Date and time Progress notes

09/20/2021 F> Ineffective airway clearance.

7:00 a.m
D> Received asleep with ongoing D5LRS x
16cc/min on the left hand and with O2 support
regulated at 1 L /min via nasal cannula; Noted
subcostal retraction at the abdominal area; 4 kg
weight; V/s as follows: HR of 155 bpm, T of 38.8
*C, RR of 45 cpm, Sp02 of 89%
A> Monitored v/s; Observed any signs of
respiratory distress; Auscultated breath sounds;
Evaluated pt’s cough, amount and type of
secretions; Suctioned nose, mouth, and trachea prn;
Repositioned the client every 2 hrs; Administered
Salbutamol 1 neb q4hrs, Cefotaxime 125 mg IV
q6hrs, Paracetamol mg IV q4hrs prn, 2 drops of
NaCI drops prn via nostril, and IVF of D5LRS 500
x 16cc/min as ordered; Instructed the mother to
change pt’s position every 2 hours; Instructed the
mother to report any unusual observations.
3:00 p.m R> Seen crying; increased RR from 45 cpm to 60
cpm; T decreased from 38.8*C to 38 *C;
Increased Sp02 from 89% to 91%.

Gracelyn Piggangay
UC-BSN 2H-2C