Neonatal-Sepsis case

I. INTRODUCTION

“Neonatal sepsis deaths at Ospital ng Makati due to neglect – DOH”

For the past few weeks, headlines about Neonatal Sepsis that take place at

Ospital ng Makati were all featured on almost all of the newspaper, news bulletin and

news on the television in the Philippines. It had made a huge impact in the Philippines

concerning health issues. The news is about the outbreak of neonatal sepsis that

happens at OSMAK causing 23 neonatal deaths. According to the investigation, poor

infection control practices and overcrowding are the reasons for the outbreak that has

lead to Makati’s legal department to consider filing administrative cases against five

hospital staff whose negligence reportedly caused the babies’ deaths.

This issue is most important to nurses working on a hospital especially to those

who are assigned in a Neonatal Intensive Care Unit or NICU department. Proper

infection control and management should be well-implemented in the hospital in order to

avoid what had happen on the affected hospital.

Neonatal Sepsis on the other hand is an infection in the blood that spreads

throughout the body and occurs in a neonate. Neonatal Sepsis is also termed as

Neonatal Septicemia and Sepsis Neonatorum. Neonatal Sepsis has 2 types: The one

that is seen in the first week of life is termed as Early- onset sepsis and most often

appears in the first 24 hours of life. The infection is often acquired from the mother. This

can be cause by a bacteria or infection acquired by the mother during her pregnancy, a

Preterm delivery, Rupture of membranes (placenta tissue) that lasts longer than 24

hours, Infection of the placenta tissues and amniotic fluid (chorioamnionitis) and frequent

vaginal examinations during labor. The second type or the Late-onset Sepsis is acquired

after delivery. This can be cause by contaminated hospital equipment, exposure to

medicines that lead to antibiotic resistance, having a catheter in a blood vessel for a long

time, staying in the hospital for an extended period of time. Signs and symptoms of

Neonatal Sepsis includes but is not limited to: body temperature changes, breathing

problems, diarrhea, low blood sugar, reduced movements, reduced sucking, seizures,

slow heart rate, swollen belly area, vomiting, yellow skin and whites of the eyes

(jaundice). Possible complications are disability and worst is death of the neonate.

(Greene, 2007)

Neonatal sepsis occurs at an estimated rate of 1 to 2 cases per 1000 live births

in the U.S. The highest rates occur in low-birth-weight (LBW) infants, those with

depressed respiratory function at birth, and those with maternal perinatal risk factors.

The risk is greater in males (2:1) and in neonates with congenital anomalies (Merck,

2005). According to the Philippine Mortality Fact Sheet 2006 of the World Health

Organization, in 1000 live births of neonates 17% of it died due to severe infection that

includes deaths from pneumonia, meningitis, sepsis/septicemia, and other infections

during the neonatal period. (www.merck.com)

Looking at the table below, according to world health statistics done in the year

2004 Neonatal Infection rank as no 11 as a leading cause of death it was further

compared to the mortality statistics of the year 2030. In the year 2030 it was projected

that in the year 2030 Neonatal Infection will be lower down to rank 21 as a leading cause

of death. Updated mortality projections are based on historically observed relationships

between trends in economic and social development and cause-specific mortality.

www.who.com

Current Issues and Trends in Neonatal Sepsis

One of the most common causes of early-onset neonatal sepsis is the Group B

Streptococcal infection. On a journal published last April 02, 2008 entitled “Stricter

Adherence to Maternal Antibiotics Is Needed to Curb GBS Neonatal Sepsis” highlighted

that adequate intrapartum prophylaxis need to be improved especially on mothers with

GBS. They also added that to improve the prevention of these proven or probable GBS

infections, not only is strict adherence to prophylaxis recommendations needed but also

sensitive and faster testing of the carrier GBS status of the mother at delivery.

"To assess the effectiveness of GBS prophylaxis and to obtain reliable data

about the results of GBS prevention, the incidence of both culture-positive and culture-

negative GBS neonatal infection should be considered after removal from the analysis

those newborns with known intrauterine GBS infection, in whom prophylaxis is less

effective," the researchers add. (www.medscape.com)

Another study was made entitled “Safety and Impact of Chlorhexidine Antisepsis

Interventions for Improving Neonatal Health in Developing Countries”. It is said in the

study that affordable, efficacious, and safe interventions to prevent infections and

improve neonatal survival in low-resource settings are needed. Chlorhexidine is a broad-

spectrum antiseptic that has been used extensively for many decades in hospital and

other clinical settings. It has also been given as maternal vaginal lavage, full-body

newborn skin cleansing, and/or umbilical cord cleansing to prevent infection in neonates.

Recent evidence suggests that these chlorhexidine interventions may have significant

public health impact on the burden of neonatal infection and mortality in developing

countries. This review examines the available data from randomized and nonrandomized

studies of chlorhexidine cleansing, with a primary focus on potential uses in low-

resource settings. Safety issues related to chlorhexidine use in newborns are reviewed,

and future research priorities for chlorhexidine interventions for neonatal health in

developing countries are discussed. It is concluded in the study that chlorhexidine-based

antisepsis interventions have the potential for significant reduction of the burden of

neonatal morbidity and mortality in developing countries, yet further information is

needed before policy recommendations can be made. (www.medscape.com)

An in-depth study about Neonatal Sepsis is so important for a nurse most

especially if the nurse is working in a Neonatal Intensive Care Unit or the NICU

department. A nurse should be properly educated regarding the cause of the neonatal

sepsis, how it is acquired and prevented, its complications, and etc. to prevent the

occurrence of late-onset neonatal sepsis that can possibly lead to legal cases like what

had happen in the case of Neonatal Sepsis in OSMAK.

After the completion of the study, a nurse shall be able to:

Identify and differentiate the types of Neonatal Sepsis

Be updated with the latest trends in the treatment of Neonatal Sepsis

Perform a comprehensive assessment of Neonatal Sepsis

Enumerate the different signs and symptoms of Neonatal Sepsis

List down the different diagnostic procedures that would help in the diagnosis of

Neonatal Sepsis.

Identify and understand different types of medical treatment necessary for the

treatment of Neonatal Sepsis.

Formulate nursing care plans utilizing the nursing process

Formulate conclusions based on the findings and enumerated a

recommendations concerning Neonatal Sepsis.

Nurse Centered Objectives:

♦ have critical thinking skills necessary for providing safe and effective nursing care.

♦ have a comprehensive assessment and implement care base on our knowledge

and skills of the condition

♦ familiarize ourselves with effective inter-personal skills to emphasized health

promotion and illness prevention.

♦ Impart the learning experience from direct patient care.

Patient and Family Centered Objectives:

At the end of this study, the patient/family will be able to:

1. Identify measures that could minimize the risk of occurrence of the disease.

2. Identify possible risk factors that may have contributed to the development of

Neonatal Sepsis.

3. Increase awareness on the risk factors of Neonatal Sepsis.

4. Develop the family’s support system and distinguish their respective roles in

improving patient’s health status.

5. Involve them in promoting the health care of the patient.

II. NURSING ASSESSMENT

A. Personal History

1. Demographic Data

Baby Boy V is a neonate born last June 24, 2008,

9:47 in the morning at OLMCMC. They resides somewhere

in Angeles City. Based on his ballard score of maturational

assessment of his gestational age, he is in between 36 to

37 weeks of age. He has a birth weight of 2.5 kg, a length

of 51 cm, head circumference of 30 cm, chest

circumference of 28cm and abdominal circumference of

25cm. He was born from a 31 years old G2P1 with a

TPAL of 1001 mother via normal spontaneous delivery.

His father is 34 years of age. Initially after birth he was

place in the nursery unit of the hospital for observation and

was transferred to NICU a day after he was born June 25,

2008. CBC with PC and Blood typing was ordered on the

same date when he was born. He was discharged from

the hospital last July 02, 2008 with a diagnosis of Neonatal

Sepsis, Culture positive (Enterobacter cloacae).

2. Socio- Economic and Cultural Factors

Baby Boy V’s family is an extended type of family.

Other than his father, mother and 1 sibling who is 5 years

older than him his grandmother is staying with them. They

are all Roman Catholics and are native kapampangans.

Baby Boy V’s father owns a jeepney and is working as a

jeepney driver while his mother is a plain housewife.

According to his mother their monthly income is

approximately P10, 000 per month and this income was

being used in budgeting for foods and daily needs,

electricity and water bills, some extras were being used for

their jeepney’s maintenance. With this expenses his

mother said that their way of living is just enough for them

to pass by.

Baby Boy V’s mother said that it is his mother who

cooks for them but usually they eat instant food and

canned goods because it’s the only food that can be

bought with their little budget. But nonetheless, they still

eat 3 times a day. And as for what they use when their

cooking they do have a gas stove but they still sometimes

use charcoal when cooking.

During his mother’s pregnancy, his mother is fond

of eating salty and sweet foods, usually fond of drinking

coffee at least 3 cups per day and drinks water of about 8-

10 glasses daily.

Baby Boy V’s father is a high school graduate while

his mother was an undergraduate who’s supposedly taking

up education as a course. But due to financial constraint

was unable to finish her education; she just then started

working as a saleslady. And when she got married she

stopped from work and was satisfied for being a plain

housewife.

With their grandmother living with them, their family

usually believes in “herbolaryos” and “albularyo” when

seeking for health advice. They also believe in

superstitions due to the influence of their grandmother.

One saying that his mother believes in is when his mother

is menstruating his mother usually does not take a bath

during her first day of menstruation believing that this

would cause her to be “insane”.

3. Environmental Factors

Baby Boy V’s family resides somewhere in Angeles

City. They lived near business establishments and

jeepney station; they have to endure the noisy and busy

environment marred by pollution. According to his mother

the place is also congested and establishments are built

almost close to each other. Their house is a bungalow type

which is made-up of hollow blocks and wood.

B. Obstetrical History

Her mother had her menarche at the age of 15 years old and

lasted for a week. From then on, she had regular menstrual period every

month and each period lasted for 5-7 days. She also experience

premenstrual dysmenorrhea and has heavy menstrual flow on the first 2

days of onset. She gave birth to her first baby at the age of 26.

1. Maternal-Obstetric Record

Baby Boy V’s mother got married when she was 25

years of age. She has an Obstetric record of Gravida 2,

Partum 2. She has a TPAL record of 2002. His mother

last menstrual period was last October 1, 2007. So her

estimated date of delivery was supposedly on July 8, 2008.

She had given birth to Baby Boy V last June 24, 2008 two

weeks ahead from her EDD. She was brought earlier than

her estimated date of confinement because she had an

early contraction and premature rupture of membrane.

She had given birth via NSD with the aid of an OB doctor

on a tertiary level hospital. She was diagnosed by her

doctor for having a Chronic Hypertension, she has a BP of

140/90 mmHg upon admission.

Baby Boy V has 1 sibling. His sibling was born via

NSD on the same hospital as a term healthy baby girl.

2. Ante-partal/ Pre-natal Preparation

According to Baby Boy V’s mother she had a

regular prenatal check-up on her doctor’s clinic. She goes

once a month during the first trimester, twice a month

during the second trimester, and every week during the

third trimester. She received 3 doses tetanus toxoid

vaccine from her doctor. It also said by the mother that she

really does have a BP of 140/90 mmHg but nothing is done

to manage it.

3. Significant Trimestral Changes (1st – 3rd trimester)

On the first trimester of the latest pregnancy, she

experienced episodes of nausea and vomiting. She is

knowledgeable that nausea and vomiting is a natural

discomfort of pregnancy. She neither did nor performed

any home remedy/management in order to relieve the

discomfort. She also felt early fatigability and manage it

through rest. Straining to defecate or constipation is also

experienced by the mother on the third month. This was a

result of the compression of the large intestine, restricting

normal bowel movement. She was advised to drink an

ample amount of liquid (8-10 glasses of water) and high

fiber food such as papaya in order to relieve the

discomfort. She accepted and followed the said advice

and constipation was gradually relieved.

On the second trimester of her pregnancy, she had

complained of frequent episodes of backache which was

caused by the weight of the developing babies. She also

experience early fatigability and headache which is a result

of hindered maternal blood flow caused by the fetal growth

and development. These second trimester discomforts

were managed by the patient through bed rest.

Third trimester pregnancy discomforts the patient

experienced shortness of breath and manage it by rest and

proper ventilation.

During her second and third trimester pregnancy

the mother had urinary tract infection. It was remedied

through oral antibiotics such as amoxicillin tablet, and by

drinking lots of water and by doing perineal hygiene.

C. Family- Health Illness History

Legend - Heart Dse. - Hypertension - UTI

The family health illness history of here indicates that the familial illness history of Baby Boy V is a heart disease that came from his grandmother on the father side, hypertension from his maternal grandfather and mother. And the disease that is associated to his current illness is UTI that came from his mother.

D. History of Present Illness

Baby Boy V was born last June 24, 2008, 9:47 am at OLOMCMC. Prior

to delivery her mother had a Premature Rupture of Membrane and early

contraction, the reason why his mother was brought early in the hospital. It is

also said by the mother that she had a difficult labor because the baby did not

come-out immediately. A lot of straining and pushing during delivery was

done as said by the midwife in the hospital, who was also present during her

delivery. Stress of the fetus during delivery is evident by him having a caput

succedaneum. Routine Newborn care was done including vitamin K

administration and giving of eye prophylaxis. His pediatrician then ordered

CBC typing and platelet count. He was not immediately brought to the NICU

unit but stayed first in the Nursery unit for further assessment. His initial CBC

count was as follows: WBC 11.5, Hgb. 213, Hct. 0.64, platelet count 130,

RBC 7.5. Though the results were slightly elevated Baby Boy V was not yet

transferred to their NICU unit. He was transferred to NICU because of poor

suck and edema in his upper and lower extremities. He has an initial

diagnosis of T/C neonatal sepsis.

E. Physical Examination

June 24, 2008 (Lifted from the chart)

Vital Signs:

RR-43 bpm

CR-135 bpm

Temp- 36.7oC

Measurements:

Length- 51 cm

Head Circumference- 50 cm

Chest Circumference- 28 cm

Abdominal Circumference- 25 cm

Weight - 2,5 kgs.

Apgar Score- 8-9

Physical Examination of the Newborn

Skin: (+) acrocyanosis, (+) thinning lanugo

Head: (+) caput, with soft, firm and flat fontanels

Eyes: (+) PERRLA, with pale palpebral conjunctiva

Ears: symmetrical, no discharge or lesions, well curved pinna; soft but ready recoil

Nose: no discharge

Chest: symmetrical lung expansion, stippled areola 12mm bud

Abdomen: (-) tenderness

Male genitalia: testes down, good rugae, with adequate urine output

Back: intact spine, (-) mass

Rectum: with patent anal opening, (+) passage of stool

Extremities: anterior transverse crease only

June 26, 2008 (Done by the researcher)

Vital Signs:

RR-63 bpm

CR-175 bpm

Temp- 38.5oC

Measurements:

Length- 51 cm

Head Circumference- 50 cm

Chest Circumference- 28 cm

Abdominal Circumference- 25 cm

Weight - 2,5 kgs.


General A ppearance: Seen baby in crib with ongoing IVF of D10W at 6-7 ugtts/min

via umbicath. He is less active and febrile. He has good cry and good suck but

does not demand feeding. He is well-flexed, with full range of motion and with

spontaneous movement.

Skin: with good turgor, nipples present and on expected locations, (-) cyanosis, skin

warm to touch.

Head: (-) Lacerations, (+) caput succedaneum, (-) bruising and swelling, with diamond-

shaped anterior fonatanel, with triangular-shaped posterior fontanel, fontanels

soft, firm and flat

Eyes: (-) tears when crying, (-) redness and purulent discharge, (+) edema around the

eyelids, (+) PERRLA, (+) blink reflex

Ears: pinna tends to bend easily, with startle reflex.

Nose: obligate nasal breathers, with bilateral patent nostrils, (-) nasal discharges, (-)

nasal flaring

Mouth: mucosa moist, tongue moves freely and does not protrude, (+) sucking and

rooting reflex

Neck: short and thick, turns easily side to side, able to raise head slightly when lying in

prone position

Chest: with evident xiphoid process, with symmetrical nipples, with symmetrical chest

movements, (-) retractions,(-) murmur

Abdomen: with (+) abdominal respirations, soft, cord dry at base, (+) bowel sounds, (+)

passage of stool, (-) mass

Male genitalia: Urinary meatus at tip of penis, with palpable testes, urine output 5gms

in an hour



Extremities: (+) edema on both extremities, (-) syndactyly, (-) polydactyly, with weak

peripheral pulses.

June 29, 2008 (Done by the researcher)

Vital Signs:

RR-48 bpm

CR-132 bpm

Temp- 36oC


General A ppearance: Seen baby in crib with ongoing IVF of D5IMB 113 cc via soluset

at 9-10 ugtts/min infusing well on his left hand. He is less active and afebrile. He has

good cry and good suck but less demand feedings. He is well-flexed, with full range of

motion and with spontaneous movement.

Skin: with good turgor, nipples present and on expected locations, (-) cyanosis, with

cold, clammy skin especially on the extremities part., (+) jaundice

Head: (-) Lacerations, (+)caput succedaneum, (-) bruising and swelling, with diamond-


soft, firm and flat

Eyes: (-) tears when crying, (-) redness and purulent discharge, (-) edema around the




nasal flaring


rooting reflex


prone position





Male genitalia: Urinary meatus at tip of penis, with palpable testes, with adequate u.o



Extremities: (+) edema on lower extremities, (-) syndactyly, (-) polydactyly, with weak

peripheral pulses.

July 01, 2008 (Done by the researcher)

Vital Signs:

RR-45 bpm

CR-135 bpm

Temp- 36.8oC


General Appearance: Seen baby in crib with ongoing IVF of D5IMB 98 cc via soluset

at 7-8 ugtts/min infusing well on his left hand. He is active and afebrile. He has good cry,

good suck and demands feedings. He is well-flexed, with full range of motion and with

spontaneous movement.

Skin: with good turgor, nipples present and on expected locations, (-) cyanosis, warm

and dry.

Head: (-) Lacerations, (+)caput succedaneum, (-) bruising and swelling, with diamond-


soft, firm and flat

Eyes: (-) tears when crying, (-) redness and purulent discharge, (-) edema around the




nasal flaring


rooting reflex


prone position





Male genitalia: Urinary meatus at tip of penis, with palpable testes, with adequate u.o



Extremities: (-) edema on extremities, (-) syndactyly, (-) polydactyly, cold clammy skin

F. DIAGNOSTIC AND LABORATORY PROCEDURES

DIAGNOSTIC/ LABORATORY PROCEDURES

DATE ORDERED

DATE RESULT(S) IN

INDICATION(S) OR PURPOSE(S)

RESULTS NORMAL VALUES

ANALYSIS AND INTERPRETATION OR

RESULTS

Complete Blood

Count (CBC)

06-24-08-

08:30 am

06-24-08-

12:00 nn

♦ CBC is done with the patient

for the purpose of identifying the

need for BT, effectiveness of BT

and if there is a presence of

infection: The CBC includes the

RBC count, hemoglobin,

hematocrit, RBC indices, WBC

count and platelet count. Blood

test done to the patient includes:

(a) Hct which measures the

concentration of RBC within the

blood volume, the blood test

evaluates blood loss, anemia,

blood replacement and fluid

balance and screens RBC

status; (b) Hgb is an important

component of RBC that carries

WBC- 11.5

Segmenter-

0.02

Lymphocyte-

0.27

Monocyte- 0.07

Eosinophil- 0.01

Hgb- 213

Hct- 0.64

5-10 x10 9/L

0.50-0.70

0.20-0.40

0.01-0.06

0.01-0.05

M 140-180

g/L

N 0.4-0.54

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.

- thrombocytopenia may

occur in neonatal sepsis in

response to the cellular

products of the

microorganisms. These

cellular products cause

platelet clumping and

adherence leading to platelet

destruction.

06-28-08-

09:00 am

06-28-08-

12:00 nn

07-01-08-

O2 and CO2 to and from tissue,

this test evaluates blood loss,

erythropoietic ability, anemia

amd response to therapy;

(c)WBC is use to evaluate

number of conditions and

differentiates causes of

alterations in the total WBC

count including infection,

inflammation and tissue

necrosis. Neutrophils and

Lymphocytes are components of

WBC; (d) Platelet count

evaluates platelet production

and use as screening test to

platelet function

Pt. Centered Indication-

1st CBC- determines presence of

infection obtained from the

mother and as part of his

newborn assessment

2nd CBC- determines if there is a

PC- 130

RBC- 7.5

WBC- 6.6

Segmenter-

0.55

Lymphocyte-

0.36

Monocyte- 0.09

Hgb- 187

Hct- 0.56

PC- 120

RBC- 6.5

WBC- 10.3

150-350 x

10 g/L

M 5.5-6.5 x

10 12/L

-The results are within the

normal limit except for the

platelet which has below

normal result.

-The results are considered to

be in the normal level except

08:50 am

07-01-08-

12:00 nn

progress from his condition

3rd CBC- determines if the baby

is ready to be discharged

Segmenter-

0.43

Lymphocyte-

0.52

Monocyte- 0.03

Eosinophil- 0.02

Hgb- 193

Hct- 0.58

PC- 120

RBC- 6.8

for the platelet count.

Nursing Responsibilities

Prior:

Explain to the mother the purpose of the test.

Inform them that the test requires a blood sample and that the patient may experience discomfort/pain from the needle

puncture.

Inform them that there are no food or fluid restrictions.

Lists drugs being taken by the client to detect any effect on results.

During:

Inform the mother that venous blood is to be collected.

Venipuncture should be performed in an aseptic technique as well as the collection of the sample.

Handle the specimen gently to avoid hemolysis.

After:

Make sure that the specimen bottles are labeled correctly.

Put pressure over the puncture site.

Inform them that the results will be out as soon as the specimen is interpreted in the laboratory.


DATE ORDEREDDATE RESULT(S)

IN


RESULTS NORMAL VALUES ANALYSIS AND INTERPRETATION

OR RESULTS

URINALYSIS 06-24-08- 08:30

am

06-24-08- 12:00

nn

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.

Color:

Yellow

Appearance:

Clear

Specific Gravity:

1.005

Pus Cells:

0-2/HPF

Red Cells:

0-1/HPF

Epithelial Cells:

Few

Mucus Threads:

Color:

Yellow

Appearance:

Clear

Specific Gravity:

1.005-1.030

Pus Cells:

None

Red Cells:

None

Epithelial Cells:

None

Mucus Threads:

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.

Light

Albumin: Negative

Glucose: Negative

None

Albumin: Negative

Glucose: Negative


Prior:

Inform the mother that there are no food or fluid restrictions before the test.

Advise the mother of the procedure and the reason for the test.

During:

The specimen should be sent to the laboratory within 1 hour after collection or if the specimen cannot be processed

immediately, refrigerate it.

If a 24 – hour urine collection is requested the specimen should be refrigerated or preserved within formalin during the

collection time.

After:

Record data.

Relay result to the doctor


DATE ORDERED

DATE RESULT(S)

IN


RESULTS NORMAL VALUES ANALYSIS AND INTERPRETATION

OR RESULTS

Blood Urea

Nitrogen (BUN)

06-25-08

08:30 am

06-25-08

12:00 nn

Blood urea nitrogen (BUN)

measures the amount of urea

nitrogen, a waste product of

protein metabolism, in the blood.

Urea is formed by the liver and

carried by the blood to the kidneys

for excretion. Because urea is

cleared from the bloodstream by

the kidneys, a test measuring how

much urea nitrogen remains in the

blood can be used as a test of

renal function. However, there are

many factors besides renal

disease that can cause BUN

alterations, including protein

breakdown, hydration status, and

liver failure.

Pt. centered indication

8.1 mg/dl 7-18 mg/dl The result is within

the normal limit

- to check how the kidneys are

functioning before starting to take

certain drug therapies.


Prior:

Select vein for venipuncture (usually antecubital space).

Apply tourniquet several inches above intended venipuncture site

Clean venipuncture site (with povidone iodine or alcohol, allow area to dry).

During:

Perform venipuncture by entering the skin with needle at approximately a 15-degree angle to the skin, needle bevel up.

If using a Vacutainer, ease tube forward in holder once in the vein. If using a syringe, pull back on the barrel with slow, even

tension as blood fills the syringe.

Release tourniquet when the blood begins to flow.

After:

After the blood is drawn, place cotton ball over site; withdraw the needle and exert pressure. Apply bandage if needed.

Properly dispose contaminated materials.

Record the date and time of blood collection. Attach a label to each blood tube.

Relay results to the doctor.

* Note: Do not use a vein site proximal to an IV infusion.

DIAGNOSTIC/ DATE INDICATION(S) OR PURPOSE(S) RESULTS NORMAL ANALYSIS AND

LABORATORY PROCEDURES

ORDEREDDATE

RESULT(S) IN

VALUES INTERPRETATION OR RESULTS

Creatinine 06-25-08

08:30 am

06-25-08

12:00 nn

Creatinine has been found to be a fairly

reliable indicator of kidney function. As

the kidneys become impaired the

creatinine level in the blood will rise.

Abnormally high levels of creatinine

thus warn of possible malfunction or

failure of the kidneys

0.68 mg/dl 0.4-1.4 mg/gl The result is within

the normal limit

*** Nursing Responsibilities same from BUN


DATE ORDERED

DATE RESULT(S)

IN

INDICATION(S) OR PURPOSE(S) RESULTS NORMAL VALUES

ANALYSIS AND INTERPRETATION

OR RESULTS

Bilirubin 06-28-08

08:30 am

06-28-08

12:00 nn

Within the first 24 hours of life, up to 50%

of full-term newborns, and an even greater

percentage of pre-term babies, may have a

high bilirubin level. After birth, newborns

begin breaking down the excess red blood

cells (RBCs) they are born with and, since

the newborn’s liver is not fully mature, it is

Total

Bilirubin:

5.35 mg/dl

Direct

Bilirubin:

2.58 mg/dl

0.2-1.2 mg/dl

0.0-0.05 mg/dl

The results are

above normal. The

results can be

caused by his

disease perse.

Though results are

high no intervention

http://www.medicinenet.com/script/main/art.asp?articlekey=4103

unable to process the extra bilirubin,

causing the infant's bilirubin levels to rise in

the blood and other body tissues. This

situation usually resolves itself within a few

days.


bilirubin diagnostic exam was ordered

when he shows evidence of jaundice

Indirect

Bilirubin:

2.77 mg/dl

was done to cure the

symptom,

intervention such as

phototherapy via

blue light.

*** Nursing Responsibilities same from BUN


DATE ORDERED

DATE RESULT(S) IN



OR RESULTS

Hemogluco Test

(HGT)

06-25-08

08:30 am

06-25-08

08:30 am

The blood glucose test is ordered

to measure the amount of glucose

in the blood right at the time of

sample collection.

45 mg/dl 40-60 mg/dl The result is within

the normal limit

http://www.labtestsonline.org/understanding/conditions/jaundice.html


Prior:

Determine for what purpose is the procedure ordered

Maintain sterile technique

During:

Gently extract blood specimen from the patient.

Apply cotton on the punctured site.

After

Document results

Relay results to the doctor


DATE ORDERED

DATE RESULT(S) IN



OR RESULTS

Blood gram stain/

culture sensitivity

test

06-25-08

08:30 am

06-27-08

12:00 nn

Gram stain is a differential stain

used to demonstrate the staining

properties of bacteria

Your doctor may order blood

cultures when you are having

symptoms of septicemia or sepsis,

No definite

Microorganism

seen

Culture positive

With aerobic,

Negative

Negative

The result is normal

The result shows a

heavy growth bacteria

identified as

enterobacter cloacae

which indicates that bacteria or

their products are causing harm in

your body. Sensitivity testing

report indicates on what antibiotics

can be used that is sensitive to the

microorganisms shown in blood

culture exam.

heavy growth

enterobacter

cloacae

Sensitive drugs

that can be used

Amikacin

Ampicillin-

Sulbactam

Cefepime

Chloramphenicol

Ciprofolaxacin

Imipenem

Levofloxacin

Meropenem

Norfloxacin

Piperacilin-

tazobactam

Sulbactam-

cefoperazon

Tigecycline

Tetracycline

which indicates the

diagnosis of

septicemia. The

result also shows

sensitive and resistant

drugs applicable to

the bacterial growth

found in blood culture.

It is also indicated that

ampicillin and claforan

is resistant to the

organism.


(Obtaining of Blood GS/CS uses stricter aseptic method in obtaining blood samples than the other blood procedure to have a more

reliable and accurate results)

Prior:

Select vein for venipuncture (usually antecubital space).

Apply tourniquet several inches above intended venipuncture site

Clean venipuncture site (with povidone iodine or alcohol, allow area to dry).

During:

Perform venipuncture by entering the skin with needle at approximately a 15-degree angle to the skin, needle bevel up.

If using a Vacutainer, ease tube forward in holder once in the vein. If using a syringe, pull back on the barrel with slow, even

tension as blood fills the syringe.

Release tourniquet when the blood begins to flow.

After:

After the blood is drawn, place cotton ball over site; withdraw the needle and exert pressure. Apply bandage if needed.

Properly dispose contaminated materials.

Record the date and time of blood collection. Attach a label to each blood tube.

Relay results to the doctor.


DATE ORDERED

DATE RESULT(S) IN



OR RESULTS

Chest X-ray/ Baby

Gram

Chest X-ray

APL

06-25-08

06-25-08

Baby Gram

06-26-08

06-26-08

X-rays - a diagnostic test which

uses invisible electromagnetic

energy beams to produce images

of internal tissues, bones, and

organs onto film. Chest

radiographs may depict segmental

or lobar infiltrate but they more

commonly reveal a diffuse, fine,

reticulogranular pattern, much like

what is observed in RDS. Pleural

effusions may also be observed.


To determine for some evidence of

diffuse infiltrates and poor overall

aeration

Normal chest

and baby gram

findings.

Baby gram- the

visualized

osseous

structures are

not remarkable.

Lungs are clear.

The intestinal

gas pattern is

within normal

Chest APL-

Both lung

parenchyma

are clear.

Cardiac shadow

Normal The result is just

normal.

is not enlarged.

The diaphragm

and bony thorax

are not unusual.


Prior:

Explain the purpose of the CXR to the mother. Inform the mother whether they will be transported to the radiology department or have the x-ray done at bedside (portable

CXR). Tell the mother that the test will take only a few minutes and is painless

During:

Provide a lead apron for any person who must hold the patient during the procedure. Provide extra blankets for patient chilled from exposure during CXR.

After: Assess respiratory status of patient.

III. ANATOMY AND PHYSIOLOGY

Immunology is the study of our protection from foreign macromolecules or

invading organisms and our responses to them. These invaders include viruses,

bacteria, protozoa or even larger parasites. In addition, we develop immune responses

against our own proteins (and other molecules) in autoimmunity and against our own

aberrant cells in tumor immunity.

Our first line of defense against foreign organisms are barrier tissues such as the

skin that stop the entry of organism into our bodies. If, however, these barrier layers are

penetrated, the body contains cells that respond rapidly to the presence of the invader.

These cells include macrophages and neutrophils that engulf foreign organisms and kill

them without the need for antibodies. Immediate challenge also comes from soluble

molecules that deprive the invading organism of essential nutrients (such as iron) and

from certain molecules that are found on the surfaces of epithelia, in secretions (such as

tears and saliva) and in the blood stream. This form of immunity is the innate or non-

specific immune system that is continually ready to respond to invasion.

A second line of defense is the specific or adaptive immune system which may

take days to respond to a primary invasion (that is infection by an organism that has not

hitherto been seen). In the specific immune system, we see the production of antibodies

(soluble proteins that bind to foreign antigens) and cell-mediated responses in which

specific cells recognize foreign pathogens and destroy them. In the case of viruses or

tumors, this response is also vital to the recognition and destruction of virally-infected or

tumorigenic cells. The response to a second round of infection is often more rapid than

to the primary infection because of the activation of memory B and T cells. We shall see

how cells of the immune system interact with one another by a variety of signal

molecules so that a coordinated response may be mounted. These signals may be

proteins such as lymphokines which are produced by cells of the lymphoid system,

cytokines and chemokines that are produced by other cells in an immune response, and

which stimulate cells of the immune system. The immune system is composed of two

major subdivisions, the innate or nonspecific immune system and the adaptive or

specific immune system (Figure 1). The innate immune system is our first line of defense

against invading organisms while the adaptive immune system acts as a second line of

defense and also affords protection against re-exposure to the same pathogen. Each of

the major subdivisions of the immune system has both cellular and humoral components

by which they carry out their protective function (Figure 1). In addition, the innate

immune system also has anatomical features that function as barriers to infection.

Although these two arms of the immune system have distinct functions, there is interplay

between these systems (i.e., components of the innate immune system influence the

adaptive immune system and vice versa).

Although the innate and adaptive immune systems both function to protect

against invading organisms, they differ in a number of ways. The adaptive immune

system requires some time to react to an invading organism, whereas the innate

immune system includes defenses that, for the most part, are constitutively present and

ready to be mobilized upon infection. Second, the adaptive immune system is antigen

specific and reacts only with the organism that induced the response. In contrast, the

innate system is not antigen specific and reacts equally well to a variety of organisms.

Finally, the adaptive immune system demonstrates immunological memory. It

“remembers” that it has encountered an invading organism and reacts more rapidly on

subsequent exposure to the same organism. In contrast, the innate immune system

does not demonstrate immunological memory.

All cells of the immune system have their origin in the bone marrow and they

include myeloid (neutrophils, basophils, eosinpophils, macrophages and dendritic cells)

and lymphoid (B lymphocyte, T lymphocyte and Natural Killer) cells (Figure 2), which

differentiate along distinct pathways (Figure 3). The myeloid progenitor (stem) cell in the

bone marrow gives rise to erythrocytes, platelets, neutrophils, monocytes/macrophages

and dendritic cells whereas the lymphoid progenitor (stem) cell gives rise to the NK, T

cells and B cells. For T cell development the precursor T cells must migrate to the

thymus where they undergo differentiation into two distinct types of T cells, the CD4+ T

helper cell and the CD8+ pre-cytotoxic T cell. Two types of T helper cells are produced

in the thymus the TH1 cells, which help the CD8+ pre-cytotoxic cells to differentiate into

cytotoxic T cells, and TH2 cells, which help B cells, differentiate into plasma cells, which

secrete antibodies.

The main function of the immune system is self/non-self discrimination. This

ability to distinguish between self and non-self is necessary to protect the organism from

invading pathogens and to eliminate modified or altered cells (e.g. malignant cells).

Since pathogens may replicate intracellularly (viruses and some bacteria and parasites)

or extracellularly (most bacteria, fungi and parasites), different components of the

immune system have evolved to protect against these different types of pathogens. It is

important to remember that infection with an organism does not necessarily mean

diseases, since the immune system in most cases will be able to eliminate the infection

before disease occurs. Disease occurs only when the bolus of infection is high, when the

virulence of the invading organism is great or when immunity is compromised. Although

the immune system, for the most part, has beneficial effects, there can be detrimental

effects as well. During inflammation, which is the response to an invading organism,

there may be local discomfort and collateral damage to healthy tissue as a result of the

toxic products produced by the immune response. In addition, in some cases the

immune response can be directed toward self tissues resulting in autoimmune disease.

NON-SPECIFIC IMMUNITY

The elements of the non-specific (innate) immune system (Table 2) include

anatomical barriers, secretory molecules and cellular components. Among the

mechanical anatomical barriers are the skin and internal epithelial layers, the movement

of the intestines and the oscillation of broncho-pulmonary cilia. Associated with these

protective surfaces are chemical and biological agents.

A. Anatomical barriers to infections

1. Mechanical factors

The epithelial surfaces form a physical barrier that is very impermeable to most

infectious agents. Thus, the skin acts as our first line of defense against invading

organisms. The desquamation of skin epithelium also helps remove bacteria and other

infectious agents that have adhered to the epithelial surfaces. Movement due to cilia or

peristalsis helps to keep air passages and the gastrointestinal tract free from

microorganisms. The flushing action of tears and saliva helps prevent infection of the

eyes and mouth. The trapping effect of mucus that lines the respiratory and

gastrointestinal tract helps protect the lungs and digestive systems from infection.

2. Chemical factors

Fatty acids in sweat inhibit the growth of bacteria. Lysozyme and phospholipase

found in tears, saliva and nasal secretions can breakdown the cell wall of bacteria and

destabilize bacterial membranes. The low pH of sweat and gastric secretions prevents

growth of bacteria. Defensins (low molecular weight proteins) found in the lung and

gastrointestinal tract have antimicrobial activity. Surfactants in the lung act as opsonins

http://cancerweb.ncl.ac.uk/cgi-bin/omd?query=Defensins

http://cancerweb.ncl.ac.uk/cgi-bin/omd?query=phospholipase

http://cancerweb.ncl.ac.uk/cgi-bin/omd?query=Lysozyme

http://cancerweb.ncl.ac.uk/cgi-bin/omd?query=cilia

(substances that promote phagocytosis of particles by phagocytic cells).

3. Biological factors

The normal flora of the skin and in the gastrointestinal tract can prevent the

colonization of pathogenic bacteria by secreting toxic substances or by competing with

pathogenic bacteria for nutrients or attachment to cell surfaces.

B. Humoral barriers to infection

The anatomical barriers are very effective in preventing colonization of tissues by

microorganisms. However, when there is damage to tissues the anatomical barriers are

breached and infection may occur. Once infectious agents have penetrated tissues,

another innate defense mechanism comes into play, namely acute inflammation.

Humoral factors play an important role in inflammation, which is characterized by edema

and the recruitment of phagocytic cells. These humoral factors are found in serum or

they are formed at the site of infection.

1. Complement system – The complement system is the major humoral non-specific

defense mechanism (see complement chapter). Once activated complement can lead to

increased vascular permeability, recruitment of phagocytic cells, and lysis and

opsonization of bacteria.

2. Coagulation system – Depending on the severity of the tissue injury, the coagulation

system may or may not be activated. Some products of the coagulation system can

contribute to the non-specific defenses because of their ability to increase vascular

permeability and act as chemotactic agents for phagocytic cells. In addition, some of the

products of the coagulation system are directly antimicrobial. For example, beta-lysin, a

protein produced by platelets during coagulation can lyse many Gram positive bacteria

by acting as a cationic detergent.

3. Lactoferrin and transferrin – By binding iron, an essential nutrient for bacteria, these

proteins limit bacterial growth.

4. Interferons – Interferons are proteins that can limit virus replication in cells.

5. Lysozyme – Lysozyme breaks down the cell wall of bacteria.

http://cancerweb.ncl.ac.uk/cgi-bin/omd?query=chemotactic

http://cancerweb.ncl.ac.uk/cgi-bin/omd?query=opsonization

http://pathmicro.med.sc.edu/ghaffar/complement.htm

http://cancerweb.ncl.ac.uk/cgi-bin/omd?phagocytes

http://cancerweb.ncl.ac.uk/cgi-bin/omd?query=edema

6. Interleukin-1 – Il-1 induces fever and the production of acute phase proteins, some of

which are antimicrobial because they can opsonize bacteria.

Cellular barriers to infection

Part of the inflammatory response is the recruitment of polymorphonuclear eosinophiles

and macrophages to sites of infection. These cells are the main line of defense in the

non-specific immune system.

1. Neutrophils – Polymorphonuclear cells (PMNs, figure 4) are recruited to the site of

infection where they phagocytose invading organisms and kill them intracellularly. In

addition, PMNs contribute to collateral tissue damage that occurs during inflammation.

2. Macrophages – Tissue macrophages (figure 5, 6, 7) and newly recruited monocytes

(figure 4 and 8), which differentiate into macrophages, also function in phagocytosis and

intracellular killing of microorganisms. In addition, macrophages are capable of

extracellular killing of infected or altered self target cells. Furthermore, macrophages

contribute to tissue repair and act as antigen-presenting cells, which are required for the

induction of specific immune responses.

3. Natural killer (NK) and lymphokine activated killer (LAK) cells – NK and LAK cells can

nonspecifically kill virus infected and tumor cells. These cells are not part of the

inflammatory response but they are important in nonspecific immunity to viral infections

and tumor surveillance.

4. Eosinophils – Eosinophils (figure 6a and b) have proteins in granules that are effective

in killing certain parasites.

PHAGOCYTOSIS AND INTRACELLULAR KILLING

A. Phagocytic cells

1. Neutrophiles/Polymorphonuclear cells

http://cancerweb.ncl.ac.uk/cgi-bin/omd?eosinophil

PMNs are motile phagocytic cells that have lobed nuclei. They can be identified

by their characteristic nucleus or by an antigen present on the cell surface called CD66.

They contain two kinds of granules the contents of which are involved in the

antimicrobial properties of these cells. The primary or azurophilic granules, which are

abundant in young newly formed PMNs, contain cationic proteins and defensins that can

kill bacteria, proteolytic enzymes like elastase, and cathepsin G to breakdown proteins,

lysozyme to break down bacterial cell walls, and characteristically, myeloperoxidase,

which is involved in the generation of bacteriocidal compounds. The second type of

granule found in more mature PMNs is the secondary or specific granule. These contain

lysozyme, NADPH oxidase components, which are involved in the generation of toxic

oxygen products, and characteristically lactoferrin, an iron chelating protein and B12-

binding protein.

2. Monocytes/Macrophages

Macrophages are phagocytic cells that have a characteristic kidney-shaped

nucleus. They can be identified morphologically or by the presence of the CD14 cell

surface marker. Unlike PMNs they do not contain granules but they have numerous

lysosomes which have contents similar to the PNM granules.

B. Response of phagocytes to infection

Circulating PMNs and monocytes respond to danger (SOS) signals generated at

the site of an infection. SOS signals include N-formyl-methionine containing peptides

released by bacteria, clotting system peptides, complement products and cytokines

released from tissue macrophages that have encountered bacteria in tissue. Some of

the SOS signals stimulate endothelial cells near the site of the infection to express cell

adhesion molecules such as ICAM-1 and selectins which bind to components on the

surface of phagocytic cells and cause the phagocytes to adhere to the endothelium.

Vasodilators produced at the site of infection cause the junctions between endothelial

cells to loosen and the phagocytes then cross the endothelial barrier by “squeezing”

between the endothelial cells in a process called diapedesis.

http://cancerweb.ncl.ac.uk/cgi-bin/omd?query=diapedesis&action=Search+OMD

http://cancerweb.ncl.ac.uk/cgi-bin/omd?query=N-formyl-methionine

http://cancerweb.ncl.ac.uk/cgi-bin/omd?query=defensin&action=Search+OMD

http://cancerweb.ncl.ac.uk/cgi-bin/omd?azurophil

Once in the tissue spaces some of the SOS signals attract phagocytes to the

infection site by chemotaxis (movement toward an increasing chemical gradient). The

SOS signals also activate the phagocytes, which results in increased phagocytosis and

intracellular killing of the invading organisms.

Initiation of Phagocytosis

Phagocytic cells have a variety of receptors on their cell membranes through which

infectious agents bind to the cells. These include:

1. Fc receptors – Bacteria with IgG antibody on their surface have the Fc region

exposed and this part of the Ig molecule can bind to the receptor on phagocytes.

Binding to the Fc receptor requires prior interaction of the antibody with an

antigen. Binding of IgG-coated bacteria to Fc receptors results in enhanced

phagocytosis and activation of the metabolic activity of phagocytes (respiratory

burst).

2. Complement receptors – Phagocytic cells have a receptor for the 3rd component

of complement, C3b. Binding of C3b-coated bacteria to this receptor also results

in enhanced phagocytosis and stimulation of the respiratory burst.

3. Scavenger receptors – Scavenger receptors bind a wide variety of polyanions on

bacterial surfaces resulting in phagocytosis of bacteria.

4. Toll-like receptors – Phagocytes have a variety of Toll-like receptors (Pattern

Recognition Receptors or PRRs) which recognize broad molecular patterns

called PAMPs (pathogen associated molecular patterns) on infectious agents.

Binding of infectious agents via Toll-like receptors results in phagocytosis and the

release of inflammatory cytokines (IL-1, TNF-alpha and IL-6) by the phagocytes.

D. Phagocytosis

After attachment of a bacterium, the phagocyte begins to extend pseudopods

around the bacterium. The pseudopods eventually surround the bacterium and

engulf it, and the bacterium is enclosed in a phagosome. During phagocytosis the

granules or lysosomes of the phagocyte fuse with the phagosome and empty their

contents. The result is a bacterium engulfed in a phagolysosome which contains the

contents of the granules or lysosomes.

http://cancerweb.ncl.ac.uk/cgi-bin/omd?query=phagolysosome

http://cancerweb.ncl.ac.uk/cgi-bin/omd?query=phagosome

http://cancerweb.ncl.ac.uk/cgi-bin/omd?query=pseudopods&action=Search+OMD

IV. THE PATIENT AND HIS ILLNESS (BOOK-BASED)

Synthesis of the Disease

Lifted from emedicine.com

General Description

Neonatal sepsis may be categorized as early or late onset. Eighty-five percent of

newborns with early-onset infection present within 24 hours, 5% present at 24-48 hours,

and a smaller percentage of patients present between 48 hours and 6 days of life. Onset

is most rapid in premature neonates. Early-onset sepsis syndrome is associated with

acquisition of microorganisms from the mother. Transplacental infection or an ascending

infection from the cervix may be caused by organisms that colonize in the mother's

genitourinary tract, with acquisition of the microbe by passage through a colonized birth

canal at delivery. The microorganisms most commonly associated with early-onset

infection include group B Streptococcus (GBS), Escherichia coli, Haemophilus

influenzae, and Listeria monocytogenes.(emedicine.com)

Late-onset sepsis syndrome occurs at 7-90 days of life and is acquired from the

caregiving environment. Organisms that have been implicated in causing late-onset

sepsis syndrome include coagulase-negative staphylococci, Staphylococcus aureus, E

coli, Klebsiella, Pseudomonas, Enterobacter, Candida, GBS, Serratia, Acinetobacter,

and anaerobes. The infant's skin, respiratory tract, conjunctivae, gastrointestinal tract,

and umbilicus may become colonized from the environment, leading to the possibility of

late-onset sepsis from invasive microorganisms. Vectors for such colonization may

include vascular or urinary catheters, other indwelling lines, or contact from caregivers

with bacterial colonization.(emedicine.com)

Risk Factors

The most common risk factors associated with early-onset neonatal sepsis

include maternal GBS colonization (especially if untreated during labor), premature

rupture of membranes (PROM), preterm rupture of membranes, prolonged rupture of

membranes, prematurity, maternal urinary tract infection, and chorioamnionitis.

Risk factors also associated with early-onset neonatal sepsis include low Apgar

score (<6 at 1 or 5 min), maternal fever greater than 38°C, maternal urinary tract

infection, poor prenatal care, poor maternal nutrition, low socioeconomic status,

recurrent abortion, maternal substance abuse, low birth weight, difficult delivery, birth

asphyxia, meconium staining, and congenital anomalies. Risk factors implicated in

neonatal sepsis reflect the stress and illness of the fetus at delivery, as well as the

hazardous uterine environment surrounding the fetus before delivery.

Late onset sepsis is associated with the following risk factors: prematurity, central

venous catheterization (duration of >10 d), nasal cannula continuous positive airway

pressure use, H2 blocker/proton pump inhibitor use, and gastrointestinal tract pathology.

Race- Black infants have an increased incidence of GBS disease and late-onset sepsis.

This is observed even after controlling for risk factors of low birth weight and decreased

maternal age.

Sex- The incidence of bacterial sepsis and meningitis, especially for gram-negative

enteric bacilli, is higher in males than in females.

Age- Premature infants have an increased incidence of sepsis. The incidence of sepsis

is significantly higher in infants with very low birth weight (<1000 g), at 26 per 1000 live

births, than in infants with a birth weight of 1000-2000 g, at 8-9 per 1000 live births. The

risk for death or meningitis from sepsis is higher in infants with low birth weight than in

full-term neonates.

Signs and Symptoms

The clinical signs of neonatal sepsis are nonspecific and are associated with

characteristics of the causative organism and the body's response to the invasion. These

nonspecific clinical signs of early sepsis syndrome are also associated with other

neonatal diseases, such as respiratory distress syndrome (RDS), metabolic disorders,

intracranial hemorrhage, and a traumatic delivery. Given the nonspecific nature of these

signs, providing treatment for suspected neonatal sepsis while excluding other disease

processes is prudent.

Cardiac signs: In overwhelming sepsis, an initial early phase characterized by

pulmonary hypertension, decreased cardiac output, and hypoxemia may occur.

These cardiopulmonary disturbances may be due to the activity of granulocyte-

derived biochemical mediators, such as hydroxyl radicals and thromboxane B2,

an arachidonic acid metabolite. These biochemical agents have vasoconstrictive

actions that result in pulmonary hypertension when released in pulmonary tissue.

A toxin derived from the polysaccharide capsule of type III Streptococcus has

http://www.emedicine.com/PED/topic1993.htm

also been shown to cause pulmonary hypertension. The early phase of

pulmonary hypertension is followed by further progressive decreases in cardiac

output with bradycardia and systemic hypotension. The infant manifests overt

shock with pallor, poor capillary perfusion, and edema. These late signs of shock

are indicative of severe compromise and are highly associated with mortality.

Metabolic signs: Hypoglycemia, hyperglycemia, metabolic acidosis, and jaundice

all are metabolic signs that commonly accompany neonatal sepsis syndrome.

The infant has an increased glucose requirement because of sepsis. The infant

may also have impaired nutrition from a diminished energy intake. Metabolic

acidosis is due to a conversion to anaerobic metabolism with the production of

lactic acid. When infants are hypothermic or they are not kept in a neutral thermal

environment, efforts to regulate body temperature can cause metabolic acidosis.

Jaundice occurs in response to decreased hepatic glucuronidation caused by

both hepatic dysfunction and increased erythrocyte destruction.

Neurologic signs: Meningitis is the common manifestation of infection of the CNS. It is

primarily associated with GBS (36%), E coli (31%), and Listeria species (5-10%)

infections, although other organisms such as S pneumoniae, S aureus, Staphylococcus

epidermis, H influenzae, and species of Pseudomonas,

IV. The patient and His Illness (Client-Centered)

General Description

As for Baby Boy V, he had an early-onset neonatal sepsis. A type of sepsis

acquired from the mother and/or before delivery. Early-onset neonatal sepsis most

often appears within 24 hours of birth

.

Risk Factors of Baby Boy V includes

Male- it is said that neonatal sepsis is common to male infants than female.

Maternal UTI- baby boy V’s mother had UTI during the third trimester

Enterobacter Cloacae Infection- the organism was found in his blood culture

Poor maternal nutrition- his mother likes eating sweet and salty foods during her

pregnancy.

Low socio-economic status- it is said by his mother that their were just passing

by in their life as evidence by their monthly income of P10,000.

Difficult delivery- his mother verbalized of having a difficult labor.

Stress and illness of the fetus at delivery- as evidenced by the presence of caput

succedaneum.

Signs and Symptoms

The patient experienced:

edema on extremities- experienced from 06-24-08 to 06-28-08

Poor suck and demand

Instability in thermoregulation

Less active

Clinical Signs includes:

(+) blood culture- result was positive of enterobacter cloacae

Results in 06-27-08

Increased WBC count of 10.3 g/L

Results in 06-24-08

Decreased Platelet Count of 120 g/L

Results in 06-24-08

Increased B1B2 increased

Results in 06-28-08

PATHOPHYSIOLOGY (BOOK-CENTERED)

Predisposing FactorGenderRaceAge- <35 wks. AOG

Precipitating FactorEarly-Onset

- Maternal Pyrexia - Recurrent Abortion- Infection - Maternal Substance Abuse

Bacteria- S. Aureus, E. Coli, - Low birth WeightChlamydia, Enterobacter - Difficult Delivery

Virus- Enterovirus, adenovirus, - Meconium StainingViral dses. - Stress and illness of the fetus

- Prolonged ROM at delivery- PROM - hazardous uterine environment- Maternal UTI- Chorioamnionitis- Poor prenatal care- Poor maternal nutrition- Low socio-economic status

Late-Onset- Prolonged Hospitalization- Presence of foreign body- Cross infection- Birth weight- H2 blocker/ proton pump inhibitor use- GI pathology

Initial Insult (Bacteria, viral, traumatic, thermal

Immune Body will respond

Systemic ReactionPathogens enters the body

Neutrophils move in

Chemotaxic occurs

Opsonization causes phagocytosis

Monocytes kills pathogens

WBC

InfectionAntibiotics

Systemic Reaction

Pro-Inflammatory Response(Cytokines)

TNF

Anti-Inflammatory Response(IL-10)

Balance Imbalance

Production of Thrombi

Coagulation Promotes Clot Formation

Homeostasis

Increase activity of Fibrinolysis Inhibitors

MARS

Decrease fibrinolysis

Platelet destruction

Decrease PC

Sepsis

Sepsis

Initial Phase (1-3 days) Late Phase

Body compensates

Slow things down

Decrease systemic vascular

resistance

Warm, bounding pulses, with brisk

capillary refill, edema

Hypometabolism

Decreased energy expenditure

Decrease CO

Decrease o2 consumption

Vasoconstriction

Hyperdrive

Poor perfusion

Inadequate o2 delivery and nutrients to tse.

Tse. hypoxia

Cool extremities, poor peripheral

pulses, hypotension

Lactic acidosis

Metabolic acidosis

Diminished energy intake

Impaired nutrition

shock

MODS

Impaired pulmonary

function

Acute renal failure

Hepatic dysfunction

DIC

DEATH

BilirubinBUN

Crea

Fluid therap

y

O2 therap

y

- Pathophysiology

Symptoms

Lab tests

Treatment

PATHOPHYSIOLOGY (CLIENT-CENTERED)

Predisposing FactorGender-Male

Precipitating FactorEarly-Onset

Maternal Pyrexia (38 oC) Infection

Bacteria- Enterobacter Cloacae culture positive Difficult Delivery Stress and illness of the fetus at delivery

PROM Maternal UTI Poor maternal nutrition Low socio-economic status hazardous uterine environment

Initial Insult (Bacteria)

Immune Body will respond

Systemic ReactionPathogens enters the body

Neutrophils move in

Chemotaxic occurs

Opsonization causes phagocytosis

Monocytes kills pathogens

WBC- 10.3

(06-24-08)

InfectionAntibiotics

Systemic Reaction

Pro-Inflammatory Response(Cytokines)

TNF

Anti-Inflammatory Response(IL-10)

Imbalance

Increase activity of Fibrinolysis Inhibitors

MARS

Decrease fibrinolysis

Platelet destruction

Decrease PC130g/L -- 06-24-08120g/L—06-28-08120g/L—07-02-08

Sepsis

Sepsis

Initial Phase (1-3 days) Late Phase

Body compensates

Slow things down

Decrease systemic vascular

resistance

Warm, bounding pulses, with brisk

capillary refill, edema (06-24-08

to 06-28-08)

Hypometabolism

Decreased energy expenditure

Decrease CO

Decrease o2 consumption

Vasoconstriction

Hyperdrive

Poor perfusion

Inadequate o2 delivery and nutrients to tse.

Tse. hypoxia

Cool extremities,

poor peripheral pulses,

hypotension

Lactic acidosis

Metabolic acidosis

Diminished energy intake

Impaired nutrition

shock

MODS

Acute renal failure

Hepatic dysfunction

06-28-08Total Bili 5.35 mg/glDirect Bili 2.58 mg/dlIndirect Bili 2.77 mg/dl

06-25-08BUN 8.1 mg/dlCrea 0.68 mg/dl

Fluid thera

py

O2 therap

y

AntibioticsTazobactam

and amikacin

Poor suck and demand to feedings- Pathophysiology

Symptoms

Lab tests

Treatment

V. THE PATIENT AND HIS CARE

A. Medical Management

a. IVFs

MEDICAL MANAGEMENT/

TREATMENT

DATE ORDERED DATE PERFORMED

DATE CHANGED

GENERAL DESCRIPTION

INDICATION(S)/ PURPOSE(S)

CLIENT’S RESPONSE TO THE TREATMENT

Dextrose 10% in Water

(D10W)

D10W—75cc in soluset

at 6-7 ugtts/min

DO: 06-25-08

DP: 06-25-08

DC: 06-27-08

This medication is a

solution given by vein

(through an IV). It is used

to supply water and

calories to the body. It is

also used as a mixing

solution (diluent) for other

IV medications. Dextrose

is a natural sugar found in

the body and serves as a

major energy source.

When used as an energy

source, dextrose allows

the body to preserve its

muscle mass.

Intravenous solutions

containing dextrose are

indicated for parenteral

replenishment of fluid

and minimal

carbohydrate calories as

required by the clinical

condition of the patient.

It is also use as a mixing

solution for other IV

medication. D10W is

used for patients >1500

kgs of weight.

The fluid was given

through an umbicath.

The patient adhered well

on his treatment by not

showing any signs of

dehydration or any side

effects of the said fluid.


Prior:

Verify with the doctor’s order.

Explain the indication to the mother.

During:

Label the IVF bottle and tubings indicating the date and time it was started with the ordered regulation.

Maintain and regulate at the rate prescribed.

Handle IVF site aseptically.

MEDICAL

MANAGEMENT/

TREATMENT

DATE ORDERED

DATE PERFORMED

DATE CHANGED

GENERAL

DESCRIPTION

INDICATION(S)/

PURPOSE(S)

CLIENT’S RESPONSE

TO THE TREATMENT

D5IMB—94.4 cc via

soluset @ 8-9

ugtts/min

DO: 06-27-08

DP: 06-27-08

Till discharged

This solution is used to

provide lost nutrients in

the body.

It was given to the

patient to maintain fluid

balance in the body and

to prevent dehydration.

The patient was able to

maintain body fluid and

has not manifested any

signs and symptoms of

dehydration. He had

also not experienced

any side effects or any

untoward reaction on his

IV site.

Change solution and IVF tubings as per hospital policy.

After:

Check the site for any signs/symptoms of infection.

b. Drugs

Name of DrugGeneric and Brand

Name

Date OrderedDate Taken or given

Date Changed

Route of Administration

Dosage andFrequency

General Action and Indication/ purpose

Client’s Response to medication with actual

side effects

Ampicillin

(Sodampen)

06-25-08

06-25-08/ 10:00am

06-27-08/ 10:00 pm

125 mg, IV every 12o Penicillin,

Anti-infective Drug

- indicated for

septicemia

- The patient did not

manifest any allergic or

untoward reaction of the

drug

- Did not develop any

side effects

- Base on the result of

the blood culture,

ampicillin is resistant to

the organism found in

the culture, the reason

why the drug was

changed.


Name


Date Changed


Dosage andFrequency



side effects

Cefotaxime

(Claforan)

06-25-08

06-25-08/ 12:00 NN

06-27-08/ 12:00 MN

125 mg, IV every 12o Cephalosphorin

Anti-infective

- for septicemia caused

by a susceptible

microorganism




drug


side effects

- Base on the result of

the blood culture,

Claforan is also resistant

to the organism found in

the culture, the reason

why the drug was also

changed.


Name


Date Changed


Dosage andFrequency



side effects

Piperacillin-Tazobactam

(Tazocin)

06-27-08

06-27-08/ 06:00 am

125 mg, IV every 12o Antibiotic

- piperacillin/tazobactam

consists of a semi-

synthetic penicillin and a

beta-lactamase inhibitor.

Tazobactam enhances and

extends the antibiotic

spectrum of piperacillin to

include beta-lactamase

producing bacteria

normally resistant to

piperacillin

- indicated for the

treatment of moderate to

severe infections caused

by susceptible strains of

bacteria




drug


side effects

- The drug is sensitive

to the microorganism

found on his culture,

making it effective as a

treatment for his

condition.

- WBC is normal prior to

discharged


Name


Date Changed


Dosage andFrequency



side effects

Amikacin Sulfate

(Amikin)

06-27-08

06-27-08/ 08:00 pm

38 mg, IV, OD Aminoglycoside

Antibiotic

- treatment of serious

infections caused by

susceptible strains of

gram-negative bacteria




drug


side effects

- The drug is sensitive

to the microorganism

found on his culture,

making it effective as a

treatment for his

condition.

- WBC is normal prior to

discharged


Prior:

Check for any hypersensitivity reaction (Skin testing was not indicated because it is believed that a neonate would not develop any

hypersensitivity reaction to a certain drug until 6 months of age due to his/her natural antibody.)

Check for the patency of the IV site

Check for the 10 R’s

Check for its expiration date

Maintain sterility during the preparation

During:

Give the drug slow IV

Maintain sterile technique during the administration

After:

Monitor for any untoward reaction

Document the time or any reaction in the chart

c. Diet

TYPES OF DIET

DATE ORDEREDDATE STARTEDDATE CHANGED

GENERAL DESCRIPTION


SPECIFIC FOODS TAKEN

CLIENT’S RESPONSE AND/ OR REACTION TO

DIET

Nothing Per

Orem

(NPO)

06-24-08

06-24-08 x 4 hours

(10:00am- 02:00 pm)

06-24-08

Restriction to take

food via mouth or

oral route.

Nothing per orem is a

standard order in NICU

for a new born neonate.

It is usually ordered for

four hours. NPO was

done to prevent

aspiration since on the

first hours of life the

neonate still has lots of

secretions.

None Patient did not

receive anything by

mouth. No

untoward reaction

was noted.

Nursing

Responsibilities

Prior: Check for the doctors order Assess client’s need Before prepare the appropriate diet for the patient be sure that proper hand washing is maintained

During:

TYPES OF DIET


GENERAL DESCRIPTION




DIET

1/4th oz. of

cooled

boiled

water

06-24-08

06-24-08 x 2 doses

every 3 hours

06-24-08

The patient is only

allowed to take

cooled boiled water

by mouth.

Cooled boiled water

was ordered to test if

the newborn can

tolerate his feedings.

Cooled boiled

water

Patient’s diet was

well tolerated. The

patient did not

vomit, but it is also

noted that the baby

has a fair to good

suck.

TYPES OF DIET


GENERAL DESCRIPTION




DIET

Feeding as

Tolerated

(FAT)

06-24-08

06-24-08

Till discharged

The patient is

allowed to take the

prescribed milk as

tolerated.

This diet is ordered to

prevent further

nutritional imbalances

and maintain patient’s

health

Milk The diet is well

tolerated; however,

the patient does not

always demand for

his feedings and

has fair to good

suck at first. But

before discharged

the patient already

has a good suck

and demanded

feedings

Give feedings with strict aspiration precaution

After:

Burped after each feedings

Place the baby on side-lying position after each feedings

Monitor if the feeding is well-tolerated

Note and document any untoward reaction.

d. Activity/Exercise*** no activity or exercise was ordered for the patient

C. Nursing Management1. Nursing Care Plans

a. Problem #1 Hyperthermia

Assessment Nursing Diagnosis

Scientific Explanation

Planning Intervention Rationale Expected Outcome

S-

O-The patient may manifest one or more of the following:

- Temperature above

Hyperthermia related to inflammatory process/ hypermetabolic state as evidenced by an increase in body temperature, warm skin and tachycardia

Due to the presence of an infectious agens, stimulation of the monocytes triggers the release of the pyrogenic cytokines that stimulate anterior hypothalamus which results in

Short-term:

After 30 minutes of nursing intervention the patient will maintain normal core temperature as evidenced by vital signs within normal limits and

Independent

1. Monitor neonate’s condition.

2. Monitor Vital signs

1. To determine the need for intervention and the effectiveness of therapy.

2. To have a baseline data

The patient shall maintain normal core temperature as evidenced by normal vital signs and normal laboratory results.

normal level (36 oC)

- Skin warm to touch

- Presence of tachycardia (above 160 bpm)

- Presence of tachypnea (above 60 bpm)

- WBC elevated

elevated thermoregulatory set point that leads to an increased heat conservation (Vasoconstriction) and increased heat production which results to Fever.

normal WBC level

Long Term:

After 3 days of NI, pt will still maintain normal core temperature as evidenced by normal vital signs and normal laboratory results.

3. Provide TSB

Interdependent

4. Ensure that all equipment used for infant is sterile, scrupulously clean. Do not share equipment with other infants

Dependent

5. Administer Anti-pyretics as ordered

3. Helps in lowering down the temperature

4. this would prevent the spread of pathogens to the infant from equipment

5. aids in lowering down temperature

b. Problem #2 Fluid volume deficit




S-

O-The patient may manifest:- decreased urine output- increased urine concentration- increased pulse rate

Fluid volume deficit related to failure of regulatory mechanism

Fluid volume deficit, or hypovolemia, occurs from a loss of body fluid or the shift of fluids into the third space one factor includes a failure of the regulatory mechanism of the newborn specifically

Short-term:

After 3 hours of nursing intervention the patient will be able to maintain fluid volume at a functional level as evidenced by individually adequate urinary output with normal specific

1. Monitor and record vital signs

2. Note for the causative factors that contribute to fluid volume deficit

1. To note for the alterations in V/S (decreased BP, Increased in PR and temp)

2. To assess what factor contributes to fluid volume deficit that may be given prompt intervention.

The patient shall be able to maintain fluid volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous

(above 160 bpm)- increased body temperature (above 36 oC)- decreased skin turgor- dry skin/ mucous membranes- elevated hct

hyperthermia gravity, stable vital signs, moist mucous membranes, good skin turgor and prompt capillary refill and resolution of edema.

Long Term:

After a couple of days the patient will still be able to maintain fluid volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor and prompt capillary refill and resolution of edema.

3. Provide TSB if patient has fever

4. Provide oral care by moistening lips & skin care by providing daily bath 5. Administer IV fluid replacement as ordered

6. Administer antipyretic drugs if patient has fever as ordered

3. To decrease temperature and provide comfort

4. To prevent injury from dryness

5. replaces fluid losses

6. to reduce body temperature

membranes, good skin turgor and prompt capillary refill and resolution of edema.

c. Problem #3 Ineffective Tissue Perfusion




S-

O-The patient may manifest one or more of the following:

- skin or temperature changes

- Weak pulses

- Edema- Inadequate

urine output

Ineffective tissue perfusion related to impaired transport of oxygen across alveolar and on capillary membrane

Since the body of the newborn is unable to compensate to the imbalances of the inflammatory response related to his condition the body tends to “hyperdrive” causing an inadequate oxygen in the tissues or capillary membrane leading to poor perfusion

Short-term:

After 3 hours of nursing intervention the patient will demonstrate increased perfusion as evidenced by warm and dry skin, strong peripheral pulses, normal vital signs, adequate urine output and absence of edema

Long Term:

After 3 days of NI, pt will maintain adequate perfusion AEB stable VS, warm

Independent

1. Monitor neonate’s condition.

2. Monitor Vital signs

3. Note quality and strength of peripheral pulses

4. Assess respiratory rate, depth, and quality

1. To determine the need for intervention and the effectiveness of therapy.

2. To have a baseline data

3. To asses pulse that may become weak or thready, because of sustained hypoxemia

4. To note for an increased respiration that occurs in response to direct effects of endotoxins on the respiratory center in the

The patient shall demonstrate increased perfusion as evidenced by warm and dry skin, strong peripheral pulses, normal vital signs, adequate urine output and absence of edema

and dry skin, absence of edema, adequate urine output and strong peripheral pulses.

5. Assess skin for changes in color, temperature and moisture

6. Elevate Head of Bead

7. Elevate affected extremities with edema once in a while

brain, as well as developing hypoxia, stress. Respirations can become shallow as respiratory insufficiency develops creating risk of acute respiratory failure.

5. To assess for compensatory mechanisms of vasodilation

6. To promote circulation /venous drainage

7. To reduce edema

Interdependent

8. Provide a quiet, restful atmosphere

Dependent

9. Administer oxygen as ordered

8. Conserves energy and lowers O2 demand

9. To maximize O2 availability for cellular uptake

d. Problem #4 Interrupted Breast Feeding




S-

O-The newborn is diagnosed with a certain disease (Sepsis)- The newborn is separated from his mother- The mother unable to provide breast milk to newborn continuously

Interrupted breastfeeding related to neonate’s present illness as evidenced by separation of mother to infant

Since the neonate is diagnosed for having a neonatal sepsis, the baby got separated from his mother and placed on a Neonatal Intensive Care Unit for better management and care. Interrupted breastfeeding develops since the mother is unable to breast fed the baby continuously due to their separation.

Short-term:

After 3 hours of nursing intervention and health teachings the mother will identify and demonstrate techniques to sustain lactation until breastfeeding is initiated

Long Term:

After 3 days of NI, the mother shall still be able to identify and demonstrate techniques to sustain lactation and identify techniques on how to provide the newborn with

1. Assess mother’s perception and knowledge about breastfeeding and extent of instruction that has been given.

2. Give emotional support to mother and accept decision regarding cessation/ continuation of breast feeding.

3. Demonstrate use of manual piston-type breast pump.

1. To know what the mother already knows and needed to know.

2. To assist mother to maintain breastfeeding as desired.

3. aid in feeding the neonate with breast milk without the mother breastfeeding the infant.

The mother shall be able to identify and demonstrate techniques to sustain lactation and identify techniques on how to provide the newborn with breast milk.

breast milk. 4. Review techniques for storage/use of expressed breast milk

5. Determine if a routine visiting schedule or advance warning can be provided

6. Provide privacy, calm surroundings when mother breast feeds.

7. Recommend for infant sucking on a regular basis

8. Encourage mother to obtain adequate rest, maintain fluid and nutritional intake, and schedule breast pumping every 3 hours while awake

4. To provide optimal nutrition and promote continuation of breastfeeding process

5. So that infant will be hungry/ ready to feed

6. To promote successful infant feeding

7. Reinforces that feeding time is pleasurable and enhances digestion.

8. to sustain adequate milk production and breast feeding process

e. Problem # 5 Risk for impaired parent/ infant attachment




S-

O-The newborn is diagnosed with a certain disease (Sepsis)- the newborn is hospitalized- The newborn is separated from his parents

Risk for Impaired parent/ neonates Attachment related to neonates physical illness and hospitalization.

Due to the newborn’s physical illness and hospitalization, the parents may have fear on how to handle their baby since the baby is on its fragile state and needed extra care. And since he is the 1st child hospitalized in their family, the parents might still be unsure on how to take care of the baby.

Short-term:

After 3 hours of nursing intervention and health teachings the mother will identify and demonstrate techniques to enhance behavioral organization of the neonate

Long Term:

After discharge the parents will be able to have a mutually satisfying interactions with their newborn.

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 accomplish successfully

1. To know what the parents feelings about the situation.

2. Helps clarify realistic expectations

3. Enhances self-concept

the parents shall be able to have a mutually satisfying interactions with their newborn.

4. Recognize and provide positive feedback for nurturant and protective parenting behaviors

4. Reinforces continuation of desired behaviors

2. ACTUAL SOAPIERS

June 26, 2008

S - Ø

O - Seen baby on crib with ongoing IVF of D10W at 6-7 ugtts/min

via umbicath. He is less active and febrile, warm to touch, (+)

tachycardia and tachypnea, latest WBC result 11.5 g/L. Vital

signs taken and recorded are as follows:

RR-63 bpm

CR-175 bpm

Temp- 38.5oC

A - Hyperthermia related to inflammatory process/ hypermetabolic

state as evidenced by an increase in body temperature, warm skin

and tachycardia

P - After 1 hour of nursing interventions, the patient’s

temperature will decrease by 1 degree centigrade.

I - Assessed body temperature every hour until temperature

normalized.

- Assessed IV site, increased pulse and respirations.

- Monitored laboratory results.

- Performed tepid sponge bath.

- Washed hands before and after giving care.

- Used sterile technique for IV maintenance.

- Stretched bed linens.

E - Goal met after an hour the newborn’s temperature subsides to

37. 5 oC

June 26, 2008

S - Ø

O - warm to touch, (+) tachycardia and tachypnea, (+) edema on

extremities latest Hct result 0.64%. Urine output 5 grams in an

hour (diaper’s weight). Vital signs taken and recorded are as

follows:

RR-63 bpm

CR-175 bpm

Temp- 38.5oC

A - Fluid volume deficit related to failure of regulatory mechanism

P - After 3 hours of nursing intervention the patient will be able to

maintain fluid volume at a functional level as evidenced by

individually adequate urinary output with normal specific gravity,

stable vital signs, moist mucous membranes, good skin turgor and

prompt capillary refill and resolution of edema.

I - Monitored and recorded vital signs

- Noted for the causative factors that contribute to fluid volume

deficit

- Provided TSB

- Provided oral care by moistening lips & skin care by providing

daily bath

- Administered IV fluid replacement as ordered

- Monitored laboratory results.

- Washed hands before and after giving care.

- Stretched bed linens.

E - Goal partially met, after 3 hours the patient has stable vital signs

but still has edema and inadequate urine output. The edema

disappears on the 3rd day of interaction.

June 29, 2008

S - Ø

O - Seen baby in crib with ongoing IVF of D5IMB 113 cc via soluset

at 9-10 ugtts/min infusing well on his left hand. He is less active

and afebrile. With weak peripheral pulses and (+) edema. Vital

signs taken and recorded are as follows:

RR-48 bpm

CR-132 bpm

Temp- 36oC

A - Ineffective tissue perfusion related to impaired transport of oxygen

across alveolar and on capillary membrane

P - After 3 hours of nursing intervention the patient will demonstrate

increased perfusion as evidenced by warm and dry skin, strong

peripheral pulses, normal vital signs, adequate urine output and

absence of edema

I - Monitor neonate’s condition.

- Monitor Vital signs

- Note quality and strength of peripheral pulses

- Assess respiratory rate, depth, and quality

- Assess skin for changes in color, temperature and moisture

- Elevate Head of Bead

- Elevate affected extremities with edema once in a while

- Provide a quiet, restful atmosphere

E - Goal partially met, after 3 hours the patient has stable vital signs

and adequate urine output but still has edema. The edema

disappears on the 3rd day of interaction.

July 01, 2008

S - Ø

O - Seen baby in crib with ongoing IVF of D5IMB 98 cc via soluset at

7-8 ugtts/min infusing well on his left hand. He is active and

afebrile. He has good cry, good suck and demanded feedings.

Vital signs taken and recorded are as follows:

RR-45 bpm

CR-135 bpm

Temp- 36.8oC

A - Interrupted breastfeeding related to neonate’s present illness as

evidenced by separation of mother to infant

P - After 3 hours of nursing intervention and health teachings the

mother will identify and demonstrate techniques to sustain

lactation until breastfeeding is initiated

I - Assessed mother’s perception and knowledge about

breast feeding and extent of instruction that has been given.

- Gave emotional support to mother

- Encouraged use of manual piston-type breast pump.

- Reviewed techniques for storage/use of expressed breast milk

- Determined if a routine visiting schedule or advance warning can

be provided

- Provided privacy, calm surroundings when mother breast feeds.

- Recommended infant sucking on a regular basis

- Encouraged mother to obtain adequate rest, maintain fluid and

nutritional intake, and schedule breast pumping every 3 hours

while awake

E - Goal met after 3 hours of nursing intervention the mother had

identified and demonstrated techniques to sustain lactation and

identified techniques on how to provide the newborn with breast

milk.

VI. CLIENT'S DAILY PROGRESS

DAYSADMISSIO

N DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7 DISCHARG

E

6/24/20086/25/200

86/26/200

86/27/200

86/28/200

86/29/200

86/30/200

87/1/200

8 7/2/2008Nursing Problems 1. Hyperthermia * 2. Fluid volume deficit * * * * 3. Ineffective Tissue Perfusion * * * * 4. Interrupted Breast Feeding * * * * * * * * *5. Risk for impaired parent/ infant attachment * * * * * * * * *Vital Signs

PR 135 bpm 133 bpm175 bpm 143 bpm 138 bpm

132 bpm 148 bpm

135 bpm 128 bpm

RR 43 bpm 44 bpm 63 bpm 35 bpm 42 bpm 48 bpm 38 bpm 45 bpm 42 bpm

Temp 36.7oC 36.2oC 38.5oC 36.7oC 36.5oC 36oC 36.3oC 36.8oC 36.2oCDiagnostic & Laboratory Procedure

CBC with PC * * * U/A *

BUN, Crea * B1B2 * HGT *

Blood GS/CS * CXRAY *

Baby gram * Medical Management

D10W * * * D5IMB * * * * * *

Drugs

Ampicillin * * *

Cefotaxime * * *

Piperacillin-Tazobactam * * * * * *

Amikacin Sulfate * * * * * *Diet

NPO * CBW * FAT * * * * * * * * *

Activity/Exercise N/A N/A N/A N/A N/A N/A N/A N/A N/ASurgical Management N/A N/A N/A N/A N/A N/A N/A N/A N/A

VII. DISCHARGE PLANNING

a. General Condition of Client upon Discharge

Baby Boy V, one day prior to discharge, is active and afebrile. He already

demands for his feedings and has good suck and well-tolerated feedings. He has

negative edema on his extremities. He is also not ill-looking unlike before. But since

that they were not that financially stable Baby Boy V is discharged with a heplock for the

continuation of his antibiotics. He is well-flexed, with full range of motion and with

spontaneous movement. His overall health condition is generally good.

b. METHOD

M - Medication

- Piperacillin-Tazobactam 125 mg/IV every 12 hours (7am- 7pm)

- Amikacin 38 mg, IV once a day (10 am)

E - Exercise

- Stressed that the baby sleeps most often times

T - Treatment

- Stressed importance of complying with the medications

H - Health Teachings

- Instructed Mother to bring back the baby in the hospital for his medication

- Instructed Mother on the time the medication will be given

- Instructed Mother for the drug’s side effect which includes constipation;

diarrhea; dizziness; headache; indigestion; nausea; pain, swelling, or

redness at the injection site; sleeplessness; vomiting.

- Instructed Mother of the importance of breastfeeding

- Instructed Mother on Proper Breastfeeding

- Instructed Mother to expose the baby to sunlight at 6:00 am to 10:00 am

- Instructed Mother that formula milk is only good for 4 hours

- Instructed Mother on strict aspiration precaution

- Instructed Mother to burped the baby after each feedings

- Instructed Mother to bathe daily their aby

D - Diet

- Instructed Mother to feed the baby as tolerated with strict aspiration

precaution

VIII. SUMMARY OF FINDINGS

The researcher has personally handled a case with an early onset neonatal

sepsis. With the information gathered and observed about Neonatal Sepsis, the

researcher was able to accomplish the objectives made.

Neonatal Sepsis is a neonatal infection of the blood that usually spreads

throughout the body. It has 2 types: the early-onset neonatal sepsis which was cause

by maternal factors and was usually brought by an infection develop before delivery.

Late-onset neonatal sepsis on the other hand was cause by unsterilility, be it from the

medical equipment, and or directly from the medical staff. Clinical signs and symptoms

of neonatal sepsis includes: body temperature changes, breathing problems, diarrhea,

low blood sugar, reduced movements, reduced sucking, seizures, slow heart rate,

swollen belly area, vomiting, yellow skin and whites of the eyes (jaundice). Diagnostic

procedures includes but not limited to: CBC, Blood GS/CS, X-ray, and UA. The most

effective method in the diagnosis of neonatal sepsis is by blood GS/CS. The main

treatment of neonatal sepsis is by administration of antibiotics and IV fluids, treatments

are also directed towards physical signs and symptoms. Different nursing care plans

can be obtained from Neonatal sepsis; it includes but is not limited to Hyperthermia,

Fluid volume deficit, Ineffective Tissue Perfusion, Interrupted Breast Feeding, Risk for

impaired parent/ infant attachment. During the process, the family is also included in the

plan of care. The researcher has also involved the family especially the mother in the

patients plan of care.

IX. CONCLUSIONS

Based on the researchers experience neonatal sepsis is not a very crucial case

although there are lots of reported cases with severe neonatal sepsis. Onset can be

prevented and be treated especially in the case of Late-onset neonatal sepsis. Prompt

treatment and adequate knowledge about the disease process is needed so that

complications won’t arise. On the other hand your care is not only confined to the

patient but extends significantly to the family. Knowledge and appropriate skills are part

of the tools of the nurse in order to be effective in handling a patient with neonatal

sepsis. Having a clear understanding of the disease and its process, with consideration

of the feelings and beliefs of the parents, most especially, will aid the nurse in skillfully

meeting patient’s needs.

X. RECOMMENDATIONS

At the course of the study, the researcher had found out that an in-depth

knowledge about the disease process will benefit not only the patient and its family but

also the nurse and the medical staff as well. The following is a list of recommendations

made by the researcher:

For the Nurses:

An in-depth knowledge should be acquired regarding the disease

condition so that proper treatment and prevention can be implemented.

Nurses must stress the need for good prenatal care and emphasize on

parents, the value of regular check-ups at well-baby clinics.

Proper infection control especially strict hand washing should be

implemented in the hospital because it is the most effective method in

controlling the spread of infection from staff to patient.

For the hospital:

sterility or cleanliness of hospital equipment should be maintained

Seminars about infection control should be conducted so that hospital

staff will be knowledgeable in the prevention of infection from

spreading.

For the patients care:

It was observed by the researcher that not all treatments was given

and ordered for the patient which includes using of phototherapy or bili

lights. The patient manifested yellowish discoloration of the skin or

jaundice and above normal results of bilirubin, yet phototherapy was

not ordered. Supportive treatment should all be given and is needed in

patients care.

XI. LEARNING DERIVED

At the end, the researcher realized that there is always something new to learn

that could help you be a better healthcare provider. It is indeed true that learning never

stops. And with the current trends that we have, it is part of the nurses’ responsibility to

keep themselves abreast with the new trends.

With the study made by the researcher, she had able to identify what neonatal

sepsis is, its risk factors, signs and symptoms of the disease, diagnostic procedure that

can be done to diagnose the disease, its medical treatment, prevention and nursing care

plan specific for the disease. With the knowledge learned during the study, the

researcher can be able to promote wellness by health teachings to mother and to

persons unfamiliar with the disease and prevention of the disease.

During the course of the study, the importance of proper infection control and

hand washing was found out for the prevention in the spread of infection especially in

the hospital.

The researcher found out that proper knowledge of the staff regarding the

disease condition of a patient with neonatal sepsis is vital for the betterment of her

service as one of the providers of care on a hospital.

This case study has also given the researcher the great opportunity to share his

personal experience in the care of a patient with neonatal sepsis.

XI. BIBLIOGRAPHY

Books:

Nelson Textbook of Pediatric. 17th edition. By Behrman.

Nurse’s Pocket Guide Diagnoses, Prioritized Intervention and Rationale. By

Doenges and et.al. 10th edition.2006

Nursing 2006 Drug Handbook. By Schilling, J. 26th edition. 2003

Laboratory and Diagnostic Test Handbook, M.K. Gaedeke, Addison – Wesley

Publishing Company, 2000

Care of the High – Risk Neonate, 7th Edition, Klaus and Fanaroff, W. B. Saunders

Company, 2000

Websites:

http://adam.about.com/encyclopedia/infectiousdiseases/Neonatal-sepsis.htm

http://www.childrenshospital.org/az/Site1574/mainpageS1574P0.html

http://www.bio-medicine.org/q/neonatorum/

http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=737031

http://www.medscape.com/viewarticle/483474

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http://infectious-diseases.jwatch.org/cgi/content/full/2000/301/4

http://www.who.int/whosis/whostat/2008/en/index.html

http://www.health.state.mn.us/divs/idepc/dtopics/neosep/index.html

http://www.co-infectiousdiseases.com/pt/re/coinfdis/abstract.00001432-

200808000-

00004.htm;jsessionid=L6tFbjhs45SMLlp1Gr38dXvNQmG53dBWyvnHQfdTCMw

P2NyNjpYT!536197444!181195628!8091!-1

http://www.gmanews.tv/largevideo/latest/25531/Neonatal-sepsis-deaths-at-

Ospital-ng-Makati-due-to-neglect---DOH

http://allnurses.com/forums/f205/nursing-care-plan-sepsis-neonatorum-

274406.html

http://allnurses.com/forums/f205/nursing-care-plan-sepsis-neonatorum-274406.html

http://allnurses.com/forums/f205/nursing-care-plan-sepsis-neonatorum-274406.html

http://www.gmanews.tv/largevideo/latest/25531/Neonatal-sepsis-deaths-at-Ospital-ng-Makati-due-to-neglect---DOH

http://www.gmanews.tv/largevideo/latest/25531/Neonatal-sepsis-deaths-at-Ospital-ng-Makati-due-to-neglect---DOH

http://www.co-infectiousdiseases.com/pt/re/coinfdis/abstract.00001432-200808000-00004.htm;jsessionid=L6tFbjhs45SMLlp1Gr38dXvNQmG53dBWyvnHQfdTCMwP2NyNjpYT!536197444!181195628!8091!-1



http://www.who.int/whosis/whostat/2008/en/index.html

http://infectious-diseases.jwatch.org/cgi/content/full/2000/301/4

http://www.wrongdiagnosis.com/n/neonatal_sepsis/signs.htm

http://www.medscape.com/viewarticle/483474

http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=737031

http://www.bio-medicine.org/q/neonatorum/

http://www.childrenshospital.org/az/Site1574/mainpageS1574P0.html

http://adam.about.com/encyclopedia/infectiousdiseases/Neonatal-sepsis.htm

Neonatal-Sepsis case

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