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 admission
subcostal
with orders made
retraction
and carried out
Informed relatives
With
regarding admission
grunting
of the patient
Admitting section
informed thru call
Secured admission

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
babys body temperature
Isolette
Temperature
adjusted based on
body temperature
Monitored body
temperature
Frequently
Placed on
continuous
ambubagging

With RR- 80s

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
doctors
order

Action

Verified doctors
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- 80s

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