Fdar 532g30

Date and Shift 8-14- 15

Focus Data Action Result Received a live baby boy from a G2P3 32 y/o mother, delivered via Normal Spontaneous Delivery under the service of Dra. Reyes at around 1:07pm. Impaired Gas  Cried at  Tactile stimulation Exchange once done through drying  With clear  Suctioned amniotic secretions gently fluid  With bluish  Free flow of Oxygen skin color given  With initial  Vernix caseosa For body spread through out thermoregulation temperature the body, of 36.4 C  Dressed and wrapped with a clean blanket  Placed on a radiant warmer  Seen and examined  With by Dra. Panaligan For ission subcostal with orders made retraction and carried out  Informed relatives  With regarding ission grunting of the patient  itting section informed thru call  Secured ission

2:45 pm 2:50 pm

       

record Secured consent for umbicatheterization Umbicatheterization done by Dra. Panaligan Placed patient on NPO Hooked to continuous pulse oximeter monitoring Placed on Isolette Hook to O2 hood at 7-8 LPM Monitored progression of respiratory distress Placed patient on close monitoring

Date and Shift

Focus

8-16- 15

Risk for altered thermal Regulation

Data  With body temperature – 37.2 C 

3-11

 Ineffective Breathing Pattern 8:40pm 8:50pm

Action Room Temperature Adjusted based on the baby’s body temperature  Isolette Temperature adjusted based on body temperature  Monitored body temperature Frequently  Placed on continuous ambubagging



With RR- 80’s



With alar flaring



Updated Relative c/o Dra. Panaligan



With subcostal retraction With O2 saturation of 70-80 %



Relative signed the consent for Intubation Intubated patient c/o Dra. Lagrimas ET size: 3.5





Result Thermoregulated

Maintained on ambubagging assitance Still waiting for mechanical ventilator O2 sat- 95%



9:00pm

9:30pm

For referral to Pediatric Cardiologist



 

   

  

Level: 9 Blood works done c/o Laboratory Dr. Vinuya informed thru call with orders made and carried out Chest x-ray done Informed relative regarding mechanical ventilator procedure and policy Secured consent for mechanical ventilator hooking Dra. Panaligan informed thru text Pulmo Department informed Hooked to continuous pulse oximeter monitoring Placed on Isolette Hook to O2 hood at 7-8 LPM Monitored



Date and Shift

Focus

8-16- 15

For Mechanical Ventilator hooking

11-7

Data  As per doctor’s order

Action 

Verified doctor’s order



Hooked to mechanical ventilator c/o pulmonary department. PIP : 16 RR: 60 PEEP: 4 IT: 0.5 FIO2 :100%



Assessed depth





progression of respiratory distress Placed patient on close monitoring

Result Thermo regulated

and rate of respiration Ineffective Breathing Pattern 8:40pm 8:50pm

Maintained on continuous pulse



With RR- 80’s



With alar flaring



Updated Relative c/o Dra. Panaligan



With subcostal retraction With O2 saturation of 70-80 %



Relative signed the consent for Intubation



Intubated patient c/o Dra. Lagrimas



Blood works done c/o Laboratory Dr. Vinuya informed thru call with orders made and carried out Chest x-ray done Slightly elevated the Head of the bed Dr. Vinuya informed thru call with orders made and carried out



9:00pm

9:30pm





For referral to Pediatric Cardiologist

  11:10pm



With desaturation upon hooking to mechanical



Maintained on ambu-bagging assistance Still waiting for mechanical ventilator O2 sat- 95%

ventilator 

11:30 pm



Still with desaturation 70-80 %



   1:10am 

Still with desaturation. O2 sat :>85% Still with respiratory distress RR80

Informed pulmo department of the current mech vent settings Dr. Vinuya informed thru text with orders made and carried out Informed pulmodepartment to increase PIP to 60 Tactile stimulation done



Dr. Vinuya informed thru call



Ambu-bagging started

 

AP informed