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 8th 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 Father Mother
†

Rand
Natali

LEGEND:

MI

Hypertens
ion
Neonatal
Sepsis

JC 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 8th 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

DATE
DIAGNOSTIC OR ORDERED
INDICATIONS OR NORMAL ANALYSIS AND
LABORATORY AND DATE RESULTS INTERPRETATION
PURPOSES VALUES
PROCEDURES RESULTS
IN
CLINICAL CHEMISTRY
the blood
sugar level is
A random within the
blood sugar is 5-9-09 normal limits,
used to test No results this is due to
Ordered: and measure the aid of the
May 9-
available
your blood 60 – 140 client’s
present, 5-10-09
sugar at any mg/dL intravenous
2009 80 mg/dL
HGT/RBS Results
point in time,
5-11-09 fluid that keeps
available: not necessarily
a certain 60 mg/dL the electrolyte
May 10 –
14, 2009 amount of time 5-12to14 levels in
after a meal, 09 normal values
snack or 80 mg/dL though the
beverage. 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 level
2. 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

This denotes
Ordered: A diagnostic that there is a
May 10 procedure bleeding within
2009
OCCULT done to detect the clients
Results positive negative
BLOOD TEST available: hidden body
May 10 bleeding inside specifically the
2009 the body. gastrointestinal
tract.

Occult Blood Test:

Prior to the procedure:
1. Inform the mother about the purpose of the said diagnostic exam
2. 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 collected
2. 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 test
2. Relay the results to the attending physician
SERUM ELECTROLYTE
Sodium Ordered: To monitor the The sodium
May 8, 09 electrolytes electrolyte
and check for 139.2 136 – level is within
Results in: imbalances mEq/ L 145 normal range.
May 8, 09
any imbalance mEq/L
in the fluid and This is due to
 the
Intravenous
fluid of the
electrolytes.
Sodium plays client that
a major role in helps in
homeostasis in maintaining
a variety of equilibrium on
ways including serum
the renal electrolyte
retention and
levels even the
excretion of
water. client is in
NPO.

The potassium
electrolyte
level is within
It is checked in normal range.
order to This is due to
assess a the
known and Intravenous
Ordered: suspected fluid of the
4.56 3.5 – 5.0
May 8, 09 disorder client that
mmoL/L mmoL/L
Potassium associated helps in
Results in: with renal maintaining
May 8, 09 disease, equilibrium on
glucose serum
metabolism, electrolyte
trauma or levels even the
burns. client is in
NPO.

Calcium Ordered: Serum 2.39 2.02 – The calcium

May 8, 09 Calcium is mmOl/L 2.60 level is within
being checked mmOl/L the normal
Results in: to observe for range which
May 8, 09
any denotes that
imbalances the client’s
with serum body is
electrolytes metabolizing
since the client calcium
has normally. This
experienced may also be
vomiting due to the
episodes. 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 order

2. Explain the procedure
3. Explain the purpose and what to expect
4. No food or fluid restrictions

 During

1. Do not take the blood sample from hand or arm with receiving IVF
2. The tourniquet should be less on a minute
3. Do not squeeze the punctured site rightly
4. 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
The
hemoglobin
- to monitor level is within
Hgb value in the normal
Ordered: the RBC range. This
May 8, 09 - to suggest denotes that
Hemoglobin 125-175
the presence 160 g/dl the client has
(Hgb) Results in: of body fluid g/dl normally
May 8, 09 deficit due to functioning
elevated Hgb blood
level components.

Hematocrit Ordered: To aid 0.47 g/L 0.40-0.52 The hematocrit

(Hct) May 8, 09 diagnosis of g/L level is within
abnormal the normal
Results in:
 states of
hydration,
polycythemia range.
and anemia.
Denoting that
- It measures the client’s
the hydration
May 8, 09
concentration status has not
of RBC within depleted.
the blood
volume and is
expressed as a
percentage.

The test is
performed to
find out how
many white
blood cells you The WBC
have. Your count denotes
Ordered: body produces 5-10 x
May 8, 09 15.9x109/L that the client
more white 109/L
WBC blood cells has an
Results in:
when you have infection.
May 8, 09
an infection or
allergic
reaction, even
when you are
under general
stress
Ordered: To detect The
May 8, 09 Neutrophils is
presence of
Neutrophils .40 .45-.65 below the
Results in: infection in the
body normal range
May 8, 09
this level of
Neutrophils
also denotes
infection.
Together with
this high
Ordered: To detect
0.55 0.20-0.35 lymphocyte
May 8, 09 presence of
Lymphocytes infection within level denotes
Results in: the body. that the client
May 8, 09 may have viral
or bacterial
infection.

Platelets Ordered: The number of 350x109 150- The platelet

 platelets in your
blood can be
affected by
many diseases. count is within
Platelets may be the normal
May 8, 09 counted to range this
monitor or 400x109 denote that the
Results in: diagnose g/L
g/L client’s body
May 8, 09 diseases, or
identify the has a good
cause of excess coagulation
bleeding. 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 5th 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 MODIFIABLE FACTORS

FACTORS
>Common among male >Congenital Infection
>common on pre term >early onset infection
babies >Late onset infection
>common on
developmental
countries Focus of
infection
Superantigen
Hyperdynamic Phase
Activated
>hypo/hyperthermia
inflammatory >tachypnea
cells >tachycardia
>↑metabolic
Activation of host demands

Sudden ↓ in
Activation of Activation of Endogenous mediator release cardiac output
complement coagulation system >pro-inflammatory cytokines
system >anti-inflammatory cytokines
>platelet activating factor
Activated endothelium >arachidonic acid metabolites
>increased >myocardial depressant
multiplication substance
>adhesion molecules >endogenous opiates
↓thrombomodulin
↑plasminogen activator
inhibitor
Thrombosis and

Hypovolemia
Cardiac and vascular failure
Capillary leak/ endothelial damage
Acute respiratory distress
Disseminated intravascular coagulation
Decreased 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 MODIFIABLE FACTORS

FACTORS
>Common among male >Late onset infection
>common on
developmental
countries
Focus of
infection
Superantigen

Activated
inflammatory
cells
Activation of host
Maculopappular
rashes (May 8,
Endogenous mediator release
2009) >pro-inflammatory cytokines
Vomiting
(May 8, 14, >anti-inflammatory cytokines
Feeding >platelet activating factor
2009) intolerance >arachidonic acid metabolites
Watery stool (May 8,2009) >myocardial depressant
(May 14, substance
tachypnea >endogenous opiates
2009) (May 11-12,
14,2009)
Cold clammy ↑lymphocyt
skin es
(May 13,2009) (May
 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
nd
2 ed. Canada: Thomson Delmar Learning Inc.

Susan Tucker Blackburn, PhD, RN, FAAN (2007) Maternal, Fetal, Neonatal
Physiology: A Clinical Perspective 3rd ed. St. Louis, Missouri: Saunders an imprint of
Elsvier’s Inc.

Kleigman R. et. al. (2007) Nelson’s Textbook of Pediatrics 18th ed. Philadelphia,
Saunders an imprint of Elsvier’s Inc.