Beruflich Dokumente
Kultur Dokumente
COHORT
COHORT 16
BLOCK
BLOCK 1
FULL NAME
I/C NUMBER
850109-03-6260
MATRIX NUMBER
TITLE
PROGRAMME COORDINATOR
MADAM ANNAMAH
CLINICAL PRECEPTOR
3062161020
MARK OBTAINED
CONTENTS
No
Contents
Page Numbers
1.
Learning Objective
2.
Personal Data
4-5
3.
Patient history
6- 14
4.
15-22
23-27
28-35
Disease Condition
35-68
Progress Report
69-104
6.
105- 122
7.
Discharge plan
123-125
12.
Conclusion
126
13.
Reference
127
14.
Appendix
128
5.
LEARNING OBJECTIVE
2. State the growth and development, milestones including physical measures, gross
motor, fine motor and socialization.
3. State the birth history and immunization history of the patient.
4. State the diet history including nutritional assessment (growth chart), feeding
milestone and 24-hour recall.
5. Explain family background including family medical history and socioeconomic
background.
6. Describe physical assessment finding on the specific body systems
7. Describe growth and development finding.
8. Explain the disease condition including definition, incidence,
etiology,
PATIENT PROFILE
Name
: Miss Y
MRN
: 407xxx
Age
: 10 hours of life
Date of birth
: 24/10/2016@0449H
Nationally
: Malaysian
Sex
: Female
Race
: Malay
Primary Language
: Nil
Religion
: Muslim
Address
Fathers occupation
: Businessman
: unknown
Date of admission
: 24 October 2016@2345H
Date of discharged
: 5 November 2016@1340H
Follow up
: 12 November 2016@0830H
Diagnosis
Consultant
: Doctor Q
PATIENT HISTORY
2.1
Miss Y transfer in from KPJ Selangor, she has an episode of Grunting, nasal flaring with
chest recession soon after delivery and was intubated after desaturated while on head box
oxygen and due to insufficient equipment she has been transfer to Kpj Damasara Hospital.
2.2
Miss Y is a preterm baby deliver at 4.49pm transferred from kpj Selangor after having
difficult Lower Segment Caesarian Section due to previous scar in the labor. The Apgar score
was 7 at 1 minute and 9 at 5 minute. Miss Y developed grunting with nasal flaring and chest
resection soon after delivery. Put on head box and CXR done in kpj Selangor. At 8.45 Miss Y
desaturated and intubated with size 3 Endotracheal tube (ETT) and anchored at 9cm. She was
ambubagged oxygen, saturation was 90 -100 from kpj Selangor. On arrival Miss Y was dusky
and central cyanosed, flat with no spontaneous movement, saturation 17 20% in 100 %
oxygen, manually ventilation by Consultant KPJ Selangor , blood noted from ETT tube. Fix
on ventilator, leaking >30%, no better, continue bagged, still no better, Spo2 <30% with fio2
1.0, Rate 50 bpm, PEEP 8, PIP 30. Review by Dr I and taking history from kpj Selangor
consultant. At 0020H spo2 23% on high ventilation setting, NIBP 66/44mmhg, manually
ventilation done by Dr I but still the same, orogastric tube size 6 inserted, noted air ++ but no
bleeding seen, CXR done and noted the tube displace, serve iv morphine 400mcg and
reintubated with endotracheal Tube (ETT) size 3.5, fixed at 9 and given curosorf 100mg/kg.
Spo2 increase > 95% and noted pinkish color. Umbilical artery catheter (UAC) & Umbilical
Venous catheter (UVC) inserted and doing CXR showed Severe Respiratory distress
syndrome (RDS) with Large Heart and no pneumothorax seen. Put on Synchronize invasive
5
positive pressure ventilation (SIPPV) with PIP: 30, PEEP: 8, Rate 50, FiO2: 0.9. Blood gases
PH:7.11, Po2 60, PCo2 69.6, BE, -7 (Mix respiratory and metabolic acidosis) Glucose
10.4mmol on admission. Miss Y brought to NICU and admitted in NICU under Dr. Q.
2.3
PAST HISTORY
Birth weight
: 3.77 kg
Head circumference
: 36 cm
Birth length
: 56 cm
According to referral letter, immediate after birth Miss Y developed sign of respiratory
distress.
2.3.3 ANTENATAL HISTORY
Madam. E had regular antenatal visit, also gain weight, have gestational diabetes on Diet
control, immunization taken.IM dexamethasone given 2 times before delivery.
2.3.4 INTRANATAL:
Delivery was Lower segment cesarean section plus vacuum and took about 20 minute to
bring Miss Y out. Birth Apgar score is 7 at birth, after 5 min 9. Miss Y develop grunting,
nasal flaring and chest recession immediately after birth.
2.3.5 POSTNATAL
Miss Y had respiratory distress Syndrome.
2.3.6 Illness & Surgeries
Miss Y got no history of surgical procedure since birth till now also unknown of having
allergic reaction to any foods or drugs or dust.
2.3.7 Medications
Intramuscular Vitamin K were given in KPJ Selangor.
2.3.8 Immunization history
Immunization is the process whereby a person is made immune or resistant to an infectious
disease, typically by the administration of a vaccine. Vaccines stimulate the body's own
immune system to protect the person against subsequent infection or disease. (CDC, 2016)
Meanwhile Vaccine is a special preparation of antigenic material that can be used to stimulate
the development of antibodies and thus confer active immunity against a specific disease or
number of diseases. It is usually given by injection but may be introduced into the skin
through light scratches; for some diseases (e.g. polio), oral vaccine is available. Many
vaccines are produced by culturing bacteria or viruses under conditions that lead to a loss of
their virulence but not of their antigenic nature. Other vaccines consist of specially treated
toxins (toxoids) or of dead bacteria that are still antigenic.
Immunization (2004), Elizabeth A.M, Dictionary of Nursing (pg 505, Malaysian ed)
Malaysia, Penerbit Fajar Bakti Sdn.Bhd.
Immunity can be divided into Active and Passive.
Active immunity
Naturally acquired active immunity occurs when the person is exposed to a live
pathogen, develops the disease, and becomes immune as a result of the primary
immune response.
Artificially acquired active immunity can be induced by a vaccine, a substance that
contains the antigen. A vaccine stimulates a primary response against the antigen
without causing symptoms of the disease.
Passive immunity
of antibodies, such as gamma globulin, that are not produced by the recipient's cells.
Naturally acquired passive immunity occurs during pregnancy, in which certain
antibodies are passed from the maternal into the fetal bloodstream. Immunologic
tolerance for foreign antigens can be induced experimentally by creating conditions of
high-zone tolerance for example by injecting large amounts of a foreign antigen into
the host organism, or low-zone tolerance, by injecting small amounts of foreign
antigen over long periods of time.
Types of vaccine
Live Attenuated vaccine
Attenuated vaccine uses pathogen that are active but have reduced virulence so they
Inactivated vaccine
Can be either whole agent vaccine produced with deactivated but whole microbes, or
Toxoid vaccine
LIVE ATTENUATED
KILLED VACCINE
TOXOID VACCINE
VACCINE
Alive suspension of
microorganisms which
have
They
been rendered
are
replication
incapable
and
of
booster doses
therefore
non-infectious.
Several doses (usually 3)
to provoke an immune
response.
necessary.
Reactions do not resemble
increased by absorption to a
mineral
aluminum salts)
carrier
(such
inoculation.
They induce relatively short
periods
of
protective
immunity.
as
11
AGE
VACCINE
DATE GIVEN
AT BIRTH
5/11/16@1145H
1 MONTHS
Hepatitis B (2 dose)
2 MONTHS
3 MONTHS
rd
5 MONTHS
6 MONTHS
Hepatitis B
9 MONTHS
MMR
12 MONTHS
MMR
18 MONTHS
7 YEARS
MR,DT (Booster)
13 YEARS
HPV
15 YEARS
Tetanus (Booster)
Dr Q examined and assess Miss Y and decided will administer BCG and Hepatitis B vaccine
later base on patients condition and before Miss Y discharge Dr Q has order to give BCG and
Hepatitis B vaccine (1st dose). BCG has been given 0.1ml intradermal at deltoid muscle.
Meanwhile, Hepatitis B vaccine was given intramuscular at rectus femoralis muscle, both
vaccine gave at 1145 on 5/11/16.
2.3.9 Diet history
Dr Q examined miss Y and according to the doctor she need to Nil by mouth till stable and
since birth till day 4 she was not given any feeding. Dr Q started trophic feeding on 28/10/16
2.3.10 Family pedigree
12
MADAM E
Mr. T
MISS
MASTER
MISS
MOTHER
Mother of Miss Y, Madam E para 3 have diabetic during pregnant of her 2 kids and Miss Y as
well. not taking any insulin during pregnancy only diet control. No history of other medical
illness and no history of allergic to any drugs, food or environment, congenital anomalies and
chronic illnesses. Madam E have surgical history of LSCS for her both kid previously and
first kid is a girl who was born on 39 week of gestation and has history of RDS after birth Her
mother has diabetes and father have hypertension but both have no surgical history or other
congenital illness.
2.3.12 Socioeconomic background
Mr. T is a businessman and earn about 8000 per month while madam E is a housewife. They
live in the bungalow house in taman USJ subang.
14
2.4 Assessment
2.4.1 Growth and development review
GROWTH
Deviation in growth patterns may be nonspecific or may be important indicators of
serious and chronic medical disorders. An accurate measurement of length/height, weight and
head circumference should be obtained at every health supervision. Growth is an increase in
number and size of cells as they divide and synthesize new proteins; result in increased size
and weight of the whole or any of its parts. Growth should be measured and compared with
statistical norms in a standard fashion growth chart. Serial measurements are much more
useful than single measurements to detect deviation from a particular childs growth pattern
even if the values remains within statistically defined normal limits ( percentile). Following
the trends help define whether growth within acceptable limits or warrants further evaluation.
15
AGE
10 hours of life
3.77KG
HEIGHT
56 CM
HEAD CIRCUMFERENCE
36CM
CHEST CIRCUMFERENCE
34CM
walking.
Fine motor: using hands and finger grasp an object.
Language: crying , syllables dada , can say 3-5 words.
Cognitive: ability to know , learn to separate from other objects in the environment.
Social: Interacting and play with others, attachment to the parent.
DEVELOPMENT MILESTONE.
Developmental milestones are a set of functional skills or age-specific tasks that most
children can do at a certain age range. Although each milestone has an age level, the actual
age when a normally developing child reaches that milestone can very quiet a bit.
16
17
GROSS MOTOR
FINE MOTOR
SPEECH
SOCIAL
LANGUAGE
3 MONTHS
regard. Squeals
with Laughs.
Ventral
suspension: Head
above plane of
in
hand.
Not
reaching out.
the body.
Prone: Pelvis flat.
Lifts head up 45
- 90
5 MONTHS
Mouthing.
straight
back.
Lying
supine:
Feet to mouth.
6 MONTHS
in cube,
grasp
of
ulnar
Moves
support
the
weight
hands,
chest,
upper
abdomen
couch.
off
Rolls
prone to supine.
18MONTHS
body
parts. housework.
Use
well.
Throws
ball
stops.
without
falling.
spoon
Casting
Sits on a chair.
INTERPRETATION:
Miss Y has shown no development milestone in the first 1 day of admission, no sucking
reflex because she was intubated, no rooting reflex. On her second day of life she was visited
by her mother and during the time she was grasp her mothers finger as her mother put finger
on her palm which showed that Miss y have palmer grasp reflex.
19
2.4.2
Nutritional assessment
Nutritional assessment is the evaluation of an individuals nutritional status and requirement,
to identify undernourished and over-nourished child. Elements of assessment include:
A structured way to establish nutritional status and energy requirement by objective
measurements and whereby, completed with objective parameters and in relation to specific
disease-indications, an adequate nutritional treatment can be developed for the patient. All
this happen preferably in a multidisciplinary setting. When judging the need for nutritional
support, an assessment must be made both of underlying reason for any feeding difficulties
and also current nutritional status.
Anthropometric data including height, weight and calculation of body mass index
(BMI). Data should be plotted on age-appropriated and gender appropriate growth
chart and assessed for weight gain trends and upward crossing of percentiles.
Dietary and physical activity history. Assess patterns and potential targets for
behavioural change.
Physical examination. Assess blood pressure, adiposity distribution (central versus
generalised) markers or comorbidities (acanthosis nigricans, hirsutism, hepatomegaly,
orthopaedic abnormalities) and physical stigmata of genetic syndrome (Prader-Willi
syndrome).
Laboratory studies. These are generally reserved for children who are obese (BMI 95 th
percentile), who have evidence of comorbidities or both. Useful laboratory test may
include fasting lipid profile, fasting glucose level, liver functions tests and thyroid
function tests. Other studies should be guided by findings in the history and physical
examination.
To ensure that the children receive the nutrients that are vital for his growth and
development.
Different food provides different nutrient and different amount.
No single food can meet all the nutritional needs of the child.
A wide variety of food is required to ensure that child get the nutrient he need daily
Breast milk is most beneficial ready-made nutrition food available for the new-born baby:
The important of breastfeeding:
To baby
1.
2.
3.
4.
5.
6.
7.
8.
To mother
1.
2.
3.
4.
Have a reduced risk of Type 2 Diabetes and certain cancers such as breast cancer
May find it easier to return to what they weighed before they got pregnant
Strengthen the bond with their children
Reduce mothers stress level and risk of postpartum depression.
Based on Dr Q, Miss Y Need Nil by mouth till 3 days and Trophic feeding started on Day 4
through NG tube feeding.
-
*Miss Y tolerate feeding well and she was given fully EBM.
21
2.5
: 37.4 C
: 140bpm
: 66 / 44
: 50/min
: 17% - 20%
: 3.77KG
: 60cm
: unconscious
: NA
: vernix and blood on the hair and body
2.5.2 Neurological:
Paediatric eye responds
Paediatric verbal response
Paediatric motor response
: no respond
: Nil
: Nil
2.5.3 Heent
Head
: round, symmetry, easily move left to right and down to up, greater
than
2.5.4
Eye
Ear
Nose
Throat
Lips
Skin/hair/nails
Integumentary system
Skin colour
: cyanosed
Turgor
: Poor
Temperature
: Cold to touch
Rashes
: NIL
Hair
: black and have vernix
Nail
: cyanosed
2.5.5
2.5.6
Chest/lung
Structure: 2 nipples symmetric. Breast tissue diameter is normal like 5 cm in diameter.
Symmetrical expansion of chest. transient breath sound is heard symmetrically as
patient is on Endotracheal tube. Sometimes brief apnea is present. heart sound
auscultates normal rate and rhythm without murmur.
Pulmonary
Respiration rate
: 50/min on SIPPV
Rhythm
: Regular
Chest movement
: Symmetry
2.5.7
CVS
Cardiovascular
Rate
Rhythm
Any murmur
: 140 bpm
: Regular
: NIL
23
Pulse
Capillary refill
Skin color
Edema
2.5.8
: Radial
: >2 sec
: Dusky and cyanosed
: NIL
Peripheral vascular
Capillaries refill time > 2 second
Weak pulsation (radial)
Blue nail bed- Poor perfusion
2.5.9
GIT
Gastrointestinal
Diet
Appetite
Oral intake
Abdomen
: NBM
: NA
: NBM
: Soft, Appears large in relation to pelvis. two arteries and one
24
2.5.12 Genitalia
Genitalia: Female Buttocks are symmetric.
2.5.13 Extremities
Cold extremities, cyanosed and dusky in color.
2.5.14 Discussion on physical examination finding
Miss Y was flat, no respond with general cyanosis, perfusion poor showed that she has
severe respiratory distress.
25
2.6
Physical examination
I.
Vernix on
Hair
General
cyanosed
Umbilical
cord
IVB AT RT
HAND
II.
26
2.7
RESPIRATORY SYSTEM
RESPIRATORY SYSTEM IN CHILDREN
RESPIRATION
Respiration is the act of breathing:
27
RESPIRATORY SYSTEM
The respiratory system is made up of the organs involved in the interchanges of gases, and
consists of the:
Nose - The nose is the passageway into and out of the respiratory system. Oxygen is inhaled
in to the nose and when it comes out it is warm and moist surfaces. Air can also leave and
enter in the body by mouth.
Pharynx - Pharynx is also called throat. When a person breathes through nose or mouth, the
air flows into the Pharynx. The pharynx has two tubes. One leads to the stomach and is called
the esophagus and the other leads to the lungs and is called the larynx.
Larynx - If you put your head up a little bit, and rub your finger up and down on the front of
your throat, you can feel a bump. That is your Larynx. It has elastic bands, which stretches
across the Larynx, which is called the vocal cords. When air flows between the vocal chords,
they vibrate and make a sound.
Trachea - The Trachea is divided into two parts of your lungs. The Trachea also is a windpipe
that travels air to the lungs. It branches into your Bronchi.
Bronchi - Bronchi are two tubes. Each bronchus goes into each of the lungs and spreads out
into tiny tubes called
Bronchiole. The bronchiole connects to the alveoli and it is where oxygen exchanges occurs
Lung - Each bronchiole in the lungs has tiny sacs called alveoli. Capillaries surround each of
them.
28
nose
nasal cavity
sinuses
o
ethmoid
frontal
maxillary
sphenoid
larynx
trachea
lungs
trachea (windpipe)
esophagus
thymus
lymph nodes
The right lung has three sections, called lobes. The left lung has two lobes. When a person
breathes, the air:
30
Travels down the throat through the larynx (voice box) and trachea (windpipe).
one main-stem bronchus leads to the right lung and one to the left lung
Bronchioles
Terminal bronchioles
Respiratory bronchioles
Alveolar duct
Alveoli
31
32
TRANSPORT OF OXYGEN
NORMAL ALVEOLI
PULMONARY BLOOD SUPPLY
The pulmonary artery divides into 2, one branch conveying deoxygenated blood to each lung.
Within the lungs each pulmonary artery divides into many branches which eventually end in
a dense capillary network around the walls of the alveoli.
The walls of the alveoli and those capillaries each consist of only one layer of flattened
epithelial cells. The exchange of gases between air in the alveoli and blood in the capillaries
take place across these 2 very fine membranes. The pulmonary capillaries join up, becoming
2 pulmonary veins in each lung.
They leave the lungs at the hilum and convey oxygenated blood to the left atrium of the heart.
33
34
4
4.1
DISEASE CONDITION
INTRODUCTION & DEFINITION
FIG. 2. Relationship of the factors resulting in respiratory distress syndrome (RDS). Hyaline
membrane formation at the alveolar-capillary membrane in RDS.
35
1.
2.
3.
4.
5.
6.
7.
8.
bronchioles.
9. Alveolar ventilation decreases, and diffusion gradient increases.
10. High FIO2 and airway pressures needed during mechanical ventilation which actually
cause further tissue damage as can be seen in diagram below
Etiology
RDS is a disease resulting from immature lung anatomy and physiology. The primary
abnormality is surfactant deficiency. Without enough surfactant, alveoli collapse with each
breath, and the lungs cannot maintain expansion. Underdeveloped alveoli and pulmonary
capillary beds further compromise gas exchange.
36
Epidemiology
37
Tachypnea
Retractions
Grunting
Nasal flaring
Cyanosis
CXR- ground Glass appearence
38
FIG. 2 Chest radiograph of a premature infant with respiratory distress syndrome (RDS).
Note the characteristic pattern of ground glass infiltrates with air bronchograms
Classic appearance in the untreated newborn is reticulogranular infiltrates described as
having a ground glass appearance. Severe RDS may progress to a total whiteout, in
which the heart border and diaphragm are indistinct because of severe atelectasis.
4.5
Laboratory data
Successful treatment of RDS requires careful monitoring and attention to the details of the
intensive care needed by preterm babies. This includes frequent blood gases, urea,
electrolytes, full blood count, and glucose estimation. Continuous monitoring of heart rate,
respiration, temperature, and blood pressure are the minimum requirements for a ventilated
baby. Visual observation should be recorded hourly. The chest should be auscultated regularly
to check for bilateral breath sounds and endotracheal tube positioning. All intravenous and
arterial lines should be checked at least hourly for patency.
Date
Normal range
25/10
@
0240
18.5
26/10
@
0903
16.1
Hb
PCV
44 70- %
5.3
48
White cells
9.0 22 10/uL
5.2
29.2
Platelet
150450 10/uL
36.4
207
Neutrophils
Sodium
Potassium
30 60 %
139-155
3.4-5.8mmol/l
23.3
139
5.5
73.2
139
4.5
69.2
145
4.7
Urea
1.4-5.7mmol/l
4.0
1.2
Chloride
95-115mmol/l
105
115
shows
ALT
< 57 U/L
14
30/10
@
0806
16.5
17.1
there
was
some
Protein
Albumin
CRP
48-76 g/L
28 44 g/L
<4.1mg/L
35
0.35
40
28
17.80
Y body.
2.48
SERUM BILIRUBIN
Date
Normal range
Serum
Bilirubin
6.0)
15.4
12.9
9.8
2-4week (0.1-2.0)
photo therapy.
Blood Gases
40
Normal
range
Mode
25/10
@
0149
PTV
25/10
@
1408
PTV
25/10
@
1758
HFOV
Fio2
0.9
0.8
1.0
PIP
30
30
PEEP
MAP
20
Rate/ Freq
40
TV(mls/Kg)
60
1.31
60
9.2
PH
7.35 7.45
7.113
6.955
7.138
Pco2
35- 45
mmhg
75 - 100
mmHg
2226mmol/l
-2-+2
2.5 mmol/L
69.6
114.3
65.4
60
19
24
22.3
25.4
22.2
-7
10.4
-7
7.3
-7
7.7
Interpretation
Mix. Respiratory
& metabolic
acidosis
Action
Suction
Mix.
Respiratory and
metabolic
acidosis
Initiation of
HFOV
Implication
and
significant
Important of
doing suction
to keep airway
clear and
improve
ventilation
Mix.
Respiratory and
metabolic
acidosis
Suction
Increase Fio2
&rate, increase
PEEP
When the
adjustment
reaching
maximum level
there is another
way of
Po2
Bic
BE
Glucose
recruiting the
lung and at the
same time
maintain CO2
within normal
value.
41
process
recruiting the
lung without
injured the lung
it self
42
Date
Normal
Mode
26/10
@
2245
HFOV
Fio2
0.45
0.4
0.3
24
70
20
55
17
9
12.9
10.4
10.7
7.518
7.39
7.373
22.5
30.3
37.3
192
123
98
18.3
18.4
21.7
-5
7.4
-4
11.1
-4
6.3
range
MAP
Rate/ Freq
TV(mls/Kg)
PH
Pco2
Po2
Bic
BE
Glucose
Interpretation
Action
Implication
and
significant
7.35
7.45
3545
mmhg
75 - 100
mmHg
2226mmol/l
-2-+2
2.5
mmol/L
Respiratory
alkalosis with
partial metabolic
compensate
Serve another
dose of
curousorf
200mg/kg.
Monitor O2
saturation and
prompt
adjustment
required to
prevent
hyperoxia
27/10
@
0138
HFOV
27/10
@
1219
HFOV
Respiratory
alkalosis with
fully metabolic
compensate
.
Normal ABG
Monitor O2
saturation and
prompt
adjustment
required to
prevent hyperoxia
Prolong
ventilation can
cause a lot of
complication,
thinking of the
weaning is
important to
minimize
complication
Planning
for
wean the mode
43
4.6
Radiology data
The EET tube from KPJ Selangor was located higher from region of carina, after reintubate
the location shows in the region of carina.
44
Before serve surfactant the CXR appearance of ground Glass and after surfactant there
some functional alveoli appear.
45
UAC and UVC looks like in Abdominal XRAY. The straight one was UVC with
46
4.7
Drug study
As the radiological appearance of RDS is similar to that of congenital pneumonia, all infants
should be given prophylactic antibiotics until an infection screen proves negative. First-line
antibiotics should be administered until a positive culture dictates specific medication.
Sedation with or without medical paralysis is usually recommended for ventilated infants to
avoid discomfort. The use of paralysing agents can cause tissue oedema and necessitate fluid
restriction. Sedation given by continuous infusion will also aid synchronous ventilation, and
should therefore be avoided in babies on CPAP and synchronised intermittent mandatory
ventilation.
Hypotension is common in sick infants with RDS who may require volume expansion or
inotropic support to improve cardiac function, and thus organ perfusion.
Calculations of medications must be carefully individualised. The infants weight must be
taken into account in association with consideration of the immature renal and hepatic
systems incapacity to metabolise and excrete drugs. Serum levels of drugs should be closely
monitored to avoid toxicity
47
Before the infusion 500 mg Amikacin is dissolved in 200 mg saline or other suitable
The maximum daily dose should not exceed 15 mg/kg body weight, and the total dose
In newborn and prematurely born infants, the single initial dose of Amikacin is 10
mg/kg body weight. After this dose the treatment continues with a dose of 7.5 mg/kg body
weight given every 12 hours during the following 7 to 10 days.
48
weight intravenously.
Contraindication:
Hypersensitivity to aminoglycoside antibiotics, pregnancy and breast-feeding.
Special precaution:
In high plasma concentrations of the drug there is an increased risk of ototoxicity and kidney
toxicity, because of which a monitoring of the pick plasma concentration is advised Amikacin
should be prescribed with increased caution in patients suffering from parkinsonism, diseases
of the auditory nerve, myasthenia gravis, severe renal and hepatic insufficiency. In cases of
prolonged treatment, regular checks of the state of hearing and creatinine clearance are
advised. The treatment should be discontinued in cases of loss of hearing of high frequency
sounds.
Adverse reaction:
After prolonged treatment with Amikacin the most common adverse effects are the
nephrotoxicity and the ototoxicity. The manifestations of ototoxicity are vestibular toxic
changes (in balance) and cochlear toxic changes (loss of hearing associated with a sensation
for pressure and noise in ears and decreased perception of high frequency sounds). After
concurrent administration of Amikacin and other nephrotoxic drugs renal failure can be
developed. Relatively rare the following adverse effects can be seen: allergic reaction,
nausea, vomiting, stomatitis, blood changes, depression of respiration, and muscle pareses.
Date on:
49
Date off:
50
CEFOTAXIME 200mg BD
Generic Name:
CEFOTAXIME SODIUM
Brand Name:
Cefotaxime, Claforan
Route:
Intravenous
Indication:
Neonatal meningitis and Empirical therapy in infants with suspected sepsis who have
previously received multiple courses of antibiotics.
Dose:
50mg/kg every 12 hour.
Contraindications
History of hypersensitivity to cephalosporins or major allergic response to a penicillin.
Precautions
Renal impairment: cefotaxime has a high renal clearance, therefore reduce dose in moderate
to severe renal impairment. This is particularly important for lower birth weight infants, as
the pharmacokinetics of cefotaxime are influenced by birth weight.1, 2
Possible Adverse Effects
51
Special Considerations
Monitor renal and hepatic function.
Date on:
Date off:
52
53
Adverse reaction:
Transient bradycardia. O2 desaturation
Date on:
Date off:
54
Dilute 30 mg/kg (0.75 ml/kg) dopamine to make 50ml with NS or D5W - 1 ml/hour =
10 micrograms/kg/minute.
Do NOT mix with any other drug, blood, or blood products. Do NOT flush line.
55
Indication:
To improve cardiac output, blood pressure and urine output in critically ill infants with
hypotension.
Dose and Administration
-
Administer via a central line (UVC, Longline, or Surgical CVL). If no central access
available, use a large vein.
Usual dilution 30 mg/kg (0.75 ml/kg) dopamine to make 50 ml with Normal Saline or
D5W
1 ml/hour = 10 micrograms/kg/minute.
Contraindications
-
Uncorrected tachyarrhythmias.
56
Special Considerations
-
Dosage range is determined by type of desired clinical effect. Start at the lower end of
the desired range and titrate according to clinical response.
Use with caution in patients with persistent pulmonary hypertension of the newborn.
Nursing Considerations
Monitor for adverse reactions.
-
Continuous cardiorespiratory monitoring & Document vital signs hourly and PRN.
Date on:
Date off:
58
should be discarded.
Dilute 30 mg/kg (0.75 ml/kg) dopamine to make 50ml with NS or D5W - 1 ml/hour =
10 micrograms/kg/minute.
Compatible with sodium chloride 0.9%, glucose 5% and glucose 10%
Compatible at Y injection site with dobutamine, morphine, heparin, PGE1.
Incompatible with acyclovir, indomethacin, insulin, frusemide,, sodium bicarbonate
and other alkaline solutions including phenytoin. No information available on IVN,
Indication:
Inotropic agent used to increase cardiac output. Cardiovascular shock
Dose and Administration
59
Special Considerations
-
60
Date on:
Date off:
61
NURSING CONSIDERATION
MONITORING Continuous cardio-respiratory and arterial blood pressure monitoring. Infant
must be on mechanical ventilation.
ADVERSE EFFECTS
-
mechanics.
Tachycardia and blood pressure changes both hypotension and hypertension.
Increased salivation and nausea. 4. Arrhythmias.
Date given:
-
63
64
Morphine infusion
4.8
Other treatment
Care procedures and treatments should coincide and be kept to a minimum - known as
minimal handling or cluster care - (Turrill, 2002), as sick infants can react to any disturbance
by becoming hypoxic. Crying (or silent crying in the case of an unsedated ventilated infant)
causes irregular respiration and compromises ventilation, increases pulmonary artery pressure
and shunting, lowering oxygen levels (Sparshott, 1994).
Endotracheal suction
Endotracheal suctioning to maintain airway patency is a necessary component of care for the
intubated baby. It removes secretions, while preventing obstruction that can lead to atelectasis
and decreased lung compliance. As suctioning is traumatic (infants may become bradycardic
or hypoxaemic, and it can damage the trachea), it should be instituted with great care and
only when absolutely necessary, based on clinical findings. It is a sterile procedure. Debate
surrounds the use of instilled normal saline prior to suction (McCormack, 2003).
Thermoregulation
Neonates have poorly developed mechanisms for thermoregulation and maintenance of a
neutral thermal environment is a perpetual challenge. Core temperature should be maintained
at 37C to minimise oxygen consumption and acidosis. Peripheral temperature should be
maintained above 36C - a fall below 34C is indicative of underperfusion, which may be due
to hypovolaemia or infection. To minimise heat loss, it is recommended that sick infants are
nursed in an incubator with a controlled temperature, or an open cot with an overhead heater
controlled by a temperature probe on the skin.
65
66
parents should be taught how to use it. The parents should also be taught how to perform
cardiopulmonary resuscitation (Jevon and Henley, 2002).
67
Poor growth and poor weight gain are often related to persistent hypoxaemia, so vigorous
attention should be paid to optimal nutritional care. Cerebral palsy and learning difficulties
are also long-term complications.PATIENT PROGRESS
On 24th July @ 2345H
Transfer in case from KPJ Selangor, new born female 10 hours of life.
On arrival baby looks very ill. Central cyanosis. Spo2 <20%. Intubated with size 3 marking at
9 cm, manually ventilation by consultant KPJ Selangor, Fix on ventilator leaking >30% With
fio2 1.0, Rate 50 bpm, PEE 8, PIP 30. SB Dr. Q, took history from KPJ Selangor Consultant.
CXR from KPJ Selangor reviewed by Dr Q.
On 25/10/16@ 0020H
Parameter as charted. NIBP 66/44 mmhg. Spo2 23% on high ventilator setting. Plan for
reintubated. Spo2 dosents pick up event manually bagging by Dr Q.OGT size 6 inserted. A
lot of Air coming out. No bleeding seen. IV Morphine 400mcg given as ordered. CXR done
and result noted Dr Q. Reintubated with size 3.5 marking at 9 cm. no bleeding noted.
On 25/10/16@ 0010H
Another CXR taken. Plan for UAC and UVC insertion. Sedated baby with morphine infusion
3.8mg/50 cc D5% at 1 mls/ hour= 20 mcg/kg/hour. IVD started D10% at 9.5 mls/hour. fluid
resus 50mls N/saline given as ordered. Curousorf 400mg given through ETT by DR Q. Spo2
increasing till >95%, noted pinkish in color, Parameter more stable. UVC inserted with size5
marking at 11cm and UAC inserted with size 3.5 marking at 20cm. Blood C&S, ABG and
Blood test taken as order. All the infusion changes to UVC. Total fluid requirement was
60mls/kg/day=9.5 mls/hour. IVD Dextrose 10% at 8 mls/hour, Infusion Morphine at
68
1mls/hour, UAC flushing at 0.5mls/h. For Blood test, CXR and ABD X ray this morning.
Order to gradually reduce fio2 till spo2 remaining around 92%.
-
On 25/10/16@ 0200H
Spo2 96%, ABP 57/ 42 mmhg with mean bp 49mmhg. Reduce fio2 0.92, Moving limbs on
and off, body warm but extremities cold to touch, cont. treatment.
On 25/10/16@ 0300H
Fio2 reduce to 0.85, spo2 maintain more than 95% heart Rate reduce till 100 -110 per minute,
mean ABP maintain more than 45 mmhg, Reduce morphine infusion at 0.5 ml as per hour=
10 mcg/kg/h. Cont. treatment.
On 25/10/16@ 0400H
Reduce fio2 0.5, spo2 maintain 100% HR: 108/minute moving limbs on and off. Parameter
stable. Cont. treatment.
69
On 25/10/16@ 0700H
Day 2 in NICU
Day 1 of life
Diagnosis: Birth Asphyxia
Consultant DR. Q
Birth weight:3.77kg- girl
Fluid requirement 60mls/kg/day
Ventilation support mode PTV, fio2 0.3, rate 60 bpm, PEEP 8, PIP 30, Ti 0.5
Taken over report, check on baby on IPPV support, mode and setting same as above,
presented:
-
UAC size 3 marking at 20 cm- intact with flushing at 0.5 mls per hour
UVC size 5.5 marking at 11 cm,IVB times 1 at left hand- spigot
IVD- dextrose 10% at 8.5 mls per hour- progress well via uvc, infusion morphine (3.6
mg/ 50cc dextrose 5%) at 0.5 mls /hours. Ogt size insitu- spigot
Parameter as charted ABP 66/40 mmhg, MABP >45mmhg, HR:100-110 bpm, spo2
98-100%
Air entry equal bilaterally with good chest expension, intermittently with good breathing
effort, upper and lower limb bluish- poor perfusion- bluish spot seen at forehead-? birth
mark,otherwise strictly hand hygiene with minimal handling.cont. incubator nursing care
On 25/10/16@ 0830H
Review by Dr IQ update baby condition, explanation given, examine baby, noted blood
result. Noted CXR n ABDO XRAY, plan readjust UAC to 18 cm marking, readjust ogt about
6 cm-pull out, Reduce PIP to 18, Reduce PEEP to 6, For CXR and ABDO XRY post
procedure. While doing procedure baby desaturated till 40%, increase fio2 till 0.7, slowly
70
pick up. Upper and lower limb bluish till- poor perfusion, otherwise observe for bleeding,
cont. current treatment
On 25/10/16@ 0900H
Visited by father. Update baby condition, explanation given, look anxious talking and
touching the baby.
On 25/10/16@ 1230H
Attended baby, all care rendered. Parameter as charted, MAP >45 mmhg, HR: 100-110bpm,
spo2: 100%, temperature 35. Air entry equal bilaterally with good chest expansion. Vte 1416mls, no sign and symptom of bleeding from umbilical site. Suction done, moderate amount
of secretion from ETT and oral nasal., Diapers change noted NPU still and BNO. Rang up Dr.
Q update baby condition, plan: For IV NACL bolus 50 mls over hour. Otherwise cont.
current treatment
On 25/10/16@ 1330H
Check on baby. Desaturate ,80%, vte:7-8 mls, all air entry equal bilaterally with good chest
expansion, Suction performed. Thick, whitish with old blood stain. ABG done- result as
charted, increase PIP to 30, increase PEEP to 8, spo2 still not pick up: 40- 60%, range up D
Q, update baby condition, for urgent CXR.
On 25/10/16@ 1430H
Attended by Dr Q, noted CXR, decided to pulled out ETT to 8.5cm marking at lips, suction
done by dr Q, secretion in thick, moderate amount. Planned Increase fio2 to 0.95%, Increase
rate to 70 bpm, Reduce PEEP to 6, spo2 pick up >90%, vte:14-16mls, Kiv HFOV.
On 25/10/16@ 1530H
Baby condition not sustained, desaturated <80%, increase fio2 to 1.0%, MAP= 40-45mmhg
71
Range up Dr IQ, noted baby condition, for infusion dobutamine (60 mg/50cc Dextrose5%)
run at 2mls/hour=10mcg/kg/min, will review patient soon
On 25/10/16@ 1600H
Review by Dr. Q, examine baby. Planned for infusion dopamine started at
0.2mls/hour=10mcg/hour. Put baby on HFOV: fio2 1.0%, Iv Esmeron 500mcg if baby awake
and fighting ventilation, repeat ABG 1 hour, otherwise cont. same
On 25/10/16@ 1700H
Review by Prof zulkifli, ECHO done- normal CVS, no special order
On 25/10/16@ 1730H
ABG done- result as charted, Range up Dr noted ABG, parameter as charted, baby still
desaturated till 50%, IV esmaron 500mcg given as ordered
On 25/10/16@ 1900H
Review by dr Q, update baby codition, explanation given, examine baby, adjust ventilator
setting, readjust UAC marking, for portable cxr and abdo Xray, increase infusion dopamine to
0.4mls/hour since MAP: 40-43mmhg. Kiv another curosuf tonight, otherwise will review
soon. Parameter as charted MAP:43mmhg, HR 180=188bpm, spo2 80-85%. Ventilator setting
remain same.
72
Night shift
On 25/10/16@ 2115H
Took over case, baby critically ill. Still on IPPV support, HFO mode: fio2 1.0%, rate Delta P:
mean. Chest wiggle seen due to HFOV mode, ETT size 3.5 marking at 8.5cm, UVC size 5
marking at 11cm.
-
UAC size 3.5 marking at 12cm- Heparine saline 5 mls plus 45 mls Nacl at 0.5mls/hour
Ogt size 6 marking at 33cm-keep free flow, baby keep NBM, on and off moving limb but
baby not fighting, ABP 68/34mmhg (48) HR:170-173bpm, spo2 83-92%, Dco2 1777, father
around, update baby condition.
On 25/10/16@ 2300H
Temperature:38.0. Condition baby same, PU done, BNO, asp Nil, UAC and UVC intact
Urine output:4mls= 0.2mls/kg/hour
*fluid resus given at 2100hour 50mls Nacl to observe
On 25/10/16@ 2330H
ABG noted to Dr via phone, PH:7.327, Pco2:37.3, PO2:34:BE :-6, Glucose :4.0mmol/L
-
On 25/10/16@ 2400H
ABP: 68/32mmhg (47) HR: 170-173bpm, spo2 83-92%, DCO2:1572
73
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Morning Shift
On 26/10/16@ 0700H
Day 3 in NICU
Day 2 of life
Diagnosis: Birth asphysia, RDS
Consultant: Dr. Q
B.Wt: 3.77kg- girl
Took over case, baby critical ill, still on IPPV support, HFO mode, Fio2:1.0, Rate :9, Delta
P:58, mean :20, chest wiggle seen due to HFOV mode, ETT size 3.5 marking at 8.5cm, UVC
size 5 marking at 11cm on progress:
IVD dextrose 10% at 10.6 mls/h
-
OGT size 6 marking at 33cm- keep free flow, baby still NBM. On and off moving limb and
open both eyes, not fighting, ABP:72/33mmhg (53) HR:174bpm, spo2: 90-95%, DCo2:1777.
Dr Q around, assess on baby, change ventilator to PTV mode, baby desaturated, change back
to HFO again.
On 26/10/16@ 0810H
75
-S/B Dr Q, Took blood for LFT, BUSE, LACTATE, FBC, CRP and order CXR, If baby
vigorous fight to give iv esmaron as per cardex, to trace culture, wean infusion dopamine to
10 mcg if MAP persistently more than 55mmhg, kiv repeat surfactant after CXR.
On 26/10/16@ 0900H
Awaiting for CXR, ABP:71/36mmhg(50)HR:175bpm, RR:9(60)
On 26/10/16@ 1030H
Noted to Dr.Q blood result, Ask to review CXR and noted SPo2 60%, DCO2:>1200.
On 26/10/16@ 1040H
Called Dr Q, noted spo2 dropping to 50%, Dr Q called back noted no pneumothorax on CXR,
Its RDS still, meaning, the lung getting stiff, order to give surfactant 200mg/kg, to get ready.
Increase pressure to 22, ABP: 81/39mmhg (57), HR:140bpm
On 26/10/16@ 1130H
Still awaiting Dr. Q, Spo2 probe adjust to both hand and legs, Spo2 still 50-68% range.
On 26/10/16@ 1200H
Seen by Dr IQ, examine baby
-
On 26/10/16@ 1230H
Both upper and lower limb looks pink, Spo2 increase gradually to 92%. Visited by parent,
condition updated, suggest to see Dr Q for more detail.
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On 26/10/16@ 1345H
Baby remain stable, spo2 94%, ABP: 92/50mmhg (66), reduce IV dopamine to 0.3 mls/h.
Afternoon shift
On 26/10/16@ 1430H
Took over case, baby critically ill, still on IPPV support HFOV mode, FIo2:1.0, Rate:9, Delta
P:60-70, mean:24. Chest wiggle seen due to HFO mode
-
On and off moving limb and open both eyes, not fighting, ABP:82/45mmhg (60)
HR:137bpm, spo2: 90-95%, DCo2:1426. Dr Q around assess on baby, ordered to reduce
fio2 gradually as spo2 >95%. Parent around, talk and touch the baby.
On 26/10/16@ 1600H
Attended to baby, pink and warm to touch, temp 38.0 gradually reduce fio2. All infusion in
progress, baby look sedated, Pu minimal-0.2 mls/kg/h. to observe. Mean bp started to drop
50-55mmhg, observe aspiration nil.
On 26/10/16@ 1730H
Noted Dr Iq regarding the MAP < 50mmhg. Spo2> 95% with fio2 75%, cont. same just obese
mean pressure ventilator. Still the same @ 24, others cont, same
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On 26/10/16@ 2000H
Parameter stable. Otherwise DCO2> 1200. Baby pink, warm. Temp: 37.5, no sign of having
secretion, no suctioning done. Iv line intact flushed, all medication infusion in progress
(morphine already off @ 5pm). Still sedated but move hand and leg once touch the baby.
Aspiration nil. Abdomen looks slightly distended but soft still NPU, bladder hard, try to
stimulate but still no urine came out, baby looks uncomfortable once palpated, urine catheter
inserted with feeding tube size 5, urine pouring good, otherwise baby still on IPPV support
with
same
setting
and
mode.
Fio2:0.60.
parameter:
SABP:65/40
(50)mmhg.
HR:129bpm.97%.
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Night shift
On 26/10/16@ 2130H
Taking over report, baby critically ill but pinkish in color, keep HFO with same setting,
sedated with Dormicum infusion (25mg/50cc D5%) @ 1mls/ h= 120 mcg/kg/hour. Parameter
as charted, body temperature around 37.7- 38. Mean BP > 50mmhg :
-
Received call from Dr. Q update baby condition, reduce dopamine infusion at 10mcg/kg/min.
keep Mean BP>46mmhg. Increase IVF to 10.3mls/hour.
On 26/10/16@ 2245H
ABG taken as orderd. Result: PH: 7.518, Pco2:22.5, Po2:192, BE:-5, HCO3: 18.3.
On 26/10/16@ 2250H
Called up Dr Q. Noted ABG result. Order to reduce Delta P to 60, Reduce Mean to 22, Aim
Dco2 around 1100, Repeat ABG after 1 hour.
On 26/10/16@2245H
SB parents, looks sad but understand baby condition., updated baby condition, continue same
treatment.
On 26/10/16@ 2330H
Baby stable. Touching by mother, parameter as charted, cont. same treatment
On 27/10/16@ 0005H
ABG taken as order. Result: PH: 7.454, PCo2:25.4,Po2:184, BE:-6, Hco3:17.9
79
Call up Dr IQ, Update baby condition. Noted ABG result. Ordered: To reduce Delta P to 55
Mean reduce to 20, Repeat ABG after 1 hour. Action taken. Baby still accompanied by
parents. Updated current status to parents, cont same.
On 27/10/16@ 0120H
Parameter stable. Noted Mean Bp level increase 55-60mmhg, already reduce dopamine
infusion to 5 mcg/kg/min, Brought in EBM by father, good production. ABG result taken as
order. Result: PH: 7.390, Pco2: 30.3, Po2: 123, BE: -7, HCO3:18.4. Called up Dr Q, Noted
ABG result, planned to reduce Delta P to 50, remain mean 20, Remain dopamine infusion
5mcg/kg/min, Reduce Dobutamine infusion to 5mcg/kg/ min=1mls/hour. Action taken:
increase IVF to 11.4 mls/hour
On 27/10/16@ 0200H
Attended baby, Body temperature 36.7 degree, whole body cold to touch, perfusion at upper
and Lower extremities bluish and mottling. Noted ABP increase 60-70mmhg, HR: 110120/min. Spo2 69-93%. DCO2 around 650-1000. Increase Fio2 to 0.5 for the time being.
Checked pampers, BNO, urine output 0.9mls/kg/hour. Iv branular checked. Intact, IV
antibiotic given as prescribed, Cont. Treatment.
On 27/10/16@ 0230H
Now much better and more stable, Spo2 increase to 100%, Reduce Fio2 to 0.4, HR: 130140/min, mean BP 50-55mmhg, Dco2 increasing around 800- 1000, cont. same.
On 27/10/16@ 0250H
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Noted baby agitated, HR: 140-160/min. Mean BP 60-70 mmhg, Spo2 80- 90%, DCo2 700900., Esmaron 500mcg given as ordered, to observe.
On 27/10/16@ 0320H
Spo2 around 89-90%, Dco2 around 500-600. Noted secretion in ETT seen. Attended baby,
Oral tracheal suction done with large amount light yellowish thick secretion from ETT and
large amount thick mucoid secretion from orally, Noted Dco2 increasing 900-1000 and spo2
increase 90-100% during procedure, baby more calm and looks comfortable after suction,
parameter stable.
On 27/10/16@ 0445H
Sleep on and off spo2 >92%, Dco2 900-1000, mean BP 60-70mmhg. HR:138/min. cont.
same.
On 27/10/16@ 0530H
S/B father. Updated baby condition, brought EBM, Good production.
On 27/10/16@ 0630H
Attended baby, awake, DCo2 900-1000, SPo2 89-95%, Change pampers again, BO large
amount meconium. Noted CBD out, Removed CBD, baby more comfortable after taken out
CBD, con. Same.
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On 27/10/16@ 0700H
Taken over report, checked baby on IPPV support, Mode and setting same as above,
presented:
-
UAC sz 3.5 marking at 12cm- intact with Heparine saline flushing 5mls plus 45mls
Nacl at 0.5ml/h.
Uvc sz 5.5 marking at 11cm
IvB x1 at lt hand- spigot
IVD dextrose 10% at 11.4 mls/h- progress well via UVC
Infusion Dobutamine (60mg in 50 mls Dextrose 5%) at 1 mls /hour
Infusion dopamine (14mg in 50 mls Dextrose 5%) at 0.1 mls /h
Infusion Midazolam at 1.0 mls/ h
OGT sz 6 marking at 33cm- spigot
Parameter as charted
ABP:66/40, MABP>50 mmhg, HR:110-120bpm, Spo2> 92%, air entry equal bilaterally with
good chest expansion, Chest vibration symmetry. Upper and Lower limbs looked bluish- poor
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perfusion, bluish spot seen at forehead ? birth mark, noted baby looks jaundice,
otherwisestrictly hand hygiene with minimal handling, cont. incubator nursing.
On 27/10/16@ 0830H
Reviewed by Dr. Q updates baby condition, explanation given, noted ABG result with
potassium 3.5 mmol/L, planned:
-
On 27/10/16@ 0900H
Visited by parent, Explanation given, bring along EBM about 20 mls, looked anxious,
reassurance given, talking and touch the baby
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On 27/10/16@ 1200H
Attended baby, all care rendered, ABG done- result as charted, parameter as charted
MAP:45-50 mmhg, HR:110-120bpm, Spo2:100% Suctioning done, secretion thick, large
amount and whitish from ETT tube and moderate whitish, thick from aral nasally.,
diaperse change, urinate well, Box 1 in large amount, IVD maintain at 15.4mls/h.
Infusion dopamine at 0.1mls/h, comfort the baby and cont. care.
On 27/10/16@ 1330H
Rang up Dr. Q, updates baby condition, Noted ABG result, no special order, cont. care.
On 27/10/16@ 1400H
Visited by mother. Bring along EBM, updates baby condition. Explanation given, talking
and touch the baby. Review by Dr. Q at the same time explained to the parent treatment
plan of their baby.
-
On 27/10/16@ 1730H
Attended to baby, all care rendered, parameter as charted, MAP>45mmhg, HR:120-130bpm,
SPO2 88-95%. Chest vibration symmetrically, suction done, secretion large amount, thick
and whitish from ETT, moderate whitish from oral nasally, diapers change- urinate well, BO
x1 in moderate amount, SPO2 78-81% post suction, DCO2 700-800, increase Mean pressure
to 16, observe baby condition.
On 27/10/16@ 1830H
84
Attend another suction, secretion remain same, Spo2 gradually picked up more than 85%,
DCO2: 900-1000, parameter as charted MAP: 45-50mmhg, HR: 130-140bpm, chest vibration
symmetry, cont care
On 27/10/16@ 2000H
Checked on baby, condition same, parameter as charted, MAP: 48mmhg, HR: 130 bpm,
Spo2:94%, mode and ventilator setting as charted, HFOV mode, Fio2:0.3%, Rate:9, Delta
P:40, Mean:15, ivd progress well at 15.4/h, infusion dopamine at 0.1mls/ hour, Infusion
midazolam at 1 mls/hour. Visited by mother, bring along EBM and updated baby progress,
touch and talking to the baby.
85
On and off moving limb but not fighting, on phototherapy started at 1000hrs.
ABP:68/34mmhg (45) HR:130-140bpm, spo2: 88-92%, DCo2:782, mother still around,
updated condition satisfied
On 27/10/16@ 2330H
Temp: 37.2. condition remain same, Pu- urine output good, BNO, Aspiration Nil
86
UAC and UVC intact, suction done, ETT whitish large amount, oronasal whitish moderate
amount, desaturated until 70% during suction, increase fio2 :40%, ABP:62/32mmhg (44) HR:
230-140bpm, spo2: 92-94%, DCo2:954. All infusion on progress, cont care
On 27/10/16@ 0130H
ABP:68/34mmhg(48) HR: 136bpm, spo2:94%, DCo2 759, sleeping and looks comfortable,
cont phototherapy.
On 28/10/16@ 0730H
Day 5 in NICU
Day 4 of life
Diagnosis:Birth asphysia, RDS
Consultant:DR Iq
B.Wt: 3.77kg- girl
Took over case, baby critical ill but stable, still on IPPV support, HFO mode, Fio2:0.3, Rate :
9, Delta P:40, mean :16, chest wiggle seen due to HFOV mode
-
On and off moving limb, not fighting, on phototherapy started at 1000H yesterday,
ABP:70/38mmhg (50) HR:130-140bpm, spo2: 90-100%, DCo2:> 750
87
S/B Dr. M, noted baby condition and parameter and ABG, planned
-
On 28/10/16@ 0800H
S/B Dr. Q. noted baby condition, parameters and changes done by Dr. M as planned:
-
Change IPPV setting to PTV mode, Rate 60, PEEP:5, Fio2:0.30, PIP:24, TI:0.38,
spo2> 90%, no spontaneous breathing
reduce midazolam to 0.5mls/h (60mcg/kg/h)
off infusion dopamine
On 28/10/16@ 0915H
Parameter stable, spo2 90-95%, resting, already visited by father, afebrile, had eye
opening and move passively once handling, aspiration minimal, change OGT to size 8.
Intact, aspiration 3.5mls saliva, PU and BO, perineal care done, feeding OGT given as
order, 5mls. Noted had minimal nasal flaring after change the mode
On 28/10/16@1000H
ABG done after 2 hour changing the mode. PH: 7.333, Po2:51, Pco2: 38.4, HCo3:20.5, cont
treatment
On 28/10/16@ 1100H
Visited by parent, updated baby condition and parameter, satisfied, talk and touch the baby
On 28/10/16@ 1230H
Attended to baby, looks stable but still had nasal flaring, to and tail clean done, suctioning
done, thick, yellowish moderate amount of ETT suction, oral whistis moderate. Lower spo2
88
during suctioning drop till 87%, slowly pickup to >95%, fio2 maintain@ 0.35, aspiration
3mls saliva + +. PU, BNO, feeding given as tolerated, other cont. same
On 28/10/16@ 1420H
Rang up Dr. Q, noted baby condition and parameter, VTE:14-18, Spo290-95% with fio2 0.35,
on and off looks tachypnic 70-85bpm, and need cont. dormicum or want to off it. (near to
empty)- to off if infusion dormicum once completed. Cont same. No futher ordered.
On 28/10/16@ 1515H
Attended to baby, parameter stable, Spo2 90-95%. Resting, aspiration minimal mucous.
Intact. Aspiration 3.5 mls saliva, PU bo done, perineal care done. Feeding OGT given as
tolerated at 5 mls. Noted had mild nasal flaring after change the mode.
On 28/10/16@ 0005H
Attended baby, looks stable, still have nasal flaring, looks slightly jaundice, warm to touch,
tem 37.8, suctioning done, thick yellowish, moderate amount, oral whitis, moderate. Lower
spo2 during suctioning drop till 70%, slowly pick up to > 90%, fio2 maintain @ 0.35,
aspiration 3mls saliva plus air ++, pu and bo, feeding given as order, other cot same.
On 28/10/16@ 1830H
Received call from father, updated baby condition and treatment via phone, satisfied, still at
home saw the other kids.
On 28/10/16@ 2030H
S/B dr iq, noted baby condition and parameters, order to increase the PEEP to 6, ABG done,
noted planned to increase fio2 as Spo2< 95% rate 60 bpm. PIP 26. Other cont. same.
89
On 28/10/16@ 2200H
Visited by parents, updates baby condition, satisfied, talking and touch the baby
90
On 28/10/16@ 2300H
Attended to baby, all care rendered, Suctioning done. Secretion in moderate amount, light
yellowish secretion from ETT, minimal amount whitish from oral nasally, no bradycardia
during the procedure, desaturated with fast pick up, diapers change- urinate well, BNO,
abdominal soft to palpation, feeding attempted at 5 mls ofEBM- asp: 2mls of mucose,
otherwise gradually reduce fio2 to 0.45%, cont same.
91
92
On 29/10/16@ 0730H
Taking over report baby more stable, keep ippv with same mode setting. Parameter as
charted. HR: 10-120/min. Mean BP around 50-60mmhg. No inotrops, more active. UAC and
UVC insitu, IVF saline 10% dextrose + 3.6 mls of KCL run at 18.5 mls /hour, UAC
flushing in progress run at 0.5mls/h. Tolerated OGT feed EBm 3 hourly 5mls. Total aspiration
yesterday 17.5mls mucous, good urine output 4.1 mls/kg/h, other cont same.
On 27/10/16@ 0830H
Seen by father updated current status, brought EBM, Good production, talking and touch the
baby, baby looks active, parameter stable.
On 29/10/16@ 0900H
Attended baby, stable, and active, pampers change, BNO, PU good urine output 4.5 mls/kg/h.
turn to rt lateral position, aspiration 1.5 mls undigest milk, feeding given 10mls of EBM.
Medication serve as order, rest cont. same.
On 29/10/16@ 1015H
S/B dr Iq, with parent, updated baby condition, review ABG result- PH:7.292, PCo2:42.6,
PO2 :62, BE:-6, HCo3: 20.6, Glucose: 3.6. Increase total fluid requirement to 150mls/kg/h,
order to change IVF to 1/5 saline 10% Dextrose + 6.7mls KCl if glucose stilllow, rest con.
Same.
On 29/10/16@ 1200H
Attended baby, pampers change, BO moderate meconium, parameter stable. Ral tracheal
suctiondone, smll amount and loose secretion, feeding given as order, rest cont same.
On 29/10/16@ 1300H
S/B parent update status, talking and touching the baby
93
On 29/10/16@ 1345H
Attended baby, medication serve as charted, ABG taken. Glucose still 3.2 mmol, called up dr
Iq, noted ABG result planned; Change IVD to 1/5 saline 10% Dextrose + 6.7 mls KCL.
Reduce total fluid requirement to 130mls/h, rest cont same.
On 29/10/16@ 1500H
Took over report baby still on ippv support as per setting, ETT size 3.5@ 8.5 cm marking
intact, air entry equall bilaterally, attended to baby, looks pink jaundice, warm to touch, look
comfortable, parameter as charted, temp 37, MAP: 50 mmhg, HR: 100-120bpm, Spo2 > 95%,
94
Pu, BO done, all care rendered., Feeding attempt at 10 mls of EBM- aspiration: 2mls of
mucose. IVB insitu- noted redness at IVB. Keep rest cont care.
On 29/10/16@ 1815H
Noted baby start Brady till 100bpm, SABP: 90/40 (68), attended to baby, parameter stable,
afebrile, active once handling. Suctioning done, thick light, yellowish with plug moderate
amount from ETT, oronasal whitish loose scanty, Better, aspiration minimal mucos. PU bno.
All care rendered, feeding given as tolerated. Repeat HGT: 4.7mmol/l HR: 115 bpm,
Map:54mmhg, Spo2, 98%, breathing 40-50bpm
On 29/10/16@ 2045H
Attended to baby, suctioning done, thick light and yellowish moderate amount from ETT.
Oronasal whitish loose scanty, aspiration minimal mucose, PU,Bo done. All care rendered.
Feeding given as tolerated, Fio2:0.28. Spo2:99%. MAP: 50 mmhg, HR:115bpm, breathing
40=50bpm.
On 29/10/16@ 2100H
Taken over report check baby on ippv support mode and setting same as above. Presented:
-
Parameter as charted, MAP: 55mmhg, HR: 110-120bpm, Spo2> 95%, good breathing effort
seen, air entry equal bilaterally with good chest expansion, Vte: 14-16mls, baby looks pink,
moving all upper and lower limbs.
On 29/10/16@ 2200H
95
Visited by parents, updating baby conditionsatisfied, touch and talk to the baby as usual.
On 29/10/16@ 2330H
Attended to baby. All care rendered, suction done, secretion in moderate amount, light
yellowish secretion seen from ETT, minimal amount, whitish secretion seen oral nasally, no
bradycardia during procedure, diapers change, urinate well- BNO, abdomen soft on
palpation, feeding attempt at 10mls of EBM- asp:1.5mls of mucus, rest cot. Same.
review by Dr IQ at the same time, updates baby condition, noted ventilator keep alarming:
low pressure, neopuff the baby, check on ventilator, after satisfied attached bat to the ETT
and ventilate well, reduce PEEP to 5, PIP 24 for phototherapy.
-
0.5ml/h.
IVD saline Dextrose 10% + 3.6 mls of KCL progress well at 18.5mls/hat 15.4 mls/h
Infusion dopamine (14mg in 50 mls Dextrose 5%) at 0.41mls /h=5mcg/kg/h
OGT sz 6 marking at 33cm insitu for feeding purpose.
IVD intact at Rt hand- Spgot
30/10/16
Day 6 in NICU
Day 5 of life
96
31/10/16
Diagnosis: Birth asphyxia, RDS
Consultant:Dr. Q
B.Wt: 3.77kg- girl
Fluid requirement 130 mls/kg/day
UAC insitu with IVD 1/5 saline 10% dextrose plus 6.7 mls KCL@ 16.6 mls/ h
UAC flushing Nacl @ 0.5 mls/h
Ventilation- mode PTV, fio2: 0.26%, Rate 30 bpm, PEEP:5, PIP:24, Ti:0.38
2100
Fluid requirement 150/kg/day
UAC insitu flushing NACL 0.5 mls
UVC insitu with IV drip 1/5 saline 10% dextrose + 6.7 mls KCL@ 11.4 mls/ hour.
OGT feeding 3 hourly 35 mls of EBM- to increase 5 mls every cycle.
Baby still on IPPV, looks pink and warm to touch. Asleep.
1st Nov 2016
Day 8 in NICU
Day 7 of life
Diagnosis: Birth asphyxia, RDS
Consultant:Dr. Q
B.Wt: 3.77kg- girl
Fluid requirement 150 mls/kg/day
0400H
PIP reduce to 18, Spo2 96% with fio2 of 0.25
Feeding at 40 mls/ 3 hourly, reduce IVD to 9.7mls/h.
98
0530h
Attended baby, suction done, desaturated till 80% increase Fio2 to 0.29%, comfort the baby,
all dressing change, rechecked IVB no redness noted,pu and BO done , feeding given as
regeim, aspirate 4 mls.
0800
S/B dr Q. noted ABG, normal, planned extubate, put pt on nasal prong oxygen at 3l/min.
Spo2 more than 95%, no bradycardia seen, Good breathing Effort.
1100
Parameter as charted. HR: 100-110bpm, Resp 20-30, Spo2:100%, reduce oxygen to 2 L/min.
2nd Nov 2016
Day 9 in NICU
Day 8 of life
Diagnosis: Birth asphyxia, RDS
Consultant:Dr. Q
B.Wt: 3.77kg- girl
0730h
99
Took over report baby asslep, keep on nasal prong 2L/min, in incubator stable overnight, S/B
dr Q. remove UAC and UVC, to full feed baby 60 mls EBM 3 hourly to transfer to SCN.
1030H
Transfer baby to SCN via incubator on room air, parameter stable.
1400
S/B dr Q. noted serum bilirubin result, planned to commence photo light (single photo)
Repeat SB cm, maintain Spo2 > 92%.
3rd Nov 2016
Day 9 in NICU
Day 8 of life
Diagnosis: Birth asphyxia, RDS
Consultant:Dr. Q
B.Wt: 3.77kg- girl
0700H
Attend baby, PU and BO, pampers change, baby active on handling, feeding 60 mls given by
cup, tolerated well, baby sleep well in prone position.
1200H
Visited by mother, breast feeding with mother, sucking well, active no tachypnea seen.
100
Attend baby, PU and BO, pampers change, baby active on handling, feeding 60 mls given by
cup, tolerated well, baby sleep well in prone position.SB taken.
1000H
S/B Dr. Q. examine baby, noted SB result, planned off photo light, give hepatitis B and BCG
vaccine, allow discharge with aperton and TCA 1 week.
BCG and HEP B given, Advice mother regarding home care of the baby. Paper work
prepared.
1300H
Bill settle, parent took the baby, health education given on Brest feeding, medication, and
knowledge on respiratory distress symptom.medication to take home given with instruction,
TCA emphasize on 12 november at 0830 in Dr Q clinic.
102
103
Monitor and document hourly FiO2 levels. Sa02 per pulse oximeter,
and vital signs (temperature, heart rate/rhythm and BP).
Assessment provides information about neonates ability to initiate and sustain an effective
breathing pattern.
I: I monitor child parameter every hourly including her SPO2, HR and BP and the result was
spo2 less than 92%, HR:140- 150bpm.
2.
3.
4.
Allows gravity to assist in lowering the diaphragm, and provides greater chest expansion
I: I adjust the incubator to be in 15 degree and maintain head mild extended with blanked.
5.
6.
EVALUATION:
Miss Y spo2 level maintain > 92 % regardless of reduce FIO2 within 1 hour after nursing
intervention given.
Date:25/10/16
Time: 1900H
Re-evaluation:
Miss Y spo2 level maintain > 92 % regardless of reduce FIO2 within 24 hours after nursing
intervention given.
Date: 27/10/16
Time:1800h
Fontanel
Skin turgor
Mucous membrane
To plan appropriate nursing intervention and as a baseline data.
I do assess child general condition by looking at the child skin, mucosa and Glucose level in
ABG.
2. Administer intravenous fluid as prescribed by doctor according to body weight.
To maintained child hydration status
I do administer and regulated intravenous fluid as prescribed by doctor and used infusion
pump.
3. Monitor intake and output by weighing the diapers and record to the chart
I do monitor the intake by looking at the infusion pump that was setting of drop/hour of
intravenous fluid and monitor the output by weighing the diaper (1gm=1ml) and record to
the chart.
4. Served feeding via orogastric tube every 3 hourly and increase the feeding gradually as
prescribed by doctor.
To ensure tolerance in oral intake before starting bottle feeding.
I do served feeding through orogastric tube every 3 hourly as prescribed by doctor and
increase gradually as tolerated from the child. The child milk digestion was very well.
5. Encourage the mother to express breast milk that can give through orogastric tube.
To maintain lactation until infant can breast feed and breast milk is high in protein that is
good and needed for the child for growth.
I do encourage the child mother to express breast milk, the mother had done express breast
milk and sent the milk to nursery and kept in the fridge that was given to the child according
to feeding time.
7. Assessed child readiness to bottle feeding and breast feeding, especially ability to
coordinate swallowing and breathing.
To minimize risk of aspiration.
The child was showed rooting reflex that I was placed my finger at one corner of the childs
mouth and the child was turn the head toward the side stroked. Other than that I put my
cleaned finger on the childs lip and the child was showed the sucking reflex.
8. Served feeding through cup feeding every 3 hourly as prescribed by doctor.
To see child progress in oral intake.
The staff nurse served the milk through cup feeding every 3 hourly as prescribed by doctor
and the child was sucking very well.
9. Encouraged and assisted the mother for breast feeding.
Breast milk is the best supplement for the child and to provide support for breast feeding.
I do encourage the mother for breast feeding and the mother always came to the hospital for
breast feeding and assisted the mother by positioning and proper latch on.
10. Informed the doctor if child oral intake is poor.
To plan for further management.
Child oral intake was good and I did not inform the doctor.
Evaluation:
106
107
Goal:
Childs axillary temperature will be maintained within normal range 36.5c 37.5c after
nursing intervention given and during hospitalization.
Nursing intervention
1. Assessed childs general condition such as:
- Acrocyanosis
- Body cold to touched
As a baseline data and plan for further nursing interventions
I do assessed childs general conditions by touching the childs body that is cold to touch and
acrocyanosis due to just delivered.
2. Monitored child vital sign especially axillary temperature every hourly until stable then
every 3 hourly.
To obtained a constant temperature reading.
I do checked childs body temperature on admission that is was 36c then repeated 1 hour
later is 36.8c and then check for every 3 hourly.
3. Kept the incubator window closed and avoid from open the incubator window frequently.
To prevent from heat loss through convection
All the staff included me do not open the incubator window frequently, only during
observation or any procedure.
4. Changed the diapers frequently eg: every 3hourly
To prevent from heat loss through evaporation.
I do change childs diaper every 3 hourly.
5. Adjusted the incubator/resusciatare temperature by increase the incubator/resusciatare
temperature according to childs body temperature.
To increased the body temperature and prevent from hypothermia.
I did not adjust the incubator/resuscitare temperature by increased the incubator temperature
because childs body temperature was maintained in normal range (36.5 37.5c).
108
Evaluation:
25th November 2016@ 1800hours
Childs axillary temperature was maintained within normal range 36.5c 37.5c.
5th November 2016@ 1200hours
Childs axillary temperature was maintained within normal range 36.5c 37.5c.
109
Goal:
Childs will exhibit no evidence of nosocomial infection after nursing intervention given and
during hospitalization.
Nursing intervention
1. Observe and report sign of infection such as
Temperature >37.5c
IV Ampicilin 400mg BD
IV Amikacin 60mg daily
Cefutaxime 200mg BD
Peripheral IV insertion
112
Goal:
Parental anxiety will be reducing to the minimum level after intervention given and during
hospitalization.
Nursing intervention
1. Assess parental level of fear and anxiety.
To know level of fear and anxiety of parents and able to plan for further intervention.
I assess parent level of anxiety by looking at the parents facial expression and Miss M
mother cried during came to special care nursery.
2. Reinforce the doctors explanation regarding respiratory distress syndrome and childs
management needed to rule out of RDS.
To enhance parents knowledge and facilitate understanding
I do reinforce to parents about the diagnosis, and the management as prescribed by doctor to
make parents more understanding.
3. Use a simple language and terms while explain to the parents and avoid from using
medical term.
For easier the parents to understand what will explain to them.
I explained to parents in Bahasa Melayu for easier parents to understand and using a simple
word.
4. Explained all procedure to be done to child to the parents.
To reduce parental fear and anxiety about the procedure to their child.
I explained to parents all procedure such as the purpose of taking vital signs, giving IV
medication and invasive oxygen therapy.
5. Keep family informed of childs progress.
To help reduce family anxiety about childs condition and parents aware or progress of
their daughter.
113
I do informed to Miss M parents regarding Miss M progress every time Miss M mother came
to special care nursery.
6. Encourage the parents to asking the question that they may not understand.
To provide parents more knowledge and understanding about the disease condition.
I encourage the parents to ask me or other staff also the doctor in charge if they have any
queries about their child condition.
Evaluation:
26th October 2016@0800 hour
Parents knowledge regarding disease condition improved by evidences of the parents is calm
and gives fully cooperation during treatment in the ward after 1 hour of intervention.
Re-evaluation
5th October @1200 hour
Parents knowledge regarding disease condition improved by evidences of the parents is calm
and gives fully cooperation during treatment in the ward and ready for discharge.
114
HEALTH EDUCATION
FEEDING
-
Breastfeeding
Baby will on demand when breastfeeding.
Position during breastfeeding eg: footballs position
Each breast atleast 10-15minutes.
Formula milk
-
Give formula milk after breast feeding if the child is not enough around 1ounc
Preparation of formula milk
1 scoop for 30mls of warm water
Feed the child every 3hourly
CLEANLINESS
-
CORD CARE
-
I did not teach the mother regarding cleanliness of the cord because the child cord
already dropped.
IMMUNIZATION
-
TREATMENT
-
Explained to mother regarding treatment and medication was given to her child.
Teaches the mother about sign and symptom of respiratory distress eg: respiration
rapid, nasal flaring.
FOLLOW UP
-
Give the appointment card to the mother that was given the date for follow up and
explained to the mother that the doctor want to see the child progress.
If any sign and symptom of respiratory distress, fever, or other abnormalities present
just come to see the doctor early and no need to wait until appointment date.
MEDICATION
-
I explain on how to give apperton, the frequency and the indication of the medication
to the mother, I also emphasize on the side effect of the medication and if she noted
any reaction like rashes in the body stop to take the medicine and come to clinic.
FOLLOW UP CALL
-
I called madam E on the 12 November 2016, she said the doctor already examine
Miss Y and found Miss y is very well. There is no sign and symptom of respiratory
distress. No medication on the follow up day. The next follow up when Miss Y 2
months old or when necessary.
116
CONCLUSION
Antenatal maternal steroids and neonatal surfactant therapy have significantly reduced the
incidence, severity, and mortality associated with RDS. However, despite enormous advances
in the management of RDS, respiratory morbidity in the form of bronchopulmonary dysplasia
remains a major problem (Rodriguez, 2003). Excellent neonatal care and subsequent followup can maximise the occurrence of optimal outcomes for these potentially sick and fragile
infants.
117
REFERENCE
Cornblath, M., Hawdon, J. M., Williams, A. F., Aynsley-Green, A., Ward-Platt, M. P.,
Schwartz, R., & Kalhan, S. C. (2000). Controversies regarding definition of neonatal
hypoglycemia: Suggested operational thresholds. Pediatrics, 105(5), 1141-1145.
Cowett, R. M., & Lougheed, J. L. (2002). Neonatal glucose metabolism: Differential
diagnosis,evaluation and treatment of hypoglycemia. Neonatal Network, 21(4), 9-19,
73-76.
Hagedorn, M. I. E., Gardner, S. L., & Abman, S. H. (2002). Respiratory Diseases. In G. B.
Merenstein & S. L. Gardner (Eds.). Handbook of Neonatal Intensive Care (pp. 485575
Hashim, M. J., & Guillet, R. (2002). Common issues in the care of sick neonates. American
Family Physician, 6(9).
Hockenberry, M., 2003, Whaley and wilsons nursing care of infants and children, 7th edition.
Houska-Lund, C., & Durand, D. J. (2002). Skin and skin care. In G. B. Merenstein & S. L.
Gardner (Eds.) Handbook of Neonatal Care (pp. 358-375).
T.L Gomela,1999, Neonatology, 4th edition, Appleton & Lange, United States of America,
pg503
W. Lois, Foundation of Maternal & Pediatric Nursing, 2 nd edition,Thomson Delmar Learning,
Texas, pg 149
Zukowsky, K. (2004). Respiratory Distress. In M. T. Verklan & M. Walden (Eds.) Core
Curriculum for Neonatal Intensive Care Nursing (pp. 487-523).
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8APPENDIX
119