SURIGAO EDUCATION CENTER
College of Allied Medical Sciences
Nursing Department
Surigao City
A CASE PRESENTATION
OF
NEONATAL SEPSIS
Prepared by:
JOANNE BERNADETTE C. AGUILAR
Presented to:
DEDICATION
This case presentation is indeed the fruit of my endeavor. A sweet success from the sweat
of my hard work that worth every single moment and time that I share in making this, precious art
of learning. Of all the sacrifices, I would heartily dedicate my case presentation to the following
people:
To my parents, who undyingly showed their moral and financial support to me, as I take
every fruitful steps of my endeavor.
To my clinical instructors, for imparting me their knowledge on how are we going to
perform all different procedures of the nursing process, to make me fully equipped as I embark
towards the realization of my chosen profession. And most especially to our Heavenly Father,
who showered me all the guidance and the abundance of grace.
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ACKNOWLEDGEMENT
As the presenters of this individual case presentation, with deep appreciation and heart
felt gratitude, I would like to acknowledge the following people who have supported me and made
this study a successful one: To my parents who morally and financially supported me. For their
encouragement and understanding why I am always late in coming home.
To my clinical instructors who undoubtedly impart their knowledge and showed their
support to me. To all staff of Surigao Medical Center, who gave me the permit to copy all the
information necessary for this educational output to be completed from the patient’s chart.
To the patient and patient’s family who never ceased to answer whatever questions I
have raised. And most especially, to our Heavenly Father for giving me all the blessings, strength,
wisdom and enlightenment that I am able to complete all the information needed. Indeed, this case
study has definitely enhanced and advanced my knowledge in my chosen career.
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TABLE OF CONTENTS
Dedication i
Acknowledgement ii
Introduction 5-6
Review of Related Literature 7-31
Nursing Health History 32-33
Client Health History 34
Treatments/ Medications 34
Past Illness/Hospitalization 34
Allergies 34
Developmental History 34
Nutritional Metabolic Pattern 35
Elimination Pattern 35
Activity Exercise Pattern 36
Sexuality Reproduction Pattern 36
Sleep-Rest Pattern 36
Sensory-Perceptual Pattern 37
Cognitive Pattern 37
Role Relationship Pattern 37
Self-Perception-Self-Concept Pattern 38
Coping Stress Tolerance 38
Value Belief Pattern 38
Health History 38
History of Present Illness 38
Past History 39
Physical Examination 40
General Physical Survey 40
Mental Status Examination 40
Skin 40
Head and Face 40
Eyes 41
Ears and Nose 41
Mouth and Throat 41
Neck 42
Arms, Hands and Fingers 42
Posterior and Lateral Chest 42
Anterior Chest 42
Breasts (Male) 43
Heart 43
Abdomen 43
Legs, Feet and Toes 43
Genitalia (Male) 43
Musculoskeletal and Neurologic Examination 44
Cranial Nerve Assessment 45-46
Review of System 47
General Survey 47
Integumentary System 47
EENT 47
Gastrointestinal System 48
Musculoskeletal System 48
Neurologic System 48
Urinary System 48
Reproductive System 48
Hematologic 49
Endocrine 49
Psychiatric 49
Laboratory Results 50
Hematology 50-51
Blood Chemistry 52-53
Urinalysis 54
Stool Exam 55-56
Anatomy and Physiology 57-70
Pathophysiology 71-74
Drug Study 75-84
Nursing Care Plan 85-97
Discharge Plan 98-99
Appendices 100
IVF Chart 100
Daily Weight 100
Vital Signs 101
I and O Sheet 102
CFAC 103
Genogram 104
References 105
INTRODUCTION
