Neonatal Sepsis (sepsis Neonatorum) Medical Management Not Included...

II. Nursing Assessment A. PERSONAL DATA JC Atenas Bermas is a 26 day old male neonate as of May 14, 2009, Filipino; he was born on the 26th day of April 2009 at San Luis Hospital, Mexico, Pampanga. He was baptized under the Roman Catholic Church. He is the son of Natalie Atenas and Randy Bermas, they are currently residing at Dolores, Mexico, Pampanga. According to his mom, he was admitted on the 8th day of May 2009. B. PERTINENT FAMILY HISTORY The family is a nuclear family and composed of three members including baby JC. Baby JC is the first baby of the family, according to Natalie, she make sure that she visit her Obstetrician regularly, she also doesn’t take any medications that are not being prescribed. But she still works even she was pregnant and she stays late at night. This was because she is the only one who is working for their family her husband is not working. She earns 280 pesos per day and they use this for their electric bill (300 pesos / month), water bill payments (400 pesos/ month) and rental fee (2000 pesos/ month) and food needs (500 – 700 pesos/ week) and in case that they have money left; they make sure that they save it on the bank. At this moment none of them is working. She told the group that she regularly sleep at around 10 in the evening and wake up at around 6 in the morning. She gave birth through normal spontaneous vaginal delivery with the assistance of a midwife. According to Natalie, they are originally residing at Tandang Sora Quezon City, wherein they are renting a room there, and according to her the houses there are close to each other, the water is not potable and they utilize mineral water for drinking water, the ventilation status is also inadequate as she have verbalized that they do not have a window. On her 8th month of pregnancy they decided to go back to Pampanga as Natalie’s parents are living in Pampanga. When Natalie was asked about the family’s health habits she confidently answered the group that they do not hesitate to visit a physician once someone get ill. They do not also practice self medication, they do not take medicines that are not prescribed and they do not rely on hilot or albularyo.

Father

Mother

Father

Mother

†

Rand

Natali LEGEND: MI Hypertens ion Neonatal Sepsis

JC

Normal

C. PERSONAL HISTORY During the course of Natalie’s pregnancy she was working on a laundry shop, she only resigned to her work when she was on her 8th month of gestation. According to her she used to visit her Obstetrician regularly, she also took vitamins that are prescribed by her Obstetrician, one of those is Obimin a certain brand of Iron Supplement. She has also mentioned that she took EnfaMama Milk. According to Natalie, when she already felt that her abdomen is starting to ache and felt that her bag of water has ruptured, they immediately rushed to the hospital at around 6 in the evening and gave birth at around 12 midnight. According to her on her 8th month of pregnancy she suffered from urinary tract infection, in which she consulted her obstetrician and she was prescribed with Amoxicillin which she took it for three times a day for seven days, her UTI was then resolved. She had an episode of fever when she was on her 7th month of pregnancy and her obstetrician prescribed her with cephalexin that she took three times a day for 7 days and paracetamol and her fever was resolved. She gave birth to a full term (38 weeks) baby boy rendering her an obstetrical history of G1P1 (1001), she delivered her baby via normal spontaneous vaginal delivery with episiotomy and episiorrhapy was done with the assistance of a midwife. She gave birth to a 6.8 pounds baby with no complications. According to her she did not practiced breastfeeding to her baby, she bottle fed her baby with BONA. The group advised her to practice breastfeeding. Upon observing baby JC, he was seen on bed always asleep, according to his mother, before baby JC went ill, he so active whenever someone visit them and play with him, JC would smile when someone plays with him. His mother have also observed him lifts his head when he is held with his abdomen against the bed. Baby JC was seen sucking a pacifier which denotes that he is on the Oral Stage based on Freud’s Developmental Stages. He was also seen behaving when his mother cuddles him when he is crying which denotes that he is on the first stage of Erik Erikson’s Psychosocial Stages of Development which is Trust vs. Mistrust. He was also seen smiling when you present him a toy which denotes Piaget’s Sensorimotor Stage on his Cognitive Stages of Development. All of these behaviors also satisfy Sullivan’s Life Stages particularly Infancy stage. Baby JC was also seen manifesting normal reactions with Rooting, Sucking, Palmar and Babinski reflexes when initiated. According to Natalie his son did

not receive any vaccinations yet, he also did not undergo newborn screening, and the group encouraged her to have her son undergo newborn screening and avail the Expanded Program on Immunization which is being offered in all barangay health centers. D. HISTORY OF PAST ILLNESS According to Natalie, Baby JC did not have any illnesses before, it was the first time he suffered such conditions. E. HISTORY IF PRESENT ILLNESS On the 8th day of May 2009, morning, and few hours prior to baby JC’s admission, after Natalie finished feeding her baby, Baby JC suddenly vomited, he continuously vomited four times. He was then immediately rushed to the hospital with chief complaints of vomiting to seek medical attention. Baby JC was then assessed and observed with all necessary laboratory and diagnostic tests were requested and performed. Baby JC was then admitted and diagnosed with Neonatal sepsis. With further exploration of the group, Natalie told the group that Baby JC does not have any fever, cough and cold or any conditions during the admission. F. PHYSICAL EXAMINATION May 8, 2009 (Lifted from chart) Weight: 7.2 pounds Skin: (+) maculopapular rashes on the face and trunk. (-) jaundice Head EENT: normocephalic, non bulging fontanels, anicteric sclera, pink palpebral conjunctiva, (-) nasal and oral discharge. Lymph nodes: (-) Cervical Lymphadenopathy Chest: Lungs: Symmetrical chest expansion, (-) retractions, clear breath sounds Cardiovascular: Adynamic Precordium, normal rate, regular rhythm, (-) murmur Breast: 2 breast buds

Abdomen: globular, normoactive bowel sounds, soft, non-tender, patent rectum. Genitals: (-) hypospadias, descended testes Extremities: symmetrical, (-) edema May 11, 2009 Baby JC was seen wearing a white over all clothes, lying on bed, asleep. With the following vital signs noted: T- 37.3°C HR- 131 bpm RR- 70 cpm Weight: not taken Skin: with maculopapular rashes on the face. No jaundice noted, no cyanosis noted, warm to touch skin, no skin tenting noted, moist skin, with good skin turgor. Head EENT: normocephalic, not bulging, flat fontanels, anicteric sclera, pink palpebral conjunctiva, no nasal and oral discharge noted. Moist to dry oral mucosa. Nonhyperemic posterior pharyngeal wall. Lymph nodes: without Cervical Lymphadenopathy Chest: Lungs: Symmetrical chest expansion, no retractions noted, with clear breath sounds Cardiovascular: Adynamic Precordium, heart beat is in normal rate and regular rhythm, no murmur noted. Breast: 2 breast buds are observed Abdomen: globular with equal skin color, umbilicus is observed dry, with normoactive bowel sounds (7 – 8 bowel sounds/ quadrant/ minute), soft and non-tender, patent rectum. With flatus reported, no bowel movement was noted. Without vomiting noted during the shift. Genitals: no hypospadias noted, with descended testes, with 1 soaked diaper changes within the shift.

Extremities: Upper: Symmetrical extremities, with no edema noted, capillary refill of 1 sec, pinkish nail beds. Untrimmed nails. Lower: Symmetrical extremities, with no edema noted, capillary refill of 1 sec, pinkish nail beds. Untrimmed nails. Neurologic: with normal reactions to rooting, sucking, palmar, and babinski reflexes upon initiation. May 12, 2009 Baby JC was seen wearing a white over all clothes, cuddled by her mother, crying. With the following vital signs noted: T- 37°C HR- 135 bpm RR- 76 cpm Weight: not taken Skin: with maculopapular rashes on the face. No jaundice noted, no cyanosis noted, warm to touch skin, no skin tenting noted, moist skin, with good skin turgor. Head EENT: normocephalic, not bulging, flat fontanels, anicteric sclera, pink palpebral conjunctiva, no nasal and oral discharge noted. Nonhyperemic posterior pharyngeal wall, dry oral mucosa. Lymph nodes: without Cervical Lymphadenopathy Chest: Lungs: Symmetrical chest expansion, no retractions noted, with clear breath sounds Cardiovascular: Adynamic Precordium, heart beat is in normal rate and regular rhythm, no murmur noted. Breast: 2 breast buds are observed Abdomen: globular with equal skin color, umbilicus is observed dry, with normoactive bowel sounds (4 - 5 bowel sounds/ quadrant/ minute), soft and non-tender, patent rectum. With flatus reported, no bowel movement was noted. With no vomiting episodes noted during the shift.

Genitals: no hypospadias noted, with descended testes, with 1 soaked diaper changes within the shift. Extremities: Upper: Symmetrical extremities, with no edema noted, capillary refill of 1 sec, pinkish nail beds. Untrimmed nails. Lower: Symmetrical extremities, with no edema noted, capillary refill of 1 sec, pinkish nail beds. Untrimmed nails. Neurologic: with normal reactions to rooting, sucking, palmar, and babinski reflexes upon initiation. May 13, 2009 Baby JC was seen wearing a white over all clothes, awake and seen sucking a pacifier. With the following vital signs noted: T- 36°C HR- 129 bpm RR- 52 cpm Weight: 6.3 pounds Skin: with maculopapular rashes on the forehead. No jaundice noted, no cyanosis noted, cold clammy skin, no skin tenting noted, dry skin, with good skin turgor. Head EENT: normocephalic, not bulging, flat fontanels, anicteric sclera, pink palpebral conjunctiva, no nasal and oral discharge noted. Nonhyperemic posterior pharyngeal wall, dry oral mucosa. Lymph nodes: without Cervical Lymphadenopathy Chest: Lungs: Symmetrical chest expansion, no retractions noted, with clear breath sounds Cardiovascular: Adynamic Precordium, heart beat is in normal rate and regular rhythm, no murmur noted. Breast: 2 breast buds are observed

Abdomen: globular with equal skin color, umbilicus is observed dry, with hypoactive bowel sounds (2 - 3 bowel sounds/ quadrant/ minute), soft and non-tender, patent rectum. With flatus reported, no bowel movement was noted. With no vomiting episodes noted during the shift. Genitals: no hypospadias noted, with descended testes, with 0 soaked diaper changes within the shift. Extremities: Upper: Symmetrical extremities, with no edema noted, capillary refill of 1 sec, pinkish nail beds. Untrimmed nails. Lower: Symmetrical extremities, with no edema noted, capillary refill of 1 sec, pinkish nail beds. Untrimmed nails. Neurologic: with normal reactions to rooting, sucking, palmar, and babinski reflexes upon initiation. May 14, 2009 Baby JC was seen wearing a white over all clothes, awake and seen sucking a pacifier. With the following vital signs noted: T- 36.8°C HR- 128 bpm RR- 74 cpm Weight: not taken Skin: with maculopapular rashes on the forehead. No jaundice noted, no cyanosis noted, cold clammy skin, no skin tenting noted, dry skin, with good skin turgor. Head EENT: normocephalic, not bulging, flat fontanels, anicteric sclera, pink palpebral conjunctiva, no nasal noted. Nonhyperemic posterior pharyngeal wall, moist oral mucosa. Lymph nodes: without Cervical Lymphadenopathy Chest: Lungs: Symmetrical chest expansion, no retractions noted, with clear breath sounds

Cardiovascular: Adynamic Precordium, heart beat is in normal rate and regular rhythm, no murmur noted. Breast: 2 breast buds are observed Abdomen: globular with equal skin color, umbilicus is observed dry, with normoactive bowel sounds (13-14 bowel sounds/ quadrant/ minute), soft and non-tender, patent rectum. With flatus reported, with bowel movement noted, soft with liquid in consistency in light brown color, in about 10-15 ml approximately. With vomiting episodes noted postprandially (milk feeding) whitish fluid and milk - like in consistency. Genitals: no hypospadias noted, with descended testes, with 1 soaked diaper changes within the shift. Extremities: Upper: Symmetrical extremities, with no edema noted, capillary refill of 1 sec, pinkish nail beds. Untrimmed nails. Lower: Symmetrical extremities, with no edema noted, capillary refill of 1 sec, pinkish nail beds. Untrimmed nails. Neurologic: with normal reactions to rooting, sucking, palmar, and babinski reflexes upon initiation.

G. DIAGNOSTICS AND LABORATORY PROCEDURES

DIAGNOSTIC OR LABORATORY PROCEDURES

DATE ORDERED AND DATE RESULTS IN

INDICATIONS OR PURPOSES

RESULTS

NORMAL VALUES

ANALYSIS AND INTERPRETATION

CLINICAL CHEMISTRY

HGT/RBS

Ordered: May 9present, 2009 Results available: May 10 – 14, 2009

A random blood sugar is used to test and measure your blood sugar at any point in time, not necessarily a certain amount of time after a meal, snack or beverage.

5-9-09 No results available 5-10-09 80 mg/dL 5-11-09 60 mg/dL 5-12to14 09 80 mg/dL

60 – 140 mg/dL

the blood sugar level is within the normal limits, this is due to the aid of the client’s intravenous fluid that keeps the electrolyte levels in normal values though the client is in NPO.

FBS, Blood:  Pre-test: 1. Inform the family that the test is used to assist in the evaluation of the client’s glucose level 2. Note any procedures that can interfere with the test results. 3. Obtain a list of medications patient is taking.  Intra-test; 1. Observe Standard precautions. 2. After obtaining the specimen, promptly transport to the laboratory for processing and analysis.  Post-test: Observe venipuncture site for bleeding or hematoma formation.

STOOL OCCULT BLOOD TEST

OCCULT BLOOD TEST

Ordered: May 10 2009 Results available: May 10 2009

A diagnostic procedure done to detect hidden bleeding inside the body.

positive

negative

This denotes that there is a bleeding within the clients body specifically the gastrointestinal tract.

Occult Blood Test: Prior to the procedure: 1. Inform the mother about the purpose of the said diagnostic exam 2. Secure a specimen bottle 3. Instruct the mother on how to get a stool sample During the procedure: 1. Inform the mother to immediately submit the specimen once collected 2. Instruct the client to do it with a glove hands and clean materials to avoid contaminating 3. Instruct to perform hand washing after collecting the specimen After the procedure: 1. Ensure the results of the test 2. Relay the results to the attending physician SERUM ELECTROLYTE Ordered: To monitor the The sodium Sodium May 8, 09 electrolytes electrolyte 136 – and check for 139.2 level is within Results in: imbalances 145 mEq/ L normal range. May 8, 09 any imbalance mEq/L This is due to in the fluid and

the Intravenous fluid of the client that helps in maintaining equilibrium on serum electrolyte levels even the client is in NPO.

electrolytes. Sodium plays a major role in homeostasis in a variety of ways including the renal retention and excretion of water.

Potassium

Calcium

Ordered: May 8, 09 Results in: May 8, 09

Ordered: May 8, 09 Results in: May 8, 09

It is checked in order to assess a known and suspected disorder associated with renal disease, glucose metabolism, trauma or burns.

Serum Calcium is being checked to observe for any imbalances with serum electrolytes since the client has experienced vomiting episodes.

4.56 mmoL/L

3.5 – 5.0 mmoL/L

2.39 mmOl/L

2.02 – 2.60 mmOl/L

The potassium electrolyte level is within normal range. This is due to the Intravenous fluid of the client that helps in maintaining equilibrium on serum electrolyte levels even the client is in NPO. The calcium level is within the normal range which denotes that the client’s body is metabolizing calcium normally. This may also be due to the Intravenous fluid of the client that helps in

maintaining equilibrium on serum electrolyte levels even the client is in NPO.

Serum Electrolyte, blood,  Before 1. 2. 3. 4.

Check the doctor’s order Explain the procedure Explain the purpose and what to expect No food or fluid restrictions

 During 1. 2. 3. 4.

Do not take the blood sample from hand or arm with receiving IVF The tourniquet should be less on a minute Do not squeeze the punctured site rightly Wipe away the first drop of blood

 After 1. Observed and record vital signs. 2. Check injection sites for bleeding, infection, tenderness or thrombosis. 3. Report untoward reaction to the physician. 4. Apply warm compress to ease discomfort, as ordered. Interpret results and provide counsel appropriately. Provide health teachings regarding proper lifestyle changes and symptoms that may warrant immediate medical attention.

BLOOD HEMATOLOGY

Hemoglobin (Hgb)

Hematocrit (Hct)

Ordered: May 8, 09 Results in: May 8, 09

Ordered: May 8, 09 Results in:

- to monitor Hgb value in the RBC - to suggest the presence of body fluid deficit due to elevated Hgb level To aid diagnosis of abnormal

160 g/dl

125-175 g/dl

0.47 g/L

0.40-0.52 g/L

The hemoglobin level is within the normal range. This denotes that the client has normally functioning blood components. The hematocrit level is within the normal

states of hydration, polycythemia and anemia.

May 8, 09

WBC

Neutrophils

Lymphocytes

Platelets

Ordered: May 8, 09 Results in: May 8, 09

Ordered: May 8, 09 Results in: May 8, 09

Ordered: May 8, 09 Results in: May 8, 09

Ordered:

range. Denoting that the client’s hydration status has not depleted.

- It measures the concentration of RBC within the blood volume and is expressed as a percentage. The test is performed to find out how many white blood cells you have. Your body produces more white blood cells when you have an infection or allergic reaction, even when you are under general stress To detect presence of infection in the body

To detect presence of infection within the body.

The number of

15.9x109/L

5-10 x 109/L

.40

.45-.65

0.55

0.20-0.35

350x109

150-

The WBC count denotes that the client has an infection.

The Neutrophils is below the normal range this level of Neutrophils also denotes infection. Together with this high lymphocyte level denotes that the client may have viral or bacterial infection.

The platelet

May 8, 09 Results in: May 8, 09

platelets in your blood can be affected by many diseases. Platelets may be counted to monitor or diagnose diseases, or identify the cause of excess bleeding.

g/L

400x109 g/L

count is within the normal range this denote that the client’s body has a good coagulation status.

Nursing Implications for Blood Hematology Test:  Pretest: 1. Inform the family that the test is used to evaluate numerous conditions inflammation, infection, and response to chemotherapy. 2. Obtain a list of medications the patient is taking. 3. Review the procedure with the mother. Explain the duration of the procedure and inform the mother that there may be some discomforts during the procedure.  1. 2. 3.

Intratest: Observe Standard precautions. apply a pressure dressing over the puncture site. Promptly transport the specimen to the laboratory for processing and analysis.

 Post-test: 1. Observe venipuncture site for bleeding or hematoma formation. Apply paper tape or other adhesive to hold pressure bandage in place.

III. ANATOMY AND PHYSIOLOGY Lymphatic System The

lymphatic

system

consists of organs, ducts, and nodes. It transports a watery clear fluid

called

lymph.

This

fluid

distributes immune cells and other factors throughout the body. It also interacts with the blood circulatory system to drain fluid from cells and tissues.

The

contains

lymphatic

immune

system

cells

called

lymphocytes, which protect the body against antigens (viruses, bacteria,

etc.)

that

invade

the

body. See more on lymphocytes below. Main Functions of Lymphatic System To

collect

and

return

interstitial fluid, including plasma protein and

to

thus

help

the maintain

blood, fluid

balance, To defend the body against disease by producing lymphocytes, To absorb lipids from the intestine and transport them to the blood. Lymph organs include the bone marrow, lymph nodes, spleen, and thymus. Precursor cells in the bone marrow produce lymphocytes. B-lymphocytes (B-cells) mature in the bone marrow. T-lymphocytes (T-cells) mature in the thymus gland.

Lymph Nodes - A lymph node is an organized collection of lymphoid tissue, through which the lymph passes on its way to returning to the blood. Lymph nodes are located at intervals along the lymphatic system. Several afferent lymph vessels bring in lymph, which percolates through the substance of the lymph node, and is drained out by an efferent lymph vessel. The Cardiovascular System The heart and circulatory system make up the cardiovascular system. The heart works as a pump that pushes blood to the organs, tissues, and cells of the body. Blood delivers oxygen and nutrients to every cell and removes the carbon dioxide and waste products made by those cells. Blood is carried from the heart to the rest of the body through a complex network of arteries, arterioles, and capillaries. Blood is returned to the heart through venules and veins. The one-way circulatory system carries blood to all parts of the body. This process of blood flow within the body is called circulation. Arteries carry oxygen-rich blood away from the heart, and veins carry oxygen-poor blood back to the heart. In pulmonary circulation, though, the roles are switched. It is the pulmonary artery that brings oxygenpoor blood into the lungs and the pulmonary vein that brings oxygen-rich blood back to the heart. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) Twenty major arteries make a path through the tissues, where they branch into smaller vessels called arterioles. Arterioles further branch into capillaries, the true deliverers of oxygen and nutrients to the cells. Most capillaries are thinner than a hair. In fact, many are so tiny, only one blood cell can move through them at a time. Once the capillaries deliver oxygen and nutrients and pick up carbon dioxide and other waste, they move the blood back through wider vessels called venules. Venules eventually join to form veins, which deliver the blood back to the heart to pick up oxygen. Vasoconstriction

or the spasm of smooth muscles around the blood vessels causes and decrease in blood flow but an increase in pressure. In vasodilation, the lumen of the blood vessel increase in diameter thereby allowing increase in blood flow. There is no tension on the walls of the vessels therefore, there is lower pressure. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) Various external factors also cause changes in blood pressure and pulse rate. An elevation or decline may be detrimental to health. Changes may also be caused or aggravated by other disease conditions existing in other parts of the body. The blood is part of the circulatory system. Whole blood contains three types of blood cells, including: red blood cells, white blood cells and platelets. These three types of blood cells are mostly manufactured in the bone marrow of the vertebrae, ribs, pelvis, skull, and sternum. These cells travel through the circulatory system suspended in a yellowish fluid called plasma. Plasma is 90% water and contains nutrients, proteins, hormones, and waste products. Whole blood is a mixture of blood cells and plasma. Red blood cells (also called erythrocytes) are shaped like slightly indented, flattened disks. Red blood cells contain an iron-rich protein called hemoglobin. Blood gets its bright red color when hemoglobin in red blood cells picks up oxygen in the lungs. As the blood travels through the body, the hemoglobin releases oxygen to the tissues. The body contains more red blood cells than any other type of cell, and each red blood cell has a life span of about 4 months. Each day, the body produces new red blood cells to replace those that die or are lost from the body. White blood cells (also called leukocytes) are a key part of the body's system for defending itself against infection. They can move in and out of the bloodstream to reach affected tissues. The blood contains far fewer white blood cells than red cells, although the body can increase production of white blood cells to fight infection. There are several types of white blood cells, and their life spans vary from a few days to months. New cells are constantly being formed in the bone marrow. Several different parts of blood are involved in fighting infection. White blood cells called granulocytes and lymphocytes travel along the walls of blood vessels. They fight bacteria and viruses and may also attempt to destroy cells that have become infected or

have changed into cancer cells. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) Certain types of white blood cells produce antibodies, special proteins that recognize foreign materials and help the body destroy or neutralize them. When a person has an infection, his or her white cell count often is higher than when he or she is well because more white blood cells are being produced or are entering the bloodstream to battle the infection. After the body has been challenged by some infections, lymphocytes remember how to make the specific antibodies that will quickly attack the same germ if it enters the body again. Platelets (also called thrombocytes) are tiny oval-shaped cells made in the bone marrow. They help in the clotting process. When a blood vessel breaks, platelets gather in the area and help seal off the leak. Platelets survive only about 9 days in the bloodstream and are constantly being replaced by new cells. Blood also contains important proteins called clotting factors, which are critical to the clotting process. Although platelets alone can plug small blood vessel leaks and temporarily stop or slow bleeding, the action of clotting factors is needed to produce a strong, stable clot. Platelets and clotting factors work together to form solid lumps to seal leaks, wounds, cuts, and scratches and to prevent bleeding inside and on the surfaces of our bodies. The process of clotting is like a puzzle with interlocking parts. When the last part is in place, the clot is formed. When large blood vessels are cut the body may not be able to repair itself through clotting alone. In these cases, dressings or stitches are used to help control bleeding. In addition to the cells and clotting factors, blood contains other important substances, such as nutrients from the food that has been processed by the digestive system. Blood also carries hormones released by the endocrine glands and carries them to the body parts that need them. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

Blood is essential for good health because the body depends on a steady supply of fuel and oxygen to reach its billions of cells. Even the heart couldn't survive without blood flowing through the vessels that bring nourishment to its muscular walls. Blood also carries carbon dioxide and other waste materials to the lungs, kidneys, and digestive system, from where they are removed from the body. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) IMMUNE SYSTEM An immune system is a collection of biological processes within an organism that protects against disease by identifying and killing pathogens and tumour cells. It detects a wide variety of agents, from viruses to parasitic worms, and needs to distinguish them from the organism's own healthy cells and tissues in order to function properly. Detection is complicated

as

pathogens

can

evolve

rapidly;

producing adaptations that avoid the immune system and allow the pathogens to successfully infect their hosts. To survive this challenge, multiple mechanisms evolved that recognize and neutralize pathogens. Even simple unicellular organisms such as bacteria possess enzyme systems that protect against viral infections. Other basic immune mechanisms evolved in ancient eukaryotes and remain in their modern descendants, such as plants, fish, reptiles,

and

insects.

These

mechanisms

include

antimicrobial peptides called defensins, phagocytosis, and the complement system. Vertebrates such as humans

have

even

more

sophisticated

defense

mechanisms. The immune systems of vertebrates consist of many types of proteins, cells, organs, and tissues, which interact in an elaborate and dynamic network. As part of this more complex immune response, the human immune system adapts over time to recognise specific pathogens more efficiently. This adaptation process is referred to as "adaptive immunity" or "acquired immunity" and creates immunological memory.

Immunological memory created from a primary response to a specific pathogen, provides an enhanced response to secondary encounters with that same, specific pathogen. This process of acquired immunity is the basis of vaccination. Disorders in the immune system can result in disease. Immunodeficiency diseases occur when the immune system is less active than normal, resulting in recurring and life-threatening infections. Immunodeficiency can either be the result of a genetic disease, such as severe combined immunodeficiency, or be produced by pharmaceuticals or an infection, such as the acquired immune deficiency syndrome (AIDS) that is caused by the retrovirus HIV. In contrast, autoimmune diseases result from a hyperactive immune system attacking normal tissues as if they were foreign organisms. Common autoimmune diseases include rheumatoid arthritis, diabetes mellitus type 1 and lupus erythematosus. Immunology covers the study of all aspects of the immune system which has significant relevance to human health and diseases. Further investigation in this field is expected to play a serious role in promotion of health and treatment of diseases.

IV. THE PATIENT AND HIS ILLNESS A. SCHEMATIC DIAGRAM NEONATAL SEPSIS (BOOK – CENTERED) NON -MODIFIABLE FACTORS >Common among male >common on pre term babies >common on developmental countries

MODIFIABLE FACTORS >Congenital Infection >early onset infection >Late onset infection

Focus of infection Superantigen Hyperdynamic Phase

Activated inflammatory cells Activation of host

Activation of complement system

Activation of coagulation system

Activated endothelium >increased multiplication >adhesion molecules

>hypo/hyperthermia >tachypnea >tachycardia >↑metabolic demands

Endogenous mediator release >pro-inflammatory cytokines >anti-inflammatory cytokines >platelet activating factor >arachidonic acid metabolites >myocardial depressant substance >endogenous opiates

Sudden ↓ in cardiac output

↓thrombomodulin ↑plasminogen activator inhibitor Thrombosis and

Hypovolemia Cardiac and vascular failure Capillary leak/ endothelial damage Acute respiratory distress Disseminated intravascular coagulation Decreased steroid synthesis

shock

Multiorgan dysfunction syndrome (MODS) death

>poor cardiac output >delayed capillary refill >Diminished peripheral and central pulses >cool extremities >↓ urine output >alteration in mental status

Neonatal Sepsis (Patient – Centered) NON -MODIFIABLE FACTORS >Common among male >common on developmental countries

MODIFIABLE FACTORS >Late onset infection

Focus of infection Superantigen Activated inflammatory cells

Vomiting (May 8, 14, 2009) Watery stool (May 14, 2009)

Maculopappular rashes (May 8, 2009) Feeding intolerance (May 8,2009) tachypnea (May 11-12, 14,2009)

Activation of host Endogenous mediator release >pro-inflammatory cytokines >anti-inflammatory cytokines >platelet activating factor >arachidonic acid metabolites >myocardial depressant substance >endogenous opiates

Cold clammy skin (May 13,2009)

↑lymphocyt es (May

B. SYNTHESIS OF THE DISEASE Neonatal sepsis, also termed Sepsis neonatorum in simplest way of defining it, refers to a group of physical and laboratory findings that occur in response to invasive infection within the first 30 days of life, this is may be a bacterial or viral etiology. This may arise from congenital infection (common among premature babies and to those babies wherein their mother suffered from infections while they are pregnant), early onset infection (most common on prolonged labor) and late onset infection which is caused by environmental factors. Congenital infection per se is an infection acquired before a neonate was born. As elaborated, this is common among premature babies and to those babies whom their mothers have suffered from infection while they are pregnant. Early and late onset infections per se are infections that were acquired after they were born. Early onset infections are infections that arise on the first week of life and late onset infection arose beyond 1 week after delivery. There are several key features of neonates that place them at increased risk for the development of sepsis. Neonates have a relatively immature immune system, and the effects on the immune system are more pronounced in more premature neonates. Such defects include a loss of protective maternal antibodies, as well as non-specific alterations in macrophage phagocytosis and clearance of invading pathogens, impaired T-cell and B-cell responses, and altered production of complement and antibodies. In addition, the newborn infant – particularly the preterm infant – has relatively permeable mucosal surfaces that allow for the trans-epithelial passage of bacteria and other pathogens. The frequency with which preterm neonates undergo invasive procedures, that themselves result in the introduction of potential pathogens, also increases the specific risk to the neonate of the development of sepsis. The presence of comorbidities, such as impaired cardiac function, anatomic defects of the gastro-intestinal or urinary tract, and abnormalities in glucose metabolism worsen the neonate’s ability to withstand infection, and lead to an increased risk for the development of neonatal sepsis. Neonates with sepsis present with a variety of subtle clinical findings that individually may not point to a specific infectious etiology, but together should alert the

caregiver to the fact that the infant is septic. These signs include subtle changes in respiration, including apnea and / or tachypnea. There may be associated changes in heart rate, including frequent episodes of bradycardia and/or tachycardia. The reasons that sepsis leads to changes in ventilation and cardiac rate are not completely understood, but they remain highly useful as markers for the presence of sepsis. In addition, neonates with sepsis commonly exhibit alterations in core body temperature, as manifested by fever and or hypothermia. Changes in skin perfusion commonly accompany sepsis, as manifested by mottling, cooling of the extremities, and a general “ill look” to the baby overall. Other subtle findings of sepsis include the development of feeding intolerance, vomiting, or diarrhea.

In more advanced stages, infants with sepsis may show signs of petechiae small areas of hemorrhage within the skin – as evidence for the platelet consumption that frequency is seen in sepsis. In association with these signs, more advanced sepsis is associated with evidence of global impaired tissue perfusion, characterized by reduced urine output and decreased systemic blood pressure. Secondary pulmonary hypertension may develop in more severe cases of sepsis, leading to impaired gas exchange in the lungs. This can result in progressive tissue hypoxia and increased work of breathing. It is important to point out that the clinical course of septic patients is unpredictable. There may be the gradual onset of tachypnea, nasal flaring and fever, or the rapid, striking development of cardio-respiratory shock. The specific course depends to some degree on the infectious agent, the overall health of the neonate, including gestational age and birth weight, and the presence of specific co-morbidities. However, it is fairly safe to predict that in the absence of aggressive treatment that is directed at maintaining tissue perfusion, supporting the function of the cardio-respiratory system and treating the underlying infection, septic neonates can be expected to have a dramatic downward spiral, characterized by systemic inflammation and multiple organ dysfunction. Fortunately, aggressive early therapy is highly successful in treating sepsis in the majority of cases (see below). The specific focus of sepsis may affect the presentation to some degree. Infants with pneumonia typically develop pulmonary symptoms first (nasal flaring followed by

increased oxygen requirements and respiratory failure). Infants with meningitis may manifest bulging fontanels. However, in general, the signs of sepsis are subtle and do not point to the precise infectious location or agent. Prevention of late-onset neonatal sepsis includes care and attention to limit nosocomial infection. Measure such as hand washing techniques, sterile techniques for any procedure, care and attention to central line access, and avoidance of exposure of at-risk infants to neonates with known infections can all limit the incidence of late-onset neonatal sepsis.

Sources: Karla L. Luxner, RNC, ND (2005) Delmar’s Maternal – Infant Nursing Care Plans nd

2 ed. Canada: Thomson Delmar Learning Inc. Susan Tucker Blackburn, PhD, RN, FAAN (2007) Maternal, Fetal, Neonatal Physiology: A Clinical Perspective 3rd ed. St. Louis, Missouri: Saunders an imprint of Elsvier’s Inc. Kleigman R. et. al. (2007) Nelson’s Textbook of Pediatrics 18th ed. Philadelphia, Saunders an imprint of Elsvier’s Inc.