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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
 Predisposing Factors: Non-predisposing factors
Immunocompromised Age 1 ½ months
Environment Male
Prolonged use of intravascular
catheter
Associated illness
Prolonged hospitalization
Contaminated equipment

Invasion of bacteria

Bacteria goes to circulation

Inflammatory Response

Release of exogenous The body release anti-inflammatory

pyrogens 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: 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.
 Date Ordered
Diagnostic or Analysis and
Indication or and Date Normal
Laboratory Results Interpretation of
Purpose Results were Values
Procedure Results
released
To identifying the need July 27, 2009 WBC- 11.5 - 5-10 x10 9/L - The results
Complete Blood for BT, effectiveness of indicates the

Count (CBC) BT and if there is a Hgb- 213 presence of

presence of infection - 140-180 g/L infection as
Hct- 0.64 manifested by an
increase in WBC
- 0.4-0.54
RBC- 7.5 count

- 5.5-6.5 x 10
- RBC,
12/L
PC- 130 hemoglobin and
hematocrit are
- 150-350 x 10
elevated and may
g/L
probably indicates
presence of
dehydration.

Diagnostic or Indication or Date Ordered Results Normal Analysis and

 and Date
Laboratory Interpretation of
Purpose Results were Values
Procedure Results
released
This was done to the July 27, 2009 Color: Yellow - Clear - The color,
Urinalysis patient as a screening appearance, and
for abnormalities within Appearance: Clear - Clear specific gravity
the urinary system as are within normal
well as for system limits. Presence of
Specific Gravity: 1.005 - 1.005-1.030
problems that may Pus cells, Red
manifest through the cells, epithelial
Pus Cells: 0-2/HPF - None
urinary tract. cells and mucus
threads indicates
- None
Red Cells: 0-1/HPF presence of
infection.
- None
Epithelial Cells: Few

- None
Mucus Threads: Light

- Negative
Albumin: Negative
- Negative
Glucose: Negative
 Date Ordered
Diagnostic or Analysis and
Indication or and Date Normal
Laboratory Results Interpretation of
Purpose Results were Values
Procedure Results
released
To identifying the need July 27, 2009 8.1 mg/dl - 7 - 18 mg/dl - The result is
Blood Urea for BT, effectiveness of within the normal
Nitrogen (BUN) 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 Contraindication Adverse Reaction Nursing

Action 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 > Give drug IM or
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- patient can’t take
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, hypersensitivity.
risk of gastritis,
maculopapular enterocolitis > Give drug 1-2
rash. 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

Diagnosis
Subjective: 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 body temperature
Objective: temperature, and body temperature 2. Monitor Vital - To have a
>Increased body warm skin. Signs baseline data
temperature Long Term: After 3 days of
>Skin warm to After 3 days of 3. Provide TSB - Helps in lowering Nursing
touch Nursing down the Intervention,
>Tachypnea Intervention, temperature patient was able to
>Tachycardia patient will maintain vital signs
> 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 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

Diagnosis
Subjective: 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 increased tissue
capillary increased 2. Monitor Vital - To have a perfusion.
Objective: membrane perfusion. Signs baseline data
> edema
> 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 maintain adequate
Temp.= 38.4 maintain adequate 4. Elevate Head of - To promote tissue perfusion.
RR= 36 perfusion. Bed circulation
PR= 120 5. Elevate - To reduce 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

Diagnosis
Subjective: 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 and demonstrate
mother. 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, organization of the
separated from his organization of the addressing neonate.
parents neonate. parental
> Vital Signs taken: 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. 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