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.

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

Monitor neonates condition.

Rationale
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 neonates 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 mothers 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,

To sustain adequate milk

maintain fluid and nutritional intake, and

schedule breast pumping every 3 hours while
awake

production and breast feeding

process

Risk for Impaired Parent/Infant Attachment

Due to the newborns physical illness and hospitalization, the parents may have fear
on how to handle their baby since the baby is on its fragile state and needed extra
care. And since he is the 1st child hospitalized in their family, the parents might still
be unsure on how to take care of the baby.
Assessment

The newborn is diagnosed with a certain disease (Sepsis)

The newborn is separated from his mother

The mother unable to provide breast milk to newborn continuously

Nursing Diagnosis

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

Reinforces continuation of

nurturing and protective parenting behaviors

desired behaviors

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