Child and family nursing Case Study: Neonatal sepsis

INTRODUCTION:

Sepsis is a widespread bacterial infection in the blood circulation. It is also referred to as septicaemia. Infants are at high risk of infection due to their low and immature immune system. The newborn has a poor response to pathogens and the local inflammatory reaction that signals the presence of an infection at the entry site is usually absent, which results in non-specific and broad symptoms. Subsequently, making the correct diagnosis and implementing a treatment is often delayed.

Neonatal sepsis, or sepsis neonatarum is an infection that can be attracted in the prenatal period through vertical transmission from the mother bloodstream or during the delivery period from ingestion of infected amniotic fluid. The literature distinguishes two types of neonatal sepsis, early onset and late onset.

Early onset sepsis is acquired in less than the 72 hours following the delivery. 85% of neonates present the sepsis in the first 24 hours, and few percentages present it later. The infection is transmitted from the mother to the infant during the perinatal period by microorganisms from the mother’s gastrointestinal or genitourinary tract.

The risk of acquiring a neonatal sepsis is increased with rupture of membranes for more than 24 hours, preterm delivery, frequent vaginal examinations and infections of the amniotic fluid and the placenta. Regarding the responsible pathogens, GBS (Group B streptococcus) was found to be the most infecting germ. Other microorganisms include E.coli, Listeria and Hemophilus influenza.

Late onset sepsis is mainly a nosocomial infection that occurs one to three weeks after birth. This type of infection can be caused by poor hand hygiene during invasive and non-invasive procedures, the presence of IV lines for a long time, resistance to antibiotics, long hospitalizations and resistance to antibiotics. The risk is increased for infants with low birth weight, preterm and late term newborns. The entry site for pathogens can be through the external organs such as the umbilical cord, the skin, the ear, and the nose … or through the internal organs like the gastrointestinal, urinary, nervous, and respiratory systems. Among the responsible organisms, we found staphylococcus, E.coli, Enterococcus and Klebsiella.

PATIENT’S PROFILE

Patient’ name	Baby girl H.O
Medical record number	1302820
Sex	Female
Date of birth	06/04/2016
Address	Imm 8 App 04 ….
Marital status	Single
Nationality	xxx
Religion	N/A
Educational level	N/A
Occupation	N/A
Health insurance	CNSS
Date of admission	06/04/2016
Department	NICU
Chief complaint	Fever
Admission diagnosis	Neonatal sepsis
Attending physician	Dr. xxx xxx
Discharge date

NURSING HEALTH HISTORY:

Baby girl H.O was born last April 06, 2016, 11:00 pm at xxx hospital. At 36 weeks of gestational age, her mother had early uterine contractions and premature rupture of membranes prior to delivery and was brought to the hospital by her husband. The mother had a difficult and prolonged labour because the baby did not come immediately. The midwife reported that the mother suffered a lot from prolonged pushing and straining during the perinatal period. Consequently, the infant manifested signs of distress including cyanosis, hypothermia and lethargy. The infant received usual neonatal care in addition to eye prophylaxis and injection of vitamin K. The MD ordered a CBC and C reactive protein before the newborn was transferred to NICU. The preterm infant was then put into an incubator, and received oxygen via nasal cannula. Her vital signs were as follow: Heart rate: 190 BPM, blood pressure 30/20, temperature 35.7°C and respiratory rate of 50 cpm with increased work of breathing. The lab results of baby girl H.O showed increased CRP level, and WBC, which confirmed the diagnosis sepsis neonatarum.

GORDON’S FUNCTIONAL HEALTH ASSESSMENT:

Health perception and health management pattern: None
Nutritional metabolic pattern: the infant is breastfed by his mother when hungry. The duration of breastfeeding is controlled by the baby’s satiety.
Elimination pattern:
- The infant passed a dark stool at the first 48 hours (meconium) at a frequency of two to three times per day. In the next 72 hours after birth, the infant passes a light green stool because of maternal milk.
- Voiding pattern: the infant urinates at least six times per day. The color of the urine is pale yellow.
Activity-exercise pattern: The majority of newborn’s reflexes are present.
Sleep rest pattern: Baby HO sleeps the most of time during the day, but he’s awakened when he’s going to be breastfed by his mother or during the nursing and medical procedures.
Cognitive perceptual pattern: None
Self perception and self concept pattern: none
Role relationship pattern: none
Sexuality reproductive pattern: none
Coping and stress tolerance pattern: the infant copes with stress with the support of her mother through skin-to-skin contact, emotional bonding, and cuddling.
Value belief pattern: none.

PHYSICAL EXAMINATION:

Vital Signs:

Respiratory rate: 43 cpm
Blood pressure: 45/23 mmHg
Heart rate: 185 bpm
Temperature: 38.7^oC

Measurements:

Length: 46 cm
Head Circumference: 47cm
Chest Circumference: 28 cm
Abdominal Circumference: 25 cm
Weight: 2 kgs.
Apgar Score- 8-9

Physical Examination of the Newborn

Skin: Acrocyanosis, thinning lanugo
Head: Soft, firm and flat fontanels
Eyes: PERRLA, with pale palpebral conjunctiva
Ears: Symmetrical, no discharge or lesions, well curved pinna
Nose: No discharge
Chest: Symmetrical lung expansion, stippled areola 12mm bud
Abdomen: No tenderness
Back: Intact spine, no mass
Rectum: with patent anal opening,
Extremities: cyanosis

DIAGNOSTIC AND LABORATORY PROCEDURES

BLOOD CHEMISTRY:

Name of the laboratory test	Normal values	Actual results	Interpretation / significance
Red blood cells	4.0 – 6.0 x10⁶/μL	4.60 x10³/μL	Normal
White blood cells	4 – 10 x10³/μL	13.3 x10³/μL	Increased due to infectious disease
Hemoglobin	13.5 – 19.5 g/dL	21.3 g/dL	Elevated due to dehydration
Hematocrit	44% – 64 %	68.1 %	Elevated due to dehydration
MCV	95 – 106 fL	95.6 fL	Normal
MCH	24 – 34 pg/cell	33.4 pg/cell	Normal
MCHC	30 – 35 g/dL	34 g/dL	Normal
Platelets	150 – 400×10³/μL	230 x10³/μL	Normal

SERUM ELECTROLYTES:

Name of the laboratory / diagnostic test	Normal values	Actual results	Interpretation / significance
Sodium	135 – 145 mEq/L	143 mEq/L	Normal
Potassium	3.5 – 5.0 mEq/L	2.9 mEq/L	Decreased due to loss of fluid from diaphoresis. (Crawford & Harris, 2011)
Chloride	95 – 105 mEq/L	100 mEq/L	Normal
Bicarbonates	22 – 28 mmol/L	22 mmol/L	Normal
Blood sugar	70 – 110 mg/L	80 mg/L	Normal
Urea	0.2 – 0.4 g/L	0.3 g/L	Normal
Creatinine	6 – 12 mg/L	8 mg/L	Normal
Calcium	8 – 11 mg/dL	8 mg/dL	Normal
Protein	65 – 80 g/L	58g/L	Low due to loss of appetite to breastfeeding.
CRP	< 6 mg/L	71.8 mg/L	Increased due to presence of an inflammatory process
Total bilirubin	0.3 to 1.9 mg/dL	5.35 mg/dl	Normal elevation in newborn
Direct bilirubin	0 – 0.3 mg/dl	2.60 mg/dl	Normal elevation in newborn

PROBLEM LIST AND PRIORITIZATION:

Actual Problems:

1- Impaired gas exchange:

2- Ineffective thermoregulation:

3- Fluid volume deficit:

Potential Problems:

1- Risk for bleeding:

2- Risk for impaired skin integrity:

Nursing Care Plans:

1- Nursing Care plan for IMPAIRED GAS EXCHANGE:

ASSESMENT CUES

Subjective data:
– None
Objective Data:
– Hypoxia,
– Tachypnea
– Cyanosis

Nursing Diagnosis :

Impaired gas exchange related to inadequate surfactant levels and immaturity of pulmonary system

Planning and Expected Outcomes :

– The infant will suffer minimal respiratory distress syndrome, with reduced work of breathing and no morbidity.

Nursing Interventions and Rationale:

Independent:

– Assess respiratory status, tachypnea, nasal flaring, grunting, retractions, rhonchi, or crackles.

Rationale: These signs indicate the presence of a respiratory distress syndrome.

– Apply transcutaneous oxygen monitor or pulse oximeter. Change site of probe every 3–4 hr.

Rationale: Provides constant noninvasive monitoring of oxygen levels.

– Maintain body temperature at 37.5°C (+/-0.5°)

Rationale: Cold stress increases infant’s oxygen consumption, may promote acidosis, and may further impair surfactant production.

Collaborative:

– Administer supplemental oxygen, as needed.

– Administer medications as indicated: Sodium bicarbonate; Surfactant.

Rationale : Sodium bicarbonate may help return pH to normal range, and surfactant decreases severity of condition and associated complications.

– Monitor laboratory/diagnostic studies, as appropriate: ABGs, Hb, Hct

Rationale : Hypoxemia, hypercapnia, and acidosis reduce surfactant production.

EVALUATION

Goal met: The patient hypoxia and cyanosis subsided after nursing interventions.

DRUG STUDY:

DRUG NAME :

Generic Name: Ceftriaxone
Brand name:Ceftriaxone
Dosage: 250 g
Route: Intravenous
Frequency: TID

DRUG ACTION :

Semisynthetic third-generation cephalosporin antibiotic. Preferentially binds to one or more of the penicillin-binding proteins (PBP) located on cell walls of susceptible organisms. This inhibits third and final stage of bacterial cell wall synthesis, thus killing the bacterium.
Classification:
Antibiotic; third-generation cephalosporin – Gram negative bacilli

INDICATION:

– Hemophilus influenza
– Escherichia coli
– Enterobacter aerogens
– Proteus Mirabilis
– Klebsiella,
– Citrobacter
– Shigella
– Actinobacter

CONTRAINDICATIONS

– Infant < 1 month
– Pregnancy
– Hypersensitivity to cephalosporins

ADVERSE REACTIONS

– Body as a Whole: Pruritus, fever, chills, pain, induration at IM injection site; Phlebitis (IV site).
– GI: Diarrhea, abdominal cramps, pseudomembranous colitis, biliary sludge.
– Urogenital: Genital pruritus.

NURSING RESPONSIBILITIES

Assess:
– Sensibility to penicillin and other cephasporins
– IV site extravasation, phlebitis
– Bleeding: ecchymosis, gums, hematuria
– Monitor heart rate during IV infusion
Evaluate:
– Therapeutic response: decreased symptoms of infection

DISCHARGE PLANNING:

Medication:

The mother will be thought about:
- The dose of the drugs to take, the time, and the duration
- Expected action of the medication and possible side effects
- What to do if a dose is missed
- Special directions for mixing and administering the medications
- Proper storage and expiration and disposal.
Instruct the mother to avoid OTC drugs
Remind the patient to consult if any adverse effects occur

Exercise:

Maintain a quiet, pleasant environment to promote relaxation
Advise the mother to schedule periods of uninterrupted rest for her baby

Treatment:

Stress the importance of complying with the prescribed medications

Health teaching:

Explain the underlying disorder and treatment plan
Follow the healthcare professional advice given to parents during hospitalization
Provide written and oral instructions about activity, diet recommendations, medications, and follow up visits
Instruct the mother about the importance of adequate sleep of the newborn
Compliance with follow up examinations

Out patient:

Give the mother information about:
- Where to go for follow-up care
- When to seek help (for example, side effects to report)
- Where to get medical equipment or medications.
Remind the parents that frequent check-ups are important to improve their infant condition and maintain optimum balance of wellness

Diet:

Instruct the mother to give strict maternal breastfeeding during the first 6 months.
Instruct the mother to breastfeed the child as often as he manifests signs of hunger (e.g: cry).

Spiritual:

Not applicable

REFERENCES:

Field, T., Diego, M., & Hernandez-Reif, M. (2010). Preterm infant massage therapy research: a review. Infant Behavior and Development, 33(2), 115-124.

Hockenberry, M. J., Wilson, D., & Wong, D. L. (2012). Wong’s Essentials of Pediatric Nursing9: Wong’s Essentials of Pediatric Nursing. Elsevier Health Sciences.Yo, C. H., Hsieh, P. S., Lee, S. H., Wu, J. Y., Chang, S. S., Tasi, K. C., & Lee, C. C. (2012).

Kardana, I. M. (2011). Incidence and factors associated with mortality of neonatal sepsis. Paediatr Indones, 51(3), 144-148.

Muhammad, Z., Ahmed, A., Hayat, U., Wazir, M. S., & Rafiyatullah, W. H. (2010). Neonatal sepsis: causative bacteria and their resistance to antibiotics. J Ayub Med Coll Abbottabad, 22(4), 33-36.

Utomo, M. T. (2010). Neonatal sepsis in low birth weight infants in Dr Soetomo General Hospital. Indonesian journal of tropical and infectious disease, 1(2), 86-89.

Utomo, M. T. (2010). Risk factors of neonatal sepsis: a preliminary study in Dr. Soetomo hospital. Indonesian Journal of Tropical and Infectious Disease, 1(1), 23-26.