5 Neonatal Sepsis Nursing Care Plans

By
Matt Vera, BSN, R.N.
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Neonatal sepsis (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 caused 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,
  • yellowish 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 and nursing diagnosis:

Hyperthermia

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

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Patient may manifest

  • Irritability
  • Weakness
  • Temperature above normal level (36 oC)
  • Skin warm to touch
  • Presence of tachycardia (above 160 bpm)
  • Presence of tachypnea (above 60 bpm)
  • WBC elevated

Nursing Diagnosis

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

Outcomes

  • Patient will maintain normal core temperature as evidenced by vital signs within normal limits and normal WBC level
  • Patient will still maintain normal core temperature as evidenced by normal vital signs and normal laboratory results.
Nursing InterventionsRationale
Monitor neonate’s condition.To determine the need for intervention and the effectiveness of therapy.
Monitor vital signsTo have a baseline data
Provide TSBHelps in lowering down the temperature
Ensure that all equipment used for infant is sterile, scrupulously clean. Do not share equipment with other infantsPrevents the spread of pathogens to the infant from equipment
Administer antipyretics as orderedAids in lowering down temperature

Fluid Volume Deficit

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

Patient may manifest

  • Decreased urine output
  • Increased urine concentration
  • Increased pulse rate (above 160 bpm)
  • Decreased body temperature (above 36 oC)
  • Decreased skin turgor
  • Dry skin/ mucous membranes
  • Elevated hct

Nursing Diagnosis

  • Fluid volume deficit related to failure of regulatory mechanism

Outcomes

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  • 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.
Nursing InterventionsRationale
Monitor and record vital signsTo note for the alterations in V/S (decreased BP, Increased in PR and temp)
Note for the causative factors that contribute to fluid volume deficitTo assess what factor contributes to fluid volume deficit that may be given prompt intervention.
Provide TSB if patient has feverTo decrease temperature and provide comfort
Provide oral care by moistening lips & skin care by providing daily bathTo prevent injury from dryness
Administer IV fluid replacement as orderedReplaces fluid losses
Administer antipyretic drugs if patient has fever as orderedTo reduce body temperature

Ineffective Tissue Perfusion

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

Patient may manifest

  • Skin or temperature changes
  • Weak pulses
  • Edema
  • Inadequate urine output

Nursing Diagnosis

Outcomes

  • Patient will demonstrate increased perfusion as evidenced by warm and dry skin, strong peripheral pulses, normal vital signs, adequate urine output and absence of edema
Nursing InterventionsRationale
Note quality and strength of peripheral pulsesTo asses pulse that may become weak or thready, because of sustained hypoxemia
Assess respiratory rate, depth, and qualityTo 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.
Assess respiratory rate, depth, and qualityTo assess for compensatory mechanisms of vasodilation
Assess skin for changes in color, temperature and moistureTo promote circulation /venous drainage
Elevate affected extremities with edema once in a whileConserves energy and lowers O2 demand
Provide a quiet, restful atmosphereTo maximize O2availability for cellular uptake

Interrupted Breastfeeding

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

  • 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

Nursing Diagnosis

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

Outcomes

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

Risk for Impaired Parent/Infant Attachment

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

  • 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

Nursing Diagnosis

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

Outcomes

  • The mother will identify and demonstrate techniques to enhance behavioral organization of the neonate
  • After discharge the parents will be able to have a mutually satisfying interactions with their newborn.
Nursing InterventionsRationale
Interview parents, noting their perception of situational and individual concernsTo know what the parents feelings about the situation.
Educate parents regarding child growth and development, addressing parental perceptionsHelps clarify realistic expectations
Involve parents in activities with the newborn that they can accomplish successfullyEnhances self-concept
Recognize and provide positive feedback for nurturing  and protective parenting behaviorsReinforces continuation of desired behaviors

See Also

You may also like the following posts and care plans:

Maternal and Newborn Care Plans

Nursing care plans related to the care of the pregnant mother and her infant. See care plans for maternity and obstetric nursing:

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