NEONATAL SEPSIS ___________

NEONATAL SEPSIS

_____________________
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

Patient’s Profile

Name: EGLC
Age:1 1/2 mos.
Gender: male
Address: Iloilo City
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: IDC
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. C. 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. C live independently so they are considered as a nuclear family. Mr. C works as a nurse while Mrs. C 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. C a smoker and alcohol drinker while Mrs. C is only a smoker.

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 July 27, 2009 WBC- 11.5

Hgb- 213

Hct- 0.64

RBC- 7.5
PC- 130
– 5-10 x10 9/L
– 140-180 g/L

– 0.4-0.54

– 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 dehydration.
Diagnostic or Laboratory Procedure Indication or Purpose Date Ordered and Date Results were released Results Normal Values Analysis and Interpretation of Results
Urinalysis
This was done to the patient as a screening for abnormalities within the urinary system as well as for system problems that may manifest through the urinary tract. July 27, 2009 Color: Yellow

Appearance: Clear

Specific Gravity: 1.005

Pus Cells: 0-2/HPF

Red Cells: 0-1/HPF

Epithelial Cells: Few

Mucus Threads: Light

Albumin: Negative
Glucose: Negative – Clear

– Clear

– 1.005-1.030

– None

– None

– None

– None

– Negative
– Negative – The color, appearance, and specific gravity are within normal limits. Presence of Pus cells, Red cells, epithelial cells and mucus threads indicates presence of infection.

Diagnostic or Laboratory Procedure Indication or Purpose Date Ordered and Date Results were released Results Normal Values Analysis and Interpretation of Results
Blood Urea Nitrogen (BUN) To identifying the need for BT, effectiveness of BT and if there is a presence of infection July 27, 2009 8.1 mg/dl – 7 – 18 mg/dl – The result is within the normal limit

Hemogluco Test (HGT) To measure the amount of glucose in the blood right at the time of sample collection. July 27, 2009 45 mg/dl -40 -60 mg/dl – The result is within the normal limit

Chest X-ray/ Baby Gram To determine for some evidence of diffuse infiltrates and poor overall aeration July 27, 2009 – Lungs are clear.
– The intestinal gas pattern is within normal
– Cardiac shadow is not enlarged. – Normal – The result is within the normal limit

Drug Name Classification Mechanism of Action Contraindication Adverse Reaction Nursing Responsibility Ampicillin
( Apo-Ampi, Novo Ampicillin, Nu-Ampi)

Available Forms:
Capsules:
250 mg, 500 mg
Injection:
250 mg, 500mg
1g and 2g
Oral Suspension:
125mg/5ml, 250 mg/5ml Anti-infectives 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: seizures, lethargy, hallucinations, anxiety, confusion, agitation, depression

CV: vein irritation, thrombophlebitis

GI: diarrhea, nausea, pseudomembranous colitis, vomiting, gastritis, enterocolitis

GU: interstitial nephritis, nephropathy

HEMATOLOGIC: leukopenia, thrombocytopenia, anemia

OTHER: hypersensitivity reaction, over growth of non susceptible organism > 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.

1. Hyperthermia

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation Subjective:
“Nilalagnat ang anak ko”, as verbalized by the mother.

Objective:
>Increased body temperature
>Skin warm to touch
>Tachypnea
>Tachycardia
> Vital Signs taken:
Temp.=38.4
RR=36
PR=120
Hyperthermia related to Inflammatory Process as evidenced by an increased in body temperature, and warm skin. Short-term:
After 30 minutes of Nursing Intervention the patient will maintain normal body temperature

Long Term:
After 3 days of Nursing Intervention, patient will maintain vital signs and normal laboratory results. 1. Monitor neonate’s condition.

2. Monitor Vital Signs

3. Provide TSB

4. Do not share equipment with other infants
5. Administer
Anti-pyretics as ordered – To determine the need for intervention
and the effective-ness of therapy.

– To have a baseline data

– Helps in lowering down the temperature

– This would prevent the spread of pathogens to the infant from
equipment

– To lowering down temperature After 30 minutes of Nursing Intervention the patient was able to maintain normal body temperature
After 3 days of Nursing Intervention, patient was able to maintain vital signs and normal laboratory results.

Goal is met.

2. Ineffective Tissue Perfusion
Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation Subjective:
“Mukhang matamlay at iba ang kulay ng anak ko”, as verbalized by the mother.

Objective:
> edema
> skin or temperature changes
> body weakness
>Vital Signs taken:
Temp.= 38.4
RR= 36
PR= 120 Ineffective tissue perfusion related to impaired transport of oxygen across alveolar and on capillary membrane Short-term:
After 30 minutes of Nursing Intervention the patient will demonstrate increased perfusion.

Long Term:
After 3 days of Nursing Intervention, patient will maintain adequate perfusion. 1. Monitor neonate’s condition.

2. Monitor Vital Signs

3. Assess skin for changes in color, temperature and moisture

4. Elevate Head of Bed
5. Elevate affected extremities with edema once in a while

6. Provide a quiet, restful atmosphere
7. Administer oxygen as ordered
– To determine the need for
intervention
and the effective-ness of therapy.

– To have a baseline data

– To assess for compensatory mechanisms of vasodilation

– To promote circulation
– To reduce edema
– Conserves energy and lowers O2 demand

– To maximize O2 availability for cellular uptake After 30 minutes of Nursing Intervention the patient was able to demonstrate increased tissue perfusion.
After 3 days of Nursing Intervention, patient was able to maintain adequate tissue perfusion.

Goal is met.
3. Risk for Impaired parent/ neonate’s attachment

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation Subjective:
“Nahiwalay sa akin ang anak ko dahil kaylangan siyang dalhin sa ospital”, as verbalized by the mother.

Objective:
> the neonate is separated from his parents
> Vital Signs taken:
Temp.= 38.4
RR= 36
PR= 120 Risk for Impaired parent/ neonates attachment related to neonates physical illness and hospitalization. Short-term:
After 30 minutes of Nursing Intervention and Health Teaching, the mother will identify and demonstrate technique to enhance behavioral organization of the neonate.

Long Term:
After discharge, the parents will be able to have a mutually satisfying interactions with their newborn. 1. Interview parents, noting their perception of situation and individual concerns

2. Educate parents regarding child growth and development, addressing parental perceptions

3. Involve parents in activities with the newborn that they can accomplish successfully

4. Recognize and provide positive feedback for protective parenting behaviors – To know what the parents feelings about the situation..

– Helps clarify realistic expectations

– Enhances self-concept

– Reinforces continuation of desired behaviors After 30 minutes of Nursing Intervention and Health Teaching, the mother was able to identify and demonstrate technique to enhance behavioral organization of the neonate.
The parents shall be able to have a mutually satisfying interactions with their newborn.

Goal is met.

Discharge Planning

Name of Person Concern: Mr. G / Mrs. C
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 soap, shampoo and use hypoallergenic powder
* Oral hygiene
* Perinial hygiene