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Neonatal Sepsis (1)

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I. INTRODUCTION The term “sepsis” has been around since ancient times; modern definitions of “sepsis” were described in detail in the early 1990s, at a consensus conference convened by the American College of Chest Physicians and the Society of Critical Care Medicine. At that time, “sepsis” was described as a systemic response to a physiologic insult – including infectious and other etiologies – that lead to the development of further organ injury, ultimately culminating in multiple organ dysfunction syndromes. Neonatal sepsis, also termed Sepsis neonatorum, refers to a group of physical and laboratory findings that occur in response to invasive infection within the first 30 days of life. As will be discussed below, there are various infectious causes of neonatal sepsis; however, the pattern of presentation is quite similar in all cases, as is the approach to treatment. The importance of neonatal sepsis as a diagnosis is found in the fact that this diagnosis occurs in between 1 to 8 children per 1000 live births in the United States, and may be associated with a fatality rate of up to 30%. As such, it is essential that caregivers that are involved with the management of neonates have a reliable approach to the diagnosis and treatment of infants with sepsis, and that appropriate intervention be instituted in a timely manner. 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
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I. INTRODUCTIONThe term sepsis has been around since ancient times; modern definitions of sepsis were described in detail in the early 1990s, at a consensus conference convened by the American College of Chest Physicians and the Society of Critical Care Medicine. At that time, sepsis was described as a systemic response to a physiologic insult including infectious and other etiologies that lead to the development of further organ injury, ultimately culminating in multiple organ dysfunction syndromes. Neonatal sepsis, also termed Sepsis neonatorum, refers to a group of physical and laboratory findings that occur in response to invasive infection within the first 30 days of life. As will be discussed below, there are various infectious causes of neonatal sepsis; however, the pattern of presentation is quite similar in all cases, as is the approach to treatment. The importance of neonatal sepsis as a diagnosis is found in the fact that this diagnosis occurs in between 1 to 8 children per 1000 live births in the United States, and may be associated with a fatality rate of up to 30%. As such, it is essential that caregivers that are involved with the management of neonates have a reliable approach to the diagnosis and treatment of infants with sepsis, and that appropriate intervention be instituted in a timely manner. 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 bacterias/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 bacterias 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.Neonatal Sepsis is an infection in the blood that spreads throughout the body and occurs in a neonate. Neonatal Sepsis is also termed as Neonatal Septicemia and Sepsis Neonatorum. Neonatal Sepsis has 2 types: The one that is seen in the first week of life is termed as Early- onset sepsis and most often appears in the first 24 hours of life. The infection is often acquired from the mother. This can be cause by a bacteria or infection acquired by the mother during her pregnancy, a Preterm delivery, Rupture of membranes (placenta tissue) that lasts longer than 24 hours, Infection of the placenta tissues and amniotic fluid (chorioamnionitis) and frequent vaginal examinations during labor. The second type or the Late-onset Sepsis is acquired after delivery. This can be cause by contaminated hospital equipment, exposure to medicines that lead to antibiotic resistance, having a catheter in a blood vessel for a long time, staying in the hospital for an extended period of time. Signs and symptoms of Neonatal Sepsis includes but is not limited to: body temperature changes, breathing problems, diarrhea, low blood sugar, reduced movements, reduced sucking, seizures, slow heart rate, swollen belly area, vomiting, yellow skin and whites of the eyes (jaundice). Possible complications are disability and worst is death of the neonate. (Greene, 2007)Neonatal sepsis occurs at an estimated rate of 1 to 2 cases per 1000 live births in the U.S. The highest rates occur in low-birth-weight (LBW) infants, those with depressed respiratory function at birth, and those with maternal perinatal risk factors. The risk is greater in males (2:1) and in neonates with congenital anomalies (Merck, 2005). According to the Philippine Mortality Fact Sheet 2006 of the World Health Organization, in 1000 live births of neonates 17% of it died due to severe infection that includes deaths from pneumonia, meningitis, sepsis/septicemia, and other infections during the neonatal period.Neonatal sepsis can occur in any infant. However, the diagnosis is significantly more common in pre-term infants than full term infants, and can affect up to 30 to 1000 live births in the pre-term population. Sepsis is also more common in males than females, and in developing countries. a. Current Issues and Trends in Neonatal SepsisMilk Protein Supplement May Help Prevent Sepsis In Very Low Birth-Weight InfantsScienceDaily (Oct. 8, 2011) 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.b. Statistics

MORTALITY STATISTICS OF NEONATAL SEPSIS 2007No.%2008No.%

1. Pulmonary Tuberculosis387.92 1. CVA46 9.83

2. Pneumonia36 7.502. Pneumonia43 9.19

3. CVA29 6.043. Pulmonary Tuberculosis27 5.77

4. Hypertension23 4.79 4. Hypertension23 4.91

5. Prematurity214.38 5. Vehicular Accident12 2.56

6. Neonatal Sepsis18 3.75 6. Acute Gastroenteritis11 2.35

7. Malaria17 3.547. Sepsis Neonatorum11 2.35

8. CNS Infection10 2.088. Congestive Heart Disease10 2.14

9. Vehicular Accident10 2.08 9. Malaria9 1.92

10. Diarrhea91.8810. Diabetes Mellitus9 1.92

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

Nursing ProcessA. PERSONAL DATAKhiefer Josh Estabillo is a 5 day old male neonate as of June 19, 2013, Filipino; Male, he was born on the 14th day of June 2013 at Diosdado P. Macapagal Memorial Hospital. He was baptized under the Roman Catholic Church. He is the son of Ricky Estabillo and Rowena Estabillo, they are currently residing at San Nicolas Sasmuan Pampanga. According to his mom, he was admitted on the 18th of June 2013. His admitting diagnosis is Neonatal Sepsis.B. PERTINENT FAMILY HISTORYThe family is a extended family and composed of 12 members including baby Khiefer. Baby Khiefer is the third baby of the family, according to Rowena, she make sure that she visit her Obstetrician regularly, she also doesnt take any medications that are not being prescribed. But she still works even she was pregnant and she stays late at night. This was because she is the only one who is working for their family her husband is not working. She earns 280 pesos per day and they use this for their electric bill (300 pesos / month), water bill payments (400 pesos/ month) and food needs (500 700 pesos/ week) and in case that they have money left; they make sure that they save it on the bank. At this moment none of them is working. She told the me that she regularly sleep at around 10 in the evening and wake up at around 6 in the morning. She gave birth through normal spontaneous vaginal delivery with the assistance of a midwife. According to Rowena, they are originally residing at Bacolor Pampanga, wherein they are renting a room there, and according to her the houses there are close to each other, the water is not potable and they utilize mineral water for drinking water, the ventilation status is also inadequate as she have verbalized that they do not have a window. On her 8th month of pregnancy they decided to go back to Pampanga as Rowenas parents are living in Sasmuan Pampanga. When Rowena was asked about the familys health habits she confidently answered me that they do not hesitate to visit a physician once someone get ill. They do not also practice self medication, they do not take medicines that are not prescribed and they do not rely on hilot or albularyo.

C. PERSONAL HISTORYDuring the course of Rowenas pregnancy she was working on a laundry shop, she only resigned to her work when she was on her 8th month of gestation. According to her she used to visit her Obstetrician regularly, she also took vitamins that are prescribed by her Obstetrician, one of those is Obimin a certain brand of Iron Supplement. She has also mentioned that she took EnfaMama Milk.According to Rowena, when she already felt that her abdomen is starting to ache and felt that her bag of water has ruptured, they immediately rushed to the hospital at around 6 in the evening and gave birth at around 12 midnight. According to her on her 8th month of pregnancy she suffered from urinary tract infection, in which she consulted her obstetrician and she was prescribed with Amoxicillin which she took it for three times a day for seven days, her UTI was then resolved. She had an episode of fever when she was on her 7th month of pregnancy and her obstetrician prescribed her with cephalexin that she took three times a day for 7 days and paracetamol and her fever was resolved. She gave birth to a prel term (36 weeks) baby boy rendering her an obstetrical history of G3T2P1A0L3, she delivered her baby via normal spontaneous vaginal delivery with episiotomy and episiorrhapy was done with the assistance of a midwife. She gave birth to a 3.8 pounds baby with no complications. According to her she did not practiced breastfeeding to her baby, she bottle fed her baby with BONA. I advised her to practice breastfeeding. Upon observing baby Khiefer, he was seen on bed always asleep, according to his mother, before baby JC went ill, he would smile when someone plays with him. His mother have also observed him lifts his head when he is held with his abdomen against the bed. Baby Khiefer was seen sucking a pacifier which denotes that he is on the Oral Stage based on Freuds Developmental Stages. He was also seen behaving when his mother cuddles him when he is crying which denotes that he is on the first stage of Erik Eriksons Psychosocial Stages of Development which is Trust vs. Mistrust. He was also seen smiling when you present him a toy which denotes Piagets Sensorimotor Stage on his Cognitive Stages of Development. All of these behaviors also satisfy Sullivans Life Stages particularly Infancy stage. Baby JC was also seen manifesting normal reactions with Rooting, Sucking, Palmar and Babinski reflexes when initiated. According to Rowena his son did not receive any vaccinations yet, he also did not undergo newborn screening, and I encouraged her to have her son undergo newborn screening and avail the Expanded Program on Immunization which is being offered in all barangay health centers.Growth and Developmenta. Erik Eriksons Psychosocial Development Theory: Trust vs. MistrustDevelopmental 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 mothers touch and a strangers 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 Freuds Psychosexual Stage: Oral StageThe 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 Piagets Theory of Cognitive Development: Sensorimotor StageBabies 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.D. HISTORY OF PAST ILLNESSAccording to Rowena, Baby Khiefer did not have any illnesses before, it was the first time he suffered such conditions.E. HISTORY IF PRESENT ILLNESSOn the 15th day of June 2013, morning, and few hours prior to baby Khiefer admission, after Rowena finished feeding her baby, Baby Khiefer suddenly vomited, he continuously vomited four times. He was then immediately rushed to the hospital with chief complaints of vomiting to seek medical attention. Baby Khiefer was then assessed and observed with all necessary laboratory and diagnostic tests were requested and performed. Baby Khiefer was then admitted and diagnosed with Neonatal sepsis. With further exploration of, Rowena told me that Baby Khiefer does not have any fever, cough and cold or any conditions during the admission. F. PHYSICAL EXAMINATIONJune 18, 2013 (Lifted from chart)Weight: 3.2 poundsSkin: (+) maculopapular rashes on the face and trunk. (-) jaundiceHead EENT: normocephalic, non bulging fontanels, anicteric sclera, pink palpebral conjunctiva, (-) nasal and oral discharge.Lymph nodes: (-) Cervical LymphadenopathyChest:Lungs: Symmetrical chest expansion, (-) retractions, clear breath soundsCardiovascular: Adynamic Precordium, normal rate, regular rhythm, (-) murmurBreast: 2 breast budsAbdomen: globular, normoactive bowel sounds, soft, non-tender, patent rectum.Genitals: (-) hypospadias, descended testesExtremities: symmetrical, (-) edemaJune 27, 2013 Baby Khiefer was seen wearing a white over all clothes, lying on bed, asleep. With the following vital signs noted: T- 37.3C HR- 131 bpm RR- 70 cpmWeight: not takenSkin: with maculopapular rashes on the face. No jaundice noted, no cyanosis noted, warm to touch skin, no skin tenting noted, moist skin, with good skin turgor.Head EENT: normocephalic, not bulging, flat fontanels, anicteric sclera, pink palpebral conjunctiva, no nasal and oral discharge noted. Moist to dry oral mucosa. Nonhyperemic posterior pharyngeal wall.Lymph nodes: without Cervical LymphadenopathyChest:Lungs: Symmetrical chest expansion, no retractions noted, with clear breath soundsCardiovascular: Adynamic Precordium, heart beat is in normal rate and regular rhythm, no murmur noted.Breast: 2 breast buds are observedAbdomen: globular with equal skin color, umbilicus is observed dry, with normoactive bowel sounds (7 8 bowel sounds/ quadrant/ minute), soft and non-tender, patent rectum. With flatus reported, no bowel movement was noted. Without vomiting noted during the shift.Genitals: no hypospadias noted, with descended testes, with 1 soaked diaper changes within the shift.

Extremities: Upper: Symmetrical extremities, with no edema noted, capillary refill of 1 sec, pinkish nail beds. Untrimmed nails.Lower: Symmetrical extremities, with no edema noted, capillary refill of 1 sec, pinkish nail beds. Untrimmed nails.Neurologic: with normal reactions to rooting, sucking, palmar, and babinski reflexes upon initiation.G. DIAGNOSTICS AND LABORATORY PROCEDURESDIAGNOSTIC OR LABORATORY PROCEDURESDATE ORDERED AND DATE RESULTS ININDICATIONS OR PURPOSESRESULTSNORMAL VALUESANALYSIS AND INTERPRETATION

CLINICAL CHEMISTRY

HGT/RBSOrdered:June 14, 2013

Results available:June 14, 2013A random blood sugar is used to test and measure your blood sugar at any point in time, not necessarily a certain amount of time after a meal, snack or beverage.June 14, 201365mg/dL80 115 mg/dL

the blood sugar level is within the normal limits, this is due to the aid of the clients intravenous fluid that keeps the electrolyte levels in normal values though the client is in NPO.

FBS, Blood: Pre-test:1. Inform the family that the test is used to assist in the evaluation of the clients glucose level2. Note any procedures that can interfere with the test results.3. Obtain a list of medications patient is taking.

Intra-test;

1. Observe Standard precautions.2. After obtaining the specimen, promptly transport to the laboratory for processing and analysis.

Post-test:Observe venipuncture site for bleeding or hematoma formation.

BLOOD HEMATOLOGY

Hemoglobin (Hgb)Ordered:June 14, 2013Results in:June 14, 16, 18, 2013- to monitor Hgb value in the RBC- to suggest the presence of body fluid deficit due to elevated Hgb level185 g/dl220g/dL216d/dL

120-170 g/dl

The HGB count denotes that the client has an infection.

Hematocrit (Hct)Ordered:June 14, 2013Results in:June 14, 16, 18, 2013To aid diagnosis of abnormal states of hydration, polycythemia and anemia.- It measures the concentration of RBC within the blood volume and is expressed as a percentage.0.560.660.670.40-0.52 g/L

The Hct count denotes that the client has an infection.

WBCOrdered:June 14, 2013

Results in:June 14, 16, 18, 2013The test is performed to find out how many white blood cells you have. Your body produces more white blood cells when you have an infection or allergic reaction, even when you are under general stress11.3x109/L15.6x109/L6.4 x109/L 5-10 x 109/L

The WBC count denotes that the client has an infection.

NeutrophilsOrdered:June 14, 2013

Results in:June 14, 16, 18, 2013To detect presence of infection in the body.40.45.51.45-.65The Neutrophils is below the normal range this level of Neutrophils also denotes infection.Together with this high lymphocyte level denotes that the client may have viral or bacterial infection.

LymphocytesOrdered:June 14, 2013

Results in:June 14, 16, 18, 2013To detect presence of infection within the body.0.550.540.50

0.20-0.35

PlateletsOrdered:June 18, 2013

Results in:June ,18, 18, 2013The number of platelets in your blood can be affected by many diseases. Platelets may be counted to monitor or diagnose diseases, or identify the cause of excess bleeding.

350x109 g/L

315x109 g/L

250x109 g/L

150-400x109 g/LThe platelet count is within the normal range this denote that the clients body has a good coagulation status.

Nursing Implications for Blood Hematology Test: Pretest:1. Inform the family that the test is used to evaluate numerous conditions inflammation, infection, and response to chemotherapy.2. Obtain a list of medications the patient is taking.3. Review the procedure with the mother. Explain the duration of the procedure and inform the mother that there may be some discomforts during the procedure.

Intratest:1. Observe Standard precautions.2. apply a pressure dressing over the puncture site.3. Promptly transport the specimen to the laboratory for processing and analysis.

Post-test:1. Observe venipuncture site for bleeding or hematoma formation. Apply paper tape or other adhesive to hold pressure bandage in place.

III. ANATOMY AND PHYSIOLOGYLymphatic SystemThe lymphatic system consists of organs, ducts, and nodes. It transports a watery clear fluid called lymph. This fluid distributes immune cells and other factors throughout the body. It also interacts with the blood circulatory system to drain fluid from cells and tissues. The lymphatic system contains immune cells called lymphocytes, which protect the body against antigens (viruses, bacteria, etc.) that invade the body.See more on lymphocytes below.Main Functions of Lymphatic SystemTo collect and return interstitial fluid, including plasma protein to the blood,and thus help maintain fluid balance,To defend the body against disease by producing lymphocytes,To absorb lipids from the intestine and transport them to the blood.

Lymph organs include the bone marrow, lymph nodes, spleen, and thymus. Precursor cells in the bone marrow produce lymphocytes. B-lymphocytes (B-cells) mature in the bone marrow. T-lymphocytes (T-cells) mature in the thymus gland.Lymph Nodes - A lymph node is an organized collection of lymphoid tissue, through which the lymph passes on its way to returning to the blood. Lymph nodes are located at intervals along the lymphatic system. Several afferent lymph vessels bring in lymph, which percolates through the substance of the lymph node, and is drained out by an efferent lymph vessel.

The Cardiovascular SystemThe heart and circulatory system make up the cardiovascular system. The heart works as a pump that pushes blood to the organs, tissues, and cells of the body. Blood delivers oxygen and nutrients to every cell and removes the carbon dioxide and waste products made by those cells. Blood is carried from the heart to the rest of the body through a complex network of arteries, arterioles, and capillaries. Blood is returned to the heart through venules and veins. The one-way circulatory system carries blood to all parts of the body. This process of blood flow within the body is called circulation. Arteries carry oxygen-rich blood away from the heart, and veins carry oxygen-poor blood back to the heart. In pulmonary circulation, though, the roles are switched. It is the pulmonary artery that brings oxygen-poor blood into the lungs and the pulmonary vein that brings oxygen-rich blood back to the heart. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)Twenty major arteries make a path through the tissues, where they branch into smaller vessels called arterioles. Arterioles further branch into capillaries, the true deliverers of oxygen and nutrients to the cells. Most capillaries are thinner than a hair. In fact, many are so tiny, only one blood cell can move through them at a time. Once the capillaries deliver oxygen and nutrients and pick up carbon dioxide and other waste, they move the blood back through wider vessels called venules. Venules eventually join to form veins, which deliver the blood back to the heart to pick up oxygen. Vasoconstriction or the spasm of smooth muscles around the blood vessels causes and decrease in blood flow but an increase in pressure. In vasodilation, the lumen of the blood vessel increase in diameter thereby allowing increase in blood flow. There is no tension on the walls of the vessels therefore, there is lower pressure. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)Various external factors also cause changes in blood pressure and pulse rate. An elevation or decline may be detrimental to health. Changes may also be caused or aggravated by other disease conditions existing in other parts of the body.The blood is part of the circulatory system. Whole blood contains three types of blood cells, including: red blood cells, white blood cells and platelets.These three types of blood cells are mostly manufactured in the bone marrow of the vertebrae, ribs, pelvis, skull, and sternum. These cells travel through the circulatory system suspended in a yellowish fluid called plasma. Plasma is 90% water and contains nutrients, proteins, hormones, and waste products. Whole blood is a mixture of blood cells and plasma.Red blood cells (also called erythrocytes) are shaped like slightly indented, flattened disks. Red blood cells contain an iron-rich protein called hemoglobin. Blood gets its bright red color when hemoglobin in red blood cells picks up oxygen in the lungs. As the blood travels through the body, the hemoglobin releases oxygen to the tissues. The body contains more red blood cells than any other type of cell, and each red blood cell has a life span of about 4 months. Each day, the body produces new red blood cells to replace those that die or are lost from the body.White blood cells (also called leukocytes) are a key part of the body's system for defending itself against infection. They can move in and out of the bloodstream to reach affected tissues. The blood contains far fewer white blood cells than red cells, although the body can increase production of white blood cells to fight infection. There are several types of white blood cells, and their life spans vary from a few days to months. New cells are constantly being formed in the bone marrow.Several different parts of blood are involved in fighting infection. White blood cells called granulocytes and lymphocytes travel along the walls of blood vessels. They fight bacteria and viruses and may also attempt to destroy cells that have become infected or have changed into cancer cells. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)Certain types of white blood cells produce antibodies, special proteins that recognize foreign materials and help the body destroy or neutralize them. When a person has an infection, his or her white cell count often is higher than when he or she is well because more white blood cells are being produced or are entering the bloodstream to battle the infection. After the body has been challenged by some infections, lymphocytes remember how to make the specific antibodies that will quickly attack the same germ if it enters the body again.Platelets (also called thrombocytes) are tiny oval-shaped cells made in the bone marrow. They help in the clotting process. When a blood vessel breaks, platelets gather in the area and help seal off the leak. Platelets survive only about 9 days in the bloodstream and are constantly being replaced by new cells.Blood also contains important proteins called clotting factors, which are critical to the clotting process. Although platelets alone can plug small blood vessel leaks and temporarily stop or slow bleeding, the action of clotting factors is needed to produce a strong, stable clot.Platelets and clotting factors work together to form solid lumps to seal leaks, wounds, cuts, and scratches and to prevent bleeding inside and on the surfaces of our bodies. The process of clotting is like a puzzle with interlocking parts. When the last part is in place, the clot is formed.When large blood vessels are cut the body may not be able to repair itself through clotting alone. In these cases, dressings or stitches are used to help control bleeding.In addition to the cells and clotting factors, blood contains other important substances, such as nutrients from the food that has been processed by the digestive system. Blood also carries hormones released by the endocrine glands and carries them to the body parts that need them. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)Blood is essential for good health because the body depends on a steady supply of fuel and oxygen to reach its billions of cells. Even the heart couldn't survive without blood flowing through the vessels that bring nourishment to its muscular walls. Blood also carries carbon dioxide and other waste materials to the lungs, kidneys, and digestive system, from where they are removed from the body. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)IMMUNE SYSTEMAn immune system is a collection of biological processes within an organism that protects against disease by identifying and killing pathogens and tumour cells. It detects a wide variety of agents, from viruses to parasitic worms, and needs to distinguish them from the organism's own healthy cells and tissues in order to function properly. Detection is complicated as pathogens can evolve rapidly; producing adaptations that avoid the immune system and allow the pathogens to successfully infect their hosts. To survive this challenge, multiple mechanisms evolved that recognize and neutralize pathogens. Even simple unicellular organisms such as bacteria possess enzyme systems that protect against viral infections. Other basic immune mechanisms evolved in ancient eukaryotes and remain in their modern descendants, such as plants, fish, reptiles, and insects. These mechanisms include antimicrobial peptides called defensins, phagocytosis, and the complement system. Vertebrates such as humans have even more sophisticated defense mechanisms. The immune systems of vertebrates consist of many types of proteins, cells, organs, and tissues, which interact in an elaborate and dynamic network. As part of this more complex immune response, the human immune system adapts over time to recognise specific pathogens more efficiently. This adaptation process is referred to as "adaptive immunity" or "acquired immunity" and creates immunological memory. Immunological memory created from a primary response to a specific pathogen, provides an enhanced response to secondary encounters with that same, specific pathogen. This process of acquired immunity is the basis of vaccination.Disorders in the immune system can result in disease. Immunodeficiency diseases occur when the immune system is less active than normal, resulting in recurring and life-threatening infections. Immunodeficiency can either be the result of a genetic disease, such as severe combined immunodeficiency, or be produced by pharmaceuticals or an infection, such as the acquired immune deficiency syndrome (AIDS) that is caused by the retrovirus HIV. In contrast, autoimmune diseases result from a hyperactive immune system attacking normal tissues as if they were foreign organisms. Common autoimmune diseases include rheumatoid arthritis, diabetes mellitus type 1 and lupus erythematosus. Immunology covers the study of all aspects of the immune system which has significant relevance to human health and diseases. Further investigation in this field is expected to play a serious role in promotion of health and treatment of diseases.

B. SYNTHESIS OF THE DISEASENeonatal 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. Congenital infection per se is an infection acquired before a neonate was born. As elaborated, this is common among premature babies and to those babies whom their mothers have suffered from infection while they are pregnant.Early and late onset infections per se are infections that were acquired after they were born. Early onset infections are infections that arise on the first week of life and late onset infection arose beyond 1 week after delivery. There are several key features of neonates that place them at increased risk for the development of sepsis. Neonates have a relatively immature immune system, and the effects on the immune system are more pronounced in more premature neonates. Such defects include a loss of protective maternal antibodies, as well as non-specific alterations in macrophage phagocytosis and clearance of invading pathogens, impaired T-cell and B-cell responses, and altered production of complement and antibodies. In addition, the newborn infant particularly the preterm infant has relatively permeable mucosal surfaces that allow for the trans-epithelial passage of bacteria and other pathogens. The frequency with which preterm neonates undergo invasive procedures, that themselves result in the introduction of potential pathogens, also increases the specific risk to the neonate of the development of sepsis. The presence of co-morbidities, such as impaired cardiac function, anatomic defects of the gastro-intestinal or urinary tract, and abnormalities in glucose metabolism worsen the neonates ability to withstand infection, and lead to an increased risk for the development of neonatal sepsis.Neonates with sepsis present with a variety of subtle clinical findings that individually may not point to a specific infectious etiology, but together should alert the caregiver to the fact that the infant is septic. These signs include subtle changes in respiration, including apnea and / or tachypnea. There may be associated changes in heart rate, including frequent episodes of bradycardia and/or tachycardia. The reasons that sepsis leads to changes in ventilation and cardiac rate are not completely understood, but they remain highly useful as markers for the presence of sepsis. In addition, neonates with sepsis commonly exhibit alterations in core body temperature, as manifested by fever and or hypothermia. Changes in skin perfusion commonly accompany sepsis, as manifested by mottling, cooling of the extremities, and a general ill look to the baby overall. Other subtle findings of sepsis include the development of feeding intolerance, vomiting, or diarrhea.

In more advanced stages, infants with sepsis may show signs of petechiae - small areas of hemorrhage within the skin as evidence for the platelet consumption that frequency is seen in sepsis. In association with these signs, more advanced sepsis is associated with evidence of global impaired tissue perfusion, characterized by reduced urine output and decreased systemic blood pressure. Secondary pulmonary hypertension may develop in more severe cases of sepsis, leading to impaired gas exchange in the lungs. This can result in progressive tissue hypoxia and increased work of breathing. It is important to point out that the clinical course of septic patients is unpredictable. There may be the gradual onset of tachypnea, nasal flaring and fever, or the rapid, striking development of cardio-respiratory shock. The specific course depends to some degree on the infectious agent, the overall health of the neonate, including gestational age and birth weight, and the presence of specific co-morbidities. However, it is fairly safe to predict that in the absence of aggressive treatment that is directed at maintaining tissue perfusion, supporting the function of the cardio-respiratory system and treating the underlying infection, septic neonates can be expected to have a dramatic downward spiral, characterized by systemic inflammation and multiple organ dysfunction. Fortunately, aggressive early therapy is highly successful in treating sepsis in the majority of cases. The specific focus of sepsis may affect the presentation to some degree. Infants with pneumonia typically develop pulmonary symptoms first (nasal flaring followed by increased oxygen requirements and respiratory failure). Infants with meningitis may manifest bulging fontanels. However, in general, the signs of sepsis are subtle and do not point to the precise infectious location or agent.

Prevention of late-onset neonatal sepsis includes care and attention to limit nosocomial infection. Measure such as hand washing techniques, sterile techniques for any procedure, care and attention to central line access, and avoidance of exposure of at-risk infants to neonates with known infections can all limit the incidence of late-onset neonatal sepsis.

2. ACTUAL SOAPIEJuly 21 2010F= Risk for spread of infectionD=Received baby on bassinette under bililight with ongoing IVF D5IMB 104.5cc + Cagluc 1.3 + D5050 13.2 cc in soluset x 3 cycles 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 babys 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 cpmA= > 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 attendedR= SO complied to health teachings

VI. PATIENTS DAILY PROGRESS IN THE HOSPITAL(From admission to discharge)1. Clients Daily Progress Chart (From admission to discharge)DAYSADMISSION1st dayJun 19, 20132nd dayJune 253rd dayJune 28

Nursing Problems1. Hyperthermia2.Ineffective Thermoregulation r/t Immaturity and Illness3.Impaired Skin Integrity r/t Mechanical Factors4. Risk for Further Infection r/t Inadequate Primary Defenses5. Deficient Fluid Volume r/t Failure of Regulatory Mechanism

Vital Signs10:45am812481248124

TEMPERATURE36.33636.438.236.736.936.3

PR6512088888285100

RR21222229252525

DXC/Lab. ProceduresMedical managements

HEMATOLOGY

COMPLETE BLOOD COUNT

INTRAVENOUS FLUID/ BLOOD TRANSFUSIONS

1. D5IMB 500 cc in soluset x 3 cycles # 1

2. D5IMB 105cc + Cagluc 1.3 + D5050 6.5 cc in soluset x 3 cycles # 2

3. D5IMB 104.5cc + Cagluc 1.3 + D5050 13.2 cc in soluset x 3 cycles # 3

4. D5IMB 104.5cc + Cagluc 1.3 + D5050 13.2 cc in soluset x 3 cycles # 4

Hgb: 216Hct: 0.67P.C.: 117

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WBC: 6.4RBC: 6.15Seg: .55Lymph: .41

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()At 7amHgb 167Hct: 0.50P.C.: 78

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At 10amHgb: 129Hct: 0.39P.C.: 42

3.

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()At 9amHgb: 121Hct: 0.36P.C.: 100

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DIET1. DAT to avoid dark colored food2. Soft diet EDCF

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DISCHARGE PLANNING METHODM-Medication-ampicillin 100mg IV q12-Amikin SO4 15mg IV q12 E-Exercise-Stressed that the baby sleeps most often timesT-Treatment-Stressed importance of complying with the medications H-Health Teachings-Instructed Mother to bring back the baby in the hospital for his medication-Instructed Mother on the time the medication will be given-Instructed Mother for the drugs side effect which includes constipation; diarrhea; dizziness; headache; indigestion; nausea; pain, swelling, or redness at the injection site; sleeplessness; vomiting.-Instructed Mother of the importance of breastfeeding-Instructed Mother on Proper Breastfeeding-Instructed Mother to expose the baby to sunlight at 6:00 am to 10:00 am-Instructed Mother that formula milk is only good for 4 hours-Instructed Mother on strict aspiration precaution-Instructed Mother to burped the baby after each feedings-Instructed Mother to bathe daily their BabyO- OPD After 1 week, the client may visit the outpatient department for follow up consultation to know the progress of his health status to give more medications that can be prescribed and for more health teachings to be given. However, immediate follow-up visit should be done when the condition of the client worsen. D-Diet-Instructed Mother to feed the baby as tolerated with strict aspiration precautionVII. Conclusion and RecommendationLearning DerivedAs 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 aserious bacterial infection (such asmeningitis,pneumonia,pyelonephritis, orgastroenteritis) 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 patients 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 ones 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 weve 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.


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