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 8 th 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

Randy

Father Mother

Natalie

JC

LEGEND:

MI

Hypertension

Neonatal Sepsis

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 8 th 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

RESULTSNORMAL VALUES

ANALYSIS AND INTERPRETATION

CLINICAL CHEMISTRY

HGT/RBS

Ordered:May 9- present,

2009Results

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.

5-9-09No results available5-10-09

80 mg/dL5-11-09

60 mg/dL5-12to14

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 level2. 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 exam2. 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 collected2. 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 test2. Relay the results to the attending physician

SERUM ELECTROLYTE

Sodium Ordered:May 8, 09

Results in:May 8, 09

To monitor the electrolytes

and check for imbalances

any imbalance in the fluid and

electrolytes. Sodium plays a major role in homeostasis in

a variety of ways including

the renal retention and excretion of

water.

139.2 mEq/ L

136 – 145

mEq/L

The sodium 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.

Potassium

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.

4.56 mmoL/L

3.5 – 5.0 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.

Calcium

Ordered:May 8, 09

Results in:May 8, 09

Serum Calcium is

being checked to observe for

any imbalances with serum electrolytes

since the client has

experienced vomiting

episodes.

2.39 mmOl/L

2.02 – 2.60

mmOl/L

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. Check the doctor’s order2. Explain the procedure3. Explain the purpose and what to expect4. No food or fluid restrictions

During

1. Do not take the blood sample from hand or arm with receiving IVF2. The tourniquet should be less on a minute3. Do not squeeze the punctured site rightly4. 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)

Ordered:May 8, 09

Results in:May 8, 09

- to monitor Hgb value in

the RBC- to suggest

the presence of body fluid deficit due to elevated Hgb

level

160 g/dl 125-175 g/dl

The hemoglobin

level is within the normal range. This denotes that the client has

normally functioning

blood components.

Hematocrit (Hct)

Ordered:May 8, 09

Results in:May 8, 09

To aid diagnosis of

abnormal states of

hydration, polycythemia and anemia.

- It measures the

concentration of RBC within

the blood volume and is

expressed as a percentage.

0.47 g/L0.40-0.52

g/L

The hematocrit level is within

the normal range.

Denoting that the client’s hydration

status has not depleted.

WBC

Ordered:May 8, 09

Results in:May 8, 09

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

15.9x109/L5-10 x 109/L

The WBC count denotes that the client

has an infection.

Neutrophils

Ordered:May 8, 09

Results in:May 8, 09

To detect presence of

infection in the body

.40 .45-.65

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.

Lymphocytes

Ordered:May 8, 09

Results in:May 8, 09

To detect presence of

infection within the body.

0.55 0.20-0.35

Platelets

Ordered:May 8, 09

Results in:May 8, 09

The number of 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.

350x109

g/L

150-400x109

g/L

The platelet 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.

Intratest:1. Observe Standard precautions.2. apply a pressure dressing over the puncture site.3. 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 lymphatic system

contains immune 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 to the blood, 

and thus help maintain 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 oxygen-

poor 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 5 th 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

Activated inflammatory cells

Activation of host defense

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

Activation of complement system

Activation of coagulation system

Activated endothelium>increased multiplication>adhesion molecules increase

Hyperdynamic Phase>hypo/hyperthermia>tachypnea>tachycardia>↑metabolic demands>↑cardiac output

Sudden ↓ in cardiac output

↓thrombomodulin↑plasminogen activator inhibitorThrombosis and antifibrinolysis

HypovolemiaCardiac and vascular failure

Capillary leak/ endothelial damageAcute respiratory distress

Disseminated intravascular coagulationDecreased steroid synthesis

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

shock

Multiorgan dysfunction syndrome (MODS)

death

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

Activation of host defense

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

Maculopappular rashes (May 8, 2009)

Feeding intolerance(May 8,2009)

tachypnea(May 11-12, 14,2009)

Cold clammy skin(May 13,2009)

Vomiting(May 8, 14, 2009)

Watery stool(May 14, 2009)

↑lymphocytes(May 8,2009)

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 co-

morbidities, 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

2 nd ed. Canada: Thomson Delmar Learning Inc.

Susan Tucker Blackburn, PhD, RN, FAAN (2007) Maternal, Fetal, Neonatal

Physiology: A Clinical Perspective 3 rd ed. St. Louis, Missouri: Saunders an imprint of

Elsvier’s Inc.

Kleigman R. et. al. (2007) Nelson’s Textbook of Pediatrics 18 th ed. Philadelphia,

Saunders an imprint of Elsvier’s Inc.