Angeles University Foundation Angeles City


Presented to: Joy Delfin RN, MN

Presented By: Pia Baluyut Shelley Cayanan Lyle Ariane Mariano Mervin Tuazon BSNIV-8 GROUP 32

INTRODUCTION Newborns are susceptible to infection because of their underdeveloped immune system. Neonatal sepsis also known as Neonatal Septicemia or Sepsis Neonatorum is an infection in the blood that spreads throughout the body and occurs of a neonate that kills 8,000 newly born babies each year based on Philippine experience. The disease can be classified as: congenital, early-onset and late-onset. Congenital neonatal sepsis is when the child is infected during pregnancy before birth. The baby can be infected by virus through placenta or birth canal. HIV (Human Immunodeficiency Virus), syphilis is some of the viruses that can infect the child before delivery. Earlyonset neonatal sepsis is when the infant is infected, while taking birth or soon after the delivery. Group B streptococcus (GBS) and Escherichia coli (E. coli) are considered as chief viruses that infect the baby, while birth. Early-onset neonatal sepsis is a result of asymptomatic colonization in the intestinal or genital tract of the mother. Colonization is existence of bacteria’s/viruses in a body part. An infant is said to be affected by lateonset neonatal sepsis, when it is infected a few days after delivery. This infection can be due to the organisms present in the environment of the hospital. After getting discharged from hospital, babies can get infected due to the bacteria’s present in the environment at home. GBS and E. coli are also responsible for late-onset neonatal sepsis. Symptoms of early-onset neonatal sepsis are observed mostly within 24 hours of delivery, while that of late-onset neonatal sepsis can be observed between 8th-89th days of delivery. Symptoms observed in infants suffering from neonatal sepsis are unstable body temperature, unable to suck breast milk properly, apnea, fever in rare cases, vomiting and diarrhea, respiratory distress, reduced heart rate, jaundice, belly area may be swollen. WHO as of 2009, an estimated 82,000 children die every year before their fifth birthday in the Philippines. Half of these deaths are related to common infectious diseases such as diarrhea, pneumonia, neonatal sepsis and measles. In fact, half of neonatal deaths occur during the first two days of life. Progress to curtail neonatal deaths is miserable, with death rates among this age group showing only the barest decline over the past 20 years. Current Issues and Trends in Neonatal Sepsis

Milk Protein Supplement May Help Prevent Sepsis In Very Low Birth-Weight Infants ScienceDaily (Oct. 8, 2009) — Very low birth-weight newborns who received the milk protein lactoferrin alone or in combination with a probiotic had a reduced incidence of late-onset sepsis, according to a study in the October 7 issue of JAMA. Infections are the most common cause of death in premature infants and a major threat for poor outcomes," the authors write. Late-onset sepsis, i.e., infections arising after the perinatal period (immediately before and after birth), mainly occur in the hospital and affect 21 percent of very low birth-weight (VLBW; less than 3.3 lbs) neonates according to background information in the article. Bovine lactoferrin (BLF; a milk glycoprotein) inhibits the growth of a wide variety of bacteria, fungi, and viruses and has been shown to exhibit even higher in vitro antimicrobial activity than human lactoferrin. Whether lactoferrin can reduce the incidence of sepsis is unknown. In animal tests, the probiotic Lactobacillus rhamnosus GG (LGG) improved the activity of lactoferrin but has not been studied in infants. The researchers examined whether oral supplementation with BLF alone or in combination with LGG reduces late-onset sepsis in VLBW neonates. The randomized trial was conducted in 11 Italian neonatal intensive care units and included 472 VLBW infants who were assessed until discharge for development of sepsis. Infants were randomly assigned to receive orally administered BLF alone (n = 153), BLF plus LGG (n = 151), or placebo (n = 168) from birth until day 30 of life (day 45 for neonates less than 2.2 lbs. at birth). Demographic, clinical and management characteristics of the 3 groups were similar, including type of feeding and intake of maternal milk. Forty-five infants had a first episode of late-onset sepsis. The researchers found that overall, late-onset sepsis occurred less frequently in the BLF and BLF plus LGG groups (9/153 [5.9 percent] and 7/151 [4.6 percent], respectively) than in the control group (29/168 [17.3 percent]). The decrease occurred for bacterial as well as fungal episodes. The sepsis-attributable risk of death was significantly lower in the two treatment groups. No adverse effects to treatment occurred. The researchers recommend this study confirming the safety and efficacy of lactoferrin in VLBW infants, including more extremely preterm infants, because they potentially will benefit the most from lactoferrin. Combination strategies, such as the use of BLF plus LGG in the study should be pursued, and substances that might affect lactoferrin activity, such as iron

supplementation, should be investigated. The effect of lactoferrin on hematocrit [the proportion of blood that consists of packed red blood cells should be monitored, and the effects of lactoferrin on neurodevelopmental outcome, hospital length of stay, and costs should be studied. Reasons for choosing the study An in-depth study about Neonatal Sepsis is extensively important for a nurse most especially if the nurse is working in the pediatric ward or 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, and its complications to prevent the occurrence of late-onset neonatal sepsis. Being able to obtain knowledge about neonatal sepsis can give the student nurses information that could help them in their health teachings to patients about factors that could predispose an individual to this disease. Being the health care provider of the patient means that student nurses have the responsibility to prevent, treat and help in the rehabilitation of patients affected by the disease. 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.  Formulate nursing care plans utilizing the nursing process.  Formulate conclusions based on the findings and enumerated recommendations concerning the disease Nurse Centered Objectives:  Shall have critical thinking necessary for providing safe and effective nursing care.

 Shall have a comprehensive assessment and implement care based on their knowledge and skills of the condition.  Shall have familiarized with effective inter-personal skills to emphasized health promotion and illness prevention.  Shall have an appropriate management and treatment to the patient and utilize it.

II. Nursing Assessment 1. Personal Data Baby Sepsis is a 2 days old baby boy who weighs 2.6kg, he is a catholic, a Filipino, and lives in Angeles City. He was born on July 9, 2010 in their house via NSD; he weighed 2.6 lbs, and was born full term. 1 day after his birth he had jaundice, he was then rushed in one of the hospitals in Angeles City and there he was confined with a diagnosis, T/C Neonatal Sepsis.

History of Past Illness Baby Sepsis is only two days old when he was admitted, and since then he has not experienced any illnesses. History of Present Illness When Baby Sepsis was only 2 days old, he began to had jaundice and had a fever of 39oC he was then rushed in one of the hospitals in Angeles City. Growth and Development a. Erik Erikson’s Psychosocial Development Theory: Trust vs. Mistrust Developmental task is to form a sense of trust versus mistrust. Child learns to love and be loved. This was exhibited by Baby Sepsis when the student nurse was holding him, he kept fidgeting and started to cry, while whenever his mother touches him, he keeps calm. This proves that he can differentiate between his mother’s touch and a stranger’s touch, he cries because he is unfamiliar with the student nurse and so has not yet

established trust. It would be important for the student nurse to provide a primary care giver, provide experiences that add to security, such as soft sound and touch, provide visual stimulation for active child involvement.

b. Sigmund Freud’s Psychosexual Stage: Oral Stage The child explores the world by using his mouth especially the tongue. Baby Sepsis manifested this through his eagerness to suck on his pacifier and his instant reaction of calming down once he begins sucking on a pacifier. It would do good to provide oral stimulation by giving pacifiers, not discouraging thumb sucking. c. Jean Piaget’s Theory of Cognitive Development: Sensorimotor Stage Babies relate to the world through their senses, using only reflex behaviour. Stimuli are assimilated into beginning mental images. This was evident from Baby Sepsis when his reflexes were tested such as rooting reflex, sucking reflex, swallowing reflex, plantar grasp reflex, babinski reflex, and magnet reflex. Physical Examination July 21 , 2010: 1st NPI VS T= 35.2oC P= 102 bpm R= 34 bpm Head: dry lips with lesions around the mouth; yellow sclera; yellow conjunctiva; without scars; without periorbital edema. Skin: yellow in color ; with purple bruises on Right arm and leg;; poor skin turgor; skin warm to touch; soft skin; no lesions; no scars. Nails: capillary refill of <3sec; smooth pail nail beds; complete set of fingers and toes; no scars; no wounds; no discolorations; no edema.

Neck: midline; no distention; no swelling lymph nodes; no lesions; no scars; no tenderness; no edema. Chest: symmetric lung expansion;; no use of accessory muscles; no sternal retractions; without rales; without wheezes; no wounds; no rashes; no scars. Abdomen: abdomen not distended no erythema; no tenderness; no scars; no wounds; no rashes;. Extremities (Upper and Lower):; IV insertion wounds on both arms; purple bruises on upper and lower extremities.

V. The Patient and his Care A. Medical Management Medical Management Treatment Date Ordered / (DO), Date General Performed (DP), Date Description Change (DC)

Indication or Purposes

Clients Response to Treatment

D10 W 500 cc in Date Ordered: soluset x 3 cycles July 11, 2010 # 1

Date Performed: July 11 – 14, 2010

Isotonic crystalloid Solution which contains multiple electrolytes in roughly the same concentration found in plasma.  130 mEq of Sodium (Na) ion  109 mEq of Chloride (Cl) ion.  28 mEq of Lactate  4 mEq of Potassiu m(K) ion

 To provide a balanced solution of fluids and electrolytes for the patient. The patient maintained good skin integrity.  For parenteral replacement of extracellular losses of fluid and electrolytes as required by the clinical condition of the patient.  To provide as a passage for intravenous medications of the patient. This solution also provided modest calories of 170 kilocalories.

Date Changed: July 14, 2010

Date Ordered:

July 18, 2010 D10 W 300 cc x 78ugtts/ min. # 2 Date Performed: July 18 - 19 2010  3 mEq of Calcium( Ca)

Date Changed: July 19, 2010 D10 W 500 cc x 78ugtts/ min. # 3 Date Performed: July 20 - 21, 2010

PNSS 500 cc x Date Ordered: KVO July 19. 2010

Date Performed: July 19, 2010

Date changed:

Hypotonic It is used for BT. solution containing a low concentration of solute relative to another solution. When a cell is placed in a hypotonic solution, the water diffuses into the cell, causing the cell to swell and possibly explode.

The client didn’t experience any allergic reaction.

D5 0.3 NaCl 500cc Date Ordered: x 10ugtts/ min July 14, 2010

Date Performed: July 14, 2010

Date Changed: July 18, 2010

(shifted to D10 W 300 cc leftover)

Nursing Responsibilities Preparation for Administration (Use aseptic technique)    Close flow control clamp of administration set. Remove cover from outlet port at bottom of container. Insert piercing pin of administration set into port with a twisting motion until the set is firmly seated. NOTE: See full directions on administration set carton.      Suspend container from hanger. Squeeze and release drip chamber to establish proper fluid level in chamber. Open flow control clamp and clear air from set. Close clamp. Attach set to venipuncture device. If device is not indwelling, prime and make venipuncture. Regulate rate of administration with flow control clamp.

Before:  Check the Doctor’s order.  Check the label of the IVF.  Check for the patency of the line.  Label the IVF on the date and time started and on the infusion rate.  Place on the Kardex the fluid type

During:  Check for the patency of the line. 1. Check the infusion rate. 2. Monitor for the level of the fluid.

After: 1. Regulate and monitor IV flow 2. Assess for the bulging of the site.

Medical Management Treatment

Date Ordered / (DO), Date General Performed (DP), Date Description Change (DC)

Indication or Purposes

Clients Response to Treatment

Oxygen Therapy

Date Ordered Oxygen therapy and Performed: is used to treat Via nasal cannula hypoxia. It can regulated 2-3 LPM July `13 - 21, be dispensed 2010 from a cylinder, piped-in-system, liquid O2 reservoir or O2 concentration.

Oxygen therapy is indicated to the The client was well oxygenated patient to provide adequate without signs of hypoxia and oxygenation and relieve respiratory distress respiratory difficulty.

Nursing Responsibilities: Before:  check doctor’s order  check availability of nasal cannula, or mask During:  ensure right regulation of oxygen liters per minute  ensure proper application of nasal cannula or mask After:  observe respiratory effort rate, depth and rhythm  monitor vital sign Medical Date Ordered Management / (DO), Date General Treatment Performed (DP), Date Description Change (DC) Phototherapy Date ordered

Indication or Purposes

Clients Response to Treatment

Phototherapy is Phototherapy was indicated to the The client still has jaundice and the use of light patient to photoisomerize unconjugated bilirubin more into waterforms that are soluble and can the because doctor of observed icteric sclera after phototherapy as icteric sclera and jaundice which diagnosed hyperbilirubinemia.

and performed: July 13, 2010

be rapidly without

excreted by the

liver and kidney glucuronidation. It provides of definitive treatment neonatal hyperbilirubinem ia prevention kernicterus. and of

Nursing responsibilities Before:  asses patients skin color  record vital signs  prepare eye and genitalia cover  check patients hydration status  remove all clothing  instruct so not to put and lotions or oils in the patient’s skin

During:  monitor Vital signs especially temperature  check IV fluid After:  breastfeed the baby after procedure to ensure adequate hydration  remove eye and genitalia cover and clothe the ba

Medical Management Treatment

Date Ordered / (DO), Date General Performed (DP), Date Description Change (DC) tube Date ordered OGT process placing plastic through a is

Indication or Purposes

Clients Response to Treatment

Oro-gastric insertion

the A oro-gastric tube is direct ito the The client was able to tolerate OGT of stomach which enable gastric when giving feeding. The patient soft lavage. On the days of nurse didn’t experience aspiration. tube patient interaction OGT is used to a deliver milk formulas to the baby’s

and performed: July 16, 2010

patient's mouth, stomach past the pharynx and a down the into esophagus

patient's stomac h. Orotubes inserted deliver substances directly into the stomach, or to remove substances from the stomach or as a means of testing stomach function contents. or gastric are to

Nursing responsibilities Before:  Check for the doctors order  Assess client’s need  Before prepare the appropriate parafenalias for the patient and be sure that proper hand washing is maintained During:

 Check patency of 0GT  Observe patient reaction to gastric lavage After:  Check lavage substance  Note and document any untoward reaction

a.4 Blood Transfusion



INDICATION(S) OR PURPOSE(S) (Patient-Centered)


Blood Transfusion (blood type B+)


cc DO: July 18, 2010

A blood transfusion is a To solve the problem The student nurses didn’t regarding the abnormal results see the client during this safe, common procedure in Hematology like anemia, procedure. in which blood is given to luekopenia and you through an thrombocytooenia. intravenous (IV) line in

DP: July 19, 2010





vessels. Blood transfusions are done to replace blood lost during surgery or due to a serious injury. A transfusion also may be done if your body can't make blood properly because of an illness. During transfusion, a a blood small

needle is used to insert an IV line into one of your blood vessels. blood. hours, Through this line, you receive healthy takes 1 to 4 The procedure usually depending on how much blood you need.

Nursing Responsibilities Prior:  Note current drug therapy before procedure.  Check the physician’s order.  Identify the client.  Prepare the needed materials.  Explain the procedure, its purpose and how it is done.  Inform the patient/SO that there are no food or fluid restrictions.  Right patient after typing and crossmatching by the lab. this is done by checking the lot, serial numbers, blood type, and expiration date with another nurse or qualified lab personnel. then the unit of blood.  Get consent forms signed by the patient or a qualified representative of the patient  Wash hands. During:  Vital signs must be checked after 15 minutes, then 30 minutes from then, then at one hour. then vital signs must be checked every hour.  Taka note any reaction of the blood  If any reaction, STOP THE INFUSION OF BLOOD, maintain infusion of NSS and notify physician  Start the saline solution, attach the blood tubing primed with NSS to the intravenous catheter  Invert the blood bag gently several times to mix cells with the plasma, pull the tab and spike the Y set  Infuse slowly for 1st 15 minutes at 10gtts/m  Maintain aseptic technique. After:

After transfusion, open normal saline and infuse ubtil tubing is clear

 Disregard all the materials used.  Continue to note the reaction of the blood.  Proper Documentation  Wash hands. DRUGS

Name of Date Drugs; Generic Ordered Name Date Brand Name Taken/ Given Date Changed/ D/C

Route of Administrati on, Dosage & Frequency of Administrati on

General Action Functional Classification

Indication(s ) or

Client’s Response to the Medication with actual side effects

Mechanism of Purpose(s) Action

Generic name: Paracetamol 30 mg IV q4 for 37.8

Date 30 mg IV q4 Anti pyretic Fever Ordered: for 37.8 Reduces fever July 16, by acting 2010 directly on the hypothalamic Brand Name: heat – Acetaminophen regulating center to cause vasodilation and sweating, which helps dissipate heat.

The client didn’t experience fever or temp of 37.8C.

Generic name: Date 30 mg IV q12 Ceftriaxone Ordered: Sodium July 16, 2010 Brand Name Date Rocephin: Performed: July 16 – 21, 2010


Bactericidal: Inhibits synthesis of microorganism found on his bacterial cell culture, making it effective as wall, causing Meningitis a treatment for his condition. cell death. Caused by H. influenxzae/ Cephalosporin some cases rd (3 generation). caused by S. pnuemoniae

Septicemia The client didn’t experience caused by E. any allergic reaction. coli, The drug is sensitive to the

NURSING RESPONSIBILITIES FOR DRUG THERAPY: Prior to the procedure:  Verify doctor’s orders  Identify the drug, frequency, dosage and route of administration  Check drug for any cloudiness and expiration date.  Proper dilution should be carried out  Identify the patient  Explain to the patient the procedures and reasons for giving the drug.  Perform handwashing During the procedure:

 Check for IVF patency/ backflow  Assess client’s vital signs before administration  Aseptic technique should be maintained at all times during the procedure  Check for bubbles in the syringe After the procedure:  Monitor for any adverse effects after administration of drug  Note patient’s response to the drug.  Do not recap needle  Dispose any unnecessary items  Document the medication given  Perform handwashing DIET TYPE OF DIET DATE ORDERED DATE STARTED DATE CHANGED GENERAL DESCRIPTION INDICATION(S) OR SPECIFIC PURPOSE(S) FOODS TAKEN CLINET’S RESPONSE AND?OR REACTION THE DIET


NPO (Nothing Per Orem)

Date Ordered and No food and fluid is Food is prohibited None Started passed through the after every lumbar July 11, 2010 alimentary canal puncture to prevent spinal headache Date Changed and vomiting. July 13, 2010

The client received nothing per orem and did not experience episodes of vomiting.

Date started: July 17 , 2010 *Back to feeding MILK

Date started: July 19, 2010 (BT)

MILK FORMULA Date Ordered and It is designed to WITH STRICT Started: simulate human ASPIRATION July 13, 2010 milk. It is PRECAUTION individualized for Date Changed: the infant and is July 17, 2010 determined in specific amounts by *Back to NPO considering the requirements for calories, CHON, Date started: vitamins and July 18 , 2010 minerals. It is prepared in the *Back to NPO most sterile manner possible and fed to the baby depending on his hunger. Nursing Responsibilities: Before:  Check physician’s order about the diet.

It used when breastfeeding is contraindicated, mothers employed outside the home, breast milk production is inadequate, sickly mother, inborn errors of metabolism wherein babies lack necessary enzymes to digest or utilize milk and for some personal reasons

The client able to tolerate her milk and didn’t experience aspiration.

 Identify patient, instruct SO or patient when diet is changed  Provide comfort measures such as offering extra cloth and napkin when eating. During:  Give foods in small frequent meals to check for tolerance.  Assist patient when eating.  Observe for aspiration precaution. After:  Encourage the patient to follow the diet regimen.  Encourage verbalization of feelings about the diet.  Involve the patient in the preparation of the menu according to the patient’s preferences.  Assess for patient’s condition, how she responds to the diet.  Be sure that the patient is taking or eating food she can tolerate



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

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




Expected Outcome Short term:

S OThe patient manifested the following: - Temperature above normal level (38 oC) - Skin warm to touch - diaphoretic - appears weak - flushed skin

Short-term: After 1-2 hrs of nursing intervention the patient will maintain normal core temperature as evidenced by vital signs within normal limits Long Term: After 3 days of NI, pt will still maintain normal core temperature as evidenced by normal vital signs

Independent 1. Monitor neonate’s condition. 1. To determine the need for intervention and the effectiveness of therapy. 2. To have a baseline data 3. Helps in lowering down the temperature

The patient shall maintain normal core temperature as evidenced by normal vital signs

2. Monitor Vital signs 3. Provide TSB

Long Term: After 3 days of NI, pt shall maintain normal core temperature as evidenced by normal vital signs

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 5. aids in lowering down temperature 4. this would prevent the spread of pathogens to the infant from equipment

PROBLEM 2: Ineffective Thermoregulation r/t Immaturity and Illness Assessment S>o O> pt. Manifested - jaundice -icteric sclera - bruises on arms and legs -cut down wounds on ankles -fluctuations inbody temperature above and below normal body temperature -poor skin turgor -capillary refill of <3sec Diagnosis Ineffective Thermoregulation Illness Scientific Explanation Body temperature represents the heat generation and heat loss processes. The skin, with its, ability to alter the rate of heat loss, is the major point of regulation of body temperature. Th erate of heat loss depends primarily on the surface temperature of the skin, which is inturn a function Long-term: nursing interventions the patient will >emphasize > to avoid cross contamination and Objectives Short-term: nursing interventions and health > assess teachings, the condition patient will be >monitor able experience temperature and will be a > loosen clothes nor mal 37oC >discourage tight clothing After 3 days of > perform TSB > to prevent heat build up > to promote surface cooling to record VS a >regulate monitor IVF Nursing Interventions >establish Rationale >to gain client’s trust and compliance > to obtain gen baseline data > to obtain and baseline data >to secure and adequate IVF flow > to promote cooling Long-term: After nursing interventions, the patient shall have maintained controlled temperature 37.5oC with of the Objectives Short-term: After nursing interventions and health teachings, the patient shall have experienced a non-fluctuating and temperature 37.5oC

After 3 hts of rapport

r/t Immaturity and balance between

shall be a normal


-c VS of T=37.7oC P= 140 bpm R= 50 bpm > pt. May manifest - tachycardia -cool skin -moderate pallor -mild shivering -piloerection -cyanotic nail beds - increased respiratory -seizures -slow capillary refill

of th eskin’s blood flow. But since neonates are poikilothermic they are easily affected by the temperature of their surroundings which make their temperatures fluctuate.



to importance of frequent proper SO >medications given as ordered

germ spread

help of the SO

experience controlled temperature of 36.5-37.5oC

and maintain a handwashing to >to comply with treatment regimen

PROBLEM 3: Impaired Skin Integrity r/t Mechanical Factors Assessment S> o O> pt. Manifested - jaundice -icteric sclera - bruises on arms and legs -cut down wounds on ankles -poor skin turgor -capillary refill of <3sec -c VS of T=37.7oC P= 140 bpm R= 50 bpm > pt. May manifest -itching -pain Diagnosis Impaired Skin Integrity r/t Mechanical Factors Scientific Explanation Wounds are openings in the skin caused by trauma, sharp objects or purposefully made to examine the inside of the body. It closes by itself for it to heal, although even if it has closed it still serves as a good entryway for bacteria to infiltrate the body and cause infection. So it is important to aid the body for timely wound Long-term: Nursing Interventions, the Objectives Short-term: Nursing Interventions and patient’s dressed properly SO hygienic practices be observed. > assess Health condition record VS and monitor IVF > advise the SO and change the patient’s wound will dressings >advise SO of regular wound cleaning for > to >keep the wound dry, optimal healing After 4 days of patient > to infection Nursing Interventions >establish Rationale >to gain client’s trust and compliance gen > to obtain baseline data and > to obtain baseline data and >to secure adequate IVF flow > to promote timely healing and prevent infection Objectives Short-term: After nursing interventions and health teachings the patient’s wounds shall have been dressed and properly cleaned by the SO ad Hygienic practices shall have been prevent observed Long-term: after nursing interventions, the promote patient’s wound shall have displayed timely healing without

After 3 hrs of rapport

Teachings the >monitor wounds will be >regulate

cleaned by the to regularly

patient’s clean and

-invasion of body structures -numbness of affected surrounding -erythema on affected area


would will be carefully able to display dressed timely healing > limit/ avoid use without any of plastic material such as plastic bed linens >use paper type of dressings > straighten wrinkles on bed > medications given as ordered > an infant’s skin is very sensitive > to avoid pressure build up on an area of skin > to comply with treatment regimen complications > moisture potentiates skin breakdown

any complications.

PROBLEM 4: Risk for Further Infection r/t Inadequate Primary Defenses

Assessment S>o O> pt. Manifested - jaundice -icteric sclera - bruises on arms and legs -cut down wounds on ankles -poor skin turgor -capillary refill of <3sec -c VS of T=37.7 C P= 167 bpm R= 59 bpm > -skin touch -flushed skin -hyperthermia pt. warm May to manifest

Diagnosis Risk for Further Infection r/t Inadequate Primary Defenses

Scientific Explanation Not all wounds heal in a timely manner or stay healed. Both intrinsic and extrinsic factors delay wound healing. With improper handling and unhygienic practices a wound can be a source of infection, because it serves as an opening for foreign agents to enter the body. Once these bacteria enter the body through the wound, the

Objectives Short-term: nursing interventions be able

Nursing Interventions >establish

Rationale >to gain client’s trust and compliance gen > to obtain baseline data and > to obtain baseline data and >to secure adequate IVF flow > to promote timely healing and prevent infection > to

Objectives Short-term: After nursing interventions the patient shall have observed necessary precautions avoid to further the

After 3hrs of rapport > assess

the patient will condition to >monitor the record VS >regulate observe necessary avoid infection through Long-term: Nursing Interventions help of the SO

precautions to monitor IVF further > advise the SO to regularly the change the patient’s wound dressings regular wound cleaning for

infection through the help of the SO Long-term: After nursing

prevent interventions the patient shall have displayed wound timely healing any

After 3 days of >advise SO of


the patient will patient have displayed >keep the timely any complications wound wound dry, carefully dressed healing without clean and



promote without complications

optimal healing

through the use of wound > to hygienic cleaning

prevent and maintenance

-tachycardia -increased WBCs -bradypnea

inflammatory process of the body will be triggered and then infection will soon set in.

through wound cleaning practices SO

the >advise the SO proper and handwashing > encouraged regular sponge

bacterial and spread > to

growth assisted by the SO. growth prevent

use of hygienic of frequent

bacterial and spread


> to comply with treatment regimen.

assisted by the baths >medications given as ordered c/o NOD

Problem 5: Deficient Fluid Volume r/t Failure of Regulatory Mechanism Assessment S>o Diagnosis Deficient Fluid Scientific Explanation Fluid volume Objectives Short-term: Nursing Interventions >establish Rationale >to gain client’s Objectives Short-term:

O> pt. Manifested - jaundice -icteric sclera - bruises on arms and legs -cut down wounds on ankles -poor skin turgor -capillary refill of <3sec -skin warm to touch - urine output of 5-4 diapers a day for -dry lips -increased pulse rate -dry skin -c VS of T=37.7 C P= 167 bpm

Volume r/t Failure of Regulatory Mechanism

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 hyperthermia

After 3 hours of nursing intervention the patient will be able to start maintaining fluid volume at a functional level as evidenced by the practice of techniques to promote adequate fluid volume. Long Term: After 3 days of nursing interventions the patient will be able to maintain fluid volume at a

rapport > assess

trust and compliance gen > to obtain baseline data and > to obtain baseline data and >to secure adequate IVF flow >To assess what factor contributes deficit that may be given prompt intervention.

After nursing interventions the patient shall have started to maintain fluid volume at a functional level as evidenced by the practice of techniques to promote adequate fluid volume. Long Term: After nursing interventions the

condition >monitor record VS >regulate monitor IVF > Note for the that contribute to fluid volume deficit

causative factors to fluid volume

> To decrease temperature and >Provide TSB if patient has fever > To prevent injury from provide comfort

patient shall have maintained fluid volume at a functional level AEB individually adequate urinary output, stable

R= 59 bpm > pt. May manifest: -sunken eyeballs dry mucous membrane -increased Hct -increased body temp normal -flushed skin -skin touch warm to above

functional level AEB individually adequate urinary output, stable vital signs, moist mucous membranes, good skin turgor and prompt capillary refill.

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


vital signs, moist mucous membranes, good skin turgor

> replaces fluid losses

and prompt

> to reduce body > Administer antipyretic drugs if patient has fever as ordered temperature

2. ACTUAL SOAPIE July 21 2010 S= O=Received baby on bassinette under bililight with ongoing IVF #3 D10W 500cc @ 40 cc level draining via soluset @ 54 cc level regulated @ 4 ugtts/min infusing well on left hand with 02 therapy via nasal cannula @ 2 LPM with OGT open draining minimal coffee ground secretions, jaundice noted, icteric bulbar conjunctiva, pinkish palpebral conjunctiva, with dried blood seen on lips with hematoma observed over baby’s extremities and buttocks, with absence of apneic episodes and seizure attacks patient remain free from signs of cyanosis with good strong cry, with good skin turgor, with presence of milia on his nose with CRT of 2 sec with good cry with presence of babinski, rooting, and mori reflex, with presence of dried blood on the umbilical cord with edema present on his penis and scrotum. With VS taken and recorded as follows T-35.2 C CR102 bpm RR- 34 cpm A=Ineffective tissue perfusion r/t abnormal blood profile AEB platelet count 60 x 109 and decrease O2 sat 86.7% P= after 3 hours of Ni the baby will demonstrate absence of signs of injury AEB absence of bleeding episodes. I= > Assessed gen condition >monitored and recorded VS >regulated IVF from 4 ugtts to 7-8 ugtts/min >provided cont bililight with eye and genitalia kept covered >bililight turned off @ 8am >dressed the baby after bililight turned off >kept thermoregulated >kept OGTopen >kept back dry

>provided frequent position changes >provided an environment conducive for resting >kept envt clean >monitored px for apneic, seizure, and cyanotic episodes >Ascertained proper aseptic technique when handling the baby >needs attended >due meds given Mupirocin ointment @ 8am Cefotaxime 250mg @10am Ranitidine 2.5 mg@10am

7am seen on rounds by dra. Cadiz with orderts made and carried out >cont meds >cont bililight >refer E= Goal met AEB the baby demonstrated absence of signs of injury AEB absence of bleeding episodes.

VI. 1.Client’s Daily Progress Chart Days Nursing Problems 1. Hyperthermia 2.Ineffective Thermoregulation Immaturity and Illness 3.Impaired Skin Integrity r/t Mechanical Factors 4. Risk for Further Infection r/t Inadequate Primary Defenses 5. Deficient Fluid Volume r/t Failure of Regulatory Mechanism Vital Signs T P R Medical Management 1. OGT 2. O2 3.D10 water 5.PNSS Drugs 1. Cefuroxime 2. Gentamicin 3. Ceftriaxone 4. Vitamin K 5.Furosemide Diet: NPO VII. Conclusion and Recommendation Learning Derived -------35.2oC 102 bpm 34 bpm * * r/t Admission * * * 1st NPI

As future nurses, our duty is to provide care to our patients and help them to recover from their illness. In order to do this, we should have enough knowledge and skills. We have to utilize these knowledge and skills to provide them with health teachings to prevent diseases. Neonatal sepsis is very broad disease, specifically refers to the presence of a serious bacterial infection (such as meningitis,pneumonia, pyelonephritis, or gastroenteritis) accompanied by fever. Many complications arise from this disease especially our patient is also diagnosed with TORCH and meningitis. The group learned that this disease is due to no sterile technique applied during the delivery of the baby and that disease is acquired to mother or during the delivery because the newborn has still weak immune system and immature cells to fight such infection. Therefore, we should practice sterile technique and have a regular prenatal checkup. And for neonates suspected of sepsis, we should have closed watch the condition of the patient, because this might lead to serious death if not cured or solved. As a student nurse, the group came up with realizations essential to the future practice of our profession. The knowledge, skills and attitudes we possess should be enhanced and improved accordingly to properly address the medical and nursing needs of the client. We are endowed with responsibility of providing the best possible care to our patient and assisting them attain towards the achievement of optimum health. Sufficient understanding of the disease condition and the therapeutic regimen involve in the course of treatment will allow us to perform our duties and responsibilities within the maximum criteria. Comprehension of the patient’s distinct needs will furnish the quality of care for our patient and will enable us to apply individualized nursing care to our patient and will strengthen for professional relation to our patient. But to top it all, the best part conducting a case study is the sense of fulfilment we felt knowing that in one way or the other we have touch one’s life by extending a hand and a heart when they needed it most. This case study helps our group in understanding the disease process of the patient. By identifying the primary needs of the patient with Neonatal sepsis. It will help our group to further learn the current trends to the disease condition, the right nursing intervention, proper drug administration, the preventive aspects for the purpose of health teaching to patients and the rationale behind the clinical manifestations. Effective management of

the problems identified will help the patient to recover faster and maintain a holistic sense of wellness even while in the hospital. This case study had also equipped the group with knowledge, skill and attitude on how to manage future patients with the same or similar disease. And gave us an overview of the concepts we’ve studied before so we could apply it to our day to day exposure to different individuals and to the hospitals and communities. During the course of making this requirement in RLE the group has learned a lot about the disease sepsis which could affect neonates due to their weak immune system and bodily response to infection. The case gave us an opportunity to study more about the certain factors that lead to the occurrence of the disease the manifestations that it would show and also the possible outcomes if it would not be treated immediately. The human body has unique ways to fight of any foreign material in the circulation and through the help of this case study not only us the researchers would benefit from it but also to others who may make this presentation as a basis in further understanding the disease condition. The encounter or handling of this certain patient would help us nurses in the pursuit of the profession to be able to apply our knowledge to the succeeding patients having the same condition and be able to provide necessary measures to control or manage the problem. Recommendations: To the Philippine Government, that they may know the latest studies and research being done in order to improve the quality of life of every people. They should put more attention to public health to improve the output a citizen can provide this country, none the less it would also be better and beneficial if they the government would also the education standards of the Filipino citizens so that in any occurrence of crisis they opt to find solution and remedies that would help to alleviate their problem. To the Department of Health, that they may implement projects or seminars in order to give adequate knowledge to the general public about the latest studies in such disease in order to inform them about its proper preventive ways as well as the benefits and risk. To the Health Care Providers, particularly physician and nurses, that they may impart their knowledge to the public in order to prevent the occurrence of further

complications, and the group would also recommend to them that they would opt to do their duties with outmost perfection in the way that they can to alleviate the circumstance of their patients and clients. To the Medical Interns and Student Nurses, that they may become aware of the current trends, studies, researchers and issues in both medicine and nursing fields, and they opt to practice their duties to the best that they can so that in the future they would be practicing the outmost care to their patients and clients. To the Filipino people specifically to the patient, that they may have the background regarding the latest studies being done to improve quality of life. The patient should also watch for factors that could again aggravate their health. Their health is in their hands so they should try to practice ways and techniques on how to avoid complications such as this disease in our case study.

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