Colegio de San Juan de Letran Calamba School of Nuroing

Case Presentation:

SEPSIS NEONATORUM

Presented by: Casunuran, Cherry Ann Catapang, Czarina May Causing, Immaulate Faye Ciarell, Ciar Corcuera, Dan Ryan Corpuz, Lady Anilin Cortez, Daserie Rose De Jesus, Eileen Jane De Leon, Ma. Clarita Deocareza, Alfrenan Diche, Satina Emata, Arlene Joy Ercia, Alphine Gael Ercia, Alvie Gael Faraon, Ara Denise Presented to: Ms. Eufemia Cortado September

I. INTRODUCTION A. Background of the Study Neonatal sepsis, also termed Sepsis neonatorum in simplest way of defining it, refers to a group of physical and laboratory findings that occur in response to invasive infection within the first 30 days of life, this is may be a bacterial or viral etiology. This may arise from congenital infection (common among premature babies and to those babies wherein their mother suffered from infections while they are pregnant), early onset infection (most common on prolonged labor) and late onset infection which is caused by environmental factors. Neonatal sepsis is also known as "sepsis neonatorum." The infection may involve the infant globally or may be limited to just one organ (such as the lungs with pneumonia). It may be acquired prior to birth (intrauterine sepsis) or after birth (extra uterine sepsis). Viral (such as herpes, rubella [German measles]), bacterial (such as group B strep) and more rarely fungal (such as Candida) causes may be implicated. During labor, several indicators may raise concern regarding the possibility of neonatal sepsis. Abnormalities of fetal heart rate, maternal fever, premature separation of the placenta from the uterine wall, or foul smelling/cloudy amniotic fluid all indicate a high-risk labor and delivery. These situations will commonly prompt consultation with the pediatrician or neonatologist regarding the potential for delivery and/or postpartum complications. Any infant who fails to make a smooth transition from intrauterine to extra uterine life should be considered at high risk for sepsis. Close monitoring of vital signs (heart rate, respiratory rate and effort, skin color, temperature, and "vigor") is a crucial part of the evaluation of the newborn. Infants may manifest neonatal sepsis by subtle signs such as poor feeding, jaundice, unusual rashes, or more obvious indicators such as seizures, projectile vomiting, or abdominal distention.

B. Focus on Incidence of Disease Neonatal sepsis occurs in 0.5 to 8.0 per 1000 live births. It is the third leading cause of neonatal deaths. Occurrence can be classified into low birth weight (weighing less than 2500 grams) and very-low-birth-weight (weighing less than 1500 grams). In which, 81% percent were low birth weight and 63.6% were very-low-birthweight. Neonatal sepsis occurs in a 2:1 ratio, with a higher occurrence in males and in neonates with congenital anomalies. In the Philippines 8,000 newly born babies die from sepsis. In May 2003, 23 neonatal deaths could be attributed alone. According to the Annual Statistics of the Philippine General Hospital (2002), neonatal sepsis accounts for 58.8% of deaths in the country. It is the second major cause of disability by a slim margin to jaundice, affecting 24.2% and 25.6% of the population respectively. The census in the National Childrens Hospital (NCH) Intensive Care Unit during one month (July 2010 to August 2010) was 61 patients having neonatal sepsis. Having a total of 61 days, the average of patients having neonatal sepsis is 1 per day.

II. CLINICAL SUMMARY / CLINICAL ABSTRACT A. Personal Data Personal Data Name: Baby G.P.B. Gender: Male Status: Newborn Address: #3604 Amihan Compound, Halang, Calamba, Laguna Birthday: August 19, 2011 Birthplace: Calamba Age: Date of Admission: Diagnosis: t/c Sepsis Neonatorum August 21, 2011 8:10pm B. History of Present Illness b.1 Past Medical History No previous illnesses &/or operations b.2 Present Medical History Chief complaint: fever

Born cesarean section upon delivery, mother was diagnosed with toxemia; BP 160/90 mmHg Secondary (+) flaring episode (+) jaundice noted

III. ASSESSMENT A. Physical Assessment HEAD TO TOE ASSESSMENT NORMAL FINDINGS Color in Caucasian infants usually pink; varies with other ethnic backgrounds. Pigmentation increases after birth. Skin may be dry. Acrocyanosis of hands and feet normal for 24 hours; may develop "newborn rash" (erythema toxicum neonatorum). Small amounts of lanugo and vernix caseosa still seen. FINDINGS Rashes over the surface of the face Pathologic Jaundice - usually appears early, up to 24 hours after birth; represents a process ongoing before birth

Skin

Nursing interventions: Identify conditions predisposing to hyperbilirubinemia, especially positive coombs test (test on cord blood for presence of maternal antibodies). Prevent progression or complications of jaundice. Assess jaundice levels (visually, lab tests) as needed. Prevent conditions that contribute to development of hyperbilirubinemia (e.g., cold stress, hypoxia, acidosis, hypoglycemia, dehydration, infection). Provide adequate hydration. Implement phototherapy if ordered; use of blue lights overhead or in blanket-device wrapped around infant. NORMAL NORMAL

Fontanels Ears

Anterior: diamond shaped Posterior: triangular Should be flat and open. Should be even with canthus of eyes.

 Eyes

Breast

Male genitalia

Legs

Feet

Muscle tone

Cry

Cartilage should be present and firm May be irritated by medication instillation, some edema/discharge present. Nodule of tissue present Normal breath sounds heard. Testes descended or in inguinal canal Rugae cover scrotum Bowed No click or displacement of head of femur observed when hips flexed and abducted Flat Soles covered with creases in fully mature infant Predominantly flexed Occasional transient tremors of mouth and chin Newborn can turn head from side to side in prone position Needs head supported when held erect or lifted Loud and vigorous. Heard when infant is

NORMAL

NORMAL

NORMAL

NORMAL

NORMAL

NORMAL

NORMAL
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hungry, disturbed, or uncomfortable.

B. Identification and Application of appropriate theory b.1 Gordons11 Functional Health Pattern of Assessment Gordons Assessment Health Pattern Norms and Standards Health Perception and Health Management - Compliance with medication regimen, use of health-promotion activities such as regular exercise, annual check-ups. Perception of being healthy. Nutrition and Metabolism - Normal Pattern of food and fluid consumption relative to metabolic need and pattern; indicators of local nutrient supply. Elimination - Frequency of bowel movements is at least once every 2 days and urination is about 1-2L per day During Hospitalization According to the mother, her baby was born in the hospital. She was told that her baby became yellow and that he needs treatment. They followed the right therapeutic management and followed the doctors order regarding the treatment of her baby. According to the mother, every now and then, she breastfeeds her baby. She also follows the rule that after breastfeeding, the infant must be allowed to burp. The mother told that she changes the diaper 2-3 times a day. The urine and stool are together. The urine has a yellow color. The stool was black in color, large in amount and has a soft consistency. Not applicable to the patient.

Activity and Exercise - Exercise, hobbies. May include cardiovascular and respiratory status, mobility, and activities of daily living. Cognition and Perception - Vision, hearing, taste, touch, smell, pain perception and management should be normal; cognitive functions such as language, memory, and decision making are intact. Sleep and Rest - Sleep pattern should be normal with hours ranging from 7-9.

Not applicable to the patient.

The mother said that her babys sleep pattern was normal. The baby was relaxed although there are times that her baby

 Self-Perception and Self Concept - Body comfort, body image, feeling state, attitudes about self, perception of abilities, objective data such as body posture, eye contact, voice tone. Roles and Relationship - Perception of current major roles and responsibilities; satisfied with family, work, or social relationships. Sexuality and Reproduction - Number and histories of pregnancy and childbirth; difficulties with sexual functioning; satisfaction with sexual relationship. Coping on Stress Tolerance - Clients usual manner of handling stress, available support systems, perceived ability to control or manage situations Values and Beliefs - Religious affiliation, what client perceives as important in life, valuebelief conflicts related to health, special religious practices.

would suddenly wake up. Not applicable to the patient.

Not applicable to the patient.

According to the mother, it was her third time getting pregnant. All her children are alive and well. The mother said that her husband and family are their main support. They visit the hospital every now and then. According to the mother, they are of a Roman Catholic religion.

b.2 Developmental Theory Erik Erickson: Trust vs. Mistrust Age Range: Birth to 18 Months Basic strength: Drive and Hope Erikson also referred to infancy as the Oral Sensory Stage (as anyone might who watches a baby put everything in her mouth) where the major emphasis is on the mother's positive and loving care for the child, with a big emphasis on visual contact and touch. If we pass successfully through this period of life, we will learn to trust that life is basically okay and have basic confidence in the future. If we fail to experience trust and are constantly frustrated because our needs are not met, we may end up with a deepseated feeling of worthlessness and a mistrust of the world in general. Sigmund Freud: Oral stage Age Range: Birth to 1 Year Erogenous Zone: Mouth During the oral stage, the infant's primary source of interaction occurs through the mouth, so the rooting and sucking reflex is especially important. The mouth is vital for eating, and the infant derives pleasure from oral stimulation through gratifying activities such as tasting and sucking. Because the infant is entirely dependent upon caretakers (who are responsible for feeding the child), the infant also develops a sense of trust and comfort through this oral stimulation. The primary conflict at this stage is the weaning process--the child must become less dependent upon caretakers. If fixation occurs at this stage, Freud believed the individual would have issues with dependency or aggression. Oral fixation can result in problems with drinking, eating, smoking or nail biting. Jean Piaget: Sensorimotor Age Range: Birth to about age 2 During this stage, the child learns about himself and his environment through motor and reflex actions. Thought derives from sensation and movement. The child learns that he is separate from his environment and that aspects of his environment --his parents or favorite toy -- continue to exist even though they may be outside the reach of his senses. Teaching for a child in this stage should be geared to the sensorimotor system. You can modify behavior by using the senses: a frown, a stern or soothing voice -- all serve as appropriate techniques.

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b.3 Nursing Theory Nightingales Environmental Theory As for the theoretical framework, Florence Nightingales Environmental theory suits best the condition of the patient. The patient is in the state of having sepsis neonatorum and the main priority with this is to avoid further spread infection throughout the system of the patient by providing him a safe and clean environment. With Nightingales theory which states that the act of utilizing the environment of the patient to assist him in his recovery is what nursing does. As she linked health with the five environmental factors that includes: fresh or pure air, pure water, efficient drainage, cleanliness and light. Combining these factors would help to alleviate the condition of the patient especially that he is in the state where he could not do things on his own. Furthermore, since the patient has an infection given that he has a fever, providing a clean environment around him would help him for his recovery. A quiet environment is also a factor. Providing the client with the right diet by ensuring that he will be able to tolerate his Doppler feeding will also help his recovery since this is a necessity for a patient to easily get well. Therefore, in its simplest term, with the integral parts of nursing, and the factors that promotes a good environment to the patient, recovery could be achieved or at least alleviation of what he feels most especially the patient will be free from harm or injury and also the spread of infection could be more prevented.

C. Diagnostics August 21, 2011 Diagnostics WBC Neutrophils HEMATOLOGY Lymphocytes Hematocrit Hemoglobin Platelet Count Blood Type Normal 5 - 10x10 9/1 0.51 - 0.67 0.21 - 0.35 M 39 - 54 F 36 - 48 M = 130 180 g/L F = 120 -160 g/L 150 400x10 g/L Result 8.5 0.60 0.40 50 166g/L 315 B positive Analysis Normal Normal Lymphocytosis Increased lymphocyte count in response to presence of infection. Normal Normal Normal Normal

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Total Bilirubin Direct Bilirubin Indirect Bilirubin

1.0 10.5 Mg/dl 0.0 0.6 Mg/dl 1.0 10.5 Mg/dl

17.6 0.3 17.3

Hyperbilirubinemia Indirect bilirubin outweighs Direct bilirubin

IV. ANATOMY AND PHYSIOLOGY A baby's immune system is not fully developed until he/she is about six months-old. In the meantime, pregnant mothers pass immunoglobulin antibodies from their bloodstream, through the placenta, and to the fetus. These antibodies are an essential part of the fetus's immune system. They identify and bind to harmful substances, such as bacteria, viruses, and fungi that enter the body. This triggers other immune cells to destroy the foreign substance. Immunoglobulin G (IgG) is the only antibody that crosses the placenta to the fetus during pregnancy. IgG antibodies are the smallest, but most abundant antibodies, making up 75-80% of all the antibodies in the body. They are present in all body fluids and they are considered to be the most important antibodies for fighting against bacterial and viral infections. These antibodies help protect the fetus from developing an infection inside the womb. Immediately after birth, the newborn has high levels of the mother's antibodies in the bloodstream. Babies who are breastfed continue to receive antibodies via breast milk. Breast milk contains all five types of antibodies, including immunoglobulin A (IgA), immunoglobulin D (IgD), immunoglobulin E (IgE), IgG, and immunoglobulin M (IgM). This is called passive immunity because the mother is "passing" her antibodies to her child. This helps prevent the baby from developing diseases and infections. During the next several months, the antibodies passed from the mother to the infant steadily decrease. When healthy babies are about two to three months old, the immune system will start producing its own antibodies. During this time, the baby will experience the body's natural low point of antibodies in the bloodstream. This is because the maternal antibodies have decreased, and young children, who are making antibodies for the first time, produce them at a much slower rate than adults.
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Once healthy babies reach six months of age, their antibodies are produced at a normal rate.

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V. PATHOPHYSIOLOGY

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VI. MEDICAL MANAGEMENT ANALYSIS A. Intravenous Therapy B alanced Multiple Maintenance Solution with 5% Dextrose (D5IM) Action The solution is administered by intravenous infusion for parenteral maintenance of routine daily fluid and electrolyte requirements with minimal carbohydrate calories Pediatric Use:The safety and effectiveness in the pediatric population are based on the similarity of the clinical conditions of the pediatric and adult populations. In neonates and very small infants the volume of fluid may affect fluid and electrolyte balance.Frequent monitoring of serum glucose concentrations is required when dextrose is prescribed to pediatric patients, particularly neonates and low birth weight infants. Adverse Reactions Nursing Responsibilities Reactions which may occur Clinical evaluation and because of the solution or periodic laboratory the technique of determinations are administration include febrile necessary to monitor response, infection at the changes in fluid balance, site of injection, venous electrolyte thrombosis or phlebitis concentrations, and acidextending from the site of base balance during injection, extravasation and prolonged parenteral hypervolemia. If an adverse therapy or whenever the reactiondoes occur, condition of the patient discontinue the infusion, warrants such evaluate the patient, evaluation. institute appropriate Caution must be therapeutic exercised in the countermeasures and save administration of the remainder of the fluid for parenteral fluids, examination if deemed especially those necessary. containing sodium ions, to patients receiving corticosteroids or corticotropin. Solutions containing acetate should be used with caution, as excess administration may result in metabolic alkalosis. Solutions containing dextrose should be used with caution in patients with known subclinical or overt diabetes mellitus. Do not administer unless solution is clear and container is undamaged. Discard unused portion. In very low birth weight infants, excessive or rapid administration of dextrose injection may

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result in increased

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B. Medications
Name of drug Classification Therapeutic action Indication Contraindication Side effects Nursing Responsibilities

Ampicilli Anti-infective n 410mg IV q 12 Ampicilin 61.5mg IV OD

Bactericidal action Binds to bacterial cell wall, resulting in cell death

Treatment of the following infections: skin structure infections, soft tissue infection, otitis media, sinusitis, respiratory infection and SEPTICEMIA

Hypersensitivity to penicillins USE CAUTIOUSLY IN: severe renal insufficiency

CNS: seizures GI: pseudomembran ous colitis, diarrhea, nausea and vomiting DERM: rashes, urticaria HEMAT: blood dycrasias MISC: allergic reaction including anaphylaxis and serum sickness, superinfection

assess patient for infection obtain history before initiating therapy to determine previous use and reactions to penicillins observe patient for signs and symptoms of anaphylaxis assess skin for ampicillin rash laboratory test considerations : may cause increased AST and ALT may cause a false-positive direct Coombs test result

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VII. PLANNING A. List Daily Nursing Problems DAY NO. 1 IDENTIFIED NURSING PROBLEMS Risk for further infection Interrupted breast feeding Skin integrity as evidenced of disruption of the skin (epidermis) PRIORITIZATION Since the baby had already an infection, our first priority is to prevent further infection to the newborn. The next priority would be the interrupted breast feeding, because a newborn only needs milk from the mother since it has all the nutrients a newborn needs including colostrum which gives the newborn immunization to fight the infection, then the skin integrity.

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VIII. NURSING CARE PLAN Assessment Objective : Bradycardia(104bpm) Lab tests: Total Bilirubin(17.6mg/dl) Lymphocytes (.40) Skin rashes Crackles(left posterior part) On phototherapy with eyeshield in place Diagnosis Risk for further infection related to inadequate secondary defense as evidenced by lymphocytosis Planning Short-term Goal: After 8 hrs. of nursing intervention, the clients mother will be able to: a. Prevent the risk from further infection to the baby b. Identify interventions to prevent / reduce the infection Long-term Goal After days of nursing intervention, the patient will be able to: a. Maintain the normal level of lymphocytes b. Be free Intervention INDEPENDENT: -Close vital signs monitoring Rationale -to monitor abnormal signs that can lead to other problem -to prevent risk of further infection on the wound site -To prevent exposure of client -Reduces risk of cross contamination -To prevent spread of further infection Evaluation After 8 hours of nursing interventions, the mother was able to verbalize / perform techniques to prevent the spread of infection

- Assess umbilical site for any signs of infection - Monitor visitors as indicated -Wash hands before and after each care activity, even gloves are used -Instruct mother in techniques to protect the integrity of skin of the baby, care for lesions -Promote childhood immunization program

-For the baby to be free / immune to further diseases like Hepatitis B

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from infection COLLABORATIVE: c.Have the -Administer antibiotics normal level of as prescribed bilirubin for jaundice to not occur

-To prevent spread of further infection

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Nursing Care Plan

Assessment Subjective: Objective: Diagnosis Planning Short-term: After 3 hours of nursing intervention and health teachings the mother will identify and demonstrate techniques to sustain lactation until breastfeeding is initiated Long Term: After 3 days of NI, the mother shall still be able to identify and demonstrate techniques to sustain lactation and identify techniques on how to provide the newborn with breast milk. Intervention 1. Assess mothers perception and knowledge about breastfeeding and extent of instruction that has been given. Rationale 1. To know what the mother already knows and needed to know. 2. To assist mother to maintain breastfeeding as desired. Evaluation The mother shall be able to identify and demonstrate techniques to sustain lactation and identify techniques on how to provide the newborn with breast milk.

Interrupted breastfeeding related to neonates present illness as evidenced by separation of mother to infant.

2. Give emotional support to mother and accept decision regarding cessation/ 3. aid in feeding continuation of the neonate with breast feeding. breast milk without the mother 3. Demonstrate use of manual breastfeeding the piston-type breast infant. pump. 4. Review techniques for storage/use of expressed breast milk 5. Determine if a routine visiting schedule or 4. To provide optimal nutrition and promote continuation of breastfeeding process 5. So that infant will be hungry/

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advance warning can be provided 6. Provide privacy, calm surroundings when mother breast feeds. 7. Recommend for infant sucking on a regular basis 8. Encourage mother to obtain adequate rest, maintain fluid and nutritional intake, and schedule breast pumping every 3 hours while awake

ready to feed 6. To promote successful infant feeding 7. Reinforces that feeding time is pleasurable and enhances digestion. 8. to sustain adequate milk production and breast feeding process

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Nursing Care Plan

Assessment Subjective: Objectives: >Jaundice >Skin rashes >Crackles >Bradycardia >Lymphocytosis Diagnosis Impaired skin Integrity related to disruption of skin surface(epidermis) as evidence skin rashes. Planning After 8hrs. of Nursing Intervention, the patient will reduce skin rashes. Intervention Independent: >Vital signs monitored and recorded. >Instruct the relatives for proper hygiene as well the surroundings of the patient. Evaluation After 8hrs. of >Changes in vital nursing signs may indicate intervention, the infection. goal is partially met through >Proper hygiene demonstration of prevent infection proper skin and complication. hygiene and A clean compliance with environment treatment and occurrence of any medication. diseases. >Vitamin C provides wound healing and diuretics decreases renal vascular resistance and may increase renal blood flow. Rationale

Dependent: >Administered prescribed meds such as ascorbic acid and furosemide.

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IX. DISCHARGE PLAN

Medications
Medications ordered by the Physician must be well administered on time. Select a drug class that has the greatest effectiveness, fewest side effects

and best chance of acceptance by the patient.

Environment
Environment free from pollutants and stress that may trigger to the complication of the patients condition. Provide a quiet and peaceful environment for the patient to be more relaxed. Provide therapeutic environment such as stretching bed linens & arranging objects on bed.

Treatment
Continue medications as ordered by the physician. Reinforce importance of follow-up care to the parents of the newborn. Parents must continue to follow treatment regimen of physician in order to prevent relapse of the disease.

Health Teaching
Encourage the mother to have a regular check-up for her baby. Tailor information according to the parents ability to understand. Parents must also know importance of proper hand washing because it the best known method of preventing many diseases.

Out- patient
Instruct the guardian of the client that they should report for possible complications of the newborn. Encourage to recommend follow up check up as noted by the physician.

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Diet
Diet must be recommended by the physician. Since the client is a newborn.

Spiritual/Sexual
Encourage the guardian to enhance their faith in God and uplift their desire to be able to surpass the condition of their baby.

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