Casepre Sepsis um

8/4/2019 Casepre Sepsis um

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Colegio de San Juan de Letran Calamba

School of Nuroing

Case Presentation:

SEPSIS NEONATORUM

Presented by:

Casunuran, Cherry AnnCatapang, Czarina May

Causing, Immaulate FayeCiarell, Ciar

Corcuera, Dan Ryan

Corpuz, Lady AnilinCortez, Daserie RoseDe Jesus, Eileen JaneDe Leon, Ma. ClaritaDeocareza, Alfrenan

Diche, SatinaEmata, Arlene JoyErcia, Alphine Gael

Ercia, Alvie GaelFaraon, Ara Denise

Presented to:

Ms. Eufemia Cortado

September


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I. INTRODUCTION

A. Background of the Study

Neonatal sepsis, also termed Sepsis neonatorum in simplest way of defining it,

refers to a group of physical and laboratory findings that occur in response to

invasive infection within the first 30 days of life, this is may be a bacterial or viral

etiology.

This may arise from congenital infection (common among premature babies and

to those babies wherein their mother suffered from infections while they are

pregnant), early onset infection (most common on prolonged labor) and late onset

infection which is caused by environmental factors.

Neonatal sepsis is also known as "sepsis neonatorum." The infection may

involve the infant globally or may be limited to just one organ (such as the lungs

with pneumonia). It may be acquired prior to birth (intrauterine sepsis) or after birth

(extra uterine sepsis). Viral (such as herpes, rubella [German measles]), bacterial

(such as group B strep) and more rarely fungal (such as Candida) causes may be

implicated.

During labor, several indicators may raise concern regarding the possibility ofneonatal sepsis. Abnormalities of fetal heart rate, maternal fever, premature

separation of the placenta from the uterine wall, or foul smelling/cloudy amniotic fluid

all indicate a high-risk labor and delivery. These situations will commonly prompt

consultation with the pediatrician or neonatologist regarding the potential for delivery

and/or postpartum complications.

Any infant who fails to make a smooth transition from intrauterine to extra uterine

life should be considered at high risk for sepsis. Close monitoring of vital signs (heart

rate, respiratory rate and effort, skin color, temperature, and "vigor") is a crucial part

of the evaluation of the newborn. Infants may manifest neonatal sepsis by subtle

signs such as poor feeding, jaundice, unusual rashes, or more obvious indicators

such as seizures, projectile vomiting, or abdominal distention.

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B. Focus on Incidence of Disease

Neonatal sepsis occurs in 0.5 to 8.0 per 1000 live births. It is the third leading

cause of neonatal deaths. Occurrence can be classified into low birth weight

(weighing less than 2500 grams) and very-low-birth-weight (weighing less than 1500

grams). In which, 81% percent were low birth weight and 63.6% were very-low-birth-

weight. Neonatal sepsis occurs in a 2:1 ratio, with a higher occurrence in males and

in neonates with congenital anomalies.

In the Philippines 8,000 newly born babies die from sepsis. In May 2003, 23

neonatal deaths could be attributed alone. According to the Annual Statistics of the

Philippine General Hospital (2002), neonatal sepsis accounts for 58.8% of deaths in

the country. It is the second major cause of disability by a slim margin to jaundice,

affecting 24.2% and 25.6% of the population respectively.

The census in the National Childrens Hospital (NCH) Intensive Care Unit during

one month (July 2010 to August 2010) was 61 patients having neonatal sepsis.

Having a total of 61 days, the average of patients having neonatal sepsis is 1 per

day.

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II. CLINICAL SUMMARY / CLINICAL ABSTRACT

A. Personal Data

Personal Data

Name: Baby G.P.B. Gender: Male Status: Newborn

Address: #3604 Amihan Compound, Halang, Calamba, Laguna

Birthday: August 19, 2011 Birthplace: Calamba Age:

Date of Admission:August 21, 2011 8:10pm

Diagnosis: t/c Sepsis Neonatorum

B. History of Present Illness

b.1 Past Medical History

No previous illnesses &/or operations

b.2 Present Medical History

Chief complaint: fever

Born cesarean section upon delivery, mother was diagnosed with

toxemia; BP 160/90 mmHg

Secondary (+) flaring episode

(+) jaundice noted

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III. ASSESSMENT

A. Physical Assessment

HEAD TO TOEASSESSMENT

NORMAL FINDINGS FINDINGS

Skin

Color in Caucasianinfants usually pink;varies with other ethnicbackgrounds.

Pigmentation increasesafter birth.

Skin may be dry.

Acrocyanosis of handsand feet normal for 24hours; may develop"newborn rash"(erythema toxicumneonatorum).

Small amounts of lanugo

and vernix caseosa stillseen.

Rashes over the surface of the face Pathologic Jaundice

- usually appears early, up to 24 hours after birth;represents a process ongoing before birth

Nursing interventions:

Identify conditions predisposing to hyperbilirubinemia, especiallypositive coombs test (test on cord blood for presence ofmaternal antibodies).

Prevent progression or complications of jaundice.

Assess jaundice levels (visually, lab tests) as needed.

Prevent conditions that contribute to development ofhyperbilirubinemia (e.g., cold stress, hypoxia, acidosis,hypoglycemia, dehydration, infection).

Provide adequate hydration. Implement phototherapy if ordered; use of blue lights overhead

or in blanket-device wrapped around infant.

Fontanels Anterior: diamond shaped

Posterior: triangularShould be flat and open.

NORMAL

Ears Should be even with

canthus of eyes.NORMAL


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Cartilage should bepresent and firm

Eyes

May be irritated bymedication instillation,

some edema/dischargepresent.

NORMAL

Breast Nodule of tissue present

Normal breath sounds

heard.

NORMAL

Male genitalia Testes descended or in

inguinal canal

Rugae cover scrotum

NORMAL

Legs

Bowed

No click or displacementof head of femurobserved when hipsflexed and abducted

NORMAL

Feet Flat

Soles covered withcreases in fully matureinfant

NORMAL

Muscle tone

Predominantly flexed

Occasional transienttremors of mouth andchin

Newborn can turn headfrom side to side in proneposition

Needs head supportedwhen held erect or lifted

NORMAL

Cry Loud and vigorous.

Heard when infant is NORMAL

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hungry, disturbed, oruncomfortable.

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B. Identification and Application of appropriate theory

b.1 Gordons11 Functional Health Pattern of Assessment

Gordons Assessment Health PatternNorms and Standards

During Hospitalization

Health Perception and HealthManagement- Compliance with medication

regimen, use of health-promotionactivities such as regular exercise,annual check-ups. Perception ofbeing healthy.

According to the mother, herbaby was born in the hospital.She was told that her babybecame yellow and that heneeds treatment. They followedthe right therapeuticmanagement and followed thedoctors order regarding thetreatment of her baby.

Nutrition and Metabolism- Normal Pattern of food and fluid

consumption relative to metabolicneed and pattern; indicators of localnutrient supply.

According to the mother, everynow and then, she breastfeedsher baby. She also follows therule that after breastfeeding, theinfant must be allowed to burp.

Elimination- Frequency of bowel movements is

at least once every 2 days andurination is about 1-2L per day

The mother told that shechanges the diaper 2-3 times aday. The urine and stool aretogether. The urine has a yellowcolor. The stool was black incolor, large in amount and has asoft consistency.

Activity and Exercise- Exercise, hobbies. May include

cardiovascular and respiratorystatus, mobility, and activities ofdaily living.

Not applicable to the patient.

Cognition and Perception- Vision, hearing, taste, touch, smell,

pain perception and managementshould be normal; cognitive

functions such as language,memory, and decision making areintact.


Sleep and Rest- Sleep pattern should be normal with

hours ranging from 7-9.

The mother said that her babyssleep pattern was normal. Thebaby was relaxed althoughthere are times that her baby


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would suddenly wake up.

Self-Perception and Self Concept- Body comfort, body image, feeling

state, attitudes about self,perception of abilities, objective

data such as body posture, eyecontact, voice tone.


Roles and Relationship- Perception of current major roles

and responsibilities; satisfied withfamily, work, or social relationships.


Sexuality and Reproduction- Number and histories of pregnancy

and childbirth; difficulties withsexual functioning; satisfaction withsexual relationship.

According to the mother, it washer third time getting pregnant.All her children are alive andwell.

Coping on Stress Tolerance- Clients usual manner of handling

stress, available support systems,perceived ability to control ormanage situations

The mother said that herhusband and family are theirmain support. They visit thehospital every now and then.

Values and Beliefs- Religious affiliation, what client

perceives as important in life, value-belief conflicts related to health,special religious practices.

According to the mother, theyare of a Roman Catholicreligion.

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b.2 Developmental Theory

Erik Erickson: Trust vs. MistrustAge Range: Birth to 18 MonthsBasic strength: Drive and Hope

Erikson also referred to infancy as the Oral Sensory Stage (as anyone might whowatches a baby put everything in her mouth) where the major emphasis is on themother's positive and loving care for the child, with a big emphasis on visual contact andtouch. If we pass successfully through this period of life, we will learn to trust that life isbasically okay and have basic confidence in the future. If we fail to experience trust andare constantly frustrated because our needs are not met, we may end up with a deep-seated feeling of worthlessness and a mistrust of the world in general.

Sigmund Freud: Oral stageAge Range: Birth to 1 YearErogenous Zone: Mouth

During the oral stage, the infant's primary source of interaction occurs throughthe mouth, so the rooting and sucking reflex is especially important. The mouth is vitalfor eating, and the infant derives pleasure from oral stimulation through gratifyingactivities such as tasting and sucking. Because the infant is entirely dependent uponcaretakers (who are responsible for feeding the child), the infant also develops a sense

of trust and comfort through this oral stimulation.

The primary conflict at this stage is the weaning process--the child must becomeless dependent upon caretakers. If fixation occurs at this stage, Freud believed theindividual would have issues with dependency or aggression. Oral fixation can result inproblems with drinking, eating, smoking or nail biting.

Jean Piaget: SensorimotorAge Range: Birth to about age 2

During this stage, the child learns about himself and his environment throughmotor and reflex actions. Thought derives from sensation and movement. The childlearns that he is separate from his environment and that aspects of his environment--his parents or favorite toy -- continue to exist even though they may be outside thereach of his senses. Teaching for a child in this stage should be geared to thesensorimotor system. You can modify behavior by using the senses: a frown, a stern orsoothing voice -- all serve as appropriate techniques.

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b.3 Nursing Theory

Nightingales Environmental Theory

As for the theoretical framework, Florence Nightingales Environmental theory suits

best the condition of the patient. The patient is in the state of having sepsis neonatorum

and the main priority with this is to avoid further spread infection throughout the system

of the patient by providing him a safe and clean environment. With Nightingales theory

which states that the act of utilizing the environment of the patient to assist him in his

recovery is what nursing does. As she linked health with the five environmental factors

that includes: fresh or pure air, pure water, efficient drainage, cleanliness and light.

Combining these factors would help to alleviate the condition of the patient especiallythat he is in the state where he could not do things on his own. Furthermore, since the

patient has an infection given that he has a fever, providing a clean environment around

him would help him for his recovery. A quiet environment is also a factor. Providing the

client with the right diet by ensuring that he will be able to tolerate his Doppler feeding

will also help his recovery since this is a necessity for a patient to easily get well.

Therefore, in its simplest term, with the integral parts of nursing, and the factors that

promotes a good environment to the patient, recovery could be achieved or at least

alleviation of what he feels most especially the patient will be free from harm or injury

and also the spread of infection could be more prevented.

C. Diagnostics

August 21, 2011

Diagnostics Normal Result Analysis

HEMATOL

OGY

WBC 5 - 10x10 9/1 8.5 Normal

Neutrophils 0.51 - 0.67 0.60 Normal

Lymphocytes 0.21 - 0.35 0.40

LymphocytosisIncreased lymphocytecount in response topresence of infection.

HematocritM 39 - 54F 36 - 48

50 Normal

HemoglobinM = 130 180 g/LF = 120 -160 g/L

166g/L Normal

Platelet Count 150 400x10 g/L 315 Normal

Blood Type B positive Normal

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Total Bilirubin 1.0 10.5 Mg/dl 17.6Hyperbilirubinemia

Indirect bilirubinoutweighs Direct bilirubin

Direct Bilirubin 0.0 0.6 Mg/dl 0.3

Indirect Bilirubin 1.0 10.5 Mg/dl 17.3

IV. ANATOMY AND PHYSIOLOGY

A baby's immune system is not fully developed until

he/she is about six months-old. In the meantime, pregnant

mothers pass immunoglobulin antibodies from their

bloodstream, through the placenta, and to the fetus. These

antibodies are an essential part of the fetus's immune

system. They identify and bind to harmful substances, such

as bacteria, viruses, and fungi that enter the body. This

triggers other immune cells to destroy the foreign substance.

Immunoglobulin G (IgG) is the only antibody that crosses

the placenta to the fetus during pregnancy. IgG antibodies are the smallest, but most

abundant antibodies, making up 75-80% of all the antibodies in the body. They are

present in all body fluids and they are considered to be the most important antibodies

for fighting against bacterial and viral infections. These antibodies help protect the fetus

from developing an infection inside the womb.

Immediately after birth, the newborn has high levels of the mother's antibodies in the

bloodstream. Babies who are breastfed continue to receive antibodies via breast milk.

Breast milk contains all five types of antibodies, including immunoglobulin A (IgA),

immunoglobulin D (IgD), immunoglobulin E (IgE), IgG, and immunoglobulin M (IgM).

This is called passive immunity because the mother is "passing" her antibodies to her

child. This helps prevent the baby from developing diseases and infections.

During the next several months, the antibodies passed from the mother to the infantsteadily decrease. When healthy babies are about two to three months old, the immune

system will start producing its own antibodies. During this time, the baby will experience

the body's natural low point of antibodies in the bloodstream. This is because the

maternal antibodies have decreased, and young children, who are making antibodies

for the first time, produce them at a much slower rate than adults.

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Once healthy babies reach six months of age, their antibodies are produced at a

normal rate.

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V. PATHOPHYSIOLOGY

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VI. MEDICAL MANAGEMENT ANALYSIS

A. Intravenous TherapyB alanced Multiple Maintenance Solution with 5% Dextrose (D5IM)

Action Adverse Reactions Nursing Responsibilities

The solution is administeredby intravenous infusion forparenteral maintenance ofroutine daily fluid andelectrolyte requirementswith minimal carbohydratecalories

PediatricUse:The safetyand effectiveness in

the pediatricpopulation are basedon the similarity of theclinical conditions ofthe pediatric and adultpopulations. Inneonates and verysmall infants thevolume of fluid mayaffect fluid andelectrolyte

balance.Frequentmonitoring of serumglucose concentrationsis required whendextrose is prescribedto pediatric patients,particularly neonatesand low birth weightinfants.

Reactions which may occurbecause of the solution orthe technique ofadministration include febrileresponse, infection at thesite of injection, venousthrombosis or phlebitisextending from the site ofinjection, extravasation andhypervolemia. If an adversereactiondoes occur,

discontinue the infusion,evaluate the patient,institute appropriatetherapeuticcountermeasures and savethe remainder of the fluid forexamination if deemednecessary.

Clinical evaluation andperiodic laboratorydeterminations arenecessary to monitorchanges in fluid balance,electrolyteconcentrations, and acid-base balance duringprolonged parenteraltherapy or whenever thecondition of the patient

warrants suchevaluation.

Caution must beexercised in theadministration ofparenteral fluids,especially thosecontaining sodium ions,to patients receivingcorticosteroids orcorticotropin.

Solutions containingacetate should be usedwith caution, as excessadministration may resultin metabolic alkalosis.

Solutions containingdextrose should be usedwith caution in patientswith known subclinical orovert diabetes mellitus.

Do not administer unlesssolution is clear andcontainer is undamaged.Discard unused portion.

In very low birth weightinfants, excessive orrapid administration ofdextrose injection may

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result in increased

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B. MedicationsName of

drugClassification

Therapeuticaction

Indication Contraindication Side effectsNursing

Responsibilities

Ampicillin 410mgIV q 12

Ampicilin61.5mgIV OD

Anti-infective Bactericidalaction

Binds tobacterialcell wall,resulting incell death

Treatment of thefollowinginfections:

skin structureinfections,

soft tissueinfection,

otitis media,

sinusitis,

respiratoryinfection and

SEPTICEMIA

Hypersensitivityto penicillins

USECAUTIOUSLYIN: severerenalinsufficiency

CNS: seizures

GI:pseudomembranous colitis,

diarrhea, nauseaand vomiting

DERM: rashes,urticaria

HEMAT: blooddycrasias

MISC: allergicreactionincludinganaphylaxis andserum sickness,superinfection

assess patientfor infection

obtain historybefore

initiatingtherapy todetermineprevious useand reactionsto penicillins

observepatient forsigns andsymptoms ofanaphylaxis

assess skinfor ampicillinrash

laboratory testconsiderations: may causeincreasedAST and ALT

may cause afalse-positivedirect Coombstest result

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VII. PLANNING

A. List Daily Nursing Problems

DAY NO. IDENTIFIED NURSING PROBLEMS PRIORITIZATION

1 Risk for further infection

Interrupted breast feeding

Skin integrity as evidenced of

disruption of the skin (epidermis)

Since the baby had already an infection, our firstpriority is to prevent further infection to thenewborn. The next priority would be the interrupted

breast feeding, because a newborn only needsmilk from the mother since it has all the nutrients anewborn needs including colostrum which givesthe newborn immunization to fight the infection,then the skin integrity.

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VIII. NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective :

Bradycardia(104bpm)

Lab tests:Total

Bilirubin(17.6mg/dl)

Lymphocytes (.40) Skin rashes

Crackles(left posteriorpart)

On phototherapy witheyeshield in place

Risk forfurtherinfectionrelated toinadequate

secondarydefense asevidenced bylymphocytosis

Short-termGoal:After 8 hrs. ofnursingintervention, the

clients motherwill be able to:a. Preventthe risk fromfurtherinfection to thebaby

b. Identifyinterventionsto prevent /reduce theinfection

Long-term

GoalAfter days ofnursingintervention, thepatient will beable to:a. Maintainthe normallevel oflymphocytes

b. Be free

INDEPENDENT:-Close vital signsmonitoring

- Assess umbilical sitefor any signs ofinfection

- Monitor visitors asindicated

-Wash hands beforeand after each careactivity, even glovesare used

-Instruct mother intechniques to protectthe integrity of skin ofthe baby, care forlesions

-Promote childhoodimmunization program

-to monitorabnormal signsthat can lead toother problem

-to prevent risk offurther infectionon the wound site

-To preventexposure of client

-Reduces risk ofcrosscontamination

-To preventspread of furtherinfection

-For the baby tobe free / immuneto furtherdiseases likeHepatitis B

After 8 hours of nursinginterventions, themother was able toverbalize / perform

techniques to preventthe spread of infection

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from infectionc.Have thenormal level ofbilirubin forjaundice to notoccur

COLLABORATIVE:-Administer antibioticsas prescribed -To prevent

spread of furtherinfection

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Nursing Care PlanAssessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:

Objective: Interrupted

breastfeeding

related to

neonates present

illness as

evidenced by

separation of

mother to infant.

Short-term:

After 3 hours of

nursing

intervention and

health teachings

the mother will

identify and

demonstrate

techniques to

sustain lactation

until breastfeeding

is initiated

Long Term:

After 3 days of NI,

the mother shall

still be able toidentify and

demonstrate

techniques to

sustain lactation

and identify

techniques on

how to provide the

newborn with

breast milk.

1. Assessmothersperception andknowledge aboutbreastfeeding andextent of

instruction thathas been given.

2. Give emotionalsupport to motherand acceptdecision regardingcessation/continuation ofbreast feeding.

3. Demonstrateuse of manualpiston-type breastpump.

4. Reviewtechniques forstorage/use ofexpressed breastmilk

5. Determine if aroutine visitingschedule or

1. To know what

the mother

already knows

and needed to

know.

2. To assist

mother to

maintain

breastfeeding as

desired.

3. aid in feeding

the neonate with

breast milk

without the mother

breastfeeding the

infant.

4. To provide

optimal nutrition

and promote

continuation of

breastfeeding

process

5. So that infant

will be hungry/

The mother shall

be able to identify

and demonstrate

techniques to

sustain lactation

and identify

techniques on

how to provide the

newborn with

breast milk.

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advance warningcan be provided

6. Provideprivacy, calmsurroundingswhen mother

breast feeds.

7. Recommendfor infant suckingon a regular basis

8. Encouragemother to obtainadequate rest,maintain fluid andnutritional intake,and schedulebreast pumpingevery 3 hourswhile awake

ready to feed

6. To promote

successful infant

feeding

7. Reinforces that

feeding time is

pleasurable and

enhances

digestion.

8. to sustain

adequate milk

production and

breast feeding

process

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Nursing Care PlanAssessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:

Objectives:>Jaundice

>Skin rashes>Crackles>Bradycardia>Lymphocytosis

Impaired skinIntegrity related todisruption of skinsurface(epidermis)as evidence skin

rashes.

After 8hrs. ofNursingIntervention, thepatient will reduceskin rashes.

Independent:>Vital signsmonitored andrecorded.

>Instruct therelatives forproper hygiene aswell thesurroundings ofthe patient.

Dependent:>Administeredprescribed medssuch as ascorbicacid and

furosemide.

>Changes in vitalsigns may indicateinfection.

>Proper hygieneprevent infectionand complication.A cleanenvironmentoccurrence of anydiseases.

>Vitamin Cprovides woundhealing anddiureticsdecreases renal

vascularresistance andmay increaserenal blood flow.

After 8hrs. ofnursingintervention, thegoal is partiallymet through

demonstration ofproper skinhygiene andcompliance withtreatment andmedication.

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IX. DISCHARGE PLAN

Medications

Medications ordered by the Physician must be well administered on time.

Select a drug class that has the greatest effectiveness, fewest side effects

and best chance of acceptance by the patient.

Environment

Environment free from pollutants and stress that may trigger to the complication of

the patients condition.

Provide a quiet and peaceful environment for the patient to be more relaxed.

Provide therapeutic environment such as stretching bed linens & arrangingobjects on bed.

Treatment

Continue medications as ordered by the physician.

Reinforce importance of follow-up care to the parents of the newborn.

Parents must continue to follow treatment regimen of physician in order to

prevent relapse of the disease.

Health Teaching

Encourage the mother to have a regular check-up for her baby.

Tailor information according to the parents ability to understand.

Parents must also know importance of proper hand washing because it

the best known method of preventing many diseases.

Out- patient

Instruct the guardian of the client that they should report for possible

complications of the newborn.

Encourage to recommend follow up check up as noted by the physician.

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Diet

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

Spiritual/Sexual

Encourage the guardian to enhance their faith in God and uplift their desire to be

able to surpass the condition of their baby.

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