SEPSIS NEONATORUM

Objectives
General Objective: The study aims that the case will elucidate information regarding sepsis neonatorum. Employ appropriate nursing information and apply proper nursing attitude and nursing skills toward the patient as well to his milieu. Specific Objectives: At the end of this study, the patient/family will be able to: Identify measures that could minimize the risk of occurrence of the disease. Identify possible risk factors that may have contributed to the development of Neonatal Sepsis. Increase awareness on the risk factors of Neonatal Sepsis. Develop the familys support system and distinguish their respective roles in improving patients health status. Involve them in promoting the health care of the patient.

Introduction
Background of the Case This is the case of 9 days old of infant. His parents noticed he had jaundice. His admitting diagnosis is Sepsis Neonatorium late onset, hyperbilirubinemia secondary to prematurity 33 wks. This case was chosen by the group because of the alarming number of infants that are affected by the disease. That in one third of four million neonatal deaths around the world are caused by severe infection, and around one million deaths are due to neonatal sepsis/pneumonia alone. Since neonatal sepsis is a common disease seen in a pediatrics ward, it is important to know more about the disease to prevent worsening, putting in to mind that environment plays a big factor in this condition.

 Definition of the Case Neonatal sepsis is also known as sepsis neonatorum or neonatal septicemia. It affects infants younger than 4 weeks, in which it can be acquired during pregnancy (congenital neonatal sepsis) or, delivery or soon after (early-onset sepsis), or a few days after (late-onset sepsis). General signs and symptoms Symptoms of neonatal sepsis are observed for 90 days. Wherein the symptoms of early-onset sepsis appears in 24 hours to one week while late-onset sepsis manifests 8 to 89 days. There is unstable body temperature, inability to suck breast milk properly, apnea, fever, vomiting and diarrhea; respiratory distress, reduced heart rate, jaundice, and the belly area may be swollen. The infant may also manifest reduced movements and low blood sugar.

 Etiology
In both early-onset sepsis and late-onset sepsis the primary pathogens are group B streptococcus and Escherichia coli. The difference is how the infant gets infected. In early-onset sepsis, it is the result of an asymptomatic colonization in the intestinal or genital tract of the mother. It occurs during passage through the birth canal. While in late-onset sepsis, the pathogens are present in the environment and at home. It may be due to prolonged stay in the hospital and an infected hospital environment. There is a third classification, in which the cause of the infection is human immunodeficiency virus, syphilis, Toxoplasma, and cytomegalovirus. It is called congenital neonatal sepsis, wherein the baby is infected before delivery. The virus can either cross the placenta or ascend the birth canal.

 Incidence
Neonatal sepsis occurs in 0.5 to 8.0 per 1000 live births. It is the third leading cause of neonatal deaths. Occurrence can be classified into low birth weight (weighing less than 2500 grams) and very-low-birth-weight (weighing less than 1500 grams). In which, 81% percent were low birth weight and 63.6% were verylow-birth-weight. Neonatal sepsis occurs in a 2:1 ratio, with a higher occurrence in males and in neonates with congenital anomalies. In the Philippines 8,000 newly born babies die from sepsis. In May 2003, 23 neonatal deaths could be attributed alone. According to the Annual Statistics of the Philippine General Hospital (2002), neonatal sepsis accounts for 58.8% of deaths in the country. It is the second major cause of disability by a slim margin to jaundice, affecting 24.2% and 25.6% of the population respectively. The census in the National Childrens Hospital (NCH) Intensive Care Unit during one month (July 2010 to August 2010) was 61 patients having neonatal sepsis. Having a total of 61 days, the average of patients having neonatal sepsis is 1 per day.

 Demographic data of the patient

Patient Profile

Name: JP Age: 9 day old Sex: Male Address: Paraaque Race: Filipino Religion: Roman Catholic Date of admission: September 8, 2010 Time of admission: 8:00 pm Admission Impairments: Sepsis neonatorum Late onset, hyperbilirubinemia, secondary to prematurity 3334 weeks

 Condition on admission: Admitted at NICU (Dec. 10-12) , SGA, PNCU HCGTA 2x, +fever, Pre-term @ 33 weeks Apgar Scoring: 7 CR=120bpm, RR=56bpm, Temp 37C Weight= 2200 grams Height= 46cm, HC= 46cm CC= 25cm asleep but arouse, afebrile but not in distress still jaundice still cyanotic
Chief Complaint
Jaundice Cyanosis

 General appearance and condition:

Physical Examination

Skin: Jaundice, good skin turgor, no cyanosis, HEENT: + generalized jaundice up to soles, no active bleeding, + icteresia, no nasal discharge Thorax & Spine: no gross deformities Lungs: symmetrical lung field, Heart: AP, no murmur Abdomen: globular, soft, no organomegaly, (+) serous on the umbilical stump Arms & spine: grossly normal Genitourinary: gross for male with descending testis Extremities: full and equal

 Nervous system:
Cerebrum: asleep but arousable Cerebellum: no nystagmus CN I: N/A CN II: pupil 2-3 mm bilateral CN III, IV, VI: (+) dolls eye CN V: (+) corneal reflex CN VII: (-) facial asymmetry CN VIII: N/A CN IX, X: (+) gag reflex CN XI: N/A CN XII: tongue at middle Motor: good motor reflex

 NEWBORN MATURITY RATING and CLASSIFICATION

Neuromuscular Maturity Posture = 3 Square window (wrist) = 2 Arm recoil = 3 Popliteal Angle = 2 Boat sign = 3 Heel to ear = 2 Physical Maturity Skin = cracking, pale area, rare veins Lanugo = thinning Plantar creases = creases anterior 2/3 Breast = strippled areola 1-2 bud

 Ear = well-curved pinna soft but ready recoil

Genitals = testes down; good rugae

Gestation by dates = 33 4/7 weeks

Birth date = August 31, 2010

Maturity rating
Score = 30

Weeks = 36
LMP = January 6, 2010

 Gordons Functional Health Pattern *patients mother during pregnancy Health Perception and Health Management Pattern
The mother perceived her health as somewhat good except for the part that during her nine months of pregnancy she usually have a yellowish, foul=smelling vaginal discharge up to time of delivery. She visits clinic regularly but was not able to complete her tetanus toxoid vaccination.

Gordons Functional Health Pattern

Nutritional and Metabolic Pattern

The mother makes sure that shell always drink milk and nutritious food for the sake of her baby. Also, she used take folic acid but wasnt able to maintain it.

Bowel-Elimination Pattern
Her bowel movement is regular for at least two times a day as well as her urination.

Activity-Exercise Pattern
For her activity and exercise pattern, the patient make sure that she can get adequate rest, and as foe her exercise she sometimes walk early in

 Sleep-Rest Pattern
The mother has no sleep problems.

Cognitive-Perceptual Pattern
The mother has no hearing or visual difficulty. No change in memory.

Self-perception and Self-concept Pattern

The patient admitted that that despite the change with his body she was able to adopt with it easily for the reason that this wasnt her first time to get pregnant.

Role-Relationship Pattern
The mother lives with her husband alone while undergoing pregnancy. She has no problems within the family except financial problems.

Sexuality-reproductive Pattern
The patient has no sexual problems.

Coping-stress Tolerance Pattern

The mother and her husband discussed and solved their financial problems together.

Value-belief Pattern
The patient believes in God and make sure she prays at least once a week.

 Past History of Illness

Delivered pre-term @ 33 weeks No Premature rupture of membrane but with twice cord coil Mother has yellowish foul smelling vaginal discharge @ 9mos AOG up to delivery.

Present History of Illness

7 days PTA noted (+) cyanosis lasting for 5minutes. (+) jaundice up to lower extremities. 6 days PTA, noted (+) cyanosis 2x a day. With increase severity. Persistent signs and symptoms until admission.

Allergies

Course in the Ward

Date September 8

Doctors Order 8:00pm Patient was admitted at the neonat intensive care unit at 8:00 in the evening. Patient remained in a no per orem state with an on-going intrvaneous fluid, IMB 500 cc to run 110 cc for eight hours. Diagnostics that need to be done are CBC with PC, Blood type, Hgt determination, TB, B1, B2, RBS, Serum Na, K and Cl, and Baby gram. The medication is already care of the resident on duty. Patient is also supported with oxygen via face mask at 5 liters per minute. Doctor ordered to keep the patient thermoregulated and refer. 9:30pm

Patient was still in the NPO state. The IVF was revised to run 135 cc in 8 hours. Doctor requested for albumin, PBS and Reticulocyte count. The patient medicines included Ampicillin 110 mg IV every 12 hours and Amikacin 33 mg once a day. The patient started to undergo phototherapy with proper shields.
September 9 11:00 am Patient is undergoing IVF TF, 265 cc to run for 12 hours. Medicine available are Ampicillin and Amikacin. Hgt needed every 12 hours, and patient is scheduled for culture and sensitivity. September 10 12:00 am Doctor ordered to discontinue running IVF of both D5IMB 500 cc #2 in 135 cc for eight hours. 9:00 am Doctor ordered that the patient may start nonnutritive feeding at 10 ml every 3 hours of expressed breast milk. Phototherapy still continued every two hours.

September 11

At 9:30 am the doctor ordered patient to undergo ABG, BUN diagnostics. Medicine is Ampicillin. Ordered to undergo At 9:45 pm the doctor ordered that the patient undergo CPAP and maintained patient in NPO state for few hours and resume the feeding through Doppler.

September 12

At 9 am the patient has no fever, no cyanosis, has a good cry, the patient is afebrile and has a temperature of 37.1. The doctor ordered to continue feeding via Doppler method with SAP. Also, the patient undergoes phototherapy and doctor ordered to lessen therapy when patient is warmer. Vital signs to be taken every four hours, input and output every end of the shift. 2:50 pm Patient was oxygen via nasal cannula at 3 liters per minute.

September 13

7am Patient was still ordered to have a vital signs to be taken every four hours and input and ouptu every end of the shift. Referred accordingly.

September 14

7pm Patient started breastfeeding and ordered to watch out for episode of cyanosis. Labs are still to follow. Ordered to watch out for tachycardia.

September 15

The doctor ordered to continue the breast feeding with strict aspiration precaution (SAP) and having oxygen ready if needed. Ampicilin and amikacin was discontinued and had started to give imipenem 50mg TIV every 12 hours.

September 16

The patient is encouraged to continue breast feeding with SAP and oxygen as PRN. Imipenem (day zero) was given. Doctor asked to keep the patient thermoregulated at all times. IVF of D5 IMB ordered was 100cc x 8 hours. Another 100cc x 8 hours was ordered again.
Another 100cc x 8 hours was ordered. Day one of imipenem is implemented The remaining 20cc +100cc of D5 IMB for 8 hours was ordered. Day two of imipenem was implemented. Laboratories for TB, B1 and B2 was ordered. The patient was also placed on phototherapy.

September 17 September 18

Anatomy and Pathophysiology

Predisposing factors:
-Cord Coil -Pre-term: AOG- 33weeks -immature neonatal immune system -male

Precipitating factors: -sterility of the environment -exposure to bacteria

Pathogens enters the body

Infection

Immune Body will respond

Leukocytes responded to the pathogens

Systemic Reaction

Increase in WBC= 12.9 x

109/L

Pro-Inflammatory Response (Cytokines)

Anti-Inflammatory Response

Imbalance

Increase activity of Fibrinolysis Inhibitors Decrease fibrinolysis Sepsis

Platelet destruction

Inadequate platelet count= 140,000

Hyperdrive

Poor perfusion

Inadequate O2 delivery hypoxia Lactic acidosis shock

Metabolic acidosis
Diminished energy intake

Multiple organ dysfunction

Imbalanced nutrition less than body need

Impaired pulmonary function

Acute renal failre Metabolic acidosis (pH= 7.34, PcO2=33.1, HCO3=17.5)

Hepatic dysfunction

Weight: 2,200 g

Cyanosis

Total bilirubin=19.04 umol/L

Laboratory Examination / Diagnostic Procedures

Culture and sensitivity
September 13, 2010
Findings: Klebsiella pneumonia Growth isolated after 24 hours of incubation Extended spectrum Beta-Lactamase (ESBL)

Clinical Chemistry September 8, 2010

Result Glucose/ RBS 1.42 mmol/L Normal 3.8-6.1 mmol/L Interpretation Decreased glucose counts due to presence of bacterial infection, Klebsiella pneumonia.

Total Bilirubin Direct Bilirubin Indirect Bilirubin

Result 32.10 umol/L 2.99 umol/L 29.11 umol/L

Normal 3.4-17.1 umol/L 0-3.4 umol/L 3.4-13-6 umol/L

Interpretation Neonatal Hyperbilirubinemia: Indirect bilirubin outweighs Direct bilirubin

September 11, 2010

Result

Normal

Interpretation

Total Bilirubin Direct Bilirubin Indirect Bilirubin September 18, 2010

18.29 umol/L 2.73 umol/L 15.56 umol/L

Result

3.4-17.1 umol/L 0-3.4 umol/L 3.4-13-6 umol/L

Normal 3.4-17.1 umol/L 0-3.4 umol/L 3.4-13-6 umol/L

Neonatal Hyperbilirubinemia Indirect bilirubin outweighs Direct bilirubin

Interpretation Hyperbilirubinemia Indirect bilirubin outweighs Direct bilirubin

Total Bilirubin Direct Bilirubin Indirect Bilirubin

20.95 umol/L 1.85 umol/L 19.10 umol/L

September 19, 2010

Result Total Bilirubin Direct Bilirubin Indirect Bilirubin

Blood Serum Analysis September 20, 2010

Normal 3.4-17.1 umol/L 0-3.4 umol/L 3.4-13-6 umol/L

Interpretation Hyperbilirubinemia Indirect bilirubin outweighs Direct bilirubin

19.04 umol/L 1.84 umol/L 17.20 umol/L

Result C-Reactive Protein Titer 6 mg/L

Normal <6 mg/L

Interpretation Increase in CRP count in response to presence of bacterial infection, Klebsiella pneumonia.

Arterial Blood Gas September 8, 2010 Interpretation: Metabolic Acidosis pH Result 7.24 tCO2 17.0 pCO2 35.5 ABE -9.7 pO2 108.4 HCO3 15.9 O2 Saturation 103.19

September 11, 2010 Interpretation: Partially compensated metabolic acidosis

pH Result 7.34

tCO2 18.5

pCO2 33.1

ABE -6.9

pO2 65.7

HCO3 17.5

O2 Saturation 101.02

Hematology September 8, 2010

Result WBC 12.9 Normal 5-10 x 109/L Interpretation Leukocytosis: increase in WBC count in response to presence of bacterial infection, Klebsiella pneumonia. Neutropenia: decreased neutrophil count in response to presence of bacterial infection, Klebsiella pneumonia. Lymphocytosis: increased lymphocyte count in response to presence of bacterial infection, Klebsiella pneumonia. Erythrocytosis: increase in RBC count indicates an overactive bone marrow that is producing an increased amount of RBCs Decreased in platelet count due to

Neutrophil

0.53

0.55-0.7 x 109/L

Lymphocyte

0.44

0.20-0.35 x 109/L

RBC

5.7

4.5-5.5 x 109/L

PLATELET

140,000

150,000-400,000

September 9, 2010

Result Reticulocyte Count 48 x 103/L

Normal 5-15 x 10-3/L

Interpretation Reticuiocytosis: increase in the reticulocyte count indicates an overactive bone marrow that is producing an increased amount of RBCs

Blood Typing September 8, 2010

Result Blood Type A Rh (+)

Theoretical Framework Nightingales Environmental Theory

As for the theoretical framework, Florence Nightingales Environmental theory suits best the condition of the patient. The patient is in the state of having sepsis neonatorum and the main priority with this is to avoid further spread infection throughout the system of the patient by providing him a safe and clean environment. With Nightingales theory which states that the act of utilizing the environment of the patient to assist him in his recovery is what nursing does. As she linked health with the five environmental factors that includes: fresh or pure air, pure water, efficient drainage, cleanliness and light. Combining these factors would help to alleviate the condition of the patient especially that he is in the state where he could not do things on his own. Furthermore, since the patient has an infection given that he has a fever, providing a clean environment around him would help him for his recovery. A quiet environment is also a factor. Providing the client with the right diet by ensuring that he will be able to tolerate his Doppler feeding will also help his recovery since this is a necessity for a patient to easily get well. Therefore, in its simplest term, with the integral parts of nursing, and the factors that promotes a good environment to the patient, recovery could be achieved or at least alleviation of what he feels most especially the patient will be free from harm or injury and also the spread of infection could be more prevented

Drug Study
Generic: Generic: amikacin ampicillin Brand: Amikin Brand: Ampicin Dose: 33mg Frequency: OD Dose: 110mg Frequency: Route: IV Q12 hrs Route: IV Generic: imipenem Brand: Primaxin Dose: 50mg Frequency: Q12 hrs Route: IV (Slow)

Nursing Care Plan

ASSESSMENT Subjective cue: talagang nangitim na siya kanina kaya nilagyan na ng tubo, hindi na siya humihinga kanina eh. As verbalized by the mother. Objective cues: -RR= 55bpm - cyanosis -slow capillary refill >2seconds -Cold clammy skin -on ET tube connected to ambu bag attached to O2

DIAGNOSIS Impaired gas exchange related to altered oxygen supply

PLANNING Short term: After 30 minutes of nursing intervention the patient will show improvement in his respiration evidenced by decrease in respiratory rate. Long term: After 8 hours of nursing intervention, the patient will have a good gas exchange evidenced by decrease in respiratory rate within normal range (30=50 bpm) and warm skin.

INTERVENTION Independent: -maintain client airway. Place on semi-fowlers position. -auscultate breath sound. Note for any crackles. -turn side to side every 2 hours. -suction when needed. -maintain adequate ventilation and provide quiet environment. -IVF proper regulation. Collaborative: -on continuous ambu bagging attached to O2 -meds as ordered

RATIONALE

EVALUATION

Short term: -enhances lung After 30 minutes of expansion reduces nursing respiratory effort. intervention the -respiratory distress patient has is an indicator of improved pulmonary respiration congestion. evidenced by -to prevent decrease in aspiration. respiratory rate. (39bpm) -Facilitates removal Long term: of secretion to After 8 hours of maximize gas nursing exchange. intervention, the - External stimuli patient has a good may inhibit sleep. gas exchange -To prevent fluid evidenced by overload decreased in -necessary for respiratory rate of respiratory failure 29bpm and warm skin.

ASSESSMENT Subjective cue: talagang nangitim na siya kanina kaya nilagyan na ng tubo, hindi na siya humihinga kanina eh. As verbalized by the mother. Objective cues: -RR= 55bpm - cyanosis -slow capillary refill >2seconds -Cold clammy skin -on ET tube connected to ambu bag attached to O2 -weak peripheral pulse

DIAGNOSIS Ineffective tissue perfusion related to reduction of arterial blood flow

PLANNING Short term: After 3 hours of nursing intervention the patient will demonstrate increased perfusion as evidenced by warm skin, strong peripheral pulses, adequate urine output and less than 2 seconds capillary refill. Long term: After 3 days of nursing intervention, pt will maintain adequate perfusion as evidenced by stable VS, warm skin adequate urine output and strong peripheral pulses and less than 2 seconds capillary refill.

INTERVENTION Independent: - Monitor neonates condition. - Monitor Vital signs -Note quality and strength of peripheral pulses -Assess respiratory rate, depth, and quality -Assess skin for changes in color, temperature and moisture -Elevate Head of Bead -Provide a quiet, restful atmosphere Collaborative: -on continuous ambu bagging attached to O2

RATIONALE

EVALUATION Short term: After 3 hours of nursing intervention the patient was able to demonstrate increased perfusion as evidenced by warm skin, strong peripheral pulses, adequate urine output and less than 2 seconds capillary refill. Long term: After 3 days of nursing intervention, patient was able to maintain adequate perfusion as evidenced by stable VS, warm skin adequate urine output and strong peripheral pulses and less than 2 seconds capillary refill.

-To determine the need for intervention and the effectiveness of therapy. - To have a baseline data -To asses pulse that may become weak or thready, because of sustained hypoxemia -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. -To assess for compensatory mechanisms of vasodilation -To promote circulation /venous drainage -Conserves energy and lowers O2 demand - To maximize O2 availability for cellular uptake

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective cue: talagang dry na yun balat niya. As verbalized by the mother Objective cues: -dry skin -braden scale=13, moderate risk -emaciation -premature

Risk for impaired skin integrity

Short term: After 8-hours of nursing intervention the clients mother will verbalize understanding of treatment regimen. Long term: After 3-days of nursing intervention the clients mother will demonstrate behaviors/techn iques to prevent skin breakdown.

Independent: -Assess skin routinely, noting moisture, color and elasticity. -Note presence of conditions that may impair skin integrity. -Review pertinent laboratory results (e.g. studies such as Hb/Hct). -Handle client gently particularly infant. -Observe for reddened areas or skin rashes. -Provide adequate clothing or covers. -Keep bedclothes dry and wrinkle-free, use nonirritating linens. -Provide preventative skin care to incontinent client: change continence diapers frequently.

-This will help assessing causative factors that may indicate particular vulnerability. -This will help in assessing the contributing factors. -This will further help the assessment on the factors that might cause impaired skin integrity. -Epidermis of infants and young children is thin and lacks subcutaneous depth that will develop with age.

Short term: After 8-hours of nursing intervention the clients mother was able to verbalize understanding of treatment regimen. Long term: After 3-days of nursing intervention the clients mother was able to demonstrate behaviors/techniq ues to prevent skin breakdown.

-Provide preventative skin -This reduces the care to incontinent client: progression to skin change continence diapers breakdown. frequently. -This will prevent -Provide information to the vasoconstriction. -This will help mother about the maintain skin importance of regular observation and effective integrity at skin care in preventing optimum level. problems. -To minimize contact with -Emphasize importance of irritants. adequate nutritional/fluid -This will help intake. promotion of -Perform periodic wellness to the assessment using a tool client. such as Braden Scale. -To maintain general good health and skin turgor. -To determine changes in risk status and need for alterations in the plan care.

ASSESSMENT Subjective cue: Naaawa na nga ako sa baby ko eh, kasi minsan hindi sya puwede painumin ng gatas. Objective cues: -poor muscle tone -loss of weight 2,200gms

DIAGNOSIS Imbalanced nutrition: less than body requirements related to altered absorption of nutrients

PLANNING Short term: After 8-hour of nursing intervention the clients mother will verbalize understanding of causative factors when known and necessary interventions. Long term: After 6-days of nursing intervention the client will display normalization of laboratory values and be free of signs of malnutrition.

INTERVENTION Independent: -Identify client at risk for malnutrition (e.g., child wit chronic illness) -Assess weight; measure mid arm muscle circumference or other anthropometric measurements. -Observe for absence of subcutaneous fat that indicate protein-energy malnutrition. -Minimize unpleasant odors. -Provide the clients mother information regarding individual nutritional needs and ways to meet these needs within financial constraint. -Teach mother the different measures on how to manage the problem.

RATIONALE

EVALUATION

Short term: -To assess the After 8-hour of causative and nursing contributing factors. intervention the -To establish baseline clients mother parameters. verbalized -This will help in understanding of evaluating the causative factors degree of deficit. when known and -To have a positive necessary effect on appetite. interventions. -This helps in Long term: promotion of After 6-days of wellness. nursing -This will help in intervention the alleviating the client displayed problem. normalization of laboratory values and be free of signs of malnutrition.

ASSESSMENT Subjective cue: Objective cues: -Hgb=61 g/L (0114-10) -Hgb=132 g/L (01-23-10) -pale -weak peripheral pulse

DIAGNOSIS Risk for infection (spread) related to inadequate secondary defenses.

PLANNING Short term: After 3 days of nursing intervention the patient will. Long term: After 1 week of nursing intervention of nursing intervention, the patient will show improvement in his secondary defense evidenced by increase in hemoglobin count.

INTERVENTION Independent: -Observe for localized signs of infection at insertion sited of invasive lines, sutures, surgical wounds/incisions -Change surgical/other wound dressings, as indicated, using proper technique for changing/ disposing contaminated materials -Stress proper hand hygiene

RATIONALE

EVALUATION Short term: . Long term:

-To reduce progression of infection -To prevent proliferation of bacteria in wounds

 MEDICATIONS

Discharge Planning

No take-home medications

ENVIRONMENT
-Promote an environment that is stress-free, calm and restful, suitable for clients wellness, to provide relaxation and recovery. -Advise the family to maintain the cleanliness, and ensure safety inside their house and surrounding environment to prevent injury to the patient.

TREATMENT
-Encourage the mother the importance of breast feeding to increase immunity of the patient.

HEALTH TEACHINGS
-Advise patients family to provide enough rest to the patient -Explain to patient importance of breastfeeding. -Advise patients parents to consult physician if symptoms of previous illness is felt.

 OUT-PATIENT FOLLOW UP
-Advise patient to strictly follow the schedule dates for follow-up check-ups to monitor clients condition and see progress

DIET
Advise the patients mother to give breastfeeding to promote nutrition to the patient

SPIRITUAL/SOCIAL
-Encourage family in praying for the patients condition.