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HOLY ANGEL UNIVERSITY

Angeles City
College of Nursing

Case Study

Neonatal Sepsis
As a partial requirement in

NCM 104 – RLE


I. INTRODUCTION

The term “sepsis” has been around since ancient times; modern definitions of “sepsis” were
described in detail in the early 1990s, at a consensus conference convened by the American
College of Chest Physicians and the Society of Critical Care Medicine. At that time, “sepsis”
was described as a systemic response to a physiologic insult – including infectious and other
etiologies – that lead to the development of further organ injury, ultimately culminating in
multiple organ dysfunction syndromes. Neonatal sepsis, also termed Sepsis neonatorum, refers to
a group of physical and laboratory findings that occur in response to invasive infection within the
first 30 days of life. As will be discussed below, there are various infectious causes of neonatal
sepsis; however, the pattern of presentation is quite similar in all cases, as is the approach to
treatment. The importance of neonatal sepsis as a diagnosis is found in the fact that this diagnosis
occurs in between 1 to 8 children per 1000 live births in the United States, and may be associated
with a fatality rate of up to 30%. As such, it is essential that caregivers that are involved with the
management of neonates have a reliable approach to the diagnosis and treatment of infants with
sepsis, and that appropriate intervention be instituted in a timely manner.

Neonatal Sepsis is an infection in the blood that spreads throughout the body and occurs
in a neonate. Neonatal Sepsis is also termed as Neonatal Septicemia and Sepsis Neonatorum.
Neonatal Sepsis has 2 types: The one that is seen in the first week of life is termed as Early-
onset sepsis and most often appears in the first 24 hours of life. The infection is often acquired
from the mother. This can be cause by a bacteria or infection acquired by the mother during her
pregnancy, a Preterm delivery, Rupture of membranes (placenta tissue) that lasts longer than 24
hours, Infection of the placenta tissues and amniotic fluid (chorioamnionitis) and frequent
vaginal examinations during labor. The second type or the Late-onset Sepsis is acquired after
delivery. This can be cause by contaminated hospital equipment, exposure to medicines that lead
to antibiotic resistance, having a catheter in a blood vessel for a long time, staying in the hospital
for an extended period of time. Signs and symptoms of Neonatal Sepsis includes but is not
limited to: body temperature changes, breathing problems, diarrhea, low blood sugar, reduced
movements, reduced sucking, seizures, slow heart rate, swollen belly area, vomiting, yellow skin
and whites of the eyes (jaundice). Possible complications are disability and worst is death of the
neonate. (Greene, 2007)
Neonatal sepsis occurs at an estimated rate of 1 to 2 cases per 1000 live births in the U.S.
The highest rates occur in low-birth-weight (LBW) infants, those with depressed respiratory
function at birth, and those with maternal perinatal risk factors. The risk is greater in males (2:1)
and in neonates with congenital anomalies (Merck, 2005). According to the Philippine Mortality
Fact Sheet 2006 of the World Health Organization, in 1000 live births of neonates 17% of it died
due to severe infection that includes deaths from pneumonia, meningitis, sepsis/septicemia, and
other infections during the neonatal period.
Neonatal sepsis can occur in any infant. However, the diagnosis is significantly more
common in pre-term infants than full term infants, and can affect up to 30 to 1000 live births in
the pre-term population. Sepsis is also more common in males than females, and in developing
countries.
Φ MORTALITY STATISTICS OF NEONATAL SEPSIS
2007 No. % 2008 No. %
1. Pulmonary Tuberculosis 38 7.92 1. CVA 46 9.83
2. Pneumonia 36 7.50 2. Pneumonia 43 9.19
3. CVA 29 6.04 3. Pulmonary Tuberculosis 27 5.77
4. Hypertension 23 4.79 4. Hypertension 23 4.91
5. Prematurity 21 4.38 5. Vehicular Accident 12 2.56
6. Neonatal Sepsis 18 3.75 6. Acute Gastroenteritis 11 2.35
7. Malaria 17 3.54 7. Sepsis Neonatorum 11 2.35
8. CNS Infection 10 2.08 8. Congestive Heart Disease 10 2.14
9. Vehicular Accident 10 2.08 9. Malaria 9 1.92
10. Diarrhea 9 1.88 10. Diabetes Mellitus 9 1.92

Nurse Centered Objectives:


At the end of this study, the student nurse will be able to:
♦ have critical thinking skills necessary for providing safe and effective nursing care.
♦ have a comprehensive assessment and implement care base on our knowledge and skills of the
condition
♦ familiarize themselves with effective inter-personal skills to emphasize health promotion and
illness prevention.
♦ Impart the learning experience from direct patient care.

www.who.com
Patient and Family Centered Objectives:
At the end of this study, the patient/family will be able to:
1. Identify measures that could minimize the risk of occurrence of the disease.
2. Identify possible risk factors that may have contributed to the development of Neonatal
Sepsis.
3. Increase awareness on the risk factors of Neonatal Sepsis.
4. Develop the family’s support system and distinguish their respective roles in improving
patient’s health status.
5. Involve them in promoting the health care of the patient.

II. NURSING HISTORY

Personal History
Ms. Sepsis is 25 years old and is of Ilokano descent because her mother was Ilokano. She
was born on September 13, 1984 in Luna, La Union. She gave birth to her first born but she is
not yet married. She lives in an apartment located in San Lorenzo Street, Sto. Domingo, Angeles
City. She was admitted in a birthing home last September 8, 2009 at 03:00 pm. Baby Boy S was
born on the same date at Our Lady of Good Birth Birthing Home near AMC via Cesarean
Section I with an Apgar score of 7 and 8at 11:20 pm. Two days after birth, September 10, 2009,
the baby was admitted at AMC Main ward because of reported continuous vomiting.

Ms. Sepsis works as a lady guard in Angeles City Jail wherein she inspects the workers
before entering the vicinity and she earns 13,000.00 per month. She spends 2,500.00 for rental
fee, water and electricity, 5,000.00 for food, and she sends 4,000.00 to her parents in La Union,
in a monthly basis. Then she has a monthly mobile bill of 800.00 for Globe line and 80.00 for a
smart line. She made a loan to AFPMI in Manila for her giving birth; this was an agency which
is readily available for police officers and workers like them.

Ms. Sepsis finished tertiary education with commerce as her course. She got the work in
the City Jail through her cousin. It was offered to her when she was still working as a clerk in an
electronic company in Batangas. She decided to apply but she did not pass the height
requirement so she was not accepted. Two years after, she applied again and got accepted. Now
she has been working there for two years as of September 4, 2009. But she worked for 2 years
and 5 months for JMP in their main headquarters.

Ms. Sepsis and her family are under Iglesia Ni Cristo (INC). Being INC they have several
beliefs such as if there was someone who is sick like having colds, flu, cough, their Jackono
(officer) would pray over him because if it was severe would they bring him/her to the hospital.
The mother of Ms. Sepsis told her to not watch television during her pregnancy and to not take
cold bath after birth because they will use steamed leaves for bathing. She also told Ms. Sepsis to
use abdominal binder while pregnant.

Family-Health Illness History


Within Ms. Sepsis’ family, only the eldest son has hypertension. No other hereditary
disease was identified by her mother. But on her partners’ side, she stated that her partner had
prostate cancer but was already cured that one of his testes was removed.

History of Past Illness


Ms. Sepsis had chicken pox; mumps at 6 years old which was treated with “tina” and
mefenamic acid, and measles wherein her mother told her to eat “balot” for treatment. She had
urinary tract infection before pregnancy which lasted for 5 days and was treated with Cefalexin
and at her 5th month during pregnancy which lasted for about 1 week as well.

History of Present Illness


After birth, the baby was found to be having neonatal sepsis so he was admitted at AMC
Main Ward. He was breastfed few hours after birth then with water by the mother and the nurse
thereafter and he was still fine. Then he was fed with Bona, formula milk, and then he vomited.
The family thought it was fine and normal but it became continuous so they notified her doctor
and the baby was admitted after.
Φ Family Health Illness History (diagram)

LEGENDS:

Deceased

With hypertension

Had prostate Cancer

Had UTI

With Neonatal Sepsis


OBSTETRICAL HISTORY

Ms. Sepsis had her menarche at the age of 13 and lasted for a week. From then on, she had
regular menstrual period every month with 5 days to 1 week maximum of delay. She gave birth
to her first baby at the age of 25. She does not use OCP rather she uses withdrawal method as
their contraceptive method. She does not live together with her partner because they are assigned
in different areas.

Maternal-Obstetric Record
Ms. Sepsis is not married to her boyfriend yet and has no plan of getting married as of the
moment. She has an Obstetric record of Gravida 1, Para 1. She has a TPAL record of 1-0-0-1.
Her last menstrual period was last December 15, 2008. So her estimated date of delivery was
supposedly on September 22, 2009. She had given birth to her first baby, Baby Boy S last
September 8, 2009 two weeks ahead from her EDD. She was brought earlier than her estimated
date of confinement because she had an early contraction and abnormal fetal position and
attitude. She had given birth via Cesarean Section I in Our Lady of Good Birth Birthing Home,
which is a specialized clinic solely for giving birth.

Ante-partal/ Pre-natal Preparation


According to Ms. Sepsis she had a regular prenatal check-up on her doctor’s clinic. She
goes once a month during the first trimester, twice a month during the second trimester, and
every week during the third trimester. She received 1 dose of tetanus toxoid vaccine from her
doctor. She missed the second dose but her doctor said it was fine.

Significant Trimestral Changes (1st – 3rd trimester)


On the first trimester of her first pregnancy, she did not experience much change. She
narrated that she once ate “bagoong with tomato” and vomited, since then she had not have the
appetite for it. On the second trimester of her pregnancy, she noticed darkening of her neck,
underarm and inguinal area. Third trimester pregnancy, she noticed stretch marks and
experienced slight itchiness. Slight discomfort was felt all throughout the pregnancy period.
During her second trimester of pregnancy, Ms. Sepsis had urinary tract infection. It was treated
through oral antibiotics such as Cefalexin and by drinking lots of water
Last September 7, 2009 she felt contractions occurring at the interval of 5 minutes. At September
8, 2009 she saw brown blood and then clear secretions of about two spoonfuls. Then she was
admitted at the same date at 03:00 pm.
She took vitamins during the course of her pregnancy like Ferrous sulfate for the first
trimester then Micron C for the second trimester then Terraferon for the last trimester. She drank
Anmum but stopped at the 8th month as advised by her ob-gyne because the baby was already
5.28 pounds.

III. PHYSICAL ASSESSMENT (IPPA-Cephalocaudal Approach)

September 10, 2009 (12:15 am)


P.A. of Baby Boy S
Upon admission (lifted from the Chart)
Vital signs:
T: 36.5°C
HR: 132 bpm
Wt: 2.9 kg
(-) Cleft lip and palate
• Clear breath sound; no rales
• Normal respiratory rate and rhythm (NRRR)
• No murmur
• Normal Abdominal Bowel Sound (NABS)
• Soft full equal pulses

September 10, 2009 (04:00 pm)


Initial Interaction
P.A. of Baby Boy S
Vital signs:
HR: 165 bpm
Temp: 37.2 mmHg
RR: 53 bpm
CEPHALO-CAUDAL APPROACH
 SKIN
- Ruddy complexion
- With good skin turgor (negative tenting)
- Skin is warm to touch
 NAILS
- When palpated, the nail base is firm
- Tissue surrounding nails is intact
- Convex curve and pinkish nails
- Blanch test: prompt return of pink color less than 2 seconds
 HEAD
Hair and Scalp
- Hair is black
- Hair is evenly distributed
- Silky, resilient hair
- No dandruff or flaking
- Normal skull configuration, rounded, smooth skull contour
Skull and Face
- Smooth skull contour
- Absence of nodules or masses
- Symmetrical facial features and movements
- Flat anterior fontanel
 EYES
- Eyebrows are evenly distributed and symmetrically aligned
- Equal movements of eyebrows
- Eyelashes are equally distributed, curled slightly outward
- lids are edematous
- transient strabismus
- Bulbar conjunctiva are clear
- Palpebral conjunctiva are shiny, smooth and pink
- No edema or tearing of lacrimal sac
- Anicteric sclerae
- Cornea are transparent, shiny and smooth
- Corneal reflex noted
- Pupil are equally round and receptive to light
- Iris is black in color

 EARS
- Auricles are symmetrical
- Auricles are firm, smooth, free from lesions and pain
- Tip of the ear is aligned with the outer canthus of eye
- Pinna recoils after it is folded
- intact startle reflex
 NOSE AND SINUSES
- Symmetrical nares
- No flaring
- Nose is located symmetrically, midline of the face
- intact glabellar reflex
 MOUTH AND THROAT
- Lips and buccal mucosa are pink in color, moist and smooth texture
- Tongue pink in color, slightly moist; veins not prominent
- Sores and ulceration are not evident.
- intact rooting reflex
 NECK
- Presence of head lag
 BREAST AND AXILLAE
- Equal in size
- Areola is light brown in color
- No palpable lump
- Bilaterally the same
- No pain and tenderness upon palpation
 RESPIRATORY
- Symmetric with full chest expansion
- cylinder shaped
- slight sternal retractions
 CARDIOVASCULAR
- Palpable arterial pulse
- Pulses are strong
 GASTROINTESTINAL
- Rounded
- With bowel sounds during auscultation
- No abnormal lumps and hardened areas in the abdominal area
 GENITAL
- Rugated scrotum
- Urinary meatus at tip of penis
 UPPER AND LOWER EXTREMITIES
- Symmetrical in shape
- Extremities are well flexed
- intact palmar grasp and babinski reflex
IV. DIAGNOSTIC AND LABORATORY PROCEDURES
Diagnostic/Laboratory Date Indications Results Normal Analysis and
Procedures Ordered/ or Purposes Values Interpretation
Date
Results
Hematology
HCT (%) D.O. - To aid 63.0 40.0- The hematocrit is
09/09/2009 diagnosis of 54.0 increased
D.R. – abnormal which is a sign of
09/09/2009 states of dehydration.
hydration,
polycythemia
and anemia
and aids in
calculation of
erythrocyte
indices

Platelet To evaluate 318 140-440 The platelet count


platelet is in normal
production amount.

WBC ct (x18/1) To determine 25.8 4.3-10.0 WBC is increased


for presence which indicates
of for further presence of
tests such as infection.
WBC
differential
infection and
also for
determination
count

Granulocytes 58 44.2-
(x10/1) 14.9 80.2
(x10/91) 10.9 2.0-8.8
1.2-5.3

Hemoglobin is
HGB (g/dL) To measure 18.4 14-18 increased which
the indicates
hemoglobin dehydration.
Nursing Responsibilities:
Patient Preparation:
• Explain to the SO the indication/purpose of the test, that this test detects presence of
infection and other abnormal conditions of the blood
• Explain to the SO the procedure that the test requires blood sample, and who will perform
it.
• Tell the SO that the baby may feel discomfort from the needle puncture and pressure on
the tourniquet. That the baby may struggle and cry.
Procedure & Post test care;
• If hematoma develops at the site, apply warm soaks.
• Ensure sub dermal bleeding has stopped before removing pressure.
• If hematoma is large monitor pulses distal to the site.

V. THE PATIENT AND HIS ILLNESS

Anatomy and Physiology

The immune system is a complex array of organs, cells and chemicals that determine self
from non-self identify potential dangers to the body and eliminate them by mounting an immune
response. Most (but not all) infections result in lifelong immunity. Some infections are
innocuous while others cause serious disease, permanent damage to the host and sometimes
death. Rather than risk serious illness it is possible to vaccinate against a number of potentially
serious diseases. Vaccination is offered from a young age against a number of diseases as an
alternative to experiencing natural infection and the associated risks.

It is important to immunize infants as soon as possible to protect against disease and the infant
immune system is known to be effective and responsive. However, their immune system is naïve
i.e. has not been exposed to any pathogens. Therefore the infant needs to develop immunity to
every pathogenic organism it encounters. By the time of birth the baby will have large numbers
of circulating antibody passed across the placenta from the mother. This antibody will protect the
baby against some infections initially, until the baby forms its own immune response to
pathogens.
Overview of the immune system

Our immune system protects us against viruses, bacteria and parasites which can cause
infectious diseases. The immune system responds to antigens. An antigen is a substance that
stimulates a specific immune response, especially the production of antibodies. Basically this
involves shape recognition. Antigens are usually proteins or polysaccharides, but can be any type
of molecule. Infectious agents such as viruses and bacteria have antigens which the immune
system responds to. Vaccines contain antigens (often purified parts of the original organism).

Types of Immunity

The white blood cells of the immune system are produced in the marrow of our bones. The cells
are carried in the blood to specialized organs such as lymph nodes, where they develop and
communicate to launch immune responses against infections.

We have three types of immunity:

1. Non-specific immunity – is a first line of defense and generally keeps infections from
entering the body. Examples of this are skin (physical barrier), mucus,tears, stomach
acid.
2. Innate immunity – is the second line of defense. In this situation certain white cells
engulf infectious agents. These cells are capable of recognising antigens which are non-
self (ie from an infectious agent), however they cannot recognize particular pathogens.
For example, these cells would not be able to distinguish an influenza virus from a
hepatitis virus, but they would be able to distinguish that there was a viral infection
occurring. Over 90% of infections are controlled by these cells. However when the
infection becomes too great these cells will alert the specific arm of the immune system.
3. Specific or adaptive immunity – This is the third line of defense. In this situation white
blood cell called lymphocytes identify each antigen individually by recognizing different
sequences of amino acids. This specific response initially takes longer to generate (4-7
days) than the non-specific arm but results in a memory to the specific antigen. The
memory response becomes quickly activated. This means that when an individual is re-
infected with the pathogen, this memory response will remove the infectious agent before
it can cause disease (i.e. in 2-3 days). This is the response that vaccination targets.
What is different about the infant immune system?

The infants’ immune system is intact but immature at birth. Some vaccines such as BCG
and Hepatitis B work well when they are administered at birth whereas others do not generate as
strong a response.

The main problem with babies’ immunity is that it is very naïve. At the time of birth babies have
not been exposed to any pathogens. This means that babies have to generate a full immune
response to every pathogen they encounter. Each immune response takes about 10 days to
generate. This is where maternal antibody can be important when present: It will help to protect
an infant if they are exposed to a pathogen in those first 10 days. Unlike other animals (such as
ruminants) which rely mainly on passive transfer of maternal antibodies in breast milk, humans
receive most of their maternal antibodies through placental transfer of IgG. However, there will
still be some antibodies transferred in breast milk, but the levels are much lower. In addition
human babies don’t have a porous stomach (like calves do) in order to absorb the antibody.
Therefore most of the antibody in breast milk will work in protecting pathogens crossing the oral
cavity.

Function Difference during Implications


infancy
Non Specific immunity Phagocytes cannot migrateSlow response to infection
towards infectious sites, although
their bactericidal (killing)
activity is normal.
Cytokine production Poor production of cytokines, inImpaired responses of other cell
particular Th1 cytokines such aspopulations that rely on their
interferon gamma by T-cells. functions such as natural killer
cells.
Natural killer T cell Is incomplete. TheseInefficient killing of viruses
cytotoxicity (killing) abnormalities are probably
caused by immaturity in cytokine
production of T cells and
monocytes.
Complement system Develops progressively duringInefficient phagocytosis
the first year of life
Specific immunity (T-cells and Develops early in prenatal life Relative naivety of T and B cells
B-cells) T and B cells first appear in keymean primary immune response
organs from an early point inis relatively inefficient
fetal development: accounting for the particular
susceptibility of newborns,
• Bone marrow (8-10 especially premature babies, to
weeks) bacterial and viral infections.
• Thymus (8 weeks) Repeated antigenic stimulation
• Spleen (8 weeks) leads to the complete maturation
• Lymph nodes (11 weeks) of specific immunity during the
• Appendix (11 weeks) first few years of life.
• Tonsils (14 weeks .

Specific immune responses


appear to be possible after as
little as 12 weeks of fetal
development. However, T and B
cells are 'naive', encountering
antigens for the first time.

IgG sub group not produced until


the second year of life
Immunoglobulin Impaired production of someInability to respond to
(Ig or antibody) production isotypes. Low serum IgM, IgApolysaccharide encapsulated
and IgE. IgG mostly of maternalbacteria such as meningococcal
origin. and pneumococcal until about 2
years of age.

Inability to respond to
polysaccharide vaccines
Maternal antibody protection IgG against some infectiousGives protection against some
from placenta organism’s crosses the placenta.infections that mother exposed or
Wanes during first year of life. immunised against including
measles and meningococcal
disease.
Can interfere with vaccines such
as MMR.
Little or no protection against
other diseases such as whooping
cough.
Maternal protection from Mostly IgA Provides additional protection
breast milk against gut microbes, less
effective against respiratory
infections
The developing immune system before and after birth

Maternal

The immune system is designed to recognize ‘self’ versus ‘non self’. This means our
own immune system can recognize our own cells as being safe and anything else as being a
threat. Obviously this has implications in pregnancy, where a developing fetus will be
expressing antigens from the father. Therefore during pregnancy modifications occur in the
maternal immune system at many levels. These changes are necessary to ensure a successful
pregnancy. In the absence of such changes the mother’s immune system would recognize the
fetus as foreign (like a pathogen) and reject it. Potentially dangerous T-cell responses are down
regulated (reduced) and some aspects of the non-specific immune system are activated. As
previously mentioned, at this time specific IgG antibody passes from the mother through the
placenta to the developing fetus providing it with temporary protection against some of the
infections that the mother has been exposed to or vaccinated against. This gives opportunities to
provide newborns with transient protection against some diseases.

Infant

The infant’s immune system is relatively complete at birth. It is clear that the IgG
antibodies received from mother are important for the protection of the infant during the first few
months of life while the infant is starting to develop its own repertoire. Passive transient
protection by IgA against many common illnesses is also provided to the infant in breast milk.
Mother’s milk provides IgA against a wide range of microbes that the mother has had in her gut.
Breast milk has also been shown to assist in the development of the infant’s own immune
system. There is some, although weak, evidence to show that breastfed infants respond better to
some vaccines. The major impetus however for the expansion of lymphocytes (B and T cells) is
the exposure to microbes which colonize the gut during birth.

Premature and low birth weight infants are at increased risk of experiencing complications of
vaccine preventable diseases and although the immunogenicity of some vaccines may be
decreased in the smallest preterm infants, the antibody concentrations achieved are usually
protective.

Φ BOOK-BASED PATHOPHYSIOLOGY
Schematic Diagram (Flow Chart)
- Pathophysiology

-Symptoms

-Lab tests

-Treatment
Synthesis of the Disease
Neonatal sepsis may be categorized as early or late onset. Eighty-five percent of
newborns with early-onset infection present within 24 hours, 5% present at 24-48 hours, and a
smaller percentage of patients present between 48 hours and 6 days of life. Onset is most rapid in
premature neonates. Early-onset sepsis syndrome is associated with acquisition of
microorganisms from the mother. Transplacental infection or an ascending infection from the
cervix may be caused by organisms that colonize in the mother's genitourinary tract, with
acquisition of the microbe by passage through a colonized birth canal at delivery. The
microorganisms most commonly associated with early-onset infection include group B
Streptococcus (GBS), Escherichia coli, Haemophilus influenzae, and Listeria monocytogenes.

Late-onset sepsis syndrome occurs at 7-90 days of life and is acquired from the
caregiving environment. Organisms that have been implicated in causing late-onset sepsis
syndrome include coagulase-negative staphylococci, Staphylococcus aureus, E coli, Klebsiella,
Pseudomonas, Enterobacter, Candida, GBS, Serratia, Acinetobacter, and anaerobes. The
infant's skin, respiratory tract, conjunctivae, gastrointestinal tract, and umbilicus may become
colonized from the environment, leading to the possibility of late-onset sepsis from invasive
microorganisms. Vectors for such colonization may include vascular or urinary catheters, other
indwelling lines, or contact from caregivers with bacterial colonization.

Risk Factors

The most common risk factors associated with early-onset neonatal sepsis include
maternal GBS colonization (especially if untreated during labor), premature rupture of
membranes (PROM), preterm rupture of membranes, prolonged rupture of membranes,
prematurity, maternal urinary tract infection, and chorioamnionitis.

Risk factors also associated with early-onset neonatal sepsis include low Apgar score (<6
at 1 or 5 min), maternal fever greater than 38°C, maternal urinary tract infection, poor prenatal
care, poor maternal nutrition, low socioeconomic status, recurrent abortion, maternal substance
abuse, low birth weight, difficult delivery, birth asphyxia, meconium staining, and congenital
anomalies. Risk factors implicated in neonatal sepsis reflect the stress and illness of the fetus at
delivery, as well as the hazardous uterine environment surrounding the fetus before delivery.
Late onset sepsis is associated with the following risk factors: prematurity, central venous
catheterization (duration of >10 d), nasal cannula continuous positive airway pressure use, H2
blocker/proton pump inhibitor use, and gastrointestinal tract pathology.

Race- Black infants have an increased incidence of GBS disease and late-onset sepsis. This is
observed even after controlling for risk factors of low birth weight and decreased maternal age.

Sex- The incidence of bacterial sepsis and meningitis, especially for gram-negative enteric
bacilli, is higher in males than in females.

Age- Premature infants have an increased incidence of sepsis. The incidence of sepsis is
significantly higher in infants with very low birth weight (<1000 g), at 26 per 1000 live births,
than in infants with a birth weight of 1000-2000 g, at 8-9 per 1000 live births. The risk for death
or meningitis from sepsis is higher in infants with low birth weight than in full-term neonates.

Signs and Symptoms

The clinical signs of neonatal sepsis are nonspecific and are associated with characteristics of the
causative organism and the body's response to the invasion. These nonspecific clinical signs of
early sepsis syndrome are also associated with other neonatal diseases, such as respiratory
distress syndrome (RDS), metabolic disorders, intracranial hemorrhage, and a traumatic delivery.
Given the nonspecific nature of these signs, providing treatment for suspected neonatal sepsis
while excluding other disease processes is prudent.

• Cardiac signs: In overwhelming sepsis, an initial early phase characterized by


pulmonary hypertension, decreased cardiac output, and hypoxemia may occur. These
cardiopulmonary disturbances may be due to the activity of granulocyte-derived
biochemical mediators, such as hydroxyl radicals and thromboxane B2, an arachidonic
acid metabolite. These biochemical agents have vasoconstrictive actions that result in
pulmonary hypertension when released in pulmonary tissue. A toxin derived from the
polysaccharide capsule of type III Streptococcus has also been shown to cause pulmonary
hypertension. The early phase of pulmonary hypertension is followed by further
progressive decreases in cardiac output with bradycardia and systemic hypotension. The
infant manifests overt shock with pallor, poor capillary perfusion, and edema. These late
signs of shock are indicative of severe compromise and are highly associated with
mortality.
• Metabolic signs: Hypoglycemia, hyperglycemia, metabolic acidosis, and jaundice all are
metabolic signs that commonly accompany neonatal sepsis syndrome. The infant has an
increased glucose requirement because of sepsis. The infant may also have impaired
nutrition from a diminished energy intake. Metabolic acidosis is due to a conversion to
anaerobic metabolism with the production of lactic acid. When infants are hypothermic
or they are not kept in a neutral thermal environment, efforts to regulate body
temperature can cause metabolic acidosis. Jaundice occurs in response to decreased
hepatic glucuronidation caused by both hepatic dysfunction and increased erythrocyte
destruction.

• Neurologic signs: Meningitis is the common manifestation of infection of the CNS. It is


primarily associated with GBS (36%), E coli (31%), and Listeria species (5-10%)
infections, although other organisms such as S pneumoniae, S aureus, Staphylococcus
epidermis, H influenzae, and species of Pseudomonas,
Φ CLIENT-BASED PATHOPHYSIOLOGY

Schematic Diagram (Flow Chart)


- Pathophysiology

-Symptoms

-Lab tests

-Treatment
Synthesis of the Disease

As for Baby Boy S, he had an early-onset neonatal sepsis. A type of sepsis acquired from the
mother and/or before delivery. Early-onset neonatal sepsis most often appears within 24 hours of
birth.
Risk Factors of Baby Boy S includes
 Male- it is said that neonatal sepsis is common to male infants than female.
 Maternal UTI- baby boy S’s mother had UTI during the second trimester
Signs and Symptoms
The patient experienced:
 Continuous vomiting during the first 24 hours of life
Clinical Signs includes:
 Increased WBC count of 25.8 g/L
Results in 09-09-09
Normal value of 4.3-10.0 g/L
 Increased hematocrit count of 63.0
Results in 09-09-09
Normal value of 40.0-54.0 for males

VI. THE PATIENT AND HIS CARE


1. Medical Management
A. IVF

IVF Date Ordered General Indications Client’s


Date Description Response
Performed
D10W 500cc Sept. 9, 2009 IV solutions the client adhered
This medication is a
x 8 ugtts/min 12:15 a.m. containing well and did not
solution given by
dextrose are manifest for any
vein (through an
indicated for side effects
IV). It is used to
parenteral
supply water and
replenishment of
calories to the body.
fluid and
It is also used as a
minimal
mixing solution
carbohydrate
(diluent) for other
calories as
IV medications.
required by the
Dextrose is a natural
clinical condition
sugar found in the
of the patient. It
body and serves as a
is also use as a
major energy
mixing solution
source. When used
for other IV
as an energy source,
medication.
dextrose allows the
body to preserve its
muscle mass.

Nursing Responsibilities
Prior:
 Verify doctor’s order.
 Know the type, amount, and indication of IV therapy
 Prepare for the IV infusion set.
 Clean the insertion site.
During:
 Do hand washing
 Open and prepare the infusion set
 Do the IV insertion procedure
 Dress and label the venipunctures site
After:
 Label the IV tubing with the date and time of attachment and initials of the nurse.
 Regulate IV.
 Observe for potential complication.
 Document relevant data and record the start of the infusion on the client’s chart.

Φ OGT

Medical Date Ordered General Indications Client’s


Management Date Description Response
Performed
OGT Sept. 10, 2009 To prevent the client adhered
Passing a
12:30 a.m. vomiting with well and did not
rubber/plastic tube
resultant manifest for any
via mouth
aspiration of side effects
gastric contents
Nursing Responsibilities
Prior:
 Verify doctor’s order.
 Inform the SO.
 Explain the purpose of OGT.
 Practice strict asepsis.
During:
 Do hand washing.
 Prepare the materials needed for the procedure.
After:
 Check for the patency.

B. Drugs

Generic Date Route of General Client’s response


Name Ordered/ administration Action
Brand Date Taken Dosage and
Name frequency and
Administration
Generic Sept. 9, 2009 IV 100mg q 12 Inhibits cell Client responded well
Name: wall synthesis and had no adverse
Ampicillin during bacterial reaction to drug.
multiplication.
Brand Name:
Ampicin

Generic Date Route of General Client’s response


Name Ordered/ administration Action
Brand Date Taken Dosage and
Name frequency and
Administration
Generic Sept. 9, 2009 IV 15mg q 12 Inhibits protein A reduction in
Name: synthesis by neutrophils has been
Amikacin binding directly noted.
Sulfate to the 30S
ribosomal
Brand Name: subunit;
Amikin bactericidal.
Nursing Responsibilities
Prior:
 Check for the doctor’s order and medication chart
 Prepare materials needed
 Before giving drug ask the patient about allergic reactions to certain drugs such as
penicillin. A negative history of the drug allergy is not a guarantee against a future
allergic reaction.
 Do skin testing
 Obtain specimen for culture and sensitivity test before giving first dose. Therapy may
begin pending results.
During:
 Remember the 10 R’s in giving medications.
After:
 Tell the patient/ SO to take the entire quantity of the drug exactly as prescribed even after
the patient feels well.
 Encouraged patient to increase fluid intake
 Therapy continuous for 7 to 10 days. If no response occur after 3 to 5 days stop the
therapy and obtain new specimens for culture and sensitivity.
 Watch signs and symptoms of super infection (esp. Upper Respiratory Tract) such as
continued fever, chills and increase pulse rate.
 Inform patient to notify prescriber if rash, fever or chills develop. A rash is a most
common allergic reaction.

C. Diet
Type of Diet Date Ordered General Indication Client’s
Description Response
NPO Sept. 9, 2009 Restriction to To prevent Patient did not
11:25 p.m. take food via oral aspiration. receive anything
route. by mouth.
Nursing Responsibilities
Prior:
 Check the doctor’s order.
 Check the right client.
 Make sure that the diet is properly instructed.
During:
 Monitor if the SO complies with the diet given for the patient.
After:
 Assess for the patient’s condition.
VII. NURSING CARE PLAN

Problem no.1 NUTRITIONAL IMBALANCE: LESS THAN BODY REQUIREMENTS

Assessment Nursing Scientific Objectives Nursing Rationale Expected


Diagnosis Explanation Interventions Outcome

S> Ø Imbalanced The patient’s After 3 hours of >Monitor and >To provide After 3 hours of
nutrition less intake of nursing record vital signs comparative nursing
O> Patient
than body nutrients is interventions, the SO baseline interventions, the
may manifest: requirement insufficient to will verbalize >Monitor weight SO will verbalize
related to meet the body’s understanding of >To monitor understanding of
> vomiting
inability to metabolic causative factors progression of causative factors
> poor muscle ingest or digest demands. The when known and when known and
>Assist in condition
food or body then reacts necessary necessary
tone
nutrients to the low interventions. developing interventions.
> body nutrient individualized >To correct or
synthesis thus regimen
weakness control underlying
compensatory
>loss of weight mechanisms are factors
activated such
as decrease in
activity, weight
loss
Problem no. 2 HYPERTHERMIA
Assessment Nursing Scientific Goal/Expected Interventions Rationale Evaluation
Diagnosis Explanation Outcome
S> Ø Hyperthermia In sepsis, it After 1 hour of >Identify >To know what are The patients’
implies the nursing underlying cause the causes of such SO had
presence of an interventions, the condition. identified
O> WBC is infection of the patient’s SO will underlying
increased, a total blood caused be able to identify > Monitor sources >To be able to cause and
of 25.8 wherein by rapidly underlying of fluid loss identify if there is cotributing
the normal is 4.3- multiplying cause/contributing dehydration and factors as well
10.0 microorganisms factors and excessive fluid loss as the
or toxins which importance of the importance of
>skin is warm can result to treatments, as >Monitor >To monitor the the treatments.
to touch hyperthermia as well as signs and laboratory status of the client
a defense symptoms studies.
mechanism of requiring further
the body. intervention. >Identify factors >To protect the cliet
that the SO can from any factor
control (if any) which may be
hazardous to the
client

>Discuss >For the SO to know


importance of the importance of
adequate fluid preventing
intake and dehydration to occur
treatments. and the ways on how
to treat the client.
Problem no. 3 INTERRUPTED BREAST FEEDING

Assessment Nursing Scientific Planning Intervention Rationale Expected


Diagnosis Explanation Outcome
S- Ø Interrupted Since the After 2hours of >Assess mother’s >To know what The mother
breastfeeding neonate is nursing perception and the mother was able to
related to diagnosed for intervention and knowledge about already knows identify and
O: neonate’s having a health teachings breastfeeding and and needed to demonstrate
-The newborn is present illness as neonatal sepsis, the mother will extent of instruction know. techniques to
diagnosed with a evidenced by the baby got identify and that has been given. sustain
certain disease separation of separated from demonstrate lactation and
(Sepsis) mother to infant his mother and techniques to >Give emotional >To assist identify
- The newborn placed on a sustain lactation support to mother mother to techniques
was separated private room until and accept decision maintain on how to
from his mother separate from breastfeeding is regarding cessation/ breastfeeding as provide the
- The mother her mother. initiated continuation of breast desired. newborn
was unable to Interrupted feeding. with breast
provide breast breastfeeding milk.
milk to her develops since >Demonstrate use of >Aid in feeding
newborn the mother is manual piston-type the neonate with
unable to breast breast pump. breast milk
fed the baby without the
continuously due mother
to their breastfeeding the
separation. infant.

>Review techniques >To provide


for storage/use of optimal nutrition
expressed breast milk and promote
continuation of
breastfeeding
process
>Determine if a >So that infant
routine visiting will be hungry/
schedule or advance ready to feed
warning can be
provided
>To promote
>Provide privacy, successful infant
calm surroundings feeding
when mother breast
feeds.
>Reinforces that
>Recommend for feeding time is
infant sucking on a pleasurable and
regular basis enhances
digestion.

>To sustain
>Encourage mother adequate milk
to obtain adequate production and
rest, maintain fluid breast feeding
and nutritional process
intake, and schedule
breast pumping every
3 hours while awake
Problem no. 4 KNOWLEDGE DEFICIT
Cues Nursing Scientific Explanation Objective Nursing Rationale Evaluation
Diagnosis Interventions
S>“May Knowledge Neonatal sepsis is caused by After 2 hours >Determine client’s >This may differ The patients’
kinalaman ba deficit an infection detected during of NPI the most urgent need from and require SO verbalized
ang laging related to or after the delivery. In this patients’ SO both client’s and adjustment in understanding
pag-iyak sa unfamiliarit case, the patient was will verbalize nurse’s viewpoint. teaching plan. of the disease
kondisyon ng y with the identified to having neonatal understanding process and
baby ko information sepsis after two days. of the >Provide situation >Prevent was able to
ngayon?” resources. Transplacental infection or condition, relevant to the overload. clarify her
O> an ascending infection from disease situation. concern.
-frequently the cervix may be caused by process and
ask organisms that colonize in treatment. >Discuss client’s >In order for the
questions. the mother's genitourinary perception of need client to feel
tract, with acquisition of the information related to competent and
microbe by passage through client’s personal respected.
a colonized birth canal at desires, needs, values,
delivery. The and beliefs.
microorganisms most State objectives clearly
commonly associated with in learner’s term.
early-onset infection include
group B Streptococcus >Begin with the >Can arouse
(GBS), Escherichia coli, information the client interest/ limit
Haemophilus influenzae, already knows and sense of being
and Listeria monocytogenes. move to what the client overwhelmed.
Whle the depression fetl by does not know
the mother was caused by progressing to simple to
hormonal changes during complex.
the pregnancy.
Problem no. 5 RISK FOR IMPAIRED PARENT/NEONATE ATTACHMENT

Assessment Nursing Scientific Planning Intervention Rationale Expected


Diagnosis Explanation Outcome
S- Ø Risk for Due to the After 3 hours of >Interview parents, >To know
Impaired parent/ newborn’s nursing noting their what the The parents will
O: neonates physical illness intervention and perception of parents be able to have a
-The newborn is Attachment and health teachings situation and feelings about mutually
diagnosed with a related to hospitalization, the mother will individual concerns the situation. satisfying
certain disease neonates the parents may identify and interactions with
(Sepsis) physical illness have fear on how demonstrate >Educate parents >Helps clarify their newborn.
- the newborn is and to handle their techniques to regarding child realistic
hospitalized hospitalization. baby since the enhance growth and expectations
- The newborn is baby is on its behavioral development,
separated from fragile state and organization of addressing parental
his parents needed extra the neonate perceptions
care. And since
he is the 1st child . > Involve parents >Enhances
hospitalized in in activities with self-concept
their family, the the newborn that
parents might they can
still be unsure on accomplish
how to take care successfully
of the baby.
>Recognize and >Reinforces
provide positive continuation
feedback for of desired
nurturant and behaviors
protective
parenting behaviors
VIII. DISCHARGE PLAN

Φ METHOD
M - Medication
- ampicillin 100mg IV q12
- Amikin SO4 15mg IV q12
E - Exercise
- Stressed that the baby sleeps most often times
T - Treatment
- Stressed importance of complying with the medications
H - Health Teachings
- Instructed Mother to bring back the baby in the hospital for his medication
- Instructed Mother on the time the medication will be given
- Instructed Mother for the drug’s side effect which includes constipation;
diarrhea; dizziness; headache; indigestion; nausea; pain, swelling, or redness at
the injection site; sleeplessness; vomiting.
- Instructed Mother of the importance of breastfeeding
- Instructed Mother on Proper Breastfeeding
- Instructed Mother to expose the baby to sunlight at 6:00 am to 10:00 am
- Instructed Mother that formula milk is only good for 4 hours
- Instructed Mother on strict aspiration precaution
- Instructed Mother to burped the baby after each feedings
- Instructed Mother to bathe daily their Baby
D - Diet
- Instructed Mother to feed the baby as tolerated with strict aspiration precaution
IX. LEARNING DERIVED FROM THE STUDY

At the end, the researcher realized that there is always something new to learn that could
help you be a better healthcare provider. It is indeed true that learning never stops. And with the
current trends that we have, it is part of the nurses’ responsibility to keep themselves abreast with
the new trends.
With the study made by the researcher, she had able to identify what neonatal sepsis is,
its risk factors, signs and symptoms of the disease, diagnostic procedure that can be done to
diagnose the disease, its medical treatment, prevention and nursing care plan specific for the
disease. With the knowledge learned during the study, the researcher can be able to promote
wellness by health teachings to mother and to persons unfamiliar with the disease and prevention
of the disease.
During the course of the study, the importance of proper infection control and hand
washing was found out for the prevention in the spread of infection especially in the hospital.
The researcher found out that proper knowledge of the staff regarding the disease
condition of a patient with neonatal sepsis is vital for the betterment of her service as one of the
providers of care on a hospital.
This case study has also given the researcher the great opportunity to share his personal
experience in the care of a patient with neonatal sepsis.

CONCLUSIONS
Based on the researchers experience neonatal sepsis is not a very crucial case although
there are lots of reported cases with severe neonatal sepsis. Onset can be prevented and be
treated especially in the case of Late-onset neonatal sepsis. Prompt treatment and adequate
knowledge about the disease process is needed so that complications will not arise. On the other
hand your care is not only confined to the patient but extends significantly to the family.
Knowledge and appropriate skills are part of the tools of the nurse in order to be effective in
handling a patient with neonatal sepsis. Having a clear understanding of the disease and its
process, with consideration of the feelings and beliefs of the parents, most especially, will aid the
nurse in skillfully meeting patient’s needs.
RECOMMENDATIONS
At the course of the study, the researcher had found out that an in-depth knowledge about
the disease process will benefit not only the patient and its family but also the nurse and the
medical staff as well. The following is a list of recommendations made by the researcher:
For the Nurses:
 An in-depth knowledge should be acquired regarding the disease condition so
that proper treatment and prevention can be implemented.
 Nurses must stress the need for good prenatal care and emphasize on parents,
the value of regular check-ups at well-baby clinics.
 Proper infection control especially strict hand washing should be implemented
in the hospital because it is the most effective method in controlling the spread of
infection from staff to patient.
For the hospital:

 Sterility or cleanliness of hospital equipment should be maintained


 Seminars about infection control should be conducted so that hospital staff will be
knowledgeable in the prevention of infection from spreading.
For the patients care:

 Supportive treatment should all be given and is needed in patients care.

X. REFERENCES
• http://www.immune.org.nz/?t=899
• http://www.doh.gov.ph/ospitalngpalawan/index.php?
option=com_content&view=article&id=18&Itemid=24
• Doenges,M.E.et.al.Nurses’ pocket guide.2008.F.A. DAVIS COMPANY
• Johnson, J.Y.2008. Textbook of Medical-surgical nursing. 11th edition. Lippincott
Williams & Wilkins