NCM 109: Neonatal Sepsis Study Guide

• Study notes for NCM 109 Midterm

Neonatal Sepsis

• A diagnosis made in infants less than 28 days of life.
• Consists of a clinical syndrome that may include systemic signs of infection, circulatory shock, and multisystem organ failure.
• Immediate antibiotic treatment is imperative.
• Bacteria or viruses enter the bloodstream.

Sources of Sepsis

• Mother anomalies to fetus
• Fetal anomalies
• External forces or Environmental factors
• Nosocomial infection, such as hospital-acquired infections

Sepsis

• A serious medical condition caused by the body's response to an infection.
• A newborn with an infection can develop sepsis, leading to inflammation throughout the body and potentially brain damage.

Causes of Neonatal Sepsis

• Escherichia Coli (E-Coli).
• Listeria and some strains of streptococcus.

Pathophysiology of Sepsis

• Pathogen entry into the body.
• E.coli, Group B Strep, or viruses enter the newborn's body.
• Immature immune systems detect infection but have weak defense mechanisms, leading to uncontrolled bacterial growth.
• Causes inflammation, damage to blood vessels, poor oxygen delivery, multi-organ failure, and circulatory collapse.
• Vital signs become unstable, leading to Respiratory Distress Syndrome and potentially death.

Newborns at Risk

• Premature or prolonged period between rupture of membranes and delivery (PROM and Incompetent Cervix)
• Dystocia
• Maternal infection
• Small for gestational age
• Meconium Aspiration, where the newborn has swallowed meconium
• Iatrogenic Infected Personnel and Equipment leading to Nosocomial Infection.

Other Causes/Risks of Sepsis

• Mother has an infection of the amniotic fluid (chorioamnionitis).
• Premature newborns are at higher risk for sepsis.
• Low birth weight in the infant is a risk factor for sepsis.
• Mother's water breaks early (PROM), especially more than 14 hours before delivery.
• Newborn is being treated for another condition in the hospital.
• Mother's birth canal is colonized with bacteria, especially if STIs were untreated.

Signs/Symptoms of Sepsis

• Temperature irregularity, including fever or hypothermia.
• Changes in tone and behavior, such as poor tone, weak suck, shrill cry, weak cry, or irritability.
• Unusual skin conditions, such as poor perfusion, cyanosis, mottling, petechiae, or unexpected jaundice.

Diagnosis of Sepsis

• Blood tests (taken cell counts): WBC, Blood Culture, and Sensitivity Test.
• Urine tests: Urinalysis and culture.
• Spinal Tap (lumbar puncture) to test for meningitis.

Treatment of Sepsis

• Intravenous (IV) fluids for medication, fluid, and electrolyte loss which are administered directly into a vein.
• IV antibiotics, (newborns do not undergo skin test)
• Oxygen administration and respiratory support.
• Blood transfusion if necessary.

Nursing Responsibilities

• Isolate the newborn.
• Practice strict handwashing.
• Observe strict asepsis in handling the newborn to prevent nosocomial infection.
• Oxygen therapy and respiratory support.
• Administer antibiotics.
• Keep the newborn warm.
• Maintain nutrition and hydration. IVF, MIO Daily
• Check and monitor: signs of dehydration: Sunken Fontanelles, Depressed eyeballs, Poor skin turgor, Oliguria, Fever and Lethargy
• Meet the newborn's emotional needs.
• Provide emotional support to the mother and family.

Neonatal Meconium Aspiration Syndrome (MAS) / Meconium Stained

• A clinical condition characterized by respiratory failure in neonates born through meconium-stained amniotic fluid.
• Occurs when newborns breathe in meconium, a sticky substance, before or during birth.
• Meconium consists of intestinal epithelial cells, desquamated epidermis, lanugo, bile salts, amniotic fluid, and mucus.

Etiology of MAS

• Meconium aspiration syndrome occurs when a fetus or neonate swallows meconium, causing problems like Respiratory Distress Syndrome (RDS) or Hyaline Membrane Disease.

Pathophysiology of MAS

• Meconium mixes with amniotic fluid in utero, and is swallowed by the fetus.
• Which then enters the lungs, irritating the airway.
• Causes airway spasm and pneumonia aspiration.
• Leading to bilateral coarse infiltration in the lungs, drowning of the lungs, difficulty of breathing, and potential neonatal sepsis.

Risk Factors for MAS

• Overdue pregnancy (more than 40 weeks gestation).
• Fetal distress caused by maternal hypertension (PIH/HELLP), preeclampsia, placental insufficiency, smoking, cocaine abuse, or maternal age.

Signs and Symptoms of MAS

• Cyanosis
• Weak cry
• Rapid breathing
• Grunting (initial manifestation)
• Apneic episodes
• Barreled chest with sternal retractions
• Poor suck
• Poor reflexes

Nursing Management of MAS

• Priority is immediate newborn care: Airway, Breathing, Circulation.
• Suction secretions if the Apgar score is less than 5.
• Observation for fetal distress during the first and second hour of birth.
• Suctioning of the airways starts once the head and shoulder are delivered with external rotation.
• Oxygen delivery and administration/mechanical ventilatory support.
• Prophylactic antibiotics to prevent neonatal sepsis.
• Monitor vital signs and well-being, including signs of infection such as poor suck, weak cry, lethargy, fever, hypothermia, or difficulty of breathing.
• Provide warmth to prevent hypothermia.
• Monitor signs of dehydration and start with IVF.
• Handwashing to prevent nosocomial infection.
• Promote Aseptic Technique

When a Newborn is Diagnosed with Meconium Stained/Aspiration

• Do not start feeding, keep the newborn NPO.
• Lavage (wash out) until secretions are clear.
• Do not feed until vital signs are stable.
• Keep NGT in place at gravity drain until the drainage is clear.
• Nurse only starts feeding once drain is clear after assessment by the doctor.
• Gavage: Feeding through a tube (NGT/OGT)

Respiratory Distress Syndrome (RDS) / Hyaline Membrane Disease

• Occurs in premature newborns whose lungs are not fully developed.
• The earlier the infant is born more likely for newborn to have RDS
• May need extra oxygen and breathing support.
• Newborns with neonatal sepsis, meconium aspiration, or other medical issues may also be susceptible to RDS.
• RDS is caused by a lack of surfactant, a substance in the lungs.
• Surfactant production begins at 24-28 weeks but adequate levels aren't usually reached until 35 weeks.
• A normal ratio for mature lungs is greater than or equal to 2:1.
• A ratio of 1:1 or lower suggests immature lungs and a higher risk of RDS.

Etiology of RDS

• Occurs due to immature lungs with decreased surfactant.
• Is seen in newborns with pulmonary, cardiac, infectious, and metabolic causes, which compromise normal lung function leading to RDS.

This is Best Aimed to Premature Births

• By 24 to 28 weeks gestation
• Surfactant is not mature enough to enable to breathe normally outside the uterus.
• With immature lungs there is less production of surfactant causing the lungs to be stiff and resistant to expansion
• Leads to difficulty of breathing = RDS

Pathophysiology of RDS

• Immature lungs of the premature newborn/compromised neonatal conditions
• Less production of surfactant/ low levels of surfactant
• Decreased blood perfusion of the lungs
• Termination of bronchioles, alveolar ducts and alveoli= result shutdown of the lungs
• Vasoconstriction, decreased pulmonary perfusion
• Distressed newborn = vital signs unstable
• Death

Nursing Alert for RDS

• Signs of RDS begin with the first hour
• Grunting as the first sign
• After birth, and if not treated with surfactant, may lead to severe conditions.
• Not all premature births administered with surfactant may be able to survive

Infants at Risk of RDS

• Premature newborn who is born before 35 weeks gestation.
• Mothers with GDM
• High insulin levels in the fetus can delay surfactant production
• Cesarean section that has no labor stress
• Reduces the release of catecholamines which help in the lung fluid clearance
• Neonatal Sepsis
• Multiple Births
• Higher risk of prematurity and low birth weight
• Infants With Meconium Aspiration Syndrome
• Meconium in the airway can block surfactant function
• Low Birth Weight Infants
• Associated with poor lung development

Complications During Pregnancy

• Mother with untreated infection
• Newborn is ill at the time of delivery
• Due to intrauterine complications
• Newborns delivered with these complications
• Hypothermia
• Hyperthermia
• Hypoglycemia
• Hyperglycemia
• Other complications

Signs and Symptoms of RDS

• Hypoxia
• Lack of low oxygen supply
• Bluish discoloration of the body
• Fast breathing very soon after birth
• Tachypnea and tachycardia
• Grunting "ugh" sound with each breath – first sign of RDS
• Changes in color of lips (Circumoral Cyanosis)
• fingers and toes (Acrocyanosis)
• entire body (generalized cyanosis)
• NASAL Flaring (widening) of the nostrils with each breath.
• Shows newborn is struggling to breath
• Chest retractions
• Sternal Retractions
• Skin over the breastbone and ribs pulls in during breathing the diagnosis is made after examining the newborn and seeing the results of chest X-rays (Glass) and blood tests.

Complications Associated with RDS

• Retrolental Fibroplasia
• Permanent blindness
• Prolonged use of oxygen may rupture/ damage retina of the eye
• This is caused by injudicious use of oxygen
• Bronchopulmonary Dysplasia
• Chronic lung disease
• affects newborn caused by damaged tissues due to lack of oxygen supply
• Atelectasis
• collapsed lungs which can lead to irreversible damage will lead to death
• the heart is also affected

Treatment of RDS

• Oxygen administration.
• Continue suctioning secretions gently
• If signs of RDS are significant, maintain NPO
• Administration of surfactant: surfactant can be given into the newborn's lungs to replace what they do not have.
• This is given directly down the breathing tube that was replace in the windpipe. (ENDOTRACHEAL TUBE)
• Continuous Positive Airway Pressure (CPAP)
• This machine gently pushes air or oxygen into the lungs to keep the air sacs open
• Preventing the occurrence of Retrolental Fibroplasia
• Non-invasive air or oxygen at a positive pressure to allow alveoli and airways to open.
• IVF to maintain hydration
• Med. Antibiotics are given if the infection is suspected

Hyperbilirubinemia

• Jaundice or yellowish discoloration of the skin due to the elevated level of bilirubin in the blood.
• Abnormal: greater than 12-13mg/100ml or dL
• Normal Range:
• 2-6mg/100ml or dL
• Not to exceed 12mg/100ml
• Occurs when bilirubin builds up in the newborn's blood
• Hyperbilirubinemia is the medical term Bilirubin
• a yellow substance that the body creates when red blood cells break down
• The newborn's liver must begin to remove bilirubin, however if the newborn's liver is immature- it may not be able to function to remove bilirubin through the process of feces and urine.

Etiology of Hyperbilirubinemia

• Genetic anomalies.
• Mother and child blood type not compatible.
• A blood infection (sepsis).
• Bruising from a difficult birth (trauma during birth delivery).
• Too many red blood cells.
• A low oxygen level (hypoxia) due to RDS.
• A liver condition such as biliary atresia.
• Premature newborn due to immature liver
• Neonatal sepsis/infection
• Birth trauma
• Women who breastfeed: PREGNANEDIOL
• A breakdown product of progesterone in the breastmilk, that depresses the action of Glucuronyl transferase- that helps process bilirubin
• Poor meconium passage
• Meconium is rich with bilirubin so frequent stool results to increased excretion of bilirubin

Types of Hyperbilirubinemia

• Physiologic Jaundice:

• (or Non-Conjugated or Indirect)

• It is the most abundant type of newborn hyperbilirubinemia, having no serious consequences

• NOT HARMFUL

• Is considered normal

• Which usually appears between or after 24-72 hours of life and between 4th-5th days can be considered as its peak in FULL TERM neonates and in PRETERM at 7th day, it disappears by 10-14 days of life

• The most common type of jaundice in newborns is physiological jaundice. This type of jaundice is normal. Physiological Jaundice develops in most newborns by their second or third day of life. After your newborn's liver develops, it will start to get rid of excess bilirubin. Physiological Jaundice usually is not serious and goes away on its own within two weeks.

Nursing Implementation for Hyperbilirubinemia

• Self-limiting

• Early monitoring sunlight exposure for 30 minutes to an hour

• Stop Breastfeeding

• Suggest milk banking

• Donating your milk in the hospital if the mother has so much milk

• Bilirubin

• Less than 12-15mg/100ml

• Pathologic Jaundice:

• (Conjugated or Direct)

• Bilirubin levels with a deviation from the normal range and requiring intervention would be described as pathologic

• Appearance of jaundice within 24 hours of life due to increase in serum bilirubin beyond 5 mg/dl/day, peak levels higher than the expected normal range. Due to MAJOR TYPE ABO or RH incompatibility

Assessment Findings for Pathologic Jaundice

• Full term level : 20mg/100mg or above
• Yellow discoloration extending to palms and soles
• Preterm : 15mg/100ml or above which may lead to KERNICTERUS Danger bilirubin mixes up the blood stream and enters the brain would cause permanent brain damage or mental disability

Kernicterus

• Signs:

1. Poor suck, weak cry and Lethargic Suggest bilirubin neurotoxicity (Kernicterus)
2. Sluggish to absent Moro Reflex
3. Opisthotonus An abnormal posturing caused by strong muscle spasms Best position for the newborn to prevent further trauma is side-lying position

Signs and Symptoms of Pathologic Jaundice

• Severe lethargy
• Projectile vomiting
• Tense bulging fontanel
• Fluid builds up in the brain or swelling inside the skull
• High pitched cry
• ΑΡΝΕΑ Resulting to RDS (Respiratory Distress Syndrome)
• Convulsion or medical term: OPISTHOTONUS Considered the late sign

Treatment of Hyperbilirubinemia

• Stop breastfeeding for a while
• Phototherapy exposure/ Bililight exposure
• Blood exchange transfusion Patient's blood type is or completely removed and replaced with the donor blood - the mother

Nursing Responsibilities During Phototherapy/Bililight Exposure

• Secure consent from the parents
• Discuss the purpose Fluorescent lights must be used for 100 hours then CHANGE TO NEW SET
• Newborn must be naked except for black cloth to cover the eyes
• For male, black cloth to cover the genitals to prevent sterility issues in the future
• MIO strictly monitored to keep hydrated. D10WATER- Glucose. Maintain IVF
• IVF must be closely monitored to be sure of patency