Respiratory Therapy Case Study

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rapy Program CASE STUDY REPORT Date: 12/14/2014 Student: Lauren Schubert Facility: Redlands Community Hospital NICU Week: 5 Chief Complaint: RDS History & Physical: Baby girl born at 23 weeks old due to mother premature rupture of membranes. APGAR scores were 5 at 1 minute and 7 at 5 minutes. The baby girl weighed 500 grams and required immeadiate intubation and mechanical ventilation, surfactant was delivered post intubation. Diagnosis: RDS and prematurity Current Medications: Name Classification Action Indication for this pt Ampicillin Antibiotic Acts as an irreversible inhibitor of the enzyme transpeptidase, needed by bacteria to make their cell walls. It inhibits the third and final stage of bacterial cell wall synthesis in binary fission, leading to cell lysis. Infection Caffeine Citrate Methyl xanthine (CNS…show more content…
Stabalize ABG and eventually wean off mechanical ventilation. Patient Assessment Summary (SOAP) Subjective: N/A Objective: HR 140, SpO2 91%, Vent settings SIMV PC on Rate 30, PS 5, Peep +5, FiO2 21%, temperature 36.9 degrees Celsius, skin is transparent and is tearing. CXR shows moderate RDS and worsening. Assessment: 23 week old premature infant weighed 500 grams and 10 in. long at birth, no known maternal history, pre-mature rupture of membranes. Plan: Mechanical Ventilation- Possibly change to HFOV due to worsening CXR, continued antibiotic therapy until infection resolves, O2 therapy to maintain saturation, and frequent turning due to pressure

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