INSTITUT LATIHAN KEMENTERIAN KESIHATAN MALAYSIA
SULTAN AZLAN SHAH PERAK
ADVANCED DIPLOMA IN NEONATAL NURSING
SEPTEMBER 2023
NNCP4014 CLINICAL PRACTICE 1
NNCP 4014
LONG CASE
NEONATAL SEPSIS
NAME: SITI NUR AISHAH BINIT SHAMSUDDIN
MATRIC ID:ADNN 2/2023 (06)-0014
UNIT/WARD: NEONATAL INTENSIVE CARE UNIT (NICU)
HOSPITAL RAJA SRI PERMAISURI BAINUN (HRPB)
NAME ASSESSOR: PUAN LIZA HARYANTI BINTI ABU BAKAR
ASSESMENT DATE: 5 DISEMBER 2023
1.DEFINITIN OF NEONATAL SEPSIS
Neonatal sepsis is an infection of the bloodstream in newborn infants smaller than 28
days old. It is currently one of the leading causes of morbidity and mortality in
newborns, especially among small and lower-income countries. Neonatal sepsis is
classified into two categories based on as it begins after birth: early-onset sepsis
(EOS) and late-onset sepsis (LOS). EOS refers to sepsis in neonates occurring
within the first 72 hours of life (other experts use seven days), whereas LOS refers to
sepsis happening within the last 72 hours of life. (Wynn, 2016)
(a) 1. Early-onset sepsis (EOS) is caused by pathogen transmission from the
female genitourinary system to the neonate or fetus. These viruses can infect
the amniotic fluid as well as the vagina, cervix, and uterus. Neonatal infections
can also occur in pregnancy or during birth as the baby passes through the
vaginal canal. Group B streptococcus (GBS), Escherichia coli, coagulase-
negative Staphylococcus, influenzae, and Listeria monocytogenes are
common bacterial infections causing EOS. Chorioamnionitis, GBS infection,
birth before 37 weeks, and protracted rupture of membranes lasting more
than 18 hours are all risk factors for newborn sepsis. (Simonsen et al., 2014)
(b) 2. Late-onset sepsis (LOS) is typically caused by bacterial transmission from
the surrounding environment after birth, such as interaction with hospital
professionals or caregivers. Some cases of LOS may also be the result of a
late manifestation of a vertically transmitted infection. Infants who require
intravascular catheter insertion or other invasive activity affecting the mucosa
are more likely to develop LOS. (Hoffman et al., 2015)
The underdeveloped immune system is the primary cause of increased newborn
sensitivity to sepsis. Polymorphonuclear neutrophils, macrophages, and T
lymphocytes are incapable of carrying out a full inflammatory response in newborns
due to their immature function. Furthermore, newborns have a restricted quantity of
immunoglobulins at birth and are unable to build an appropriate quantitative and/or
qualitative response against pathogenic pathogens. Premature pregnancy's limited
time in the uterus reduces the transfer of immune globulins to the fetus. When
compared to term infants, preterm infants have a substantially higher risk of sepsis
due to immunoglobulin deficiencies. (Raymond et al.,2017)
SIGN AND SYMPTOMS
Neonatal sepsis can range from nonspecific or vague symptoms to hemodynamic
collapse. Early symptoms may include
1. irritability,
2. lethargy, or poor feeding.
3. develop respiratory distress.
4. fever
5. hypothermia or hypotension with poor perfusion and shock.
6. Sometimes the diagnosis may only be suspected on the basis of laboratory
findings, which may reveal hyperglycemia or hypoglycemia, acidosis, or
hyperbilirubinemia.
Prematurity and very low birth weights are also important risk factors to
consider. (Snowden et al., 2015)
2.BACKGROUND OF THE CASE
BABY DETAILS
Name: B/O Wong hoi mei
Date of birth:5th December 2023 at 0039hrs Hospital Raja Permaisuri Bainun
Date of admission in Nicu :5th December 2023 at 0130hrs
Mode of delivery: SVD due to prem contraction
Birth weight :1280gram
Length:36cm
Circumference of the head:26cm
Apgar score:9 in 10 minutes.
Vital sign at labour room
Temperature: 35.6°C
HR:120bpm
RR:67/min
BP:52/48 (40) mmhg map within the gestation age
Spo2:60% ↓ RA
Cbs:3.8mmol/L
*5min of life put on neo puff spo2 pickup to 95-97% with peep 5cmH2o
HR :135bpm
Upon enter Nicu vital sign
Temperature: 35.7°C
HR:139bpm
RR:63/min
BP:57/45 (44) mmhg map within the gestation age
Spo2:97% ↓ RA
Antenatal care (ANC)
Anemia in pregnancy on treatment with iv cosmofer at 28/52, HB:10.2mmol/L.
The latest HB :10 mmol/L.
Assessment
Since last Friday, 29th November 2023, mother has had spotting the size of 10 cents
coins and when she went to the Gp clinic, she had clotrimazole pessaries on 4th
December 2023, mother experienced contraction at 1am monitor at labour
room.Received 1dose iv dexamethasone 6mg at 1320hrs 4th December 2023.SROM
at midnight later on baby was deliver on 5th December 2023 at 0039hrs with good
tone and breathing.Mild tahcypneic and mild recession present HR:120bpm
RR:67/min Spo2:60% ↓ RA ,nurse with neopuff SPO2 pickup 95-97% and
transferred to Nicu.
Admitted Nicu on 5th December 2023 at 0130 hours connected Pc-cmw with rate 30 ,
pressure :16/5 , fio2:30%. Baby was kept Nbm ,oral gastric tubes inserted with iv drip
dextrose 10% support run at 3.2mls/hrs via right hand. Uvc insertion by Dr.Stat chest
xray ,findings glass chest xray .continue management with iv antibiotics iv cpenicillin
1280000 units daily12 hly and iv gentamycin 6mg 36hly.
PHYSICAL EXAMINATION
General condition baby was ill and nursed with Pc-cmv ventilation and phototherapy
due to jaundice
Head
Anterior fontanel diamond shape,closed at 18 months
Posterior fontanel triangular shape closed by 4-6weeks
Face
Eyes, nose and mouth symmetry
No milia, no ecchymosis
Eyes
Symmetrical eye
No eye discharge
Eye pad attached
Ears
Presence of external ear
No skin tag, no low set of ear
Symmetry parallel with eyes
Nose
Nasal bridge and septum present
In uses of nasal prong cpap
Mouth
Dry mucosa membrane
Midline and symmetry
No cleft lip and palate
Neck
No mass,no webbing and no torticolis
Chest
Round symmetry shape with AP diameter same as transverse diameter
Baby got barren chest
Rate >60 bpm
Hand
No syndactly ,no polydactly
Arm adducted
Abdomen
Rounded shape abdomen
No abdomen distended
Umbilical
Got UVC insitu anchored at 9cm
Anus
Anal opening: seen
Genitalia
No hypospadias
No hydrocele
Have scrotum and testes
Back
No spinal bifida, no tuft of hair
No scoliosis
No sacral dimple
Leg
No syndactyly,no polydactyly
No webbing fingers
INVESTIGATION
Blood investigation
1.full blood count
(05/12/2023)
Component Result Range
TWC 16.9 4.5-11.00/L
NEUTROPHILS 48.88 2.0-8.0/L
HB 20.8 11-17g/dL
HCT 59.5 35.5-59
PLATELET 200 150-450/L
Result: indicate infection
2.Atrial blood gas
(5/12/2023)
PH 7.34 7.35 -7.45
PCO2 46.8 35-45mm Hg
PO2 78 72-104mm Hg
HCO3 22 22-26meQ/L
BE -1.5 -2 to +2
Reading show: Respiratory acidosis
Atrial blood gas
6/12/2023
PH 7.23 7.35 -7.45
PCO2 50.5 35-45mm Hg
PO2 43.9 72-104mm Hg
HCO3 22 22-26meQ/L
BE -2.5 -2 to +2
Reading show: Respiratory acidosis
i. Total serum bilirubin at 9 hours of life 6/12/2023
TSB 99.8
PL 49
IP 97
ET 254
3. ECHO
Small ASD 2.3mm L to R shunt
Moderate PDA 2.7mm L to R shunt
4. Abdominal and chest X-Ray
5/12/2023
Chest X Ray show: glass lung
Tip seen at T11
MANAGEMENT
Virgina Henderson emphasized the importance of addressing basic human needs.
For premature babies, this includes providing essential care such as warmth,
nutrition, and protection from infection.
Premature infant care is highly individualized, with the specific treatment plan based
on the baby's gestational age, birth weight, and overall health.
1. Respiratory Support:
Many premature infants have underdeveloped lungs and may require
respiratory support.
Treatment may include oxygen therapy, continuous positive airway
pressure (CPAP), or mechanical ventilation.
2. Temperature Regulation:
Premature infants have difficulty regulating their body temperature.
Keep them in a warm environment using incubators or radiant
warmers.
Monitor temperature closely to prevent hypothermia.
3. Nutritional Support:
Provide appropriate nutrition to support growth and development.
Nutrition may be provided through parenteral (intravenous) or enteral
(tube feeding) routes, depending on the baby's ability to feed.
4. Infection Prevention:
Premature infants are at a higher risk of infections. Implement strict
infection control measures.
Administer prophylactic antibiotics when necessary.
5. Monitoring and Surveillance:
Monitor vital signs, including heart rate, respiratory rate, blood
pressure, and oxygen saturation.
Conduct regular assessments of growth, development, and
neurological status.
6. Developmental Care:
Practice developmental care strategies, such as kangaroo care (skin-
to-skin contact) to promote bonding and stability.
Create a quiet and low-stimulus environment to reduce stress.
7. Management of Complications:
Address complications such as respiratory distress syndrome (RDS),
intraventricular hemorrhage (IVH), and necrotizing enterocolitis (NEC)
promptly and appropriately.
8. Eye Care:
Premature infants are at risk of retinopathy of prematurity (ROP).
Regular eye examinations and, if needed, laser therapy may be
recommended.
9. Neurological Support:
Monitor for signs of neurodevelopmental issues and provide early
intervention services when needed.
Supportive care, including physical and occupational therapy, may be
required.
10. Family-Centered Care:
Involve parents in the care of their premature infant.
Provide emotional support, education, and involve parents in decision-
making.
11. Follow-up Care:
Schedule regular follow-up appointments to monitor growth and
development.
Assess for potential long-term complications and address them
proactively
TREATMENT
1. Iv C penicillin (100,000 units/kg)
Frequency BD (8am and 8pm)
Route intravenous
Dosage:128 ,000 units
Brand name: Bicillin L-A, Pfizerpen
Indications: severe infection
2. Iv gentamicin (5mg/kg)
Frequency daily (8pm)
Route intravenous
Brand name:Garamycin
Dosage: 6mg
3.Syrup caffein (5mg/kg/)
Brand name: Cafcit.
Dosage:5mg
Route:oral
To treat apnea
4. Total parenteral nutrition (TPN)
B/o W Bwt:1.28kg D1 lipid:1gm Nbm
Total fluid:1.28kg x 60mls/kg
=76.8mls/kg/day
Lipid calculation:
( ? lipid ) x ( wt ) x 18
lipid =
÷ 3.2÷ 24
1gmx1.28kgx18
÷3.2 ÷24
=0.3mls
=0.3mls x 24
=7.2mls
Tpn calculation
*76.8mls-7.2mls=69.6mls
=69.6mls÷24
=2.9mls/hrs
4.ivd dextrose 10%
ivd drip calculation
Bwt x total fluid
÷ 24
= 1.28kg x 60mls/kg
÷ 24
= 3.2mls/hrs
DISCUSSION
Nursing care plan
Actual
1. Impaired gas exchange, related low lung function and compliance to
extrauterine life.
2. Electrolyte imbalance related to prematurity.
3. Insensible water loss related large surface area.
Potential
1. Risk for hyperbilirubenimia due to immature liver function.
2. Risk for hyponatremia related to less brown fat.
B/o W neonatal sepsis at 29/52 with AGA appropriate gestional age
Nursing care plan: Impaired gas exchange, related low lung function and compliance
to extrauterine life
Goal: Patient able to maintain clear airway and obtain good oxygenation saturation
1. Nursed baby under radiant warmer with serval control attach and temperature
setting within 36.5-37.2. To maintain NTE and to prevent high oxygenation
consumption
2. Put baby in sniffing position, to help in expand the lung
3. Ensure the nasal mask/nasal prong in place by checking the string are attach
and secure properly and can hear air are equal in both lung with stethoscope.
4. Do gentle suction with aseptic technique to clear out the secretion.
5. Ensure the water inside the humidifier is enough to maintain humidity of the
airways
6. Monitor vital sign every hours: Temperature: 36.5 -37.2 , HR:120-160bpm RR
:40-60 , SPO2:>95% BP: more than gestation age> 29. Any changes in vital
sign especially HR, shown tahycardia. May indicate early warning sign for
sepsis
7. Perform hand hygiene before and after touching the patient to reduce the risk
of nosocomial infection.
8. Make sure plan your work to minimize the risk of infection by minimal
handling.
9. Documentation any abnormalities and inform the doctor
