopa at 16mcg/k/min. Received
last dose hydrocortisone this shift. Dopa weaned to
8mcg/k/min. Color remains mottled, but less grey from
yesterday. No audible murmur. HR 130-140's. A/ Weaning
pressor support. P/ Cont to monitor closely.
#4. G&D. O/ Awake and active with cares. Temp instability as
documented on flow sheet. On radiant warmer--adjusting temps
as needed. Eye meds given today. Both eyes open. Nested on
sheepskin. [**Last Name (un) **] bumper in place. A/ AGA. P/ Cont to support
developmental needs of infant.
#5. Sepsis. O/ Conts on ampi and gent as ordered. Active.
Temp instability noted this shift, requiring multiple
cahnges on radiant warmer. See flow sheet for details. BC
pending. A/ temp instability. P/ Cont to monitor for s/s
sepsis. Cont abx as ordered.
#6. Parenting. O/ Mom and dad in with multiple visitors
today. Updated breifly at bedside. Aware of weaning vent and
pressor support. Talking lovingly to infant at bedside. A/
Updated. P/ Cont to provide info and suport to family.
#7. Hyperbili. Rebound ordered for am.
| Overall Neutral Note |
769 | Nursing Progress Note
#1 RESP
Remains intubated on SIMV rate and pressures increased due
to hypercarbia (PCO2 up to 101 with PH 7.05) and resp
acidosis. At present on Rate of 30 with Pressures 20/5.
FIO2 25 up to 50% with cares.Breathing over vent 30-60's.
Slightly coarse BS with good air entry. Suctioned large amt
of whitish [** 656**] from ET Q 4 hours and large clear
[** 656**] orally.No brady spells on Caffeine. P/Cont to
monitor and assess for increasing S/S of resp distress.
#2 FEN
Enteral feeding held since 0800 for loud murmur pending
echo. On TF 150cc/k/d of IVF D11 TPN with lipids via L arm
PICC. IV site benign. Line intact and patent.Abdomen soft,
no loops (+)BS. Minimal nonbilious asp from NGT.Team aware
of no BM for over 24 hours. Baby gram benign. Voiding
2.5cc/k/hour.Latest BS 157. Left tibial A line inserted by
Dr. [**Last Name (STitle) 184**] for blood draws. Transduced with fair waveform
with Alarms on. P/ Cont to hold feeds as ordered and monitor
BS closely on D11 TPN.
#3 CV
Seen and examined by Dr. [**Last Name (STitle) 184**] for loud murmur. Warm and
well perfused. 3 sec cap refill. Stable upper and lower SBP.
with mean BP in 30's. Echo done this evening. Final result
pending. P/ Cont to assess for increasing S/S of hemodynamic
instability.
#4 G/D
No temp instability on Servo isolette. Calms with bounderies
and containment care. P/ Cont to support G/D
#6 Parenting
[**Last Name (STitle) 8**] in. Spoke with Dr. [**Last Name (STitle) **] and Dr [**Last Name (STitle) 184**]. Aware of
preliminary result of ECHO and updated with plan of care.
Mom appropriately concerned and emotional. Support given by
SS [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 33**] and RN. P/ COnt to update and support family
family.
| Overall Neutral Note |
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