PAMANTASAN ng LUNGSOD ng MARIKINA J.P. Rizal St. Conception Uno, Marikina City _______________ NEONATAL SEPSIS ______________________
A Group Case Study Submitted to: Mrs.Vilma S. Cordova, RN In Partial Fulfillment Of the Course NCM 101 RLE “ACMH” Antipolo City Medical Hospital GENERAL WARD 2:00-10:00 PM Submitted By: Gomez, Richerylle C. Gutierrez, Floren Angelie V. Hernandez, Richelle Joy T. Hussin, Johanna Fariza T. Ison, Sheila May H. Javier, Jayson R. Jayme, Carolyn Eleanor F. Labide, Prima Encar T. Ladjahasan, Irish Princess A. Lagumbay, Joanne B. Lardillo, Catherine A. Lomocso, Jamielyn Kate B.
Table of Contents
Pages I. Introduction II. Goals III. Patient’s Profile IV. Anatomy and Physiology V. Pathophysiology VI. Physical Assessment VII. Diagnostic and Laboratory Results VIII. Drug Study IX. Nursing Care Plan X. Discharge Planning
Introduction Neonatal sepsis, sepsis neonatorum and neonatal septicemia are terms that have been used to describe the systemic response to infection in the new born infant. There is a little agreement on the proper use of terms i.e. whether it should be restricted to bacterial infections, positive blood cultures, or severity of illness. Currently, there is considerable discussion of the appropriate definition of sepsis in the critical care literature. This is a result of an explosion of information on the pathogenesis of sepsis and the availability of new potentially therapeutic agents. e.g. monoclonal antibodies to endotoxin and tumor necrosis factor (TNF) which can alter the lethal outcome of sepsis in animal experiments. To evaluate and utilize these new therapeutic modalities appropriately “sepsis” requires a more rigorous definition. In adults, the term “systemic inflammatory response syndrome (SIRS) is used to describe a clinical syndrome characterized by two or more of the following: (1) fever or hypothermia (2) tachycardia (3) tachypnea and (4) abnormal white blood cells (WBC) or increase in immature forms. SIRS maybe a result of trauma, hemorrhagic shock, other causes of ischemia, pancreatitis, or immunologic injury. When it is a result of infection, it is termed sepsis. These criteria have not been established in infants and children and are unlikely to be applicable to the newborn infant. Nevertheless, the concept of sepsis as a syndrome caused by a metabolic and hemodynamic consequences of infection is logical and important. In the future, the definition of sepsis in the new born infant and child will become more precise. At these time criteria for neonatal sepsis should include documentation of infection in a new born infant with a serious systemic illness in which noninfectious explanations for the abnormal pathophysiology state are excluded or unlikely. Serious systemic illness in the new born infant may be caused by perinatal asphyxia, respiratory tract, cardiac, metabolic, neurologic, hematologic disease. Sepsis occurs in a small proportion of all neonatal infections. Bacteria and Candida are the usual etiologic agents, but viruses, and, rarely protozoa may also caused sepsis. Blood cultures may be negative, increasing the difficulty in establishing infection
etiologically. Finally infections with or without sepsis may be present concurrently with a non infectious illness in the new born infant, child or adult. References: Chapter 98 Neonatal sepsis and meningitis pages 528-529 Part XII- infections of the Neonatal Infants: Section 2 Clinical Syndromes Textbook of Pediatrics 15th Edition By Behrman, Kliegman, Arvin
Goal
General Goal: To be knowledgeable about the nature of Neonatal Sepsis, its diagnosis, its treatment and nursing responsibilities
Specific Goal: To be familiar with the etiology of the disease To be aware of the signs and symptoms To know the complications of the disease To be knowledgeable on how to prevent the disease To know the treatment To know the difference of the disease from the normal laboratory values To assure that nursing implementation must be given
Anatomy and Physiology
The inflammatory response is a complex sequence of events involving many of the chemical mediation and cells of innate immunity. Tissue injury, regardless of the type, can cause inflammation, trauma, burns, chemicals, or infections can damage tissue, resulting inflammation. A bacterial infection is use here to illustrate an inflammatory response. The bacteria, or damage to tissues, cause the release or activation of chemical mediators, such as: 1
Histamine,
2
Complement kinins,
3
Eicosanoids. (Ex. Prostaglandins and Leucotriens).
The chemical mediators produce several effects: 1. Vasodilation, which increases blood flow and bring phagocytes and other white blood cells to the area. 2. Chemotactic attraction of phagocytes, which leave the blood and enter the tissue. 3. Increase vascular permeability, which allows fibrinogen and complement to enter the tissue from the blood. Fibrinogen is converted to fibrin, which prevent the spread of infection by walling off the infected area. Complement further enhances the inflammatory response and attracts additional phagocytes. The process of releasing chemical mediators and attracting phagocytes and other white blood cells continues until the bacteria
are
destroyed.
Phagocytes,
such
as
neutrophils
and
macrophages, remove microorganism and dead tissue, and the damaged tissue are repaired.
INFLAMMATORY RESPONSE
Bacteria enter Tissue
Tissue damage bacteria
Chemical mediators are released
Increased blood flow
Chemotaxis
Increased Vascular permeability
Increased number of WBC & chemical mediators at site of tissue damage
Bacteria are contained, destroyed & phagocitized
Bacteria gone
Bacteria remain
Tissue repair
Additional chemical mediators activated
Non-predisposing factors Age 1 ½ months Male
Predisposing Factors: Immunocompromised Environment Prolonged use of intravascular catheter Associated illness Prolonged hospitalization Contaminated equipment
Invasion of bacteria
Bacteria goes to circulation
Inflammatory Response
Release of exogenous pyrogens
The body release anti-inflammatory mediators
↑ WBC (neutrophils & macrophage)
Vascular response
Release of endogenous pyrogens
Redness and heat
Reset of hypothalamic thermostat
Pain
Fever (Temp. 38°C) Blood vessels constrict to prevent loss of body heat and cause chills
Patient’s Profile Name: EGLC Age:1 ½ mos. Gender: male Address: B-15 L-17 Door E Jackson Street Broadway Pines Subdivision Manggahan Date of birth: June 10, 2009 Nationality: Filipino Religion: Roman Catholic Civil status: N/A Date of admission: July 27, 2009 Time of admission: 5:04 pm Place of admission: Antipolo City Medical Hospital Admitting diagnosis: t/c neonatal sepsis a.1 Chief Complain: fever a.2 Present Illness Baby Elijah has an admitting diagnosis of T/C neonatal sepsis. The baby is experiencing fever for almost 3 days and rashes can be seen on his cheeks and partially n his shoulders. a.3 Family History According to Mrs. Clavio they do have a history of hypertension, DM, asthma and allergies while on her husband’s side its hypertension only. a.4 Medical History If and if the baby is experiencing a fever and colds the parents immediately bring him to the hospital for further check-ups and examination. And give the baby some prescribed medications given by the physician.
a.5 Social History Mr. and Mrs. Clavio live independently so they are considered as a nuclear family. Mr. Clavio works as a nurse while Mrs. Clavio as a bank teller. Both parents are working so either the relatives on mother side or father side are the one taking care of the baby. Although sometimes they find time taking care of their own baby. Furthermore, both parents do have their own vices. Mr. Clavio a smoker and alcohol drinker while Mrs. Clavio is only a smoker.
Diagnostic or Laboratory Procedure
Date Ordered Indication or
and Date
Purpose
Results were
To identifying the need
Complete Blood Count (CBC)
released July 27, 2009
Normal
Results
WBC- 11.5
Values - 5-10 x10 9/L
for BT, effectiveness of BT and if there is a
Analysis and Interpretation of Results - The results indicates the presence of
Hgb- 213
presence of infection
- 140-180 g/L
infection as manifested by an
Hct- 0.64
- 0.4-0.54 RBC- 7.5
- 5.5-6.5 x 10 12/L PC- 130
increase in WBC count - RBC, hemoglobin and hematocrit are
- 150-350 x 10 g/L
elevated and may probably indicates presence of dehydration.
Diagnostic or Laboratory Procedure
Date Ordered Indication or
and Date
Purpose
Results were
This was done to the
Urinalysis
released July 27, 2009
Results
Color: Yellow
Normal Values - Clear
patient as a screening for abnormalities within
problems that may manifest through the urinary tract.
Interpretation of Results - The color, appearance, and
Appearance: Clear
- Clear
the urinary system as well as for system
Analysis and
specific gravity are within normal
Specific Gravity: 1.005 - 1.005-1.030 Pus Cells: 0-2/HPF
- None
Red Cells: 0-1/HPF
- None
limits. Presence of Pus cells, Red cells, epithelial cells and mucus threads indicates presence of infection.
Epithelial Cells: Few
- None
Mucus Threads: Light
- None
Albumin: Negative
- Negative
Glucose: Negative
- Negative
Diagnostic or Laboratory Procedure
Date Ordered Indication or
and Date
Purpose
Results were released July 27, 2009
To identifying the need
Blood Urea Nitrogen (BUN)
Normal
Results
Values
8.1 mg/dl
- 7 - 18 mg/dl
Analysis and Interpretation of Results - The result is
for BT, effectiveness of
within the normal
BT and if there is a
limit
presence of infection
To measure the
July 27, 2009
45 mg/dl
-40 –60 mg/dl
- The result is
Hemogluco Test
amount of glucose in
within the normal
(HGT)
the blood right at the
limit
time of sample collection. To determine for some
July 27, 2009
- Lungs are clear.
- Normal
- The result is
Chest X-ray/
evidence of diffuse
- The intestinal gas
within the normal
Baby Gram
infiltrates and poor
pattern is within
limit
overall aeration
normal - Cardiac shadow is not enlarged.
Drug Name
Classification
Mechanism of Action
Contraindication
Adverse Reaction
Nursing Responsibility
Ampicillin
Anti-infectives
Inhibits cell wall
> Contraindicated
CNS: seizures,
> Before giving
( Apo-Ampi, Novo
synthesis during
in patients
lethargy,
drug ask patient
Ampicillin, Nu-
bacterial
hypersensitive to
hallucinations,
about allergic
Ampi)
multiplication.
drug or other
anxiety, confusion,
reaction to
penicillin.
agitation,
penicillin.
Available Forms:
> Use cautiously
depression
Capsules:
in patients with
250 mg, 500 mg
other drug
CV: vein irritation,
IV only if infection
Injection:
allergies because
thrombophlebitis
is severe and if
250 mg, 500mg
of possible cross-
1g and 2g
sensitivity and in
GI: diarrhea,
oral dose.
Oral Suspension:
those with
nausea,
.Watch for signs
125mg/5ml, 250
mononucleosis
pseudomembranous and symptoms of
mg/5ml
because of high
colitis, vomiting,
risk of
gastritis,
maculopapular
enterocolitis
> Give drug IM or
patient can’t take
rash.
hypersensitivity. > Give drug 1-2 hours before or 2-
GU: interstitial
3 hours after
nephritis,
meals.
nephropathy > Monitor sodium
HEMATOLOGIC:
level because
leukopenia,
each gram of
thrombocytopenia,
penicillin contains
anemia
2.9 mEq of sodium
OTHER: hypersensitivity
> In patient with
reaction, over
impaired renal
growth of non
function,
susceptible
decrease dosage.
organism
1. Hyperthermia Assessment
Nursing
Planning
Intervention
Rationale
Evaluation
Subjective:
Diagnosis Hyperthermia
Short-term:
1. Monitor
- To determine the After 30 minutes
“Nilalagnat ang
related to
After 30 minutes
neonate’s
need for
of Nursing
anak ko”, as
Inflammatory
of Nursing
condition.
intervention
Intervention the
verbalized by the
Process as
Intervention the
and the effective-
patient was able
mother.
evidenced by an
patient will
ness of therapy.
to maintain normal
increased in body
maintain normal
Objective:
temperature, and
body temperature
>Increased body
warm skin.
body temperature 2. Monitor Vital
- To have a
Signs
baseline data
temperature
Long Term:
>Skin warm to
After 3 days of
touch
Nursing
down the
Intervention,
>Tachypnea
Intervention,
temperature
patient was able to
>Tachycardia
patient will
> Vital Signs taken:
maintain vital signs 4. Do not share
- This would
and normal
Temp.=38.4
and normal
equipment with
prevent the
laboratory results.
RR=36
laboratory results.
other infants
spread of
PR=120
After 3 days of 3. Provide TSB
- Helps in lowering Nursing
maintain vital signs
pathogens to the
Goal is met.
infant from equipment 5. Administer
- To lowering
Anti-pyretics as
down temperature
ordered
2. Ineffective Tissue Perfusion Assessment
Nursing
Planning
Intervention
Rationale
Evaluation
Subjective:
Diagnosis Ineffective tissue
Short-term:
1. Monitor
- To determine the After 30 minutes
“Mukhang
perfusion related
After 30 minutes
neonate’s
need for
of Nursing
matamlay at iba
to impaired
of Nursing
condition.
intervention
Intervention the
ang kulay ng anak transport of
Intervention the
and the effective-
patient was able
ko”, as verbalized
oxygen across
patient will
ness of therapy.
to demonstrate
by the mother.
alveolar and on
demonstrate
capillary
increased
2. Monitor Vital
- To have a
membrane
perfusion.
Signs
baseline data
> skin or
Long Term:
3. Assess skin for
- To assess for
After 3 days of
temperature
After 3 days of
changes in color,
compensatory
Nursing
changes
Nursing
temperature and
mechanisms of
Intervention,
> body weakness
Intervention,
moisture
vasodilation
patient was able to
>Vital Signs taken:
patient will
Temp.= 38.4
maintain adequate 4. Elevate Head of
- To promote
RR= 36
perfusion.
Bed
circulation
5. Elevate
- To reduce
Objective:
increased tissue perfusion.
> edema
PR= 120
maintain adequate tissue perfusion. Goal is met.
affected
edema
extremities with edema once in a while 6. Provide a quiet,
- Conserves
restful
energy and
atmosphere
lowers O2 demand
7. Administer
- To maximize O2
oxygen as ordered
availability for cellular uptake
3. Risk for Impaired parent/ neonate’s attachment Assessment
Nursing
Planning
Intervention
Rationale
Evaluation
Subjective:
Diagnosis Risk for Impaired
Short-term:
1. Interview
- To know what
After 30 minutes
“Nahiwalay sa
parent/ neonates
After 30 minutes
parents, noting
the parents
of Nursing
akin ang anak ko
attachment
of Nursing
their perception of
feelings about the
Intervention and
dahil kaylangan
related to
Intervention and
situation and
situation..
Health Teaching,
siyang dalhin sa
neonates physical
Health Teaching,
individual
the mother was
ospital”, as
illness and
the mother will
concerns
able to identify
verbalized by the
hospitalization.
identify and
mother.
and demonstrate
demonstrate
2. Educate
- Helps clarify
technique to
technique to
parents regarding
realistic
enhance
Objective:
enhance
child growth and
expectations
behavioral
> the neonate is
behavioral
development,
separated from his
organization of the addressing
parents
neonate.
> Vital Signs taken:
organization of the neonate.
parental perceptions
Temp.= 38.4
Long Term:
The parents shall
RR= 36
After discharge, the 3. Involve parents
- Enhances self-
be able to have a
PR= 120
parents will be able in activities with
concept
mutually satisfying
to have a mutually
the newborn that
interactions with
satisfying
they can
their newborn.
interactions with
accomplish
their newborn.
successfully
Goal is met.
4. Recognize and
- Reinforces
provide positive
continuation of
feedback for
desired behaviors
protective parenting behaviors
Discharge Planning Name of Person Concern: Mr. Glenn / Mrs Clavio Name of Patient: EGLC Diet: Breast milk or formulated milk Medicine: Paracetamol (Acetaminophen) •
If temperature is 37.8 above
•
Should take with food or milk to decrease GI upset
•
Tablet can be taken submerged in 10 ml hot water and added 10 ml of honey
Treatment: Check for the following: •
CBC
•
Urinalysis
•
Fecalysis
Things to do Before Treatment: •
Check urine for occult of blood
•
Check Intake and Output such as: 1. Fluid/ liquid 2. Urine 3. BM 4. Vomit
•
Check record of medicine intake per day
•
Check record of vital sign such as: 1. Temperature 2. Pulmonary Rate 3. Respiratory Rate
Health Teaching: •
Teach TSB in Start of fever when the patient temp. reach 37.7 above
•
Warn not to combine products containing acetaminophen many of which OTC. Read labels on all OTC products.
•
Take Paracetamol with food or milk to reduce GI upset
•
Monitor Vital sign vital sign such as: 1. Temperature 2. Pulmonary Rate 3. Respiratory Rate
And report any abnormalities such as: •
Low Temperature- may be symptoms of chronic poisoning
•
Fast, weak pulse
•
Record Intake and Output 1. Fluid/ liquid 2. Urine 3. BM 4. Vomit
Activity: •
The infant with temperature instability needs thermoregulatory support with a radiant warmer or incubator. Once the infant is stable from a cardiopulmonary standpoint, parental contact is important.
Hygiene: •
Keep the patient neat
•
Bath
the
patient
with
hypoallergenic powder •
Oral hygiene
hypoallergenic
soap,
shampoo
and
use
•
Perinial hygiene
