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NEONATAL SEPSIS

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Introduction

Neonatal sepsis, sepsis neonatorum and neonatal septicemia are terms

that have been used to describe the systemic response to infection in the new

born infant. There is a little agreement on the proper use of terms i.e. whether it

should be restricted to bacterial infections, positive blood cultures, or severity of

illness. Currently, there is considerable discussion of the appropriate definition of

sepsis in the critical care literature. This is a result of an explosion of information

on the pathogenesis of sepsis and the availability of new potentially therapeutic

agents. e.g. monoclonal antibodies to endotoxin and tumor necrosis factor (TNF)

which can alter the lethal outcome of sepsis in animal experiments. To evaluate

and utilize these new therapeutic modalities appropriately “sepsis” requires a

more rigorous definition. In adults, the term “systemic inflammatory response

syndrome (SIRS) is used to describe a clinical syndrome characterized by two or

more of the following: (1) fever or hypothermia (2) tachycardia (3) tachypnea and

(4) abnormal white blood cells (WBC) or increase in immature forms. SIRS

maybe a result of trauma, hemorrhagic shock, other causes of ischemia,

pancreatitis, or immunologic injury. When it is a result of infection, it is termed

sepsis. These criteria have not been established in infants and children and are

unlikely to be applicable to the newborn infant. Nevertheless, the concept of

sepsis as a syndrome caused by a metabolic and hemodynamic consequences

of infection is logical and important. In the future, the definition of sepsis in the

new born infant and child will become more precise. At these time criteria for

neonatal sepsis should include documentation of infection in a new born infant

with a serious systemic illness in which noninfectious explanations for the

abnormal pathophysiology state are excluded or unlikely. Serious systemic

illness in the new born infant may be caused by perinatal asphyxia, respiratory

tract, cardiac, metabolic, neurologic, hematologic disease. Sepsis occurs in a

small proportion of all neonatal infections. Bacteria and Candida are the usual

etiologic agents, but viruses, and, rarely protozoa may also caused sepsis. Blood

cultures may be negative, increasing the difficulty in establishing infection

etiologically. Finally infections with or without sepsis may be present concurrently

with a non infectious illness in the new born infant, child or adult.

References:

Chapter 98

Neonatal sepsis and meningitis pages 528-529

Part XII- infections of the Neonatal Infants:

Section 2 Clinical Syndromes

Textbook of Pediatrics 15th Edition

By Behrman, Kliegman, Arvin

Goal

General Goal:

To be knowledgeable about the nature of Neonatal Sepsis, its diagnosis,

its treatment and nursing responsibilities

Specific Goal:

To be familiar with the etiology of the disease

To be aware of the signs and symptoms

To know the complications of the disease

To be knowledgeable on how to prevent the disease

To know the treatment

To know the difference of the disease from the normal laboratory values

To assure that nursing implementation must be given

Anatomy and Physiology

The inflammatory response is a complex sequence of events involving

many of the chemical mediation and cells of innate immunity. Tissue injury,

regardless of the type, can cause inflammation, trauma, burns, chemicals, or

infections can damage tissue, resulting inflammation. A bacterial infection is use

here to illustrate an inflammatory response. The bacteria, or damage to tissues,

cause the release or activation of chemical mediators, such as:

1 Histamine,

2 Complement kinins,

3 Eicosanoids. (Ex. Prostaglandins and Leucotriens).

The chemical mediators produce several effects:

1. Vasodilation, which increases blood flow and bring phagocytes and other

white blood cells to the area.

2. Chemotactic attraction of phagocytes, which leave the blood and enter the

tissue.

3. Increase vascular permeability, which allows fibrinogen and complement

to enter the tissue from the blood. Fibrinogen is converted to fibrin, which

prevent the spread of infection by walling off the infected area.

Complement further enhances the inflammatory response and attracts

additional phagocytes. The process of releasing chemical mediators and

attracting phagocytes and other white blood cells continues until the

bacteria are destroyed. Phagocytes, such as neutrophils and

macrophages, remove microorganism and dead tissue, and the damaged

tissue are repaired.

INFLAMMATORY RESPONSE

Bacteria enter Tissue

Tissue damage bacteria

Chemical mediators are released

Increased blood flow Chemotaxis Increased Vascular permeability

Increased number of WBC & chemical mediators at site of tissue damage

Bacteria are contained, destroyed & phagocitized

Bacteria gone Bacteria remain

Tissue repair Additional chemical mediators activated

Predisposing Factors:ImmunocompromisedEnvironmentProlonged use of intravascular catheter Associated illnessProlonged hospitalizationContaminated equipment

Non-predisposing factorsAge 1 ½ monthsMale

Invasion of bacteria

Bacteria goes to circulation

Inflammatory Response

Release of exogenous pyrogens

↑ WBC (neutrophils & macrophage)

Release of endogenous pyrogens

Reset of hypothalamic thermostat

The body release anti-inflammatory mediators

Vascular response

Redness and heat

Pain

Fever (Temp. 38°C)

Blood vessels constrict to prevent loss of body heat and

cause chills

Patient’s Profile

Name: EGLC

Age:1 ½ mos.

Gender: male

Address: Iloilo City

Date of birth: June 10, 2009

Nationality: Filipino

Religion: Roman Catholic

Civil status: N/A

Date of admission: July 27, 2009

Time of admission: 5:04 pm

Place of admission: IDC

Admitting diagnosis: t/c neonatal sepsis

a.1 Chief Complain: fever

a.2 Present Illness

Baby Elijah has an admitting diagnosis of T/C neonatal sepsis. The baby

is experiencing fever for almost 3 days and rashes can be seen on his cheeks

and partially n his shoulders.

a.3 Family History

According to Mrs. C. they do have a history of hypertension, DM, asthma

and allergies while on her husband’s side its hypertension only.

a.4 Medical History

If and if the baby is experiencing a fever and colds the parents

immediately bring him to the hospital for further check-ups and examination. And

give the baby some prescribed medications given by the physician.

a.5 Social History

Mr. and Mrs. C live independently so they are considered as a nuclear

family. Mr. C works as a nurse while Mrs. C as a bank teller. Both parents are

working so either the relatives on mother side or father side are the one taking

care of the baby. Although sometimes they find time taking care of their own

baby. Furthermore, both parents do have their own vices. Mr. C a smoker and

alcohol drinker while Mrs. C is only a smoker.

Diagnostic or

Laboratory

Procedure

Indication or

Purpose

Date Ordered

and Date

Results were

released

ResultsNormal

Values

Analysis and

Interpretation of

Results

Complete Blood

Count (CBC)

To identifying the need

for BT, effectiveness of

BT and if there is a

presence of infection

July 27, 2009 WBC- 11.5

Hgb- 213

Hct- 0.64

RBC- 7.5

PC- 130

- 5-10 x10 9/L

- 140-180 g/L

- 0.4-0.54

- 5.5-6.5 x 10

12/L

- 150-350 x 10

g/L

- The results

indicates the

presence of

infection as

manifested by an

increase in WBC

count

- RBC,

hemoglobin and

hematocrit are

elevated and may

probably indicates

presence of

dehydration.

Diagnostic or

Laboratory

Procedure

Indication or

Purpose

Date Ordered

and Date

Results were

released

ResultsNormal

Values

Analysis and

Interpretation of

Results

Urinalysis

This was done to the

patient as a screening

for abnormalities within

the urinary system as

well as for system

problems that may

manifest through the

urinary tract.

July 27, 2009 Color: Yellow

Appearance: Clear

Specific Gravity: 1.005

Pus Cells: 0-2/HPF

Red Cells: 0-1/HPF

Epithelial Cells: Few

Mucus Threads: Light

Albumin: Negative

Glucose: Negative

- Clear

- Clear

- 1.005-1.030

- None

- None

- None

- None

- Negative

- Negative

- The color,

appearance, and

specific gravity

are within normal

limits. Presence of

Pus cells, Red

cells, epithelial

cells and mucus

threads indicates

presence of

infection.

Diagnostic or

Laboratory

Procedure

Indication or

Purpose

Date Ordered

and Date

Results were

released

ResultsNormal

Values

Analysis and

Interpretation of

Results

Blood Urea

Nitrogen (BUN)

To identifying the need

for BT, effectiveness of

BT and if there is a

presence of infection

July 27, 2009 8.1 mg/dl - 7 - 18 mg/dl - The result is

within the normal

limit

Hemogluco Test

(HGT)

To measure the

amount of glucose in

the blood right at the

time of sample

collection.

July 27, 2009 45 mg/dl -40 –60 mg/dl - The result is

within the normal

limit

Chest X-ray/

Baby Gram

To determine for some

evidence of diffuse

infiltrates and poor

overall aeration

July 27, 2009 - Lungs are clear.

- The intestinal gas

pattern is within

normal

- Cardiac shadow is

not enlarged.

- Normal - The result is

within the normal

limit

Drug Name Classification Mechanism of

Action

Contraindication Adverse Reaction Nursing

Responsibility

Ampicillin

( Apo-Ampi, Novo

Ampicillin, Nu-

Ampi)

Available Forms:

Capsules:

250 mg, 500 mg

Injection:

250 mg, 500mg

1g and 2g

Oral Suspension:

125mg/5ml, 250

mg/5ml

Anti-infectives Inhibits cell wall

synthesis during

bacterial

multiplication.

> Contraindicated

in patients

hypersensitive to

drug or other

penicillin.

> Use cautiously

in patients with

other drug

allergies because

of possible cross-

sensitivity and in

those with

mononucleosis

because of high

risk of

maculopapular

rash.

CNS: seizures,

lethargy,

hallucinations,

anxiety, confusion,

agitation,

depression

CV: vein irritation,

thrombophlebitis

GI: diarrhea,

nausea,

pseudomembranous

colitis, vomiting,

gastritis,

enterocolitis

GU: interstitial

nephritis,

> Before giving

drug ask patient

about allergic

reaction to

penicillin.

> Give drug IM or

IV only if infection

is severe and if

patient can’t take

oral dose.

.Watch for signs

and symptoms of

hypersensitivity.

> Give drug 1-2

hours before or 2-

3 hours after

nephropathy

HEMATOLOGIC:

leukopenia,

thrombocytopenia,

anemia

OTHER:

hypersensitivity

reaction, over

growth of non

susceptible

organism

meals.

> Monitor sodium

level because

each gram of

penicillin contains

2.9 mEq of

sodium

> In patient with

impaired renal

function,

decrease dosage.

1. Hyperthermia

Assessment Nursing

Diagnosis

Planning Intervention Rationale Evaluation

Subjective:

“Nilalagnat ang

anak ko”, as

verbalized by the

mother.

Objective:

>Increased body

temperature

>Skin warm to

touch

>Tachypnea

>Tachycardia

> Vital Signs taken:

Temp.=38.4

RR=36

PR=120

Hyperthermia

related to

Inflammatory

Process as

evidenced by an

increased in body

temperature, and

warm skin.

Short-term:

After 30 minutes

of Nursing

Intervention the

patient will

maintain normal

body temperature

Long Term:

After 3 days of

Nursing

Intervention,

patient will

maintain vital signs

and normal

laboratory results.

1. Monitor

neonate’s

condition.

2. Monitor Vital

Signs

3. Provide TSB

4. Do not share

equipment with

other infants

- To determine the

need for

intervention

and the effective-

ness of therapy.

- To have a

baseline data

- Helps in lowering

down the

temperature

- This would

prevent the

spread of

pathogens to the

infant from

After 30 minutes

of Nursing

Intervention the

patient was able

to maintain normal

body temperature

After 3 days of

Nursing

Intervention,

patient was able to

maintain vital signs

and normal

laboratory results.

Goal is met.

5. Administer

Anti-pyretics as

ordered

equipment

- To lowering

down temperature

2. Ineffective Tissue Perfusion

Assessment Nursing

Diagnosis

Planning Intervention Rationale Evaluation

Subjective:

“Mukhang

matamlay at iba

ang kulay ng anak

ko”, as verbalized

by the mother.

Objective:

> edema

> skin or

temperature

changes

> body weakness

>Vital Signs taken:

Temp.= 38.4

RR= 36

PR= 120

Ineffective tissue

perfusion related

to impaired

transport of

oxygen across

alveolar and on

capillary

membrane

Short-term:

After 30 minutes

of Nursing

Intervention the

patient will

demonstrate

increased

perfusion.

Long Term:

After 3 days of

Nursing

Intervention,

patient will

maintain adequate

perfusion.

1. Monitor

neonate’s

condition.

2. Monitor Vital

Signs

3. Assess skin for

changes in color,

temperature and

moisture

4. Elevate Head of

Bed

5. Elevate

- To determine the

need for

intervention

and the effective-

ness of therapy.

- To have a

baseline data

- To assess for

compensatory

mechanisms of

vasodilation

- To promote

circulation

- To reduce

After 30 minutes

of Nursing

Intervention the

patient was able

to demonstrate

increased tissue

perfusion.

After 3 days of

Nursing

Intervention,

patient was able to

maintain adequate

tissue perfusion.

Goal is met.

affected

extremities with

edema once in a

while

6. Provide a quiet,

restful

atmosphere

7. Administer

oxygen as ordered

edema

- Conserves

energy and

lowers O2

demand

- To maximize O2

availability for

cellular uptake

3. Risk for Impaired parent/ neonate’s attachment

Assessment Nursing

Diagnosis

Planning Intervention Rationale Evaluation

Subjective:

“Nahiwalay sa

akin ang anak ko

dahil kaylangan

siyang dalhin sa

ospital”, as

verbalized by the

mother.

Objective:

> the neonate is

separated from his

parents

> Vital Signs taken:

Temp.= 38.4

RR= 36

PR= 120

Risk for Impaired

parent/ neonates

attachment

related to

neonates physical

illness and

hospitalization.

Short-term:

After 30 minutes

of Nursing

Intervention and

Health Teaching,

the mother will

identify and

demonstrate

technique to

enhance

behavioral

organization of the

neonate.

Long Term:

After discharge, the

parents will be able

to have a mutually

satisfying

1. Interview

parents, noting

their perception of

situation and

individual

concerns

2. Educate

parents regarding

child growth and

development,

addressing

parental

perceptions

3. Involve parents

in activities with

the newborn that

they can

- To know what

the parents

feelings about the

situation..

- Helps clarify

realistic

expectations

- Enhances self-

concept

After 30 minutes

of Nursing

Intervention and

Health Teaching,

the mother was

able to identify

and demonstrate

technique to

enhance

behavioral

organization of the

neonate.

The parents shall

be able to have a

mutually satisfying

interactions with

interactions with

their newborn.

accomplish

successfully

4. Recognize and

provide positive

feedback for

protective

parenting

behaviors

- Reinforces

continuation of

desired behaviors

their newborn.

Goal is met.

Discharge Planning

Name of Person Concern: Mr. G / Mrs. C

Name of Patient: EGLC

Diet: Breast milk or formulated milk

Medicine: Paracetamol (Acetaminophen)

If temperature is 37.8 above

Should take with food or milk to decrease GI upset

Tablet can be taken submerged in 10 ml hot water and added 10 ml of

honey

Treatment: Check for the following:

CBC

Urinalysis

Fecalysis

Things to do Before Treatment:

Check urine for occult of blood

Check Intake and Output such as:

1. Fluid/ liquid

2. Urine

3. BM

4. Vomit

Check record of medicine intake per day

Check record of vital sign such as:

1. Temperature

2. Pulmonary Rate

3. Respiratory Rate

Health Teaching:

Teach TSB in Start of fever when the patient temp. reach 37.7 above

Warn not to combine products containing acetaminophen many of which

OTC. Read labels on all OTC products.

Take Paracetamol with food or milk to reduce GI upset

Monitor Vital sign vital sign such as:

1. Temperature

2. Pulmonary Rate

3. Respiratory Rate

And report any abnormalities such as:

Low Temperature- may be symptoms of chronic poisoning

Fast, weak pulse

Record Intake and Output

1. Fluid/ liquid

2. Urine

3. BM

4. Vomit

Activity:

The infant with temperature instability needs thermoregulatory support

with a radiant warmer or incubator. Once the infant is stable from a

cardiopulmonary standpoint, parental contact is important.

Hygiene:

Keep the patient neat

Bath the patient with hypoallergenic soap, shampoo and use

hypoallergenic powder

Oral hygiene

Perinial hygiene