MARCH 2019

Introduction

This report is produced on monthly basis based on nurse’s progress notes to demonstrate the improvement of
patient’s status and feedback on the need to continue the services as required.

PATIENT DEMOGRAPHICS MEDICAL HISTORY

Patient’s Name: BABY LATIFA AL-DOSARI 37 weeks gestation w/ antenatal Diagnosis of TRISOMY 21
Birthdate: 16/07/2018 with balanced AVSD.
Age: 8 MONTHS OLD
Gender: FEMALE Admitted to NICU SIDRA risk case post natal Diagnosis
HC Number: HC05317980 confirmation. Cardio Surgery finished. Date discharged
November 13, 2018.

November 17, 2018 NGT Insertion changed at Sidra Hospital

EMERGENCY CONTACT INFORMATION
CLIENT’S NAME: NOORA ABDULAZIZ SALMAN
CONTACT NUMBER: 7737 7808
5555 8874
RELATIONSHIP TO PATIENT: Mother
@ 9:30pm appointment @ Left nostril.
December 4, 2018 NGT removed as per mothers request
with physician notified as verbalized by the mother. Baby
can suck efficiently.
December 10, 2018 Follow up checkup @ Sidra Hospital
1:30pm. Patient is stable. Physician ordered to stop
Omeprazole and continue other cardio medicines as
prescribed. Feeding every 2 – 2.5hrs. After 3 months follow
up checkup, preferably March 10, 2019.

January 09, 2019 Follow up checkup @ Sidra Hospital

7:30am. Patient stable. Physician ordered bottled feeding
80cc for 30 minutes every 2 to 3 hours as ordered.

January 17, 2019 To start cerelac small feeding next week,

observe if patient can tolerate. 5.3kls latest weight.

January 30, 2019 Appointment @ Sidra Hospital 8am for

Blood Collection @ L arm. Urine collection @ 6qm. Started
cerelac/mixed fruit soft feeding tonight 8pm dinner, 4tsp.
BID.

February 01, 2019 Patient has conjunctivitis @ OU Eyes,

noticed as may communicable by her elder brother who
have also. (+) Watery eyes. Went to pharmacist and
prescribed Fenistil drops 6gtts TID PO for 5 days.

February 11, 2019 Patient has cough and fever. Check up @

Sidra Hospital. No discharge medications.

February 16, 2019 Patient admitted @5pm Sidra Hospital,

nurse was informed by the sister to go directly in the
Hospital. Checked and examined by the attending
physician. (+) Fever 38.3°C, (+) tachycardic 166bpm (+)
tachypneic 58cpm, (+) productive cough, (+) poor feeding
and body malaise. Chest Xray done, result was Bronchiolitis.
Admission room 6A 122, inserted NGT @ L nostril, Blood
extractions done, on Oxygen 0.5LPM if O2 Sat is >90%. For
monitoring.

February 18, 2019 Patient was discharged @ 3pm.

Discharged medications:
Salbutamol 1 puff used with spacer every 6 hours PRN for
DOB & Wheezing x 3 days

Cetirizine 2.5ml OD @ Night PO x 3 days.

Do back tapping. Nebulization PNSS 3ml PRN.

March 3,2019 Started oral food feeding such as mash

vegetables, meat etc. Lunch and mash fruits in the
afternoon. (-) NKA.

Vaccines 1st dose 2nd dose 3rd dose

09/09/1
1. Hepatitis B
8

2. BCG For OPD

17/09/1
3. PCV
8
17/09/1
4. Rotavirus
8
17/09/1 28/01/1
5. Hexavalent
8 9

6. Pentavalent

7. OPV

8. Hepatitis A

9. MMR

10. Varicella

11. Pentaxim

28/01/1
12. PCV B
9
15/10/1
13. RSV 8-
▪4.37wt
PHYSICAL ASSESSMENT PRESENT MEDICATION / NGT

GENERAL: flattened facial appearance. 1. Vitamin D3 4gtt/day OD

2. Captopril 1mg/ml PO TID
Small head. Folds at the inner angle of the eyes are 3. Furosemide 10mg/ml Solution 0.5ml/NGT OD
present. There is an “almond-shaped” appearance of 4. Panadol 100ml 2.5ml q6’ Prn for fever
the eyes. 5. Simethicone 40mg/ml 0.5ml QID for gas PC PRN

Flat nasal bridge. Small nose and small mouth. (+)

Protruding tongue. Ears are also small. (+) Shallow deep
Breathing noted. (-) Tachypnea.

No nappy rashes.

DEVELOPMENTAL MILESTONES NUTRITION

8 MONTHS MILESTONES To gain desired weight as per Doctors requirements prior to

heart surgery.
Recognition:
Moves eyes to stare well especially during feedings and Feeding Plan:
focuses on lights.
FORMULA- PRIMALAC PREMIUM CMA
Pronunciation:
Can make loud cry and smiling. 100ml feeds every 2-3 hours routine:

Sense of touch: ●Bottle (100 CC) Oral feeding to be consumed in 30

Glanced at hands, control fists to hold small objects minutes.
well.  Mash fruits, vegetables and meat during Lunch or
afternoon.
Movement:
Able to raise head but uncontrolled. Arching of head
when lying done for comfort or turning to sides
sometimes. Unable to turn body from one side to the
other.

NURSING CARE PLAN

NURSING DIAGNOSES NURSING INTERVENTIONS

1.RISK FOR FALL  Make sure to put close observation upon leaving from
rocking chair or to wash bottles or even use bathroom.
 Makes sure Pt. Safety by keeping pt. As possible on the
ground with mats on upon changing diaper or keeping
bed low as much as possible.
 Encourage to hold pt. Well with non-slip slippers on
esp. When baby is actively moving a lot.

 Assess vital signs every 4 hours per shift. If

2. RISK FOR IMBALANCED BODY TEMPERATURE temperature is above 37.6°C, take measures
to bring temperature to normal range:
 Administer antipyretics as ordered
 Monitor and document related symptoms
with specific regard to febrile seizures.
 Assess the skin for color, texture, elasticity, and
moisture.
 Check the patient’s immunization history.
  Wash hands before and after any procedure
before handling the baby.
 Help patient change positions frequently.

EVALUATION, FEEDBACK AND RECOMMENDATION

Evaluation: Feedback:

Patient was able to maintain afebrile, s and free from
any falls and vital signs remains within normal limits
during our care.
Very comfortable when assisted to prone position on lap
upon post vomiting episodes.
Baby can suck efficiently without sweating.
Likes to be carried to sleep.
Doesn’t like noise.
Nursed assigned already provided stethoscope.
Requested Nebulizer for patient needs.

Provided by: assigned staff nurses: Michelle I. Macabata

Nurse Supervisor

Reviewed by HMC