Course in the Ward Date 11/19/2009 > Routine NB Care > Suction Secretions > Oil/H2O warm bath

> Cord Dress w/ Betadine > Opthalmic Ointment > Vit K admin. > thermo regulation > Monitor VS and record > O2 inhalation at 1-2 lpm > Start IVF D10W 52cc TSS to run for 6-7 ugtts/min x 8 x 24 hours > Secure Consent 11/20/2009 > Continue Meds > Keep warm Doctor's Order Nursing Interventions done 2pm to 10pm > routine NB care done > placed flat on crib with droplight > VS taken and recorded > kept warm and dry 10pm to 6am > O2 inhalation @ 1-2 lpm > IVF D10W 52cc thru soluset at 6-7 ugtts at L hand > Due meds given > VS was taken and recorded > Kept warm 6am to 2pm > VS was taken and recorded > preesent IVF consumed and refilled > due meds given > needs attended 2pm to 10pm > received patient asleep on crib with ongoing IVF of D 10 @ TSS infusing well > baby has a good cry > VS taken and recorded > kept warm and dry > IVF consumed and refilled 10pm to 6am > with ongoing IVF of D 10 W TSS infusing well > baby is active with good cry > VS taken and recorded > patient is on NPO > due meds given thru heplock > kept warm and dry > IVF consumed and refilled

11/21/2009 > NPO temporarily

6am to 2pm > VS was taken and recorded > due meds given > baby may start feeding > needs attended 2pm to 10 pm > VS taken and recorded > feeding was performed > IVF consumed and refilled > kept warm > needs attended 10pm - 6am > IV site checked (+) leaking and inflammed > IVF temporarily d/c then placed on bedside for reinsertion > VS taken and recorded > kept warm > needs attended

11/22/2009 1:00pm

> DIC O2 Temporarily > observe for sign of cyanosis > still on NPO > resumed O2 inhalation at 1-2 lpm > repeat cbc

2:40pm

6am to 2pm > on continuous phototherapy with proper shield > due meds given thru slow IV push > needs attended > O2 inhalation dic temporarily 2pm to 10pm > pale in color > weak cry > O2 inhalation at 2lpm > IV line terminated and reinserted on the R hand 10pm to 6am > received patient with ongoing O2 inhalation > cont. phototherapy > VS taken and recorded > IVF regulated @ desired rate

11/23/2009

6am to 2pm > VS taken and recorded > on cont. phototherapy > First dose of raniridine given > needs attended > kept warm and dry 2pm to 10pm > VS taken and recorded > Needs attended > kept warm and dry 10pm to 6am > VS was taken and recorded > IVF unable to reinsert > kept warm and dry > needs attended > due meds given

11/24/2009

6am to 2pm > VS was taken and recorded > due meds given > kept warm and dry > d/c O2 temporarily > heplock reinserted 2pm to 10pm > received patient asleep on crib with heplock intact > needs attended > VS was taken and recorded 10pm to 6am > received with heplock at R hand dry and intact > VS was taken and recorded > due meds given thru heplock

11/25/2009 > keep warm and dry

6am to 2pm > on continuous phototherapy with proper shield > needs attended > VS was taken and recorded > kept warm and dry

2pm to 10pm > Received on crib under droplight > with heplock on R hand dry and intact > VS taken and recorded > Needs attended > due meds given 10pm to 6am > received asleep on crib with heplock at R hand dry & intact >on cont. phototherapy > VS taken and recorded > needs attended 11/26/2009 > Cefuroxime - Day 3 6am to 2pm > VS was taken and recorded > due meds given > Kept warm and dry > needs attended 2pm to 10pm > with heplock on R hand dry and intact > VS taken and recorded > kept warm and dry > needs attended 10pm to 6am > received asleep with heplock at R hand > food given with good suck > burped well > due meds given > VS taken and recorded 11/27/2009 > Vitamin K 1mg > Strict hand washing 6am to 2pm > received asleep on crib with heplock on R hand intact > on cont. photo theraphy > Vit K given > VS taken and recorded >kept warm and dry

2pm to 10pm > with heplock at R Hand dry and intact > on going photo therapy > VS taken and recorded > needs attended 10pm to 6am > due meds given > VS takend and recorded > needs attended > kept warm and dry 11/28/2009 > Cefuroxime - Day 5 > Strict infectious Control > May transfer room 6am to 2pm > received asleep on crib with heplock on R hand intact > on cont. photo theraphy > VS taken and recorded >kept warm and dry 2pm to 10pm > received asleep on crib with heplock at right hand dry and intact > on going photo therapy > VS taken and recorded > needs attended 10pm to 6am > due meds given > VS takend and recorded > needs attended > kept warm and dry 11/29/2009 > Cefuroxime - Day 6 > Amikacin - Day 1 6am to 2pm > received asleep on crib with heplock on R hand intact > on cont. photo theraphy > VS taken and recorded >kept warm and dry 2pm to 10pm > received asleep on crib with heplock at right hand dry and intact

> on going photo therapy > VS taken and recorded > needs attended > for transfer to ward > still waiting for available room 10pm to 6am > due meds given > VS takend and recorded > needs attended > kept warm and dry > on cont. photo therapy 11/30/2009 > Cefuroxime Day 7-8 > Amikacin Day 2-3 > rectal stimulation every shift proper waste disposal infection control 6am to 2pm > received asleep on crib with heplock on R hand intact > on cont. photo theraphy > VS taken and recorded >kept warm and dry 2pm to 10pm > received asleep on crib with heplock at right hand dry and intact > on going photo therapy > VS taken and recorded > needs attended 10pm to 6am > due meds given > VS takend and recorded > needs attended > kept warm and dry > on cont. photo therapy 12/1/2009 6am to 2pm > received asleep on crib with heplock on R hand intact > afebrile > VS taken and recorded > needs attended > on going photo therapy