1.

PATIENT ASSESSMENT

A. GENERAL DATA

1. Patient’s Name: B.D.

2. Address: Tarlac
3. Sex: Male
4. Birth Date: 07-26-2010
5. Rank in the family: 7th.
6. Nationality: Filipino
7. Civil Status: Newborn
8. Date of Admission: 07-26-2010
9. Attending Physician: Dr.Guide
B. CHIEF COMPLIANT:
PREMATURITY
D. HISTORY OF PRESENT ILLNESS:
SEPSIS NEONATARUM DUE TO PREMATURITY
E. FAMILY ASSESSMENT
NAME RELATION AGE SEX OCCUPATION EDUC’L ATTAINMENT

M.D HUSBAND 52 MALE DRIVER HIGH SCHOOL GRADUATE

K.D WIFE 40 FEMALE HOUSE WIFE HIGH SCHOOL GRADUATE
K.D BROTHER 25 MALE VENDOR HIGH SCHOOL GRADUATE
N.D BROTHER 22 MALE VENDOR HIGH SCHOOL GRADUATE
L.D SISTER 20 FEMALE NONE HIGH SCHOOL GRADUATE
R.D BROTHER 19 MALE VENDOR HIGH SCHOOL GRADUATE
A.D SISTER 15 FEMALE STUDENT STUDENT
B.D SISTER 09 FEMALE STUDENT STUDENT
B.D PATIENT 0 MALE NEWBORN NEWBORN
1. NUTRITIONAL – METABOLIC PATTERN

Usual Daily Menu

mother
Food - meat and vegetables
Water - 5-6 glasses per day
Beverages – juice, cola

2. Elimination Pattern:

Bowel habits note for any frequency of defecation, characteristics of stool

Color - greenish
Odor - good smell
Consistency -
Laxative use if any – none
Bladder frequency of urination, characteristics of urine
Color - yellowish
Odor -
Alterations if any - none

3. Activity – Exercise Pattern

Self-care ability
_IV_Feeding _IV_Dressing _IV_Grooming
_IV_Bathing _IV_Toileting ___Cooking
_IV_Bed mobility ___Home maintenance ___others
 Legend
0 - full care
I - requires use of equipment
II - requires assistance or supervision from others
III - requires assistance or supervision from another, and equipment a
device
IV - dependent; doesn’t participate

SLEEP – REST PATTERN

Sleep habits:
Special sleeping problems: irritability
Hours of sleep: 2-3 hours
Sleeping aids: none

4. Role Relationship Pattern

Perception of major roles and responsibilities in the family

Perception of major roles and responsibilities at work

Perception of major social roles and responsibilities

5. SEXUALITY-REPRODUCTIVE PATTERN

Menstrual History
Age of onset of menarche - 5
Number of menstrual days - 5 days
Number of pads every menstruation – 3 pads

Obstetric History
TPAL
Operation - none

F. Developmental History
Theories Age Sex Patient Description
Freud 0 male Mouth is the center of pleasure
Security is the primary need
feeding procedure,
pleasure and sense of comfort and
safety feeding should be
pleasurable
and provided the when required.

Regional Exam
1. Hair, head and face
2. Eyes –
3. Nose -
4. Ears – soft slow recoil
5. Mouth and Throat –
6. Skin – smooth, pinkish, visible veins
 7. Nails –
8. Thorax and lungs –
9. Breast and axilla – perceptible
10.Abdomen –
11.Extremities –
12.Genitals – testes and upper canal rugea
13. Rank in the family – 7th
14.Educational attainment – new born

Pediatric History
a. Maternal and birth history
Date of birth
Birth weight
Type of delivery
Condition after birth
Hospital
b. mother
Complications of delivery
Anesthesia – epidural anesthesia
Exposure to teratogens – no such exposure to teratogens
c. neonates
Neonatal history - prematurity
Feeding history – Nothing per orem
Type of feeding – strict aspiration precautions
Laboratory and Diagnostic Exam
Date: January 26, 2010
Type of Examination:
Test Results normal values significance

WBC 20.3 GL 4.1 – 10.9 g/L - The result denotes that

The client has infection
LYM 17.2 RO 84.7/L
*MID 0.9-4.3%M
GRAN 2.2 R3 11.0 %G

RBC 4.43 T/L 4.3 – 5.9 mill/mm3

HGB 176. G/L 125-175 g/dL - This denotes that the

Client high altitudes
HCT 521 L/L 0.40 – 0.52 g/L
MCV 117.5 PG 80 – 100 cu/µm

MCH 39.7 PG 25.4 – 34.6 pg/cell

CHC 338 G/L

PLT 70 GL 140 – 440 g/L

Generic Name: oxacillin
Brand Name: bactocill
Dosage: Infants and Children: I.M., I.V.: 100-200 mg/kg/day in divided doses every 6
hours (maximum: 12 g/day)
Indication: treatment of infections caused by penicillinase-producing staphyloccicci;
initial therapy of suspected staphylococcal infection.

Mechanism of Side effects Contraindication Adverse reaction Nursing

action consideration
Interferes with - Mild Before using - fever • Assess
cell wall diarrhea oxacillin, tell - rash result of
replication of - Nausea your doctor if - diarrhea culture and
susceptible - Swelling at you are allergic - nausea sensitivity
organisms; the to - neutropenia test.
osmotically injection cephalosporins - hepatotoxicity • Patient
unstable cell site such as Ceclor, should be
wall swells, - Chest pain Ceftin, Duricef, monitored
bursts from - Mouth Keflex, and closely.
osmotic pressure irritration others, or if
• Evaluate
you have asthma,
results of
liver disease,
laboratoty
kidney disease,
test.
or a history of
Assess
any type of
bowel
allergy.
pattern
everyday.
• Assess for
overgrowth
of
 infection.

Generic Name: ranitidine

Brand Name: zantac
Dosage: dosage for babies is typically 2 mg to 4 mg per kg (a little less than 1 mg to 2
mg per pound) once a day, but no more than 150 mg per day.
Indication: used In the management of various gastrointestinal (GI) disorders such as
dyspepsia, gastro-esophageal reflux disease (GERD),peptic ulcer and Zollinger-Ellison
syndrome. Prophylaxis of GI hemorrhage from stress ulceration and in patients at risk of
developing acid aspiration during general anesthesia; prophylaxis of Mendelson syndrome.

Mechanism of Side effects Contraindication Adverse reaction Nursing

action consideration
Inhibits - Sometimes - any patient - dizziness • Use caution
histamine at H2 babies can hypersensit - abdominal in presence
receptor site in become a ive to the pain of renal or
the gastric bit sleepy drug or its - delirium hepatic
parietal cells, - Diarrhea components - constipation impairment.
which inihibits - Blurred vision - should be - myalgia • Evaluate
gastric acid - Constipation used - sinus results of
secretion. - Dizziness cautiously tachycardia laboratory
- headache in those - insomnia test.
patients - jaundice
- feeling of a • Assess
with renal - bradycardia
whirling motion potential
disease, - alopecia
- general body for
specificall
discomfort interaction
y in those
- nausea with other
with renal
- stomach pain pharmacolog
impairment
- vomiting ical agents
or renal
maybe
failure
taking.
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.
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

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.
 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
The Cardiovascular System 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.
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.
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.
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 blood stream
to battle the infection.
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 gathering 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.
 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,
IMMUNE SYSTEM
organs, and tissues, which interact in an
An immune system is a collection of
elaborate and dynamic network. As part of
biological processes within an organism
this more complex immune response, the
that protects against disease by
human immune system adapts over time
identifying and killing pathogens and
torecognise specific pathogens more combined immunodeficiency, or be produced
efficiently. This adaptation process is by pharmaceuticals or an infection, such
referred to as "adaptive immunity" or as the acquired immune deficiency syndrome
"acquired immunity" and creates (AIDS) that is caused by the retrovirus
immunological memory. 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 disease
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
 INTRODUCTION

Sepsis in a newborn (sepsis neonatorum) is an infection that spreads throughout the

baby’s body. Sepsis occurs in less than 1 percent of newborns (1 out of every 100), but
accounts for up to 30 percent of deaths in the first few weeks of life. Infection is 5-10
times more common in premature newborns and in babies weighing less than 5½ pounds than
in normal-weight, full-term newborns. Complications experienced during birth, such as
premature or prolonged rupture of the membranes or infection in the mother, put the
newborn at increased risk of infection. Sepsis is a term for severe infection that is
present in the blood and spreads throughout the body. In newborns, it is also called
sepsis neonatorum or neonatal septicemia.
 Case Study
(sepsis neonatorum)

Submitted by:
Roxanne J. Saplala

Submitted to: