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1. Clonidine 5.5mcg PO Q3H

2. Hydrocortisone 1% DAILY

3. Vitamin D Drops DAILY

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Baby is under the care of the Ministry

Foster parents provide support during night feeds

Limited daytime caregiver presence

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Name: Maya Van Tol

Age: 1 month and 18 days

Diagnosis: Neonatal Abstinence Syndrome (NAS)

Admitting Reason: Assisting with feeds

Weight: 3.6kg

PEWS Score: 1

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Diagnosis: Neonatal Abstinence Syndrome (NAS)

Exhibiting jitteriness, irritability, and difficulty settling

Poor sleep overnight per kardex, likely related to withdrawal symptoms

Responds to swaddling and pacifier use (comfort measures)

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Feeding 60 mL Q3H via bottle, which is appropriate volume for age

Feeding pattern is consistent

has poor coordination of suck/swallow reflex, and feeding intolerance

has experienced recent weight loss (-2g past 1 day)

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BP: 113/78

PR: 108

MAP: 90

RR: 42

SpO2: 99

TEMP: 37.3

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Mother is aware the baby is under the Ministry

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RR within normal limits for age

No signs of respiratory distress (no nasal flaring, grunting, retractions)

On room air

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Rash noted on cheek area

Redness noted on neck, and crown of head

Possible irritation from frequent movement

Skin appears intact

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Biological Mom received no prenatal care

Known to have taken Effexor, Seroquel, Cocaine, Risperidone

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Baby shows signs of discomfort, including jitteriness and poor sleep (per kardex).

Non-verbal pain cues: high-pitched cry, restlessness, difficulty settling

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Foster parents have support from the Ministry, including resources for managing NAS and infant care.

Social worker support for both the baby and the foster parents

Cuddler Volunteer provided comfort during shift

Foster parents involved during night feeds

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Adequate wet diapers

No stool observed during shift

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Erikson’s stage: Trust vs. Mistrust (infant needs consistent comfort/care)

Also Piaget’s Sensorimotor stage, learning through touch, movement

Given the baby's age, assessment of normal developmental milestones would be appropriate.

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Clonidine dose increased to better manage NAS symptoms

24-hour oxygen monitoring initiated

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RDW 15 H

Plt count 641 H

Potassium 6.2 H

Chloride 112 H