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 Rationale

To determine the need for

Monitor neonates condition. intervention and the
effectiveness of therapy.

Monitor vital signs To have a baseline data

 Helps in lowering down the
Provide TSB
temperature

Ensure that all equipment used for infant is Prevents the spread of
sterile, scrupulously clean. Do not share pathogens to the infant from
equipment with other infants equipment

Aids in lowering down

Administer antipyretics as ordered
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)

To assess what factor contributes to fluid

Note for the causative factors that
volume deficit that may be given prompt
contribute to fluid volume deficit
intervention.

Provide TSB if patient has fever To decrease temperature and provide comfort

Provide oral care by moistening

lips & skin care by providing daily To prevent injury from dryness
bath

Administer IV fluid replacement as

Replaces fluid losses
ordered

Administer antipyretic drugs if

To reduce body temperature
patient has fever as ordered

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
Rationale
Interventions

Note quality and

To asses pulse that may become weak or thready, because of
strength of
sustained hypoxemia
peripheral pulses

To note for an increased respiration that occurs in response to

Assess respiratory direct effects of endotoxins on the respiratory center in the
rate, depth, and brain, as well as developing hypoxia, stress. Respirations can
quality become shallow as respiratory insufficiency develops creating
risk of acute respiratory failure.

Assess respiratory
rate, depth, and To assess for compensatory mechanisms of vasodilation
quality

Assess skin for

changes in color,
To promote circulation /venous drainage
temperature and
moisture

Elevate affected
extremities with
Conserves energy and lowers O2 demand
edema once in a
while

Provide a quiet,
To maximize O2availability for cellular uptake
restful atmosphere

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. Interruptedbreastfeeding 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

To know what the mother already
about breastfeeding and extent of instruction
knows and needed to know.
that has been given.

Give emotional support to mother and accept

To assist mother to
decision regarding cessation/ continuation of
maintain breastfeeding as desired.
breast feeding.

Aid in feeding the neonate

Demonstrate use of manual piston-type breast
with breast milkwithout the
pump.
mother breastfeeding the infant.

To provide optimal nutrition and

Review techniques for storage/use of
promote continuation
expressed breast milk
of breastfeeding process

Determine if a routine visiting schedule or So that infant will be hungry/ ready

advance warning can be provided to feed

Provide privacy, calm surroundings when To promote successful infant

mother breast feeds. feeding

Reinforces that feeding time is

Recommend for infant sucking on a regular
pleasurable and enhances
basis
digestion.

Encourage mother to obtain adequate rest,

To sustain adequate milk
maintain fluid and nutritional intake, and
production and breast feeding
schedule breast pumping every 3 hours while
process
awake
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 theirnewborn.

Nursing Interventions Rationale

Interview parents, noting their perception of To know what the parents

situational and individual concerns feelings about the situation.

Educate parents regarding child growth and Helps clarify realistic

development, addressing parental perceptions expectations

Involve parents in activities with the newbornthat

Enhances self-concept
they can accomplish successfully

Recognize and provide positive feedback for Reinforces continuation of

nurturing and protective parenting behaviors desired behaviors