Documentation Do's & Don'ts
Your patient is diagnosed with NEC and antibiotics are started. You navigate to here to verify correct dosing was ordered.
What is the Neonatal Dosing Guideline?
A 4.5kg patient with a blood glucose of 22 will receive this volume of a D10 bolus.
What is 9mL?
This is the environment into which you would admit a 33 weeker.
What is an air control isolette? (Temperature determined per Appendix A)
When accidentally dislodged, this airway can be replaced by the bedside nurse.
What is the (established) tracheostomy tube?
BONUS: LMA
This defect is diagnosed when X-ray reveals an NG tube coiled in the esophagus of a patient with excessive oral secretions and difficulty feeding.
What is esophageal atresia?
To be considered exceptionally good at charting, this is how you document assessment findings.
What is by exception?
TPN0 @ 100mL/kg
What is the admission fluid order for a patient weighing <1500g?
The volume of waste required before drawing up labs from an arterial line.
What is 1mL? 2mL? 3mL?
The required volume for a VBG or ABG.
What is 0.2mL?
This congenital defect involves herniation of the intestines outside the abdominal wall in a membranous sac.
What is omphalocele?
You have no contact with your patient's family overnight. This is where you fulfill your shift education documentation requirement.
Where is the Comments in the Education activity tab?
You have drawn up your patient's dose of ampicillin. This is the process for administering it.
What is . . . 1. Stop fluids and clamp all other ports 2. Scrub hub and let dry 3. Flush using first NS syringe 4. Scrub hub and let dry 5. Administer amp over 1-2min 6. Scrub hub and let dry 7. Flush using second NS syringe over 1-2 min
A UVC passes through these two fetal adaptive features.
What are the umbilical vein and ductus venosus?
This is the reason that biphasic positive airway pressure (BiPAP) has a set rate.
What is . . . the rate indicates how often the higher pressure (PEEP) is initiated to encourage continued recruitment of the alveoli?
It is NOT giving a breath!
During safety checks, you ensure that your patient with a chest tube has these items available.
What are vaseline gauze, tegaderm and clamps?
1 Goal. 1 Intervention. 1 brief outcome summary.
What is a complete shift care plan?
A patient with a known ductal-dependent congenital heart defect is started on a Prostaglandin E1 ("PGEs") drip to maintain this.
What is a patent ductus arteriosus (PDA)?
Surfactant performs this function within the alveoli.
What is reducing surface tension and preventing collapse at end of expiration?
Inhaled nitric oxide (iNO) is utilized in patients with persistent pulmonary hypertension of the newborn (PPHN) because of this action.
What is selective pulmonary vasodilation?
This is how often you assess the patency of your patient's Replogle using air instillation.
When is every 4 hours?
Rate Verify at shift change. Rate change with titrations.
When do you document on FiO2?
Flush volume and rate for the following medication: 0.6mL IV caffeine
What is 1mL @ rate of 1.2mL/hr?
The acronym STEPS in the Small Baby Protocol stands for these areas of IVH preventions.
What are Stress, Temperature, Environment, Position and Skin?
Your patient was born at 25 weeks and is now 5 weeks old. This is their correct Philips monitor profile.
What is the <28 Weeks? (alarm settings 90-95%)
This will only change when the patient is 32 weeks CGA!!!
These congenital defects are seen in VACTERL association.
What are Vertebral anomalies, Anal atresia, Cardiac anomalies, TEF/EA, Renal anomalies, Limb anomalies?