Clinical Assignment by

Patient Profile:

delanie_mccauley — 2020-02-03 04:21:49 UTC

I.M
2 months 30 days old.
RSV
2.949 Kg
PEWS score: 1

Family

delanie_mccauley — 2020-02-03 04:34:48 UTC

-Mom stays with patient most days
-Dad works during day and prepping house for new baby
-No siblings-first born to parents
-Parents married, live in Aldergrove
-Parents have hx of infertility

Strengths

delanie_mccauley — 2020-02-03 04:36:45 UTC

-Baby has good support from mom-very loving and supportive
-Baby recognizes moms voice and can easily be calmed/soothed by mom
-Mother is almost always available for baby
-Baby has lots of cousins who are excited to meet and babysit
-Mom has sister with children
-Baby starting to show hunger cues while being on NG, opening eyes, stirring, opening mouth around feeding time.

Skin/Integ

delanie_mccauley — 2020-02-03 23:39:13 UTC

-Cap refill <3 seconds
-Pt. pink in colour-no cyanosis noted
-Temp: 36.6 C

Gastrointestinal

delanie_mccauley — 2020-02-03 23:41:23 UTC

-Pt. was on NG-removed 01/21/2020
-Feeding E20 formula by bottle PO.

Respiratory

delanie_mccauley — 2020-02-03 23:42:42 UTC

-Mild work of breathing
-Chest sounds clear
-38 Breaths/min
-O2 sat 96% RA.
-Good air entry
-Taken off supplemental O2 01/18/2020.
-Nasopharyngeal wash 01/06/2020=RSV+'ive

Med profile

delanie_mccauley — 2020-02-03 23:45:41 UTC

-Ferrous Sulphate 15 mg PO OD
-Vit. D 400 u OD
-Acetaminophen 40 mg PRN

Cardiovascular

delanie_mccauley — 2020-02-03 23:48:32 UTC

-HR: 166 BPM

Skeletal

delanie_mccauley — 2020-02-04 01:45:37 UTC

-Baby born breech-Has hip ultrasound scheduled in March
-Risk of vit. D deficiency d/t prematurity.