A Case Study in

Impetigo

Presented/Submitted by:

ARIAS, Julian Andre A.

ASILO, Jumelle Ma. Eloise L.
BANAAG, Justin Bernard G.
DELUVIO, Donne Louis Raphael D.
HAU, Julienne Varnee T.
LITTAUA, Jan Miguel C.
MENDOZA, Princess Ann G.
NARCISO, Brendan Justin T.
VALLEJO, Renz Jord Harvey V.

October 29, 2023

 I. Demographic Data

Patient’s Biographical Data

Client’s Initial: NKB

Age: 0Y0M9D
Gender: Female
Marital Status: Single
Nationality: Filipino
Religion: N/A
Address: Riverside Sampaloc 1, Dasmariñas, Cavite

II. Medical History

A. Chief Complaint
- T/C Sepsis Neonatorum (From OPD)

B. Present Medical History

- born PT to a 26 y/o G4P4 (4004) mother, delivered via NSD on Oct. 19, 2023 in
a lying-in clinic. She denied maternal illness during prenancy. 6 days after, came
in to the ER with positive pustular lesions on the chest. No medications given.
Developed multiple pustules.

C. Past Medical History

- N/A

D. Family History
 III. Physical Assessment

Date of Assessment:

A. Review of System & Physical Examination

System/Organs ASSESSMENT FINDINGS

Review of Systems (ROS)
(Subjective Data)
General Status Responsive and coherent.
Head, Eyes, Ears, Nose, No history of head injury,
no tinnitus, and sinuses
Mouth, Throat, & Sinuses
were not inflamed
Integumentary lesions on chest
Respiratory No difficulty of breathing
is present
Cardiovascular No palpitation, cyanosis,
dyspnea on exertion,
coldness, and numbness
Gastrointestinal Breastfeeding
Genitourinary No frequency and dysuria
Reproductive No abnormalities found
Neurologic No presence of seizures,
stroke, tremor and paresis
recorded
Musculoskeletal Normal motion of
movement
Physical Examination (PE) Implication
(Objective Data)
Asleep, comfortable, not in Normal
cardio respiratory distress
Negative pallor Normal
honey colored and flaky Isolation, hygiene,
skin and thorough wound
care is advised
No couch, wheezing, and Normal
history of TB
No heart murmurs heard Normal
stomach circumference is Normal
within normal range
Normal urination Normal
No abnormalities found Normal
15/15 pediatric glasgow Normal
coma scale
Negative for edema Normal

B. Gordon’s Functional Pattern

HEALTH PATTERNS ASSESSMENT FINDINGS

(Narrative Form)
Health Perception-Health A. History of present illness
a. Patient is hospitalized in Pagamutan ng Dasmarinas due to
Management
impetigo.
b. The mother of the patient verbalized that a day after birth
the patient’s chest had lesions with pus.
B. Medical history of past health

Nutritional-Metabolic
Elimination
Activity-Exercise
Sleep-Rest
Cognitive-Perceptual
Self-Perception-Self-Concept
Role-Relationship
Sexuality-Reproductive
Coping-Stress Tolerance
Value-Belief
a. The mother of the patient verbalized that there is no history
of impetigo in their family, and no history of diabetes
mellitus. Also denies any maternal illness during pregnancy
that may contribute to the health condition of the patient.
The patient is under breastfeeding. The mother of the patient verbalized
that the patient typically breastfeeds 6x a day. In addition, the patient has
Intravenous fluid Balanced Multiple Maintenance Solution with 5% dextrose
at the left heel of the patient.
The patient eliminates 5x a day in diapers. The patient’s mother states that
her stool is water due to the mixture of the urine.
The 9-day-old baby will mostly engage in spontaneous movements. Lay
them on a soft and safe surface, like a blanket on the floor. Encourage
tummy time for short periods to help develop neck muscles and prevent flat
head syndrome.
Newborns sleep a lot. Ensure your baby has a safe and comfortable
sleeping environment, placing them on their back to sleep. Follow a
consistent sleep routine to help establish good sleep habits over time.
At this age, your baby’s vision is still developing. Show them high-contrast
black and white images or toys to stimulate their visual perception. Talk to
them in a soothing tone to promote auditory development.
N/A
As a parent, you play a crucial role in building a secure attachment with
your baby. Engage in responsive caregiving, and take time to bond through
eye contact, smiles, and soothing lullabies.
N/A
N/A
The patient has not been baptized yet. In addition, there are no religious
practices that interfere with the illness or the hospitalization of the patient.

IV. Diagnostic Tests

A. Laboratory Test

Complete Result SI UNIT Ref Range Conv. Unit Ref

Blood Count Range
(CBC)

Liver Function

Bilirubin (Total) 192.7 umd/L 3.2-283.8 mg/dL 0.19-16.60

Bilirubin (Direct) 8.5 umd/L 5.7-12.2 mg/dL 0.33-0.71

Bilirubin 184.2 umd/L <=17.0 mg/dL <=1.00
(Indirect)

V. Anatomy & Physiology

ANATOMY OF INTEGUMENTARY SYSTEM

The skin and its derivatives (sweat and oil glands, hair and nails) serve a number of functions,
mostly protective; together, these organs are called the integumentary system.

Structure of the Skin

The skin is composed of two kinds of tissue: the outer epidermis and the underlying dermis.

Epidermis

The outer epidermis is composed of stratified squamous epithelium that is capable of keratinizing or
becoming hard and tough.

· The epidermis is composed of five layers: stratum basale, spinosum, granulosum, lucidum,
and corneum. It is avascular and contains keratinocytes, which produce keratin, a fibrous
protein that forms a protective layer. The stratum basale is the deepest layer, connected to
the dermis via a wavy borderline. The stratum spinosum is the superficial layer, followed by
stratum granulosum and stratum lucidum. The stratum corneum is the outermost layer, 20-
30 layers thick, and accounts for about three-quarters of epidermal thickness. Cornified
cells, shingle-like dead cells filled with keratin, are horny cells. Keratin, produced by
melanocytes, provides a durable "overcoat" for the body. Melanin is produced by
melanocytes and accumulated in melanosomes.

Dermis

The underlying dermis is mostly made up of dense connective tissue.

· The dermis is a dense connective tissue consisting of two major regions: the papillary and
reticular layers. The papillary layer is the upper dermal region, with dermal papillae and capillary
loops for nutrients and gripping. The reticular layer is the deepest skin layer, containing blood
vessels, sweat glands, and deep pressure receptors. Collagen and elastic fibers contribute to the
skin's toughness and elasticity. Blood vessels maintain body temperature homeostasis, and the
dermis has a rich nerve supply with specialized receptor end-organs for communication.
Appendages of the Skin

The skin appendages include cutaneous glands, hair and hair follicle, and nails.

Cutaneous Glands

As these glands are formed by the cells of the stratum basale, they push into deeper skin regions and
ultimately reside almost entirely in the dermis.

· Exocrine glands, including sebaceous and sweat glands, release their secretions to the
skin surface via ducts. Sebaceous glands produce sebum, a lubricant that keeps the skin
soft and moist. Sweat glands, also known as sudoriferous glands, are found all over the
body and produce sweat, primarily water, salts, vitamin C, metabolic wastes, and lactic acid.
Apocrine glands, confined to the axillary and genital areas, contain fatty acids, proteins, and
substances from eccrine secretion. They function during puberty under androgens and play
minimal role in thermoregulation.

Hair and Hair Follicles

There are millions of hair scattered all over the body, but other than serving a few minor protective
functions, our body hair has lost much of its usefulness.

· Hairs are flexible epithelial structures formed by a hair follicle. They consist of a root, shaft,
and a central core called the medulla surrounded by a cortex layer. The cortex is enclosed
by an outermost cuticle, which provides strength and compacts the inner hair layers. Hair
pigment, produced by melanocytes in the hair bulb, produces various hair colors. Hair
follicles are compound structures with an epidermal sheath, dermal sheath, papilla, and
arrector pili. These structures provide blood supply to the hair bulb and create
"goosebumps" when the hair is pulled upright.

Nails

A nail is a scalelike modification of the epidermis that corresponds to the hoof or claw of other animals.

· Nails consist of parts, including a free edge, body, and root. They have nail folds, a cuticle, a
nail bed, and a thickened nail matrix. Nails are transparent but pink due to blood supply in the
dermis. The lunula, a white crescent over the nail matrix, is the exception.

PHYSIOLOGY OF INTEGUMENTARY SYSTEM

The normal processes that occur in the integumentary system are:

Development of Skin Color

Three pigments and even emotions contribute to skin color:

· Melanin. The amount and kind (yellow, reddish brown, or black) of melanin in the
epidermis.

· Carotene. The amount of carotene deposited in the stratum corneum and

subcutaneous tissue; carotene is an orange-yellow pigment abundant in carrots and
other orange, deep yellow, or leafy green vegetables; the skin tends to take on a
yellow-orange cast when the person eats large amounts of carotene-rich foods.

· Hemoglobin. The amount of oxygen-rich hemoglobin in the dermal blood vessels.

· Emotions. Emotions also influence skin color, and many alterations in skin color
signal certain disease states.

· Redness or erythema. Reddened skin may indicate embarrassment, fever,

hypertension, inflammation, or allergy.

· Pallor or blanching. Under certain types of emotional stress, some people become
pale; pale skin may also signify anemia, low blood pressure, or impaired blood flow
into the area.

· Jaundice or a yellow cast. An abnormal yellow skin tone usually signifies a liver
disorder in which excess bile pigments are absorbed into the blood, circulated
throughout the body, and deposited in body tissues.

· Bruises or black-and-blue marks. Black-and-blue marks reveal sites where blood

has escaped from circulation and have clotted in tissue spaces; such clotted blood
masses are called hematomas.

Hair Growth Cycle

At any given time, a random number of hairs will be in one of three stages of growth and shedding:
anagen, catagen, and telogen.

· Anagen. Anagen is the active phase of hair; the cells in the root of the hair are
dividing rapidly; a new hair is formed and pushes the club hair (a hair that has
stopped growing or is no longer in the anagen phase) up the follicle and eventually
out.
 · Catagen. The catagen phase is a transitional stage; growth stops and the outer root
sheath shrinks and attaches to the root of the hair.

· Telogen. Telogen is the resting phase; during this phase, the hair follicle is
completely at rest and the club hair is completely formed.

Nail Growth

Nail growth is separated into 3 areas: (1) germinal matrix, (2) sterile matrix, and (3) dorsal roof of the
nail fold.

· Germinal matrix. It is found on the ventral floor of the nail fold; the nail is produced
by gradient parakeratosis, then cells near the periosteum of the phalanx duplicate
and enlarge (macrocytosis); newly formed cells migrate distally and dorsally in a
column toward the nail; cells meet resistance at the established nail, causing them to
flatten and elongate as they are incorporated into the nail; it initially retains nuclei
(lunula); more distal cells become nonviable and lose nuclei.

· Sterile matrix. The area of the sterile matrix is distal to the lunula and it has a
variable amount of nail growth; it contributes to squamous cells, aiding in nail
strength and thickness and it has a role in nail plate adherence by linear ridges in the
sterile matrix epithelium.

· Dorsal roof of the nail fold. The nail is produced in a similar manner as the germinal
matrix, but the cells lose nuclei more rapidly and it imparts shine to the nail plate.

VI. Pathophysiology
f
 VII. Problem Lists

Date Identified:

ACTUAL PROBLEM POTENTIAL OR RISK PROBLEM

Impaired skin integrity Risk for Infection
Hyperthermia Risk for dehydration
Diarrhea Risk for electrolyte imbalance
Fatigue Risk for fall
 VIII. Nursing Care Plan
(Based from prioritized problem list only)
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EXPECTED
Nursing Action Rationale OUTCOME
Objective: Impaired skin Short term goal: Independent: ● Monitor for Short term goal:
integrity related signs of
T - 36.4 to trauma or After 8 hours of ● Assess the systemic After 8 hours of
PR - 110 infection nursing patient’s skin infection or nursing
RR - 59 interventions, the on her whole complication. interventions, the
Spo2 - 100 patient will have body. GOAL WAS
show no signs and ● To COMPLETELY MET
symptoms of ● Educate the determine as the baby will
infection, such as patient and the severity have no signs and
redness, swelling, caregiver of impetigo symptoms of
warmth, and about proper and any infection, such as
purulent discharge. wound affected redness, swelling,
hygiene areas that warmth, and
Long term goal: through require purulent discharge.
washing the special
After 24 hours of sores with attention or Long term goal:
nursing soap and wound care.
intervention, the water. Advise After 24 hours of
baby will have no the patient ● The doctor nursing intervention,
worsening skin and caregiver may also the goal was
breakdown, to prevent prescribe completely met as
implementation of scratching antibiotic the baby will have
preventive the affected drugs in no worsening skin
measures, and areas. patients who breakdown,
patient and have a lot of implementation of
caregiver education impetigo preventive
on proper skin care ● Teach the sores. Even measures, and
and prevention patient/ if the patient and
strategies. caregiver the symptoms caregiver education
proper have already on proper skin care
application of improved and prevention
non-stick and healing strategies.
bandages is evident, it
over the is still
affected important to
areas can finish the
also help course of
prevent the antibiotic
spread of therapy to
sores and prevent
further recurrence
infection. of infection
and
Dependent: antibiotic
resistance.
● Administer
antibiotics as ● Maintain the
prescribed. cleanliness
Ensure that of the
the patient affected
finishes the areas by
course of washing with
antibiotic mild soap
prescribed by and water.
the physician. The sores
may cause
mild itching,
Collaborative: but it is
● Collaborating advisable to
with other prevent the
healthcare child from
providers on scratching
how to take the affected
properly the areas to
medications. prevent
worsening
and spread
of the
infection.

● Proper
application
of non-stick
bandages
over the
affected
areas can
also help
prevent the
spread of
sores and
further
infection.
 IX. Drug Study

Drug No. 1 ACTION EFFECTS NURSING RESPONSIBILITY

Side Effect Adverse Effect
Generic Name: Inhibit essential ● ● Special Senses: Assessment & Drug Effects
Gentamicin protein synthesis in Neurotoxicity Ototoxicity ● Lab tests: Perform C&S and renal
the bacterial cell (spinning (vestibular function prior to first dose and
(Brand Name): required for survival. sensation disturbances, periodically during therapy;
Garamycin, It is used in the [vertigo], impaired hearing), therapy may begin pending test
Garamycin treatment of severe- loss of optic neuritis. results. Determine creatinine
Ophthalmic, gram negative control of ● CNS: clearance and serum drug
Genoptic infections and also bodily neuromuscular concentrations at frequent
has some activity movemen blockade: skeletal intervals, particularly for patients
Dosage: against coagulase ts) muscle weakness, with impaired renal function,
Moderate to positive ● Gait apnea, respiratory infants (renal immaturity), older
Severe Infection staphylococci instability paralysis (high adults, patients receiving high
● Adult: IV/IM ● doses); doses or therapy beyond 10 d,
1.5–2 mg/kg Pharmacokinetics arachnoiditis patients with fever or extensive
loading (ADME) Ototoxicit (intrathecal use). burns, edema, obesity.
dose ● Absorption: y ● CV: hypotension or ● Repeat C&S if improvement does
followed by Well (auditory, hypertension. not occur in 3–5 d; reevaluate
3– 5 absorbed vestibular ● GI: Nausea, therapy.
mg/kg/d in from IM site. ) vomiting, transient ● Note: Dosages are generally
2–3 divided ● Peak: 30–90 ● Kidney increase in AST, adjusted to maintain peak serum
doses min IM. damage ALT, and serum gentamicin concentrations of 4–
Intrathecal ● Distribution: (decrease LDH and bilirubin; 10 g/mL, and trough
4–8 mg Widely d CrCl) hepatomegaly, concentrations of 1–2 g/mL. Peak
preservative distributed in ● Kidney splenomegaly concentrations above 12 g/mL
free q.d. body fluids damage if ● Hematologic: and trough concentrations above
 Topical 1–2 including trough Increased or 2 g/mL are associated with
drops of ascitic, greater decreased toxicity.
solution in peritoneal, than 2 reticulocyte counts; ● Draw blood specimens for peak
eye q4h up pleural, mg/L granulocytopenia, serum gentamicin concentration
to 2 drops synovial, and ● Swelling thrombocytopenia 30 min–1h after IM administration,
q1h or small abscess (edema) (fever, bleeding and 30 min after completion of a
amount of fluids; poor ● Rash tendency), 30–60 min IV infusion. Draw blood
ointment CNS ● Itching thrombocytopenic specimens for trough levels just
b.i.d. or t.i.d. penetration; ● Stomach purpura, anemia. before the next IM or IV dose. Use
● Child: IV/IM concentrates upset ● Body as a Whole: nonheparinized tubes to collect
6– 7.5 in kidney and ● Injection Hypersensitivity blood.
mg/kg/d in inner ear; site (rash, pruritus, ● Check baseline weight and vital
3–4 divided crosses reactions urticaria, exfoliative signs; determine vestibular and
doses placenta. (pain, dermatitis, auditory function before therapy
Intrathecal ● Metabolism: irritation, eosinophilia, and at regular intervals. Check
>3 mo, 1–2 Not and burning sensation of vestibular and auditory function
mg metabolized. redness) skin, drug fever, again 3–4 wk after drug is
preservative ● Elimination: joint pains, discontinued (the time that
free q.d. Excreted laryngeal edema, deafness is most likely to occur).
● Neonate: unchanged in anaphylaxis). Monitor I&O. Keep patient well
IV/IM 2.5 urine; small ● Urogenital: hydrated to prevent chemical
mg/kg q12– amounts Nephrotoxicity: irritation of renal tubules. Report
24h accumulate proteinuria, tubular oliguria, unusual appearance of
Acute Pelvic in the kidney necrosis, cells or urine, change in I&O ratio or
Inflammatory and are casts in urine, pattern, and presence of edema
Disease eliminated hematuria, rising (prolongs elimination time).
● Adult: IV/IM over 10– 20 BUN, nonprotein ● Note: Ototoxic effect (see
2 mg/kg d; small nitrogen, serum Appendix F) is greatest on the
followed by amounts creatinine; vestibular branch of eighth cranial
1.5 mg/kg excreted in decreased (acoustic) nerve (symptoms:
q8h breast milk. creatinine headache, dizziness or vertigo,
Prophylaxis of ● Half-Life: 2–4 clearance. nausea and vomiting with motion,
Bacterial h ● Other: Local ataxia, nystagmus). However,
Endocarditis irritation and pain damage to the auditory branch
● Adult: IV/IM following IM use; (tinnitus, roaring noises, sensation
1.5 mg/kg thrombophlebitis, of fullness in ears, hearing
30 min abscess, impairment) may also occur.
before superinfections, Report promptly to prevent
procedure, syndrome of permanent damage.
may repeat hypocalcemia ● Watch for S&S of bacterial
in 8 h (tetany, weakness, overgrowth (opportunistic
● Child: IV/IM hypokalemia, infections) with resistant or
< 27 kg, 2 hypomagnesemia) nonsusceptible organisms
mg/kg 30 ● Topical and (diarrhea, anogenital itching,
min before Ophthalmic: vaginal discharge, stomatitis,
procedure, Photosensitivity, glossitis).
may repeat sensitization, Patient & Family Education
in 8 h erythema, pruritus; ● Note: When using topical
burning, stinging, applications: Avoid excessive
Route: and lacrimation exposure to sunlight because of
IV, IM, Topical, (ophthalmic danger of photosensitivity;
Intrathecal formulation). withhold medication and notify
physician if condition fails to
Frequency: improve within 1 wk, worsens, or
Q4 signs of irritation or sensitivity
occur; and apply medication as
Classification: directed and only for length of
Anti-infective, time prescribed (overuse can
Aminoglycoside result in superinfections).
Antibiotic ● Do not breast feed while taking
this drug without consulting a
physician.
 Drug No. 2 ACTION EFFECTS NURSING
Side Effect Adverse Effect RESPONSIBILITY
Generic Name: Oxacillin By binding to specific ● Fever ● Anaphylactic Assessment:
(Brand Name): Bactocil penicillin-binding proteins ● Rash shock with ● Watch for seizures;
(PBPs) located inside the ● Nausea collapse notify physician
Dosage: bacterial cell wall, Oxacillin ● Diarrhea ● Clostridium immediately if
Oral: 1g inhibits the third and last stage ● Vomiting difficile- patient develops or
Parenteral: of bacterial cell wall synthesis. ● Eosinophilia associated increases seizure
200-500mg - Adult Cell lysis is then mediated by ● Leucopenia diarrhea activity.
50-100mg - Child bacterial cell wall autolytic ● Neutropenia ● Monitor signs of
enzymes such as autolysins; it allergic reactions
Route: IM, IV, Oral is possible that Oxacillin and anaphylaxis,
interferes with an autolysin including pulmonary
Frequency: Q8 inhibitor. symptoms
(tightness in the
Classification: Beta- throat and chest,
Lactam Antibiotics wheezing, cough
dyspnea) or skin
reactions (rash,
pruritus, urticaria).
Notify physician or
nursing staff
immediately if these
reactions occur.
● Assess muscle
aches and joint pain
(arthralgia) that
may be caused by
serum sickness.
Notify physician if
 these symptoms
seem to be drug-
related rather than
caused by
musculoskeletal
injury or if muscle
and joint pain are
accompanied by
allergy-like
reactions (fever,
rashes, etc.)
● Monitor signs of
eosinophilia
(fatigue, weakness,
myalgia) or
leukopenia (fever,
sore throat, signs of
infection); report
these signs to the
physician.
● Monitor injection
site for pain,
swelling, and
irritation. Report
prolonged or
excessive injection
site reactions to the
physician.

Evaluate:
● Always wash hands
thoroughly and
 disinfect equipment
(whirlpools,
electrotherapeutic
devices, treatment
tables, and so forth)
to help prevent the
spread of infection.
Use universal
precautions or
isolation
procedures as
indicated for
specific patients.

Teach Patient/Family:
Instruct patient to notify
physician immediately if
signs of the following
occur:

Pseudomembranou
s colitis (diarrhea,
abdominal pain,
fever, pus or mucus
in stools) or other
severe or prolonged
GI problems
(nausea, vomiting,
heartburn).
● Superinfection
 (black, furry
overgrowth on
tongue; vaginal
itching or
discharge; loose or
foul-smelling
stools).
● Interstitial nephritis
(blood in urine,
decreased urine
output, weight gain
from fluid retention).
● Instruct patient and
family/caregivers to
report other
troublesome side
effects such as
severe or prolonged
skin problems
(rash, itching) or GI
problems (nausea,
vomiting, diarrhea,
heartburn).
 X. Discharge Planning / Progress Report

(Discharge planning for MGH patient only & Progress report for not MGH patient)

Current Health Status: -The infant has shown significant improvement in specific
conditions or symptoms. Vital signs, including
temperature, heart rate, respiratory rate, and oxygen
saturation, are stable and within normal ranges.

Monitor vital signs: -Regularly check the infant's temperature, heart rate, and
respiratory rate to detect any signs of dehydration or
distress.

Maintain strict hand

-Ensure proper handwashing techniques to prevent the
hygiene:
spread of infection.

Education: -Educating parents or caregivers empowers them to

provide appropriate care, recognize signs of worsening
conditions, and seek timely medical assistance.

Wound Care: -Continue with wound care at home as demonstrated by

the nursing staff.

Assessment: - Infant presented with multiple impetigo lesions on.

Lesions were erythematous, crusted, and occasionally
purulent.

Interventions:
-Administered antibiotics as prescribed.

Implemented strict infection control measures.

Monitored the infant's progress and vital signs regularly

Response to - Lesions have started to heal and show signs of
Treatment: improvement.

No new lesions have developed during the hospital stay.

The infant appears comfortable and feeds well.

Recommendations: -Continue with prescribed medications and wound care.

Maintain strict hygiene practices at home.

Monitor for any signs of worsening or recurrence.