Author: Jeana

polyethylene glycol
SE: none significant

ferrous sulfate
SE: nausea, constipation, dark stools, epigastric pain

Chronic Lung Disease

levalbuterol
SE: paradoxical
bronchospasms

Productive Cough
Moderate amount; thin; white

Bronchio-pulmonary
Dysplasia (BPD)

Impaired Spontaneous
Ventilation r/t Decreased
Airway Size

Oxygen
Dependent

CHEMISTRY
GLUCOSE 43
CREATININE 0.24
K+ 7.5
CALCIUM 10.9

HEMATOLOGY
RBC 5.17
MCV 68.7
MCH 22.4
EOS 6%

Safety Concerns:
Crib rails up X2
Bag/Mask @ bedside
Suction @ bedside
Aspiration/Reflux Precautions
HOB 30° AAT
Safe sleep precautions
Extra trach tube/suction with pt AAT

Hearing
Impairment

Laryngeal
Stricture

Trust vs. Mistrust

PT/OT/RT

Premature Birth: 25 wks.

Strict I/O

Daily Weights

ELBW: 500g

B/L Inguinal
Hernias

Retinopathy of Prematurity

8/19/12
Direct
Laryngoscopy

Hx of Maternal
Drug Abuse, infrequent visitation

Height 63.5 cm

Weight
5.435 g

BSA 0.31m2

Head Circ:
36.5 cm

Abdominal Circ:
42 cm

Birth Hx: 25 wks.
Age: 7 mo.

Subglottic
Stenosis

NKDA

Symmetrical Chest
Expansion

Capillary Refill <3 seconds

Regular Heart Tones

Pain: 0/10

T-37.1
P-138
R-36
BP-93/53
O2-98%

Tracheostomy
Dependent

Tachypnea

Adventitious
Breath Sounds

Dyspnea

Poor
Nutritional
Intake

Neosure 27Kcal
240mL/feeding
Q4h (30 min. max)

Continuous ECG,
Pulse-Ox, RR monitoring

Trach Suction PRN
To 6.5cm

Trach: Shiley 3.0

O2 1/8 L/min TC

PT/OT/RT

metoclopromide
SE: drowsiness, EPS, restlessness, NMS

Monitor for s/s EPS and NMS

Productive Cough
Moderate amount; thin; white

nystatin powder
SE: none significant

Rash under trach
ties

Aquaphor
SE: none significant

Rash on back &
butt

hydrocortisone cream
SE: none significant

MEDICAL DIAGNOSIS ♦ DIAGNOSTICS ♦ PATIENT SYMPTOMS ♦ TREATMENTS ♦ MEDICATIONS ♦ ASSESSMENT DATA ♦ NURSING DIAGNOSIS