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mimic_attitude_dataset

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NPN 1900-0700 cont'd 6. PAR: O: [** 8**] in at start of shift to say good night to [**Known lastname 644**]. Dad called for update X1. [**Known lastname 8**] made aware of cardiology plans. Dad also aware of dopa gtt started. A: Loving, vested family in crisis. P: Continue to support [**Known lastname **]. 7. SEPSIS: O: Pt started on Vanco and Gent this shift, due to clinical picture at start of shift. CBC was benign. Blood cultures pending. A: Pot for sepsis. P: Abx as ordered.

Overall Neutral Note

Nursing Note 2 Alt in resp status. 3 Alt in FEN 4 Alt in Development 5 Alt in neuro status 6 Alt in parenting Alt in Resp Status: Received baby intubated on settings 16/5 rate 10 FiO2 21%. Sxn'd ETT for large amount cloudy secretions x1. Parents and team discussed plan to withdraw support today(had been discussed yesterday also). Baby medicated with MSO4 0.3mg at 1245 as ordered and RRT extubated baby at 1300. Medicated again with 0.3mg MSO4 at 1600 for comfort. Baby with intermittent breathing until about 1730 when he became apneic. Absent HR as of 1744 as confirmed by Dr. [**Last Name (STitle) 184**]. Alt in FEN: NPO. Received on TF 80cc/kg/day D12.5 via PIV. IV fluids stopped as of 1300 in agreement with plan to withdraw all support. PIV in foot dc'd. PIV in hand dc'd after baby's death. Urine was sent for organic acids this morning as ordered. Catheter dc'd at 1300. Parents in all day and held baby while still intubated. Gave baby a [**Name2 (NI) 870**]. Held baby after extubation until time of death. Pronounced time of death 1744. This RN dc'd IV and disconnected leads and parents holding again. Funeral home contact[**Name (NI) **] and will come to pick up baby. REVISIONS TO PATHWAY: 2 Alt in resp status.; d/c'd 3 Alt in FEN; d/c'd 4 Alt in Development; d/c'd 5 Alt in neuro status; d/c'd 6 Alt in parenting; d/c'd

Overall Negative Note

NPN 0700-1030 Baby girl [**Known lastname **] expired at 07:46 this am per Dr. [**First Name (STitle) **]. Infant prepared per demise protocol. Digital/35mm pictures done. Media services notified per answering machine. Parents aware of infant's death and returned to mom's room after holding infant for several hours. Memory box to be given to parents today. Infant brought to morgue per protocol at 1030 this am.

Overall Neutral Note

NPN DAYS Alt in Resp Status: Remains on IMV 25/7 rate 40 FiO2 48-65%. LS coarse and tight. Sxn'd ETT for scant secretions. Has desats at rest occasionally. Need to increase FiO2 to 100% prior to cares. Does have occasional brady's with cares, none at rest. CBG at 12pm 7.30/38/31/19/-7. Will continue with current plan of care. Alt in CV status: + murmur. Pink and well perfused. Perfusion has improved throughout the shift. Pulses full this morning to normal this afternoon. BP M 32-37. BP 47/27 M33. Will continue to monitor for any changes in status. FEN: NPO. TF 150cc/kg/day. DUVC with Fentanyl at 1.5mcg/kg= 0.53cc/hr. Lipids, PND10 also infusing. NS with heparin changed to NA Acetate at 1530 r/t Na 123. Will check lytes again tonight at 2100. D/S 98. AG 17. Stooling trace mec stools. Urine output 0.6cc/kg/hr for the shift. NNP attempted catheterization of bladder with no success. Crede of bladder resulted in a couple of drops of urine. Team may increase fluids. Will continue to monitor closely. I/D: Remains on Vanco and Gent. Team to consult ID in case of need for further antibiotics. [** 194**] with generalized foul odor. Will continue to follow closely. Alt in Growth and Dev/Pain/Neuro: Temp stable on warmer under plastic tent. Awake and quietly active with cares. No movement of lower extremities noted. When cath'd, [** **] had no response of discomfort. Continues on Fentanyl drip at 1.5mcg/kg/hr. Moves upper extreemities. Tolerating hand placed on head by mom quite well(no desats or brady's). Will continue to provide for developmental needs. Parents: Parents in much of the day. They are updated at the bedside during the day. Offered them the opportunity or just the thought of possibly holding the [** **] at some point. They are aware that the [** **]'s condition may deteriorate if held and are understandably scared. Will continue to offer support and teaching.

Overall Neutral Note

Neonatology-[** 96**] Progress Note Team met with family with [**Last Name (LF) 2609**], [**First Name4 (NamePattern1) 515**] [**Last Name (NamePattern1) 648**] to update regarding curent clinical issues including rds, pda tx with indo & possibility of need for surgical repair. [**Last Name (NamePattern1) **] prepared to recieve more clincial info tomorrow regarding PDA. Encouraged to continue calling, Mom expects to visit more often in 2 weeks. Will continue to keep informed

Overall Neutral Note

NPN DAYS Resp: Currently on vent settings of IMV 19/5 rate 20 FiO2 24-31%. Last gas on these settings 7.28/44/52/22/-5. LS clear, diminished at times. Received 1st dose of Vitamin A. RR 40's-60's. Continue to monitor closely. CV: + murmur heard x1. HR 120's-150's. Color ruddy. Pulses normal. TBO 5.3cc. BP means via UAC 34-41. Cuff BP's stable 58/29/36. Follow closely for any changes in CV status. FEN: TF reduced to 120cc/kg/day. UAC with 1/2NS plus [**1-16**] unit heparin/ml at 0.8ml/hr. Primary line of DUVC infusing starter PND5 at 50cc/kg/day. Secondary port infusing D5 with 1/2 unit heparin/ml at 1.3ml/hr. Lytes today 147/6.7/116/21. Repeated at 1800 QNS. Sending another sample. Urine output 5ml/kg/hr. Smears of mec stool. D/S 83, 67. Continue to follow lytes closely. I/D: continues on Ampi and Gent. Blood culture negative to date. To repeat CBC with diff on nights. G/D: Temp stable on warmer under tent. [**Month/Day (2) 194**] is sensitive to temp changes. Nested on warmer, turning [**Month/Day (2) **] side to side r/t myelomeningocele. Eyes remain fused. HUS this morning showed enlarged lateral ventricles. continue to support developmental needs. Parents: parents in to visit and updated on the [**Month/Day (2) **]'s day. Family meeting held and MD [**First Name (Titles) **] [**Last Name (Titles) **]'s diagnosis and prognosis. Parents teary and verbalizing feelings of loss. Will continue to provide support and updates to parents. Neuro: Continued to irrigate dressing q4hrs. No changes since this morning.

Overall Neutral Note

NPN NPN#1 O= remains intubated on settings of 23/6 x38 .. ABG: 7.29/ 50/ 56/ 25/ -2....no changes made overnight, FIO2 52-66%..remains liable..especially with any intervention..tends to desat/brady....ETT retaped ( pushed in..too high on xray), need to dial up to 100%/^rate prior to cares, spont RR 38-44, LS coarse with IC/SCR, sxn'd for scant via ETT/ mod THW from mouth, A= remains liable P= cont to monitor closely,^O2/rate prior to cares NPN#2 O= loud murmer heard on exam, HR 130-140's, pulses sl full, pink, cap refill sl delayed, - [**Location (un) 36**] pulse noted, BP MAP's 30-49, Hct= 38.6 plt= 251, A= loud murmer/ PDA P= cont to monitor BP / assess presence of murmer NPN#3 O= BW= 710gms..not reweighed overnight...TF at 150cc/kg/d, NPO, PN D10% & lipids infusing well via DUVC, piggybacked with Fentanyl drip at 1.5mcg/kg/hr..NGT removed with retaping of ETT, abd exam soft/ rounded, hypoactive BS, no loops, appears nontender to palp., no stool, uo= 2.3cc/kg/hr, DS= 113, lytes 129/6.0/95/24..off aterial draw..NNP aware of results, bili= 4.0/.4..unchanged, A=good uo, DS stable, ^ K level/decreasing Na P=cont to monitor lytes closely, cont with I & O, follow abd exams, cont plan of care NPN#4 O= cont on IV Abx Vanco & Gent as ordered, ID called yesterday for input re: coverage, A= r/o sepsis P=cont with Abx as ordered, monitor for S & S of sepsis NPN#5 O= remains on open warmer on servo under plastic tent with Tmax 99.2..weaned slightly, AF soft & flat with split sutures, active & alert with cares/ opening eyes moving upper ext..still no purposeful movement noted in lower ext.., nested in sheepskin with boundaries in place, cares q6hrs, A=very sesitive to interventions P= cont to follow & support dev needs/ cont with q6hr cares NPN#7 O= both parents in at begining of night ..overnighting in family resource room in unit...[**Location (un) **] [**Name (NI) 5186**] to bed at 2300 but mom up at sibling's bedside most of night..updated on [**Known lastname 5184**] status...

Overall Neutral Note

NPN DAYS Resp: Remains on IMV 25/7 rate 40 FiO2 44-62%. Increasing rate to 46 and FiO2 to 100% with cares. CBG this afternoon was 7.33/36/37/20/-6. LS continue to be tight. Sxn'd ETT for scant secretions. [** 194**] very labile with sats at rest and with cares. Has drops in HR with any cares, resolves when left alone. [** 194**] continues to be labile. Will continue with current plan of care. CV: HR 120's-140's. Loud murmur. BP stable, see flow sheet. Pink and well perfused. CV status currently stable, will continue to follow closely. FEN: TF increased to 170cc/kg/day r/t BUN 54 and CR 2.0. Lytes 128/4.2/91/18. Will repeat lytes at 9pm. Fluids are infusing via DUVC. Fluids include Fental, Lipids, D12.5, Na Acetate and NS. D/S 108. Belly soft with hypoactive bowel sounds. No loops. Urine output so far this shift is >2cc/kg/hr. Urine output has increased in the last 24 hours. Will continue with current plan of care. I/D: Remains on Vanco and Gent. ID consulted to assess [** **] for need for antifungal medication. Skin is macerated in peri area and upper thighs. Skin is open to air to dry the skin. Wound to back has a foul odor. Will continue with Vanco and Gent. Continue to assess for s/s infection. G/D/Neuro/Pain: Temp stable under tent on warmer. Nested on sheepskin with boundaries in place. Awake and active today. Has movement in legs today. Fentanyl given x2 prior to cares and dressing change. Fontanels soft and flat with widened sutures. HC remains 21.5cm. Increased movement of extremities today. Will continue to provide for developmental needs. Parents: Mom in today to visit. Updated her on the [** **]'s day. Family meeting planned for today. Awaiting [** **]'s arrival. Will continue to provide support and teaching. Wound: Dressing changed to back. Window of Duoderm applied around wound. Wet sterile dressing applied to wound with dry ABD pad over that. Plastic wrap secured over dsg with Hy-tape attached to Duoderm. Dressing to be changed daily. Wound clean.

Overall Neutral Note

Addendum ...verbalizing feelings re: sibling's sudden change in status over last 24hrs..support provided..A=involved/loving devastated parents of critically ill twins P= cont to keep updated & involved, offer emotional support NPN#8 & 10 O= dsg to myelomeningocele remains intact..cont to irrigate with warm/ sterile NS q2hrs...A=open myelomeningocele P= cont plan of care, daily dsg change & inspection of area, cont irrigations as ordered NPN#9 O= remains on fentanyl drip ..receiving 1.5mcg/kg/hr... appears to be providing good relief, A/P=cont per plan of care, assess pain & effectiveness of fentanyl drip

Overall Neutral Note

NPN NPN#1 O= remains intubated on weaned setting of 25/7 x40..weaned rate by 2 after CBG: 7.33/ 34/ 55/ 19/ -6..FIO2 36-55%..increased to 100% with cares...remains liable but didn't brady as much with cares/interventions in comparision to other night...LS coarse/tight with fine crackles..IC/SCR, sxn'd for sm cloudy from ETT/ sm-lg white OP, A=cont to require significant vent support / remains liable P= cont to monitor closely/ gases as ordered NPN#2 O= loud murmer persists..good perfusion/ pink/ cap refill delayed, pulses full, HR 120's-140's, MAP's 31-38, yest Hct 38.6, plt 251 A= murmer/ PDA P= cont to follow closely NPN#3 O= WT up 68gms to 739gms ..infant hadn't been weighed since Thurs due to instability...NPO, TF at 150cc/kg/hr...PND10% with lipids infusing via DUVC/ piggybacked into line Fentanyl drip at 1.5mcg/kg/hr and NS with .5uheparin at 1.0cc/hr...started after lytes : Na 125/ 4.9/90/18...DS=108, abd soft/ sl rounded AG= 17.5CM/ HYPOACTIVE BS, NO LOOPS, uo=1.8cc/kg/hr/ sm mec stool A=Na level cont to decrease P= cont I & O's, qod weight, monitor lytes closely, cont plan of care NPN#4 O= remains on Vanco &gent as ordered, afebrile/ awaiting ID's input re: Abx coverage today A= r/o sepsis P= cont to closely monitor for any S & S of sepsis NPN#5 O= remains on servo on open warmer with stable temp, AF soft & flat with wide spread sutures, moving upper ext..still haven't noted purposefully mov't of lower ext, nested in sheepskin under plastic tent with boundaries in place, alert to drowsy overnight, occ opening eyes A/P=cont to assess & support dev needs/ decrease stim/ cluster cares q6hrs... NPN#7 O= parents in at begining of shift..left to go home overnight to sleep..cont to be very involved/ loving and total overwhelmed..attempting to process events of last week/ days..emotional support provided A/P=cont to update & support NPN#9 O= cont on continous fentanyl drip at 1.5mic/kg/hr.. appears to be providing good/adequate pain control

Overall Neutral Note

continutaion #8 Infant is currently maintaining temp on warmer nested with pillow for head and stuff that is awesome. Skin seems to be healing, aquaphor given to her and seems to be healping??? cont to support and monitor if you ever need me ok... [**First Name8 (NamePattern2) **] [**Last Name (un) **] me :) #9 No parental contact so far this shift of nights. Will cont to support and inform. #10 Infant currently getting Gent and Vanco and they are currently getting them for about 7 days and gent trough drawn this am. Monitor for increased signs of sepsis noted. Monitor closely.

Overall Positive Note

NPN: (Continued) 2&3: Does vagal with cares and repositioning of head and ETT and requires mod stim for recover. Does recover fairly quickly. 6. G/D: Temp stable in servo controlled isolette. Monitored closely due to probe not sticking well. Due to skin fragility, reflector placed on top of dueoderm, but probe more easily dislodged. No interest in sucking. Eyes remain fused. Plan: Continue to provide age appropriate cares. 7. ID: R/O complete at this time. Plan: Resolve this problem. 8. Skin Integrity: Skin dry and cracked with some scabbed areas and peeling. Aquaphor reordered but not brought from pharmacy at this time. Due to some bleeding from umbi site on previous shifts, not placed prone.Plan: Apply Aquaphor per orders when available. Use extra caution to prevent further impaired skin integrity issues. 9. Parent: Mother called for update on infant condition. Father came and saw infant, touhed her and asked basic questions. Picked up breast pump for mother that was delivered here by the company. Plan: Continue to promote family bonding with recognition of cultural difference that include period of confinement for mother. Provide support and education re: infant condition and cares.

Overall Negative Note

Nursing Progress Note #2. O: Infant remains orally intubated. CBG tonight 7.17-62. Settings adjusted to currently 24/6 x30. FiO2 overnight has been 33-68% (higher FiO2 while infant supine) RR 28-36. Breath sounds are coarse and equal. IC/SC retractions noted. ETT suctioned for sm/mod white, mod clear orally. A: Continue to be labile with O2, needing increased settings. P: Continue to monitor resp status. Obtain CBG this a.m. #3. O: Harsh, loud murmur heard tonight. NNP aware and examined infant. Infant pink and well perfused. BP stable with MAP's 28-36. Pulses 2+. Estimated blood out 2.3cc's. A: New murmur. P: ?contact cardiology re: new murmur. #4. O: Infant remains under single phototherapy. Eye shields in place. A: Hyperbili. P: Continue with treatment. #5. O: Infant remains NPO on TF's of 150cc/k/d. D8PN, IL's and fentanyl drip infusing well via PICC. D/S 76. Abd soft and flat with hypoactive bowel sounds. No loops. Voiding 3.9cc/k/hr x12hrs. Trace mec x1. Wgt is down 3gms tonight to 711gms. A: NPO P: Continue to monitor FEN status. #6. O: Infant remains in servo control isolette with stable temp. She is alert and active with cares. Right eye begining to open. Sucking on ETT intermittently. Remains on fentanyl drip at 3mcg/k/min. A: AGA. P: Continue to assess and support developmental needs. ?ween fentanyl drip today. #8. O: Skin remains dry, peeling but intact. Aquaphor applied to lower extremities. A: Intact skin. P: Continue to monitor. #9. O: Dad and grandmother in tonight. Dad asking if LP done yet. Very appropriately talking softly to daughter. A: Involved family. P: Continue to inform and support family. #10. O: Infant remains on vancomycin for sepsis. A: Presumed sepsis. P: Continue with treatment. Obtain LP soon.

Overall Neutral Note

0700-[**2115**] ADDENDUM TO NPN PAIN: Fentanyl given prn, see above DEV/NEURO note. Infant is resting comfortably at this time, no evidence of pain. Stress/pain reduced with low-lighting and q6hr cluster cares. VS within normal limits. Plan: continue to monitor for evidence of pain. PARENTING: Parents have been visiting since 1330. Updated by RN, asking appropriate questions. Parents are loving and invested. Plan: continue to comfort and support, provide updates.

Overall Positive Note

NPN [** **]: [** 72**] and grandmom in to visit. Asking appropriate questions. Appear loving and caring toward infant. Pain: See G&D.

Overall Positive Note

NPN DAYS CONTINUED ALT IN NUTRITION R/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 595**]:NPO, TF 200CC/K/D IVF VIA UAC WAS 1/2NS WITH 1/2 UNIT HEPARING. CHANGED AT 1PM TO [**1-16**] NA ACETATE WITH 12 UNIT HEPARIN/CC AT 0.8CC/HR DUE TO METABOLIC ACIDOSIS. DUVC WITH PN D8 INFUSING WITHOUT INCIDENCE WITH LIPIDS AT 0.2CC/HR. ABD EXAM BENIGN. NO LOOPS, NO SPITS. NO STOOL. HE DOES HAVE BOWEL SOUNDS TODAY. D/S 141 AT 9AM, 170 AT 2PM AND 151 AT 5PM. UOP 4.7CC/K/HR. LYTES AT 5PM 135/3.8/107/12. WILL REPEAT LYTES AT 11PM. BICARB GIVEN AT 5PM. OBTAIN LYTES IN THE MORNING ALSO. CONTINUE TO MONITOR EXAM AND LABS CLOSELY. NEURO:[**Month/Day (2) **] MOVING ALL EXTREMITIES INDEPENDENTLY. FONTS SOFT AND FLAT, SUTURES SPREAD. WET TO DRY DRESING CHANGE TO BACK DONE AT 2PM. MENINGOMYLOCELE STILL OPEN ABOUT 2INCHES, COVERED WITH GELATINOUS RED BLOOD CLOT. SMALL AMT OF BLOOD AND CSF ON DRESSING. EDGES AROUND WOUND ARE NOW TURNING BLACK. EDGES WERE PINK YESTERDAY. MD AWARE. CONTINUE STERIL DRESSING CHANGES ONCE A DAY, AND WET DRESSING Q2HRS WITH WARM STERILE NS. ALT IN GROWTH AND DEVELOPMENT D/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 595**]:SLEEPS WELL BTW CARES. DROWSY DURING CARES, BUT MOVES EXTREMITIES. EYES STILL FUSED. NESTED IN SHEEPSKIN ON SERVO CONTROLLED WARMER. CONTINUE DEVELOPMENTAL CARES. ALT IN PARENTING:PARENTS IN TO VISIT BREIFLY SEVERAL TIMES. FAMILY MEETING WITH MD, FELLOW, SW, RN AND NEURO MD HELD THIS AFTERNOON. EXPLAINED TO PARENTS [**Last Name (NamePattern4) **]'S CONDITION AND PROGNOSIS, AND OPTIONS FOR CARE. PARENTS ASKED GGOD QUESTIONS AND APPEAR TO UNDERSTAND [**Last Name (NamePattern4) **]'S CONDITION. THEY WOULD LIKE TO WAIT UNTIL [**Last Name (NamePattern4) **] SHOWS SIGNS OF DECLINE BEFORE REDIRECTING CARE, BUT NOT TO WAIT UNTIL HE IS VERY SICK. THEY WANT HIM TO BE COMFORTABLE. CONTINUE WITH PARTIAL DNR, OF NO EPI, NO HIFI, NO CHEST COMPRESSIONS, NO CHEST TUBES. PARENTS WILL BE BACK TO VISIT TOMORROW MORNING. CONTINUE TO SUPPORT AND UPDATE.

Overall Neutral Note

NPN/1900-0700 #1 RESP: Infant remains orally intubated on settings of 23/6 r46. FiO2 45-75%. CBG at 0300=7.41/38; no vent changes made at this time. Cont. to be labile with cares and interventions; having HR drops to the 60-70's and desats to 50-60%'s, however is relatively quiet/stable at rest. LS coarse w/ rales; sxn ETT for small secretions and orally for large cloudy secretions. RR=46; no spontaneous resp. effort. Cont. on Vit A injections 3x/week. Cont. to monitor blood gases and make vent changes as necessary. #2 CV: Cont. to have loud murmur. Full peripheral pulses. No [**Location (un) 36**] pulses. HR 130's. BP's stable w/ means 33-55. Completed second course of Indocin. Cont. to monitor. Monitor clinically for PDA. #3 FEN: Remains NPO at this time. TF=160cc/k/d of PN(D9) and IL thru DUVC; fentanyl piggybacked into primary port. Voiding 1.4cc/k/12hrs; small mec. stool. Hypoactive BS. DS=115. AM lytes and bili sent; pending. Monitor FEN needs. #4 ID: Cont. on Vanco and Gent Q24hrs. Follow teams orders in regards to duration of antibx therapy. Monitor drug levels and adjust dosage accordingly. #5 DEVELOPMENT: Nested on sheepskin on open warmer. Initial temp 96.7; warming lights used and warmer temp ^'d. Subsequent temps 98.5-98.8. Eyes remain fused. Lethargic; moving upper extremities slightly w/ cares. AFOF. Monitor developmental needs. Use [**Doctor Last Name 744**] over infant to help maintain temp stability. #7 PARENTS: Mom called x1 and updated by nursing. No questions for nursing but seemed pleased with update. NNP also spoke w/ mom in regards to twin b. Parents visit daily. Cont. to support parental needs. #8 NEURO: Cont. with dsg. change daily to myelomeningocele. Receiving warm NS irrigations Q2hrs to site underneath dressing. Moves upper extremities w/ cares; has occ. twitches/spasms in lower extremities, but does not move legs otherwise. Neurosurgery involved w/ pt's care. Cont. with daily dressing changes and irrigations.

Overall Neutral Note

Nursing Note Cont'd #9 [** **] O: Mom and Dad at 220. Asking approrpiate questions. Updated at bedside. A: Coping well with critically ill infant, good support for each other. P: Continue to educate and support. #10 Sepsis O: Continues on vanco and gent as ordered. Levels due today. CBC tonight : WBC 23.0, hct 37.5, plt 72 (increase from 69). A/P: COntinue ivabx as ordered.

Overall Neutral Note

NPN 1500-1900 1. Resp: Received infant orally intubated on settings of 22/5 with a rate of 40. At 1600 ABG was sent - 7.37/37/47/22/-3. Settings were weaned to where they are currently at 22/5 with a rate of 37. Please see flowsheet for further explanation of gases and settings. FiO2 was between 34-60%. Lung sounds coarse. IC/SCR noted. Infant was surfed x 2 (last ~ 17). P: Cont. to monitor resp. status and follow blood gases. 2. CV: No murmur appreciated this shift. B/P cuff means 28-37. Last B/P 49/31 m37. Blood out is 2.5 cc. Infant is pink/ruddy. Pulses wnl. P: Cont. to monitor cv status. 3. FEN: TF remain at 100 cc/kg/day. UAC is running 1/2 NS with 1/2 unit hep/cc. DUVC is running starter PND5 through primary and through the secondary is D5w with 1/2 unit hep/cc. D/S 96/77/78. 6 hour lytes and bili were drawn - results pending. Abd soft, flat, pink. Infant has voided and stooled med amts of mec. P: Cont. to support nutritional needs. 4. G/D: Temps stable on servo-warmer. Infant is nested in sheepskin with boundaries and water pillow in place. Infant's position was changed q 6 hours this shift. Infant is placed side to side sec to lesion on back. Lesion on back has been covered with a sterile wrap. Q 2 hours warm NS is being instilled into dressing to keep moist. Neurosurgery over to consult this afternoon. AFSF. AGA. P: Cont. to support developmental needs. 5. I/D: CBC sent - benign, BC sent - pending. Infant was started on ampi/gent. P: Cont. to administer abx as ordered, follow BC results, and monitor for s/s of infection. 6. Parents: Mom came on stretcher on her way to postpartum. [** 72**] in throughout afternoon. Parents have been updated on infant's condition and plan of care by team. Appropriately concerned. Loving, invested parents. P: Cont. to support and update parents.

Overall Neutral Note

NPN 1900-0700 RESP: Received infant on SIMV 25/6 X30. FiO2 55-80% and increased with cares. ABG 7.22/59/38/25/-4 with no changes made. RR 30-50's, infant occ. riding the vent. LS coarse bilaterally with mod IC/SC rtx. Sxn'd X3 for mod. amts of thick white secretions via ETT, and small amts of cloudy oral secretions. O2sat >93%, with frequent drifting, at times requiring an incr in O2. (see flowsheet). CV: No murmur hear on exam. HR 150-170's. Infant appears pink, well-perfused. Received lasix as ordered, with good resutls. Received second aliquot of blood as ordered. Infant remains on dopamine. Presently receiving 17.5 mcg/k/m. Infant was as high as 25 mcg/k/m earlier in shift (please see flowsheet). to maintain BP means 28-35. BP are very labile and fluctuate greatly. Cuff BP's are correlating. No spontaneous brady's. Hyperbili: Infant remains on single phototherapy with eye shields on. Bili sent this AM. 3.3/0.4. FEN: wt=775g (down 5g). TF restricted=90cc/kg/d. Infant receiving NS with heparin via PAL, D15W with 3mEq of sodium acetate and 2mEq of potassium acetate, and dopamine in D10W via PICC. Patent heplock in L foot. D-Stick 93. Ltyes drawn and are pending. Abdominal exam benign. AG stable. Hypoactive BS. No stools this shift. UO=7.3cc/kg/hr X12hrs with lasix. UO=4.5cc/kg/hr X24hrs. G&D: AFSF. Infant alert and active with cares. At times, extremely irritable and constantly moving about. Settles slowly for short periods of time. Receiving fentanyl q3hrs with questionable effectiveness. Temp stable on servo-controlled isolette and under phototherapy. Nestled on sheepskin with boundaries. Takes binki. Sucks on ETT. [** **]: [** 72**] in to visit. Asking appropriate questions. Appears loving and invested in infant. No contact from mom. [**Name (NI) 72**] stated mom is pumping at home. Pain: Infant is receiving fentanyl boluses q 3hrs. with questionable results. Patient remains difficult to settle. Once settled, only for short periods of time.

Overall Negative Note

NPN 0700-[**2115**] 1. RES: Infant received on 19/6, r46. Currently 23/6, r46; PIP increased based on CBG, F/U CBG done, see laboratory for results. FiO2 requirements 45-60%. Infant desaturates and brady's with cares, requiring ^ in O2 to 100%. Infant has had 3 spontaneous brady's with desats requiring moderate stim and ^ in O2. RR 46 consistently. LS are coarse with rales bilaterally. Sx small amount of cloudy from ETT and mouth x2. Plan: Continue to monitor respiratory status. 2. CV: No murmur audible this shift. S/P second course of Indocin. Pulses are full and non bounding. No [**Location (un) 36**] pulses present. Infant is pink. NBP MAPS 31-46. BP 49/35 MAP 40. Plan: Continue to monitor cv status. 3. FEN: TF 160cc/kg/d. PN D7.5 infusing through primary port of DLUVC with Fentanyl (100mcg Fentanyl in 50cc D7.5W) piggybacked at 1mcg/kg/hr. PN D7.5 infusing through secondary port of DLUVC with lipids. Abd soft and round, no loops, hypoactive BS. U.O. 3.6cc/kg/hr over 12 hrs. Small grren stools qdiaper change. DS 126. Plan: Continue to monitor FEN. Check bilirubin and electrolytes tomorrow morning. 4. ID: Infant continues on Gentamicin and Vancomycin. Vancomycin trough today 13.4. Plan: Continue to monitor for evidence of infection. 5. G&D: Infant nested on sheepskin on an open warmer with tent in place. Hypotonic in UE, small spastic movements in LE. Temperatures stable. Fontanels are soft and flat. Lethargic during cares. Repositioned right to left with q6hr cluster cares. Plan: Continue to monitor G&D. 7. PAR: Mom and [**Location (un) 72**] in today, family meeting held with team. Parents very loving and invested. Plan: Continue to support and educate parents. 8. NEURO: Infant responds to stimuli/cares when UE is involved, infant shows no response to LE stimulation (heel sticks). Moving UE, only spastic movements noted in LE. Plan: Continue to monitor neuro status.

Overall Neutral Note

NICU Nursing Note 1900-0700 #2 Respiratory Rec'd on 30/7 X30, FiO2 100%. Gradually weaned FiO2 to 63%. ABG at 0200: 7.44/38/62/27/1. Weaned PIP to 29. FiO2 remains 62-70%. Increased to 100% with cares. RR 30-34. Riding the vent most of the shift. Suctioned Q3-4hrs for mod cloudy secretions from ETT, mod clear from mouth. No spells. Continue to follow gases, wean as tolerated. #3 CV O: Weaned dopamine off at 2300. Continues on hydrocortisone as ordered. MAP's (by [**Last Name (LF) **], [**First Name3 (LF) **] out) 32-39. No murmur. HR 150-160's. Pink, well perfused. Normal pulses. #4 Hyperbilirubinemia Conitnues under single phtx, AM bili pending. #5 FEN Not weighed tonight, hemodynamically unstable. TF 150 cc/kg/day. Basing fluids on 750gm. PN D12.5, IL, fentanyl gtt and NS (to replace fluids lost via art line) infusing via PICC. D/S 127-193. Abd is soft, flat, hypoactive BS, AG 16.5-17cm. 24 hr u/o was 6.0cc/kg/hr. No stool. AM lytes pending. #6 G&D Nested on open warmer. Removed tent [**First Name9 (NamePattern2) 5157**] [**Known lastname 337**] kept getting too warm under there. Temps stable. Irritable tonight, settled with positioned, pacifier and continues on fentanyl gtt. #9 Parent [**Known lastname 72**] in tonight. Crying at bedside. Good understanding of devastating news earlier today. Continue to support [**Known lastname 26**]. #11 Pain Continues on fentanyl gtt for comfort. REc'd one bolus dose for attempted a-line plct. Good pain control with fentanyl and developmental interventions.

Overall Neutral Note

NPN/1900-0600 #1 RESP: Infant remains orally intubated on settings 25/7 r40. FiO2 49-60%. Labile; needing 100% with cares. Having frequent drifts to 80%'s. RR 40; no spont. resp. effort. LS coarse w/ rales. Sxn scant secretions from ETT. No gases obtained this shift. Cont. on fentanyl drip at 1.5mcg/k/hr (100mcg/50ml D5). Cont. to monitor resp. needs. Make vent changes as necessary. #2 CV: Cont. to have loud murmur. HR 130-140's. Normal pulses. BP means 36-41. Brisk cap refill. Cont. to monitor. #3 FEN: NPO at this time. TF=150cc/k/d. Cont. to have low Na over noc. Lytes this shift 122/5.1/87/16; 0.9%NS w/ hep hung at 1cc/hr following results and 6hrs later lytes were 125/4.5/88/18. NNP aware and no further changes made at this time. Remainder of fluids consist of PN(D12.5), IL, and NaAcetate infusing thru DUVC. DS=106. Voiding 1.2cc/k/hr; passing small mec stools. Hypoactive BS. Cont. to monitor electrolytes and urine output. #4 ID: Cont. on Gent and Vanco. Stable over noc. No s/s sepsis. Cont. to monitor. #5 DEVELOPMENT: Nested on sheepskin on open warmer. Temps stable. Active w/ cares; moving upper extremities and slightly opening eyes. Repositioning Q6hrs. Water pillow in place. Cont. to support developmental needs. #7 PARENTS: Mom called x1 over noc and updated. Parents will be in on days to visit. Udpated daily at bedside. Parents very loving and involved. Cont. to support parental needs. #8 NEURO: Fontanels soft and flat; widened sutures. Moving upper extremities; having occ. spasms in lower extremities but does not otherwise move legs. Dsg to meningocele intact. Irrigating w/ warm saline Q3hrs over noc. Cont. to monitor neuro needs. Cont. dsg changes qday.

Overall Neutral Note

6. [** 8**]: O: [** 8**] and other family were in to visit at the beginning of the shift. Mom then came up on her own to visit @ 1a and bring some breast milk. The family are very appropriate and loving. A: Lovely family. P: Continue to support. 7. G/d: O: [** 360**]'s temp is dependent on the servo placement and the phototx. He is active w/ cares and is tolerating them better. He occasionally sucks on the ETT. He is nestled on the sheepskin w/ a gel pillow under his head, on an opn warmer. A/P: Continue to support [** **] needs. 8. Bili: O: [** 360**] is very ruddy/jaundiced and his bruises are getting better. He is under double phototx w/ his eyes covered. A: Hyperbilirubinemia. P: Check bili w/ gent level. Phototx as ordered.

Overall Positive Note

Nursing Progress Note #1-O/A- Cont on Amp/Gent. Gent dose increased for low peak. No current s/s of infection. P- Cont to assess for s/s of sepsis. #2-O/A- Received [** **] on HFOV on Amp=16, MAP=12.5. Increased settings for less than desireable gases. Got 1.4mEq of Neut. Last ABG 7.31, 42,110,22,-4. Settings weaned to Amp=17 and MAP 12. Sxn x2 this shift for mod-lg old blood tinged secretions. P- Cont to assess for resp needs. #3-O/A- TF=140cc/kg/d. Through UAC has 1/2NS w/1/2uhep/cc. DLUVC has TPN D9.5 w/IL through prim port and TPN D9.5 through sec port. Abd exam benign. Has bowel sounds. Voiding, no stool so far this shift. DS wnl. Lytes drawn, results pending. P- Cont to assess for FEN needs. #4-O/A- HR and BP wnl. No audible murmur. Good pulses and perfusion. No cv distress. P- Cont to assess for CV needs. #5-O/A- Skin thin, becoming dry. Sm area of excoriation at feet where sat probe is. Also sm area above umbi sl red and excoriated. Team aware. [** 360**] placed in isolette on sheepskin and gel cushion for comfort. P- Cont to assess for changes in skin integrity. #6-O/A- Parent in to visit. Mom held [** **] during transition to isolette. Loving interaction. Family meeting held to discuss infants course. MD, NNP and RN present. MD explained course to this point. [** 8**] asked questions about what to expect the future regarding [** **] IVH. We explained that we are not completely sure and will follow up with HUS on Friday. Mom was [**Name2 (NI) 6**] when she expressed that mornings are most difficult for her. She states she feels quite desperate in am. She asked team how desperate and concerned she should be, she said she is not sure. Mom will be d/c home today. Mom [**Name (NI) **] to call hospital. P- Cont to [**Name (NI) **] parental calls and visits. #7-O/A- [**Last Name (un) 2953**] cont to be active with cares q6hrs. Eyes remain fused. Sleeps well between cares. Nested on sheepskin with [**Last Name (un) **] bumper. [**Last Name (un) 360**] moved from warmer to isolette for comfort. P- Cont to assess for G&D needs.

Overall Negative Note

NPN 7a-7p #1: Blood cultures remain negative to date. Temps stable on an open warmer. CBC with diff from 06 stable. [** 360**] has been alert and active with cares. Conts on Ampicillin and Genatmycin as ordered. Will need Genta levels with next dose. A: stable P:Cont with antbx as ordered. Follow labs. #2: Received [** **] on [** 202**] vent, settings deltaP 20, and MAP 13.5. Several weans made throughout the day based on stable ABG's. Last ABG at 12pm, 7.33/37. Currently on settings of deltaP 18, and MAP 12.5. FIO2= 36-43%. Rare drifts noted, usually recovering without needing to ^ O2. [** **]'ing cares and minipulation with only slight ^O2, if at all. BBS coarse, with some crackles noted on rights. Sx'ed x1 thus far for trace clr secretions. CXR done this am, showing improvement. Repeat CXR pending. Conts with mild IC/SC rtractions. A: Weaning in vent settings P:Cont with [** 202**] ventilation, wean as tolerated. Check ABG's as needed. CXR as needed. #3: [**Last Name (un) 2953**] remains NPO. TF weaned x2, now at 140cc/k/d based on stable lytes. UAC patent with 1/2NS & 1/2uhep/cc infusing. Double lumen UVC also patent- PND7.5 & IL infusing via primary port, and D10 with 1/2uhep/cc infusing via 2ndary port. D/S 121, 115. WT checked at 12pm= .620(down 106gms). U/O: 6.6cc/k/hr in past 8hrs. Abd soft, no [**Last Name (un) 87**] noted thus far. No loops. AG 17cm. No stool thus far. Did place NGtube inserted briefly to decompress abd. Only ~1cc air aspirated, no gastic contents noted. A: NPO, stablizing Na P:Cont with q6hts lytes as ordered. Follow wt and exam. Strict I&O. Urine dip. Cont with PN at 100cc/k/d as ordered. #4: Hr stable. No murmur noted. BP means stable 35-45. Slightly wide pulse pressures 17-23. Noted to have full pulses throughout. No palmar pulses noted. Color remains ruddy pink. Brisk capillary refill. Toes on both feet remain bruised, but both warm to touch with nml pulses and brisk refill. Hct this am 33.4. [**Last Name (un) 360**] being trasfused with PRBC's at 20cc/k divided into 2 aliquots. 1st aliquot transfusion complete- [**Last Name (un) **]'ed well. Plt trending down again- 176 at 06am, now 112 at noon. Will check plt level at 18. A: maintaining stable BP's P:Cont to monitor closely for murmur &/or signs&symptoms of PDA. Monitor BP. Will start 2nd aliquot PRBC's once ready from blood bank. Monitor Plt. #5: Skin mostly intact. Sm intact irritation noted on abd. Sm abrasion noted on top of penis. Team aware and Aquaphor applied as orderd. Bruising noted on feet, legs. P:Cont to monitor closely. Apply Aquaphor as needed. #6: Mom and Dad in several times today for visits. Updated by RN, RRT, and Dr. [**Last Name (STitle) **]. Pleased with [**Last Name (STitle) **]'s weans on vent settings. Asking appropriate questions. Very loving and supportive of each other. Both bonding with [**Last Name (un) 2953**]. Uncle and Grandmother did visit as well. A: Involved, loving [**Last Name (un) **] P:Cont to support and educate. Dr. [**Last Name (STitle) **] to discuss DNR order with [**Last Name (STitle) **] and obtain consent if order is to cont. #7: [**Last Name (un) 2953**] conts to [**Doctor First Name **]

Overall Neutral Note

NPN DAYS Alt Resp: Remains on [** 202**] MAP 13 DeltaP22 with FiO2 ranging from 36-80%, needing 100%FiO2 at times with cares. LS crse with wheeze. Sxn'd small white secretions. Self extubated this afternoon, reintubated by Dr. [**Last Name (STitle) **]. CXR confirmed placement of ETT. Continues to be very labile with his sats. Will check gas this evening. Alt F/N: TF 120cc/kg/day PND12.5 and lipids via PIV. Both PIV in right hand and right leg fell out this afternoon and were replaced, see flow sheet. This am, [**Last Name (un) 2953**] had a grossly heme + stool, so enteral feeds are on hold. NG tube in place and open to [**Last Name (un) **]. No spits. D/S 135. Belly soft, + bowel sounds. Urine out this shift 2.4cc/kg/hr. Cotninue to follow closely. Check lytes in the am. Alt C/V: Color pink with greyish undertone. Pulses not bounding. No murmur heard today by this RN. HCT 31.5 PT 16 PTT 49.3. to receive 2 alloquots of blood this eve with lasix between alloqouts. Was started on Dopamine this am, see flow sheet to hopefully increase perfusion to the kidneys. BP MAP's 30-42. On call for PDA ligation at [**Hospital1 45**] tomorrow. Alt Parenting: [**Hospital1 8**] in for a good part of this shift. Very concerned about [**Last Name (un) 2953**]. Both [**Last Name (un) **] very quiet. Requested social work to check in on [**Last Name (un) **]. [**Last Name (un) 8**] were more open towards the end of the shift. ? their support systems outside of the hospital. will continue to provide suppport. Alt G/D: See flowsheet for temps. Baby under heat lamp this am for low temp, has since stabilized. Fentanyl given x1 prior to big turn this afternoon. Baby is very sensitive to touch and noise and needs a low stim environment. Potential Hyperbili: Continues under single phototherapy. Sepsis: Latest blood cx remains negative. Oxacillin dc'd today r/t ID's recommendation. Will continue with Cefotaxime as ordered.

Overall Neutral Note

NPN 7pm-7am #2: [** 360**] remains on [**Last Name (LF) 202**], [**First Name3 (LF) **] P has been weaned throughout shift for good ABG's. At 2200 DP weaned from 32 to 30 for ABG 7.32/45/89/24/-3. Rechecked at 0200 7.23/37/52/20/-6 weaned DP to 28. Currently DP 28 Map 18, FiO2 34-80% with sats 93-100%. RR 16-48 with periods of riding the [**First Name3 (LF) **]. LS coarse with aeration throughout all lobes. Mild SC/IC rets noted. Sx sm-mod cloudy/yell secretions from ETT and sm white from mouth. A: Able to wean O2. Comfortable on [**First Name3 (LF) **]. P: Will recheck ABG before end of shift. Cont to monitor resp status. #3: [**First Name3 (LF) 360**] not weighed due to very busy day and unstable BP. [**First Name3 (LF) 360**] on TF 120cc/kg/d IV fluids. Currently NPO. [**First Name3 (LF) 360**] has PICC line in left arm with PN, IL, Fent and Dopamine. Peripheral Art line placed in left hand with 1/2 NS with 1unit hep/cc running at 1cc/hr. PIV in right hand patent and hepflushed. Abd soft, girth stable, no loops noted. No BS noted. BS 114, Lytes 136/3.1/94/21/24. No urine at this point, Stooled med heme +. A: Titrating fluids as needed. P: Cont to monitor urine out put and exam. #4: [**First Name3 (LF) 360**] started on Dopamine 5mcg/kg/hr at 2200 to keep means > 30. Mean BP from 1900-2200 20-25 after receiving 9cc PRBC's. Currently [**First Name3 (LF) **]'s mean BP stable at 30-32 on 5mcg/kg/hr. HR stable, no murmur noted. Pulse present and equal, non-bounding. A: [**First Name3 (LF) 360**] requiring dopamine for low BP. P: Will cont to monitor BP and titrate dopamine as [**First Name3 (LF) **]. #6: Mom called at 2200 for update on [**First Name3 (LF) **]. She was pleased to hear that the periph. art line was placed. She asked if that Dr. [**First Name (STitle) 608**] had been in to see [**First Name (STitle) **]. A: Aware that [**First Name (STitle) **] is critically ill. P: Cont to support and involve [**First Name (STitle) **] as much as possible in infants care. #7: [**First Name (STitle) 360**] on open warmer, nested with sheepskin. Temp stable. Active and alert with cares. Irritable at times with over stimulation, comforts with firm touch. Position changed q12 hrs [**First Name (STitle) **] well. Currently [**First Name (STitle) **] is on Fent drip, [**First Name (STitle) **] well and pain managed. MAE. Fonts soft and flat. Sucks on ETT.

Overall Neutral Note

NPN DAYS Alt Resp/Alt in Skin Integrity: Remains on [** 202**] Map17 DeltaP21 with FiO2 anywhere from 67-90% and increasing to 100% with cares. LS squeeky bilaterally. Dsg to incisions CD&I. ABG today 7.29/53. NO [** **] changes made. Will continue to monitor closely. Alt F/N: TF 100cc/kg/day PND12.5, Lipids, and Dopamine via PIV in hand. Basing fluids on 870gm. NPO. Belly soft and flat with no loops noted. See flow sheet for urine output. No stool. D/S 106. Ionized Ca 1.19. To check Mg, Lytes in the am. [** 1**] to place PIC line tonight. Alt CV: No murmur heard. HR 160-180's. Received baby on Dopa 12mcg/hr. BP MAP >32 so at 12pm, Dopa decreased to 10mcg/hr. By 2pm baby needed Dopa increased back to 12mcg/hr. Lasix given at 0915 with good effect. To check HCT and PLT in the am. Will wean Dopa as tolerated. Alt Parenting: [** 8**] in much of the shift, asking appropriate questions and appear loving and concerned. Updated them on [**Last Name (un) 2954**] day so far and what the plan for the day was. Will continue to provide support and teaching. Alt G&D: Temp unstable, see flow sheet. Warmer turned off r/t increased temp as a result of triple phototherapy. Will continue to follow temp closely. Baby very sensitive to any stimulation and quickly [**Last Name (un) 571**]. Fentanyl given every 1-2.5 hrs with good effect. Baby nested on sheepskin with boundaries in place. Position change done q12hrs. Will continue to support developmental needs. Potential Hyperbili: Bili level this am 8.8/0.5. Triple phototherapy and a bili blanket started at approx 1045. Will check bili again at 1800. Sepsis: Repeat blood cx sent today. Baby remains on Cefotaxime q12hrs. Today is day [**1-1**] of antibiotics. Continue with same plan.

Overall Neutral Note

2. Resp: O: [** 360**] received on the [** 202**] [** **] at [** 203**] P = 21, MawP = 17, FiO2 = 100%. After PIC attempt and attempts for an arterial line, (for which he was medicated w/ fentanyl), He was placed prone and left alone. By this writing, he is currently in 56% FiO2. His MawP was weaned after the CXR for the PIC line showed a somewhat flat diaphragm so he is now at a MawP of 16.5. Ls tight, squeeky. He was sxned X 2 for a small amt of cloudy secretions from the ETT and a very large amt of tan oral secretions. RR varies from riding the [** 202**] to @ 30. A: Weaning slightly on the [** 202**], FiO2 requirement much lower when [** **] is quiet. P: Monitor. Wean as [** **]. 3. F/N: O: [** 360**] is NPO. He is on TF = 100cc/k/d of TPN and lipids and dopamine. A PIC line was placed tonight but is not central. However, the line is being used. [** 360**] also has two HL in place. He is puffy and being transfused. U/o for the last 6 hours was @ 2.3-2.7cc/k/hr, depending on whether the weight used to calculate the u/o is 870g (what we're basing the fluids on) or 995g, yesterday's wt. [** 360**] was not weighed tonight. Labs will be drawn @ 6am. A: NPO, on TPN and lipids. P: Monitor. Labs at 6cm. I & O. 4. CV: O: [** 360**] is post a PDA ligation. No murmur audible. HR 150-160s. Dopa has been as high as 20 mcg/k/min and is now at 9mcg/k/min. He is being transfused. A: Weaning dopa. P: Monitor. Continue to wean dopa as [** **]. 6. [** 8**]: O: Mom and Dad called while [** **] was in the middle of procedures then Mom called once [** **] was all settled. It is difficult to tell if [** **] is improving, what with all the procedures. However, he is improving from the beginning of the night and I relayed this to Mom. A: [**Name2 (NI) **] [**Name2 (NI) 8**], who appear to be understanding [**Name2 (NI) **]'s course. P: Continue to support. 8. Bili: O: [**Name2 (NI) 360**] is on quadruple phototx w/ his eyes covered. His bili was 8.0 at 6p, down from 8.8. He is jaundiced and not stooling. He is currently being transfused, and had a couple of hours on and off phototx

Overall Negative Note

NPN 7am-7pm #1: Currently on Amp/Gent. Bld cx neg to date. Repeat CBC's begnin. Temp up and down today due to isolette and temp probe unable to stay on and bili lights. A: R/O sepsis. P: Cont to follow bld cx and finish 7 days of abx. #2: Recieved [** **] on [** 202**] DP 16 and MAP 12. FiO2 28-34%. Sats 90-94%. At 11am MAP weaned to 11. LS coarse off [** 202**], with mod SC/IC ret. Mod old blood sx'd at 12pm. Repositioned at 12pm head turned to right. ABG at 1400 7.29/46/45/23/-4. DP weaned to 14 from ABG. Repeat ABG at 1800 7.20/59/37/24/-6. Team notified and changed DP 16. A: Stable on vent. [** **] weans well. P: Repeat ABG tonight. Cont to support resp needs. #3: TF increased from 140cc/kg/d to 150cc/kg/d = 4.5cc/hr [** 360**] remains NPO. UAC with 1/2 NS and [**1-7**] Uhep at 1cc. Double UVC, Primary has PN D12% and IL, Secondary has PN D12%. Lines secure with bridge. Abd soft, girth stable, no loops noted. No BS noted. Voiding, heme tr +, ph 6, tr protien. No stool this shift. D/S 101. A: On PN will remain NPO through night. P: Poss start troph feeds tomorrow. Cont to monitor D/S. Lytes and Plts in am. #4: No murmur noted, HR stable, BP stable. [**Month/Day (2) 360**] pink and well perfused. Pulse equal non bounding. 1400 Plt's 80. Team aware. A: Stable with no murmur. P: Will check Plts in am. Monitor for murmur. #5: [**Month/Day (2) 360**] has multipule abrasions on both feet from sat probe, healing well. Probe being repositioned more often. Small abrasion above umbilical cord from temp probe, healing well. A: No need for over all aquaphor, skin healing well. P: Provide gentle care with skin. #6: [**Month/Day (2) 8**] here for 12pm care time. Updated on plan of care for [**Month/Day (2) **]. Spoke with Dr. [**Last Name (STitle) **]. At 1130 [**Last Name (STitle) **] put hands on [**Last Name (STitle) **] and spoke to him. Mom took temp and changed diaper. A: Very loving and understanding [**Last Name (STitle) **]. P: Plan to be in for later care. Cont to support and educate. #7: [**Last Name (STitle) 360**] in servo isolette. Temp up and down due to probe coming off, bili lights and touch times. Worked with temp through out day to stablize.

Overall Neutral Note

NPN Days continued #6 O: [** 360**]'s [** **] in late this morningand then throughout the shift. "Family meeting" at the bedside prompted by [** **]'s spell this afternoon - MD [**First Name (Titles) 106**] [**Last Name (Titles) **] [**Last Name (Titles) **]'s current status and potential prognosis with [**Last Name (Titles) **]. [**Last Name (Titles) 8**] asking many questions and verbalized their concerns about [**Last Name (Titles) **]'s care course. Mom [**Name (NI) 6**]-eyed at times and [**Name (NI) **] obviously struggling with issues of continued and current care of [**Name (NI) **]. A: invested, involved and [**Name (NI) 118**] [**Name (NI) **], struggling with concerns about [**Name (NI) **]'s status and plan of care. P: Continue to support and keep [**Name (NI) **] updated on [**Name (NI) **]'s status. #7 O: [**Name (NI) 360**] alert with cares, eyes open. Temp remains elevated while under phototherpay despite warmer being off. Remains on Fentanyl infusion to provide pain/comfort control. Received 2 mcgs fentayl bolus doses prior to procedures. Somewhat "fidgetty"/agitated at times, but overall slept well on open warmer. Sheepskin and water pillow in place. A: temp elevated on open warmer, receiving fentanyl infusion. P: Continue to moniter. #8 O: [**Name (NI) 360**] remains under 4 phototherapy lights and is laying on a biliblanket. Skin remains bronze-like in color.. Eye patches in place. A: continued hyperbilirubinemia. P: Continue per plan and check bili in the morning. #9 O: Remains on Vanco and Zosyn per order for history of past + blood cultures and pseudomonas+ trach aspirate. [**Name (NI) 360**] is appr active with cares. Temp remain elevated on open warmer (?prob. r/t phototherapy lights). Hct this morning was 35, PT/PTT sent. A: continues on antibiotics, now day #16. P: Continue per plan. #10 O Left scapula area incision site remains intact. [**Name (NI) 1**] Rivers attempted remove "stitch" at old chest tube site - area moistened briefly with surgilube but stitch remained adhered to old scab in the area, small amount serosanguinous drainge noted. A: skin integrity as noted. P: Continue to moniter.

Overall Neutral Note

2. Resp: O: [** 360**] received on settings of 25/7 X 30, needing 75-85% FiO2. He proceeded to do poorly after being weighed, needing 100% FiO2 and desatting anyway, and having very poor color, inspite of being bagged during cares. A CXR was obtained and showed [** **]'s lungs in white out and his ETT tube too low. The tube was pulled back and [** **] has been improving steadily since. He also went up on his settings to a pip of 30. (His ABG shortly thereafter was 53/44/732/24/-3.)He has been able to wean his FiO2 to 44%. A: Episode of doing poorly resolving. P: Monitor. 3. F/N: O: [** 360**] remains NPO, on TF = 150cc/k/d, consisting of TPN and lipids, dopa and fentanyl drips. Abd is benign, no audible bs tonight. No stool. His u/o was 6.3cc/k/hr for the last 8 hours. He lost 9g. D/s = 122. A: Stable, npo. P: Labs in the early am. Monitor. 4. CV: O: [** 360**] has an audible murmur. HR 140-160s. He is up and down on dopa, ranging from 2mcg/k/min to 10. Color is bronze/pink. A: Still needing dopa. P: Monitor. Titrate dopa accordingly. 6. [** 8**]: O: [** 8**] were still visiting from the day. Mom appeared [**Name2 (NI) 6**] and Dad quiet. They have had a lot to think about after the events of earlier today and talking w/ Dr. [**First Name (STitle) 106**]. A: [**First Name (STitle) **] [**First Name (STitle) **] of a very early, very [**First Name (STitle) 219**] [**First Name (STitle) **]. P: Continue to support. 7. G/d: O: [**First Name (STitle) 360**]'s temp is warm under multiple phototx on a warmer w/ the heat off. However, he is cooling down. He was active all evening until settling down after his tube was retaped (see above). He is now quiet. He continues on his Fentanyl drip. A/P: Continue to support [**First Name (STitle) **] needs. 8. Bili: O: [**First Name (STitle) 360**] continues under quintuple phototx (three spots, the phototx on the warmer and one blanket). He is bronze in color. TF = 150cc/k/d. No stools this shift. A: Hyperbilirubinemia. P: Check a bili w/ am labs.

Overall Neutral Note

9. Sepsis: O: [** 360**] continues on his vanco and zocyn for sepsis. He is also on dopa. A: Hx staph aureus bacteremia and pseudomonas in his trach asp. P: Continue w/ antibx. 10. Skin: O: Thoracotomy site D & I and OTA. CT site w/o redness or oozing. Stitch in place still. A: Healing well. P: Monitor.

Overall Neutral Note

NPN Days continued #6 O: [** **]'s mom and maternal g.mother were in to visit this morning - mom stayed throughout the day and dad came in this afternoon. [** 8**] updated at the bedside. Mom helped with cares and talked and read to [**Last Name (un) 2953**] quietly. A: involved and invested [**Last Name (un) **]. P: Continue to support and keep [**Last Name (un) **] updated on plan of care. #7 O: [**Last Name (un) 360**] alert and active with cares. Was very agitated/"fidgety" this morning (and with increased WOB noted) - was therefore given a 2mcg bolus of fentanyl and his continuous infusion rate of fentanyl was increased to 4 mcgs/k/hr - [**Last Name (un) **] has seemed more calm, sleeping better with continued occasional periods of agitation. Temp has been warm, 98.4-99.8 on an off warmer (heat provided by phototherapy lights). repositioned q 4 hrs by has primarily been maintained in a prone position to facilitate resp status. Sheepskin and water pillow in place. A: decreased agitation with increased fentanyl today. Temp okay on open wamrer. P: COntinue to moniter for milestones, support developmental needs. #8 O: [**Last Name (un) 360**] remains on biliblanket and "quadruple" over head lights (3 spotlights and warmer phototx lights), with eye patches in place. Skin remain "bronze" in color with underlying ruddy color. Bilirubin this afternoon was 9.9/1./8.9 (has been 10.2/.9). A: continued hyperbilirubinemia. P: Continue with phototherapy as planned and recheck biil levels in AM. #9 O: [**Last Name (un) 360**] remains on q 12 hr Zosyn and q day dose of Vancomycin, for history of + blood culture and trach aspirate (see attending's note above). A: continues on antibiotics. P: Continue to moniter for s/s sepsis and cont with antibiotics as planned. #10 O: surgical incision over left scapula area remains dry and intact. Old chest tube site with "stitch" visible, no drainage noted. No other area of breakdown noted. A/P: altered skin integrity as noted - continue to moniter.

Overall Neutral Note

1. Resp: O: Infant received on the vent at settings of 18/5 X 25. Rate weaned to 22 per ABG and then upped again to 25. Infant has been gradually getting more acidotic so is currently on 18/5 X 25 and currently getting a dose of bicarb. Otherwise, ls clear, after sxning. Sxned X 3 so far for a mod amt of cloudy secretions. No spells. FiO2 has been 23-28% and RR have been in the 40s. A: Acidotic. P: Continue to check gasses as ordered. Interventions as needed. 2. CV: O: Infant has no audible murmur. His R bicep and R upper chest have visible pulses. He is stable on dopa at 9 mcg/k/min and is not labile w/ his O2 sats. A: Stable. P: Monitor. 3. F/N: O: INfant is NPO w/ TF now at 140cc/k/d (due to a Na of 147), consisting of TPN, D10 infusing via a DUV and acetate infusing via the UAC. D/s have been up and down and infant currently has some D15 piggybacked into the TPN. Last d/s was 60. Abd is benign, w/ hypoactive bc. No stool so far, u/o was 5.8cc/k/hr for the last 10 hours. He lost 85g. A: D/s issues. P: Monitor. Continue w/ plan. Check lytes. 4. Parents: O: Parents were up to visit w/ two other of their children. Every one asked appropriate questions. Once the other kids had left and Dad was in, Mom asked if it was a "waste" to keep this infant alive considering his vasculature. I told them to sleep on all the information they had received during the day and meet w/ the team in the morning to go over this infant's diagnosis and prognosis before making a decision. A: Loving parents w/ a big decision to make. 5. Sepsis: O: Infant continues on his ampi and gent. Gent level were sent and they were WNL. Infant is relatively stable tonight. BC remain negative. A/P: Monitor. Meds as ordered. 6. G/d: O: Infant is nestled in a sheepskin w/ bounderies. His eyes are covered w/ a bili mask. A: Generally quiet. P: Continue w/ plan. 7. Hemodynamics. A: Infant is on dopa w/ stable b/p means. A visible pulse is present in his upper R arm and upper R chest. A/P: Monitor.

Overall Neutral Note

8 Hyperbilirubinemia Nursing Progress Note: #1 - RESP: Began shift on 18/5 rate of 27 FIO2 (21-24%). Arterial Gas at 10am - 7.24/53/68/24/-5. Increased rate to 29 at ~12noon. Repeated Art.gas at 1600 - 7.29/44/64/22/-14. No changes made since. Acidosis is thought to be related to either AVM or more likely PDA. RR (50-60). Int/sub retractions. Suctioned with cares. Small to moderate cloudy from tube. and Moderate white from mouth. No spells noted. To receive Vit [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 163**]. #2 - CV: HR 140-160. Pink well perfused. Remains on Dopamine. Changed concentration to 60mg in 50cc's of D10W. Goal for MAPs (25-30). Dopa for most of shift 8-9mcqs. Briefly up to 12mcqs after syringe change. Heard Murmur this evening. Started first course of Indomethocin with presumed PDA. No echo done. AVM on right chest/arm unchanged at this point. Vessil seen in axilla and between the bicept and tricept pulsating. Right arm remains slightly swollen. Brachial pulses normal. No palmar pulses. Completed second alloquot of PRBC this morning (20cc/kilo). Tolerated transfusion without difficulty. Total BLood out since 1.8cc's. #3 - F&N: Started day at 160cc/kilo. Increased TF up to 190cc/kilo/day = 5.9cc's/hour after 10am lytes. (156/4.1/121/21) BUN 21, Creat 0.7. Lytes this evening at 1600pm - 150/3.6/118/22. UAC - has NaAcetate in Sterile H2O infusing at .9cc/hour. DLUVC - New TPN with D6.5 and lipids infusing as ordered. and D10W infusing at 60cc/kilo. Dsticks stable at 56, 62, 74. Urine output 4.4cc/kilo/hour for 12 hours. Girths 15cm. Hypoactive BS. No loops. PLAN: Lytes and Bili at 2200pm. #4 - PARENTS: Dad in several times today with 3 y.o. and other family members. Updated at the bedside. No contact with mom today. Attending went down to speak with family in their room. Family planning to wait it out for now. THey are aware that [**Known lastname **]'s longterm outcome is not considered good secondary to AVM eventually causing heart failure. Continue to update and support this lovely family. REVISIONS TO PATHWAY: 8 Hyperbilirubinemia; added Start date: [**2159-6-19**]

Overall Neutral Note

6. [** 8**]: (continued) O: Mom returned w/ some family after Dad had left. Family seems very supportive. A: Loving [** **] w/ a tiny, critical premie. P: Continue to support. 7. G/d: O: [** 360**] is nestled in a sheepskin w/ bounderies, on servo on a heated warmer under a plastic box. His temp is stable. He was slightly irritable when on his side but has been quiet since he was placed prone. A/P: Continue to support [** **] needs. 8. Bili: O: [** **] had a bili sent at the change of shift. He went from single to double phototx for a bili of 4.7, up from 3.4. He is not stooling. A: Hyperbilirubinemia. P: Continue w/ phototx as ordered. Labs as ordered.

Overall Neutral Note

NPN 7a-7p #1: Blood cultures remain negative to date. Temps stable. [** 360**] stable on current vent settings. Min O2 req. MAE. Appropriate behavior. Completed full 7days of antbx. A: stable P:Cont to monitor for s&s of infection. Antbx d/c'ed as ordered. Plan for LP in future-consent in chart. #2: [**Last Name (un) 2953**] remains on [**Last Name (un) 202**] vent, settings: deltaP 16, MAP 11. FIO2 30-46%. Rare drifts in sats noted, usually recovering quickly on own or with slight ^'ed O2. No apnea/brady spells noted. BBS coarse/=. Conts with mild IC/SC retractions. Sx'ed x1 for mod amt old bldy secretions from ETT. A: stable on current settings P:Cont to monitor. Wean O2 as [**Last Name (un) **]'ed. Check gas overnight. #3: TF: 150cc/k/d. NPO. UAC infusing 1/2NS with 1/2u hep/ cc. Double UVC infusing PND12.5 & IL. Abd remains soft and flat. No [**Last Name (un) 87**] noted. AG stable. U/O: 4.5cc/k/hr in 12hrs. No stool. Urine dip- see flowsheet. A: NPO P:[**Month (only) **] consider starting trophic feeds tomorrow per Team in rounds. Cont to monitor wt and exam. Plan to remove UAC tonight, and eventually UVC when PICC is placed. Dr. [**Last Name (STitle) 2776**] spoke with [**Last Name (STitle) **] and did obtain consent for PICC. #4: Hr stable. Soft murmur noted. O2 req min. BP stable. Nml pulses. Recevied 1 aliquot PRBC's, total of 11cc over 4hrs as ordered. [**Last Name (STitle) **]'ed well. A: soft murmur P:Cont to monitor. Plan to obtain echo to eval for PDA now s/p 2 courses of indocin. #5: Skin maturing. Small scabs noted on feet and abd, but intact and heeling. No new areas of irritation noted. A: healing skin P:Cont to monitor. Cont to reposition q12hrs, and reposition sat probe frequently. #6: [**Last Name (STitle) 8**] in most of the day. Mom eager to take temp and change diaper. Both updated. Mom met with LC. Mom conts to pump. Both spoke with Dr. [**Last Name (STitle) 2776**] and gave consent for PICC and LP. A: Involved, loving family P:Cont to support and educate. #7: Temps stable in servo isolette. Nested on sheepskin. Alert and active with cares. [**Last Name (STitle) **]'ed [**Last Name (STitle) **] [**Location (un) **] story to him today.

Overall Neutral Note

NPN 0700-1900 [** **]: Mom and Dad were in to visit this afternoon. Family mtg held at bedside w/ Dr. [**Last Name (STitle) **], NNP-Rivers and myself. [**Last Name (STitle) 8**] were updated on [**Last Name (un) 2954**] status and the vents since his birth. [**Last Name (un) 8**] were appropriately concerned about the [**Last Name (un) **] and expressed their wishes about using excessive measures to maintain life and concerns about [**Last Name (un) 2954**] quality of life. They were comfortable w/ level care at this time and that things could change " hour to hour". They were pleased that he had stabilized overnight but were finding the uncertainty of his prognosis overwhelming. SW. [**First Name4 (NamePattern1) 32**] [**Last Name (NamePattern1) 33**] was to meet w/ [**Last Name (NamePattern1) **] also. [**Last Name (NamePattern1) 8**] have much support in their family. Informed [**Last Name (NamePattern1) **] that the team could meet w/ them as often as they needed. Mom is also still recovering herself on 12th floor. States she is feeling better but focusing more on [**Last Name (un) 2953**]. G&D: Temp has remained stable on open warmer- under tent. He has been MAE. Resting comfortably when not disturbed, but required up to 100% FIo2 and containment s/p repositioning. BP and HR remained stable w/ cares but as noted increased FIO2 was required. He has slowly been able to ( over 3hrs) to return to baseline FIO2. HUS done today - moderate IVH ( grade 2) on left side- No ventriculomegaly. Right side - wnl. Findings and implications explained to [**Last Name (un) **]. No change in plan of care. HUS to be repeated on Wednesday. Fontanelle is soft and flat, sutures are slightly overrriding. A/P: Cluster cares/ limit interventions as possible. HUS - Wed.

Overall Neutral Note

NPN #2 Requiring 60-70% O2 today, CXR done, Continues on HiFOV, Map of 11 increased to 12, [** **] P increased to 18 following cap gas of 7.21/72. Will recheck cap gas later this shift. REsp rate 30-50, lung sounds coarse, suctioning for old blood. Desats to the 80'2 resolving with increased O2. See flow sheet for all details. #3 Continues NPO, Total fluid 130cc/kg/day of D14 Pn with lipids via central PICC. Voiding qs, no stool, abd soft and benign. DS 125. Lytes pending. See flow sheet for details. #4 BP stable, HR stable, no murmur noted. Continues on indocin dose q 24 hrs. #5 Skin warm dry and intact. Small areas of redness on legs, ankles and hands. #6 Mom and dad in today for update. DNR order removed from chart after discussion with [** 1**] and MD. [** 8**] feel baby is doing better and are hopefull things will improve. Mom had OB appt today, will be in later today again. #7 Active and alert with cares, fiesty at times. Nested in sheepskin with [**Last Name (un) **] bumper, pacifier offered, sucking occasionally. Temp stable in servo controlled warmer. HUS to be repeated on Friday. #8 Continues on single photo. Bili today, 5.4/.5. #9 Bcx positive, repeat BCx sent today. Continues on vanco and gent. Gent levels drawn today. LP cx pending. Will continue to monitor.

Overall Positive Note

Neonatal NP-Exam See Dr.[**Name (NI) 10**] note for details and plan of care as discussed in rounds this am. AFOF. Breath sounds course with decrease aeration in Right lower lobe. Nl S1S2, no audible murmur appreciated. Pulses full X4. Pink, jaundiced and well perfused. Abd benign, absent bowel sounds. [**Name (NI) 360**] active with exam. Spoke with [**Name (NI) **] at bedside and updated on status and plan of care. Asking appropriate questions. Dad very saddened and concerned today.

Overall Neutral Note

NPN 1900-700 #1 RESP S/O: [** 360**] on [** 202**] with settings of [** 203**] P 16 and MAP of 11. FiO2 from 35-70% tonight, rr 30-50. FiO2 decreased when [** **] positioned prone. [** 360**] had some desats into the 70's which required an increase in FiO2. Lungs sounds coarse, sx x1 for old bloody secretions. Capillary blood gas tonight 7.26/59. A: [** 360**] stable on [** 202**]. P: Continue to monitor and wean as tolerated. #3 FEN S/O: TF= 130cc/k/d. Infants wt tonight was .690g which is down 65g. Getting PND14 with lipids via PICC line. [** 360**] also has scalp IV placed. Abdomen benign, AG stable. [** 360**] voiding, no stools tonight. DS 123. A: Stable P: Monitor. #4 CV S/O: [** 360**] appears ruddy. HR 150-160's. No murmer heard tonight. [** 360**] received dose of indocin as ordered for hx of PDA. BP 55/33/40. Well perfused, good pulses. [** 360**] received second alloquat of PRBC's at 2230p. [** 360**] received 7cc over 3hrs, tolerated well. A: Stable P: Continue to monitor. #5 Skin S/O: Infants skin appears intact. Dry area on abdomen. Aquafor applied as ordered. A: [** 360**] at risk for skin breakdown. P: Continue to monitor and use Aquafor as ordered. #6 Parenting S/O: [** 8**] called in evening for update. Mom asking appropriate questions. Updated by nurse. A: Involved, loving. P: Continue to support and update. #7 DEV S/O: [** 360**] alert and irritable with cares. Settles when positioned prone. [** 360**] sucking on pacifier. Eyes begining to open. Good tone. A: AGA P: Continue to support development. #8 Hyperbili S/O: [** 360**] under single phototherapy. Appears jaundice/ruddy. A: Hyperbili P: Continue with phototherapy, get bili level as ordered.

Overall Neutral Note

Nursing Progress Note #1. O: Infant remains on ampicillin and gentamicin for r/o sepsis. Blood cultures pending. A: Sepsis. P: Obtain gentamicin levels this a.m. #2. O: Infant remains intuabted on SIMV. Settings weened overnight. Currently at 23/5 x20. FiO2 overnight has RA most of night. Breath sounds are coarse and equal. IC/SC retractions noted. Occaisional O2 sat drifts noted. A: Weening vent settings. P: Continue to monitor resp status. Obtain ABG this a.m. #3. O: Infant remains on TF's of 120cc/k/d. 1/2NS with heparin infusing well via UAC. D10W, D5PN and dopamine infusing well via DLUVC. D/S 132 this evening. Elec's stable at 142-5.1-108-21. Infant NPO. Abd soft and flat. No audible bowel sounds noted. No loops. Voiding 3.5cc/k/hr x12hours. No stools. Wgt is up 11gms overnight to 726gms. A: NPO. P: Continue to monitor FEN status closely. Obtain elec's this a.m. #4. O: No murmur heard thus far. Infant ruddy and well perfused. Pulses 2+. Precordium quiet. No [**Location (un) 283**] pulses. Infant requiring 7mcg/k/min of dopamine to maintain MAP's 30-34. Hct this evening 37. A: Continues to need pressor support. P: Ween from dopamine as tolerated. #5. O: Infant skin and edematous and fragile. Bruising noted on all extremities. Infant on lambswool. Gel pillow in place. Monitor probe sited rotated with cares. No open areas noted thus far. Aquaphor applied. A: Fragile but intact skin. P: Continue to monitor skin integrity closely. #6. O: Dad up for brief visit this evening. Stated that he is very overwhelmed with what has happened over the last 24hrs. [**Name8 (MD) 799**] RN called tonight for update. Mom very ill and out of breath. RN updated and to relay to Mom. A: Involved, appropriately concerned family. P: Continue to inform and support. #7. O: Infant remains on radiant warmer with stable temp. He has been more active during cares tonight, otherwise sleeping soundly. Sucking on ETT intermittently, grabbing ETT with hands. MAEW. A: AGA. P: Continue to assess and support developmental needs.

Overall Neutral Note

Nursing Progress Note #1. O: [** 360**] remains on ampicillin and gentamicin for r/o sepsis. Blood cultures pending. Rpt CBC this a.m. WBC 4.2, Hct 33.2, Plt 87. Repeat peak gent level pending. A: Sepsis. P: Continue to monitor for sepsis. #2. O: Received [** **] on [** 202**] settings of delta P 26, MAP 14.5 and in 100% FiO2. Settings weened overnight per ABG's to currently delta P 20, MAP 14.5. FiO2 most of night has been ~65%. ETT suctioned for pink/cloudy secretions. A: Weening settings. P: Continue to monitor closely. #3. O: [** 360**] remains on TF's of 160cc/k/d. NPO. 1/2NS with heparin infusing well via UAC. D7.5 and D7.5PN infusing well via DLUVC. D/S overnight 65-72. Abd soft and noted to be [**Hospital1 2719**] tonight. No loops. Voiding 7cc/k/hr x12hrs. No stools. Elec's stable overnight. No weight done due to infants critical status. A: NPO. P: Continue to follow FEN status closely. A.M. elec's pending. #4. O: [**Hospital1 360**] received 2nd dose of indocin at 0500. Pulses normal. [**Hospital1 360**] ruddy and well perfused when at rest. Quiet precordium. No [**Location (un) 283**] pulses. [**Location (un) 360**] was not taken off [**Location (un) 202**] to listen for murmur tonight. Dopamine d/c'd this a.m. at 0500. MAP's 31-37. Hct this a.m. down to 33.2. Plt's down to 87. Blood out is currently 3.9cc's. A: Unstable CV status. P: Continue to follow. #5. O: Skin remains edematous and fragile. Position changed q6hrs. Probe sites changed q6hrs. No open areas noted. Extremities bruised. Aquaphor applied. A: Intact, but very fragile skin. P: Continue to assess. #6. O: Parents in this evening, preparing to say good-bye to [**Last Name (un) 2953**]. Grandparents in [**Name (NI) 799**] sister in to visit and support parents. Asking lots of appropriate questions. Parents updated by attending. Mom still quite ill and remains inpatient. Parents able to get some rest most of night. RN from 12th floor called this a.m. to get update for parents. A: Involved loving family in crisis. P: Continue to inform and support.

Overall Neutral Note

NICU Nursing Addition Parents in deep thought following family meeting and further discussion was held to sort out their true wishes regarding specifics such as replacing IV's, foley cath, or ETT if unplanned dislodging occurred. Parents are focused on having the best final moments with their child and are fearful of unpleasant sequelae such as bleeding, etc. They are requesting to speak with [**First Name8 (NamePattern2) 746**] [**Doctor Last Name 555**] regarding options available to them and how to carry through the final arrangements for their baby. She will have a telephone conference with them within the next hour.

Overall Negative Note

NPN DAYS Alt in Resp Status: Remains intubated on vent settings 16/5 rate 10 FiO2 21%. CBG at 2045- 7.37/49. No changes made. LS clear. + UAC. Sxn'd ETT for no secretions and orally for large clear/tan tinges secretions. RR 20's-40's. Spontaneous breathing is irregular. No desats. Will continue with current plan of care. Infant with Potential Sepsis: Resolved.. Alt in FEN: NPO. TF 80cc/kg/day PND12.5 and lipids via PIV in right foot. HL patent and intact to left hand. D/S 112, 122. Lytes grossly hemolyzed 131/8.0/88/20. Sent repeat lytes but blood was clotting as it was being put into tube. Results pending. Urine output decreased to 0.6cc/kg/hr. Stooling meconium/green stools. Belly slightly firm r/t edema. Hypoactive bowel sounds. UA sent. See lab results. Baby to have labs [**3-18**] at 0800 BUN, CR, ionized Ca, PLT, Phenobarb level and lytes. Alt in Dev: Temp unstable 96ax on off warmer, warmer turned on to 35.0 degrees and temp increased to 99.6ax within a few hrs. Warmer is currently off with baby's temp 98.3ax. Continue to monitor. Alt in Neuro status: EEG currently recording and will be on until the morning. EEG staff to remove leads in the morning and baby is scheduled for MRI at 0900. Baby continues to be hypertonic,rigid, especially his upper extremities. Non-responsive. No movements. Pupils fixed. Eyes now closed r/t generalized edema. No seizure activity noted. Continues on Phenobarbital and will have a level in the morning. Alt in Parenting: Parents and other supportive family members in to visit. Parents verbalizing need to check with their church about funeral services next week. Mentioning where they might bury [**Known lastname **]. They are anxious to hear official EEG results from today and anxious about MRI tomorrow. Will continue to provide support.

Overall Neutral Note

NPN 2300-0700 2. RESP: Infant remains intubated on settings of 16/5 X10. FiO2 21%. RR 30-40's and irregular. Lung sounds are coarse. Sxn for large thick white secretions via ETT and copious thick white oral secretions. No retractions. No spells or desats noted. Will monitor. 3. F&N: NPO. TF 80cc/k/d of PND12.5 with IL infusing well via PIV in right foot. Hep lock in left hand patent. Lytes at stasrt of this shift were 127/6.4/88/21. NNP [**First Name8 (NamePattern2) **] [**Last Name (un) 1189**] made aware and no new orders obtained. Abd firm with edema. U/O 1.3cc/k/h. He passed small green stool with each diaper change. Labs to be followed up at 0800. 4. DEV: Infant receievd on off warmer and temp was 97.6. Warmer turned on and temp up to 99.2 at 0400. Lacrilube to eyes. Nested on sheepskin on servo-radiant warmer. 5. NEURO: Infant continues to have EEG monitor. No seizure activity noted. Infant remains on phenobarbital with level to be drawn at 0800. No purposeful movements noted. Eyes closed due to swelling. Pupils remain fixed. He is hypertonic, especially in his upper extremities. MRI scheduled for 0900. 6. PAR: Parents in at start of shift. They ask appropriate questions and speak lovingly to [**Known lastname 384**]. They are appropriately concerned and appear exhausted. They are in the parent room on postpartum presently trying to get some sleep.

Overall Neutral Note

NPN cont They are fully aware of the seriousness of the baby's status. They continue to want everything done. They are teary at the bedside and state they are realists but are hoping for a miracle. They have had multiple supportive family members in and out throughout the day. Will continue to keep the parents updated and provide support.

Overall Negative Note

NICU Nursing Progress No vent changes attempted so far today. Requiring 25% O2 to maintain O2 sats within parameters. Next blood gas scheduled for [**2188**]. Infant breathing above the vent rate with abdominal gasping breaths only. Poor air excursion auscultated at those times. Suctioned q2-4hrs for lge amt tan secretions. No bradycardia or desat noted. Infant is chalky white. No murmur appreciated. Cap refill is delayed. Extremities are cool to touch. PIV in right hand removed for puffiness and new PIV started in right foot after some difficulty. Bp stable. Remains NPO and TF increased to 80cc/kg/day. Will change over to PN this evening with Protein load adjusted for infants condition and minus potassium. Electrolytes followed every 12 hrs. K+ slightly decreased to 6.8 this a.m. Will check BUN, creat, Ionized Ca and platelets tomorrow a.m. Dextrostix=70-114 with increased TF. Urinary catheter draining yellow fluid. Still necessary to crede infant as bladder distension is still occurring. Will obtain repeat urinalysis later today. Bowel sounds barely there. Antibiotics d/c'd today. Infant makes no spontaneous movements. Joints are rigid but moveable. No observable seizure activity seen. EEG done this morning revealing extended seizure activity in the brain. Another loading dose of Phenobarb (10mg/kg) given at 1400. EEG leads replaced and infant will be on continuous tracing as well as videocamera through the night. Will capture on the machine any observable abnormal neuro activity. MRI is scheduled for 0900 tomorrow. Eyes open with fixed pupils. No corneal reflex. Lacrilube applied. Temp 97.9-98.2 on off warmer dressed only in diaper. Parents in frequently during the day with many visitors who are great emotional support to them. Updated at bedside about infant's status and plan of care. Dad states "things are sinking in, the process is happening, we don't want him to suffer, holding out hope for a miracle. Anxiously awaiting tomorrow's MRI.

Overall Neutral Note

0700-[**2083**] NPN RESP: Infant remains on HFOV, current settings of MAP 14 and [**Year (4 digits) **] P 21, fi02 38-56% (increased with cares). CBG drawn this morning 7.23(pH)/55(pC02), no changes made. LS course and tight; suctioned prn for moderate amt cloudy/pink-tinged secretions via ETT. Baseline SC/IC retractions present. CV: HR 130s-150s, no murmur. BP MAPs mostly 31-35 (see flowsheet). Transfused with 8cc of platelets over 2hrs this morning, TW. Platelet level prior to transfusion 91; plan to check a CBC with differential tomorrow morning per order. Infant is pink and well-perfused. Significant edema present, particularly in head, trunk and upper extremities. Right arm (location of AVM) is severely edematous but remains pink. FEN: Currently NPO; TF 100cc/kg/d PND11.5w and IL infusing via PICC. Dsticks 94, 80. See lab for this morning's electrolytes; plan to check again tomorrow morning. Abdomen soft, full, no loops, hypoactive BS. Urinary catheter in place; UO approximately 1cc/kg/hr over the past 9hrs. Infant voided into and around catheter this [**Last Name (NamePattern4) 2483**] NNP provided Crede maneuver. No stool at this time. PARENTING: Parents visited for about an hour this afternoon. RN providing update and support. Parents asking appropriate questions re infant's clinical status and comfort. They expressed appropriate concern and appear to be aware of the critical nature of infant's current condition. Mom prayed over infant and both parents spoke lovingly to him. They stated that they would like to have infant baptized and have tentatively scheduled to have it done on Tuesday afternoon with the [**Hospital 32**] hospital pastoral services. BILI: Remains under max Neo-blue photothx. Plan to check bili level tomorrow a.m. DEV: Temps stable, nested with sheepskin and [**Last Name (un) 58**] bumper on servo control warmer. Fontanels soft and flat, sutures overriding. MAE, however has restricted movement of right extremity d/t edema. Infant is lethargic with cares and has sleeping throughout the day. Morphine given x2 for comfort.

Overall Neutral Note

NPN cont'd DEV: Temp range-97.5-98.6 w/o making any chages in warmer temp. Activity level as noted previously. Neuro and Genetics following- Genetics labs sent- infant will need urine sent in am for genetics work up. PARENTS: Mom and Dad and supportive family in throughout the day. Parents are updated on [**Known lastname 1725**] status and prognosis after family mtg w/ Neuro this afternoon. Parents are aware of potentially very poor prognosis and have decided to make [**Known lastname **] a DNR for tonight. He will go for his MRI tomorrow and they will make further decisions once those results are known. Mom did diaper change this afeternoon. Both parents held [**Known lastname **] this evening. MAt. grandmother blessed [**Name (NI) **] and I asked parents if they would like to baptize [**Known lastname **]- they are discussing this ( How and when). Parents are understanding the gravity of the situation and are awaiting MRI results. RESP: Rec'd infant intubated on settings of 24/5 x25, FIO2 -100%. Breath sounds were coarse in am- improved throughout the day. ETT re-taped at 8am- advanced .5cm for right middle lobe atelectasis. No retractions. ETT sxn'd q 4hrs for sma-mod thick white secretions. Infant pooling thick secretions in mouth. Venous gas at 11am-7.36/30/39/18/-6. Infant needing to be bagged for desats w/ sz activity- settings increased to 25/6 x 25. Had one spontaneous desat to 54 needed sxn and bagging to recover. FIO2 ranged 100- 75%. Repeat cap gas-7.29/48. Art gas at 1700-7.29/41/75/21/-5. No further changes made. Does not tolerate lying on either side- prefers supine. A?P: Cont to follow gases/ fio2 requirement.

Overall Neutral Note

1. Resp: O: Infant is on the [** 941**] vent at a [** 942**] P = 24 and MawP = 14. FiO2 has been 29-37%. Ls coarse w/ a large air leak evident. Sxned twice so far. Once, when flipped and weighed, for a large amt of clear secretions and once for small amt of cloudy secretions. A: Stable on the [** 941**] vent. P: check a gas. Monitor. Wean as tol. 2. CV: O: No murmur audible. HR in the 130s. bp means 32-39. Color pink. No spells. Very puffy. A: Stable. P: Monitor. 3. F/N: O: Infant started the shift on TF = 130cc/k/d and trophic feeds. He had a 1cc asp of undigested BM before his 8p feed (of 1cc of BM) and had gained 203g. He was made NPO and TF reduced to 120cc/k/d. Infant is very puffy. His u/o was 1.3cc/k/hr for the last 10 hours. No stool, though he had audible bs. D/s was 92. A: Feeds stopped. P: Check labs as ordered. Monitor infant as per NICU protocol. 4. Parents: O: Mom and her teenaged step daughter were in to visit. [**Name (NI) 1814**] (Mom) talked to [**Known lastname 2481**] and appeared to be praying for him. They stayed for about 1 hour. A: [**Name (NI) 12**] Mom w/ a tough situation. P: Continue to support. 8. Bili: O: Infant continues under double phototx w/ his eyes covered. He has never stooled. He has a hx of multiple blood transfusions. His liver is enlarged. A: Hyperbilirubinemia. P: Continue w/ phototx as ordered. Check bili w/ labs. 10. Pain: O: Infant is on prn Morphine for pain. He received some before he was weighed and will receive more before his blood draws. He has been calm all night. A: Morphine appears effective for pain in this infant. P: Continue w/ plan. 11. Sepsis; O: Infant is on gent and vanco. Levels will be drawn before the next doses are given. BC remain negative at this writing. A: Possible sepsis. P: Meds as ordered after levels checked.

Overall Neutral Note

NPN 1900-0700 RESP: Infant continues on [**Last Name (LF) 941**], [**First Name3 (LF) 942**] P 24 MAP 14. FiO2 42-77%. ABG drawn at 2300= 7.29/76/41/21/-6; no changes made to settings at this time. LS coarse bil. Lg air leak noted. Infant sxn'd with cares. Mod amt blood tinged sxns sxn'd at [**2153**]. NNP aware. Small amt cloudy via ETT & small amt old blood tinged sxns sxn'd at 0200. No spells thus far this shift. CV: Infant s/p indo. No mumur auscultated. HR 120-140s, BP means 29-43. Labs drawn [**Year (4 digits) 1107**]. HCT= 39.9, PLT 133. 2nd alloquot PRBCs (8cc) infused at 0230, consents in chart. No adverse rxns noted. Mod amt dependant edema noted head/neck & R side of body. [**Location (un) **] pulses noted R hand, no [**Location (un) **] pulses appreciated in left hand. Infant ruddy, WP. FEN: Infant not weighed [**Last Name (LF) 1107**], [**Name8 (MD) 6**] NNP, due to pt decompensation with interventions. Yesterdays wt: 807g. Infant remains NPO. TF 140cc/k/day. DLUVC patent and infusing PND10.5 via primary and secondary ports + IL. Abd soft, round, no loops. hypo BS. UO minimal 0.2cc/k/hr x 12hrs. NNP aware. No stool yet. Labs drawn 2300, Lytes: 130/3.3/92/18/23, BUN: 34, Creat: 2.1, Trig: 69, DS= 129. PAR: Mom and godmother in to visit at 2100, updated at bedside by this RN. Asking approp questions. Mom seemed to be focused on pts O2 requirement as verification of how "well" he is doing. Mom stated that she was going to move 2 cribs in her 3yr old's room for the twins. Mom appeared as though she did not fully understand the severity of twin#2's condition as she stated many times "when he comes home". At this time, pt has DNR order in chart. This RN discussed infants condition re: poor UO and major organ failure. Verified home # to reach parents in case of emergency. Mom called for update at 0100. Appeared saddened by report. Will suggest baptisim of infant and SW involvement for emotional stress/denial. Continue to support and update.

Overall Negative Note

DESAT THIS AM WITH SLOW RECOVERY DESPITE 100% FIO2 REQUIRED HAND BAGGING FOR SHORT TIME. BABY VERY STRESSED AND MOVING--FENTANYL INFUSING.

Overall Neutral Note

0700-[**2083**] NPN RESP: Remains on HFOV, current settings MAP 15, [**Year (4 digits) **] P 24. [**Year (4 digits) 942**] P increased from 21 this morning following an ABG of 7.12(pH)/74(pC02)/142(p02)/26(tC02)/-7(BXS). MAP was increased from 14 shortly thereafter d/t increased oxygen requirement. Fi02 has been 72-100% and infant has had to be hand-bagged with 100% oxygen twice so far to bring saturation above 60%. LS course and tight; suctioned x2 for small amt cloudy secretions via ETT. Chest x-ray done shows left-sided PIE; attempting to position infant left-side down. CV: HR 130s-150s, soft murmur auscultated. See lab for most recent CBC (drawn yesterday). BP MAPs 30-37, see flowsheet. Infant is pink and well-perfused. Pulses slightly full, hyperactive precordium. Infant with dx A-V malformation; pulse noted in right bicep and below right shoulder. Severe edema present, most notably in head, trunk and upper extremities. FEN: Remains NPO; TF restricted at 80cc/kg/d PND12w and IL infusing via central PICC. Dstick 65; see lab for today's electrolytes. BUN and creatinine were also sent however lab was unable to process results. Abdomen soft, full, hypoactive BS. Infant has voided 1cc thus far this shift. Urinary catheter was [**Name6 (MD) **] [**Name8 (MD) 6**] M.D. this a.m. PARENTING: Dad called this a.m. for update. This RN informed him of infant's worsening respiratory and fluid status and emphasized that the team is "very worried" about infant. Dad was relatively quiet on the phone but seemed receptive to the information. He stated that he and Mom plan to visit this afternoon. Pastoral services was called and updated. If parents request it, a priest is available to baptize infant today. BILI: Remains under max Neo-Blue photothx. DEV/PAIN: Temps stable, nested with sheepskin on servo control warmer. Infant is very sensitive to stimulation but settles easily when undisturbed. Stress minimized with q6hr cluster cares. Morphine boluses given q4hrs for comfort. I/D: On Cefotaxime. Vancomycin held d/t 24hr level of 20.7, rpt in 24hrs.

Overall Neutral Note

0700-[**2083**] ADDENDUM TO NPN Correction to FEN: BUN and Creatinine tests were run, see lab for results. PARENTING: This RN called parents at home at approximately 3:45 p.m. to update them and to inquire what time they plan to be in today. RN reiterated to mother over the phone that infant is in very worrisome condition at this time and that Dr. [**Last Name (STitle) **] would like to discuss his condition with she and her husband when they arrive. Mom stated that her husband was "fixing dinner" at the moment and that they would be in after they ate which would probably be in 2hrs (about 5p.m.).

Overall Negative Note

0700-[**2083**] ADDENDUM TO NPN Family meeting was held at approximately 1730. Both [**Year (4 digits) 4**] were present as well as Dr. [**First Name8 (NamePattern2) 1505**] [**Last Name (NamePattern1) **] and this RN. After discussion with Dr. [**Last Name (STitle) **], [**Last Name (STitle) 4**] expressed that they wish to redirect care. Father stated, "do whatever you can to make him comfortable." Both [**Last Name (STitle) 4**] appropriately tearful and distraught. RN and M.D. are providing family with comfort and support. Priest arrived and baptized infant at bedside with [**Last Name (STitle) 4**] and other family members present. [**Name2 (NI) **] and family are spending time with infant at the bedside at this time. [**Name2 (NI) **] expressed that they wish to hold infant at the time that they are prepared to remove him from the ventilator.

Overall Positive Note

NPN 1900-2103 Received baby [** **], oximeter dc'd, family pursuing redirection after discussion with MD. Baby had been baptized. Morphine dose given as ordered prior to extubation at [**2163**] by RT. Placed in mother's arms. [**Year (4 digits) **] and family members present, taking turns holding [**Known lastname 2481**]. Pictures taken of family and [**Known lastname 2481**] per [**Known lastname 4**] request. Hr checked q 15 minutes, Baby expired peacefully at 9:03 pm [**Name6 (MD) 6**] [**Last Name (NamePattern4) 2486**] MD. Family provided with [**Last Name (NamePattern4) 2487**] folder and left hospital to discuss plans for burial privately. Baby and [**Name2 (NI) 2487**] box prepared per protocol, appropriate depts notified. Transported to and signed into morgue at 2220.

Overall Positive Note

NPN 7am-7pm 8 Neuro #1: Received infant on prong CPAP 6. FiO2 21-35%. RR 20-40's. LS sl diminished in bases. Mild SC/IC ret. Attempted to wean peep to 5 with increased apnea. Went back up to peep of 6. Went to CT scan on NC 1 1/2L. Cont on NC with EEG placement. Tol well. NP tube placed at 1800 CPAP 6. FiO2 21-35%. Apnea spell through out day, with desats to 60's req increase in 02 and [**Last Name (un) 377**] stim. (see neuro note). Team aware. A: On NPCPAP 6. P: Cont to monitor resp status and provide support as needed. Intubate if necessary. #2: Infant on TF of 80cc/kg/d. Currently NPO. Received infant on D10W through PIV in right hand. Fluids changed to PN D10W running at 50cc/kg/d and D10W at 30cc/kg/d. Infant has gen. edema. Eye's puffy. Abd soft, girth stable, no loops noted, +BS. Voiding and Stooling. D/S 86. 24hr lytes 139/3.7/106/23 BUN 10/CR 0.6. A: Infant NPO. P: Cont to monitor weight and exam. #3: Infant on open warmer with skin probe on, nested on sheepskin. Temp stable. Active and alert with cares. MAE. Font full and sutures [**Month (only) **]. No seizure activity noted. A: Premature infant. P: Cont to support dev needs. #4: Parents here in morning to visit infant. They were able to touch and talk with [**Known lastname 3375**]. App questions asked. Later in day parents spoke with Dr. [**Last Name (STitle) **] about test that had been done and plan of care for infant. Parents very sad and crying over news about infant. They sat with [**Known lastname 3375**] for a while. A: Parents very upset. P: Cont to support and inform parents about cares for infant. #5: Infant on Amp/Gent. R/O sepsis. CBC begnin, Bld cx neg to date. Repeat CBC begnin. Temp stable. Infant with apnea throughout day, not believed to be related to sepsis. (see neuro note). A: On Amp/Gent. P: Cont to monitor Bld cx and s/s of sepsis. #6: 24hrs labs today: WBC 10.6, Hct 57.1, N 22, B 0, L 70, Plt 120. Hct sl increased from 55 to 57.1. Plts 120 after plt trans. Team aware of labs. A: Infant currently heme stable. P: Repeat Plts. in am. Cont to follow hct. REVISIONS TO PATHWAY: 8 Neuro; added Start date: [**2118-5-7**]

Overall Neutral Note

1. Resp: O: Infant received on the vent at settings of 16/5 X 12 and in RA. RR 30-50s, no episodes of apnea observed. Ls clear. Sxned for a small amt of secretions. A: Stable on low settings on the vent in RA. P: Monitor. 2. F/N: O: Infant remains NPO for now, on TF = 100cc/k/d consisting of TPN and lipids infusing via a PIV. Lytes were sent and results are pnd at this writing. D/s = 77. Abd is benign, occasionally a bit loopy, soft and transient. She has no ngt for decompression. No stool tonight so far. She lost 105g. A; Losing wt. Labs pnd. P: Monitor. 3. G/d: O: Infant is on servo, nestled on a sheepskin on an open warmer. She is hooked up to an EEG machine. She is under double phototx w/ her eyes covered. She is generally sleeping. A/P: Continue to support infant needs. 4. Parents: O: Parents were in @ 11p to visit. (Mom had gone home today and they live nearby.) They asked about when the MRI will take place. Mom held the baby for @ 30 [**Name2 (NI) **] and then she took infant's temp and both parents changed her diaper. They were given info about Hep B and the newborn screen. A: Loving, involved parents. P: Continue to support. 6 & 9: Heme/CV: O: Infant's platelets tonight are 121, up from the previous lab draw. No murmur. HR 130-150s, color pink/[**Name2 (NI) 527**]. A: Stable, platelets improving. P: Monitor. 7. Bili: O: Infant is very [**Name2 (NI) 527**]. She continues under double phototx w/ her eyes covered. A bili is pnd at this writing. A: Hyerbili r/t polycythemia/thrombocytopenia. P: Phototx as ordered. Check results of labs. 8. Neuro: O: Infant is hooked up to an EEG machine. No s/sx seizures, no apnea noted. She is pretty sleepy. HC not obtained because of the EEG electrodes. A: Stable, no sx noted. P: Monitor. MRI today?

Overall Neutral Note

NPN: Baby girl [**Known lastname 3371**], "[**Name2 (NI) 3379**]", died at @ 0130. She was pronounced by Dr. [**First Name (STitle) **]. Her [**First Name (STitle) 4**] had been in with her all evening and were at her bedside when she died. Dr. [**First Name (STitle) **] spoke w/ the [**First Name (STitle) 4**] -- they do not want an autopsy and want both infants, (this baby was a twin) buried together. Social work notified by phone message.

Overall Negative Note

1. Resp: O: Received infant on the vent at settings of 21/6 X 34. Due to increasing acidosis (per ABG) and increasing pCO2, infant was put on the HiFi vent @ 9p. He has been weaning his Delta P ever since. (See flow sheet.) He is still labile w/ his FiO2, needing 35-50% and still needing much higher FiO2 w/ cares. He has had no spells. A: Improving on the HiFi vent. P: Monitor. 6. G/d: O: Infant has been requiring Fentanyl w/ cares and is now receiving it frequently now that he is on the HiFi. He is fidgity and sometimes calms w/ sucking on a binkie. He tends to desat w/ too much activity. A/P: Continue to support infant needs. 4. Parents: O: Parents came in when they were called w/ the news about the change to HiFi. They were updated extensively by Dr. [**Last Name (STitle) **] and myself and spent a few hours here. They left after infant had a few good gasses and was weaning. Mom will be back in the morning. A: Loving, concerned parents. P: Continue to support. 3. F/n: O: Infant remains NPO on TPN and lipids infusing via his DUV. D/s were up, then went down. He will get a series of labs this am. His wt was unchanged from yesterday. No stool. U/o was 4.0cc/k/hr for 8 hours. A: Stable so far. P: Send and check labs. Monitor d/s. 5. Sepsis: O: Infant continues on ampi and gent. A CBC will be drawn w/ his other labs. He is now on HiFi but weaned off dopa. A: Not appearing to be septic at this point. P: Check CBC. Meds as ordered. 2. CV: O: Infant has no audible murmur. HR 140-160s. BP went up dramatically once infant was placed on HiFi and dopa was weaned off. A: Dopa off. P: Monitor. 8. Bili: O: Infant continues under double phototx. He is not stooling. A Bili will be checked w/ his labs. A: Hyperbilirubinemia. P: Phototx as ordered. Check a bili w/ labs.

Overall Neutral Note

1. Resp: O: Received infant on the vent at settings of 18/5 X 29. FiO2 has been 21% all night. RR 30-40s, ls clear. Sxned @ 3 times so far for small to mod amt of cloudy secretions. No spells. No changes made to vent after ABG. A: Stable, no changes. P: Monitor. Labs as ordered. 2 & 7: CV/Hemodynamics: O: HR 140-150s, no murmur audible. Infant is being treated w/ indocin for a presumed PDA. He has just received his second dose. He is also on dopa and has been needing more as the night has been going on. He is now up to 13mgc/k/min. His Hct was 38.6 and his plts were 73. He has received platelets and will receive PRBC (for low bp and Hct.) His precordium is very active, both over his heart and because of his AVM. A: Dopa increasing, platelets given. P: Continue to monitor. Meds as ordered. 3. F/N: O: Infant remains NPO, on TF = 190cc/k/d, consisting of TPN of D6.5 and lipids and D10W and NaAcetate (running through the UAC). U/o for the last 9 hours was 4.4cc/k/hr. He gained 7g but is still well under BW. Abd is benign, no stool. Hypoactive bs. D/s have been stable. A: Tol fluids. P: Continue w/ plan. 4. Parents: O: Dad stopped in w/ visitors at the beginning of the shift and Mom stopped in and stayed awile. A: Loving parents faced w/ a tough decision. P: Continue to support. 6. G/d: O: Temp has been relatively stable considering that it has been hard to keep infant's temp probe on. He is active but settles. No Fentanyl given. A/P: Continue to support infant needs. 8. Bili: O: Infant is under double phototx. No stool. He is red/jaundiced. He has not yet stooled. His bili tonight was unchanged from the previous one. A: Hyperbilirubinemia. P: Phototx as ordered. Check labs as ordered.

Overall Neutral Note

NPN/Expiration Note Rec'[**Initials (NamePattern4) **] [**Known lastname **] intubated on settings of 25/6 x 25, FIO2 70-100%. He cont'd on pressor support- Dobutamine gtt ( that needed to increase to 12mcgs) and Dopamine gtt at 3mcgs. No spontaneous movement noted this morning w/little gag reflex- ? seizure activity x 1. He rec'd Phenobarb and Ativan and also written for prn Fentanyl. Severe 3rd spacing over enitre body- ROM done but joints are tight w/ limited movement in lower extremities. Parents in early this morning. Extended family joined them. MRI results obtained from TCH neuro-radiologist by Dr [**Last Name (STitle) **]. Results were- severe diffuse white and [**Doctor Last Name **] matter injury c/w an older ischemic injury ( please see Dr.[**Name (NI) 72**] note for further detail of MRI results). We met w/ the family to deliver these results. Parents then decided to no longer continue w/ pressor support and vent support. Parents spent the day w/ [**Known lastname **]. They did hand and foot prints and gave him his first bath. Supportive Family was given time to hold and grieve together. Biophotography in to take pictures. Infant had been baptized. Grandparents each got to hold [**Known lastname **]. Both parents held him as well. Mom held [**Known lastname **] as he was extubated at 1755. He was declared dead at 1827. Parents have decided to procedd w/ autopsy and [**Known lastname 1725**] body was received by Dr. [**First Name8 (NamePattern2) 1728**] [**Last Name (NamePattern1) 1727**], pathology from TCH. Parents proceeding w/ funeral arrangements. Memory box given to parents at their request.

Overall Negative Note

1. Resp: O: Infant continues on the Vent at settings of 21/5 X 30. RR 35-40s, ls coarse to clear. Sxned X 2 so far this shift for a small amt of secretions. FiO2 has been 25-30%. ABG at mn was good, no changes were made. A: Stable on the vent. P: Monitor. ABG as ordered. Wean as tol. 2 & 7: CV/hemodynamics: O: No murmur audible. HR 150-160s. Dopa started at 12 mcg/k/min at the beginning of the shift. Now weaned to 9mcg/k/min. R arm appears unchanged, pulses visible. Plts = 154 and Hct is 39.8. A: Stable, dopa weaning. P: Continue w/ plan. 3. F/N: O: Infant remains NPO w/ TPN and lipids infusing via a DUV. D/s = 149. Abd is benign, w/ hypoactive bs. U/o was 3.5 for the last 24 hours. Lytes are pnd at this writing. A: Stable, NPO. P: As per plan. 4. Parents: O: Mom was in for the first cares and weighing of infant. She asked appropriate questions and took pictures of the infants being weighed etc. She had a long talk w/ [**Last Name (NamePattern4) 2482**] NNP tonight. A: Loving,involved Mom. P: Continue to support. 5. Sepsis: O: CBC sent was benign. Infant continues on his ampi and gent for now. VSS, dopa weaning. A: Stable. P: Continue w/ plan. 6. G/d: O: Infant has been prone for the last several hours and is very calm. He was given fent. X 1 for agitation. He has since settled well when placed prone. A/P: Continue to support infant needs. 8. Bili: O: Infant remains under double phototx w/ his eyes covered. A bili is pnd at this writing. He has not yet stooled. A: Hyperbilirubinemia. P: Continue to support infant cares.

Overall Neutral Note

NPN 0700-1900 #1 O: Infant remains on amp and gent as ordered. Bl cx remains neg to date. A: Potential for sepsis. P: Cont to monitor. #2 O: TF=180cc/kg/d. Infant receiving D10 with hep infusing at 1.0cc/h via UAC. This was increased from D5 this am for a DS of 45 at 0800. DLUVC remains in place with D10 with 1 meq of K and hep infusing via secondary port and TPN D5 infusing via primary port at 50cc/kg/d or 1.6cc/h. Infant to have TPN increased to D10 this eve with IL added. Dopamine d/c'd at 1500. NPO status. Abdomen flat and pink with hypoactive BS. Voiding 3.3cc/kg/h in past two diaper changes. No stool. DS 45, then rising to 64 after increasing to D10 via uac. Last DS was 54. Lytes 151/3.6/116/22. A: NPO. P: Cont to monitor. #3 O: Received infant intubated on 18/5 rate 24. ABG today 7.26/50; no vent changes. FIO2 22-30%. LS clear and =. RR 30's-40's with mild IC/SC retractions. Suctioned with cares for mod amounts cloudy secretions form ETT and mouth. A: Remains on current settings. P: Cont to monitor. #4 O: Mom in to visit throughout day. Family meeting held at bedside with dad also present. MD presented results of HUS. Parents deciding about treatment options such as redirection of care. Dad at home with other children this afternoon. Mom stating they would like to do this tomorrow at lunchtime (next time dad able to be here). Dad asking a lot of appropriate questions regarding infant's pronosis and care. Mom very crying and appearing in shock. SW here to talk with mom who at this time has no support person with her this eve. A: Involved. P: Cont to support as needed. #5 O: Infant maintaining temp on open warmer set in servo mode. Awake and irritable at times with cares. Fent given x1 for comfort. Eyes remain fused. Nested in sheepskin with plastic tent; Hypertonic especially in lower extremeties. Skin in fairly good condition. Aquaphor applied to reddened areaas under arm pits and on knees. Bruise noted on right knee. A: AGA/Irritable. P: Cont to support as needed.

Overall Neutral Note

Mom holding infant while infant swaddled. Mom appearing to enjoy this experience very much; smiling and holding infant's hand.

Overall Positive Note

NICU Nursing Note Rec'd Infant orally intubated on settings of 22/5 x28 FiO2 21-29%. Needed to adjust vent settings according to multiple blood gases. Infant mainly breathing in sync with the vent, but having a few gasps in between. BS clear with good aeration. Suctioned x1 for small blood tinged secretions. Infant was seizing when rec'd. A dose of dilatin was given which resulted in eventual cessation of seisure activity. Infant rec'd a total of 3 doses of Na HCO3 and 2 doses of Calcium gluconate. NS bolus given x2. Dopamine started d/t falling BP and dose slowly increasing as BP drifted. Dobutamine started to help attain adequate BP, but BP cont'd to fall. 1 dose of hydrocortisone given as well. TF increased from 60cc/k/d->80cc/k/d d/t falling ds to 48. Unable to maintain adequate BP despite multiple meds. CXR obtained. Parents called. Mom came up and held infant, while father was driving in. Infant was baptized. When father arrived infant was taken off meds and ventilator support. Mom held infant--father refused to hold him despite encouragement to do so. Parents spoke with Dr [**Last Name (STitle) **]. SW will be contact[**Name (NI) **] later today. Post-mortem care done per protocol and infant taken to morgue.

Overall Negative Note

NPN 0700-1900 #2 O: TF increased to 160cc/kg/d at 1230 today. Lytes to be checked later tonight or tomorrow am. UAC in place receiving 1/2 NS with hep at 1.0cc/h. Big toe on left foot and second toe in noted to be on and off dusky throughout day. NNP attempted PAL. ? d/c uac this shift. DLUVC remains in place with TPN D5 infusing via primary port and D5 with hep and IL infusing via secondary port. TPN rate to be increased to run at 100cc/kg/d this eve. NPO. Belly soft and flat with hypoactive BS. Voiding 3.1cc/kg/h, no stool. DS 111. AG stable. A: NPO. P: Cont to monitor. #3 O: Received infant intubated on settings of 20/5 rate 28 where he presently remains. FIO2 26-46%. More labile today than days previous. Two desats this eve to low 70's; taking his time to recover needing increase in o2. LS coarse prior to suctioning; suctioned q 2-4h for mod amounts of thick cloudy/white secretions from ETT and mouth. ABG obtained at 1230; 7.27/52. A: Labile on current settings. P: Cont to monitor. #4 O: Dad called x1 today; update given. Inquired with [** **] if either one of them had any questions and dad stating they had no questions. ASsed when they would visit next; dad stating not today but "maybe tomorrow". Encouraged this dad to call frequently and visit as able. A: Involved. P: Cont to support this family as needed. Plan another family meeting. #5 O: Infant maintaining temp on open warmer set in servo mode. Awake and moving extremeties with cares. Sometimes irritable between cares flailing arms around. Infant responding well to fentanyl given x2. Nested in sheepskin. Right eye remains fused. A: AGA. P: Cont to support development. #6 O: No murmur heard. Coloring pink and well perfused. BP means 32-37. See flow sheet for other cuff pressures done. Total blood out since last transfusion is 1.6cc's. A: CV stable thus far. P: Cont to monitor. #7 O: Infant remains under single phototherapy with eye shields in place. Today's bili reported as 4.9/0.4. Bili to be checked in am with lytes.

Overall Neutral Note

NPN 0700-1900 #2 O: TF= 160cc/kg/d. Infant receiving TPN D5 via primary port of DLUVC at 100cc/kg/d and D5 with hep and IL at 50cc/kg/d via secondary port of uvc. TPN D6 to be started through both ports of uvc this eve as well as IL continued. Gavage feeds of PE20 initiated at 1200 at 10cc/kg/d or 1.3cc's q 4h. Abdomen flat and soft with hypoactive BS. Voiding, no stool. DS 93. AG stable at 17cm. A: Feeds initiated. P: Cont to monitor closely. #3 O: Received infant on vent settings of 20/5 rate 28. Fio2 34-40% this shift. RR 30's with mild IC/SC retractions. LS coarse prior to suctioning; suctioned with cares for sm cloudy secretions from ETT and mod white from mouth. No a's or b's; occasional drifts in o2 sats needing o2 increased. Infant can be labile at times. A: Stable on current settings. P: Cont to monitor. #4 O: Both [** **] in to visit with infant's older siblings. [** 2**] asking a lot of appropriate questions r/t infant's status and re-direction of care. Mom stating "we're still not sure what we're going to do". [** 2**] verbalizing they would like to talk with other [** **] who may have had a child in our unit with similiar brain injury. Also offered to [** **] another family meeting to discuss present issues. A: Involved, loving family. P: Cont to support as needed. #5 O: Infant maintaining temp on open warmer set in servo mode. Awake with cares; occasionally opens left eye. Right eye remains fused. AFSF. Not as irritable today as previous day. Fentanyl given x1 with cares so far. Nested in sheepskin with plastic tent in place and water pillow under head. A: AGA. P: Cont to support development. #6 O: No murmur heard. Coloring pink and well perfused. BP means 32,43. A: Stable CV. P: Cont to monitor. #7 O: Infant remains under single phototherapy with eye shields in place. Bili this am was 4.5/0.5/4.0. Next bili to be drawn Tues. with lytes. A: Hyperbili. P: Cont to monitor.

Overall Neutral Note

NPN 0700-1900 cont'd F&N: ABd is flat and soft w/ very hypoactive bowel sounds heard this evening. No stool passed in 24hrs ( has stooled since birth). U/o decreased slightly to 2.7cc/kg/hr x 12hrs. BILI: Infant is jaundiced. Bili sent at 1800- pending. DEV: Minimal spontaneous movement, though per team movement is increased from yesterday. Infant will occasionally move feet, splay toes. Has moved fingers on both hands and moved his eyebrows. Has not opened his eyes yet, though his eyes tear frequently. No rhythmic movements noted, though infant has hda episodes( very brief) when HR will increase to 170-180's and sats will drift to low 90's. ? EEg tomorrow per Dr. [**Last Name (STitle) **]. Neuro is following. Gentics involved. Labs sent today for FISH studies( r/o Prader-[**Male First Name (un) 3142**]) + chromosomes. Infant repositioned q 2hrs due to edema. Rolls placed in hands as infant keeps them mostly clenched ( not as tight as yesterday). A/P; closely monitor for any seizure activity or change in spontaneous movements.F/u w Genetic w/u. [**Male First Name (un) **]: Mom here alone today. Dad had to return to work. Met + updated Mom at [**Name2 (NI) 1470**] w/ her OB who translated. Family mtg held, also w/ [**Name2 (NI) **], today. Mom asked a lot of apporpriate questions. Frustrated by lack of information available and uncertain prognosis. Appropriately upset when told of the possiblity that infant might not survive. She left the unit shortly after that mtg and I spoke w/ post-partum nurse to support MOm. [**Name (NI) **] family support other than Dad. Sw- [**First Name8 (NamePattern2) 433**] [**Doctor Last Name **] is involved and will try to assist Mom w/ [**Name2 (NI) 1610**] her baby once d/c'd ( ? Sat). A/P: Try to support [**Name2 (NI) **], keep them informed.

Overall Negative Note

NPN 7a-7p #1: [**Known lastname 103**] remains on [**Known lastname **] vent with MAP 12, and amp 28. FIO2 has been increasing slighlty during latter part of shift, range 34-48% today. ABG stable. No changes made to settings. BBS cl/=. Sx'ed ETT for sm amt blood tinged secretions x1. Did have sm amt dark green bilious secretions orally this am, followed by lg amt cloudy. Lips very dry- frequent mouth care given. A: stable P:Cont on current settings. Follow labs. Follow exam. Provide support as needed. #2: TF: 140cc/k/d. Currently, on PND12.5 & IL infusing via patent double lumen UVC. D/S stable. NPO. Abd soft, with very hypoactive [**Last Name (un) 259**]. Ag 22-23cm. Liver enlagred and easily palpable. No stool. U/O: ~3.2cc/k/hr in past 17hrs. K 2.6. Team aware and will follow up. LFT's improving. Infant noted to haven generalized edema, especially in face and groin/scrotum. Scrotum dark in color and skin is shiny. Team has assessed several times. Cont to monitor. A: NPO P:Change to PND15 tonight as ordered. Monitor labs. Follow wt, exam, and I&O. #3: Skin intact. Right foot noted to have necrotic toes, with white sole just under toes. Also noted to have scab on heel. No drainage noted from any site. Right foot warm to touch and had strong pulse on doppler. Capillary refill to foot stable. Bruising noted on extremities. Infant is nested on sheepskin and repositioned with cares for comfort. P:Cont to monitor and provide support as needed. #5: Temps stable while nested on servo warmer. [**Known lastname 103**] has been [**Known lastname **] and active with cares. MAE. Fonts soft/flat. Does suck on ETT at times. Rest easiest with minimal noise and intervention. A: stable P:Cont to support dev needs. #6: Parents in several times for quick visits. Both updated by [**First Name9 (NamePattern2) 41**] [**Doctor Last Name 137**]. Dad stating that it is difficult to see infant this way. Support offered. Parents were planning on staying in parent room, but at Dad's last visit he said they might just go home. Dad's cell # is in chart- call if needed.

Overall Neutral Note

NPN DAYS CONTINUED HYPERBILIRUBIINEMIA:REMAINS UNDER SINGLEPHOTOTHERAPY WITH EYE SHIELDS ON AT ALL TIMES. BILI AT 8AM 6.0 1.8. LFT'S AT 8AM, ALT 512, AST 747, ALK PHOS 284. ALONG WITH DIC, BABY [**Month (only) **] HAVE HAD SOME LIVER DAMAGE DUE TO TWIN TO TWIN TRANSFUSION SYNDROME INUTERO. WILL REPEAT LFT'S TONIGHT. ALT IN SKIN INTEGRITY:CONTINUES TO HAVE NECROSIS ON TIPS OF TOES ON RIGHT FOOT, SMALL BLACK SCABS, AND TAN COLORED SCAB ON HEEL OF RIGHT FOOT. NO OPEN AREAS, OR DRAINAGE. LEFT OPEN TO AIR, NO DRESSINGS. NO CHANGES TO EXAM FROM YESTERDAY. COLOR OF RIGHT LOWER LEG AND FOOT IS A LITTLE PALER THAN THE REST OF THE BABY, BUT IS PINK. RIGHT LOWER LEG AND FOOT IS ALSO COOLER TO TOUCH. CONTINUE TO MONITOR FOR ANY CHANGES IN EXAM OF RIGHT LEG AND FOOT. NEURO:HEAD U/S TODAY SHOWED A BLEED IN PARIETAL LOBE. EVALUATED BY NEURO THIS AFTERNOON. WILL NEED AN MRI WHEN BABY STABLE. UNTIL THEN WILL DO DAILY HEAD CIRC, AND QOD HEAD U/S. BABY IS [**Name2 (NI) **] AND ACTIVE AND MOVING ALL EXTREMITIES. ALT IN NUTRITION R/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 59**]:NPO. TF 140CC/K/D. IVF OF PN D10.5 WITH LIPDS AT 0.3CC INFUSING WIHTOUT INCIDENCE VIA DLUVC. ABD EXAM BENIGN. NO LOOPS. GIRTH 19-20. HYPOACTIVE BS. NO STOOL YET. UOP 7CC/K/HR FOR THE PAST 12HRS. D/S 88, AND 69. LYTES AT 8AM 146/4.8/100/21. BUN 15, CREAT 1.5. WILL RECHECK LYTES LATER TONIGHT. MONITOR FOR ANY CHANGES IN ABD EXAM. ALT IN GROWTH AND DEVELOPMENT D/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 59**]:[**Last Name (NamePattern4) **] AND ACTIVE WITH CARES. SLEEPS ON AND OFF DURING THE DAY. AGITATED AT TIMES. FENTANYL GIVEN TWICE TODAY FOR AGITATION. MAINTAINS TEMP ON SERVO CONTROLLED ISOLETTE. NESTED IN SHEEPSKIN. CONTINUE DEVELOPEMNTAL CARES. GIVE FENTANYL PRN Q1-2HRS. ALT IN PARENTING:PARENTS IN TO VISIT TWICE TODAY. FAMILY MEETING HELD WITH PARENTS, MD, [**Name8 (MD) 41**], RN AND SW. EXPLAINED BABY'S EVENTS FOR TODAY, AND PROGNOSIS. PARENTS TEARFUL, ASKING APPROPRIATE QUESTIONS. CONTINUE TO SUPPORT AND UPDATE.

Overall Neutral Note

NPN 7a-7p cont'ed 11 Pain/stress: Dad informed that infant's coags were improving and that he would be receving more blood components overnight. A: Involved, concerned family P:Cont to support and educate. #7: Loud murmur noted. HR stable. BP with lower diastolics at times. Means mostly 33-34. Team aware. Pulses in general are normal. At times left foot with delayed refill 5secs. Has improved to 3secs throughout the day. Generalized edema present. Hct 35.8, due to receive PRBC transfusion 10cc/k. Lasix to be given after transfusion. PT/PTT improving s/p cryoprecipitate x1 and FFP x1. Due for another 10cc/k of FFP tonight. Plt lower= 59. To receive platelet transfusion tonight. Blood out thus far 7.5cc. A: stablizing coags P:Administer various blood components overnight as ordered. Follow exam closely. Plan for PDA ligation as soon as labs stablize. Check coags after FFP given. #8: Overall color dark, grayish, pinkish. Conts under single phototherapy with eye shields on. LFT's improving. NPO. Voiding. No stool. A: hyperbili P:Cont with phototherpay as ordered. Check bili level in am. #9: Blood cultures remain negative to date. Conts on antibiotics as ordered. Temps stable. A: stable P:Cont to monitor for s&s of infection. Meds as ordered. #10: HUS done this am. See radiology report for details. Fonts soft/flat. Infant with appropriate behavior. A: stable P:Cont with daily HC and every other day HUS. #11: Infant started on a Fentanyl drip this afternoon for pain/stress control. Infant having a difficult time settling after care/intervention, or when there is a lot going on around him. Conts on [** **] and NPO. Currently on 1.5mcg of Fentanyl with good control. A: pain P:Cont to monitor and provide support as needed. REVISIONS TO PATHWAY: 11 Pain/stress:; added Start date: [**2178-4-8**]

Overall Neutral Note

Nursing Progress/Expiration Note Received infant vented at 21/5 with rate of 20. FIO2 ~24%. ABG of 7.20, 50 at 1130am. Plans to redraw gas @ 1300 then assess need for NaHCO3. Infant began to drop HR and O2 sat @1250pm. Did not respond to increased O2 or bag mask ventilation. Chest compressions started. Family consulted before Epi administration as they were present at that time. 3 doses of Epi and 6cc NS bolus given with no response. Infants HR and Sats remained in 30-40's. Family consulted and decision was made to redirect care. Infant was extubated and disconnected from IVF's. Parents held infant wrapped in blanket. Infant kept warm under warming lights. [** 41**] administered 0.1cc of MSO4 for comfort via Umbilical lines. Parents crying and greiving during this time. Priest called to bedside for prayer. Social work called to bedside. Photographer came to photograph infant. MD [**First Name (Titles) **] [**Last Name (Titles) 41**] intermittently visited room to assess for HR. Infants time of death called at 13:49. Parents and paternal grandfather held and said goodbye to infant. After parents left infant was photographed, wrapped and sent to morgue. Appropriate ID tags in place. Bereavement box completed and given to social worker to give to parents. See flowsheet for further details.

Overall Negative Note

Nursing Progress Note: #1 - RESP: Tried off Vent today. Did not do very well. Needing facial CPAP and head positioning to keep sats up. Taking some breaths on own just unable to keep Sats up. Reintubated to settings of 16/5 rate of 14. FIO2 since [**03**]-40%. Art gas done after reintubation - 57/38/7.41/25/0. RR(20-40's). SUbcostal retractions. Suctioned for small amount of secretions. Loaded with Caffeine. No spells. #2 - F&N: TF at 80cc/kilo. Access includes Arterial line in left foot with 1/2 NS with heparin infusing. DLUVC has - in the primary port - TPN (D18) infusing at 50cc/kilo. in secondary port - D15 with heparin and other fluids (Fent/dopamine) Abdomin round and distended. DUsky jaundice bruised color. Girth 28-29cm. Voided 2.1cc/kilo for last 12 hours. Urine remains dark amber color with clots in tubing. Stooled 2 times - green mucusy stool. Guaic pos. PLAN: Lytes, BUN, Creat, Ca and other labs this evening. #3 - SKIN: Right foot - toes with blackened toes. RIght heal with necrotic area. + PT/DP and [**Doctor Last Name 1078**]. pulses Q 4 hours. RIght calf with area of erythema which branches around outer aspect of leg - ? pressure sore starting. Skin intact with perfusion. OT consulted - suggested getting plastics involved to help with skin suggestions. Question whether a split would be good or bad at this point. Placed baby on water pillow under sheepsskin to help with edema. #5 - DEV: Temps stable on open warmer. [**Doctor Last Name 25**] with cares. MAE. TUrned and repositioned with cares. #6 - Social: [**Doctor Last Name **] in this afternoon from 3p-7pm. Updated at the bedside. Worried about [**Known lastname 103**], but happy that he is doing a little better. #7 - CV: +murmur. PPS. HR ( 140-160). Goal for MAP's 31-35. Using Cuff pressures only. WEaned off Dobutamine ~1300pm. Remains on Dopamine. Goal is to keep at 3 mqcs to keep kidneys perfused. Had been stable at 3mqcs until line changes at 1800pm. Continues to need q 4hour FFP tranfusions for DIC status. Today's PT 21.5, PTT 75.7.

Overall Neutral Note

Nursing Admit note #4CV: Pt. currently on dopamine @ 25mcg/kg/min. Dobutamine added for brief time but was d/c'd d/t hypotension. MAP 16-24, goal MAP's 25-32. Unable to obtain cuff BP. NS boluses given X 4. Pt. has very poor perfusion, delayed cap refill. Palpable brachial pulses only, team aware. Initial HCT 44.9 & repeat 44.1. P: continue to monitor CV status. #5Skin integrity: Pt. very bruised throughout entire body, L side > R side. ? necrotic areas on L foot, L calf, & L hand. Laceration noted on R foot. White blotchy areas noted on trunk & face. L finger tips pink. Bruising down back & head. Skin very sensitive to leads & temp probe. Duoderm used as barrier. Aquaphor applied. P: continue diligent skin care. #1Sepsis: CBC & blood cx sent on admission. WBC 8.8, Polys 4, Lymphs 94, Bands 0, Plts 212/263. Ampi & gent started. P: continue to monitor for s/s of infection. #3Social: Parents in X 2 & grandparents in X 1. All very hopeful. Dad very emotional & teary -eyed. Both parents talking to infant & holding their hands. MD [**Doctor Last Name 387**] went to mother's room & spoke about infants current status & potential outcome. SW met w/ parents as well. P: keep parents informed of status of pt. #6G&D: Temps unstable throughout shift. Requiring warming lights & warm packs under oxy [**Doctor Last Name 571**]. Initially moving all extremities. More lethargic towards end of shift. Fentanyl given for pain management. HUS done. Rhythmic opening & closing of left hand noted. NNP observed as well. Eyes fused. P: continue to monitor for seizure activity. See flowsheet for further details.

Overall Neutral Note

NPN 7pm-7am RESP: Received infant on SIMV 28/6 with rate of 38. FiO2 has been 31-44% this shift. No need for increase with cares at this time. Infant has little to no spont resps. LS are coarse and diminished. Upper airway congestion noted. Sx'd with cares for mod to lg thick cloudy to yellow secretions. A: No changed in status. P: Will cont to monitor. CV: Infant has no murmur noted. HR and BP stable. Infant has good perf pulses and delayed cap refill noted. Infant is pale and sl jaundice. [**Known lastname 3143**] remains on Digoxin [**Hospital1 64**] and lasix. A: Stable P: Will cont to monitor. FEN: Current weight 2935gms down 75gms. TF 140cc/kg/day of IVF and Ent feeds. Currently IVF are at 20cc/kg/day of D10W with hep. and Fentanyl. Ent feeds are at 120cc/kg/day of [**Doctor Last Name **] 24cals = 62cc's q4hrs gavaged over 1hr 30mins. Abd soft, +bs, no loops noted. Spit x 1 at this time in shift. Min asp. Voiding and stooled heme neg. A: Cont to spit. P: Will cont to monitor weight and exam. Plan to get lytes this am. G/D & PAIN: Infant is on open warmer, nested on gel blanket with sheepskin rolls. Temp stable with one blanket. Infant is drowsy, he does open is eyes and occ move extremities very little. Hypotonic tone noted. Infant has splits on feet which are removed with cares for ROM. [**Doctor Last Name **] well. Infant is on Fentanyl for comfort measures. Pain is also managed with decreased stimulation, light and positioning. A: No pain noted. P: Will cont to support dev needs and monitor pain control. [**Doctor Last Name **]: [**Doctor Last Name 2**] were in at 10:30pm to visit. Mom held infant. Dad was asking questions for Mom about infants day. Mom changed diaper, took temp and washed infant down with cloth. A: Mom was kissing and talking to infant. Dad stated that Mom was having a hard time letting the baby go. P: Will cont to support and educate.

Overall Neutral Note

NPN #1 Infant remains off antibiotics since yesterday am. Infant had a temp last evening of 100.3. CBC/BC drawn(please see lab sheet for results). Antibiotics not restarted. Temp has been 98.3-98.9 for remainder of night. #2 Infant remains orally intubated on same settings of 22/5x32; FIO2=~24-37% maintaining sats mid 90s. No changes made tonight. BS clear=. Infant suctioned x2 for a small amount of clear secretions down ETT; mod/lge amount of cloudy thick secretions orally. Infant continues to breathe in synch with [** **] for most of time; occasionally with RR=40-50s. #3 Infant's color remains grey/yellow throughout. Infant has delayed cap refill; active precordium. Murmer not audible. Skin slightly cool to touch. Infant remains on Digoxin [**Hospital1 64**]. He is also receiving Dobutamine at 5mcg/kg/min and Dopamine which is presently at 12mcg/kg/min (received infant on 19mcg/kg/min and able to wean to 10mcg/kg/min) to maintain BP mean >35. #4 Infant continues NPO. TF=150cc/k. Wt tonight is down 120gms=2685. Infant continues with a per. arterial line with NS and heparin as ordered; PICC line with PN D15W/lipids/Dopa/Dobutamine/Fenanyl as ordered. HL in hand is flushed and patent. Abd is soft; hypoactive BS; no stool. Voided 4.3cc/kg/hr over past 24 hours. DS=92. #5 Infant remains on an off warmer nestled with boundaries and a gel pillow under head. Eyes have not open tonight; yellow tears noted. Upper extremities remain hypotonic; lower extremities remain hypertonic. Passive ROM provided. Mouth care given. Infant's position has been changed q6 hours. #6 Mom was here all evening talking and singing to infant. [**Hospital1 **] from time to time. Dad came in after work. Able to speak with him somewhat, but ? how much he understood. Aware that infant had a repeat CBC drawn for slightly elevated temp. Asking whether infant had openned his eyes. #7 Infant remains jaundiced with bronze color throughout. No new bili level this am.

Overall Neutral Note

NPN Days #8 Pain: Pt's HR and BP were elevated this AM, given 5 mcg FAddendum: Dopamine weaned to 14mcg/kg/min and Dobutamine weaCont of Day Note: #6 Parenting: Had FM with [** **], interprentanyl x 1 with good effect. P: Cont to monitor for signs [**Name8 (MD) 3148**], RN, RT, MD, and social work this PM. [**Name8 (MD) 2**] updated oned to 7mcg/kg/min.f pain/stress, given Fentanyl as needed.n test results, plan of care, and all information available at this time. Asking appropriate questions. Mom and Dad visited with pt t/o the afternoon, very attentive and [**Name8 (MD) **], talking and touching the infant continually. Will attempt to have FM with [**Name8 (MD) **], [**Name8 (MD) **], and medical team next Thursday and weekly as needed (Dad does not work on Thursdays) P: Cont to encourage parental calls and visits, f/u with weekly FM's. #7 Hyperbili: 14.3/1.8 this AM-team aware, no interventions at this time. Pt cont to be jaundiced. P: Cont to monitor for signs of hyperbili.

Overall Neutral Note

NPN Days 1 Infant with Potential Sepsis #2 Resp: Pt received vented 24/6 with a rate of 38. No changes made t/o shift. Fi02 26-32%, sat goals>93%. C/=, sxn ETT for small cloudy secretions, large amounts yellow from nares and mouth. RR 38-40's, often riding the [** **]. P: Cont to monitor resp status, will recheck ABG in the AM. #3 Cardiac/Heme: No murmur heard, 160's-180's, +PPP, delayed cap refill, active precordium. Coloring cont to be bronzed/grayish with duskiness around eyes and umbi. Cont Digoxin [**Hospital1 64**]. Received pt with Dopa at 4mcg/kg/min, pt off Dopa at 1400, MAP goal >35. P: Cont to monitor CV status. #4 FEN: CW 2950 (down 50), cont to use old wt of 2850 for calc r/t wide fluctuations in wt. TF=140cc/kg/day. Pt receiving PND16, IL, and Fent drip via PICC and NS with Hep via A line, infusing without diff. HL flushed and patent. Abd soft, round, no loops. AG 28-28.5, BS hypoactive. No stool, V/S. P: Cont to monitor FEN status. #5 G&D: Pt cont to be hypoactive, with tightened muscles of LE. OT in this AM, performed passive ROM and placed LE splints to prevent foot drop. Weak spontaneous mvmt at times. Sent labwork for SMA and muscular dystrophy, results P. Temp stable on servowarmer. P: Cont to monitor and support G&D. #6 [**Hospital1 2**]: Mom and Dad in this AM, had FM with MD, RNs, social work, and [**Hospital1 **]. Discussed new test results and updated on the plan to cont testing. Discussed potential outcomes and possibility of not finding a diagnosis. [**Hospital1 2**] grasp the idea and are aware they may have to discuss this further if no clear diagnosis can be made from the future testing. Mom was tearful, both [**Hospital1 **] asking appropriate questions and spent a few hours with infant after the meeting being very [**Hospital1 **] and attentive. P: Cont to encourage and support parental calls and visits. #7 Hyperbili: Stable, pt remains jaundiced. P: Cont to monitor for signs of hyperbili. # 8 Pain: Pt remains on Fent drip, no signs of pain. P: Cont to monitor for signs of pain, cont Fent drip. See flowsheet for further details. REVISIONS TO PATHWAY: 1 Infant with Potential Sepsis; d/c'd

Overall Neutral Note

npn cont. from 1900-0730 Upper body remains hypotonic. Hands clentching at times with increased stimulus. Hands able to be opened easily, remain blueish at knuckles. Le hypertonic. L foot more dusky than r. Not new for infant. Did not open eyes entire shift. Sheepskin removed d/t increaesed temp. Plan; cont. to monitor muscular movement, monitor temps on warmer. Monitor tolerance to activity. Fentynal q 2hrs. 6. Mom in for 2100 cares. Some language barrier therfore difficult to teach. Mom singing to infant and holding briefly but infant not tlerating well with increased bp and increased hr, desatting. Dad in later. [** 2**] emotional, crying when alone. Plan; cont. to support and educate [** **]. Teach to not bother infant b/t cares. Bili 11.8/2.4/9.4. Infant not eating. Remains slight jaundice. No stool this shift. [** 18**] aware of results no change in plan. Plan; obtain bili as per team. Monitor for increasing jaundice. Monitor direct bili d/t not eating. 8. Medicated with fentynal 5mcg via slow iv push x 4 this shift. Appears to to help for about 1-2 hrs. Does not tolerate movement well. Plan; cont. to give fentynal as needed.

Overall Neutral Note

npn cont. 1900-0730 5[cont.] removed splints q 4hrs to assess for breakdown. Cont. with reddness to bilat knees when prone. No change in color. good refill. No open ateas. + pitting edema. Tolerating all ngt feedings so far. Cont. to be repositioned on sheepskin. Temps 98.1-98.4 on servo warmer. Plan; cont. to monitor movement since decrease of fentynal at [**2034**]. Monitor for s/sx increased pain. MOnitor mobility and response to stimuli. 6. MOther in and touching and kissing infant. Very [**Year (4 digits) **] and caring. Dad in later. Mom and dad [**Name (NI) 3155**]. Very supportive with each other. Plan; cont. to support and educate [**Name (NI) **]. 7. NO plans to obtain bili this shift. Cont. with jaundice undertones. [**Location (un) **] drainage from eyes and nose r/t high direct bil. Remains without having been under phototherapy. Plan; will cont. to evaluate. Monitor bili per team. 8. Remains on a fentynal gtt now at .56meq/min. Appears comfortable. Increased response to stimuli by moving extremeties with decrease in fent. RR 30's-60's. No change in vs with cares therefore pain seems to be under control for now. Plan; cont. to monitor s/sx increased pain.

Overall Neutral Note

cont note above #4 will give last indocin dose this p.m. A: murmur cont P: meds as ordered, observe #5 remains stable on open warmer. sucks on pacifier, sleeps well between cares, sl irritable with do-ups. A: AGA P: cont to support development #6mom and dad visiting frequently, both talking softly to infants, mom explaining infants status to her guests, seems to have good understanding of NICU routine. A: involved, loving family P: cont support #7 Cont under single phototherapy for elevated bili. Repeat bili this eve 1/8/0.3/1.5. remains sl jaundice. A: inc. bili P: no change at present.

Overall Positive Note

NPN 1900-0700 1. [**Month (only) 314**]: O: 48 hour rule out complete. A/P: Will D/C problem. 2. RESP: O: Pt received on 15/5 X12. FiO2 21%. Art gas at 0100 was 7.48/22. Vent weaned to 14/5 X10. RR 30-60's. Lung sounds are clear. No spells noted. Sxn for mod white ETT and mod white oral secretions. A: Stable on vent. P: Monitor. 3. F&N: O: TF remain at 130cc/k/d. IVF of D7.5 with Na/K acetate remains infusing at 60cc/k/d. PN D7.5 infusing at 60 cc/k/h and lipids infusing at 10cc/k/d. IVF infusing well via DLUVC. D/S 61-53. Lytes 143/5.1/118/17. NPO. Abd soft. Hypo BS. U/O 7cc/k/h. No stool noted. Weight loss 70 grams. NNP Buck aware. A: Diuresing. Lytes stabilizing. P: Monitor. 4. C/V: O: Pt had a loud murmur. Initial dose of Indocin given at 2300. HR 120-140's. Active precordium. BP stable. Repeat echo palnned for tomorrow per cardiology. A: Murmur. P: Indocin as ordered. Monitor closely. 5. DEV: O: Temp stable on radiant servo-warmer. Active and alert drung cares. Putting hand to face and occasionally sucking on pacifier. A: AGA. P: Continue to support infant's needs. 6. PAR: O: Parents in for brief visit to get update. Mom states that she remains febrile with a low Hct and states that she will not be discharged for a few more day. Family meeting still schedule for tomorrow at 1500. A: Loving, vested family. P: Continue to support parents. 7. HYPERBIL: O: Pt is jaundiced. Pt is under single photptherapy. Bili level this am was 3.6/0.3/3.3. A: Hyperbilirubinemia. P: Bili lights and levels as ordered.

Overall Neutral Note

Neonatal NP-Exam See Dr.[**Name (NI) 135**] note for details and plan of care as discussed in rounds this am. AFOF, sutures overriding. Orally intubated with [**Last Name (un) **] in Left nares. Generalized palor with [**Doctor Last Name **] undertone noted. Breath sounds clear throughout with exception of upper right lobe->crackles but aeration audible! Nl S1S2, grade I/VI murmur audible. Pulses [**1-8**]+/4. Abd full, distended with visable loops throughout. No HSM appreciated. Active bowel sounds audible. Urinary catheter remains in place and draining. Infant unresponsive by gross movements to exam and repositioning.

Overall Neutral Note

NPN 1900-0700 1. [**Month (only) 314**]: O: 48 our rule out complete. A/P: Will D/C problem but continue to monitor for S&S of sepsis. 2. RESP: O: Pt remains on conventional vent with settings of 15/5 X12. FiO2 21%. RR 30-50's. No spells/desats noted. Lung sounds are clear. Baseline IC/SC retractions. Sxn for small amount of secretions Q 6 hours. A: Stable on vent. P: Monitor. 3. F&N: O: TF remain at 120cc/k/d of PN D5 and IL infusing well via DLUVC. D/S 74. Abd soft and flat. NPO. BS hypoactive. U/O 6.1cc/k/h. No stool noted. Weight loss 83 grams. NNP Buck aware. Lytes 139/5.4/110/19. A: Diuresing well. P: Monitor. 4. C/V: O: Soft murmur hear. Precordium slightly active. HR 120-140's. BP stable with means 33-46. Pt is pink nad well-perfused. A: Murmur. P: Monitor. 5. DEV: O: [**Known lastname 1364**] is active and alert during her cares. Temp stable on servo-radiant warmer. MAE. Fontanels are soft and flat. HUS planned for later today. Sucks on her fingers. A: AGA. P: Continue to support infant's needs. 6. PAR: O: Parents in for brief visit and brought visitors to meet infant and her twin sibling. Parents ask appropriate questions and spoke lovingly to pt. They would like a family meeting on Friday at 1500. A: Loving, vested family. P: Continue to support parents. 7. HYPERBIL: O: Pt is slightly jaundiced. Bili level this am was 5.3/0.3/5.0. NNP Buck aware. Pt remains under single phototherapy. A: Hyperbilirubinemia. P: Bili lights and levels as ordered.

Overall Neutral Note

NPN 7a-7p Resp: Infant remains orally vented. Present settings 22/6x36. CBg on above settings pending. CBg this am 7.44/52. rate weaned. Repeat 7.16/64. Above changes made. RR 36 no effort to breathe above vent. Fi02 48-100%. Ls coarse. Sxn x3 for sm-mod clr secretions via et tube. Cxr this am showed rul infant remains positioned with rt side up. Unable to tol prone position. Infant had desat x2 today sats 40-60%. Dusky recovered with bagging. Cont to monitor await cbg. Fen: Infant remains NPO. TF 120cc/kg. PN d15 with lipids infusing. Fentanyl at 2.5mcg/kg and Dopamine 7-21mcg/kg. All infusing via picc line. Abd full distened with soft loops. Dusky in color Ag today 24-25cm. Repogle in place to lcs. draining coffeground secretions. Infant had lg spit repogle replaced by [** 41**] and abd decompressed. [** 41**] present and sxn infant for lg coffee ground emesis. [** **] done today. Showed more movement than previous. No stool thus far. Active bs. Indwelling foley in situ. See carevue for amounts. Dsricks 70-113. Cont with current plan. Cv: Infant is pale. Mottles with cares. Cap refill 3secs. Pulses palpable. Conts on dopamine 60mg/50cc. 7-21mcg/kg today. Bp means 28-40. Cont to wean dopa as tol. G&D: Temp stable on servo warmer. Infant is opening eyes today. Suckig on et tube. Conts on fentanyl gtt at 2.5mcg/kg. HUs done today. See carvue for results. Nested in sheepskin with boundries in place. Cont to support developmental milestones. [** **]: Mom and Dad in today. Fully updated at bedside by [**First Name8 (NamePattern2) 811**] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 41**] and Dr. [**Last Name (STitle) **]. Also meet with Tch surgery. Asking appropriate questions. Mom [**Name (NI) 366**] eyed today. Will be back [**Doctor First Name 172**]. Requested family meeting for Wed at 1500. cont to support and update. Sepsis: Infant conts on ceftazidime and gent. Bld cx neg to date. Planning to do lp this evening. Neuro: Conts on Phenobarb. No sz activity noted today.

Overall Neutral Note

Nursing Note Pls see attending note for history and details. 1. Patient received on HiFi MAP 12, Delta P30, FiO2 100%. ABG's 7.10/54/27/18/-15. Sats <80%. IC/SC retractions.(Pls see flowsheet for further lab values) Due to poor oxygenation and baby's prognosis decision was made to redirect care. Attending Dr. [**Last Name (STitle) 2458**] discussed with both parents. 2. Recieved infant on dopamine drip. Pls see flowsheet for BP values.No murmur, HR ~130's-180's. Pale with poor cap refill. 3. Baby recieved with DLUVC and radial art line. D10 was infusing [**Last Name (STitle) 2215**] DLUVC without incident. 4. For comfort measures 6.5 mcg at [**2051**] slow IV push, drip started at [**2136**] at 2mcg/kg/hr. Prior to redirection at 2100 6.5mcg of fentanyl given. 5. On warmer. Left ear abnormality. Irritable to touch. Fentanyl 6.5mcg given [**2051**]. Total of 13 mcg of Fentanyl and started drip at [**2136**]. 6. Parents updated at bedside by nursing, attending, NNP. Father in frequently with family members during [**Name2 (NI) **]. Very loving towards babies. Mom in x1 and held baby [**Name (NI) 2215**] redirection. Attending came in spoke with parents, ett removed by resp., parents given opportuntiy to hold [**Known lastname 832**]. Photos taken (digital and black and white). Postmortum care completed by RN, flowsheet completed. Baby brought down to morgue.

Overall Neutral Note

Admission Note Baby [**Name (NI) 4**] ([**Known lastname **]) [**Known lastname **] is a 28 [**4-23**] week gestation infant (according to due dat of [**2147-7-13**]). He was [**Date Range **] by C-section to a 41yo Mom who is G-2 now P-2 for bleeding. Mom had [**Name2 (NI) 2369**] at 18 wks which was followed by PROM and placenta previa. Mom was on bedrest and followed and then presented again with PROM. Mom received Beta. Baby was [**Name2 (NI) **] with apgars of 6,6 and 7 at 1,5 and 10 minutes of life. Infant cried and had HR >100 but had poor color and perfusion and fair tone. Infant was noted to spit up blood with attempted intubation in OR. ( Mom had [**Name2 (NI) 2543**] and there was blood in amniotic fluid that infant swallowed.) Blood was found by in stomach by sxn, no blood in lungs. Infant was intubated in OR after several attempts and was transferred to NICU in heated isolette after breif visit at Mom's bedside. In NICU infant had normal vitals except for O2 Sat. Hand bagging took much effort with litte increase in O2 Sats. Decision was made to start Nitric Oxide with HFOV as life saving measure for this atypical 28 weeker who appeared to present with significant pulmonary HTN. Infant showed remarkable improvement in both pre and post ductal sats moments after NO started. Infant has had several blood gases and has been treated accordingly. Echo showed no cardiac abnormalities. Infant BP began to drop and was started on Dobutamine and then Dopamine with improvement. Infant received several NS boluses as well before Dopa and Dobuta. Infant started on TF of 100cc/kg/d of D10w via PIV. Received D10 bolus for low 2nd Dstick with good results. UAC and DLUVC placed. IVF then switched to those lines. Currently [**12-19**] NaAcetate w/ 1/2u heparin/cc via UAC, D10W w/[**12-19**] u hep/cc via primary port and Starter TPN D10 via secondary port. Infant remains NPO and has voided. Abd exam benign. Blood cx and CBC w/diff drawn and sent. No shift. Started on Amp/Gent. Infant received several doses of Pavulon and Fentanyl for comfort and sedation to better treat him. Infant now on Fentanyl drip. Infant has stable temp on open warmer. Infant is nested on sheepskin with boundries for comfort and positioning during sedation. This infant has gone up and down on both sats and BP's throughout the day, meds and vent setting have been adjusted to meet infant needs. Infant has also had to be hand bagged multiple times to rescue him from decreasing Sat's. Several Xrays have been done of chest and abdomen to evaluate clinical status and tube and line placement. Changes have been made as needed. This infant remains critical and unstable. MD, NNP, RNs and RT's will continue to monitor closely and treat infant as needed. Please see Resp note, MD note and flowsheet for further details.

Overall Neutral Note

NPN #5 NPN#5 O= parents up earlier in shift, met at front door and discussed with mom what to expect when she entered the room..brought to room to see [**Known lastname **], oriented to equipment then brought to family resource room for family meeting between mom & dad, RN from floor , RN from NICU & Dr, [**Name (NI) **]...[**Known lastname 2468**] condition discussed at length, Dr. [**Last Name (STitle) **] reviewed PPHN & treatments, critical status made clear..discussed parents wishes in re: to treatment and at this time they conveyed they "want everything done" to save their son..^ emotional support given..dad called x1 overnight & updated..currently parents up at bedside updated by team on critical unstable status of [**Known lastname **] over last few, hours, mom quiet/ [**Name2 (NI) 366**] at times/ holding son's hand..infant earlier in night Baptized by Fr, [**Last Name (un) **] at request of parents..dad present for ceremony A=parents of critical ill infant/ overwhelmed P= cont to keep updated/involved in decision process & supported

Overall Neutral Note

NPN 0700-1900 1. RESP: O: Pt received on vent with settings of 17/6 X22. Gas in am required increased to 19/6 X24 and bicarb was given. Subsequent gases allowed us to wean vent to 19/6 X22. FiO2 21-32%. RR 30-60's. Lung sounds are coarse with improving aeration throughout this shift. Pt had 3 desats/spells requiring suctioning. A: Stable on vent. Occasional apnea. P: Monitor closely. 2. C/V: O: No murmur heard this shift. Echo report from yesterday revealed small PDA. Indocin course started at 1530 today. Pt has UAC which was showing unreliable BP's. Cuff BP's have been followed this afternoon. Dopa infsuign between 17-25 mcg/kg/min. NS bolus given X 1. Pt is pale pink and well-perfused. No palpable pulses noted. Hct41.1/plt 146. A: PDA. P: Monitor closely. Indocin as ordered. Wean dopa as tol. 3. F&N: O: TF remain at 160cc/k/d. NPO. UAC has 1/2 NS with hep infusing at .5cc/h. DLUVC had PND7.5/dopa/lipids infusing well. PN changed to D14 at change of shift this evening. D/S stable between 119-150 this shift. Abd soft. BS absent. No stool noted. Voiding well. Lytes this afternoon were WNL. Urine dip benign. Weight gain 4 grams. U/A to be sent on night shift. A: D/S stable. P: Monitor. 4. DEV: O: Pt's skin is transparent. Aquaphor applied. No areas of breakdown noted. Temp stable on servo-warmer with tent. Very active and alert during cares. Eyes remain fused. Genetics in to eval pt and confirm Down's syndrome diagnosis. They spoke with [** **] at length. Head U/S showed no bleed this morning. A: AGA. Down's. P: Continue to support infant's needs. 5. PAR: O: [** **] in to visit throughout this shift. They spoke lovingly to [**Known lastname 115**] and her twin sibling. Lengthy family meeting held with [**Known lastname **], SW, NNP, MD, med student and Genetics MD's from TCH. They were teary thought the meeting. They ask very intelligent and caring questions. A: Loving, vested family in crisis.

Overall Neutral Note

Neonatology - NNP Progress Note Baby [**Name (NI) 4**] [**Known lastname 1969**] is active with good tone. AFOF. He is pink with mod jaundice, well perfused, no murmur auscultated. He is comfortable in room air. Breath sounds clear and equal. WOB much decreased since yesterday. Rpt CXR today showed no focal areas in RUL as yesterday. + fluid in fissure. Mild diffused haze. He is bottling and breast feeding without difficulty. Abd soft, active bowel sounds, no loops. Voiding and stooling lg transitional stools. Antibiotics dc'd given low risk for sepsis, improved CXR, and rapid improvement in resp status. Infant ready for trasfer to newborn nursery. Have contact[**Name (NI) **] Dr [**Last Name (STitle) 4657**] to inform her of NICU course and transfer to newborn nursery. please refer to neonatology attending note for detailed plan.

Overall Neutral Note

NICU NSG NOTE CONT #5. [** **]. O/ Mom and dad this shift. Family mtg held with Dr [**First Name (STitle) **], NNP [**Name8 (MD) 114**], RRT [**Name (NI) 4658**] and this RN. Dr [**First Name (STitle) **] discussed with [**First Name (STitle) **] changes in infant's status and concerns re: worsening support. Parnets asking appropriate questions re: quality of life. DNR paper signed by [**First Name (STitle) **]. See Dr[**Name (NI) 419**] note for details. Order signed in front of infant's chart. [**Name (NI) **] spent time after at infants' bedsides after meeting; talking to each of them lovingly. Teary-eyed. A/ Loving, appropriate [**Name (NI) **]. P/ Cont to provide info and supportto family. #6. Sepsis. O/ Conts on ampi and gent as ordered. After manipualtion of UVC, started on oxacillin for 2 doses. Received first odse at 1400. Temps stable. Active. BC ngtd. A/ 7day course ampi and gent for initial shifted cbc.. 2 dose course of oxacillin for Line manipulation. P/ Cont to monitor for s/s sepsis. Cont abx as ordered. #7. Bili. AM bili 5.6 0.3. Increased from single to double phototherapy. Bili 8h later 2.1. Back to single phototherapy. Eye shields on. Bili in am.

Overall Neutral Note

Nursing Progress Note: #2 - RESP: Received infant on IMV settings of 18/6 rate of 24. 21% all day. O2Sats 100%. No spontaneous resp effort. RR 24. Suctioned for small to moderate white secretions. Intercostal and subcostal retractions. No spells/drifts. #3 - F&N: TF at 120cc/kilo/day = 5cc/hour. IVF - PN (D21) and lipids infusing without difficulty into central PIC. Abdominal girth 23cm. Remains loopy, yet soft. Bluish hue improved from several days ago. REpoggal to LCS. Draining minimal amounts of clear to light green secretions. Voiding good amounts. No stool thus far this shift. #4 - CV: Continues with loud murmur. Hyperactive precordium. HR 130-150. Pink and well perfused. REmains on Dopamine (60mg/50cc) [**11-20**] mcqs. WEaning when able. Sensitive to cares and position changes. MAPS 30-40. #5 - DEV/Neuro: TEmp warm at last cares. Probe loose. Opens eyes spontaneously. Sucking on ET tube. No spontaneous movement of extremities. AFSF. TUrned and repositioned with cares. Passive ROM done with cares. NEsted in fluff and water pillow. No seizure activity noted. REmains on phenobarb. NEuro and Neuro [**Doctor First Name **] following. #6 - [**Doctor First Name **]: Mom in earlier today. Got to hold both girls at the same time. She was very happy to have them together. Have not spoken to her on this shift yet. #8 - SEPSIS: Day 13/21 of triple antibiotics for E.Coli sepsis - meningitis. REceived gent, ceftaz as ordered. Ambizone due overnoc. ID following.

Overall Neutral Note

NPN 0700-1900 #2 O: Received infant intubated on settings of 18/6 rate 35 where she currently remains. ABG's x2 clotted. CBG drawn 7.48/50; no changes made. FIO2 29-44% this shift. LS are clear but diminished. Infant RR with vent. Suctioned for lg copious amounts of cloudy secretions from ET tube and lg white from mouth. Babygram done today. No spells. A: Stable on current vent settings. P: Cont to monitor closely. #3 O: TF= 120cc/kg/d (basing fluids on weight of 1kg). NPO with repolgle in to LCS; no drainage noted. Abdomen distended and slightly firm; sm dusky area noted. Infant had PAL infusing but d/c'd when clotted. PICC in place infusing TPN D16 at 4.0cc/h (to be increased to D17 tonight) and IL at .6cc/h. Infant also receiving fentanyl drip at 0.36cc/h or 4mcg/kg/[** **]. UO= 2.9cc/kg/h in past 12h. No stools. DS 64 at 1000 and then 90 after increasing TPN by the 1.0cc/h that the PAL was infusing. Lytes in am with CBC and phenobarb level. A: NPO. P: Cont to monitor abdomne closely. #4 O: + murmur. Coloring pale pink. HR 1 teens-120's. BP means 32-44. A: CV satble thus far. P: Cont to monitor. #5 O: Maintaining temp on open warmer set in servo mode. Sleeping all shift; sedated with fentanyl drip. Infant did open eyes this afternoon when [** **] in and occasionally when disturbed. Not moving any extremeties; very hypotonic. AFOF. Nested in sheepskin with boundaries and water pillow in place. A: AGA. P: Cont to support development. #6 O: Both [** **] in to visit; family meeting held. Asking appropriate questions. See twin #1 parenting note. A: Involved, loving. P: Cont to support as needed. #8 O: Infant remains on ceftaz and gent. Temp at 98.8-98.9. Not able to obtain repeat bl cx this shift as infant was stuck numerous times. A/P: Cont to monitor closely. Obtain repeat CBC with other labs tonight. #9 O: No seizure activity noted this shift. Remains on phenobarb once daily. Last level 25.7. To recheck another level in am. A/P: Cont to monitor for seizure activity.

Overall Neutral Note

2. Resp: O: Received infant on CPAP of 6 cm via nasal prongs. FiO2 is 21%, ls clear, RR 30-50s, sxned q 4 nasally for a mod amt of yellow secretions. She is on caffeine. She has had 4 bradys so far this shift w/ apnea needing moderate stim and increased O2. A: having bradys on CPAP. P: Monitor. Meds as ordered. Sxn prn. 3. F/N: O: Infant is on TF = 150cc/k/d of TPN, lipids and pg feeds at 30cc/k/d. She is on breast milk. Abd is benign, no spits, no asps. She is voiding 5.2cc/k/hr, no stool so far this shift. Lytes were WNL, d/s was 85. She gained 40g. A: Tol feeds so far. P: Monitor. Continue as per plan. 4. CV: O: Infant has a loud murmur. HR 130-150s. Color is jaundiced. A: Murmur. P: Murmur to be evaluated further. 5. G/d: O: Infant is appropriately fussy w/ cares but barely moves [** 1536**] cares. A/P: Continue to support infant needs. 6. [** **]: O: Dad called for an update at the beginning of the shift and spoke to the day nurse. A: Loving [** **]. P: Continue to support.

Overall Neutral Note

Nursing progress note #1 O: Blood cultures neg to date. remains on Amp & Gent. Gent levels to be drawn prior to next dose. A: Stable. P: Cont to assess. #2 O: Remains orally intubated in 15/5 X's 12, 21 % O2. See flow sheet for ABG's. Breath sounds equal & clear with mild IC/SC retractions. Suctioned X's 1 for mod white. A: Weaning on vent settings. P: Cont to assess. Suct prn. #3 O: Total fluids remain 100cc/k/d, via UAC & DUV. PN started in primary UVC port. DS 72. uop 1.8cc/k/h. Abd soft, hypoactive bowel sounds. No stools. A: Sl low UOP. P: Cont to assess. #4 O: Received baby on 12.5mcg/k/m of Dopamine. Baby weaned from dopamine by 3PM. BP means 30-34 since Dopa d/c'd. No murmur heard. Baby has low resting HR, 118-130. At 2PM baby's right leg noted to be blue with blanching at knee. Baby had been prone. Baby turned, diaper loosened & heel warmer placed on L leg. NNP examined baby. Color slowly improved. Color does pale intermittently but improves with warming of L leg. A: BP stable off dopa. Perfusion to R leg may be due to UAC. P: Assess legs for color & perfusion. Assess BP. #5 O: Remains on warmer, nested in sheepskin with heat shield. Temp labile when heat shield removed. Alert with cares. A: Temp instability d/t prematurity. P: Cont to assess. #6 O: Parents visited in AM. Parents spoke at bedside with this nurse & NNP. Mom plans to breast feed. A: Mom seems overwhelmed. P: Educate & support.

Overall Neutral Note

NPN 0700-1900 [** **]: Family mtg held today. [** **] met Dr. [**Last Name (STitle) **] who thoroughly explained [**Known lastname 3451**] critical status. He reviewed the current information, HUS/LP/clinical exam and current treatments being used and [**Known lastname **] lack of response to the treatment. [**Known lastname **] responded appropriately- Mom tearful and they asked many appropriate questions. They stated that "they were aware of how sick [**Known lastname 1364**] is and had thought about the fact that she may not survive this". [**First Name8 (NamePattern2) 223**] [**Doctor Last Name 116**] was present at the meeting and the family has relied on her for support. [**Doctor Last Name **] are supportive of each other and their family is in the area. A/P Plan to re-evaluate/ fam mtg on Friday. SEPSIS: Infant is on Gent and ceftazadime ( doses increased and interval of Cafetaz increased by ID recommendations). day [**9-25**]. Urinalysis sent- found large amt yeast- treatment w/ Amphotericn to begin. Urine cx is pending. Unable to obtain cx from LP yestereday. repeat blood cx to be sent tonight. Infant remains very unstable. Requiring max support w/ Dopamine and increased vent support. Minimal response and unstable with movement/interventions. A/P: Septic- cont with curent management- ? amphotericin. NEURO: No obvious seizure activity. Continues on Phenobarb, level this am-17.6. Will obtain another EEG - ?tomorrow. clinical exam as noted above. fentanl gtt weaned to .1.5mcgs/kg/hr - infant without signs of pain- will try to wean off fentanyl to not obscure neuro exam. A/P: Cont Phenobarb- EEg tomorrow. Monitor response to fentanyl wean.

Overall Neutral Note