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College of Nursing
Case Study Neonatal Sepsis
As a partial requirement in NCM 104 – RLE
The term “sepsis” has been around since ancient times; modern definitions of “sepsis” were described in detail in the early 1990s, at a consensus conference convened by the American College of Chest Physicians and the Society of Critical Care Medicine. At that time, “sepsis” was described as a systemic response to a physiologic insult – including infectious and other etiologies – that lead to the development of further organ injury, ultimately culminating in multiple organ dysfunction syndromes. Neonatal sepsis, also termed Sepsis neonatorum, refers to a group of physical and laboratory findings that occur in response to invasive infection within the first 30 days of life. As will be discussed below, there are various infectious causes of neonatal sepsis; however, the pattern of presentation is quite similar in all cases, as is the approach to treatment. The importance of neonatal sepsis as a diagnosis is found in the fact that this diagnosis occurs in between 1 to 8 children per 1000 live births in the United States, and may be associated with a fatality rate of up to 30%. As such, it is essential that caregivers that are involved with the management of neonates have a reliable approach to the diagnosis and treatment of infants with sepsis, and that appropriate intervention be instituted in a timely manner. Neonatal Sepsis 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 Earlyonset 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. Neonatal sepsis can occur in any infant. However, the diagnosis is significantly more common in pre-term infants than full term infants, and can affect up to 30 to 1000 live births in the pre-term population. Sepsis is also more common in males than females, and in developing countries. Φ MORTALITY STATISTICS OF NEONATAL SEPSIS 2007 1. Pulmonary Tuberculosis 2. Pneumonia 3. CVA 4. Hypertension 5. Prematurity 6. Neonatal Sepsis 7. Malaria 8. CNS Infection 9. Vehicular Accident 10. Diarrhea Nurse Centered Objectives: At the end of this study, the student nurse will be able to: ♦ 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 themselves with effective inter-personal skills to emphasize health promotion and illness prevention. ♦ Impart the learning experience from direct patient care. No. 38 36 29 23 21 18 17 10 10 9 % 7.92 7.50 6.04 4.79 4.38 3.75 3.54 2.08 2.08 1.88 2008 1. CVA 2. Pneumonia 3. Pulmonary Tuberculosis 4. Hypertension 5. Vehicular Accident 6. Acute Gastroenteritis 7. Sepsis Neonatorum 8. Congestive Heart Disease 9. Malaria 10. Diabetes Mellitus No. 46 43 27 23 12 11 11 10 9 9 % 9.83 9.19 5.77 4.91 2.56 2.35 2.35 2.14 1.92 1.92
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. Personal History Ms. Sepsis is 25 years old and is of Ilokano descent because her mother was Ilokano. She was born on September 13, 1984 in Luna, La Union. She gave birth to her first born but she is not yet married. She lives in an apartment located in San Lorenzo Street, Sto. Domingo, Angeles City. She was admitted in a birthing home last September 8, 2009 at 03:00 pm. Baby Boy S was born on the same date at Our Lady of Good Birth Birthing Home near AMC via Cesarean Section I with an Apgar score of 7 and 8at 11:20 pm. Two days after birth, September 10, 2009, the baby was admitted at AMC Main ward because of reported continuous vomiting. Ms. Sepsis works as a lady guard in Angeles City Jail wherein she inspects the workers before entering the vicinity and she earns 13,000.00 per month. She spends 2,500.00 for rental fee, water and electricity, 5,000.00 for food, and she sends 4,000.00 to her parents in La Union, in a monthly basis. Then she has a monthly mobile bill of 800.00 for Globe line and 80.00 for a smart line. She made a loan to AFPMI in Manila for her giving birth; this was an agency which is readily available for police officers and workers like them. Ms. Sepsis finished tertiary education with commerce as her course. She got the work in the City Jail through her cousin. It was offered to her when she was still working as a clerk in an electronic company in Batangas. She decided to apply but she did not pass the height requirement so she was not accepted. Two years after, she applied again and got accepted. Now NURSING HISTORY
she has been working there for two years as of September 4, 2009. But she worked for 2 years and 5 months for JMP in their main headquarters. Ms. Sepsis and her family are under Iglesia Ni Cristo (INC). Being INC they have several beliefs such as if there was someone who is sick like having colds, flu, cough, their Jackono (officer) would pray over him because if it was severe would they bring him/her to the hospital. The mother of Ms. Sepsis told her to not watch television during her pregnancy and to not take cold bath after birth because they will use steamed leaves for bathing. She also told Ms. Sepsis to use abdominal binder while pregnant. Family-Health Illness History Within Ms. Sepsis’ family, only the eldest son has hypertension. No other hereditary disease was identified by her mother. But on her partners’ side, she stated that her partner had prostate cancer but was already cured that one of his testes was removed. History of Past Illness Ms. Sepsis had chicken pox; mumps at 6 years old which was treated with “tina” and mefenamic acid, and measles wherein her mother told her to eat “balot” for treatment. She had urinary tract infection before pregnancy which lasted for 5 days and was treated with Cefalexin and at her 5th month during pregnancy which lasted for about 1 week as well. History of Present Illness After birth, the baby was found to be having neonatal sepsis so he was admitted at AMC Main Ward. He was breastfed few hours after birth then with water by the mother and the nurse thereafter and he was still fine. Then he was fed with Bona, formula milk, and then he vomited. The family thought it was fine and normal but it became continuous so they notified her doctor and the baby was admitted after.
Φ Family Health Illness History (diagram)
LEGENDS: Deceased With hypertension Had prostate Cancer
With Neonatal Sepsis
OBSTETRICAL HISTORY Ms. Sepsis had her menarche at the age of 13 and lasted for a week. From then on, she had regular menstrual period every month with 5 days to 1 week maximum of delay. She gave birth to her first baby at the age of 25. She does not use OCP rather she uses withdrawal method as their contraceptive method. She does not live together with her partner because they are assigned in different areas.
Ms. Sepsis is not married to her boyfriend yet and has no plan of getting married as of the moment. She has an Obstetric record of Gravida 1, Para 1. She has a TPAL record of 1-0-0-1. Her last menstrual period was last December 15, 2008. So her estimated date of delivery was supposedly on September 22, 2009. She had given birth to her first baby, Baby Boy S last September 8, 2009 two weeks ahead from her EDD. She was brought earlier than her estimated date of confinement because she had an early contraction and abnormal fetal position and attitude. She had given birth via Cesarean Section I in Our Lady of Good Birth Birthing Home, which is a specialized clinic solely for giving birth. Ante-partal/ Pre-natal Preparation According to Ms. Sepsis 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 1 dose of tetanus toxoid vaccine from her doctor. She missed the second dose but her doctor said it was fine. Significant Trimestral Changes (1st – 3rd trimester) On the first trimester of her first pregnancy, she did not experience much change. She narrated that she once ate “bagoong with tomato” and vomited, since then she had not have the appetite for it. On the second trimester of her pregnancy, she noticed darkening of her neck, underarm and inguinal area. Third trimester pregnancy, she noticed stretch marks and experienced slight itchiness. Slight discomfort was felt all throughout the pregnancy period. During her second trimester of pregnancy, Ms. Sepsis had urinary tract infection. It was treated through oral antibiotics such as Cefalexin and by drinking lots of water
Last September 7, 2009 she felt contractions occurring at the interval of 5 minutes. At September 8, 2009 she saw brown blood and then clear secretions of about two spoonfuls. Then she was admitted at the same date at 03:00 pm. She took vitamins during the course of her pregnancy like Ferrous sulfate for the first trimester then Micron C for the second trimester then Terraferon for the last trimester. She drank Anmum but stopped at the 8th month as advised by her ob-gyne because the baby was already 5.28 pounds. III. PHYSICAL ASSESSMENT (IPPA-Cephalocaudal Approach) September 10, 2009 (12:15 am) P.A. of Baby Boy S Upon admission (lifted from the Chart) Vital signs: T: 36.5°C HR: 132 bpm Wt: 2.9 kg (-) Cleft lip and palate • • • • • Clear breath sound; no rales Normal respiratory rate and rhythm (NRRR) No murmur Normal Abdominal Bowel Sound (NABS) Soft full equal pulses
September 10, 2009 (04:00 pm) Initial Interaction P.A. of Baby Boy S Vital signs: HR: 165 bpm Temp: 37.2 mmHg
RR: 53 bpm
CEPHALO-CAUDAL APPROACH SKIN NAILS HEAD Hair and Scalp EYES Eyebrows are evenly distributed and symmetrically aligned Equal movements of eyebrows Eyelashes are equally distributed, curled slightly outward lids are edematous transient strabismus Bulbar conjunctiva are clear Palpebral conjunctiva are shiny, smooth and pink No edema or tearing of lacrimal sac Hair is black Hair is evenly distributed Silky, resilient hair No dandruff or flaking Normal skull configuration, rounded, smooth skull contour Smooth skull contour Absence of nodules or masses Symmetrical facial features and movements Flat anterior fontanel When palpated, the nail base is firm Tissue surrounding nails is intact Convex curve and pinkish nails Blanch test: prompt return of pink color less than 2 seconds Ruddy complexion With good skin turgor (negative tenting) Skin is warm to touch
Skull and Face
EARS NECK -
Anicteric sclerae Cornea are transparent, shiny and smooth Corneal reflex noted Pupil are equally round and receptive to light Iris is black in color
Auricles are symmetrical Auricles are firm, smooth, free from lesions and pain Tip of the ear is aligned with the outer canthus of eye Pinna recoils after it is folded intact startle reflex Symmetrical nares No flaring Nose is located symmetrically, midline of the face intact glabellar reflex Lips and buccal mucosa are pink in color, moist and smooth texture Tongue pink in color, slightly moist; veins not prominent Sores and ulceration are not evident. intact rooting reflex Presence of head lag Equal in size Areola is light brown in color No palpable lump Bilaterally the same No pain and tenderness upon palpation
NOSE AND SINUSES
MOUTH AND THROAT
BREAST AND AXILLAE
RESPIRATORY Symmetric with full chest expansion cylinder shaped slight sternal retractions Palpable arterial pulse Pulses are strong Rounded With bowel sounds during auscultation No abnormal lumps and hardened areas in the abdominal area Rugated scrotum Urinary meatus at tip of penis Symmetrical in shape Extremities are well flexed intact palmar grasp and babinski reflex
UPPER AND LOWER EXTREMITIES
IV. DIAGNOSTIC AND LABORATORY PROCEDURES Diagnostic/Laboratory Date Indications Results Normal Analysis and Procedures Ordered/ or Purposes Values Interpretation Date Results Hematology HCT (%) D.O. To aid 63.0 40.0The hematocrit is 09/09/2009 diagnosis of 54.0 increased D.R. – abnormal which is a sign of 09/09/2009 states of dehydration. hydration, polycythemia and anemia and aids in calculation of erythrocyte indices Platelet To evaluate platelet production To determine for presence of for further tests such as WBC differential infection and also for determination count 318 140-440 The platelet count is in normal amount. WBC is increased which indicates presence of infection.
WBC ct (x18/1)
Granulocytes (x10/1) (x10/91)
58 14.9 10.9
44.280.2 2.0-8.8 1.2-5.3 14-18 Hemoglobin is increased which indicates dehydration.
To measure the hemoglobin
Nursing Responsibilities: Patient Preparation: • •
Explain to the SO the indication/purpose of the test, that this test detects presence of infection and other abnormal conditions of the blood Explain to the SO the procedure that the test requires blood sample, and who will perform it. Tell the SO that the baby may feel discomfort from the needle puncture and pressure on the tourniquet. That the baby may struggle and cry.
Procedure & Post test care; • • • If hematoma develops at the site, apply warm soaks. Ensure sub dermal bleeding has stopped before removing pressure. If hematoma is large monitor pulses distal to the site. V. THE PATIENT AND HIS ILLNESS
Anatomy and Physiology The immune system is a complex array of organs, cells and chemicals that determine self from non-self identify potential dangers to the body and eliminate them by mounting an immune response. Most (but not all) infections result in lifelong immunity. Some infections are innocuous while others cause serious disease, permanent damage to the host and sometimes death. Rather than risk serious illness it is possible to vaccinate against a number of potentially serious diseases. Vaccination is offered from a young age against a number of diseases as an alternative to experiencing natural infection and the associated risks. It is important to immunize infants as soon as possible to protect against disease and the infant immune system is known to be effective and responsive. However, their immune system is naïve i.e. has not been exposed to any pathogens. Therefore the infant needs to develop immunity to every pathogenic organism it encounters. By the time of birth the baby will have large numbers of circulating antibody passed across the placenta from the mother. This antibody will protect the baby against some infections initially, until the baby forms its own immune response to pathogens.
Overview of the immune system
Our immune system protects us against viruses, bacteria and parasites which can cause infectious diseases. The immune system responds to antigens. An antigen is a substance that stimulates a specific immune response, especially the production of antibodies. Basically this involves shape recognition. Antigens are usually proteins or polysaccharides, but can be any type of molecule. Infectious agents such as viruses and bacteria have antigens which the immune system responds to. Vaccines contain antigens (often purified parts of the original organism). Types of Immunity The white blood cells of the immune system are produced in the marrow of our bones. The cells are carried in the blood to specialized organs such as lymph nodes, where they develop and communicate to launch immune responses against infections. We have three types of immunity: 1. Non-specific immunity – is a first line of defense and generally keeps infections from entering the body. Examples of this are skin (physical barrier), mucus,tears, stomach acid. 2. Innate immunity – is the second line of defense. In this situation certain white cells engulf infectious agents. These cells are capable of recognising antigens which are nonself (ie from an infectious agent), however they cannot recognize particular pathogens. For example, these cells would not be able to distinguish an influenza virus from a hepatitis virus, but they would be able to distinguish that there was a viral infection occurring. Over 90% of infections are controlled by these cells. However when the infection becomes too great these cells will alert the specific arm of the immune system. 3. Specific or adaptive immunity – This is the third line of defense. In this situation white blood cell called lymphocytes identify each antigen individually by recognizing different sequences of amino acids. This specific response initially takes longer to generate (4-7 days) than the non-specific arm but results in a memory to the specific antigen. The memory response becomes quickly activated. This means that when an individual is reinfected with the pathogen, this memory response will remove the infectious agent before it can cause disease (i.e. in 2-3 days). This is the response that vaccination targets.
What is different about the infant immune system?
The infants’ immune system is intact but immature at birth. Some vaccines such as BCG and Hepatitis B work well when they are administered at birth whereas others do not generate as strong a response. The main problem with babies’ immunity is that it is very naïve. At the time of birth babies have not been exposed to any pathogens. This means that babies have to generate a full immune response to every pathogen they encounter. Each immune response takes about 10 days to generate. This is where maternal antibody can be important when present: It will help to protect an infant if they are exposed to a pathogen in those first 10 days. Unlike other animals (such as ruminants) which rely mainly on passive transfer of maternal antibodies in breast milk, humans receive most of their maternal antibodies through placental transfer of IgG. However, there will still be some antibodies transferred in breast milk, but the levels are much lower. In addition human babies don’t have a porous stomach (like calves do) in order to absorb the antibody. Therefore most of the antibody in breast milk will work in protecting pathogens crossing the oral cavity.
Function Non Specific immunity
Natural killer T cytotoxicity (killing)
Difference during Implications infancy Phagocytes cannot migrateSlow response to infection towards infectious sites, although their bactericidal (killing) activity is normal. Poor production of cytokines, inImpaired responses of other cell particular Th1 cytokines such aspopulations that rely on their interferon gamma by T-cells. functions such as natural killer cells. cell Is incomplete. TheseInefficient killing of viruses abnormalities are probably caused by immaturity in cytokine production of T cells and monocytes. Develops progressively duringInefficient phagocytosis the first year of life
Specific immunity (T-cells and Develops early in prenatal life Relative naivety of T and B cells B-cells) T and B cells first appear in keymean primary immune response organs from an early point inis relatively inefficient fetal development: accounting for the particular susceptibility of newborns, especially premature babies, to • Bone marrow (8-10 bacterial and viral infections. weeks) Repeated antigenic stimulation • Thymus (8 weeks) leads to the complete maturation • Spleen (8 weeks) • Lymph nodes (11 weeks) of specific immunity during the first few years of life. • Appendix (11 weeks) . • Tonsils (14 weeks Specific immune responses appear to be possible after as little as 12 weeks of fetal development. However, T and B cells are 'naive', encountering antigens for the first time. IgG sub group not produced until the second year of life Impaired production of someInability to respond to isotypes. Low serum IgM, IgApolysaccharide encapsulated and IgE. IgG mostly of maternalbacteria such as meningococcal origin. and pneumococcal until about 2 years of age.
Immunoglobulin (Ig or antibody) production
Inability to respond to polysaccharide vaccines Maternal antibody protection IgG against some infectiousGives protection against some from placenta organism’s crosses the placenta.infections that mother exposed or Wanes during first year of life. immunised against including measles and meningococcal disease. Can interfere with vaccines such as MMR. Little or no protection against other diseases such as whooping cough. Maternal protection from Mostly IgA Provides additional protection breast milk against gut microbes, less effective against respiratory infections
The developing immune system before and after birth
Maternal The immune system is designed to recognize ‘self’ versus ‘non self’. This means our own immune system can recognize our own cells as being safe and anything else as being a threat. Obviously this has implications in pregnancy, where a developing fetus will be expressing antigens from the father. Therefore during pregnancy modifications occur in the maternal immune system at many levels. These changes are necessary to ensure a successful pregnancy. In the absence of such changes the mother’s immune system would recognize the fetus as foreign (like a pathogen) and reject it. Potentially dangerous T-cell responses are down regulated (reduced) and some aspects of the non-specific immune system are activated. As previously mentioned, at this time specific IgG antibody passes from the mother through the placenta to the developing fetus providing it with temporary protection against some of the infections that the mother has been exposed to or vaccinated against. This gives opportunities to provide newborns with transient protection against some diseases. Infant The infant’s immune system is relatively complete at birth. It is clear that the IgG antibodies received from mother are important for the protection of the infant during the first few months of life while the infant is starting to develop its own repertoire. Passive transient protection by IgA against many common illnesses is also provided to the infant in breast milk. Mother’s milk provides IgA against a wide range of microbes that the mother has had in her gut. Breast milk has also been shown to assist in the development of the infant’s own immune system. There is some, although weak, evidence to show that breastfed infants respond better to some vaccines. The major impetus however for the expansion of lymphocytes (B and T cells) is the exposure to microbes which colonize the gut during birth. Premature and low birth weight infants are at increased risk of experiencing complications of vaccine preventable diseases and although the immunogenicity of some vaccines may be decreased in the smallest preterm infants, the antibody concentrations achieved are usually protective. Φ BOOK-BASED PATHOPHYSIOLOGY
Schematic Diagram (Flow Chart)
Synthesis of the Disease 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. 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. 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 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,
Φ CLIENT-BASED PATHOPHYSIOLOGY Schematic Diagram (Flow Chart)
Synthesis of the Disease
As for Baby Boy S, 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 S includes Male- it is said that neonatal sepsis is common to male infants than female. Maternal UTI- baby boy S’s mother had UTI during the second trimester Signs and Symptoms The patient experienced: Continuous vomiting during the first 24 hours of life Clinical Signs includes: Increased WBC count of 25.8 g/L Results in 09-09-09 Normal value of 4.3-10.0 g/L Increased hematocrit count of 63.0 Results in 09-09-09 Normal value of 40.0-54.0 for males
VI. THE PATIENT AND HIS CARE 1. Medical Management A. IVF IVF Date Ordered Date Performed Sept. 9, 2009 12:15 a.m. General Description 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 Indications Client’s Response the client adhered well and did not manifest for any side effects
D10W 500cc x 8 ugtts/min
IV solutions containing dextrose are indicated for parenteral replenishment of fluid and minimal carbohydrate calories as required by the clinical condition of the patient. It
major energy source. When used as an energy source, dextrose allows the body to preserve its muscle mass.
is also use as a mixing solution for other IV medication.
Nursing Responsibilities Prior: Verify doctor’s order. Know the type, amount, and indication of IV therapy Prepare for the IV infusion set. Clean the insertion site. During: Do hand washing Open and prepare the infusion set Do the IV insertion procedure Dress and label the venipunctures site After: Label the IV tubing with the date and time of attachment and initials of the nurse. Regulate IV. Observe for potential complication. Document relevant data and record the start of the infusion on the client’s chart. Φ OGT Medical Management OGT Date Ordered Date Performed Sept. 10, 2009 12:30 a.m. General Description Passing a rubber/plastic tube via mouth Indications Client’s Response the client adhered well and did not manifest for any side effects
To prevent vomiting with resultant aspiration of gastric contents
Nursing Responsibilities Prior: Verify doctor’s order. Inform the SO. Explain the purpose of OGT. Practice strict asepsis. During: Do hand washing. Prepare the materials needed for the procedure. After: Check for the patency. B. Generic Name Brand Name Generic Name: Ampicillin Brand Name: Ampicin Generic Name Brand Name Generic Name: Amikacin Sulfate Brand Name: Amikin Date Ordered/ Date Taken Route of General administration Action Dosage and frequency and Administration IV 15mg q 12 Inhibits protein synthesis by binding directly to the 30S ribosomal subunit; bactericidal. Client’s response Drugs Date Ordered/ Date Taken Route of administration Dosage and frequency and Administration IV 100mg q 12 General Action Client’s response
Sept. 9, 2009
Inhibits cell wall synthesis during bacterial multiplication.
Client responded well and had no adverse reaction to drug.
Sept. 9, 2009
A reduction in neutrophils has been noted.
Nursing Responsibilities Prior: Check for the doctor’s order and medication chart Prepare materials needed Before giving drug ask the patient about allergic reactions to certain drugs such as penicillin. A negative history of the drug allergy is not a guarantee against a future allergic reaction. Do skin testing Obtain specimen for culture and sensitivity test before giving first dose. Therapy may begin pending results. During: Remember the 10 R’s in giving medications. After: Tell the patient/ SO to take the entire quantity of the drug exactly as prescribed even after the patient feels well. Encouraged patient to increase fluid intake Therapy continuous for 7 to 10 days. If no response occur after 3 to 5 days stop the therapy and obtain new specimens for culture and sensitivity. Watch signs and symptoms of super infection (esp. Upper Respiratory Tract) such as continued fever, chills and increase pulse rate. Inform patient to notify prescriber if rash, fever or chills develop. A rash is a most common allergic reaction. C. Diet Type of Diet NPO
Date Ordered Sept. 9, 2009 11:25 p.m.
General Indication Description Restriction to To prevent take food via oral aspiration. route.
Client’s Response Patient did not receive anything by mouth.
Nursing Responsibilities Prior: Check the doctor’s order.
Check the right client. Make sure that the diet is properly instructed. During: Monitor if the SO complies with the diet given for the patient. After: Assess for the patient’s condition.
VII. NURSING CARE PLAN Problem no.1 NUTRITIONAL IMBALANCE: LESS THAN BODY REQUIREMENTS Assessment Nursing Diagnosis Imbalanced nutrition less than body requirement related to inability to ingest or digest food or nutrients Scientific Explanation The patient’s intake of nutrients is insufficient to meet the body’s metabolic demands. The body then reacts to the low nutrient synthesis thus compensatory mechanisms are activated such as decrease in activity, weight loss Objectives Nursing Interventions >Monitor and record vital signs >Monitor weight Rationale Expected Outcome After 3 hours of nursing interventions, the SO will verbalize understanding of causative factors when known and necessary interventions.
S> Ø O> Patient may manifest: > vomiting > poor muscle tone > body weakness >loss of weight
After 3 hours of nursing interventions, the SO will verbalize understanding of causative factors when known and necessary interventions.
>To provide comparative baseline >To monitor progression of condition >To correct or control underlying factors
>Assist in developing individualized regimen
Problem no. 2 HYPERTHERMIA Assessment Nursing Scientific Diagnosis Explanation S> Ø Hyperthermia In sepsis, it implies the presence of an O> WBC is infection of the increased, a total blood caused of 25.8 wherein by rapidly the normal is 4.3multiplying 10.0 microorganisms or toxins which >skin is warm can result to to touch hyperthermia as a defense mechanism of the body.
Goal/Expected Outcome After 1 hour of nursing interventions, the patient’s SO will be able to identify underlying cause/contributing factors and importance of the treatments, as well as signs and symptoms requiring further intervention.
Interventions >Identify underlying cause
Rationale >To know what are the causes of such condition.
Evaluation The patients’ SO had identified underlying cause and cotributing factors as well as the importance of the treatments.
> Monitor sources >To be able to of fluid loss identify if there is dehydration and excessive fluid loss >Monitor laboratory studies. >Identify factors that the SO can control (if any) >To monitor the status of the client >To protect the cliet from any factor which may be hazardous to the client >For the SO to know the importance of preventing dehydration to occur and the ways on how to treat the client.
>Discuss importance of adequate fluid intake and treatments.
Problem no. 3 INTERRUPTED BREAST FEEDING Assessment S- Ø O: -The newborn is diagnosed with a certain disease (Sepsis) - The newborn was separated from his mother - The mother was unable to provide breast milk to her newborn Nursing Diagnosis Interrupted breastfeeding related to neonate’s present illness as evidenced by separation of mother to infant Scientific Explanation Since the neonate is diagnosed for having a neonatal sepsis, the baby got separated from his mother and placed on a private room separate from her mother. Interrupted breastfeeding develops since the mother is unable to breast fed the baby continuously due to their separation. Planning After 2hours of nursing intervention and health teachings the mother will identify and demonstrate techniques to sustain lactation until breastfeeding is initiated Intervention >Assess mother’s perception and knowledge about breastfeeding and extent of instruction that has been given. >Give emotional support to mother and accept decision regarding cessation/ continuation of breast feeding. >Demonstrate use of manual piston-type breast pump. Rationale >To know what the mother already knows and needed to know. >To assist mother to maintain breastfeeding as desired. >Aid in feeding the neonate with breast milk without the mother breastfeeding the infant. >To provide optimal nutrition and promote continuation of breastfeeding process Expected Outcome The mother was able to identify and demonstrate techniques to sustain lactation and identify techniques on how to provide the newborn with breast milk.
>Review techniques for storage/use of expressed breast milk
>Determine if a routine visiting schedule or advance warning can be provided >Provide privacy, calm surroundings when mother breast feeds. >Recommend for infant sucking on a regular basis
>So that infant will be hungry/ ready to feed >To promote successful infant feeding >Reinforces that feeding time is pleasurable and enhances digestion. >To sustain adequate milk production and breast feeding process
>Encourage mother to obtain adequate rest, maintain fluid and nutritional intake, and schedule breast pumping every 3 hours while awake
Problem no. 4 KNOWLEDGE DEFICIT Cues Nursing Scientific Explanation Diagnosis S>“May Knowledge Neonatal sepsis is caused by kinalaman ba deficit an infection detected during ang laging related to or after the delivery. In this pag-iyak sa unfamiliarit case, the patient was kondisyon ng y with the identified to having neonatal baby ko information sepsis after two days. ngayon?” resources. Transplacental infection or O> an ascending infection from -frequently the cervix may be caused by ask organisms that colonize in questions. 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. Whle the depression fetl by the mother was caused by hormonal changes during the pregnancy.
Objective After 2 hours of NPI the patients’ SO will verbalize understanding of the condition, disease process and treatment.
Nursing Interventions >Determine client’s most urgent need from both client’s and nurse’s viewpoint. >Provide situation relevant to the situation. >Discuss client’s perception of need information related to client’s personal desires, needs, values, and beliefs. State objectives clearly in learner’s term. >Begin with the information the client already knows and move to what the client does not know progressing to simple to complex.
Rationale >This may differ and require adjustment in teaching plan. >Prevent overload. >In order for the client to feel competent and respected.
Evaluation The patients’ SO verbalized understanding of the disease process and was able to clarify her concern.
>Can arouse interest/ limit sense of being overwhelmed.
Problem no. 5 RISK FOR IMPAIRED PARENT/NEONATE ATTACHMENT
Assessment S- Ø O: -The newborn is diagnosed with a certain disease (Sepsis) - the newborn is hospitalized - The newborn is separated from his parents
Nursing Diagnosis Risk for Impaired parent/ neonates Attachment related to neonates physical illness and hospitalization.
Scientific Explanation 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.
Planning After 3 hours of nursing intervention and health teachings the mother will identify and demonstrate techniques to enhance behavioral organization of the neonate .
Intervention >Interview parents, noting their perception of situation and individual concerns >Educate parents regarding child growth and development, addressing parental perceptions > Involve parents in activities with the newborn that they can accomplish successfully >Recognize and provide positive feedback for nurturant and protective parenting behaviors
Rationale >To know what the parents feelings about the situation. >Helps clarify realistic expectations
Expected Outcome The parents will be able to have a mutually satisfying interactions with their newborn.
>Reinforces continuation of desired behaviors
VIII. DISCHARGE PLAN Φ METHOD M E T H Medication ampicillin 100mg IV q12 Amikin SO4 15mg IV q12 Exercise Stressed that the baby sleeps most often times Treatment Stressed importance of complying with the medications 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. D 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 Baby Diet Instructed Mother to feed the baby as tolerated with strict aspiration precaution
LEARNING DERIVED FROM THE STUDY
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. 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 will not 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.
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 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: Supportive treatment should all be given and is needed in patients care.
that proper treatment and prevention can be implemented.
X. REFERENCES • http://www.immune.org.nz/?t=899 • http://www.doh.gov.ph/ospitalngpalawan/index.php? option=com_content&view=article&id=18&Itemid=24 • Doenges,M.E.et.al.Nurses’ pocket guide.2008.F.A. DAVIS COMPANY • Johnson, J.Y.2008. Textbook of Medical-surgical nursing. 11th edition. Lippincott Williams & Wilkins