Angeles University Foundation

Angeles City

T/C NEONATAL SEPSIS

Presented to:

Joy Delfin RN, MN

Presented By:

Pia Baluyut

Shelley Cayanan

Lyle Ariane Mariano

Mervin Tuazon

BSNIV-8

GROUP 32
INTRODUCTION

Newborns are susceptible to infection because of their underdeveloped immune system.

Neonatal sepsis also known as Neonatal Septicemia or Sepsis Neonatorum is an
infection in the blood that spreads throughout the body and occurs of a neonate that kills
8,000 newly born babies each year based on Philippine experience.

The disease can be classified as: congenital, early-onset and late-onset. Congenital
neonatal sepsis is when the child is infected during pregnancy before birth. The baby
can be infected by virus through placenta or birth canal. HIV (Human Immunodeficiency
Virus), syphilis is some of the viruses that can infect the child before delivery. Early-
onset neonatal sepsis is when the infant is infected, while taking birth or soon after the
delivery. Group B streptococcus (GBS) and Escherichia coli (E. coli) are considered as
chief viruses that infect the baby, while birth. Early-onset neonatal sepsis is a result of
asymptomatic colonization in the intestinal or genital tract of the mother. Colonization is
existence of bacteria’s/viruses in a body part. An infant is said to be affected by late-
onset neonatal sepsis, when it is infected a few days after delivery. This infection can be
due to the organisms present in the environment of the hospital. After getting discharged
from hospital, babies can get infected due to the bacteria’s present in the environment at
home. GBS and E. coli are also responsible for late-onset neonatal sepsis. Symptoms of
early-onset neonatal sepsis are observed mostly within 24 hours of delivery, while that of
late-onset neonatal sepsis can be observed between 8th-89th days of delivery.

Symptoms observed in infants suffering from neonatal sepsis are unstable body
temperature, unable to suck breast milk properly, apnea, fever in rare cases, vomiting
and diarrhea, respiratory distress, reduced heart rate, jaundice, belly area may be
swollen.

WHO as of 2009, an estimated 82,000 children die every year before their fifth birthday
in the Philippines. Half of these deaths are related to common infectious diseases such
as diarrhea, pneumonia, neonatal sepsis and measles. In fact, half of neonatal deaths
occur during the first two days of life. Progress to curtail neonatal deaths is miserable,
with death rates among this age group showing only the barest decline over the past 20
years.

Current Issues and Trends in Neonatal Sepsis

Milk Protein Supplement May Help Prevent Sepsis In Very Low Birth-Weight Infants
ScienceDaily (Oct. 8, 2009) — Very low birth-weight newborns who received the milk
protein lactoferrin alone or in combination with a probiotic had a reduced incidence of
late-onset sepsis, according to a study in the October 7 issue of JAMA.

Infections are the most common cause of death in premature infants and a major threat
for poor outcomes," the authors write. Late-onset sepsis, i.e., infections arising after the
perinatal period (immediately before and after birth), mainly occur in the hospital and
affect 21 percent of very low birth-weight (VLBW; less than 3.3 lbs) neonates according
to background information in the article. Bovine lactoferrin (BLF; a milk glycoprotein)
inhibits the growth of a wide variety of bacteria, fungi, and viruses and has been shown
to exhibit even higher in vitro antimicrobial activity than human lactoferrin. Whether
lactoferrin can reduce the incidence of sepsis is unknown. In animal tests, the probiotic
Lactobacillus rhamnosus GG (LGG) improved the activity of lactoferrin but has not been
studied in infants.

The researchers examined whether oral supplementation with BLF alone or in

combination with LGG reduces late-onset sepsis in VLBW neonates. The randomized
trial was conducted in 11 Italian neonatal intensive care units and included 472 VLBW
infants who were assessed until discharge for development of sepsis. Infants were
randomly assigned to receive orally administered BLF alone (n = 153), BLF plus LGG (n
= 151), or placebo (n = 168) from birth until day 30 of life (day 45 for neonates less than
2.2 lbs. at birth). Demographic, clinical and management characteristics of the 3 groups
were similar, including type of feeding and intake of maternal milk.

Forty-five infants had a first episode of late-onset sepsis. The researchers found that
overall, late-onset sepsis occurred less frequently in the BLF and BLF plus LGG groups
(9/153 [5.9 percent] and 7/151 [4.6 percent], respectively) than in the control group
(29/168 [17.3 percent]). The decrease occurred for bacterial as well as fungal episodes.
The sepsis-attributable risk of death was significantly lower in the two treatment groups.
No adverse effects to treatment occurred. The researchers recommend this study
confirming the safety and efficacy of lactoferrin in VLBW infants, including more
extremely preterm infants, because they potentially will benefit the most from lactoferrin.
Combination strategies, such as the use of BLF plus LGG in the study should be
pursued, and substances that might affect lactoferrin activity, such as iron
supplementation, should be investigated. The effect of lactoferrin on hematocrit [the
proportion of blood that consists of packed red blood cells should be monitored, and the
effects of lactoferrin on neurodevelopmental outcome, hospital length of stay, and costs
should be studied.

Reasons for choosing the study

An in-depth study about Neonatal Sepsis is extensively important for a nurse most
especially if the nurse is working in the pediatric ward or neonatal Intensive Care Unit or
the NICU department. A nurse should be properly educated regarding the cause of the
neonatal sepsis, how it is acquired and prevented, and its complications to prevent the
occurrence of late-onset neonatal sepsis. Being able to obtain knowledge about
neonatal sepsis can give the student nurses information that could help them in their
health teachings to patients about factors that could predispose an individual to this
disease. Being the health care provider of the patient means that student nurses have
the responsibility to prevent, treat and help in the rehabilitation of patients affected by the
disease.

After the completion of the study, a nurse shall be able to:

 Identify and differentiate the types of Neonatal Sepsis

 Be updated with the latest trends in the treatment of Neonatal Sepsis
 Perform a comprehensive assessment of Neonatal Sepsis
 Enumerate the different signs and symptoms of Neonatal Sepsis
 List down the different diagnostic procedures that would help in the diagnosis of
Neonatal sepsis.

 Formulate nursing care plans utilizing the nursing process.

 Formulate conclusions based on the findings and enumerated recommendations

concerning the disease

Nurse Centered Objectives:

 Shall have critical thinking necessary for providing safe and effective nursing
care.
  Shall have a comprehensive assessment and implement care based on their
knowledge and skills of the condition.

 Shall have familiarized with effective inter-personal skills to emphasized health

promotion and illness prevention.

 Shall have an appropriate management and treatment to the patient and utilize it.

II. Nursing Assessment

1. Personal Data

Baby Sepsis is a 2 days old baby boy who weighs 2.6kg, he is a catholic,
a Filipino, and lives in Angeles City. He was born on July 9, 2010 in their house
via NSD; he weighed 2.6 lbs, and was born full term. 1 day after his birth he had
jaundice, he was then rushed in one of the hospitals in Angeles City and there he
was confined with a diagnosis, T/C Neonatal Sepsis.

History of Past Illness

Baby Sepsis is only two days old when he was admitted, and since then he has
not experienced any illnesses.

History of Present Illness

When Baby Sepsis was only 2 days old, he began to had jaundice and had a
fever of 39oC he was then rushed in one of the hospitals in Angeles City.

Growth and Development

a. Erik Erikson’s Psychosocial Development Theory: Trust vs. Mistrust

Developmental task is to form a sense of trust versus mistrust. Child learns to love and
be loved. This was exhibited by Baby Sepsis when the student nurse was holding him,
he kept fidgeting and started to cry, while whenever his mother touches him, he keeps
calm. This proves that he can differentiate between his mother’s touch and a stranger’s
touch, he cries because he is unfamiliar with the student nurse and so has not yet
established trust. It would be important for the student nurse to provide a primary care
giver, provide experiences that add to security, such as soft sound and touch, provide
visual stimulation for active child involvement.

b. Sigmund Freud’s Psychosexual Stage: Oral Stage

The child explores the world by using his mouth especially the tongue. Baby Sepsis
manifested this through his eagerness to suck on his pacifier and his instant reaction of
calming down once he begins sucking on a pacifier. It would do good to provide oral
stimulation by giving pacifiers, not discouraging thumb sucking.

c. Jean Piaget’s Theory of Cognitive Development: Sensorimotor Stage

Babies relate to the world through their senses, using only reflex behaviour. Stimuli are
assimilated into beginning mental images. This was evident from Baby Sepsis when his
reflexes were tested such as rooting reflex, sucking reflex, swallowing reflex, plantar
grasp reflex, babinski reflex, and magnet reflex.

Physical Examination

July 21 , 2010: 1st NPI

VS

T= 35.2oC

P= 102 bpm

R= 34 bpm

Head: dry lips with lesions around the mouth; yellow sclera; yellow conjunctiva;
without scars; without periorbital edema.

Skin: yellow in color ; with purple bruises on Right arm and leg;; poor skin turgor;
skin warm to touch; soft skin; no lesions; no scars.

Nails: capillary refill of <3sec; smooth pail nail beds; complete set of fingers and toes; no
scars; no wounds; no discolorations; no edema.
Neck: midline; no distention; no swelling lymph nodes; no lesions; no scars; no
tenderness; no edema.

Chest: symmetric lung expansion;; no use of accessory muscles; no sternal retractions;

without rales; without wheezes; no wounds; no rashes; no scars.

Abdomen: abdomen not distended no erythema; no tenderness; no scars; no wounds;

no rashes;.

Extremities (Upper and Lower):; IV insertion wounds on both arms; purple bruises
on upper and lower extremities.
V. The Patient and his Care

A. Medical Management

Medical Date Ordered

Management / (DO), Date
Treatment Performed General Indication or Purposes Clients Response to Treatment
(DP), Date Description
Change (DC)

D10 W 500 cc in Date Ordered: Isotonic  To provide a balanced

soluset x 3 cycles crystalloid solution of fluids and
# 1 July 11, 2010 Solution which electrolytes for the patient. The patient maintained good skin
contains multiple integrity.
electrolytes in
 For parenteral
roughly the replacement of
same extracellular losses of fluid
Date concentration and electrolytes as
Performed: found in plasma. required by the clinical
condition of the patient.
July 11 – 14,  130 mEq
2010 of
Sodium  To provide as a passage
(Na) ion for intravenous
 109 mEq medications of the patient.
Date Changed: of This solution also provided
Chloride modest calories of 170
July 14, 2010 kilocalories.
(Cl) ion.
 28 mEq
of
Lactate
 4 mEq of
Potassiu
m(K) ion
Date Ordered:
 July 18, 2010
 3 mEq of
D10 W 300 cc x 7- Calcium(
8ugtts/ min. # 2 Ca)

Date
Performed:

July 18 - 19
2010

Date Changed:

July 19, 2010

D10 W 500 cc x 7-
8ugtts/ min. # 3 Date
Performed: July
20 - 21, 2010
PNSS 500 cc x Date Ordered: Hypotonic It is used for BT. The client didn’t experience any
KVO solution allergic reaction.
July 19. 2010 containing a low
concentration of
solute relative to
Date another solution.
Performed: When a cell is
placed in a
July 19, 2010 hypotonic
solution, the
water diffuses
Date changed: into the cell,
causing the cell
to swell and
possibly
explode.

D5 0.3 NaCl 500cc Date Ordered:

x 10ugtts/ min
July 14, 2010

Date
Performed:

July 14, 2010

Date Changed:

July 18, 2010

(shifted to D10
W 300 cc
leftover)
Nursing Responsibilities

Preparation for Administration

(Use aseptic technique)

 Close flow control clamp of administration set.

 Remove cover from outlet port at bottom of container.
 Insert piercing pin of administration set into port with a twisting motion until the set is firmly seated. NOTE: See full directions on
administration set carton.
 Suspend container from hanger.
 Squeeze and release drip chamber to establish proper fluid level in chamber.
 Open flow control clamp and clear air from set. Close clamp.
 Attach set to venipuncture device. If device is not indwelling, prime and make venipuncture.
 Regulate rate of administration with flow control clamp.

Before:

 Check the Doctor’s order.

 Check the label of the IVF.
 Check for the patency of the line.
 Label the IVF on the date and time started and on the infusion rate.
 Place on the Kardex the fluid type
During:

 Check for the patency of the line.

1. Check the infusion rate.
2. Monitor for the level of the fluid.

After:

1. Regulate and monitor IV flow

2. Assess for the bulging of the site.

Medical Date Ordered

Management / (DO), Date
Treatment Performed General Indication or Purposes Clients Response to Treatment
(DP), Date Description
Change (DC)

Oxygen Therapy Date Ordered Oxygen therapy Oxygen therapy is indicated to the The client was well oxygenated
and Performed: is used to treat patient to provide adequate without signs of hypoxia and
Via nasal cannula hypoxia. It can oxygenation and relieve respiratory distress
regulated 2-3 LPM July `13 - 21, be dispensed respiratory difficulty.
2010 from a cylinder,
piped-in-system,
liquid O2
reservoir or O2
concentration.
Nursing Responsibilities:

Before:

 check doctor’s order

 check availability of nasal cannula, or mask
During:

 ensure right regulation of oxygen liters per minute

 ensure proper application of nasal cannula or mask
After:

 observe respiratory effort rate, depth and rhythm

 monitor vital sign
Medical Date Ordered
Management / (DO), Date
Treatment Performed General Indication or Purposes Clients Response to Treatment
(DP), Date Description
Change (DC)

Phototherapy Phototherapy is Phototherapy was indicated to the The client still has jaundice and
the use of light patient because of observed icteric sclera after phototherapy
Date ordered
to icteric sclera and jaundice which
and performed:
photoisomerize the doctor diagnosed as
July 13, 2010 unconjugated hyperbilirubinemia.
bilirubin into
forms that are
more water-
soluble and can
 be excreted
rapidly by the
liver and kidney
without
glucuronidation.
It provides
definitive
treatment of
neonatal
hyperbilirubinem
ia and
prevention of
kernicterus.

Nursing responsibilities

Before:

 asses patients skin color

 record vital signs
 prepare eye and genitalia cover
 check patients hydration status
 remove all clothing
 instruct so not to put and lotions or oils in the patient’s skin
During:

 monitor Vital signs especially temperature

 check IV fluid
After:

 breastfeed the baby after procedure to ensure adequate hydration

 remove eye and genitalia cover and clothe the ba

Medical Date Ordered

Management / (DO), Date
Treatment Performed General Indication or Purposes Clients Response to Treatment
(DP), Date Description
Change (DC)

Oro-gastric tube OGT is the A oro-gastric tube is direct ito the The client was able to tolerate OGT
insertion process of stomach which enable gastric when giving feeding. The patient
Date ordered
placing a soft lavage. On the days of nurse didn’t experience aspiration.
and performed:
plastic tube patient interaction OGT is used to
July 16, 2010 through a deliver milk formulas to the baby’s
patient's mouth, stomach
past the pharynx
and down the
esophagus into
a
 patient's stomac
h.

Oro- gastric
tubes are
inserted to
deliver
substances
directly into the
stomach, or to
remove
substances from
the stomach or
as a means of
testing stomach
function or
contents.

Nursing responsibilities

Before:

 Check for the doctors order

 Assess client’s need
 Before prepare the appropriate parafenalias for the patient and be sure that proper hand washing is maintained
During:
  Check patency of 0GT
 Observe patient reaction to gastric lavage
After:

 Check lavage substance

 Note and document any untoward reaction

a.4 Blood Transfusion

MEDICAL DATE GENEREAL INDICATION(S) CLIENT RESPONSE TO

MANAGEMENT/TREATMENT ORDERED DESCRIPTION THE TREATMENT
OR PURPOSE(S)
DATE
PERFORMED (Patient-Centered)

DATE
CHANGED

Blood Transfusion 40
(blood type B+)
cc DO: A blood transfusion is a To solve the problem The student nurses didn’t
safe, common procedure regarding the abnormal results see the client during this
July 18, 2010 in Hematology like anemia, procedure.
in which blood is given to
luekopenia and
you through an thrombocytooenia.
intravenous (IV) line in
DP:
one of your blood
July 19, 2010 vessels.

Blood transfusions are

done to replace blood
lost during surgery or
due to a serious injury. A
transfusion also may be
done if your body can't
make blood properly
because of an illness.

During a blood
transfusion, a small
needle is used to insert
an IV line into one of
your blood vessels.
Through this line, you
receive healthy blood.
The procedure usually
takes 1 to 4 hours,
depending on how much
blood you need.
Nursing Responsibilities

Prior:

 Note current drug therapy before procedure.

 Check the physician’s order.
 Identify the client.
 Prepare the needed materials.
 Explain the procedure, its purpose and how it is done.
 Inform the patient/SO that there are no food or fluid restrictions.
 Right patient after typing and crossmatching by the lab. this is done by checking the lot, serial numbers, blood type, and
expiration date with another nurse or qualified lab personnel. then the unit of blood.
 Get consent forms signed by the patient or a qualified representative of the patient
 Wash hands.
During:

 Vital signs must be checked after 15 minutes, then 30 minutes from then, then at one hour. then vital signs must be checked every
hour.
 Taka note any reaction of the blood
 If any reaction, STOP THE INFUSION OF BLOOD, maintain infusion of NSS and notify physician
 Start the saline solution, attach the blood tubing primed with NSS to the intravenous catheter
 Invert the blood bag gently several times to mix cells with the plasma, pull the tab and spike the Y set
 Infuse slowly for 1st 15 minutes at 10gtts/m
 Maintain aseptic technique.
After:
  After transfusion, open normal saline and infuse ubtil tubing is clear

 Disregard all the materials used.

 Continue to note the reaction of the blood.

 Proper Documentation
 Wash hands.

DRUGS
Name of Date Route of General Action Indication(s Client’s Response to the
Drugs; Generic Ordered Administrati ) Medication with actual side
Name on, Dosage Functional effects
Date & Frequency Classification or
Brand Name Taken/ of
Given Mechanism of Purpose(s)
Administrati Action
on
Date
Changed/

D/C

Generic name: Date 30 mg IV q4 Anti pyretic Fever The client didn’t experience
Paracetamol 30Ordered: for 37.8 fever or temp of 37.8C.
mg IV q4 for July 16, Reduces fever
37.8 2010 by acting
directly on the
Brand Name: hypothalamic
Acetaminophen heat –
regulating
center to cause
vasodilation
and sweating,
which helps
dissipate heat.

Generic name: Date 30 mg IV q12 Antibiotic Septicemia The client didn’t experience
Ceftriaxone Ordered: caused by E. any allergic reaction.
Sodium July 16, Bactericidal: coli,
2010 Inhibits The drug is sensitive to the
Brand Name synthesis of microorganism found on his
Date bacterial cell
culture, making it effective as
Rocephin: Performed: wall, causing Meningitis
cell death. a treatment for his condition.
July 16 – Caused by
21, 2010 H.
influenxzae/
Cephalosporin some cases
rd
(3 generation). caused by S.
pnuemoniae
NURSING RESPONSIBILITIES FOR DRUG THERAPY:

Prior to the procedure:

 Verify doctor’s orders
 Identify the drug, frequency, dosage and route of administration
 Check drug for any cloudiness and expiration date.
 Proper dilution should be carried out
 Identify the patient
 Explain to the patient the procedures and reasons for giving the drug.
 Perform handwashing

During the procedure:

  Check for IVF patency/ backflow
 Assess client’s vital signs before administration
 Aseptic technique should be maintained at all times during the procedure
 Check for bubbles in the syringe

After the procedure:

 Monitor for any adverse effects after administration of drug
 Note patient’s response to the drug.
 Do not recap needle
 Dispose any unnecessary items
 Document the medication given
 Perform handwashing
DIET

TYPE OF DIET DATE ORDERED GENERAL INDICATION(S) OR SPECIFIC CLINET’S

DATE STARTED DESCRIPTION PURPOSE(S) FOODS RESPONSE
DATE CHANGED TAKEN AND?OR
REACTION TO
THE DIET

NPO Date Ordered and No food and fluid is Food is prohibited None The client received
(Nothing Per Orem) Started passed through the after every lumbar nothing per orem
July 11, 2010 alimentary canal puncture to prevent and did not
spinal headache experience
Date Changed and vomiting. episodes of
July 13, 2010 vomiting.
 Date started:
July 17 , 2010

*Back to MILK
feeding

Date started:
July 19, 2010 (BT)

MILK FORMULA Date Ordered and It is designed to It used when The client able to
WITH STRICT Started: simulate human breastfeeding is tolerate her milk
ASPIRATION July 13, 2010 milk. It is contraindicated, and didn’t
PRECAUTION individualized for mothers employed experience
Date Changed: the infant and is outside the home, aspiration.
July 17, 2010 determined in breast milk
specific amounts by production is
*Back to NPO considering the inadequate, sickly
requirements for mother, inborn
calories, CHON, errors of
Date started: vitamins and metabolism wherein
July 18 , 2010 minerals. It is babies lack
prepared in the necessary enzymes
*Back to NPO most sterile manner to digest or utilize
possible and fed to milk and for some
the baby depending personal reasons
on his hunger.
Nursing Responsibilities:

Before:

 Check physician’s order about the diet.

  Identify patient, instruct SO or patient when diet is changed
 Provide comfort measures such as offering extra cloth and napkin when eating.
During:

 Give foods in small frequent meals to check for tolerance.

 Assist patient when eating.
 Observe for aspiration precaution.
After:

 Encourage the patient to follow the diet regimen.

 Encourage verbalization of feelings about the diet.
 Involve the patient in the preparation of the menu according to the patient’s preferences.
 Assess for patient’s condition, how she responds to the diet.
 Be sure that the patient is taking or eating food she can tolerate
NURSING MANAGEMENT
1.NURSING CARE PLAN

Problem no.1 Hyperthermia

 Assessment Nursing Scientific Planning Intervention Rationale Expected
Diagnosis Explanation Outcome

S- Hyperthermia Due to the Short-term: Independent Short term:

 related to presence of an
inflammatory infectious agens, After 1-2 hrs of 1. Monitor 1. To determine The patient shall
process/ stimulation of the nursing neonate’s the need for maintain normal
O- hypermetabolic monocytes intervention the condition. intervention and core temperature
The patient state as triggers the patient will the effectiveness as evidenced by
manifested the evidenced by an release of the maintain of therapy. normal vital signs
following: increase in body pyrogenic normal core
- Temperature temperature, cytokines that temperature as 2. To have a
above normal warm skin stimulate anterior evidenced by 2. Monitor Vital baseline data
level (38 oC) hypothalamus vital signs signs
- Skin warm to which results in within normal
touch elevated limits 3. Helps in Long Term:
- diaphoretic thermoregulatory 3. Provide TSB lowering down the
- appears weak set point that Long Term: temperature After 3 days of NI,
- flushed skin leads to an pt shall maintain
increased heat After 3 days of normal core
conservation NI, pt will still Interdependent temperature as
(Vasoconstriction) maintain 4. this would evidenced by
and increased normal core 4. Ensure that prevent the normal vital signs
heat production temperature as all equipment spread of
which results to evidenced by used for infant pathogens to the
Fever. normal vital is sterile, infant from
signs scrupulously equipment
clean. Do not
share
equipment with
other infants

Dependent
5. aids in lowering
5. Administer down temperature
Anti-pyretics as
ordered
PROBLEM 2: Ineffective Thermoregulation r/t Immaturity and Illness

Assessment Diagnosis Scientific Objectives Nursing Rationale Objectives

Explanation Interventions
S>o Ineffective Body temperature Short-term: >establish >to gain client’s Short-term:
O> pt. Thermoregulation represents the After 3 hts of rapport trust and After nursing
Manifested r/t Immaturity and balance between nursing compliance interventions and
- jaundice Illness heat generation interventions > to obtain health teachings,
-icteric sclera and heat loss and health > assess gen baseline data the patient shall
- bruises on processes. The teachings, the condition > to obtain have experienced
arms and legs skin, with its, patient will be >monitor and baseline data a non-fluctuating
-cut down ability to alter the able to record VS >to secure temperature and
wounds on rate of heat loss, experience a >regulate and adequate IVF flow shall be a normal
ankles is the major point non-fluctuating monitor IVF > to promote 37.5oC
-fluctuations of regulation of temperature cooling
inbody body and will be a > loosen clothes Long-term:
temperature temperature. Th nor mal 37oC > to prevent heat After nursing
above and below erate of heat loss >discourage build up interventions, the
normal body depends primarily Long-term: tight clothing > to promote patient shall have
temperature on the surface After 3 days of > perform TSB surface cooling maintained
-poor skin turgor temperature of nursing controlled
-capillary refill of the skin, which is interventions > to avoid cross temperature of
<3sec inturn a function the patient will >emphasize contamination and 37.5oC with the
-c VS of of th eskin’s be able to importance of germ spread help of the SO
T=37.7oC blood flow. But experience frequent proper
P= 140 bpm since neonates and maintain a handwashing to
R= 50 bpm are poikilothermic controlled SO >to comply with
> pt. May they are easily temperature of treatment regimen
manifest affected by the 36.5-37.5oC >medications
- tachycardia temperature of given as ordered
-cool skin their
-moderate pallor surroundings
-mild shivering which make their
-piloerection temperatures
-cyanotic nail fluctuate.
beds
- increased
respiratory
-seizures
-slow capillary
refill
PROBLEM 3: Impaired Skin Integrity r/t Mechanical Factors

Assessment Diagnosis Scientific Objectives Nursing Rationale Objectives

Explanation Interventions
S> o Impaired Skin Wounds are Short-term: >establish >to gain client’s Short-term:
O> pt. Integrity r/t openings in the After 3 hrs of rapport trust and After nursing
Manifested Mechanical skin caused by Nursing compliance interventions and
- jaundice Factors trauma, sharp Interventions > assess gen > to obtain health teachings
-icteric sclera objects or and Health condition baseline data the patient’s
- bruises on purposefully Teachings the >monitor and > to obtain wounds shall
arms and legs made to examine patient’s record VS baseline data have been
-cut down the inside of the wounds will be >regulate and >to secure dressed and
wounds on body. It closes by dressed and monitor IVF adequate IVF flow properly cleaned
ankles itself for it to heal, properly > advise the SO > to promote by the SO ad
-poor skin turgor although even if it cleaned by the to regularly timely healing and Hygienic
-capillary refill of has closed it still SO and change the prevent infection practices shall
<3sec serves as a good hygienic patient’s wound have been
-c VS of entryway for practices will dressings > to prevent observed
T=37.7oC bacteria to be observed. >advise SO of infection Long-term:
P= 140 bpm infiltrate the body regular wound after nursing
R= 50 bpm and cause Long-term: cleaning for interventions, the
> pt. May infection. So it is After 4 days of patient > to promote patient’s wound
manifest important to aid Nursing >keep the optimal healing shall have
-itching the body for Interventions, wound dry, displayed timely
-pain timely wound the patient’s clean and healing without
 -invasion of healing. would will be carefully any
body structures able to display dressed > moisture complications.
-numbness of timely healing > limit/ avoid use potentiates skin
affected without any of plastic breakdown
surrounding complications material such as
-erythema on plastic bed > an infant’s skin
affected area linens is very sensitive
>use paper type > to avoid
of dressings pressure build up
> straighten on an area of skin
wrinkles on bed > to comply with
treatment regimen
> medications
given as ordered

PROBLEM 4: Risk for Further Infection r/t Inadequate Primary Defenses

Assessment Diagnosis Scientific Objectives Nursing Rationale Objectives
Explanation Interventions
S>o Risk for Further Not all wounds Short-term: >establish >to gain client’s Short-term:
O> pt. Infection r/t heal in a timely After 3hrs of rapport trust and After nursing
Manifested Inadequate manner or stay nursing compliance interventions the
- jaundice Primary Defenses healed. Both interventions > assess gen > to obtain patient shall have
-icteric sclera intrinsic and the patient will condition baseline data observed the
- bruises on extrinsic factors be able to >monitor and > to obtain necessary
arms and legs delay wound observe the record VS baseline data precautions to
-cut down healing. With necessary >regulate and >to secure avoid further
wounds on improper precautions to monitor IVF adequate IVF flow infection through
ankles handling and avoid further > advise the SO > to promote the help of the
-poor skin turgor unhygienic infection to regularly timely healing and SO
-capillary refill of practices a through the change the prevent infection Long-term:
<3sec wound can be a help of the SO patient’s wound After nursing
-c VS of source of Long-term: dressings > to prevent interventions the
o
T=37.7 C infection, After 3 days of >advise SO of infection patient shall have
P= 167 bpm because it serves Nursing regular wound displayed timely
R= 59 bpm as an opening for Interventions cleaning for wound healing
> pt. May foreign agents to the patient will patient > to promote without any
manifest enter the body. have displayed >keep the optimal healing complications
-skin warm to Once these timely wound wound dry, through the use
touch bacteria enter the healing without clean and of hygienic
-flushed skin body through the any carefully wound cleaning
-hyperthermia wound, the complications dressed > to prevent and maintenance
 -tachycardia inflammatory through the >advise the SO bacterial growth assisted by the
-increased process of the use of hygienic of frequent and spread SO.
WBCs body will be wound proper > to prevent
-bradypnea triggered and cleaning and handwashing bacterial growth
then infection will maintenance > encouraged and spread
soon set in. practices regular sponge > to comply with
assisted by the baths treatment
SO regimen.
>medications
given as ordered
c/o NOD

Problem 5: Deficient Fluid Volume r/t Failure of Regulatory Mechanism

Assessment Diagnosis Scientific Objectives Nursing Rationale Objectives

Explanation Interventions
S>o Deficient Fluid Fluid volume Short-term: >establish >to gain client’s Short-term:
O> pt. Volume r/t Failure deficit, or After 3 hours rapport trust and After nursing
Manifested of Regulatory hypovolemia, of nursing compliance interventions the
- jaundice Mechanism occurs from a intervention > assess gen > to obtain patient shall have
-icteric sclera loss of body fluid the patient will condition baseline data started to
- bruises on or the shift of be able to start >monitor and > to obtain maintain fluid
arms and legs fluids into the maintaining record VS baseline data volume at a
-cut down third space one fluid volume at >regulate and >to secure functional level as
wounds on factor includes a a functional monitor IVF adequate IVF flow evidenced by the
ankles failure of the level as >To assess what practice of
-poor skin turgor regulatory evidenced by > Note for the factor contributes techniques to
-capillary refill of mechanism of the the practice of causative factors to fluid volume promote
<3sec newborn techniques to that contribute to deficit that may be adequate fluid
-skin warm to specifically promote fluid volume given prompt volume.
touch hyperthermia adequate fluid deficit intervention. Long Term:
- urine output of volume.
5-4 diapers a Long Term: After nursing
day for interventions the
-dry lips After 3 days of > To decrease patient shall have
-increased pulse nursing temperature and maintained fluid
rate interventions >Provide TSB if provide comfort volume at a
-dry skin the patient will patient has fever functional level
-c VS of be able to AEB individually
o
T=37.7 C maintain fluid > To prevent adequate urinary
P= 167 bpm volume at a injury from output, stable
R= 59 bpm functional level >Provide oral dryness vital signs, moist
> pt. May AEB care by mucous
manifest: individually moistening lips membranes,
-sunken eyeballs adequate & skin care by good skin turgor
- dry mucous urinary output, providing daily > replaces fluid and prompt
membrane stable vital bath losses
-increased Hct signs, moist >Administer IV
-increased body mucous fluid
temp above membranes, replacement as
normal good skin ordered
-flushed skin turgor and
-skin warm to prompt > to reduce body
touch capillary refill. > Administer temperature
antipyretic drugs
if patient has
fever as ordered
2. ACTUAL SOAPIE

July 21 2010

S=

O=Received baby on bassinette under bililight with ongoing IVF #3 D10W 500cc @ 40
cc level draining via soluset @ 54 cc level regulated @ 4 ugtts/min infusing well on left
hand with 02 therapy via nasal cannula @ 2 LPM with OGT open draining minimal
coffee ground secretions, jaundice noted, icteric bulbar conjunctiva, pinkish palpebral
conjunctiva, with dried blood seen on lips with hematoma observed over baby’s
extremities and buttocks, with absence of apneic episodes and seizure attacks patient
remain free from signs of cyanosis with good strong cry, with good skin turgor, with
presence of milia on his nose with CRT of 2 sec with good cry with presence of babinski,
rooting, and mori reflex, with presence of dried blood on the umbilical cord with edema
present on his penis and scrotum. With VS taken and recorded as follows T-35.2 C CR-
102 bpm RR- 34 cpm

A=Ineffective tissue perfusion r/t abnormal blood profile AEB platelet count 60 x 109 and
decrease O2 sat 86.7%

P= after 3 hours of Ni the baby will demonstrate absence of signs of injury AEB absence
of bleeding episodes.

I= > Assessed gen condition

>monitored and recorded VS

>regulated IVF from 4 ugtts to 7-8 ugtts/min

>provided cont bililight with eye and genitalia kept covered

>bililight turned off @ 8am

>dressed the baby after bililight turned off

>kept thermoregulated

>kept OGTopen

>kept back dry

>provided frequent position changes

>provided an environment conducive for resting

>kept envt clean

>monitored px for apneic, seizure, and cyanotic episodes

>Ascertained proper aseptic technique when handling the baby

>needs attended

>due meds given

Mupirocin ointment @ 8am

Cefotaxime 250mg @10am

Ranitidine 2.5 mg@10am

7am seen on rounds by dra. Cadiz with orderts made and carried out

>cont meds

>cont bililight

>refer

E= Goal met AEB the baby demonstrated absence of signs of injury AEB absence of
bleeding episodes.
VI. 1.Client’s Daily Progress Chart

Days Admission 1st NPI

Nursing Problems
1. Hyperthermia *
2.Ineffective * *
Thermoregulation r/t
Immaturity and Illness
3.Impaired Skin Integrity *
r/t Mechanical Factors
4. Risk for Further
Infection r/t Inadequate
Primary Defenses
5. Deficient Fluid Volume
r/t Failure of Regulatory *
Mechanism

Vital Signs
T ---- 35.2oC
P --- 102 bpm
R --- 34 bpm
Medical Management
1. OGT
2. O2
3.D10 water
5.PNSS
Drugs
1. Cefuroxime
2. Gentamicin
3. Ceftriaxone
4. Vitamin K
5.Furosemide

Diet: NPO
VII. Conclusion and Recommendation

Learning Derived
 As future nurses, our duty is to provide care to our patients and help them to
recover from their illness. In order to do this, we should have enough knowledge and
skills. We have to utilize these knowledge and skills to provide them with health
teachings to prevent diseases.

Neonatal sepsis is very broad disease, specifically refers to the presence of

a serious bacterial infection (such as meningitis,pneumonia, pyelonephritis,
or gastroenteritis) accompanied by fever. Many complications arise from this disease
especially our patient is also diagnosed with TORCH and meningitis. The group learned
that this disease is due to no sterile technique applied during the delivery of the baby
and that disease is acquired to mother or during the delivery because the newborn has
still weak immune system and immature cells to fight such infection. Therefore, we
should practice sterile technique and have a regular prenatal checkup. And for neonates
suspected of sepsis, we should have closed watch the condition of the patient, because
this might lead to serious death if not cured or solved.

As a student nurse, the group came up with realizations essential to the future
practice of our profession. The knowledge, skills and attitudes we possess should be
enhanced and improved accordingly to properly address the medical and nursing needs
of the client. We are endowed with responsibility of providing the best possible care to
our patient and assisting them attain towards the achievement of optimum health.
Sufficient understanding of the disease condition and the therapeutic regimen involve in
the course of treatment will allow us to perform our duties and responsibilities within the
maximum criteria. Comprehension of the patient’s distinct needs will furnish the quality
of care for our patient and will enable us to apply individualized nursing care to our
patient and will strengthen for professional relation to our patient. But to top it all, the
best part conducting a case study is the sense of fulfilment we felt knowing that in one
way or the other we have touch one’s life by extending a hand and a heart when they
needed it most.

This case study helps our group in understanding the disease process of the patient.
By identifying the primary needs of the patient with Neonatal sepsis. It will help our group
to further learn the current trends to the disease condition, the right nursing intervention,
proper drug administration, the preventive aspects for the purpose of health teaching to
patients and the rationale behind the clinical manifestations. Effective management of
the problems identified will help the patient to recover faster and maintain a holistic
sense of wellness even while in the hospital. This case study had also equipped the
group with knowledge, skill and attitude on how to manage future patients with the same
or similar disease. And gave us an overview of the concepts we’ve studied before so we
could apply it to our day to day exposure to different individuals and to the hospitals and
communities.

During the course of making this requirement in RLE the group has learned a lot
about the disease sepsis which could affect neonates due to their weak immune system
and bodily response to infection. The case gave us an opportunity to study more about
the certain factors that lead to the occurrence of the disease the manifestations that it
would show and also the possible outcomes if it would not be treated immediately. The
human body has unique ways to fight of any foreign material in the circulation and
through the help of this case study not only us the researchers would benefit from it but
also to others who may make this presentation as a basis in further understanding the
disease condition. The encounter or handling of this certain patient would help us nurses
in the pursuit of the profession to be able to apply our knowledge to the succeeding
patients having the same condition and be able to provide necessary measures to
control or manage the problem.

Recommendations:

To the Philippine Government, that they may know the latest studies and research
being done in order to improve the quality of life of every people. They should put more
attention to public health to improve the output a citizen can provide this country, none
the less it would also be better and beneficial if they the government would also the
education standards of the Filipino citizens so that in any occurrence of crisis they opt to
find solution and remedies that would help to alleviate their problem.

To the Department of Health, that they may implement projects or seminars in

order to give adequate knowledge to the general public about the latest studies in such
disease in order to inform them about its proper preventive ways as well as the benefits
and risk.

To the Health Care Providers, particularly physician and nurses, that they may
impart their knowledge to the public in order to prevent the occurrence of further
complications, and the group would also recommend to them that they would opt to do
their duties with outmost perfection in the way that they can to alleviate the circumstance
of their patients and clients.

To the Medical Interns and Student Nurses, that they may become aware of the
current trends, studies, researchers and issues in both medicine and nursing fields, and
they opt to practice their duties to the best that they can so that in the future they would
be practicing the outmost care to their patients and clients.

To the Filipino people specifically to the patient, that they may have the
background regarding the latest studies being done to improve quality of life. The patient
should also watch for factors that could again aggravate their health. Their health is in
their hands so they should try to practice ways and techniques on how to avoid
complications such as this disease in our case study.