Neonatal-Sepsis-NCP

Definition

Neonatal Sepsis or Neonatal Septicemia or Sepsis Neonatorum is an infection in the blood that spreads throughout the body and occurs in a neonate. Neonatal Sepsis has two types:

Early-onset Sepsis

Onset of sepsis and most often appears in the first 24 hours of life. The infection is often acquired from the mother.  This can be cause by a bacteria or infection acquired by the mother during her pregnancy, a Preterm delivery, Rupture of membranes (placenta tissue) that lasts longer than 24 hours, Infection of the placenta tissues and amniotic fluid (chorioamnionitis) and frequent vaginal examinations during labor.

Late-onset Sepsis

The second type or the Late-onset Sepsis is acquired after delivery.  This can be cause by contaminated hospital equipment, exposure to medicines that lead to antibiotic resistance, having a catheter in a blood vessel for a long time, staying in the hospital for an extended period of time.

Signs and Symptoms

Signs and symptoms of Neonatal Sepsis includes but is not limited to: body temperature changes, breathing problems, diarrhea, low blood sugar, reduced movements, reduced sucking, seizures, slow heart rate, swollen belly area, vomiting, yellow skin and whites of the eyes (jaundice). Possible complications are disability and worst is death of the neonate.

Nursing Care Plans

Here are 5 Neonatal Sepsis Nursing Care Plans.

Hyperthermia

NDx: Hyperthermia related to inflammatory process/ hypermetabolic state as evidenced by an increase in body temperature, warm skin and tachycardia

Due to the presence of an infectious agents, stimulation of the monocytes triggers the release of the pyrogenic cytokines that stimulate anterior hypothalamus which results in elevated thermoregulatory set point that leads to an increased heat conservation (Vasoconstriction) and increased heat production which results to fever.

Assessment Planning Intervention Rationale Expected Outcome
Subjective: May manifest:

  • Irritability
  • Weakness
  • Objective:
  • The patient may manifest one or more of the following:
  • Temperature above normal level (36 oC)
  • Skin warm to touch
  • Presence of tachycardia (above 160 bpm)
  • Presence of tachypnea (above 60 bpm)
  • WBC elevated
Short-term:After 30 minutes of nursing intervention the patient will maintain normal core temperature as evidenced by vital signs within normal limits and normal WBC level

Long Term:

After 3 days of NI, pt will still maintain normal core temperature as evidenced by normal vital signs and normal laboratory results.

  1. Monitor neonate’s condition.
  2. Monitor Vital signs
  3. Provide TSB
  4. Ensure that all equipment used for infant is sterile, scrupulously clean. Do not share equipment with other infants
  5. Administer Anti-pyretics as ordered
  1. To determine the need for intervention and the effectiveness of therapy.
  2. To have a baseline data
  3. Helps in lowering down the temperature
  4. this would prevent the spread of pathogens to the infant from equipment
  5. aids in lowering down temperature
The patient shall maintain normal core temperature as evidenced by normal vital signs and normal laboratory results.

Fluid Volume Deficit

NDx: Fluid volume deficit related to failure of regulatory mechanism

Fluid volume deficit, or hypovolemia, occurs from a loss of body fluid or the shift of fluids into the third space one factor includes a failure of the regulatory mechanism of the newborn specifically hyperthermia

Assessment Planning Intervention Rationale Expected Outcome
Subjective:Objective:The patient may manifest one or more of the following:

  • decreased urine output
  • increased urine concentration
  • increased pulse rate (above 160 bpm)
  • increased body temperature (above 36 oC)
  • decreased skin turgor
  • dry skin/ mucous membranes
  • elevated hct
Short-term:After 3 hours of nursing intervention, the patient will be able to maintain fluid volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor and prompt capillary refill and resolution of edema.Long Term:

After a couple of days the patient will still be able to maintain fluid volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor and prompt capillary refill and resolution of edema.

  1. Monitor and record vital signs
  2. Note for the causative factors that contribute to fluid volume deficit
  3. Provide TSB if patient has fever
  4. Provide oral care by moistening lips & skin care by providing daily bath
  5. Administer IV fluid replacement as ordered
  6. Administer antipyretic drugs if patient has fever as ordered
  1. To note for the alterations in V/S (decreased BP, Increased in PR and temp)
  2. To assess what factor contributes to fluid volume deficit that may be given prompt intervention.
  3. To decrease temperature and provide comfort
  4. To prevent injury from dryness
  5. replaces fluid losses
  6. to reduce body temperature
The patient shall be able to maintain fluid volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor and prompt capillary refill and resolution of edema.

Ineffective Tissue Perfusion

NDx: Ineffective tissue perfusion related to impaired transport of oxygen across alveolar and on capillary membrane

Since the body of the newborn is unable to compensate to the imbalances of the inflammatory response related to his condition the body tends to “hyperdrive” causing an inadequate oxygen in the tissues or capillary membrane leading to poor perfusion.

Assessment Planning Intervention Rationale Expected Outcome
Subjective:Objective:The patient may manifest one or more of the following:

  • skin or temperature changes
  • Weak pulses
  • Edema
  • Inadequate urine output
Short-term:After 3 hours of nursing intervention the patient will demonstrate increased perfusion as evidenced by warm and dry skin, strong peripheral pulses, normal vital signs, adequate urine output and absence of edemaLong Term:

After 3 days of NI, pt will maintain adequate perfusion AEB stable VS, warm and dry skin, absence of edema, adequate urine output and strong peripheral pulses.

  1. Monitor neonate’s condition
  2. Monitor Vital signs
  3. Note quality and strength of peripheral pulses
  4. Assess respiratory rate, depth, and quality
  5. Assess skin for changes in color, temperature and moisture
  6. Elevate Head of Bead
  7. Elevate affected extremities with edema once in a while
  8. Provide a quiet, restful atmosphere
  9. Administer oxygen as ordered
  1. To determine the need for intervention and the effectiveness of therapy.
  2. To have a baseline data
  3. To asses pulse that may become weak or thready, because of sustained hypoxemia
  4. To note for an increased respiration that occurs in response to direct effects of endotoxins on the respiratory center in the brain, as well as developing hypoxia, stress. Respirations can become shallow as respiratory insufficiency develops creating risk of acute respiratory failure.
  5. To assess for compensatory mechanisms of vasodilation
  6. To promote circulation /venous drainage
  7. To reduce edema
  8. Conserves energy and lowers O2 demand
  9. To maximize O2availability for cellular uptake
The patient shall demonstrate increased perfusion as evidenced by warm and dry skin, strong peripheral pulses, normal vital signs, adequate urine output and absence of edema

Interrupted Breastfeeding

NDx: Interrupted breastfeeding related to neonate’s present illness as evidenced by separation of mother to infant

Since the neonate is diagnosed for having a neonatal sepsis, the baby got separated from his mother and placed on a Neonatal Intensive Care Unit for better management and care.  Interrupted breastfeeding develops since the mother is unable to breastfeed the baby continuously due to their separation.

Assessment Planning Intervention Rationale Expected Outcome
Subjective:Objective:The patient may manifest one or more of the following:

  • The newborn is diagnosed with a certain disease (Sepsis)
  • The newborn is separated from his mother
  • The mother unable to provide breast milk to newborn continuously
Short-term:After 3 hours of nursing intervention and health teachings the mother will identify and demonstrate techniques to sustain lactation until breastfeeding is initiatedLong Term:

After 3 days of NI, the mother shall still be able to identify and demonstrate techniques to sustain lactation and identify techniques on how to provide the newborn with breast milk.

  1. Assess mother’s perception and knowledge about breastfeeding and extent of instruction that has been given.
  2. Give emotional support to mother and accept decision regarding cessation/ continuation of breast feeding.
  3. Demonstrate use of manual piston-type breast pump.
  4. Review techniques for storage/use of expressed breast milk
  5. Determine if a routine visiting schedule or advance warning can be provided
  6. Provide privacy, calm surroundings when mother breast feeds.
  7. Recommend for infant sucking on a regular basis
  8. Encourage mother to obtain adequate rest, maintain fluid and nutritional intake, and schedule breast pumping every 3 hours while awake
  1. To know what the mother already knows and needed to know.
  2. To assist mother to maintain breastfeeding as desired.
  3. aid in feeding the neonate with breast milk without the mother breastfeeding the infant.
  4. To provide optimal nutrition and promote continuation of breastfeeding process
  5. So that infant will be hungry/ ready to feed
  6. To promote successful infant feeding
  7. Reinforces that feeding time is pleasurable and enhances digestion.
  8. to sustain adequate milk production and breast feeding process
The mother shall be able to identify and demonstrate techniques to sustain lactation and identify techniques on how to provide the newborn with breast milk.

Risk for Impaired Parent/Infant Attachment

NDx: Risk for Impaired parent/ neonates Attachment related to neonates physical illness and hospitalization.

Due to the newborn’s physical illness and hospitalization, the parents may have fear on how to handle their baby since the baby is on its fragile state and needed extra care.  And since he is the 1st child hospitalized in their family, the parents might still be unsure on how to take care of the baby.

Assessment Planning Intervention Rationale Expected Outcome
Subjective:Objective:The patient may manifest one or more of the following:

  • The newborn is diagnosed with a certain disease (Sepsis)
  • The newborn is separated from his mother
  • The mother unable to provide breast milk to newborn continuously
Short-term:After 3 hours of nursing intervention and health teachings the mother will identify and demonstrate techniques to enhance behavioral organization of the neonateLong Term:

After discharge the parents will be able to have a mutually satisfying interactions with their newborn.

  1. Interview parents, noting their perception of situational and individual concerns
  2. Educate parents regarding child growth and development, addressing parental perceptions
  3. Involve parents in activities with the newborn that they can accomplish successfully
  4. Recognize and provide positive feedback for nurturing  and protective parenting behaviors
  1. To know what the parents feelings about the situation.
  2. Helps clarify realistic expectations
  3. Enhances self-concept
  4. Reinforces continuation of desired behaviors
The parents shall be able to have a mutually satisfying interactions with their newborn.

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