I. PATIENT ASSESSMENT DATA BASE
A. GENERAL DATA
1. Patient’s Name: Baby Boy B.
2. Address: Dolores, Capas, Tarlac
3. Age: Newborn
4. Sex/Gender: Male
5. Birth Date: August 6, 2010
6. Rank in the Family: 2nd child
7. Nationality: Filipino
8. Civil Status: Single
9. Date of Admission: August 6, 2010
10. Order of Admission:
11. Attending Physician:
B. CHIEF COMPLAINT
C. HISTORY OF PRESENT ILLNESS:
Baby boy B has an admitting diagnosis of T/C neonatal sepsis. The baby is experiencing fever and rashes can be seen on his cheeks and partially in his shoulders.
PAST HEALTH HISTORY/STATUS:
1. Childhood Illnesses: Fever
2. Immunization: Hepa, Vit. K, BCG only at birth
3. Major Illnesses: No past major operation
4. Current Medications: None, not even vitamins.
5. Allergies: No allergies reported
D. FAMILY ASSESSMENT:
NAME RELATION AGE SEX OCCUPATION EDUCATIONAL ATTAINMENT 1. O. B. B Wife 26 y/o Female Housewife High School Graduate 2. L.F.B. Father 28 y/o Male Farmer High School Graduate 3. A.B.B. Eldest Son 2 y/o Male N/A N/A
E. SYSTEM’s REVIEW
1. Health Perception – Health Management Pattern
Patient is awake but merely moving.
2. Nutritional – Metabolic Pattern
Patient is only a baby and drinks only milk if not ordered NPO by the pediatrician.
3. Elimination Pattern
* Bowel movements: everyday
* Color: Dark Brown
* Odor: Foul Smell
* Consistency: Firm
* Laxative used if any: No laxatives used
* Bladder: Regularly
* Color: Yellowish
* Odor: Pungent
* Alterations if any: No Alterations
4. Activity – Exercise Pattern
_IV Feeding __IV _ Dressing __IV _Grooming
_IV Bathing __IV _ Toileting __IV _Cooking
_IV Bed Mobility __IV _Home Maintenance __IV _Others
0 – Full Care
I – Requires use of equipment
II – Requires assistance or supervision of others
III – Requires assistance or supervision of others and equipment
IV – Dependent; doesn’t participate
5. Cognitive – Perceptual Pattern
* Hearing: He is able to hear sounds with both ears and there are no discharges
* Vision: Not able to assess yet
* Sensory: He can feel soft and hard sensation.
* Learning Styles: Patient is newborn and doesn’t have learning pattern yet.
6. Sleep – Rest Pattern
* The patient sleeps all the time and only wakes up if he is hungry or he feels like uncomfortable.
F. HEREDO – FAMILIAL PATTERN
*Maternal – HPN
*Paternal – HPN
A. GENERAL SURVEY:
1. Over-all appearance and grooming: Pale in appearance has a difficulty of breathing.
2. Actual Height and Weight : 42 centimeters and 2.4 kilograms
3. Signs of distress: Pale looking
4. Posture, gait: patient is only in bed
5. Affect: flat affect.
6. Relevance and organization of thoughts: can’t assess yet
B. VITAL SIGNS
Vital Signs Baseline V/S (7:30 A.M.) Temp: 38.2°C RR: 46 breaths/min CR: 148 beats/min
C. REGIONAL EXAM
1. Hair, head, face: evenly distributed hair, normocephalic head and symmetrical face.
2. Eyes: symmetrical, pale conjunctiva
3. Nose: moist and pale in color
4. Ears: symmetrical, aligned with eyes
5. Mouth and throat: moist, dry lips and no lesions
6. Neck and lymph nodes: equal in size, no enlargement of nodules
7. Skin: pale in color
8. Nails: vascular and pale in color
9. Thorax and Lungs: palpable for vibrations
10. Cardiovascular: Heart sound is normal and no abnormal sound
11. Breast and Axilla: symmetrical and no discharges.
12. Abdomen: fair in color, umbilical area covered with OS
13. Extremities: limited range of motion
14. Genitals: Have no discharges, no foul odor
15. Rectum and anus: not assessed
16. Neurological /Cranial Nerves: not assessed
II. PERSONAL/SOCIAL HISTORY
1. Caffeine: None
2. Smoking: None
3. Alcohol: None
4. Tea: None
5. Drugs: None
B. SOCIAL AFFILIATION – no
C. RANK IN THE FAMILY – 2nd child
D. TRAVEL (within 6 months) – None
E. EDUCATIONAL ATTAINMENT: Newborn
III. ENVIRONMENTAL HISTORY
They have a simple life style, house and environment. They live by their own. They are happy yet sometimes there are arguments because of misunderstanding but it doesn’t last for long. Their neighbors are kind and they are not arguing.
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.
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:
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
VIII . Laboratory and Diagnostic Examination
Diagnostic or Laboratory Procedure Indication or Purpose Date Ordered and Date Results were released Results Normal Values Analysis and Interpretation of Results
Complete Blood Count (CBC)
To identifying the need
for BT, effectiveness of
BT and if there is a
presence of infection
August 6, 2010
-5-10 x10 9/L
– 140-180 g/L
-5.5-6.5 x 10 12/L
– 150-350 x 10 g/L
-The results indicates the
presence of infection as
manifested by an increase in WBC count
– RBC, hemoglobin and
hematocrit are elevated and may probably indicates presence of
iX. Nursing Care Plan
Assessment Nursing Diagnosis Planning Nursing Interventions Rationale Evaluation
matamlay at iba
ang kulay ng anak
ko”, as verbalized
by the mother.
> skin or
> body weakness
>Vital Signs taken:
Ineffective tissue perfusion related to impaired transport of
oxygen across alveolar and on capillary membrane
After 30 minutes of Nursing Intervention the
patient will demonstrate
1. Monitor neonate’s
2. Monitor Vital Signs
3. Assess skin for changes in color, temperature and
4. Elevate Head of Bed
5. Elevate affected extremities with edema once in a while
6. Provide a quiet, restful
7. Administer oxygen as ordered
-To determine the need for intervention and the effectiveness of therapy.
– To have a baseline data
– To assess for compensatory mechanisms of vasodilation
– To promote
– To reduce edema
– To maximize O2
After 30 minutes
patient was able
X. DRUG STUDY:
GENERIC NAME: Ampicillin
BRAND NAME: Novo-Ampicillin
DOSAGE: 50mg IVP q8hrs
MECHANISM OF ACTION SIDE EFFECTS CONTRA INDICATION ADVERSE REACTION NURSING CONSIDERATION Inhibits cell wall synthesis during bacterial multiplication
* Contraindicated in patients hypersensitive to drug or other penicillin
* Use cautiously in patients with other drug allergies because of possible cross-sensitivity and in those with mononucleosis because of high risk of maculopapular rash CNS: sei zures,
CV: vein irritation, thrombophlebitis
GI: diarrhea, nausea,
GU: interstitial nephritis, nephropathy > Before giving drug ask patient about allergic reaction to penicillin.
> Give drug IM or IV only if infection is severe and if patient can’t take oral dose. .Watch for signs and symptoms of hypersensitivity.
> Give drug 1-2 hours before or 2- 3 hours after meals.
> Monitor sodium level because each gram of penicillin contains 2.9 mEq of sodium
> In patient with impaired renal function, decrease dosage.
Panpacific University North Philippines
College of Nursing
(Tarlac Provincial Hospital)
Submitted by :
Marish G. Lambino
Ms. Psyche Antonio