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mimic_attitude_dataset

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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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[** 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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[** 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

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

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

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

[** 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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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