HOLY ANGEL UNIVERSITYAngeles City

College of Nursing

Case Study

Neonatal Sepsis

As a partial requirement in

NCM 104 – RLE

I. INTRODUCTION

The term “sepsis” has been around since ancient times; modern definitions of “sepsis” were

described in detail in the early 1990s, at a consensus conference convened by the American

College of Chest Physicians and the Society of Critical Care Medicine. At that time, “sepsis”

was described as a systemic response to a physiologic insult – including infectious and other

etiologies – that lead to the development of further organ injury, ultimately culminating in

multiple organ dysfunction syndromes. Neonatal sepsis, also termed Sepsis neonatorum, refers to

a group of physical and laboratory findings that occur in response to invasive infection within the

first 30 days of life. As will be discussed below, there are various infectious causes of neonatal

sepsis; however, the pattern of presentation is quite similar in all cases, as is the approach to

treatment. The importance of neonatal sepsis as a diagnosis is found in the fact that this diagnosis

occurs in between 1 to 8 children per 1000 live births in the United States, and may be associated

with a fatality rate of up to 30%. As such, it is essential that caregivers that are involved with the

management of neonates have a reliable approach to the diagnosis and treatment of infants with

sepsis, and that appropriate intervention be instituted in a timely manner.

Neonatal Sepsis is an infection in the blood that spreads throughout the body and occurs

in a neonate. Neonatal Sepsis is also termed as Neonatal Septicemia and Sepsis Neonatorum.

Neonatal Sepsis has 2 types: The one that is seen in the first week of life is termed as Early-

onset sepsis and most often appears in the first 24 hours of life. The infection is often acquired

from the mother. This can be cause by a bacteria or infection acquired by the mother during her

pregnancy, a Preterm delivery, Rupture of membranes (placenta tissue) that lasts longer than 24

hours, Infection of the placenta tissues and amniotic fluid (chorioamnionitis) and frequent

vaginal examinations during labor. The second type or the Late-onset Sepsis is acquired after

delivery. This can be cause by contaminated hospital equipment, exposure to medicines that lead

to antibiotic resistance, having a catheter in a blood vessel for a long time, staying in the hospital

for an extended period of time. Signs and symptoms of Neonatal Sepsis includes but is not

limited to: body temperature changes, breathing problems, diarrhea, low blood sugar, reduced

movements, reduced sucking, seizures, slow heart rate, swollen belly area, vomiting, yellow skin

and whites of the eyes (jaundice). Possible complications are disability and worst is death of the

neonate. (Greene, 2007)

Neonatal sepsis occurs at an estimated rate of 1 to 2 cases per 1000 live births in the U.S.

The highest rates occur in low-birth-weight (LBW) infants, those with depressed respiratory

function at birth, and those with maternal perinatal risk factors. The risk is greater in males (2:1)

and in neonates with congenital anomalies (Merck, 2005). According to the Philippine Mortality

Fact Sheet 2006 of the World Health Organization, in 1000 live births of neonates 17% of it died

due to severe infection that includes deaths from pneumonia, meningitis, sepsis/septicemia, and

other infections during the neonatal period.

Neonatal sepsis can occur in any infant. However, the diagnosis is significantly more

common in pre-term infants than full term infants, and can affect up to 30 to 1000 live births in

the pre-term population. Sepsis is also more common in males than females, and in developing

countries.

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

 1. Pulmonary Tuberculosis 38   7.92   1. CVA 46   9.83  2. Pneumonia  36  7.50   2. Pneumonia  43   9.19 

 3. CVA  29   6.04   3. Pulmonary Tuberculosis  27   5.77  4. Hypertension 23  4.79   4. Hypertension  23   4.91  5. Prematurity  21   4.38   5. Vehicular Accident  12   2.56 

 6. Neonatal Sepsis  18   3.75   6. Acute Gastroenteritis  11   2.35  7. Malaria 17   3.54   7. Sepsis Neonatorum  11   2.35 

 8. CNS Infection  10   2.08   8. Congestive Heart Disease  10   2.14  9. Vehicular Accident 10   2.08   9. Malaria  9   1.92 

 10. Diarrhea 9   1.88   10.  Diabetes Mellitus  9   1.92 

Nurse Centered Objectives:

At the end of this study, the student nurse will be able to:

♦ have critical thinking skills necessary for providing safe and effective nursing care.

♦ have a comprehensive assessment and implement care base on our knowledge and skills of the

condition

♦ familiarize themselves with effective inter-personal skills to emphasize health promotion and

illness prevention.

♦ Impart the learning experience from direct patient care.

www.who.com

Patient and Family Centered Objectives:

At the end of this study, the patient/family will be able to:

1. Identify measures that could minimize the risk of occurrence of the disease.

2. Identify possible risk factors that may have contributed to the development of Neonatal

Sepsis.

3. Increase awareness on the risk factors of Neonatal Sepsis.

4. Develop the family’s support system and distinguish their respective roles in improving

patient’s health status.

5. Involve them in promoting the health care of the patient.

II. NURSING HISTORY

Personal History

Ms. Sepsis is 25 years old and is of Ilokano descent because her mother was Ilokano. She

was born on September 13, 1984 in Luna, La Union. She gave birth to her first born but she is

not yet married. She lives in an apartment located in San Lorenzo Street, Sto. Domingo, Angeles

City. She was admitted in a birthing home last September 8, 2009 at 03:00 pm. Baby Boy S was

born on the same date at Our Lady of Good Birth Birthing Home near AMC via Cesarean

Section I with an Apgar score of 7 and 8at 11:20 pm. Two days after birth, September 10, 2009,

the baby was admitted at AMC Main ward because of reported continuous vomiting.

Ms. Sepsis works as a lady guard in Angeles City Jail wherein she inspects the workers

before entering the vicinity and she earns 13,000.00 per month. She spends 2,500.00 for rental

fee, water and electricity, 5,000.00 for food, and she sends 4,000.00 to her parents in La Union,

in a monthly basis. Then she has a monthly mobile bill of 800.00 for Globe line and 80.00 for a

smart line. She made a loan to AFPMI in Manila for her giving birth; this was an agency which

is readily available for police officers and workers like them.

Ms. Sepsis finished tertiary education with commerce as her course. She got the work in

the City Jail through her cousin. It was offered to her when she was still working as a clerk in an

electronic company in Batangas. She decided to apply but she did not pass the height

requirement so she was not accepted. Two years after, she applied again and got accepted. Now

she has been working there for two years as of September 4, 2009. But she worked for 2 years

and 5 months for JMP in their main headquarters.

Ms. Sepsis and her family are under Iglesia Ni Cristo (INC). Being INC they have several

beliefs such as if there was someone who is sick like having colds, flu, cough, their Jackono

(officer) would pray over him because if it was severe would they bring him/her to the hospital.

The mother of Ms. Sepsis told her to not watch television during her pregnancy and to not take

cold bath after birth because they will use steamed leaves for bathing. She also told Ms. Sepsis to

use abdominal binder while pregnant.

Family-Health Illness History

Within Ms. Sepsis’ family, only the eldest son has hypertension. No other hereditary

disease was identified by her mother. But on her partners’ side, she stated that her partner had

prostate cancer but was already cured that one of his testes was removed.

History of Past IllnessMs. Sepsis had chicken pox; mumps at 6 years old which was treated with “tina” and

mefenamic acid, and measles wherein her mother told her to eat “balot” for treatment. She had

urinary tract infection before pregnancy which lasted for 5 days and was treated with Cefalexin

and at her 5th month during pregnancy which lasted for about 1 week as well.

History of Present IllnessAfter birth, the baby was found to be having neonatal sepsis so he was admitted at AMC

Main Ward. He was breastfed few hours after birth then with water by the mother and the nurse

thereafter and he was still fine. Then he was fed with Bona, formula milk, and then he vomited.

The family thought it was fine and normal but it became continuous so they notified her doctor

and the baby was admitted after.

Φ Family Health Illness History (diagram)

LEGENDS: Deceased

With hypertension

Had prostate Cancer

Had UTI

With Neonatal Sepsis

OBSTETRICAL HISTORY

Ms. Sepsis had her menarche at the age of 13 and lasted for a week. From then on, she had

regular menstrual period every month with 5 days to 1 week maximum of delay. She gave birth

to her first baby at the age of 25. She does not use OCP rather she uses withdrawal method as

their contraceptive method. She does not live together with her partner because they are assigned

in different areas.

Maternal-Obstetric Record

Ms. Sepsis is not married to her boyfriend yet and has no plan of getting married as of the

moment. She has an Obstetric record of Gravida 1, Para 1. She has a TPAL record of 1-0-0-1.

Her last menstrual period was last December 15, 2008. So her estimated date of delivery was

supposedly on September 22, 2009. She had given birth to her first baby, Baby Boy S last

September 8, 2009 two weeks ahead from her EDD. She was brought earlier than her estimated

date of confinement because she had an early contraction and abnormal fetal position and

attitude. She had given birth via Cesarean Section I in Our Lady of Good Birth Birthing Home,

which is a specialized clinic solely for giving birth.

Ante-partal/ Pre-natal Preparation

According to Ms. Sepsis she had a regular prenatal check-up on her doctor’s clinic. She

goes once a month during the first trimester, twice a month during the second trimester, and

every week during the third trimester. She received 1 dose of tetanus toxoid vaccine from her

doctor. She missed the second dose but her doctor said it was fine.

Significant Trimestral Changes (1st – 3rd trimester)

On the first trimester of her first pregnancy, she did not experience much change. She

narrated that she once ate “bagoong with tomato” and vomited, since then she had not have the

appetite for it. On the second trimester of her pregnancy, she noticed darkening of her neck,

underarm and inguinal area. Third trimester pregnancy, she noticed stretch marks and

experienced slight itchiness. Slight discomfort was felt all throughout the pregnancy period.

During her second trimester of pregnancy, Ms. Sepsis had urinary tract infection. It was treated

through oral antibiotics such as Cefalexin and by drinking lots of water

Last September 7, 2009 she felt contractions occurring at the interval of 5 minutes. At September

8, 2009 she saw brown blood and then clear secretions of about two spoonfuls. Then she was

admitted at the same date at 03:00 pm.

She took vitamins during the course of her pregnancy like Ferrous sulfate for the first

trimester then Micron C for the second trimester then Terraferon for the last trimester. She drank

Anmum but stopped at the 8th month as advised by her ob-gyne because the baby was already

5.28 pounds.

III. PHYSICAL ASSESSMENT (IPPA-Cephalocaudal Approach)

September 10, 2009 (12:15 am)

P.A. of Baby Boy S

Upon admission (lifted from the Chart)

Vital signs:

T: 36.5°C

HR: 132 bpm

Wt: 2.9 kg

(-) Cleft lip and palate

Clear breath sound; no rales

Normal respiratory rate and rhythm (NRRR)

No murmur

Normal Abdominal Bowel Sound (NABS)

Soft full equal pulses

September 10, 2009 (04:00 pm)

Initial Interaction

P.A. of Baby Boy S

Vital signs:

HR: 165 bpm

Temp: 37.2 mmHg

RR: 53 bpm

CEPHALO-CAUDAL APPROACH

SKIN

- Ruddy complexion

- With good skin turgor (negative tenting)

- Skin is warm to touch

NAILS

- When palpated, the nail base is firm

- Tissue surrounding nails is intact

- Convex curve and pinkish nails

- Blanch test: prompt return of pink color less than 2 seconds

HEAD

Hair and Scalp

- Hair is black

- Hair is evenly distributed

- Silky, resilient hair

- No dandruff or flaking

- Normal skull configuration, rounded, smooth skull contour

Skull and Face

- Smooth skull contour

- Absence of nodules or masses

- Symmetrical facial features and movements

- Flat anterior fontanel

EYES

- Eyebrows are evenly distributed and symmetrically aligned

- Equal movements of eyebrows

- Eyelashes are equally distributed, curled slightly outward

- lids are edematous

- transient strabismus

- Bulbar conjunctiva are clear

- Palpebral conjunctiva are shiny, smooth and pink

- No edema or tearing of lacrimal sac

- Anicteric sclerae

- Cornea are transparent, shiny and smooth

- Corneal reflex noted

- Pupil are equally round and receptive to light

- Iris is black in color

EARS

- Auricles are symmetrical

- Auricles are firm, smooth, free from lesions and pain

- Tip of the ear is aligned with the outer canthus of eye

- Pinna recoils after it is folded

- intact startle reflex

NOSE AND SINUSES

- Symmetrical nares

- No flaring

- Nose is located symmetrically, midline of the face

- intact glabellar reflex

MOUTH AND THROAT

- Lips and buccal mucosa are pink in color, moist and smooth texture

- Tongue pink in color, slightly moist; veins not prominent

- Sores and ulceration are not evident.

- intact rooting reflex

NECK

- Presence of head lag

BREAST AND AXILLAE

- Equal in size

- Areola is light brown in color

- No palpable lump

- Bilaterally the same

- No pain and tenderness upon palpation

RESPIRATORY

- Symmetric with full chest expansion

- cylinder shaped

- slight sternal retractions

CARDIOVASCULAR

- Palpable arterial pulse

- Pulses are strong

GASTROINTESTINAL

- Rounded

- With bowel sounds during auscultation

- No abnormal lumps and hardened areas in the abdominal area

GENITAL

- Rugated scrotum

- Urinary meatus at tip of penis

UPPER AND LOWER EXTREMITIES

- Symmetrical in shape

- Extremities are well flexed

- intact palmar grasp and babinski reflex

IV. DIAGNOSTIC AND LABORATORY PROCEDURESDiagnostic/Laboratory Procedures

Date Ordered/

Date Results

Indications or

Purposes

Results

Normal

Values

Analysis and Interpretation

HematologyHCT (%)

Platelet

WBC ct (x18/1)

Granulocytes(x10/1)(x10/91)

HGB (g/dL)

D.O. - 09/09/2009D.R. – 09/09/2009

To aid diagnosis of abnormal states of hydration, polycythemia and anemia and aids in calculation of erythrocyte indices

To evaluate platelet production

To determine for presence of for further tests such as WBC differential infection and also for determination count

To measure the hemoglobin

63.0

318

25.8

5814.910.9

18.4

40.0-54.0

140-440

4.3-10.0

44.2-80.22.0-8.81.2-5.3

14-18

The hematocrit is increasedwhich is a sign of dehydration.

The platelet count is in normal amount.

WBC is increased which indicates presence of infection.

Hemoglobin is increased which indicates dehydration.

Nursing Responsibilities:

Patient Preparation:

Explain to the SO the indication/purpose of the test, that this test detects presence of

infection and other abnormal conditions of the blood

Explain to the SO the procedure that the test requires blood sample, and who will perform

it.

Tell the SO that the baby may feel discomfort from the needle puncture and pressure on

the tourniquet. That the baby may struggle and cry.

Procedure & Post test care;

If hematoma develops at the site, apply warm soaks.

Ensure sub dermal bleeding has stopped before removing pressure.

If hematoma is large monitor pulses distal to the site.

V. THE PATIENT AND HIS ILLNESS

Anatomy and Physiology

The immune system is a complex array of organs, cells and chemicals that determine self

from non-self identify potential dangers to the body and eliminate them by mounting an immune

response. Most (but not all) infections result in lifelong immunity. Some infections are

innocuous while others cause serious disease, permanent damage to the host and sometimes

death. Rather than risk serious illness it is possible to vaccinate against a number of potentially

serious diseases. Vaccination is offered from a young age against a number of diseases as an

alternative to experiencing natural infection and the associated risks.

It is important to immunize infants as soon as possible to protect against disease and the infant

immune system is known to be effective and responsive. However, their immune system is naïve

i.e. has not been exposed to any pathogens. Therefore the infant needs to develop immunity to

every pathogenic organism it encounters. By the time of birth the baby will have large numbers

of circulating antibody passed across the placenta from the mother. This antibody will protect the

baby against some infections initially, until the baby forms its own immune response to

pathogens.

Overview of the immune system

Our immune system protects us against viruses, bacteria and parasites which can cause

infectious diseases. The immune system responds to antigens. An antigen is a substance that

stimulates a specific immune response, especially the production of antibodies. Basically this

involves shape recognition. Antigens are usually proteins or polysaccharides, but can be any type

of molecule. Infectious agents such as viruses and bacteria have antigens which the immune

system responds to. Vaccines contain antigens (often purified parts of the original organism).

Types of Immunity

The white blood cells of the immune system are produced in the marrow of our bones. The cells

are carried in the blood to specialized organs such as lymph nodes, where they develop and

communicate to launch immune responses against infections.

We have three types of immunity:

1. Non-specific immunity – is a first line of defense and generally keeps infections from

entering the body. Examples of this are skin (physical barrier), mucus,tears, stomach

acid.

2. Innate immunity – is the second line of defense. In this situation certain white cells

engulf infectious agents. These cells are capable of recognising antigens which are non-

self (ie from an infectious agent), however they cannot recognize particular pathogens.

For example, these cells would not be able to distinguish an influenza virus from a

hepatitis virus, but they would be able to distinguish that there was a viral infection

occurring. Over 90% of infections are controlled by these cells. However when the

infection becomes too great these cells will alert the specific arm of the immune system.

3. Specific or adaptive immunity – This is the third line of defense. In this situation white

blood cell called lymphocytes identify each antigen individually by recognizing different

sequences of amino acids. This specific response initially takes longer to generate (4-7

days) than the non-specific arm but results in a memory to the specific antigen. The

memory response becomes quickly activated. This means that when an individual is re-

infected with the pathogen, this memory response will remove the infectious agent before

it can cause disease (i.e. in 2-3 days). This is the response that vaccination targets.

What is different about the infant immune system?

The infants’ immune system is intact but immature at birth.  Some vaccines such as BCG

and Hepatitis B work well when they are administered at birth whereas others do not generate as

strong a response.

The main problem with babies’ immunity is that it is very naïve.  At the time of birth babies have

not been exposed to any pathogens.  This means that babies have to generate a full immune

response to every pathogen they encounter. Each immune response takes about 10 days to

generate.  This is where maternal antibody can be important when present: It will help to protect

an infant if they are exposed to a pathogen in those first 10 days.  Unlike other animals (such as

ruminants) which rely mainly on passive transfer of maternal antibodies in breast milk, humans

receive most of their maternal antibodies through placental transfer of IgG.  However, there will

still be some antibodies transferred in breast milk, but the levels are much lower.  In addition

human babies don’t have a porous stomach (like calves do) in order to absorb the antibody. 

Therefore most of the antibody in breast milk will work in protecting pathogens crossing the oral

cavity.

Function Difference during infancy

Implications

Non Specific immunity Phagocytes cannot migrate towards infectious sites, although their bactericidal (killing) activity is normal.

Slow response to infection

Cytokine production Poor production of cytokines, in particular Th1 cytokines such as interferon gamma by T-cells.

Impaired responses of other cell populations that rely on their functions such as natural killer cells.

Natural killer T cell cytotoxicity (killing)

Is incomplete. These abnormalities are probably caused by immaturity in cytokine production of T cells and monocytes.

Inefficient killing of viruses

Complement system Develops progressively during the first year of life

Inefficient phagocytosis

Specific immunity (T-cells and B-cells)

Develops early in prenatal life T and B cells first appear in key organs from an early point in fetal development:

Bone marrow (8-10 weeks)

Thymus (8 weeks)  Spleen (8 weeks)  Lymph nodes (11

weeks) Appendix (11 weeks) Tonsils (14 weeks

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

IgG sub group not produced until the second year of life

Relative naivety of T and B cells mean primary immune response is relatively inefficient accounting for the particular susceptibility of newborns, especially premature babies, to bacterial and viral infections. Repeated antigenic stimulation leads to the complete maturation of specific immunity during the first few years of life. .

 

Immunoglobulin (Ig or antibody) production

Impaired production of some isotypes. Low serum IgM, IgA and IgE. IgG mostly of maternal origin.

Inability to respond to polysaccharide encapsulated bacteria such as meningococcal and pneumococcal until about 2 years of age.    Inability to respond to polysaccharide vaccines

Maternal antibody protection from placenta

IgG against some infectious organism’s crosses the placenta. Wanes during first year of life.

Gives protection against some infections that mother exposed or immunised against including measles and meningococcal disease. Can interfere with vaccines such as MMR.Little or no protection against other diseases such as whooping cough.

Maternal protection from breast milk

Mostly IgA Provides additional protection against gut microbes, less effective against respiratory infections

The developing immune system before and after birth

Maternal

The immune system is designed to recognize ‘self’ versus ‘non self’.  This means our

own immune system can recognize our own cells as being safe and anything else as being a

threat.  Obviously this has implications in pregnancy, where a developing fetus will be

expressing antigens from the father.  Therefore during pregnancy modifications occur in the

maternal immune system at many levels. These changes are necessary to ensure a successful

pregnancy.  In the absence of such changes the mother’s immune system would recognize the

fetus as foreign (like a pathogen) and reject it.  Potentially dangerous T-cell responses are down

regulated (reduced) and some aspects of the non-specific immune system are activated.  As

previously mentioned, at this time specific IgG antibody passes from the mother through the

placenta to the developing fetus providing it with temporary protection against some of the

infections that the mother has been exposed to or vaccinated against.  This gives opportunities to

provide newborns with transient protection against some diseases.

Infant

The infant’s immune system is relatively complete at birth.  It is clear that the IgG

antibodies received from mother are important for the protection of the infant during the first few

months of life while the infant is starting to develop its own repertoire.  Passive transient

protection by IgA against many common illnesses is also provided to the infant in breast milk.  

Mother’s milk provides IgA against a wide range of microbes that the mother has had in her gut.

Breast milk has also been shown to assist in the development of the infant’s own immune

system.  There is some, although weak, evidence to show that breastfed infants respond better to

some vaccines.  The major impetus however for the expansion of lymphocytes (B and T cells) is

the exposure to microbes which colonize the gut during birth.

Premature and low birth weight infants are at increased risk of experiencing complications of

vaccine preventable diseases and although the immunogenicity of some vaccines may be

decreased in the smallest preterm infants, the antibody concentrations achieved are usually

protective.

Φ BOOK-BASED PATHOPHYSIOLOGY

Schematic Diagram (Flow Chart)

- Pathophysiology

-Symptoms

-Lab tests

-Treatment

Synthesis of the Disease

Neonatal sepsis may be categorized as early or late onset. Eighty-five percent of

newborns with early-onset infection present within 24 hours, 5% present at 24-48 hours, and a

smaller percentage of patients present between 48 hours and 6 days of life. Onset is most rapid in

premature neonates. Early-onset sepsis syndrome is associated with acquisition of

microorganisms from the mother. Transplacental infection or an ascending infection from the

cervix may be caused by organisms that colonize in the mother's genitourinary tract, with

acquisition of the microbe by passage through a colonized birth canal at delivery. The

microorganisms most commonly associated with early-onset infection include group B

Streptococcus (GBS), Escherichia coli, Haemophilus influenzae, and Listeria monocytogenes.

Late-onset sepsis syndrome occurs at 7-90 days of life and is acquired from the

caregiving environment. Organisms that have been implicated in causing late-onset sepsis

syndrome include coagulase-negative staphylococci, Staphylococcus aureus, E coli, Klebsiella,

Pseudomonas, Enterobacter, Candida, GBS, Serratia, Acinetobacter, and anaerobes. The

infant's skin, respiratory tract, conjunctivae, gastrointestinal tract, and umbilicus may become

colonized from the environment, leading to the possibility of late-onset sepsis from invasive

microorganisms. Vectors for such colonization may include vascular or urinary catheters, other

indwelling lines, or contact from caregivers with bacterial colonization.

Risk Factors

The most common risk factors associated with early-onset neonatal sepsis include

maternal GBS colonization (especially if untreated during labor), premature rupture of

membranes (PROM), preterm rupture of membranes, prolonged rupture of membranes,

prematurity, maternal urinary tract infection, and chorioamnionitis.

Risk factors also associated with early-onset neonatal sepsis include low Apgar score (<6

at 1 or 5 min), maternal fever greater than 38°C, maternal urinary tract infection, poor prenatal

care, poor maternal nutrition, low socioeconomic status, recurrent abortion, maternal substance

abuse, low birth weight, difficult delivery, birth asphyxia, meconium staining, and congenital

anomalies. Risk factors implicated in neonatal sepsis reflect the stress and illness of the fetus at

delivery, as well as the hazardous uterine environment surrounding the fetus before delivery.

Late onset sepsis is associated with the following risk factors: prematurity, central venous

catheterization (duration of >10 d), nasal cannula continuous positive airway pressure use, H2

blocker/proton pump inhibitor use, and gastrointestinal tract pathology.

Race- Black infants have an increased incidence of GBS disease and late-onset sepsis. This is

observed even after controlling for risk factors of low birth weight and decreased maternal age.

Sex- The incidence of bacterial sepsis and meningitis, especially for gram-negative enteric

bacilli, is higher in males than in females.

Age- Premature infants have an increased incidence of sepsis. The incidence of sepsis is

significantly higher in infants with very low birth weight (<1000 g), at 26 per 1000 live births,

than in infants with a birth weight of 1000-2000 g, at 8-9 per 1000 live births. The risk for death

or meningitis from sepsis is higher in infants with low birth weight than in full-term neonates.

Signs and Symptoms

The clinical signs of neonatal sepsis are nonspecific and are associated with characteristics of the

causative organism and the body's response to the invasion. These nonspecific clinical signs of

early sepsis syndrome are also associated with other neonatal diseases, such as respiratory

distress syndrome (RDS), metabolic disorders, intracranial hemorrhage, and a traumatic delivery.

Given the nonspecific nature of these signs, providing treatment for suspected neonatal sepsis

while excluding other disease processes is prudent.

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

pulmonary hypertension, decreased cardiac output, and hypoxemia may occur. These

cardiopulmonary disturbances may be due to the activity of granulocyte-derived

biochemical mediators, such as hydroxyl radicals and thromboxane B2, an arachidonic

acid metabolite. These biochemical agents have vasoconstrictive actions that result in

pulmonary hypertension when released in pulmonary tissue. A toxin derived from the

polysaccharide capsule of type III Streptococcus has also been shown to cause pulmonary

hypertension. The early phase of pulmonary hypertension is followed by further

progressive decreases in cardiac output with bradycardia and systemic hypotension. The

infant manifests overt shock with pallor, poor capillary perfusion, and edema. These late

signs of shock are indicative of severe compromise and are highly associated with

mortality.

Metabolic signs: Hypoglycemia, hyperglycemia, metabolic acidosis, and jaundice all are

metabolic signs that commonly accompany neonatal sepsis syndrome. The infant has an

increased glucose requirement because of sepsis. The infant may also have impaired

nutrition from a diminished energy intake. Metabolic acidosis is due to a conversion to

anaerobic metabolism with the production of lactic acid. When infants are hypothermic

or they are not kept in a neutral thermal environment, efforts to regulate body

temperature can cause metabolic acidosis. Jaundice occurs in response to decreased

hepatic glucuronidation caused by both hepatic dysfunction and increased erythrocyte

destruction.

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

primarily associated with GBS (36%), E coli (31%), and Listeria species (5-10%)

infections, although other organisms such as S pneumoniae, S aureus, Staphylococcus

epidermis, H influenzae, and species of Pseudomonas,

Φ CLIENT-BASED PATHOPHYSIOLOGY

Schematic Diagram (Flow Chart)

- Pathophysiology

-Symptoms

-Lab tests

-Treatment

Synthesis of the Disease

As for Baby Boy S, he had an early-onset neonatal sepsis. A type of sepsis acquired from the

mother and/or before delivery. Early-onset neonatal sepsis most often appears within 24 hours of

birth.

Risk Factors of Baby Boy S includes

Male- it is said that neonatal sepsis is common to male infants than female.

Maternal UTI- baby boy S’s mother had UTI during the second trimester

Signs and Symptoms

The patient experienced:

Continuous vomiting during the first 24 hours of life

Clinical Signs includes:

Increased WBC count of 25.8 g/L

Results in 09-09-09

Normal value of 4.3-10.0 g/L

Increased hematocrit count of 63.0

Results in 09-09-09

Normal value of 40.0-54.0 for males

VI. THE PATIENT AND HIS CARE1. Medical ManagementA. IVF

IVF Date OrderedDate

Performed

General Description

Indications Client’s Response

D10W 500cc x 8 ugtts/min

Sept. 9, 200912:15 a.m.

This medication is a solution given by vein (through an IV). It is used to supply water and calories to the body. It is also used as a mixing solution (diluent) for other IV medications. Dextrose is a natural sugar found in the body and serves as a major energy

IV solutions containing dextrose are indicated for parenteral replenishment of fluid and minimal carbohydrate calories as required by the clinical condition of the patient. It is also use as a

the client adhered well and did not manifest for any side effects

source. When used as an energy source, dextrose allows the body to preserve its muscle mass.

mixing solution for other IV medication.

Nursing ResponsibilitiesPrior:

Verify doctor’s order.

Know the type, amount, and indication of IV therapy

Prepare for the IV infusion set.

Clean the insertion site.

During:

Do hand washing

Open and prepare the infusion set

Do the IV insertion procedure

Dress and label the venipunctures site

After:

Label the IV tubing with the date and time of attachment and initials of the nurse.

Regulate IV.

Observe for potential complication.

Document relevant data and record the start of the infusion on the client’s chart.

Φ OGT

Medical Manageme

nt

Date OrderedDate

Performed

General Description

Indications Client’s Response

OGT Sept. 10, 200912:30 a.m.

Passing a rubber/plastic tube via mouth

To prevent vomiting with resultant aspiration of gastric contents

the client adhered well and did not manifest for any side effects

Nursing Responsibilities

Prior:

Verify doctor’s order.

Inform the SO.

Explain the purpose of OGT.

Practice strict asepsis.

During:

Do hand washing.

Prepare the materials needed for the procedure.

After:

Check for the patency.

B. Drugs

Generic NameBrand Name

Date Ordered/

Date Taken

Route of administration

Dosage and frequency and Administration

General Action

Client’s response

Generic Name:Ampicillin

Brand Name:Ampicin

Sept. 9, 2009 IV 100mg q 12 Inhibits cell wall synthesis during bacterial multiplication.

Client responded well and had no adverse reaction to drug.

Generic NameBrand Name

Date Ordered/

Date Taken

Route of administration

Dosage and frequency and Administration

General Action

Client’s response

Generic Name:Amikacin Sulfate

Brand Name:Amikin

Sept. 9, 2009 IV 15mg q 12 Inhibits protein synthesis by binding directly to the 30S ribosomal subunit; bactericidal.

A reduction in neutrophils has been noted.

Nursing Responsibilities

Prior:

Check for the doctor’s order and medication chart

Prepare materials needed

Before giving drug ask the patient about allergic reactions to certain drugs such as

penicillin. A negative history of the drug allergy is not a guarantee against a future

allergic reaction.

Do skin testing

Obtain specimen for culture and sensitivity test before giving first dose. Therapy may

begin pending results.

During:

Remember the 10 R’s in giving medications.

After:

Tell the patient/ SO to take the entire quantity of the drug exactly as prescribed even after

the patient feels well.

Encouraged patient to increase fluid intake

Therapy continuous for 7 to 10 days. If no response occur after 3 to 5 days stop the

therapy and obtain new specimens for culture and sensitivity.

Watch signs and symptoms of super infection (esp. Upper Respiratory Tract) such as

continued fever, chills and increase pulse rate.

Inform patient to notify prescriber if rash, fever or chills develop. A rash is a most

common allergic reaction.

C. DietType of Diet Date Ordered General

DescriptionIndication Client’s

ResponseNPO Sept. 9, 2009

11:25 p.m.Restriction to take food via oral route.

To prevent aspiration.

Patient did not receive anything by mouth.

Nursing ResponsibilitiesPrior:

Check the doctor’s order.

Check the right client.

Make sure that the diet is properly instructed.

During:

Monitor if the SO complies with the diet given for the patient.

After:

Assess for the patient’s condition.

VII. NURSING CARE PLAN

Problem no.1 NUTRITIONAL IMBALANCE: LESS THAN BODY REQUIREMENTS

Assessment Nursing Diagnosis

Scientific Explanation

Objectives Nursing Interventions

Rationale Expected Outcome

S> Ø

O> Patient

may manifest:

> vomiting

> poor muscle

tone

> body

weakness

>loss of weight

Imbalanced nutrition less than body requirement related to inability to ingest or digest food or nutrients

The patient’s intake of nutrients is insufficient to meet the body’s metabolic demands. The body then reacts to the low nutrient synthesis thus compensatory mechanisms are activated such as decrease in activity, weight loss

After 3 hours of nursing interventions, the SO will verbalize understanding of causative factors when known and necessary interventions.

>Monitor and record vital signs

>Monitor weight

>Assist in developing individualized regimen

>To provide comparative baseline

>To monitor progression of condition

>To correct or control underlying factors

After 3 hours of nursing interventions, the SO will verbalize understanding of causative factors when known and necessary interventions.

Problem no. 2 HYPERTHERMIA

Assessment Nursing Diagnosis

Scientific Explanation

Goal/Expected Outcome

Interventions Rationale Evaluation

S> Ø

O> WBC is increased, a total of 25.8 wherein the normal is 4.3-10.0

>skin is warm to touch

Hyperthermia In sepsis, it implies the presence of an infection of the blood caused by rapidly multiplying microorganisms or toxins which can result to hyperthermia as a defense mechanism of the body.

After 1 hour of nursing interventions, thepatient’s SO will be able to identify underlying cause/contributing factors and importance of the treatments, as well as signs and symptoms requiring further intervention.

>Identify underlying cause

> Monitor sources of fluid loss

>Monitor laboratory studies.

>Identify factors that the SO can control (if any)

>Discuss importance of adequate fluid intake and treatments.

>To know what are the causes of such condition.

>To be able to identify if there is dehydration and excessive fluid loss

>To monitor the status of the client

>To protect the cliet from any factor which may be hazardous to the client

>For the SO to know the importance of preventing dehydration to occur and the ways on how to treat the client.

The patients’ SO had identified underlying cause and cotributing factors as well as the importance of the treatments.

Problem no. 3 INTERRUPTED BREAST FEEDING

Assessment Nursing Diagnosis

Scientific Explanation

Planning Intervention Rationale Expected

OutcomeS- Ø

O:-The newborn is diagnosed with a certain disease (Sepsis)- The newborn was separated from his mother- The mother was unable to provide breast milk to her newborn

Interrupted breastfeeding related to neonate’s present illness as evidenced by separation of mother to infant

Since the neonate is diagnosed for having a neonatal sepsis, the baby got separated from his mother and placed on a private room separate from her mother. Interrupted breastfeeding develops since the mother is unable to breast fed the baby continuously due to their separation.

After 2hours of nursing intervention and health teachings the mother will identify and demonstrate techniques to sustain lactation until breastfeeding is initiated

>Assess mother’s perception and knowledge about breastfeeding and extent of instruction that has been given.

>Give emotional support to mother and accept decision regarding cessation/ continuation of breast feeding.

>Demonstrate use of manual piston-type breast pump.

>Review techniques for storage/use of expressed breast milk

>To know what the mother already knows and needed to know.

>To assist mother to maintain breastfeeding as desired.

>Aid in feeding the neonate with breast milk without the mother breastfeeding the infant.

>To provide optimal nutrition and promote continuation of breastfeeding process

The mother was able to identify and demonstrate techniques to sustain lactation and identify techniques on how to provide the newborn with breast milk.

>Determine if a routine visiting schedule or advance warning can be provided

>Provide privacy, calm surroundings when mother breast feeds.

>Recommend for infant sucking on a regular basis

>Encourage mother to obtain adequate rest, maintain fluid and nutritional intake, and schedule breast pumping every 3 hours while awake

>So that infant will be hungry/ ready to feed

>To promote successful infant feeding

>Reinforces that feeding time is pleasurable and enhances digestion.

>To sustain adequate milk production and breast feeding process

Problem no. 4 KNOWLEDGE DEFICITCues Nursing

DiagnosisScientific Explanation Objective Nursing

InterventionsRationale Evaluation

S>“May kinalaman ba ang laging pag-iyak sa kondisyon ng baby ko ngayon?”O>-frequently ask questions.

Knowledge deficit related to unfamiliarity with the information resources.

Neonatal sepsis is caused by an infection detected during or after the delivery. In this case, the patient was identified to having neonatal sepsis after two days. Transplacental infection or an ascending infection from the cervix may be caused by organisms that colonize in the mother's genitourinary tract, with acquisition of the microbe by passage through a colonized birth canal at delivery. The microorganisms most commonly associated with early-onset infection include group B Streptococcus (GBS), Escherichia coli, Haemophilus influenzae, and Listeria monocytogenes.Whle the depression fetl by the mother was caused by hormonal changes during the pregnancy.

After 2 hours of NPI the patients’ SO will verbalize understanding of the condition, disease process and treatment.

>Determine client’s most urgent need from both client’s and nurse’s viewpoint.

>Provide situation relevant to the situation.

>Discuss client’s perception of need information related to client’s personal desires, needs, values, and beliefs.State objectives clearly in learner’s term.

>Begin with the information the client already knows and move to what the client does not know progressing to simple to complex.

>This may differ and require adjustment in teaching plan.

>Prevent overload.

>In order for the client to feel competent and respected.

>Can arouse interest/ limit sense of being overwhelmed.

The patients’ SO verbalized understanding of the disease process and was able to clarify her concern.

Problem no. 5 RISK FOR IMPAIRED PARENT/NEONATE ATTACHMENT

Assessment Nursing Diagnosis

Scientific Explanation

Planning Intervention Rationale Expected Outcome

S- Ø

O:-The newborn is diagnosed with a certain disease (Sepsis)- the newborn is hospitalized- The newborn is separated from his parents

Risk for Impaired parent/ neonates Attachment related to neonates physical illness and hospitalization.

Due to the newborn’s physical illness and hospitalization, the parents may have fear on how to handle their baby since the baby is on its fragile state and needed extra care. And since he is the 1st child hospitalized in their family, the parents might still be unsure on how to take care of the baby.

After 3 hours of nursing intervention and health teachings the mother will identify and demonstrate techniques to enhance behavioral organization of the neonate

.

>Interview parents, noting their perception of situation and individual concerns

>Educate parents regarding child growth and development, addressing parental perceptions

> Involve parents in activities with the newborn that they can accomplish successfully >Recognize and provide positive feedback for nurturant and protective parenting behaviors

>To know what the parents feelings about the situation.

>Helps clarify realistic expectations

>Enhances self-concept

>Reinforces continuation of desired behaviors

The parents will be able to have a mutually satisfying interactions with their newborn.

VIII. DISCHARGE PLAN

Φ METHOD

M - Medication

- ampicillin 100mg IV q12

- Amikin SO4 15mg IV q12

E - Exercise

- Stressed that the baby sleeps most often times

T - Treatment

- Stressed importance of complying with the medications

H - Health Teachings

- Instructed Mother to bring back the baby in the hospital for his medication

- Instructed Mother on the time the medication will be given

- Instructed Mother for the drug’s side effect which includes constipation;

diarrhea; dizziness; headache; indigestion; nausea; pain, swelling, or redness at

the injection site; sleeplessness; vomiting.

- Instructed Mother of the importance of breastfeeding

- Instructed Mother on Proper Breastfeeding

- Instructed Mother to expose the baby to sunlight at 6:00 am to 10:00 am

- Instructed Mother that formula milk is only good for 4 hours

- Instructed Mother on strict aspiration precaution

- Instructed Mother to burped the baby after each feedings

- Instructed Mother to bathe daily their Baby

D - Diet

- Instructed Mother to feed the baby as tolerated with strict aspiration precaution

IX. LEARNING DERIVED FROM THE STUDY

At the end, the researcher realized that there is always something new to learn that could

help you be a better healthcare provider. It is indeed true that learning never stops. And with the

current trends that we have, it is part of the nurses’ responsibility to keep themselves abreast with

the new trends.

With the study made by the researcher, she had able to identify what neonatal sepsis is,

its risk factors, signs and symptoms of the disease, diagnostic procedure that can be done to

diagnose the disease, its medical treatment, prevention and nursing care plan specific for the

disease. With the knowledge learned during the study, the researcher can be able to promote

wellness by health teachings to mother and to persons unfamiliar with the disease and prevention

of the disease.

During the course of the study, the importance of proper infection control and hand

washing was found out for the prevention in the spread of infection especially in the hospital.

The researcher found out that proper knowledge of the staff regarding the disease

condition of a patient with neonatal sepsis is vital for the betterment of her service as one of the

providers of care on a hospital.

This case study has also given the researcher the great opportunity to share his personal

experience in the care of a patient with neonatal sepsis.

CONCLUSIONSBased on the researchers experience neonatal sepsis is not a very crucial case although

there are lots of reported cases with severe neonatal sepsis. Onset can be prevented and be

treated especially in the case of Late-onset neonatal sepsis. Prompt treatment and adequate

knowledge about the disease process is needed so that complications will not arise. On the other

hand your care is not only confined to the patient but extends significantly to the family.

Knowledge and appropriate skills are part of the tools of the nurse in order to be effective in

handling a patient with neonatal sepsis. Having a clear understanding of the disease and its

process, with consideration of the feelings and beliefs of the parents, most especially, will aid the

nurse in skillfully meeting patient’s needs.

RECOMMENDATIONSAt the course of the study, the researcher had found out that an in-depth knowledge about

the disease process will benefit not only the patient and its family but also the nurse and the

medical staff as well. The following is a list of recommendations made by the researcher:

For the Nurses: An in-depth knowledge should be acquired regarding the disease condition so

that proper treatment and prevention can be implemented.

Nurses must stress the need for good prenatal care and emphasize on parents,

the value of regular check-ups at well-baby clinics.

Proper infection control especially strict hand washing should be implemented

in the hospital because it is the most effective method in controlling the spread of

infection from staff to patient.

For the hospital:

Sterility or cleanliness of hospital equipment should be maintained

Seminars about infection control should be conducted so that hospital staff will be

knowledgeable in the prevention of infection from spreading.

For the patients care:

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

X. REFERENCES http://www.immune.org.nz/?t=899 http://www.doh.gov.ph/ospitalngpalawan/index.php?

option=com_content&view=article&id=18&Itemid=24 Doenges,M.E.et.al.Nurses’ pocket guide.2008.F.A. DAVIS COMPANY Johnson, J.Y.2008. Textbook of Medical-surgical nursing. 11th edition. Lippincott Williams &

Wilkins