SURIGAO EDUCATION CENTER

College of Allied Medical Sciences

Nursing Department

Surigao City

A CASE PRESENTATION

OF

NEONATAL SEPSIS

Prepared by:

JOANNE BERNADETTE C. AGUILAR

Presented to:
 DEDICATION

This case presentation is indeed the fruit of my endeavor. A sweet success from the sweat

of my hard work that worth every single moment and time that I share in making this, precious art

of learning. Of all the sacrifices, I would heartily dedicate my case presentation to the following

people:

To my parents, who undyingly showed their moral and financial support to me, as I take

every fruitful steps of my endeavor.

To my clinical instructors, for imparting me their knowledge on how are we going to

perform all different procedures of the nursing process, to make me fully equipped as I embark

towards the realization of my chosen profession. And most especially to our Heavenly Father,

who showered me all the guidance and the abundance of grace.

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 ACKNOWLEDGEMENT

As the presenters of this individual case presentation, with deep appreciation and heart

felt gratitude, I would like to acknowledge the following people who have supported me and made

this study a successful one: To my parents who morally and financially supported me. For their

encouragement and understanding why I am always late in coming home.

To my clinical instructors who undoubtedly impart their knowledge and showed their

support to me. To all staff of Surigao Medical Center, who gave me the permit to copy all the

information necessary for this educational output to be completed from the patient’s chart.

To the patient and patient’s family who never ceased to answer whatever questions I

have raised. And most especially, to our Heavenly Father for giving me all the blessings, strength,

wisdom and enlightenment that I am able to complete all the information needed. Indeed, this case

study has definitely enhanced and advanced my knowledge in my chosen career.

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 TABLE OF CONTENTS

 Dedication i

 Acknowledgement ii

 Introduction 5-6

 Review of Related Literature 7-31

 Nursing Health History 32-33

 Client Health History 34

 Treatments/ Medications 34

 Past Illness/Hospitalization 34

 Allergies 34

 Developmental History 34

 Nutritional Metabolic Pattern 35

 Elimination Pattern 35

 Activity Exercise Pattern 36

 Sexuality Reproduction Pattern 36

 Sleep-Rest Pattern 36

 Sensory-Perceptual Pattern 37

 Cognitive Pattern 37

 Role Relationship Pattern 37

  Self-Perception-Self-Concept Pattern 38

 Coping Stress Tolerance 38

 Value Belief Pattern 38

 Health History 38

 History of Present Illness 38

 Past History 39

 Physical Examination 40

 General Physical Survey 40

 Mental Status Examination 40

 Skin 40

 Head and Face 40

 Eyes 41

 Ears and Nose 41

 Mouth and Throat 41

 Neck 42

 Arms, Hands and Fingers 42

 Posterior and Lateral Chest 42

 Anterior Chest 42

 Breasts (Male) 43

 Heart 43

 Abdomen 43

 Legs, Feet and Toes 43

  Genitalia (Male) 43

 Musculoskeletal and Neurologic Examination 44

 Cranial Nerve Assessment 45-46

 Review of System 47

 General Survey 47

 Integumentary System 47

 EENT 47

 Gastrointestinal System 48

 Musculoskeletal System 48

 Neurologic System 48

 Urinary System 48

 Reproductive System 48

 Hematologic 49

 Endocrine 49

 Psychiatric 49

 Laboratory Results 50

 Hematology 50-51

 Blood Chemistry 52-53

 Urinalysis 54

 Stool Exam 55-56

 Anatomy and Physiology 57-70

 Pathophysiology 71-74
 Drug Study 75-84

 Nursing Care Plan 85-97

 Discharge Plan 98-99

 Appendices 100

 IVF Chart 100

 Daily Weight 100

 Vital Signs 101

 I and O Sheet 102

 CFAC 103

 Genogram 104

 References 105
INTRODUCTION