Far Eastern University Institute of Nursing

Submitted by: Deluao, Arby A. BSN-214/ Group 54 Submitted to: Ms. Jennifer Padual FEU-NRMF (Pedia Ward)

Far Eastern University Institute of Nursing

DEMOGRAPHIC DATA

Date of interaction: January 18, 2012

I. NAME

BIOGRAPHIC DATA : : B.B.C.D. 223 Evergreen street Group 1 Area B Barangay Payatas, Quezon City

ADDRESS

AGE GENDER DATE OF BIRTH PLACE OF BIRTH MARITAL STATUS RELIGIOUS ORIENTATION HEALTH CARE FINANCER ROOM AND BED # PROVISIONAL DIAGNOSIS ATTENDING PHYSICIAN

: : : : : : : : : :

Newborn Male January 11, 2012 Quezon City Single Roman Catholic None 504 A Newborn (increased WBC, early jaundice) Dr. Patricia Balingit

II. NURSING HEALTH HISTORY A. PAST HEALTH HISTORY According to the mother of the client, he had immunizations such as BCG (bacillus calmette-guerin) and hepatitis B vaccine. According to the mother of the client, she had regular prenatal check-ups as well as intake of multivitamins, calcium tablets and ferrous sulfate. She is a non-smoker and non-alcoholic. She is also a non-diabetic, non-hypertensive and non-asthmatic. She has no allergies to food or drugs, no history of accidents, operations, exposure to radiation or toxic chemicals. They also did not take any local or foreign travel in the past six months. B. PRESENT HEALTH HISTORY The mothers chief complaint of the client upon admission was yellow discoloration of the skin and the sclera of the eyes. C. FAMILY HISTORY On the maternal side of the client, there is no known disease while on his paternal side, there is history of hypertension. He has three siblings, and the client is the third and youngest among them. GENOGRAM Maternal side
56 63

Paternal side
58 HPN 64

35

34

32

30

37

10

NB

LEGEND:
FEMALE MALE

CLIENT GRANDMOTHER GRANDFATHER AUNTIE UNCLE MOTHER FATHER SISTER BROTHER

D. DEVELOPMENTAL HISTORY Psychosocial Development According to the mother, she breastfeed the client in demand whenever he is hungry. She satisfies the clients needs by giving food, comfort and sustenance. That is why he views the world to be one of trust because he is satisfied and his basic needs are being met regularly. Psychosexual Development In the psychosexual development of an infant, the mouth is the focus of gratification. As stated by the mother, the client derived the pleasure by feeding at his mothers breast and from the oral exploration of his or her environment. He is exploring the world with his mouth most specifically sucking. Cognitive Development The client begins to differentiate himself from his mother because he can now identify the physical boundaries between his body and the environment. In this stage, he uses his sensory-motor reflexes. Moral Development According to the mother, the client smiles in response to her and grasp her finger. The mother also added that she knows that she plays a big role in developing a positive outlook, learning values and moral development.

I.

PATTERNS OF FUNCTIONING

NUTRITIONAL AND METABOLIC PATTERN DIET RECALL January 11-18, 2012 Breast Feeding

With good suck

The client only feeds breast milk and it he usually feed on demand, usually 10 times a day and last for about 30 minutes. The client is being fed during the day and night. He is being fed in an upright position and burped every after feeding. According to the mother of the client, he is being fed several times and alternating sides of her breasts during feedings.
INTERPRETATION: The infant has a normal health management pattern; his mother is feeding him in demand throughout the day and night. His mother is also giving the baby comfort measures by feeding him in upright position and burped every after feeding. ANALYSIS: Good nutrition is essential for the growth and development that occurs during an infants first year of life. When developing infants are fed the appropriate types and amounts of foods, their health is promoted. Positive and supportive feeding attitudes and techniques demonstrated by the caregiver help infants develop healthy attitudes toward foods, themselves, and others. (Reference: www.nal.usda.gov)

ELLIMINATION PATTERN According to the clients mother, the client does not have any problem in his bowel movement. He has frequent bowel movement and usually consumes 6 to 8 diapers a day. His mother describes his stool as yellowish to greenish in color and semiliquid in form. While his urine is pale in color and he usually soak the diaper after breast feeding. The client sometimes cries whenever his diapers are soaked or become restless when he has defecated.
INTERPRETATION: The childs urination and defecation pattern are normal. He sometimes cries whenever his diapers were soaked after breastfeeding. ANALYSIS: Newborns tend to urinate every 1020 minutes, sometimes very regularly, which makes timing extremely useful. It varies in timing based on when they have last eaten or slept. Signals of urinating or defecating vary widely from one infant to another, and include a certain facial expression, a particular cry, squirming, a sudden unexplained fussiness, as well as others. For defecation, many babies will grunt or pass gas as a signal. (Reference: Maternal and Child health Nursing)

SLEEP AND REST/ACTIVITY ACTIVITY RECALL

Time
3:00 am 3:00-3:30 3:30-4:00 4:00-7:00 7:00-7:45 7:45-8:00

Activities
Woke up Breast feeding Go to sleep again Sleep Breast feeding Bowel movement with urination Change soaked diaper Breast feeding Sleep Breast feeding Bowel movement with urination Change soaked diaper Breast feeding

8:00-8:15 8:15-8:45 8:45-12:00 noon 12:00-12:30 12:30-1:30

1:30-2:30 2:30-4:30 4:30-5:15 5:15-6:00 6:00-11:00 11:00-11:45 11:45-12:00 12:00-12:30 am 12:30- 3:00 am

Nap Change soaked diaper Breast feeding Sleep Breast feeding Change soaked diaper Breast feeding Sleep

The mother of the client verbalized, Madalas ko siyang hinehele at binubuhat para na rin makatulog siya pero paputol putol ang tulog niya eh, gigising sya pag nagugutom, halos kada apat na oras, tapos matutulog na ulit. The client approximately sleeps a total of 16 hours a day most often, as stated by the mother. Sa tingin ko nakakadede naman siya ng maayos at sapat na yon kasi madami siyang nagagamit na diaper eh. the mother verbalized. The client also flails his arms out and cries whenever he is startled by suddenly changing position or by a loud noise.
INTERPRETATION: The clients sleeping pattern is normal, since he sleeps most of the day and night. ANALYSIS: The amount of sleep an infant needs is greater than as they grow older. They have sleeping and napping time during the day. Newborns sleep in short duration of time, typically ranging from 30 minutes to 4 hours at seemingly random times throughout the day and night. Finally, newborns vary greatly in the total amount of time they spend sleeping. In the first few days, the average newborn sleeps between 1618 hours a day. By four weeks, newborn sleep averages about 14 hours. But the range is considerable. Some four week old babies sleep as little as 9 out of 24 hours. Others sleep for 19 hours a day. (Reference: Maternal and Child health Nursing)

SEXUALITY PATTERN The client salivates whenever he is in demand of food and he feeds with good sucking reflex. The palm of the clients hand closes when it is being stroked.
INTERPRETATION: The clients sexuality pattern is normal since mouth is the center of gratification in infants according to psychosexual theory. ANALYSIS: The oral stage is the first Freudian stage of development, occurring during the first 18 months of life, in which the infants pleasure centers on the mouth. Chewing, sucking, and biting are the chief sources of pleasure. These actions reduce tension in the infant. (Reference: http://highered.mcgraw-hill.com)

Far Eastern University Institute of Nursing

PHYSICAL ASSESSMENT

General Appearance and Mental Status a. height and weight in relation to clients age and lifestyle. b. Posture and gait, standing, sitting, and walking c. Hygiene and grooming d. Body and breath odor e. Signs of distress in posture or facial expression f. Obvious signs of health or illness g. Mood Skin a. color and uniformity of color b. presence of edema c. lesions d. skin moisture e. temperature f. skin turgor Skull a. size, shape and symmetry b. palpate nodule, masses and depression Hair

Normal Findings Proportionate, varies with age and life style *(Fundamentals of Nursing 7th edition by Kozier page. 532) Relaxed posture, erect posture, coordinated movement *(Fundamentals of Nursing 7th edition by Kozier page. 532) Clean and neat *(Fundamentals of Nursing 7th edition by Kozier page. 532) No body or breath odor *(Fundamentals of Nursing 7th edition by Kozier page. 532) No signs of distress noted *(Fundamentals of Nursing 7th edition by Kozier page. 532) Healthy appearance *(Fundamentals of Nursing 7th edition by Kozier page. 532) Appropriate for the situation *(Fundamentals of Nursing 7th edition by Kozier page. 532) Color varies from light, uniform except in areas exposed to the sun *(Fundamentals of Nursing 7th edition by Kozier page. 538) No presence of edema *(Fundamentals of Nursing 7th edition by Kozier page. 538) No lesions *(Fundamentals of Nursing 7th edition by Kozier page. 538) Moisture in skin folds *(Fundamentals of Nursing 7th edition by Kozier page. 539) Normal in body temperature *(Fundamentals of Nursing 7th edition by Kozier page. 539) Good skin turgor *(Fundamentals of Nursing 7th edition by Kozier page. 539) Rounded, normal in size, smooth *(Fundamentals of Nursing 7th edition by Kozier page. 544) Absence of nodule and masses *(Fundamentals of Nursing 7th edition by Kozier page. 544)

Actual Findings Height = 50 cm Weight = 3.3 kg Coordinated, relaxed posture

Analysis Within Normal Within Normal Within Normal Within Normal Within Normal Deviated from normal Within Normal Deviation from normal Within Normal Within Normal Within Normal Within Normal Within Normal Within Normal Within Normal

Clean and neat No body or breath odor No signs of distress

Looks unhealthy Appropriate, respond to stimuli, behave Skin is yellowish

No edema

No lesions Slight moisture in skin folds 36.5 C, warm to touch, uniform throughout the body Returns back immediately

Rounded, normal, head circumference is 33 cm No nodules, masses, tenderness

Thorax Posterior Thorax Inspect the size, shape, symmetry, and compare the diameter of anteroposterior thorax to transverse diameter Assess respiratory excursion

Anteroposterior to tranverse diameter in ratio of 1:2; Chest symmetric *(Fundamentals of Nursing by Kozier page. 576)

Chest circumference- 35 cm 2:1 symmetric

Within Normal

Auscultate the posterior thorax Anterior Thorax Inspect breathing patterns Palpate for temperature, tenderness and masses Asses respiratory excursion

Full and symmetric chest; Expansion (when the client takes a deep breath, your thumbs should move apart an equal distance and at the same time, normally the thumbs separate 3 to 5 cm. (1.5 to 2 inches) during deep inspiration *(Fundamentals of Nursing by Kozier page. 576) Vesicular and bronchovesicular breath sounds *(Fundamentals of Nursing by Kozier page. 576) Quiet, rhythmic, and effortless respirations *(Fundamentals of Nursing by Kozier page. 578) Uniform temperature; No tenderness; No masses *(Fundamentals of Nursing by Kozier page. 578) Full and symmetric chest; expansion (when the client takes a deep breath, your thumbs should move apart an equal distance and at the same time, normally the thumbs separate 3 to 5 cm (1.5 to 2 inches) during deep inspiration *(Fundamentals of Nursing by Kozier page. 578) Symmetric pulse volumes, full pulsation, quality remains same when client breathes and change position *(Fundamentals of Nursing 7th edition by Kozier page. 583) Unblemished skin, uniform in color *(Fundamentals of Nursing by Kozier page. 590)

Symmetric chest expansion

Within Normal

Vesicular and bronchovesicular breath sounds Quiet, rhythmic, and with good air entry/ effortless Uniform temperature; No tenderness; No masses Symmetric chest expansion

Within Normal

Within Normal Within Normal Within Normal

Cardiovascular Heart

Regular rate, rhythm, quality, no murmurs

Within Normal

Abdomen Abdomen skin integrity Uniform in color Within Normal

Abdomen contour and symmetry Genitalia Male genitalia Extremities Inspect the size and any deformities Measurements Temperature Pulse Rate Respiratory rate Weight Height Head circumference Chest circumference Arm circumference

Rounded contour line and symmetric contour Normal genitalia *(Fundamentals of Nursing by Kozier page. 595) Equal size on both sides of the body and no deformities *(Fundamentals of Nursing by Kozier page. 600) Actual findings 36.5 C 140c/min 40c/min 3.3 kg 50 cm 33 cm 35 cm 29 cm

Globular, soft, and symmetric contour Normal looking male genitalia, bilateral descending testes Equal size on both sides of the body, no deformities

Within Normal Within Normal Within Normal

Far Eastern University Institute of Nursing

DIAGNOSTIC RESULTS

Date January 13, 2012

Procedure Complete Blood Count

Norms RBC count: (Male) 5.56.5x10^12/L WBC count: 510^9/L

Result RBC count: 4.42x10^12/L WBC count: 44.30x10^9/L

Interpretation
RED BLOOD CELLS A lower than normal RBC can result from a number of causes, including: Massive RBC loss, such as acute hemorrhage Abnormal destruction of red blood cells Lack of substances needed for RBC production Bone marrow suppression Anemia can occur from either a decrease in the number of red blood cells, a decrease in the hemoglobin content, or both. WHITE BLOOD CELLS When a person has a bacterial infection, the number of white cells rises very quickly. The number of white blood cells is sometimes used to find an infection or to see how the body is dealing with cancer treatment. The numbers of white blood cells give important information about the immune system. Too many or too few of the different types of white blood cells can help find an infection, an allergic or toxic reaction to medicines or chemicals, and many conditions, such as leukemia.

January 12, 2012

Clinical Chemistry

Total bilirubin: less than 102.60 Direct Bilirubin: B2: 0.6

TB: 176.9

BILIRUBIN For a patient who shows signs of abnormal liver function. A bilirubin level may be ordered when a patient:

B2: 10.30

shows evidence of jaundice

B1: less than 94.0 B1: 166.30

(Determining a bilirubin level in newborns with jaundice is considered standard medical care.) Excessive bilirubin damages developing brain cells in infants (kernicterus) and may cause mental retardation, learning and developmental disabilities, hearing loss, or eye movement problems. Increased total: hepatic damage (hepatitis, toxins, cirrhosis), biliary obstruction, hemolysis, fasting.

Far Eastern University Institute of Nursing

PROBLEM IDENTIFICATION AND PRIORITIZATION

RANK 1 NURSING DIAGNOSIS Risk for infection related to compromised immune system. CUES Objective Cues Flushed skin Skin and sclera appearing light yellow weak looking under phototherapy with heplock at right hand JUSTIFICATION This problem is a health threatening and needs prompt treatment even it is a risk because if the problem persist it can be life threatening. When pathogenic bacteria gain access into the blood stream, they may cause

III. Measurement

Temp.: 36.5C Pulse Rate: 140 Respiratory Rate: 40 Weight: 3.3 kg

overwhelming infection. This problem can lead to organ dysfunction, spread of infection and septic shock. Neonatal sepsis is the single most important cause of neonatal deaths in the community. With early and aggressive treatment, it can save lives of many.

WBC increased 44.30 x 10^9/L

Risk for Injury related to abnormal blood profile as evidenced by increase bilirubin level

Objective Cues skin appearing light yellow sclera appearing light yellow weak looking afebrile under phototherapy with heplock at right hand

The problem is a health threat and needs immediate action. It is included in Maslows hierarchy of needs, which is safety. If the problem will be resolved, it can make the life of the client better in a way that his body can function well and can adapt to certain situations.

III. Measurement

Temp.: 36.5C Pulse Rate: 140 Respiratory Rate: 40 Weight: 3.3 kg

bilirubin level of 176.9 umol/L

Far Eastern University Institute of Nursing

Ecologic Model A. Hypothesis I hypothesized that there are many factors that predispose the infant in acquiring the disease. It may be due to his age, the nature or exposure to the environment and the mothers lack of knowledge about the risks of infection. These are the factors which lead the infant in having Neonatal Sepsis and Hyperbilirubinemia. B. Predisposing factors Agent

Biologic During pregnancy, the placenta excretes bilirubin. When the baby is born, the baby's liver take over this function. Babys limited ability to excrete bilirubin in the first days of life and inadequate liver function due to infection.

Host

Age- Newborn Sex- Male Behavior- delivered via spontaneous vaginal delivery

Environment

Socio-economic- resides at Payatas, Quezon City in a congested area Income is just enough for the expenses

Ecologic model Agent-Triangle-Host-Triangle

A. Analysis

The model is used primarily in predicting illness rather than in promoting wellness, although identification of risk factors that result from the interaction of the agent, host, and environment are helpful in promoting and maintaining health. Because each of the agent-host environment factors constantly interacts with the others, health is an ever-changeable state. When the variables are in balance, health is maintained, when the variables are not in balance, disease occurs. (Kozier and Erbs Fundamentals of Nursing vol. 1 page 298)

A. Conclusion and recommendation

I therefore conclude that the clients neonatal sepsis and hyperbilirubinemia is related to his livers limited ability to excrete bilirubin in the first days of life and also due to inadequate liver function due to infection. I recommend to the family of the client to provide daily bath/hygiene. I recommend exposing the client in direct sunlight for the excretion of bilirubin. I also recommend meeting the physiologic needs of the client. Breast feeding the client and giving comfort and care.

Discharge Plan

M-edications There are no drugs prescribed by his physician. E-xercise Advise the mother of the client to expose him to indirect sun light to help speed up the process of the breakdown of bilirubin. Advise to put your skin-exposed baby/client next to a closed window and let the rays of sunlight shine on him for around fifteen minutes, four times a day. Sunlight dissolves the bilirubin in the skin so that it can be excreted in the baby's urine. T -reatment Instruct the patients parents to comply with the physicians arranged schedule for follow-up check-ups and immunization schedules. H-ealth Teachings Advise mother to feed the client on an upright position. Advise the mother to feed the client breast milk because as the client gets more fluid, it is easier for his body to flush out the excess bilirubin. Feed the client at least every two to three hours during the day and when he awakens at night. Advise the mother to burp the client every after feeding. Advise to maintain daily bath and hygiene. O-ut patient

 Instruct the patients parents to comply with the physicians arranged schedule for follow-up check-ups and other programs. D-iet Advise the mother of the client to continue breast feeding.

PATHOPHYSIOLOGY
Pathophysiology of neonatal sepsis Early onset: Certain maternal perinatal and obstetric factors increase risk, particularly of earlyonset sepsis, such as the following: Premature rupture of membranes occurring 18 h before birth Maternal bleeding (eg, placenta previa, abruptio placentae) Preeclampsia Precipitous delivery Maternal infection (particularly of the urinary tract or endometrium, most commonly manifests as maternal fever shortly before or during delivery) Heavy colonization with GBS Preterm delivery

Hematogenous and transplacental dissemination of maternal infection occurs in the transmission of certain viral (eg, rubella, cytomegalovirus), protozoal (eg, Toxoplasma gondii), and treponemal (eg, Treponema pallidum) pathogens. A few bacterial pathogens (eg, L. monocytogenes, Mycobacterium tuberculosis) may reach the fetus transplacentally, but most are acquired by the ascending route in utero or as the fetus passes through the colonized birth canal. Though the intensity of maternal colonization is directly related to risk of invasive disease in the neonate, many mothers with low-density colonization give birth to infants with high-density colonization who are therefore at risk. Amniotic fluid contaminated with meconium or vernix caseosa promotes growth of GBS and E. coli. Hence, the few organisms in the vaginal vault are able to proliferate rapidly after PROM, possibly contributing to this paradox. Organisms usually reach the bloodstream by fetal aspiration or swallowing of contaminated amniotic fluid, leading to bacteremia. The ascending route of infection helps to explain such phenomena as the high incidence of PROM in neonatal infections, the significance of adnexal inflammation (amnionitis is more commonly associated with neonatal sepsis than is central placentitis), the increased risk of infection in the twin closer to the birth canal, and the bacteriologic characteristics of neonatal sepsis, which reflect the flora of the maternal vaginal vault.

Late onset: The most important risk factor in late-onset sepsis is preterm delivery. Others include Prolonged use of intravascular catheters Associated illnesses (which may, however, be only a marker for the use of invasive procedures) Exposure to antibiotics (which selects resistant bacterial strains) Prolonged hospitalization Contaminated equipment or IV or enteral solutions

Gram-positive organisms (eg, coagulase-negative staphylococci and Staphylococcus aureus) may be introduced from the environment or the patient's skin. Gram-negative enteric bacteria are usually derived from the patient's endogenous flora, which may have been altered by antecedent antibiotic therapy or populated by resistant organisms transferred from the hands of personnel (the major means of spread) or contaminated equipment. Therefore, situations that increase exposure to these bacteria (eg, crowding, inadequate nurse staffing or provider hand washing) result in higher rates of hospital-acquired infection. Risk factors for Candida sp sepsis include prolonged (> 10 days) use of central IV catheters, hyperalimentation, use of antecedent antibiotics, necrotizing enterocolitis or other abdominal pathology, and previous surgery. Initial foci of infection can be in the urinary tract, paranasal sinuses, middle ear, lungs, or GI tract, and may later disseminate to meninges, kidneys, bones, joints, peritoneum, and skin. Pathophysiology of hyperbilirubinemia The majority of bilirubin is produced from the breakdown of Hb into unconjugated bilirubin (and other substances). Unconjugated bilirubin binds to albumin in the blood for transport to the liver, where it is taken up by hepatocytes and conjugated with glucuronic acid by the enzyme uridine diphosphogluconurate glucuronosyltransferase (UGT) to make it water-soluble. The conjugated bilirubin is excreted in bile into the duodenum. In adults, conjugated bilirubin is reduced by gut bacteria to urobilin and excreted. Neonates, however, have sterile digestive tracts. They do have the enzyme -glucuronidase, which deconjugates the conjugated bilirubin, which is then reabsorbed by the intestines and recycled into the circulation. This is called enterohepatic circulation of bilirubin

PATHOPHYSIOLOGY
Modifiable factors Sterility of the environment/delivery Exposure to bacteria Non-modifiable factors Age/ limited ability to excrete bilirubin Liver immaturity Decreased immune system Increased white blood cells

RBC lifespan is 120 days

RBC will become fragile

Cellular content will be released

Macrophages will phagocytized it

Reduct into bilirubin (indirect, unconjugated) fat soluble Transport to the liver with the help of albumin

Absence of glucuronyl transferase produced by liver Unconjugated to convert Increase unconjugated bilirubin

To the blood stream

Yellow discoloration of sclera, skin, conjunctiva

HYPERBILIRUBINEMIA