\CASE STUDY

NEONATAL SEPSIS
 INTRODUCTION

Newborn infants are at much higher risk for developing sepsis than children and adults because of
their immature immune system—especially premature infants, where 1 out of every 250 will be
diagnosed with sepsis. Sepsis is one of the major leading causes of death in the first few months of a
newborn’s life. Infections can contribute up to 13-15% of all deaths during the neonatal period with the
mortality rate reaching as high as 50% for infants who are not treated timely. The combination of an
immature and slow responding immune system increases the risk of infection in the neonate. One reason
for the increased risk is that antibodies, which help protect mothers from infections, do not cross through
the placenta to the fetus until approximately 30 weeks of gestation. The antibodies present at birth take
time to reach optimum levels, which also affects the protection provided.

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. Comparatively higher rates of mortality were seen among home-delivered newborn infants
and those referred from other maternity facilities.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.

The physical and chemical barriers to infection in the human body are present in the newborn but
are functionally deficient. Skin and mucus membranes are broken down easily in the premature infant.
Neonates who are ill and/or premature are additionally at risk because of the invasive procedures that
breach their physical barriers to infection. Because of the interdependence of the immune response, these
individual deficiencies of the various components of immune activity in the neonate conspire to create a
hazardous situation for the neonate exposed to infectious threats.

Other risk factors is when the newborn is in distress before being born, has a very low birth
weigh, has a bowel movement before being born, and meconium (fetal stool) is present in the uterus, the
amniotic fluid surrounding the baby has a bad smell, or the baby has a bad smell right after being born
and male babies are at greater risk for neonatal sepsis than female babies while some of the symptoms
that the doctor will need to check for include fever or frequent changes in temperature, doesn’t drink
formula or breast milk well, not urinating, stomach is bloated or puffy, drool or spit is yellowish,
vomiting or diarrhea, extreme redness around the belly button or skin rashes, unexplained high or low
blood sugar, irritability or difficulty waking up and baby is sleepy all the time, skin is jaundice (yellow)
or overly pale, abnormally slow or fast heartbeat, stops breathing, breathes rapidly, or has difficulty
breathing, bruising or bleeding, seizures and a cool, clammy skin.

Our group chose this case due to the existing fact that neonatal sepsis in becoming widespread in
some parts of the country especially to home-born babies and some hospitals that fail to maintain the ideal
environment and care for the newborn. Recently, it was shown in the news that a lot babies died in some
parts of Luzon due to neonatal sepsis and though despite the major advances in neonatal medicine, many
infants still develop life-threatening infections during the first month of life. Identifying and caring for an
infant with a possible infection starts with a skilled nurse who is proficient in performing neonatal
assessments. The assessment begins with a nurse’s innate knowledge of the many different risk factors for
newborn infection. The nurse needs to be observant for any sign that may indicate sepsis. It cannot be
overemphasized that prompt recognition, early diagnosis, and immediate treatment of sepsis can
dramatically improve the infant’s outcome and limit any potential disability.
 OBJECTIVES

GENERAL OBJECTIVE:

This study aims to discuss a case where a nursing process is comprehensively

utilized in care of the patient having neonatal sepsis providing a thorough and clear

understanding of the client’s history, health condition, pathophysiology of the disease,

treatment and management; and to identify the drugs and its implications to develop a

better medical and nursing management of the disease.

SPECIFIC OBJECTIVE:

After the case presentation, the student nurse will be able to:

1. formulate nursing diagnosis

2. Present the anatomy and physiology of fetal circulation and infant’s immune

system.

3. Discuss the pathophysiology of neonatal sepsis.

4. Present a thorough physical assessment and Gordon’s functional health pattern.

5. Identify laboratory and diagnostic tests ordered and their significance.

6. Discuss the medical and surgical management of the disease.

7. Identify and enumerate the various drugs prescribed and their actions

8. Formulate an individualized nursing care plan for the patient

9. Construct an appropriate health teaching plan in relation to client’s present

condition using the METHOD format.

 ANATOMY AND PHYSIOLOGY
Fetal Circulation

During pregnancy, the fetal circulatory system works differently than after birth:

• The fetus is connected by the umbilical cord to the placenta, the organ that develops and
implants in the mother's uterus during pregnancy.
• Through the blood vessels in the umbilical cord, the fetus receives all the necessary
nutrition, oxygen, and life support from the mother through the placenta.
• Waste products and carbon dioxide from the fetus are sent back through the umbilical
cord and placenta to the mother's circulation to be eliminated.

Blood from the mother enters the fetus through the vein in the umbilical cord. It goes to
the liver and splits into three branches. The blood then reaches the inferior vena cava, a major
vein connected to the heart.

Inside the fetal heart:

• Blood enters the right atrium, the chamber on the upper right side of the heart. Most of
the blood flows to the left side through a special fetal opening between the left and right
atria, called the foramen ovale.
• Blood then passes into the left ventricle (lower chamber of the heart) and then to the
aorta, (the large artery coming from the heart).
• From the aorta, blood is sent to the head and upper extremities. After circulating there,
the blood returns to the right atrium of the heart through the superior vena cava.
• About one-third of the blood entering the right atrium does not flow through the foramen
ovale, but, instead, stays in the right side of the heart, eventually flowing into the
pulmonary artery.

Because the placenta does the work of exchanging oxygen (O2) and carbon dioxide (CO2)
through the mother's circulation, the fetal lungs are not used for breathing. Instead of blood
flowing to the lungs to pick up oxygen and then flowing to the rest of the body, the fetal
circulation shunts (bypasses) most of the blood away from the lungs. In the fetus, blood is
shunted from the pulmonary artery to the aorta through a connecting blood vessel called the
ductus arteriosus.
 Blood circulation after birth:

With the first breaths of air the baby takes at birth, the fetal circulation changes. A larger
amount of blood is sent to the lungs to pick up oxygen.

• Because the ductus arteriosus (the normal connection between the aorta and the
pulmonary valve) is no longer needed, it begins to wither and close off.
• The circulation in the lungs increases and more blood flows into the left atrium of the
heart. This increased pressure causes the foramen ovale to close and blood circulates
normally.

IMMUNE SYSTEM DEVELOPMENT

The immune system begins very early in fetal development with the origin of blood
formation in the third week of gestation. In the fourth week of gestation the thymus forms. The
thymus helps to mature and develop white blood cells so that they can play a key role in fighting
infections. By the eighth week of gestation, T cells, B cells, and natural killer cells can all be
found in the thymus.
T cells, which make an important component in cell-mediated immunity, are formed
solely in the thymus. B cells, which are the precursors of antibody producing cells, are first
produced in the liver but by 12 weeks gestation move into the bone marrow where it remains.
Natural killer cells, which are cytotoxic cells that have the ability to attack viruses, mature in the
thymus. Interestingly, greater concentrations of natural killer cells are found in the peripheral
blood of newborns and the newborn usually has adult levels of these cells at birth, but they
diminish rapidly. Orlando Regional Healthcare, Education & Development © Copyright 2004 Page 4
Neutrophils are relatively numerous in both the term and pre-term infant. A neutrophil is
a type of white blood cell that defends the body from organisms that cause infection. The stages
of neutrophil development, from immature to mature, are myeloblast, promyelocyte, myelocyte,
metamyelocte, band, and segmented neutrophil. When an infection is present, the neutrophils
migrate out of the capillaries and into the infected site, where they ingest and destroy the
pathogens causing the infection. The amount of circulating neutrophils in the newborn peaks
around 12 hours after birth and then starts to decline to normal levels. Even though a large
number of circulating neutrophils can be found in the newborn, the bone marrow storage pool of
neutrophils at birth is only 20% to 30% of the circulating pool in adults.

Differences in Immune Responses in Full and Preterm Infants

Immune System Full Term Infant Preterm Infant

Component

Immunoglobulin G Complete placental transfer, concentrations Incomplete placental transfer, concentrations

comparable to mother decreased

Lymphocytes Concentrations of T and B cells comparable Concentrations of T and B cells comparable

to those in adults with normal response to to those in adults with normal response to
antigens antigens

Complement 50%-75% of concentration in adult Decreased concentration

Neutrophils Elevated numbers at birth, with impaired Elevated numbers at birth, with impaired
functional ability functional ability

Monocytes Normal number at birth but have impaired Normal number at birth but have impaired
chemotaxis chemotaxis

Macrophages Normal number at birth but decreased Normal number at birth but decreased
function function

Natural Killer Cells Concentration similar to adult level, but have Concentration similar to adult level, but have
diminished cytotoxic effects diminished cytotoxic effects
 Immune System Physiology
Despite the immune system and immune system components, early development during
gestation the newborn still remains vulnerable to infections after they are born because of the
immaturity of their immune system.
A newborn has a poor response to invading pathogens. This immune response will
gradually improve with age. During the initial postpartum phase, the infant relies on maternal
antibodies and the mother’s breast milk, which is rich with immunoglobulins. When a
pathogenic organism overcomes the infant’s defenses, infection and sepsis result. Sepsis is
defined as the presence of microorganisms or their toxins in blood or other tissues. Newborn
sepsis is still one of the most significant causes of neonatal disability and death today.
Reviewing the functions of the infant’s immune system will help provide a better
understanding of the interaction between the pathogenic organisms and the newborn’s
susceptibility to infection. Infections occur when the infant comes in contact with a pathogenic
organism. The organism, whether it is a virus, fungus, or bacteria, enters into the infant’s body
system and begins to multiply.
The infant’s immune system response to an organism is divided into three phases. The
first phase is the primary or nonspecific phase, which occurs immediately following the infant’s
inoculation with a pathogenic organism. During this phase, there is a migration of the neutrophils
to the primary site of the infection. The neutrophils enter into the cells through membrane filters
and adhere to the pathogen. Ingestion and destruction of the invading organism then takes place.
The next phase in the immune response is called the secondary phase or the specific
response phase. During this phase, there is interaction of T and B cells to help develop
immunoglobulins or antibodies to protect the infant from the infection. There are three major
types of immunoglobulins: Immunoglobulin G (IgG), Immunoglobulin M (IgM), and
Immunoglobulin A (IgA).
Immunoglobulin G is the major immunoglobulin of the serum and interstitial fluid. It
provides immunity against both bacterial and viral pathogens. It starts to cross the
placenta and enter into fetal circulation around 30 weeks’ gestation and continues until
the 40th week. Term infants have IgG levels that are equal to or exceed maternal levels.
Since IgG is not transferred until around the 30th week of gestation, the preterm infant
does not have this protective barrier. Preterm infants are thus at higher risk for infections.
Research has shown that there are also decreased levels of IgG in post-term and small for
gestation age infants, which suggest that there may be some inhibition of transfer with
placental damage.
Immunoglobulin M does not cross the placenta thus, little or no IgM is transferred to the
fetus. This lack of IgM increases the infant’s susceptibility to gram negative infections.
The infant does however begin synthesis of this immunoglobulin very early in their fetal
life. Levels of IgM have been detected around 30 weeks’ gestation with higher levels
detected when there is an intrauterine infection present.
Immunoglobulin A is the most common immunoglobulin found in the gastrointestinal
tract, respiratory tract, human colostrum, and breast milk. IgA does not cross the
placenta, and intrauterine synthesis is minimal. Levels of IgA are usually not detected
until the infant is around 2 to 3 weeks old.
The last immune response is the tertiary phase. This phase provides long-term immunity
against the organism. During the second phase, the B cells produce memory cells that recognize
the invading pathogen on subsequent exposures. These memory cells recognize the invading
organism and cause them to be neutralized, preventing the infant from becoming sick again.
Although adequate numbers of B cells are present at birth, antibody production is diminished in
the neonate due to a lack of uterine exposure to foreign pathogens.

BASELINE DATA

Name: Baby Girl D.

Address: Tres Y Media, Taloc, Bago City

Age: 3 days old

Educational Level: N/A

Marital Status: Single

Religion: N/A

Birthdate: December 2, 2006

No. of Dependents:none

Birthplace: Bago City

Gender: Female

Occupation: N/A

Nationality: Filipino

Person next to Kin:Mother

Source of history/reliability: Significant other (mother) and patient’s charts

Date of Admission:December 4, 2006

Attending Physician:Dr. Beñosa

Chief Complaints: Upward rolling of eyeballs

Admission Diagnosis: Neonatal Sepsis: Full term AGA via NSD t/c neonatal asphyxia

rolled out CNS infection, neonatal tetanus

Temperature: 37.0°C

Heart Rate: 114 bpm

Respiratory Rate: 33 cpm

 GORDON’S 11 FUNCTIONAL HEALTH

PATTERN

Typical Day Activities

The mother usually do the household chores takes care of the infant.

Nutritional – Metabolic Pattern

The mother eats nutritional foods such as fruits and vegetables with no tea, coffe

or softdrink during pregnancy. While the baby is breastfed with aspiration precaution.

The baby is with diaper and has a soft stool due to breastfeeding.

Activity and Exercise Patterns

The mother usually do household chores and walks early in the morning as a

form of exercise during pregnancy. After delivery while both mother and child is in the

hospital, the mother usually gives the child sun bathing to eliminate the yellowish

discoloration of the skin. The primitive reflexes of the child are present and strong.

Recreational/ Pets/ Hobbies

The client’s mother and family has no pets and only spend their spare time in

mahjong, card games and tsismis.

Sleep-rest Pattern

The child sleeps most of the time and only wakes up when she urinates, pass out

stool or when hungry.

Personal Habits
 The mother usually do the household chores and only takes care of her child and

husband. She stays in their house oftenly and only goes out when necessary like

helping out in the farm or taking her child to a health center for immunization.

Occupational – Health Patterns

The mother works in the farm and do most of the household chores. Her

husband works as a contractual carpenter to support the family.

Socio – Economic Status

The family is below poverty line with only their relatives especially her sister to

help them in financial aspect.

Environmental – Health Patterns

They have a poor environmental condition with dirty surroundings and unsanitary

personal hygiene.

Roles, Relationship, Self-Concept

Mother has a positive outlook for her child’s future if God would lengthen the

child’s life. She has also a good relationship with her husband and their in laws. The

mother carry out her roles positively with enthusiasm and happiness in her heart as a

mother, wife, in law, sister and relative.

Religious, Spiritual, and Cultural Influences

The patient has no hard liquor, no coffee and tea during pregnancy only

nutritious foods like fruits and vegetables. She believes that her children should be

delivered by a “paltera”, they should go to “manoghilot” to massage the gravid uterus,

mother and child should bathe together one week after delivery with herbal medicines.

Family Roles and Relationships

 The members in the patient’s family are very close. They have a healthy

relationship with one another and supports each other during trying moments in their

lives.

Stress and Coping Patterns

The patient shares that praying and reading the Bible gives her strength and

helps her face the stresses in life although she does not go to church regularly. Her

family and her relatives show support by visiting her in the hospital and through texting

or calling her to ask how she and the baby is doing.

Sexuality Patterns

The patient is married and has a normal sex life. She cannot remember her LMP

and did not undergo any reproductive examination due to knowledge deficit and

financial instability.

Social Support

Aside from her family, she is also grateful for the support and prayer that her

relatives and friends are showing.

 HEALTH HISTORY

History of Present Illness:

a. Usual health status: The patient has been experiencing an on and off fever with

cool, clammy and jaundiced skin with upward rolling of eyeballs, febrile seizure,

irritability and poor feeding.

b. Chronologic story:

1. October 2002 – During the mother’s first pregnancy (on the 28th week

gestation) she experienced an accident , she slipped and fell

while in the bathroom and to manage the pain she went to a

“manoghilot” and had her gravid uterus massaged to keep

the baby safe. Then, she continued to work in the farm and

do the household chores.

2. December 2002 – The mother experienced the same accident and resorted

to the same management for pain.

3. January 2003 – The mother delivered her first baby through a home birth

and delivered a full term AGA infant in cephalic position

facilitated by a “paltera” (unlicensed practitioner of midwifery)

using a non-sterile instrument, unsterile materials in an

unsterile environment. The “paltera” conducted an improper

newborn care to the infant leading to the development of

sepsis, in which the infant was able to exhibit the signs and

symptoms persistent within 3 days after delivery. The

mother admitted the sick infant to CLMMRH. The diagnostic

tests revealed that the infant was already in distress while

inside the womb leading the child to develop meningitis and

 developed neonatal sepsis due unsterile delivery and

improper newborn care. The child went through atrio-

ventricular shunt and had series of antibiotic therapy. After

28 days of admission they decided to go home thus resorted

to DAMA (discharge against medical advice) and brought the

child home.

4. April 2003 – Her first baby acquired measles thought to come from a

neighboring infant, then experienced on and off fever, chills

and upward rolling of eyes. The mother brought her first

baby to CLMMRH and the baby was diagnosed to have

acquired German measles however, due to lack of financial

support they went home and was not able to do anything to

aid the infant’s condition.

5. May 17, 2003 – The first baby died at four months old after suffering from

different prevailing conditions left unaided.

6. December 2, 2006 – The mother had her second delivery still a home birth

and delivered via NSD to a full term AGA infant in a breech

position facilitated by “paltera” (unlicensed practitioner of

midwifery). The environment was unsterile, the mother lying

down to a plastic covered bamboo floor. The infant given

birth is our client, after the delivery the “paltera” did the

newborn care and cord care to the infant where she cut the

umbilical cord 1 inch from the abdomen tied it with three

layers of ordinary thread (usually used in sewing cloths) and

covered the tip of the umbilical cord with a cotton.

7. December 3, 2006 – The mother noticed that our client was having chills,

upward rolling of eyes, high fever, cool and clammy skin.

After which, she called the “paltera” and informed her of her

observations and as a response the “paltera” instructed her

 to take the following drugs such as methergin, ferrous sulfate

and paracetamol and breastfeed the infant so that the drugs

can be passed on to the infant via breastmilk.

8. December 4, 2006 – The mother brought the client to Bago Health Center

for BCG vaccination and reported the child’s case to the

resident physician. The physician did not give the BCG

immunization and referred her to the Bago City Hospital for

admission and further observation.

c. Relevant family history: N/A

d. Disability assessment: N/A

Past Health History (infant):

Childhood illness: upward rolling of eyes, chills, cool and clammy skin, on and off

fever

Hospitalizations: none

Serious injuries/chronic illnesses: none

Immunizations: none

Allergies (food, drugs, environmental): none

Medications (prescribed/OTC): Paracetamol

Family History:

The child’s grandparent had a history of death due to tuberculosis.

Psychosocial Profile:

Health practices and beliefs/self-care activities (mother): Children should be delivered

by a “paltera”, they should go to “manoghilot” to

massage the gravid uterus, mother and child should

bathe together one week after delivery with herbal

medicines.
Typical day: Irritable, breatfed when hungry, frequent change of diaper due to urination

and stooling.

Nutritional patterns: Breastfeed with aspiration precaution

Activity/exercise patterns: Primitive reflexes present and strong

Recreation: none

Sleep/rest patterns: Sleeps most of the time and only wakes up when she urinates,

pass out stool or when hungry.

Personal habits: none

Socioeconomic status: Below poverty line

Environmental health patterns: Poor environmental condition with dirty surroundings

and unsanitary personal hygiene.

Roles, Relationships, Self-concept (mother): Mother has a positive outlook for her

child’s future given that the child’s life will be

prolonged. She has also a good relationship with her

husband and their in laws. The mother carry out her

roles positively with enthusiasm and happiness in her

heart as a mother, wife, in law, sister and daughter.

Cultural/Religious influences (mother): No hard liquor, no coffee and tea during

pregnancy only nutritious foods like fruits and vegetables.

Family Roles/Relationships (mother): She has a healthy relationship with her husband,

daughter, in laws and relatives

Sexuality Patterns (mother): The mother was unable to recall her LMP. She never

undergone any reproductive examinations due to knowledge deficit

and financial instability. She got pregnant twice and delivered both

infants alive but accompanied with illnesses. Her first born died

due to meningitis, neonatal sepsis and german measles. While,

her second born was also diagnosed with neonatal sepsis.

Social supports (mother and child): Relatives and family

 Stress/coping patterns (mother and child): Mother copes up with stress through prayers

and family support. Her child copes up with stress with the help of her

mother through cuddling, feeding and cleaning her.

PHYSICAL ASSESSMENT

A. General Appearance

Upon assessment, the client looks unclean and untidy with blood tinged dress as

she is cuddled by her mother. Upward rolling of eyes is observed but with good

primitive reflexes present. Pseudomenstruation is present as evidenced by white

secretions going out of the vagina. The umbilical cord is dry and looks very unclean

tied with a non-sterile thread (the usual thread we use in sewing cloths) and cord

clamp. The client’s nails were long and uncut. Client was febrile and in

cardiopulmonary distress with vital signs T = 37.7°C, HR = 180 bpm and RR = 20

cpm. There is also a yellowish discoloration in the skin, eyes and tongue.

B. Neurologic System

The client is as she is cuddled by her mother.

C. HEENT (head, eyes, ears, nose and throat)

The client’s pupil is equally round and reactive to light and accommodation

(PERRLA) with upward rolling of eyes present. There is also a yellowish

discoloration of the sclera and tongue.

D. Respiratory System

The client breath through the nose with wheezes present in both lungs upon

auscultation, experiences difficulty of breathing, slightly dyspneic having a

respiratory rate of 33 breaths per minute.

E. Cardiovascular System
 She has a good capillary refill <2 seconds with strong and rapid pulse and has a

heart rate of 180 beats per minute.

F. Gastrointestinal Tract System

The patient has a normoactive bowel sounds at four quadrants of the abdomen.

She is on breastfeeding with aspiration precaution and was able to defecate to a soft

green mushy stool approximately 80 cc.

G. Genitourinary Tract System

The client voided freely to a clear urine approximately 15 cc with diaper. Her

perineum is unclean with pseudomenstruation as evidenced by presence of blood

secretions going out of the vagina.

H. Musculoskeletal System

The baby moves freely with primitive reflexes present and strong.

I. Integumentary System

The client has a good skin turgor. Her umbilical cord is dry and looks very

unclean tied with thread and cord clamp. There is also a yellowish discoloration of

the skin. Her nails are long and uncut. She is febrile with temperature of 37.7°C.

SUMMARY OF PERTINENT PHYSICAL ASSESSMENT FINDINGS

In general, the patient’s health status upon physical assessment is altered. There is

upward rolling of eyeballs but with good primitive reflexes. Client was febrile and in

cardiopulmonary distress with vital signs T = 37.7°C, HR = 180 bpm and RR = 20 cpm

She looks unclean and untidy with blood tinged dress, nails are long and uncut. She

has an unclean perineum with pseudomenstruation present. Her umbilical cord is

infected due to non-sterile and improper cord care and tied with thread and cord clamp.
The rest of the body systems are within normal limits as evidenced by stable vital signs,

PERRLA and good skin turgor.

LABORATORY REPORTS AND TESTS

Laboratory/
Result Normal Value Interpretation Implication
Diagnostic Test

CHEMISTRY I
December 4, 2006 113 mg/dL or up to 130 mg/dL or up
2 HPPBS, RBS 6.21 mmol/ L to 7.2 mmol/L Normal

HEMATOLOGY
REPORT
December 5, 2006
Hematocrit 0.38 vol/L 0.38 – 0.47 Normal
Hemoglobin 127 g/L 120-160 g/L Normal
WBC Count 14.3 x 10/L 5.0- 10.0 x 10/L Elevated May indicate hemolytic
anemia and infection

RBC Count 3.7 x 10/L 4.0-6.0 x 10/L Decreased May indicate hemorrhage
anemia, or hemodilatation
(over hydration)

Direct Platelet 315 x 10/L 150- 400 x 10/ L Normal Normal

BLOOD There is decreased

CHEMISTRY II Decreased Hemoglobin and Hematocrit
December 6, 2006 Decreased because of surgery.
Calcium
2.1 mmol/L or 2.02- 2.6 mmol/L or
8.4 mg/dL 8.1- 10.4 mg/ dL Normal Normal

SERUM SODIUM
AND POTASSIUM
December 6, 2006
Serum Sodium 163.9 mEq/L 135- 145 mEq/ L Elevated Indicates dehydration severe
diarrhea (water loss is greater
than sodium loss)

Serum Potassium 4.10 mEq/L 3.5- 5.0 mEq/L Normal Normal

CHEMISTRY I
December 7, 2006 90 mg/dL or 50 up to 130 mg/ dL or Normal Normal
mmol/ L up to 7.2 mmol/ L
URINALYSIS

Parameter Patient Normal Value Interpretation Implication

COLOR PALE LIGHT STRAW ABNORMAL Indicates
diluted urine
( Large fluid
intake)
TRANSPARENCY SLIGHT HAZY CLEAR ABNORMAL May indicate
bacteruria
SPECIFIC 1.010 1.001- 1.020 NORMAL NORMAL
GRAVITY
pH 6.0 5-7 NORMAL NORMAL
RBC 1-3 hpf 0-2 hpf ELEVATED May indicate
renal failure
problems
PUS CELLS 1-4 hpf NONE ELEVATED Indicates
genitourinary
tract infection/
contamination
of external
genetalia
 PATOPHISIOLOGY

Home birth through the help of a "paltera"

Unsanitary conditions and unsterile equipments used

Increased likelihood of bacterial growth

Insufficient knowledge of the guardians as to proper cord

care

Increased bacterial growth and infestation

Immature body systems of the infant

Infection of the umbilical stump

Another form of tetanus, neonatal tetanus, occurs in newborns who

are delivered in unsanitary conditions, especially if the umbilical cord stump
becomes contaminated. Once the bacteria are in the body, it produces two
endotoxins, a Tetanolysis and Tetanospasmin. Neurotoxic effects are
produced by the Tetanospasmin. Most of the toxin enters the peripheral
endings of motor neurons form the bloodstream, travels up the fibers to the
spinal cord and brainstem, and crosses the synaptic nerve to the inhibitory
neurons, where it prevents the release of glycine. glycine is a neuromuscular
transmitter secreted mainly in the synapses of the spinal cord; acting as an
inhibitor. The action of tetanospasmin is through an affinity for the SNS.
medullary enters, the anterior horn cells of the SC and the motor end plates
in the skeletal muscles. It produces uninhibited motor responses leading to
the typical muscle spasms.
NDX: RISK FOR INFECTION
Assessment Nursing Rationale NURSING CARE PLAN Nursing
Desired Outcome Justification Evaluation
Data Diagnosis Interventions
Actual/ Risk for Infection Schematic After 8 hours of Independent: Goal met. The
Abnormal [progression of Diagram nursing • Monitor VS • To monitor increase or client was
Findings: sepsis to septic Predisposing intervention the closely decrease in VS that relieved of
The client looks shock, Factors client will be able would suggest hyperthermia,
unclean and untidy development of Financial to: potentially fatal afebrile= 37.0°C,
with blood tinged dress opportunistic instability
• Achieve complications the babies WBC
Intermittent fever Poor decreased,
infections] timely • Provide • Body substance
Febrile seizure, environmental
related to sanitation healing, be isolation/ isolation should be
irritability and poor
feeding compromised Knowledge free of monitor visitors employed for all infectious
Yellowish immune system, Deficit purulent as indicated patients. Umbilical Cord/
discoloration in the environmental Superstitious secretions / linen isolation and
skin, eyes and tongue exposure, Beliefs drainage or handwashing may be all
Nails were long and invasive  erythema, that is required for
uncut procedures, Delivered and be umbilical cord care.
The umbilical cord is failure to through home afebrile Patients with diseases
dry and looks very exercise proper birth by a
unclean tied with
transmitted through air
preventive “paltera”
thread and cord clamp may also need respiratory

Pseudomenstruation is measures, non- sterile
precautions. Reverse
present improper isolation/ restriction of
procedures and
WBC Count= 14.3 x hygiene environment visitors may be needed to
10/L protect the

Upward rolling of improper immunosuppressed patient
eyes umbilical cord • Wash hands • Reduces risk of cross-
T = 37.7°C, HR = care by using a before/ after contamination
180 bpm and RR = ordinary thread
20 cpm each care
to tie the activity, even if
remaining cord
Risk/ Related sterile gloves
Definition: 
are used. • Good pulmonary toilet
Factors: yellowish
Risk for • Encourage/ may reduce respiratory
Decreased discoloration,
infection- at provide compromise
energy/ fatigue upward rolling of
increased risk frequent
Septic Shock eyes, febrile • Reduces number of
for being position
Septicemia seizures and sites of entry of
invaded by intermittent fever changes opportunistic
pathogenic  • Limit use of organisms
organisms NEONATAL
Strengths/ invasive
SEPSIS devices/
Wellness: • Prevents introduction
 procedures
Strong Family of bacteria, reducing
Support when possible risk of nosocomial
Risk for
infection[progre • Maintain sterile infection
ssion of sepsis technique when
putting invasive • Fever 38.50 C- 400 is
Assessment Data Nursing Diagnosis Rationale Desired Outcome Nursing Justification Evaluation
Interventions
Actual/ Abnormal (SINCE OUR Schematic Diagram After 8 hours of nursing Independent: Goal partially met.
Findings: CLIENT IS AN PREDISPOSING intervention the client • Review • Provide The client was able to
The first baby of the INFANT IN WHICH FACTORS will be able to disease process knowledge base verbalize her own
mother was delivered THE COGNITIVE 1) Financial • Verbalize and future on which the understanding, and the
through home birth DEVELOPMENT IS Status understanding of expectations. patient can make client was made to
also, died by four NOT YET  disease process informed choices participate in the
months old due to PREVAILING WE Finished and prognosis • Review • Awarene treatment regimen but
unaided and not ASSESSED THE elementary level • Correctly individual risk ss of means of the client shows no
intervened conditions MOTHER OF OUR only perform factors and mode infection signs that she will
such as meningitis and CLIENT) 2) Inaccessibility necessary of transmission/ transmission improve her lifestyle
German measles to resources and procedures and portal of entry of provides and that her personal
The mother believes Knowledge Deficit institutions explain reasons infections opportunity to hygiene and
the old beliefs and [learning need]  for actions plan for/institute environment are still
superstitious beliefs regarding illness, Unaware of the • Initiate necessary protective left unattended.
The mother resorts to a prognosis, present help in lifestyle changes measures
“paltera” or treatment, self- the community, • Participate in • Provide • Promotes
“manoghilot” if there care and ignorance treatment information understanding of
is an arising problem discharge needs towards the regimen about drug and enhances
both to her and her related to lack of society due to therapy, cooperation in
baby and would seek exposure/recall; isolation interactions, side treatment/
admission in the information 3) Generativity effects, and prophylaxis and
hospital if the misinterpretation; importance of reduces risk of

condition is no longer cognitive Passed on beliefs adherence to recurrence and
manageable limitation as regimen complications.
which are
Both parents of our evidenced by • Review • Helps to
believed to be a
client are elementary Inaccurate follow- necessity of control
fallacy and may
graduate through of personal environmental
at times
UNAWARE that there instructions/ hygiene and exposure by
endanger lives
are institutions who development of environmental diminishing the
can cater the needs of 
preventable The mother cleanliness number of
the people for free like complications; pathogens
lying in clinics trusts the
inattentiveness; capability of a present
statement of “paltera” and a • Discuss • Necessar
misconception “manoghilot” in need for good y for optimal
times of distress nutritional intake/ healing and
Risk/ Related
both to her and balanced diet general well-
Factors: Definition: her baby • Identify being of the baby
Decreased Knowledge Deficit-  signs and • For early
energy/ fatigue Absence or The mother had symptoms recognition of
Septic Shock deficiency of an accident while requiring medical developing/
Septicemia cognitive pregnant seek for evaluation, e.g. recurring
information the manoghilots persistent infection allows
related to specific help temperature for timely
topic [Lack of  elevation, intervention and
Strengths/ specific tachycardia, reduces risk for
Wellness: The “manoghilot”
 Assessment Data Nursing Rationale Desired Outcome Nursing Justification Evaluation
Diagnosis Interventions
Actual/ Abnormal Findings: Ineffective Schematic Diagram Independent: Goal Met:
The client looks unclean and thermoregulation Newborns Immature
untidy with blood tinged dress related to Body Systems After a week the • Take vital • To monitor if • Newborn client
Intermittent fever newborn’s  newborn client will be signs q15 temperature maintains
Febrile seizure, irritability and transition to Adaptation to warm able to maintain body mins. X 2H reached the axillary body
poor feeding extrauterine uterine environment temperature within then q 30 mins normal value temperature of
Yellowish discoloration in the environment as  normal limits x 2h then q between 36.5- 370C.
skin, eyes and tongue evidenced by upon delivery exposure hourly until 37.50C.
Nails were long and uncut intermittent fever, to a different climate stable.
The umbilical cord is dry and prevailing illness  • Assist with • To be able to
looks very unclean tied with maladaptation to measures to determine
thread and cord clamp extrauterine identify what
Pseudomenstruation is present environment causative interventions
WBC Count= 14.3 x 10/L  factors may be given
Upward rolling of eyes Plus the new born underlying the to the client
T = 37.7°C, HR = 180 bpm experienced NEONATAL condition and the
and RR = 20 cpm SEPSIS at 3 days old precautions
 that may come
Risk/ Related Factors: along with it
reoccurring fever,
Decreased energy/ • To restore or
presence of febrile
fatigue • Administer maintain
seizures, occasionally
Septic Shock fluids and body/ organ
the new born is cool to
Septicemia electrolytes , function
touch, chills, upward
rolling of eyeballs and
 medications as
Definition: indicated
Ineffective Ineffective
Strengths/ Wellness:
thermoregulation thermoregulation
Strong Family Support
is the inability to Collaborative:
maintain a steady Source:
body temperature • Nurse’s Pocket Guide,:
As physicians order: • To maintain
regardless of Doenges
Medical-Surgical Nursing: • Place double normal body
changes in the droplight. temperature
environment Source:
• Pillitteri, Adele
Maternal and Child
Health Nursing 4th Ed.
Lippincott Williams
&Wilkins. Copyright
2003
 DRUG STUDY
DOSAGE &
GENERIC NAME/BRAND MODE OF FREQUENCY/ ADVERSE NURSING
INDICATIONS CONTRAINDICATIONS
NAME/CLASSIFICATION ACTION ROUTE OF EFFECTS CONSIDERATIONS
ADMINISTRATION
• Before giving drug,
Generic: Inhibits cell-wall 195 mg IVTT Q12h • Respiratory • Contraindicated in • CNS: seizures ask patient about
Ampicillin synthesis during tract or skin and patients hypersensitive to • CV: vein irritation allergic reactions to
bacterial multiplication skin structure drug or other penicillins. • GI: nausea, penicillin. A negative
Brand: infections • Use cautiously in vomiting, diarrhea, history of penicillin
Novo Ampicillin, Apo-Ampi, • GI infections patients with other drug stomatits, gastritis allergy is no
Nu-Ampi or UTI’s allergies (especially to • GU: interstitial guarantee against
• Bacterial cephalosporins) because nephritis, future allergic
Classification: meningitis or of possible cross- reaction
nephropathy,
Anti-infectives septicemia sensitivity, and in those • Do skin testing to
vaginitis
Penicillins with mononucleosis determine allergic
• Hematologic:
because of high risk of reactions.
anemia,
maculopapular rash • Give drug 1 to 2
thrombocytopenia,
thrombocytopenia hours before or 2 to 3
purpura, hours after meals.
eosinophilia, When given orally
leucopenia, the drug may cause
hemolytic anemia, GI disturbances.
agranulocytosis • Monitor sodium
• Other: level because each
hypersensitivity gram of ampicillin
reactions, contains 2.9 mEq of
overgrowth of sodium
nonsusceptible • Watch for signs and
organisms symptoms of
hypersensitivity,
such as erythematous
maculopapular rash,
urticaria, and
anaphylaxis
• To prevent bacterial
endocarditis in
patients at high risk,
give the drug with
gentamicin
 DOSAGE &
GENERIC NAME/BRAND MODE OF FREQUENCY/ ADVERSE NURSING
INDICATIONS CONTRAINDICATIONS
NAME/CLASSIFICATION ACTION ROUTE OF EFFECTS CONSIDERATIONS
ADMINISTRATION

Generic: Inhibiots protein 19mg IVTT OD • Serious infections • Contraindicated in • CNS: fever, • Do skin testing
Gentamicin Sulfate synthesis by binding caused by patients hypersensitive seizures, vertigo, • Evaluate patient’s
directly to the 30S sensitive strains of to drug or other dizziness hearing before and
Brand: ribosomal subunit; Pseudomonas aminoglycosides • EENT: ototoxicity, during therapy, report if
Cidomycin, Garamycin bactericidal aeruginosa, E. blurred vision, there are alterations in
• Use cautiously in
Coli, Proteus, tinnitus the hearing process
neonates.
Classification: Klebsiella, or • GI: Nausea and • Weigh patient and
Anti-infectives, Staphyloccocus vomiting review renal function
Aminoglycosides • GU: nephrotoxicity studies before therapy
• Hematologic: begins.
anemia, leucopenia, • Obtain blood peak
thrombocytopenia, gentamicin level 1 hour
agranulocytosis after I.M injection
• Respiratory: apnea • Watch signs and
symptoms of
superinfection
• Therapy usually
continues for 7 to 10
stop therapy and obtain
new specimens for
culture and sensitivity
testingjh
 DOSAGE &
GENERIC NAME/BRAND MODE OF FREQUENCY/ ADVERSE NURSING
INDICATIONS CONTRAINDICATIONS
NAME/CLASSIFICATION ACTION ROUTE OF EFFECTS INTERVENTIONS
ADMINISTRATION

Generic: Promotes immunity to 5ml IM @ the left thigh • Primary • Contraindicated in • CNS: slight fever, • Obtain history of
Tetanus Toxoid, Fluid tetanus by inducing anti immunization to immunosuppressed headache, seizures, allergies nad
toxin production prevent tetanus patients, in those with malaise, reaction to
Brand: • Postexposure immunoglobulin encephalopathy immunization.
prevention of abnormalities, and in • CV: tachycardia, • Keep epinephrine 1:
tetanus those with severe hypotension, 1,000 available to
Classification: hypersensitivity or flushing treat anaphylaxis
Anti-ulcer agent neurologic reactions to • Musculoskeletal: • Adsorbed from
toxoid or its ingredients. aches, pains produces longer
Contraindicated with • Skin: erythema, immunity. Fluid
patients with induration, nodule at form provides
thrombocytopenia or injection site, quicker booster
other coagulation urticaria, pruritus effect in patients
disorders that would • Other: chills, actively immunized
contraindicate IM anaphylaxis previously.
injection unless benefits
outweigh risks.
• Use adsorbed form
cautiously in infants or
children with cerebral
damage, neurologic
disorders, or history of
febrile seizures
• Postpone vaccination
in patients with acute
illness and during polio
outbreaks, except in
emergencies
 M E T H O D
*Make sure that
*Inform the mother *Instruct the * Instruct the *Emphasize the *Instruct the the bottles are
of the patient about guardian to increase guardians as to importance of proper guardians to follow sterilized before
the medication, its the infant's proper skin care: grooming, care of the OPD schedule using or the
effects, dosage and ambulation and/or the nails, hair, oral as nipples to be
movement so as to - Bathe the infant at and wound care to instructed cleaned before
correct timing.
prevent the least once a day in both the letting the baby
*Instruct the accumulation of lukewarm guardians and the *Instruct the suck.
guardian to follow pulmonary water and mild baby infant guardian to make
the therapeutic secretions. soap or shampoo sure that the *Feed the infant on
regimen religiously *Stress that the infant demand, few
- Clean the equipments used for receives all the amount only and
so as not to exceed
umbilical, genital and the infant should recommended only
the recommended
perineal area after be sterilized or clean immunizations increase it if the
dosage.
urination and/or enough so as to baby is still hungry
defecation. prevent *Teach the and le the
bacteria to come in guardians self-care baby burp every
- Practice frequent contact with the baby and continuity of after feeding.
handwashing before care to ensure the
handling the infant *Stress the important promotion of home *Instruct the
and after having role of frequent and community- guardian to consult
contact with soiled handwashing in based care. their pediatrician
things of the baby. the prevention of once the infant
bacterial infestation shows symptoms
- The guardian and and growth of allergy to milk
the infant should
so that the pedia
wear as much as
can give the
possible clean and
appropriate milk
well-washed clothes
for the baby.
to minimize
 bacterial contact

References:
 LeMone and Burke, Medical-Surgical Nursing: Critical thinking in client care

 Doenges, Moorhouse and Geissler, Nursing Care Plans: Guidelines for individualizing patient care

 Lippincott, Pathophisiology: Concepts of altered health states

 Marieb, Essentials of Human Anatomy and Physiology 6th edition

 http://www.cancer-info.com/analcanc.htm

 http://www.nlm.nih.gov/medlineplus/analcancer.html

 www.emedicine.com

 http://www.massgeneral.org/cancer/crr/types/gi/anal.asp

 http://en.wikipedia.org/

 http://www.intelihealth.com/IH/ihtIH/WSIHW000/9339/9396.html