case_study_bago_neonatal_sepsis_pike

\CASE STUDY \

NEONATAL SEPSIS

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. Earlyonset 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 lateonset 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.

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.

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.

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. 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

Normal number at birth but decreased function

Normal number at birth but decreased function

Concentration similar to adult level, but have diminished cytotoxic effects

Concentration similar to adult level, but have diminished cytotoxic effects

Macrophages

Natural Killer Cells

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 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 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 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.

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.

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) 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 atrioventricular 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 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: 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

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.

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