5 Neonatal Sepsis Nursing Care Plans

November 12, 2011

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

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 Interventions	Rationale
Monitor neonate’s condition.	To determine the need for intervention and the effectiveness of therapy.
Monitor vital signs	To have a baseline data
Provide TSB	Helps in lowering down the temperature
Ensure that all equipment used for infant is sterile, scrupulously clean. Do not share equipment with other infants	Prevents the spread of pathogens to the infant from equipment
Administer antipyretics as ordered	Aids 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

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 Interventions	Rationale
Monitor and record vital signs	To note for the alterations in V/S (decreased BP, Increased in PR and temp)
Note for the causative factors that contribute to fluid volume deficit	To assess what factor contributes to fluid volume deficit that may be given prompt intervention.
Provide TSB if patient has fever	To decrease temperature and provide comfort
Provide oral care by moistening lips & skin care by providing daily bath	To prevent injury from dryness
Administer IV fluid replacement as ordered	Replaces fluid losses
Administer antipyretic drugs if patient has fever as ordered	To 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

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

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 Interventions	Rationale
Note quality and strength of peripheral pulses	To asses pulse that may become weak or thready, because of sustained hypoxemia
Assess respiratory rate, depth, and quality	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.
Assess respiratory rate, depth, and quality	To assess for compensatory mechanisms of vasodilation
Assess skin for changes in color, temperature and moisture	To promote circulation /venous drainage
Elevate affected extremities with edema once in a while	Conserves energy and lowers O2 demand
Provide a quiet, restful atmosphere	To 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 Interventions	Rationale
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 milk	To provide optimal nutrition and promote continuation of breastfeeding process
Determine if a routine visiting schedule or advance warning can be provided	So 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 basis	Reinforces 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 awake	To 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 1^st 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

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 Interventions	Rationale
Interview parents, noting their perception of situational and individual concerns	To know what the parents feelings about the situation.
Educate parents regarding child growth and development, addressing parental perceptions	Helps clarify realistic expectations
Involve parents in activities with the newborn that they can accomplish successfully	Enhances self-concept
Recognize and provide positive feedback for nurturing and protective parenting behaviors	Reinforces continuation of desired behaviors