The document provides information about neonatal sepsis, including: - Neonatal sepsis is a leading cause of death for newborns, especially premature infants, due to their underdeveloped immune systems. It can be caused by bacteria passing from the mother during or after birth. - Symptoms of neonatal sepsis include fever, poor feeding, jaundice, and respiratory distress. Prompt diagnosis and treatment are important to prevent disability or death. - The case study focuses on a 3-day old infant admitted with a diagnosis of neonatal sepsis. Nursing assessments and care plans are developed to properly treat the condition.

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CASE STUDY
NEONATAL SEPSIS

2. INTRODUCTION
Newborn infants are at much higher risk for developing sepsis than children and adults because of
their immature immune system—especially premature infants, where 1 out of every 250 will be
diagnosed with sepsis. Sepsis is one of the major leading causes of death in the first few months of a
newborn’s life. Infections can contribute up to 13-15% of all deaths during the neonatal period with the
mortality rate reaching as high as 50% for infants who are not treated timely. The combination of an
immature and slow responding immune system increases the risk of infection in the neonate. One reason
for the increased risk is that antibodies, which help protect mothers from infections, do not cross through
the placenta to the fetus until approximately 30 weeks of gestation. The antibodies present at birth take
time to reach optimum levels, which also affects the protection provided.
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. Comparatively higher rates of mortality were seen among home-delivered newborn infants
and those referred from other maternity facilities.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.
The physical and chemical barriers to infection in the human body are present in the newborn but
are functionally deficient. Skin and mucus membranes are broken down easily in the premature infant.
Neonates who are ill and/or premature are additionally at risk because of the invasive procedures that
breach their physical barriers to infection. Because of the interdependence of the immune response, these
individual deficiencies of the various components of immune activity in the neonate conspire to create a
hazardous situation for the neonate exposed to infectious threats.
Other risk factors is when the newborn is in distress before being born, has a very low birth
weigh, has a bowel movement before being born, and meconium (fetal stool) is present in the uterus, the
amniotic fluid surrounding the baby has a bad smell, or the baby has a bad smell right after being born
and male babies are at greater risk for neonatal sepsis than female babies while some of the symptoms
that the doctor will need to check for include fever or frequent changes in temperature, doesn’t drink
formula or breast milk well, not urinating, stomach is bloated or puffy, drool or spit is yellowish,
vomiting or diarrhea, extreme redness around the belly button or skin rashes, unexplained high or low
blood sugar, irritability or difficulty waking up and baby is sleepy all the time, skin is jaundice (yellow)
or overly pale, abnormally slow or fast heartbeat, stops breathing, breathes rapidly, or has difficulty
breathing, bruising or bleeding, seizures and a cool, clammy skin.
Our group chose this case due to the existing fact that neonatal sepsis in becoming widespread in
some parts of the country especially to home-born babies and some hospitals that fail to maintain the ideal
environment and care for the newborn. Recently, it was shown in the news that a lot babies died in some
parts of Luzon due to neonatal sepsis and though despite the major advances in neonatal medicine, many
infants still develop life-threatening infections during the first month of life. Identifying and caring for an
infant with a possible infection starts with a skilled nurse who is proficient in performing neonatal
assessments. The assessment begins with a nurse’s innate knowledge of the many different risk factors for
newborn infection. The nurse needs to be observant for any sign that may indicate sepsis. It cannot be
overemphasized that prompt recognition, early diagnosis, and immediate treatment of sepsis can
dramatically improve the infant’s outcome and limit any potential disability.

3. OBJECTIVES
GENERAL OBJECTIVE:
This study aims to discuss a case where a nursing process is comprehensively
utilized in care of the patient having neonatal sepsis providing a thorough and clear
understanding of the client’s history, health condition, pathophysiology of the disease,
treatment and management; and to identify the drugs and its implications to develop a
better medical and nursing management of the disease.
SPECIFIC OBJECTIVE:
After the case presentation, the student nurse will be able to:
1. formulate nursing diagnosis
2. Present the anatomy and physiology of fetal circulation and infant’s immune
system.
3. Discuss the pathophysiology of neonatal sepsis.
4. Present a thorough physical assessment and Gordon’s functional health pattern.
5. Identify laboratory and diagnostic tests ordered and their significance.
6. Discuss the medical and surgical management of the disease.
7. Identify and enumerate the various drugs prescribed and their actions
8. Formulate an individualized nursing care plan for the patient
9. Construct an appropriate health teaching plan in relation to client’s present
condition using the METHOD format.

4. ANATOMY AND PHYSIOLOGY
Fetal Circulation
During pregnancy, the fetal circulatory system works differently than after birth:
• The fetus is connected by the umbilical cord to the placenta, the organ that develops and
implants in the mother's uterus during pregnancy.
• Through the blood vessels in the umbilical cord, the fetus receives all the necessary
nutrition, oxygen, and life support from the mother through the placenta.
• Waste products and carbon dioxide from the fetus are sent back through the umbilical
cord and placenta to the mother's circulation to be eliminated.
Blood from the mother enters the fetus through the vein in the umbilical cord. It goes to
the liver and splits into three branches. The blood then reaches the inferior vena cava, a major
vein connected to the heart.
Inside the fetal heart:
• Blood enters the right atrium, the chamber on the upper right side of the heart. Most of
the blood flows to the left side through a special fetal opening between the left and right
atria, called the foramen ovale.
• Blood then passes into the left ventricle (lower chamber of the heart) and then to the
aorta, (the large artery coming from the heart).
• From the aorta, blood is sent to the head and upper extremities. After circulating there,
the blood returns to the right atrium of the heart through the superior vena cava.
• About one-third of the blood entering the right atrium does not flow through the foramen
ovale, but, instead, stays in the right side of the heart, eventually flowing into the
pulmonary artery.
Because the placenta does the work of exchanging oxygen (O2) and carbon dioxide (CO2)
through the mother's circulation, the fetal lungs are not used for breathing. Instead of blood
flowing to the lungs to pick up oxygen and then flowing to the rest of the body, the fetal
circulation shunts (bypasses) most of the blood away from the lungs. In the fetus, blood is
shunted from the pulmonary artery to the aorta through a connecting blood vessel called the
ductus arteriosus.

5. Blood circulation after birth:
With the first breaths of air the baby takes at birth, the fetal circulation changes. A larger
amount of blood is sent to the lungs to pick up oxygen.
• Because the ductus arteriosus (the normal connection between the aorta and the
pulmonary valve) is no longer needed, it begins to wither and close off.
• The circulation in the lungs increases and more blood flows into the left atrium of the
heart. This increased pressure causes the foramen ovale to close and blood circulates
normally.
IMMUNE SYSTEM DEVELOPMENT
The immune system begins very early in fetal development with the origin of blood
formation in the third week of gestation. In the fourth week of gestation the thymus forms. The
thymus helps to mature and develop white blood cells so that they can play a key role in fighting
infections. By the eighth week of gestation, T cells, B cells, and natural killer cells can all be
found in the thymus.
T cells, which make an important component in cell-mediated immunity, are formed
solely in the thymus. B cells, which are the precursors of antibody producing cells, are first
produced in the liver but by 12 weeks gestation move into the bone marrow where it remains.
Natural killer cells, which are cytotoxic cells that have the ability to attack viruses, mature in the
thymus. Interestingly, greater concentrations of natural killer cells are found in the peripheral
blood of newborns and the newborn usually has adult levels of these cells at birth, but they
diminish rapidly. Orlando Regional Healthcare, Education & Development © Copyright 2004 Page 4
Neutrophils are relatively numerous in both the term and pre-term infant. A neutrophil is
a type of white blood cell that defends the body from organisms that cause infection. The stages
of neutrophil development, from immature to mature, are myeloblast, promyelocyte, myelocyte,
metamyelocte, band, and segmented neutrophil. When an infection is present, the neutrophils
migrate out of the capillaries and into the infected site, where they ingest and destroy the
pathogens causing the infection. The amount of circulating neutrophils in the newborn peaks
around 12 hours after birth and then starts to decline to normal levels. Even though a large
number of circulating neutrophils can be found in the newborn, the bone marrow storage pool of
neutrophils at birth is only 20% to 30% of the circulating pool in adults.

6. Immune System Physiology
Despite the immune system and immune system components, early development during
gestation the newborn still remains vulnerable to infections after they are born because of the
immaturity of their immune system.
A newborn has a poor response to invading pathogens. This immune response will
gradually improve with age. During the initial postpartum phase, the infant relies on maternal
antibodies and the mother’s breast milk, which is rich with immunoglobulins. When a
pathogenic organism overcomes the infant’s defenses, infection and sepsis result. Sepsis is
defined as the presence of microorganisms or their toxins in blood or other tissues. Newborn
sepsis is still one of the most significant causes of neonatal disability and death today.
Reviewing the functions of the infant’s immune system will help provide a better
understanding of the interaction between the pathogenic organisms and the newborn’s
susceptibility to infection. Infections occur when the infant comes in contact with a pathogenic
organism. The organism, whether it is a virus, fungus, or bacteria, enters into the infant’s body
system and begins to multiply.
The infant’s immune system response to an organism is divided into three phases. The
first phase is the primary or nonspecific phase, which occurs immediately following the infant’s
inoculation with a pathogenic organism. During this phase, there is a migration of the neutrophils
to the primary site of the infection. The neutrophils enter into the cells through membrane filters
and adhere to the pathogen. Ingestion and destruction of the invading organism then takes place.
The next phase in the immune response is called the secondary phase or the specific
response phase. During this phase, there is interaction of T and B cells to help develop
immunoglobulins or antibodies to protect the infant from the infection. There are three major
types of immunoglobulins: Immunoglobulin G (IgG), Immunoglobulin M (IgM), and
Immunoglobulin A (IgA).
Immunoglobulin G is the major immunoglobulin of the serum and interstitial fluid. It
provides immunity against both bacterial and viral pathogens. It starts to cross the
placenta and enter into fetal circulation around 30 weeks’ gestation and continues until
the 40th
week. Term infants have IgG levels that are equal to or exceed maternal levels.
Since IgG is not transferred until around the 30th
week of gestation, the preterm infant
Differences in Immune Responses in Full and Preterm Infants
Immune System
Component
Full Term Infant Preterm Infant
Immunoglobulin G Complete placental transfer, concentrations
comparable to mother
Incomplete placental transfer, concentrations
decreased
Lymphocytes Concentrations of T and B cells comparable
to those in adults with normal response to
antigens
Concentrations of T and B cells comparable
to those in adults with normal response to
antigens
Complement 50%-75% of concentration in adult Decreased concentration
Neutrophils Elevated numbers at birth, with impaired
functional ability
Elevated numbers at birth, with impaired
functional ability
Monocytes Normal number at birth but have impaired
chemotaxis
Normal number at birth but have impaired
chemotaxis
Macrophages Normal number at birth but decreased
function
Normal number at birth but decreased
function
Natural Killer Cells Concentration similar to adult level, but have
diminished cytotoxic effects
Concentration similar to adult level, but have
diminished cytotoxic effects

7. does not have this protective barrier. Preterm infants are thus at higher risk for infections.
Research has shown that there are also decreased levels of IgG in post-term and small for
gestation age infants, which suggest that there may be some inhibition of transfer with
placental damage.
Immunoglobulin M does not cross the placenta thus, little or no IgM is transferred to the
fetus. This lack of IgM increases the infant’s susceptibility to gram negative infections.
The infant does however begin synthesis of this immunoglobulin very early in their fetal
life. Levels of IgM have been detected around 30 weeks’ gestation with higher levels
detected when there is an intrauterine infection present.
Immunoglobulin A is the most common immunoglobulin found in the gastrointestinal
tract, respiratory tract, human colostrum, and breast milk. IgA does not cross the
placenta, and intrauterine synthesis is minimal. Levels of IgA are usually not detected
until the infant is around 2 to 3 weeks old.
The last immune response is the tertiary phase. This phase provides long-term immunity
against the organism. During the second phase, the B cells produce memory cells that recognize
the invading pathogen on subsequent exposures. These memory cells recognize the invading
organism and cause them to be neutralized, preventing the infant from becoming sick again.
Although adequate numbers of B cells are present at birth, antibody production is diminished in
the neonate due to a lack of uterine exposure to foreign pathogens.
BASELINE DATA
Name: Baby Girl D.
Address: Tres Y Media, Taloc, Bago City
Age: 3 days old
Educational Level: N/A
Marital Status: Single
Religion: N/A
Birthdate: December 2, 2006
No. of Dependents:none
Birthplace: Bago City
Gender: Female
Occupation: N/A
Nationality: Filipino
Person next to Kin:Mother
Source of history/reliability: Significant other (mother) and patient’s charts
Date of Admission:December 4, 2006
Attending Physician:Dr. Beñosa
Chief Complaints: Upward rolling of eyeballs

8. Admission Diagnosis: Neonatal Sepsis: Full term AGA via NSD t/c neonatal asphyxia
rolled out CNS infection, neonatal tetanus
Temperature: 37.0°C
Heart Rate: 114 bpm
Respiratory Rate: 33 cpm
GORDON’S 11 FUNCTIONAL HEALTH PATTERN
Typical Day Activities
The mother usually do the household chores takes care of the infant.
Nutritional – Metabolic Pattern
The mother eats nutritional foods such as fruits and vegetables with no tea, coffe
or softdrink during pregnancy. While the baby is breastfed with aspiration precaution.
The baby is with diaper and has a soft stool due to breastfeeding.
Activity and Exercise Patterns
The mother usually do household chores and walks early in the morning as a
form of exercise during pregnancy. After delivery while both mother and child is in the
hospital, the mother usually gives the child sun bathing to eliminate the yellowish
discoloration of the skin. The primitive reflexes of the child are present and strong.
Recreational/ Pets/ Hobbies

9. The client’s mother and family has no pets and only spend their spare time in
mahjong, card games and tsismis.
Sleep-rest Pattern
The child sleeps most of the time and only wakes up when she urinates, pass out
stool or when hungry.
Personal Habits
The mother usually do the household chores and only takes care of her child and
husband. She stays in their house oftenly and only goes out when necessary like
helping out in the farm or taking her child to a health center for immunization.
Occupational – Health Patterns
The mother works in the farm and do most of the household chores. Her
husband works as a contractual carpenter to support the family.
Socio – Economic Status
The family is below poverty line with only their relatives especially her sister to
help them in financial aspect.
Environmental – Health Patterns
They have a poor environmental condition with dirty surroundings and unsanitary
personal hygiene.
Roles, Relationship, Self-Concept
Mother has a positive outlook for her child’s future if God would lengthen the
child’s life. She has also a good relationship with her husband and their in laws. The
mother carry out her roles positively with enthusiasm and happiness in her heart as a
mother, wife, in law, sister and relative.

10. Religious, Spiritual, and Cultural Influences
The patient has no hard liquor, no coffee and tea during pregnancy only
nutritious foods like fruits and vegetables. She believes that her children should be
delivered by a “paltera”, they should go to “manoghilot” to massage the gravid uterus,
mother and child should bathe together one week after delivery with herbal medicines.
Family Roles and Relationships
The members in the patient’s family are very close. They have a healthy
relationship with one another and supports each other during trying moments in their
lives.
Stress and Coping Patterns
The patient shares that praying and reading the Bible gives her strength and
helps her face the stresses in life although she does not go to church regularly. Her
family and her relatives show support by visiting her in the hospital and through texting
or calling her to ask how she and the baby is doing.
Sexuality Patterns
The patient is married and has a normal sex life. She cannot remember her LMP
and did not undergo any reproductive examination due to knowledge deficit and
financial instability.
Social Support
Aside from her family, she is also grateful for the support and prayer that her
relatives and friends are showing.

11. HEALTH HISTORY
History of Present Illness:
a. Usual health status: The patient has been experiencing an on and off fever with
cool, clammy and jaundiced skin with upward rolling of eyeballs, febrile seizure,
irritability and poor feeding.
b. Chronologic story:
1. October 2002 – During the mother’s first pregnancy (on the 28th
week
gestation) she experienced an accident , she slipped and fell
while in the bathroom and to manage the pain she went to a
“manoghilot” and had her gravid uterus massaged to keep
the baby safe. Then, she continued to work in the farm and
do the household chores.
2. December 2002 – The mother experienced the same accident and resorted
to the same management for pain.
3. January 2003 – The mother delivered her first baby through a home birth
and delivered a full term AGA infant in cephalic position
facilitated by a “paltera” (unlicensed practitioner of midwifery)

12. using a non-sterile instrument, unsterile materials in an
unsterile environment. The “paltera” conducted an improper
newborn care to the infant leading to the development of
sepsis, in which the infant was able to exhibit the signs and
symptoms persistent within 3 days after delivery. The
mother admitted the sick infant to CLMMRH. The diagnostic
tests revealed that the infant was already in distress while
inside the womb leading the child to develop meningitis and
developed neonatal sepsis due unsterile delivery and
improper newborn care. The child went through atrio-
ventricular shunt and had series of antibiotic therapy. After
28 days of admission they decided to go home thus resorted
to DAMA (discharge against medical advice) and brought the
child home.
4. April 2003 – Her first baby acquired measles thought to come from a
neighboring infant, then experienced on and off fever, chills
and upward rolling of eyes. The mother brought her first
baby to CLMMRH and the baby was diagnosed to have
acquired German measles however, due to lack of financial
support they went home and was not able to do anything to
aid the infant’s condition.
5. May 17, 2003 – The first baby died at four months old after suffering from
different prevailing conditions left unaided.
6. December 2, 2006 – The mother had her second delivery still a home birth
and delivered via NSD to a full term AGA infant in a breech
position facilitated by “paltera” (unlicensed practitioner of
midwifery). The environment was unsterile, the mother lying
down to a plastic covered bamboo floor. The infant given
birth is our client, after the delivery the “paltera” did the

13. newborn care and cord care to the infant where she cut the
umbilical cord 1 inch from the abdomen tied it with three
layers of ordinary thread (usually used in sewing cloths) and
covered the tip of the umbilical cord with a cotton.
7. December 3, 2006 – The mother noticed that our client was having chills,
upward rolling of eyes, high fever, cool and clammy skin.
After which, she called the “paltera” and informed her of her
observations and as a response the “paltera” instructed her
to take the following drugs such as methergin, ferrous sulfate
and paracetamol and breastfeed the infant so that the drugs
can be passed on to the infant via breastmilk.
8. December 4, 2006 – The mother brought the client to Bago Health Center
for BCG vaccination and reported the child’s case to the
resident physician. The physician did not give the BCG
immunization and referred her to the Bago City Hospital for
admission and further observation.
c. Relevant family history: N/A
d. Disability assessment: N/A
Past Health History (infant):
Childhood illness: upward rolling of eyes, chills, cool and clammy skin, on and off
fever
Hospitalizations: none
Serious injuries/chronic illnesses: none
Immunizations: none
Allergies (food, drugs, environmental): none
Medications (prescribed/OTC): Paracetamol
Family History:

14. The child’s grandparent had a history of death due to tuberculosis.
Psychosocial Profile:
Health practices and beliefs/self-care activities (mother): Children should be delivered
by a “paltera”, they should go to “manoghilot” to
massage the gravid uterus, mother and child should
bathe together one week after delivery with herbal
medicines.
Typical day: Irritable, breatfed when hungry, frequent change of diaper due to urination
and stooling.
Nutritional patterns: Breastfeed with aspiration precaution
Activity/exercise patterns: Primitive reflexes present and strong
Recreation: none
Sleep/rest patterns: Sleeps most of the time and only wakes up when she urinates,
pass out stool or when hungry.
Personal habits: none
Socioeconomic status: Below poverty line
Environmental health patterns: Poor environmental condition with dirty surroundings
and unsanitary personal hygiene.
Roles, Relationships, Self-concept (mother): Mother has a positive outlook for her
child’s future given that the child’s life will be
prolonged. She has also a good relationship with her
husband and their in laws. The mother carry out her
roles positively with enthusiasm and happiness in her
heart as a mother, wife, in law, sister and daughter.
Cultural/Religious influences (mother): No hard liquor, no coffee and tea during
pregnancy only nutritious foods like fruits and vegetables.
Family Roles/Relationships (mother): She has a healthy relationship with her husband,
daughter, in laws and relatives

15. Sexuality Patterns (mother): The mother was unable to recall her LMP. She never
undergone any reproductive examinations due to knowledge deficit
and financial instability. She got pregnant twice and delivered both
infants alive but accompanied with illnesses. Her first born died
due to meningitis, neonatal sepsis and german measles. While,
her second born was also diagnosed with neonatal sepsis.
Social supports (mother and child): Relatives and family
Stress/coping patterns (mother and child): Mother copes up with stress through prayers
and family support. Her child copes up with stress with the help of her
mother through cuddling, feeding and cleaning her.
PHYSICAL ASSESSMENT
A. General Appearance
Upon assessment, the client looks unclean and untidy with blood tinged dress as
she is cuddled by her mother. Upward rolling of eyes is observed but with good
primitive reflexes present. Pseudomenstruation is present as evidenced by white
secretions going out of the vagina. The umbilical cord is dry and looks very unclean
tied with a non-sterile thread (the usual thread we use in sewing cloths) and cord
clamp. The client’s nails were long and uncut. Client was febrile and in
cardiopulmonary distress with vital signs T = 37.7°C, HR = 180 bpm and RR = 20
cpm. There is also a yellowish discoloration in the skin, eyes and tongue.
B. Neurologic System
The client is as she is cuddled by her mother.
C. HEENT (head, eyes, ears, nose and throat)
The client’s pupil is equally round and reactive to light and accommodation
(PERRLA) with upward rolling of eyes present. There is also a yellowish
discoloration of the sclera and tongue.

16. D. Respiratory System
The client breath through the nose with wheezes present in both lungs upon
auscultation, experiences difficulty of breathing, slightly dyspneic having a
respiratory rate of 33 breaths per minute.
E. Cardiovascular System
She has a good capillary refill <2 seconds with strong and rapid pulse and has a
heart rate of 180 beats per minute.
F. Gastrointestinal Tract System
The patient has a normoactive bowel sounds at four quadrants of the abdomen.
She is on breastfeeding with aspiration precaution and was able to defecate to a soft
green mushy stool approximately 80 cc.
G. Genitourinary Tract System
The client voided freely to a clear urine approximately 15 cc with diaper. Her
perineum is unclean with pseudomenstruation as evidenced by presence of blood
secretions going out of the vagina.
H. Musculoskeletal System
The baby moves freely with primitive reflexes present and strong.
I. Integumentary System
The client has a good skin turgor. Her umbilical cord is dry and looks very
unclean tied with thread and cord clamp. There is also a yellowish discoloration of
the skin. Her nails are long and uncut. She is febrile with temperature of 37.7°C.
SUMMARY OF PERTINENT PHYSICAL ASSESSMENT FINDINGS

17. In general, the patient’s health status upon physical assessment is altered. There is
upward rolling of eyeballs but with good primitive reflexes. Client was febrile and in
cardiopulmonary distress with vital signs T = 37.7°C, HR = 180 bpm and RR = 20 cpm
She looks unclean and untidy with blood tinged dress, nails are long and uncut. She
has an unclean perineum with pseudomenstruation present. Her umbilical cord is
infected due to non-sterile and improper cord care and tied with thread and cord clamp.
The rest of the body systems are within normal limits as evidenced by stable vital signs,
PERRLA and good skin turgor.
LABORATORY REPORTS AND TESTS

18. URINALYSIS
Parameter Patient Normal Value Interpretation Implication
COLOR PALE LIGHT STRAW ABNORMAL Indicates
Laboratory/
Diagnostic Test
Result Normal Value Interpretation Implication
CHEMISTRY I
December 4, 2006
2 HPPBS, RBS
HEMATOLOGY
REPORT
December 5, 2006
Hematocrit
Hemoglobin
WBC Count
RBC Count
Direct Platelet
BLOOD
CHEMISTRY II
December 6, 2006
Calcium
SERUM SODIUM
AND POTASSIUM
December 6, 2006
Serum Sodium
Serum Potassium
CHEMISTRY I
December 7, 2006
113 mg/dL or
6.21 mmol/ L
0.38 vol/L
127 g/L
14.3 x 10/L
3.7 x 10/L
315 x 10/L
2.1 mmol/L or
8.4 mg/dL
163.9 mEq/L
4.10 mEq/L
90 mg/dL or 50
mmol/ L
up to 130 mg/dL or up
to 7.2 mmol/L
0.38 – 0.47
120-160 g/L
5.0- 10.0 x 10/L
4.0-6.0 x 10/L
150- 400 x 10/ L
2.02- 2.6 mmol/L or
8.1- 10.4 mg/ dL
135- 145 mEq/ L
3.5- 5.0 mEq/L
up to 130 mg/ dL or
up to 7.2 mmol/ L
Normal
Normal
Normal
Elevated
Decreased
Normal
Decreased
Decreased
Normal
Elevated
Normal
Normal
May indicate hemolytic
anemia and infection
May indicate hemorrhage
anemia, or hemodilatation
(over hydration)
Normal
There is decreased
Hemoglobin and Hematocrit
because of surgery.
Normal
Indicates dehydration severe
diarrhea (water loss is greater
than sodium loss)
Normal
Normal

19. diluted urine
( Large fluid
intake)
TRANSPARENCY SLIGHT HAZY CLEAR ABNORMAL May indicate
bacteruria
SPECIFIC
GRAVITY
1.010 1.001- 1.020 NORMAL NORMAL
pH 6.0 5-7 NORMAL NORMAL
RBC 1-3 hpf 0-2 hpf ELEVATED May indicate
renal failure
problems
PUS CELLS 1-4 hpf NONE ELEVATED Indicates
genitourinary
tract infection/
contamination
of external
genetalia
PATOPHISIOLOGY

20. Home birth through the help of a "paltera"
Unsanitary conditions and unsterile equipments used
Increased likelihood of bacterial growth
Insufficient knowledge of the guardians as to proper cord care
Increased bacterial growth and infestation
Immature body systems of the infant
Infection of the umbilical stump
Another form of tetanus, neonatal tetanus, occurs in newborns who are delivered in
unsanitary conditions, especially if the umbilical cord stump becomes contaminated. Once the
bacteria are in the body, it produces two endotoxins, a Tetanolysis and Tetanospasmin. Neurotoxic
effects are produced by the Tetanospasmin. Most of the toxin enters the peripheral endings of
motor neurons form the bloodstream, travels up the fibers to the spinal cord and brainstem, and
crosses the synaptic nerve to the inhibitory neurons, where it prevents the release of glycine.
glycine is a neuromuscular transmitter secreted mainly in the synapses of the spinal cord; acting as
an inhibitor. The action of tetanospasmin is through an affinity for the SNS. medullary enters, the
anterior horn cells of the SC and the motor end plates in the skeletal muscles. It produces
uninhibited motor responses leading to the typical muscle spasms.

21. Assessment Data Nursing Diagnosis Rationale Desired Outcome Nursing
Interventions
Justification Evaluation
Actual/ Abnormal
Findings:
The client looks
unclean and untidy
with blood tinged dress
Intermittent fever
Febrile seizure,
irritability and poor
feeding
Yellowish
discoloration in the
skin, eyes and tongue
Nails were long and
uncut
The umbilical cord is
dry and looks very
unclean tied with
thread and cord clamp
Pseudomenstruation is
present
WBC Count= 14.3 x
10/L
Upward rolling of
eyes
T = 37.7°C, HR =
180 bpm and RR =
20 cpm
Risk/ Related
Factors:
Decreased energy/
fatigue
Septic Shock
Septicemia
Strengths/ Wellness:
Strong Family
Support
Risk for Infection
[progression of sepsis
to septic shock,
development of
opportunistic
infections] related to
compromised
immune system,
environmental
exposure, invasive
procedures, failure
to exercise proper
preventive
measures, improper
hygiene
Definition:
Risk for infection-
at increased risk for
being invaded by
pathogenic organisms
Schematic Diagram
Predisposing Factors
Financial instability
Poor environmental
sanitation
Knowledge Deficit
Superstitious Beliefs

Delivered through
home birth by a
“paltera”

non- sterile
procedures and
environment

improper umbilical
cord care by using a
ordinary thread to
tie the remaining
cord

yellowish
discoloration,
upward rolling of
eyes, febrile seizures
and intermittent
fever

NEONATAL
SEPSIS

Risk for
infection[progressio
n of sepsis to septic
shock, development
of opportunistic
infections]
Source:
• Nurse’s
Pocket Guide,:
After 8 hours of
nursing intervention
the client will be able
to:
• Achieve timely
healing, be free
of purulent
secretions /
drainage or
erythema, and
be afebrile
Independent:
• Monitor VS closely
• Provide isolation/
monitor visitors as
indicated
• Wash hands
before/ after each
care activity, even
if sterile gloves are
used.
• Encourage/
provide frequent
position changes
• Limit use of
invasive devices/
procedures when
possible
• Maintain sterile
technique when
putting invasive
devices
• Monitor
temperature trends
• To monitor increase or
decrease in VS that would
suggest potentially fatal
complications
• Body substance isolation
should be employed for all
infectious patients.
Umbilical Cord/ linen
isolation and handwashing
may be all that is required
for umbilical cord care.
Patients with diseases
transmitted through air may
also need respiratory
precautions. Reverse
isolation/ restriction of
visitors may be needed to
protect the
immunosuppressed patient
• Reduces risk of cross-
contamination
• Good pulmonary toilet may
reduce respiratory
compromise
• Reduces number of sites of
entry of opportunistic
organisms
• Prevents introduction of
bacteria, reducing risk of
nosocomial infection
• Fever 38.50
C- 400
is the
result of endotoxin effect on
the hypothalamus and
pyrogen released
Goal met. The client
was relieved of
hyperthermia,
afebrile= 37.0°C, the
babies WBC
decreased,
NDX: RISK FOR INFECTION NURSING CARE PLAN

23. Assessment Data Nursing Diagnosis Rationale Desired Outcome Nursing Interventions Justification Evaluation
Actual/ Abnormal
Findings:
The first baby of the
mother was delivered
through home birth
also, died by four
months old due to
unaided and not
intervened conditions
such as meningitis and
German measles
The mother believes
the old beliefs and
superstitious beliefs
The mother resorts to a
“paltera” or
“manoghilot” if there
is an arising problem
both to her and her
baby and would seek
admission in the
hospital if the
condition is no longer
manageable
Both parents of our
client are elementary
graduate
UNAWARE that there
are institutions who
can cater the needs of
the people for free like
lying in clinics
Risk/ Related Factors:
Decreased energy/
fatigue
Septic Shock
Septicemia
Strengths/ Wellness:
Strong Family
Support
(SINCE OUR
CLIENT IS AN
INFANT IN
WHICH THE
COGNITIVE
DEVELOPMENT IS
NOT YET
PREVAILING WE
ASSESSED THE
MOTHER OF OUR
CLIENT)
Knowledge Deficit
[learning need]
regarding illness,
prognosis,
treatment, self-
care and discharge
needs related to
lack of
exposure/recall;
information
misinterpretation;
cognitive
limitation as
evidenced by
Inaccurate follow-
through of
instructions/
development of
preventable
complications;
inattentiveness;
statement of
misconception
Definition:
Knowledge
Deficit- Absence
or deficiency of
cognitive
information
related to specific
topic [Lack of
specific
information
Schematic Diagram
PREDISPOSING
FACTORS
1) Financial Status

Finished elementary
level only
2) Inaccessibility to
resources and
institutions

Unaware of the
present help in the
community,
ignorance towards
the society due to
isolation
3) Generativity

Passed on beliefs
which are believed to
be a fallacy and may
at times endanger
lives

The mother trusts
the capability of a
“paltera” and a
“manoghilot” in times
of distress both to
her and her baby

The mother had an
accident while
pregnant seek for the
manoghilots help

The “manoghilot”
manipulated the
gravid uterus of the
mother thinking it
would salvage the life
of the baby

The mother gave
birth to her baby
through home birth
by a “paltera”
After 8 hours of nursing
intervention the client will
be able to
• Verbalize
understanding of
disease process
and prognosis
• Correctly perform
necessary
procedures and
explain reasons
for actions
• Initiate necessary
lifestyle changes
• Participate in
treatment regimen
Independent:
• Review disease
process and
future
expectations.
• Review
individual risk
factors and mode
of transmission/
portal of entry of
infections
• Provide
information
about drug
therapy,
interactions, side
effects, and
importance of
adherence to
regimen
• Review
necessity of
personal
hygiene and
environmental
cleanliness
• Discuss need for
good nutritional
intake/ balanced
diet
• Identify signs
and symptoms
requiring medical
evaluation, e.g.
persistent
temperature
elevation,
tachycardia,
syncope, rashes
of unknown
• Provide
knowledge base
on which the
patient can make
informed choices
• Awareness of
means of
infection
transmission
provides
opportunity to
plan for/institute
protective
measures
• Promotes
understanding of
and enhances
cooperation in
treatment/
prophylaxis and
reduces risk of
recurrence and
complications.
• Helps to control
environmental
exposure by
diminishing the
number of
pathogens
present
• Necessary for
optimal healing
and general well-
being of the baby
• For early
recognition of
developing/
recurring
infection allows
for timely
intervention and
reduces risk for
progression to
life threatening
situation.
Goal partially met.
The client was able to
verbalize her own
understanding, and the
client was made to
participate in the
treatment regimen but
the client shows no
signs that she will
improve her lifestyle
and that her personal
hygiene and
environment are still
left unattended.

25. Assessment Data Nursing
Diagnosis
Rationale Desired Outcome Nursing
Interventions
Justification Evaluation
Actual/ Abnormal Findings:
The client looks unclean and
untidy with blood tinged dress
Intermittent fever
Febrile seizure, irritability and
poor feeding
Yellowish discoloration in the
skin, eyes and tongue
Nails were long and uncut
The umbilical cord is dry and
looks very unclean tied with
thread and cord clamp
Pseudomenstruation is present
WBC Count= 14.3 x 10/L
Upward rolling of eyes
T = 37.7°C, HR = 180 bpm
and RR = 20 cpm
Risk/ Related Factors:
Decreased energy/ fatigue
Septic Shock
Septicemia
Strengths/ Wellness:
Strong Family Support
Ineffective
thermoregulation
related to
newborn’s
transition to
extrauterine
environment as
evidenced by
intermittent fever,
prevailing illness
Definition:
Ineffective
thermoregulation
is the inability to
maintain a steady
body temperature
regardless of
changes in the
environment
Schematic Diagram
Newborns Immature Body
Systems

Adaptation to warm uterine
environment

upon delivery exposure to a
different climate

maladaptation to extrauterine
environment

Plus the new born experienced
NEONATAL SEPSIS at 3
days old

reoccurring fever, presence of
febrile seizures, occasionally
the new born is cool to touch,
chills, upward rolling of
eyeballs

Ineffective thermoregulation
Source:
• Nurse’s Pocket Guide,:
Doenges
Medical-Surgical Nursing:
Source:
• Pillitteri, Adele
Maternal and Child
Health Nursing 4th
Ed.
Lippincott Williams
&Wilkins. Copyright
2003
After a week the
newborn client will be
able to maintain body
temperature within
normal limits
Independent:
• Take vital
signs q15
mins. X 2H
then q 30 mins
x 2h then q
hourly until
stable.
• Assist with
measures to
identify
causative
factors
underlying the
condition
• Administer
fluids and
electrolytes ,
and
medications as
indicated
Collaborative:
As physicians order:
• Place double
droplight.
• To monitor if
temperature
reached the
normal value
between 36.5-
37.50
C.
• To be able to
determine
what
interventions
may be given
to the client
and the
precautions
that may come
along with it
• To restore or
maintain
body/ organ
function
• To maintain
normal body
temperature
Goal Met:
• Newborn client
maintains
axillary body
temperature of
370
C.

26. GENERIC NAME/BRAND
NAME/CLASSIFICATION
MODE OF
ACTION
DOSAGE &
FREQUENCY/
ROUTE OF
ADMINISTRATION
INDICATIONS CONTRAINDICATIONS
ADVERSE
EFFECTS
NURSING
CONSIDERATIONS
Generic:
Ampicillin
Brand:
Novo Ampicillin, Apo-Ampi,
Nu-Ampi
Classification:
Anti-infectives
Penicillins
Inhibits cell-wall
synthesis during
bacterial multiplication
195 mg IVTT Q12h • Respiratory tract
or skin and skin
structure
infections
• GI infections or
UTI’s
• Bacterial
meningitis or
septicemia
• Contraindicated in patients
hypersensitive to drug or
other penicillins.
• Use cautiously in patients
with other drug allergies
(especially to
cephalosporins) because
of possible cross-
sensitivity, and in those
with mononucleosis
because of high risk of
maculopapular rash
• CNS: seizures
• CV: vein irritation
• GI: nausea,
vomiting, diarrhea,
stomatits, gastritis
• GU: interstitial
nephritis,
nephropathy,
vaginitis
• Hematologic:
anemia,
thrombocytopenia,
thrombocytopenia
purpura,
eosinophilia,
leucopenia,
hemolytic anemia,
agranulocytosis
• Other:
hypersensitivity
reactions,
overgrowth of
nonsusceptible
organisms
• Before giving drug,
ask patient about
allergic reactions to
penicillin. A negative
history of penicillin
allergy is no
guarantee against
future allergic
reaction
• Do skin testing to
determine allergic
reactions.
• Give drug 1 to 2
hours before or 2 to 3
hours after meals.
When given orally
the drug may cause
GI disturbances.
• Monitor sodium
level because each
gram of ampicillin
contains 2.9 mEq of
sodium
• Watch for signs and
symptoms of
hypersensitivity,
such as erythematous
maculopapular rash,
urticaria, and
anaphylaxis
• To prevent bacterial
endocarditis in
patients at high risk,
give the drug with
gentamicin
DRUG STUDY

27. GENERIC NAME/BRAND
NAME/CLASSIFICATION
MODE OF
ACTION
DOSAGE &
FREQUENCY/
ROUTE OF
ADMINISTRATION
INDICATIONS CONTRAINDICATIONS
ADVERSE
EFFECTS
NURSING
CONSIDERATIONS
Generic:
Gentamicin Sulfate
Brand:
Cidomycin, Garamycin
Classification:
Anti-infectives,
Aminoglycosides
Inhibiots protein
synthesis by binding
directly to the 30S
ribosomal subunit;
bactericidal
19mg IVTT OD • Serious infections
caused by
sensitive strains of
Pseudomonas
aeruginosa, E.
Coli, Proteus,
Klebsiella, or
Staphyloccocus
• Contraindicated in patients
hypersensitive to drug or
other aminoglycosides
• Use cautiously in
neonates.
• CNS: fever,
seizures, vertigo,
dizziness
• EENT: ototoxicity,
blurred vision,
tinnitus
• GI: Nausea and
vomiting
• GU: nephrotoxicity
• Hematologic:
anemia, leucopenia,
thrombocytopenia,
agranulocytosis
• Respiratory: apnea
• Do skin testing
• Evaluate patient’s
hearing before and
during therapy, report if
there are alterations in
the hearing process
• Weigh patient and
review renal function
studies before therapy
begins.
• Obtain blood peak
gentamicin level 1 hour
after I.M injection
• Watch signs and
symptoms of
superinfection
• Therapy usually
continues for 7 to 10
stop therapy and obtain
new specimens for
culture and sensitivity
testingjh

28. GENERIC NAME/BRAND
NAME/CLASSIFICATION
MODE OF
ACTION
DOSAGE &
FREQUENCY/
ROUTE OF
ADMINISTRATION
INDICATIONS CONTRAINDICATIONS
ADVERSE
EFFECTS
NURSING
INTERVENTIONS
Generic:
Tetanus Toxoid, Fluid
Brand:
Classification:
Anti-ulcer agent
Promotes immunity to
tetanus by inducing anti
toxin production
5ml IM @ the left thigh • Primary
immunization to
prevent tetanus
• Postexposure
prevention of
tetanus
• Contraindicated in
immunosuppressed
patients, in those with
immunoglobulin
abnormalities, and in
those with severe
hypersensitivity or
neurologic reactions to
toxoid or its ingredients.
Contraindicated with
patients with
thrombocytopenia or
other coagulation
disorders that would
contraindicate IM
injection unless benefits
outweigh risks.
• Use adsorbed form
cautiously in infants or
children with cerebral
damage, neurologic
disorders, or history of
febrile seizures
• Postpone vaccination in
patients with acute illness
and during polio
outbreaks, except in
emergencies
• CNS: slight fever,
headache, seizures,
malaise,
encephalopathy
• CV: tachycardia,
hypotension,
flushing
• Musculoskeletal:
aches, pains
• Skin: erythema,
induration, nodule at
injection site,
urticaria, pruritus
• Other: chills,
anaphylaxis
• Obtain history of
allergies nad
reaction to
immunization.
• Keep epinephrine 1:
1,000 available to
treat anaphylaxis
• Adsorbed from
produces longer
immunity. Fluid
form provides
quicker booster
effect in patients
actively immunized
previously.

29. M E T H O D
*Inform the mother of
the patient about the
medication, its effects,
dosage and correct timing.
*Instruct the guardian to
follow the therapeutic
regimen religiously
so as not to exceed
the recommended
dosage.
*Instruct the guardian to
increase the infant's
ambulation and/or
movement so as to
prevent the
accumulation of
pulmonary secretions.
* Instruct the guardians as
to proper skin care:
- Bathe the infant at
least once a day in
lukewarm
water and mild baby
soap or shampoo
- Clean the
umbilical, genital and
perineal area after
urination and/or
defecation.
- Practice frequent
handwashing before
handling the infant
and after having
contact with soiled
things of the baby.
- The guardian and the
infant should wear as much
as possible clean and well-
washed clothes to
minimize
bacterial contact
*Emphasize the importance
of proper grooming, care of
the nails, hair, oral and
wound care to both the
guardians and the infant
*Stress that the equipments
used for the infant should
be sterilized or clean
enough so as to
prevent
bacteria to come in
contact with the baby
*Stress the important role
of frequent handwashing in
the prevention of
bacterial infestation
and growth
*Instruct the guardians
to follow the OPD
schedule as
instructed
*Instruct the guardian
to make sure that the
infant
receives all the
recommended
immunizations
*Teach the guardians
self-care and continuity
of care to ensure
the promotion of
home and community-
based care.
*Make sure that the
bottles are sterilized
before using or the
nipples to be
cleaned before
letting the baby
suck.
*Feed the infant on
demand, few amount
only and only
increase it if the baby is
still hungry and le the
baby burp every after
feeding.
*Instruct the guardian
to consult their
pediatrician once the
infant shows
symptoms of allergy
to milk so that the
pedia can give the
appropriate milk
for the baby.

30. References:
 LeMone and Burke, Medical-Surgical Nursing: Critical thinking in client care
 Doenges, Moorhouse and Geissler, Nursing Care Plans: Guidelines for individualizing patient care
 Lippincott, Pathophisiology: Concepts of altered health states
 Marieb, Essentials of Human Anatomy and Physiology 6th
edition
 http://www.cancer-info.com/analcanc.htm
 http://www.nlm.nih.gov/medlineplus/analcancer.html
 www.emedicine.com
 http://www.massgeneral.org/cancer/crr/types/gi/anal.asp
 http://en.wikipedia.org/
 http://www.intelihealth.com/IH/ihtIH/WSIHW000/9339/9396.html
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