INSTITUT LATIHAN KEMENTERIAN KESIHATAN MALAYSIA

SULTAN AZLAN SHAH, PERAK

ADVANCED DIPLOMA IN NEONATAL NURSING (ADNN)
INTAKE SEPTEMBER 2023
CLINICAL PRACTICE OF NEONATAL CARE 1
NNCP 4014

CASE STUDY
NEONATAL SEPSIS

NAME: SITI NUR AISHAH BINTI SHAMSUDDIN

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:5DISEMBER 2023
SUBMISSION DATE:22DISEMBER 2023
TABLE OF CONTENT

NO CHAPTER PAGE

1 DEFINITION AND BACKGROUND

2 BACKGROUND OF THE CASE

2.1) DEMOGRAPHIC DATA

2.2) ASSESSMENT

2.3) INVESTIGATION

3 TREATMENT AND MANAGEMENT

4 DISCUSSION

5 CONCLUSION

6 REFERENCE
1.DEFINITION 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)
PATOPHYSIOLOGY

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
2.1)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 29/52 +1/7
Birth weight :1280gram
Length:36cm
Circumference of the head:26cm
Apgar score:9 in 10 minutes.
Vital sign
Temperature:35.6°C
HR:120bpm
RR:67/min
BP: 54/25 mmhg (34)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.
2.2)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
128 ,000 units daily12 hly and iv gentamycin 6mg 36hly.
Assessment for 3 days
5/12/2023
 Baby develop 1 episode of apnea and bradycardia (72bpm) respond with
tactilce stimulation,suction done small amount whitish.Cbs
checked :7.2mmol/L. Cbs 4hourly monitoring.
 Nbm with oral gastric anchored at 15cm
 TPN Starter pack started 1, total fluid 60mls/kg/day
 IVD D10%
 Ultrasound cranium done by Dr Tan findings:no ivh,ventricles slit
 Echo small PDA left to right
 Continues Pc-cmv rate :30 pressure :16/5 fio2: 30%, nasal score: 0. Alternate
nasal prong and nasal mask every 3hourly.Nurse in lateral position
 Patient on iv cpenicllin 128 ,000 units daily12 hly , iv gentamycin 6mg 36hly.
 Oral caffeine 5mg/kg
 Oral nystatin 1mls
6/12/2023
 Tsb level:122umol/L, Photo level :108 umol/Lnursed under phototherapy
 4hourly monitoring Cbs
 To change TPN preterm sodium
 Total fluid :80mls/kg/day increases
 Desaturation occurs but respond to stimulation. Vital sign spo2:80-89%
fluctuating.
 Suction small amount whitish
 Continues Pc-cmw rate:30 pressure :16/5 fio2:40%↑
 No desaturation at night fio2:30%↓
7/12/2023
 Continue nbm
 Total fluid :100mls/kg/day
 Suction PRN
 6hourly Cbs :7.8mmol/L
 Tpn preterm NA + 2gm lipid run via Uvc
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
2.3)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.
Conclusion
Neonatal sepsis is a serious and potentially life-threatening condition that requires
prompt recognition, diagnosis, and intervention. In conclusion, addressing neonatal
sepsis involves a multi-faceted approach, including preventive measures, early
identification of risk factors, timely administration of antibiotics, and ongoing
monitoring of neonates at risk. Additionally, efforts to improve maternal health,
hygiene practices, and healthcare infrastructure play a crucial role in reducing the
incidence of neonatal sepsis.

The importance of a collaborative and multidisciplinary healthcare team cannot be

overstated in the effective management of neonatal sepsis. Vigilance in the neonatal
intensive care unit (NICU), clear communication among healthcare providers, and a
commitment to evidence-based practices contribute to improved outcomes for
neonates affected by sepsis.
Reference
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3. Neonatal Sepsis. (2021, January 1). PubMed. Retrieved December 21, 2023,
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4. Yadav, P., & Yadav, S. K. (2022, March 11). Progress in Diagnosis and
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