Neonatal Progress Note (Phill)

VCOFH Baby Smith Day: 7 GA: 38 weeks cGA: 37 weeks Birth weight: 2.8 kg Current weight: 2.7 kg (down 100g since yesterday) ISSUES - Admitted to NICU for respiratory distress syndrome (RDS) and prematurity. Currently stable on CPAP. MEDICATIONS - Caffeine citrate 20mg IV q12h (last dose 08:00) - Curosurf 200mg via ETT (given at birth) - Paracetamol 60mg PRN for pain (last dose not given) PROGRESS - Baby Smith is showing improvement in respiratory effort and oxygen requirements. Tolerating feeds well. ASSESSMENT AND EXAMINATION A - Airway patent, on CPAP at 5cm H2O, FiO2 30%. Chest auscultation reveals equal air entry bilaterally. No retractions. B - Respiratory rate 45 breaths/min. CPAP at 5cm H2O, FiO2 30%. Oxygen saturations consistently above 90%. C - Heart rate 140 bpm, blood pressure 55/30 mmHg. Capillary refill time < 3 seconds. No murmurs auscultated. Maintaining blood pressure with fluids. D - Responding to stimuli appropriately. Moving all limbs. GCS 15. No seizures observed. E - Skin intact. No rashes or lesions. Electrolytes within normal limits. FEEDS / FLUIDS TFI 150 mL/kg/day - Currently receiving EBM via orogastric tube at 2ml every 3 hours. - Tolerating feeds well, with minimal residual. - IV fluids: D10W at 60ml/hr via peripheral cannula in right hand, cannula site clean and dry. - Wet nappies 6 per day, dirty nappies 2 per day. - Blood sugar readings stable, between 4.5-6.0 mmol/L. H - Hb 150 g/L, WCC 12 x 10^9/L, Platelets 250 x 10^9/L. No transfusions required. I - Temperature 37.2°C. Blood cultures negative. Started on IV amoxicillin and gentamicin for suspected sepsis. SOCIAL - Parents present and at bedside. They are concerned about the baby's breathing but are reassured by the improvement. They are asking about when they can hold the baby. PLAN - Continue CPAP and monitor respiratory status. - Continue feeds as tolerated. - Review antibiotics in 48 hours. - Monitor blood sugars. - Discuss with parents about holding the baby. - Review daily.