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Acknowledgement

We humbly recognize the limitedness of our young minds thus, we had to consult

different people concerning this case presentation, people who are more knowledgeable than us.

Now we see this case study printed, we would like to express our utmost gratitude to our

significant others whom have inspired and helped us dedicate ourselves in the success of our

case study.

First, to the Almighty God, for giving and showering us blessings, further, strengthening

our spirit to face the inherent demands of the task assigned, thereby, molding us to become

useful citizens of this land.

To the family of our patient, for their willingness to be the subject for our case study, for

being responsive and open to inquiries during the interview process and for being cooperative in

everything that we did.

To our wonderful Clinical Instructors, Mrs. Mary Hazel Facundo, RN MN, Ms. Grace

Guitguiten, RN, MN, Mrs. Dinna Rose Bayog, RN MN, and Mrs. Yvonne Kuan, RN, MN, who

imparted their best knowledge for us to be able to work our best as student nurses, may they all

find it in their hearts to keep going and keep teaching the eager young minds of tomorrow.

To the residents-on-duty, staff, and nurses-on-duty at Southern Philippines Medical

Center Pediatrics Ward, for accommodating us and for being understanding and patient with us

during the whole time of our duty.


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Lastly, to our parents and family who never left us and remained with us during our hard

times, may they remain in our hearts all through the years as we finish and reach our goals.


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INTRODUCTION

We, the group 3 of Section 2A of the Ateneo de Davao University, conducted an

interview and physical assessment last February 9 and 10, 2012 at the Pediatrics Ward of the

Southern Philippines Medical Center as part of our case study in relation to Pediatrics

Abnormalities concept. Our case is about Errshen, who was admitted to the Pediatrics-Sick

Neonate ward, with a medical diagnosis of neonatal sepsis and suspected patent ductus

arteriosus.

The circulatory system is a vital system in the human body. Without it, there will be no

transporter of nutrients, water, and oxygen to our billions of body cells and carrier away of

wastes such as carbon dioxide that body cells produce.It is an amazing highway that travels

through your entire body connecting all sour body cells. (hes.ucfsd.org). But what if the system

itself has defect, will we still survive?

The first condition of our patient is septicemia or more commonly known as sepsis.

Septicemia is a serious systemic illness caused by bacteria and bacterial toxins circulating in the

bloodstream. During the past 30 years, it has become an increasingly common condition among

hospitalized patients. Of newborns with early-onset infection, 85% present within 24 hours, 5%

present at 24-48 hours, and a smaller percentage present within 48-72 hours

(www.emedicine.medscape.com). According to the World Health Organization, neonatal sepsis

accounts for 33% of over 40,000 newborns death in the Philippines each year.


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Onset is most rapid in premature neonates. Early-onset sepsis syndrome is associated

with acquisition of microorganisms from the mother. Transplacental infection or an ascending

infection from the cervix may be caused by organisms that colonize in the mother's genitourinary

tract, with acquisition of the microbe by passage through a colonized birth canal at delivery.

The second condition of our patient is Patent ductus arteriosus (PDA) which is one of the

most common congenital heart defects. The ductus arteriosus is a remnant of the distal sixth

aortic arch and connects the pulmonary artery at the junction of the main pulmonary artery and

the origin of the left pulmonary artery to the proximal descending aorta just after the origin of the

left subclavian artery. Most typically, it is a left aortic remnant. In PDA, abnormal blood flow

occurs between two of the major arteries connected to the heart. These arteries are the aorta and

the pulmonary artery. A right-sided patent ductus arteriosus can occur, or the ductus arteriosus

can be present on both the right and the left. Although a left ductus arteriosus is a normal

structure during normal fetal development, the presence of a right ductus arteriosus is usually

associated with other congenital abnormalities of the cardiovascular system, most typically

involving the aortic arch or conotruncal development. The presentation widely varies. Depending

on the size of the patent ductus arteriosus, the gestational age of the neonate, and the pulmonary

vascular resistance, a premature neonate may develop life-threatening pulmonary overcirculation

in the first few days of life. Conversely, an adult with asmall patent ductus arteriosus may

present with a newly discovered murmur well after adolescence.


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The incidence of this anomaly is twice in females than males. After Ventricular septal

defect the Patent Ductus Arteriosus is the commonest congenital heart defect in children. Around

the world, it accounts for approximately 10% in newborns (www.clevelandclinic.org). In the

Philippines, the case rises at an unacceptable increasing level. The patent ductus arteriosus

incidence best estimates for the Philippines suggest that approximately 0.25% children are

affected by this. Those cases that were left untreated have led to death by 78% (The Mindanao

Daily Mirror, 2009).

The group chose the case of Errshen which are neonatal sepsis and patent ductus

arteriosus primarily because we already have the prior knowledge on thess type of pediatric

illnesses, thus requiring us to apply this knowledge in the actual setting. This would serve as a

good avenue for us to develop our skills in relation to the facts and information that we have

already learned in the university.


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OBJECTIVES

General:

Within our 2 days of duty at the Pediatrics Ward of the Southern Philippines Medical

Center, the goal of the group is to be able to provide holistic nursing care to our client and to be

able to apply the knowledge we have gained in the university to the actual clinical situation.

Specific:

Cognitive

Formulate objectives to be followed on the course of making this case study;

Gather pertinent data of the past and present health history of the patient through

interview and assessment;

Collect necessary information about our clients personal data regarding patients profile,

family background, social status and nutritional status;

Draw the family genogram of the patient to trace disease inheritance;

Ascertain the patients developmental status using the theories of Robert Havighurst, Erik

Erikson and Jean Piaget;

Provide a precise cephalocaudal assessment obtained from the client;

Define the complete diagnosis of the patient by directly citing it from three different

sources;

Discuss the anatomy and physiology of the affected body systems related to the case of

our patient;

Identify and rationalize the signs and symptoms associated with the disease

Trace and explain the pathophysiology of the disease


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Present the doctors orders and make rationales for each order;

Obtain, analyze and interpret laboratory and diagnostic procedures done on the patient

and include the normal and abnormal values and findings for comparison, and the

specific nursing responsibilities associated with each diagnostic procedure;

Make a drug study on the medications given to our patient that includes the generic and

brand names, classification, indication, contraindication, action, adverse effects, side

effects, and nursing responsibilities.

Relate the clients condition to three nursing theories

Correlate the different nursing theories with the nursing care plans that are presented in

this case study;

Make a specific, measurable, attainable, realistic, and time-bounded nursing care plans

for the patient;

Validate patients prognosis according to onset of illness, duration of illness, precipitating

factors, willingness to take medications and treatment, age, environmental factors and

family support;

Make a discharge plan for the patient with the use of M.E.T.H.O.D.S.;

Evaluate the enhancement of the clients condition from the interventions rendered.

Psychomotor

Find a patient who will be the subject of our case presentation;

Perform a thorough physical assessment which will serve as our baseline data;

Identify clients health problems and provide care based on the various nursing care plans

formulated by the researchers;

Give the family health teachings to provide wellness for the betterment of the patient;


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Share information about Patent Ductus Arteriosus and the related factors that may be of

concern to the patient.

Affective

Establish a trusting relationship with the patients family to gain necessary information

regarding the patients status.

Approach the patient and the significant others in a non-judgmental demeanor.

Respect the patients familys right for confidentiality and their religious, cultural, and

personal beliefs.


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HEALTH ASSESSMENT

PATIENTS DATA

BIOGRAPHICAL:

Patients Name: Errshen

Address: Purok 5, Buda, Marilog District, Davao City

Date of birth: January 15, 2012

Parents Religion: Christianity (Roman Catholic)

Parents Occupation:

Mother: Housewife

Father: Security Guard

Occupation: None

Health Insurance: PhilHealth (under fathers name)

Source and Reliability of Information: Mother

Profile:

Age: 14 days old

Gender: Female

Parents Race/Ethnic Background: Bagobo

Chief Complaint: Referral from a local hospital (German Doctors Hospital);

episode of respiratory arrest, cyanosis

Date of Admission

January 29, 2012

Healthcare institution

Southern Philippines Medical Center


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Admitting Diagnosis: Neonatal Sepsis R/O CHD probably PDA

Admitting Physician: Dr. Mardigrace B. Puracan

Admitting Clerk: Daisy Mae Maniquit

Vital Signs upon admission:

Pulse Rate: 133 bpm

Respiratory Rate: 54 cpm

Temperature: 36.7C

B.PRESENT HEALTH HISTORY

Last January 20, 2012, according to the mother, the patient experienced convulsions

around 10:30 in the evening and was rushed to German Doctors Hospital. The patient was

admitted at that hospital for continuous care. By January 29, 2012 at around 9:00 AM, the

mother noticed that her child was pale and had difficulty in breathing. Later on, the child had

cyanosis and they immediately rushed to the doctor. The patient was diagnosed to have

congenital heart defect, which is probably patent ductus arteriosus. Since the institution cannot

provide the childs needs for care, the patient was referred to SPMC for continuous recovery. At

around 1:00 PM, they have arrived at the institution.


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C. PAST HEALTH HISTORY

According to the mother, the child didnt have any communicable disease or any illness except

for the childs convulsions and heart defect. Her first hospitalization was at German Doctors

Hospital due to convulsions. The child has not encountered any injuries or accidents. For the

childs immunizations, only Hepatitis B vaccine was given to her when s he was delivered. She

didnt undergo any surgery or blood transfusions yet.

Medication Reconciliation

Medication Indication as known

by the parents

Dosage Prescribing Health

Care Provider

Cefotaxime

Amikacin

Ceftriaxone

Both the parents

doesnt know about

the medications are

for.

300g IVTT

45g IVTT OD

15g IVTTq 12

Dr. Mardigrace B.

Puracan


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D. Family Health History


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E. Social History

The mother verbalized that upon their stay inside the hospital, mother-child bonding was

implemented. The mother usually breastfeeds the child, changes the diapers and clothes, and

provides comfort to the patient. The mother verbalized ginapunasan nako ni siya adlaw-adlaw

gamit ang labakara. The mother usually watches over the patient. She never left the hospital

since their child was admitted. The father works as a security guard in a hardware located at

Uyanguren and earns 4,500 pesos in a month. He works daily except for Sundays from 8 in the

morning to 5 in the afternoon. He visits their child every after work. He provides the needs of

the mother like clothes and food. To support the childs needs aside from using his own money,

he asked for a cash advance in order to pay for the hospital expenses and the childs medications,

except for the childs lumbar puncture since they cant afford it. The mother verbalized

ginasuportahan man namo sya sa mga gastuhunon pareho anang magpalaboratory ug kanang

makaya lang namo bayaran. They both ensure the wellbeing of their child. Inside the ward, the

patient shares a bed with another patient. The room was crowded with things which make it look

untidy. Regarding the childs condition, the mother verbalized ang nahibal-an lang namo kay

naa siyay buslot sa dughan, wala gyud mi kabalo kung unsa to siya.

F. Health Maintenance Activities

According to the mother, her child wakes up to breastfeed. The doctor ordered

breastfeeding with strict aspiration precaution and is advised to have nothing per orem if

respiratory rate is greater than 60. After breastfeeding, the child will immediately go to sleep.

The mother tries to let the child burp, but she couldnt do it. The child is also lethargic;

sometimes the child suddenly goes to sleep while shes breastfeeding. Whenever the child is


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experiencing difficulty or fast breathing, the mother would administer oxygen to the child via

face mask, 4 liters per minute as ordered.

G. Nutritional Assessment

Height: 54 cm

Weight: 3.5 Kg

BMI: 12.00

Head circumference: 35 cm

Chest circumference: 36 cm

Abdominal Circumference: 37 cm

Diet History

The mother verbalized that the baby was purely breastfed; she complies with the doctors

order that she should limit the childs intake both orally and intravenously due to the possible

cardiac overload that may happen.


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DEVELOPMENTAL DATA

Developmental task theory of Robert Havighurst

Is a task which arises at or about a certain period in the life of an individual , successful

achievement of which leads to his happiness and to success with later tasks, while failure leads to

unhappiness in the individual, disapproval by society, and difficulty with later tasks

(Havighurst, 1972, p.2).

Havighurst also identified Six Major Stages in human life covering birth to old age which are the

following:

Infancy & early childhood (Birth till 6 years old)

Middle childhood (6-12 years old)

Adolescence (13-18 years old)

Early Adulthood (19-30 years old)

Middle Adulthood (30-60years old)

Later Maturity (60 years old and over)

Our patient is in Infancy and early childhood because at this age he learns to walk, crawl, eat

solid food, talk, eliminate body waste, and differentiate sexuality. Forming concepts and

learning language to describe social and physical reality.
http://g/wiki/Infancyhttp://g/wiki/Adolescencehttp://g/wiki/Adolescencehttp://g/wiki/Infancy


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DEVELOPMENTAL

TASK

ACHIEVED OR NOT

ACHIEVED

JUSTIFICATION

Learning to Walk Not achieved The patient is only 14 days old and hasnt

learned to walk. The child is only being

carried.

Learning to take solid

food

Not achieved The patient is purely breastfed by the

mother. Also, she is not yet on the weaning

phase (not less than 4 months, not more

than 6 months.)

Learning to Talk Not achieved The child cannot talk. Because the infants

brain is not yet at the age of learning or

expressing. The child only cries whenever

she needs something.

Learning to control the

elimination of bodywastes

Not achieved The child was unable to defecate and

urinate. She depends on diaper usage for herto eliminate body wastes.

Achieving psychological

stability

Not achieved The child is only 14 days old. At that age,

infants still depend on crying to express of

what they feel and need.

Forming simple concepts

of social and physical

reality

Not achieved The child at the age of 14 days old does not

have the awareness of the environment

around her; may it be her family or the

physical environment around her.

Learning to relate

emotionally to parents,

siblings, and other people

Not achieved At her age of 14 days old, ways of

expression is dependent on crying.

Learning to distinguish

right from wrong and

developing conscience

Not achieved 14 day old infants cannot distinguish

between right and wrong because at that

age, infants do what they want and they

something were to hinder, they would

express by crying.

Learning Sex differences

and sexual modesty

Not achieved The child is only 14 days old. Awareness of

sex and sexual differences is beyond her

understanding.


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Psychosocial theory of Erik Erickson

Eriksons theory proposes that life is a sequence of developmental stages or levels of

achievement. Each stage signals a task that must be accomplished. The resolution of the task can

be complete, partial, or unsuccessful. Erikson believed that the more success an individual has at

each developmental stage, the healthier the personality of the individual.

Stages of Eriksons Psychosocial Theory are as follows:

Infancy Birth-18 months Trust vs. mistrust

Early childhood 1-3 years Autonomy vs. Shame

Late childhood 3-6 years Initiative vs. Guilt

School age 6-12 years Industry vs. Inferiority

Adolescence 12-18 years Identity vs. Role Confusion

Young adulthood 18-30 years Intimacy vs. Isolation

Adulthood 30-65 years Generativity vs. Stagnation

Maturity 65 years to death Integrity vs. Despair

Being an infant at the age of 3 days old, he is considered as a part of the Trust versus

mistrust stage of Erikson.

Stage Description Result Justification

Infancy

(Birth-18

months)

TRUST

VERSUS

MISTRUS

T

Erikson also referred to infancy as

the Oral Sensory Stage (as anyone

might who watches a baby put

everything in her mouth) where the

major emphasis is on the mother's

positive and loving care for the

child, with a big emphasis on visual

contact and touch. If we pass

successfully through this period of

life, we will learn to trust that life is

basically okay and have basicconfidence in the future. If we fail to

experience trust and are constantly

frustrated because our needs are not

met, we may end up with a deep-

seated feeling of worthlessness and

a mistrust of the world in general.

Achieved The infant is only 14 days old

and is fully dependent to her

parents. Whenever the child is

hungry, her mother would

breastfeed her. Her mother also

does the changing of her diapers

from time to time whenever it is

wet and full. The mother also

provides comfort to her child

whenever she is crying and

whenever she goes to sleep. Themother always gives what her

child needs from her.


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Cognitive Theory of Piaget

Cognitive Theory refers to the manner in which people learn to think, reason, and use

language. It involves a persons intelligence, perceptual ability, and ability to process

information. Cognitive development represents a progression of mental abilities form illogical to

logical thinking, from simple to complex problem solving, and from understanding concrete

ideas to understanding abstract concepts

Piagets Phases of Cognitive Development

Phases and Stages Age Significant Behavior

Sensorimotor Phase Birth to 2 years The first is centered on the

infant trying to make sense of

the world. During the

sensorimotor stage, an infants

knowledge of the world is

limited to their sensory

perceptions and motor

activities. Behaviors are

limited to simple motor

responses caused by sensory

stimuli. Children utilize skills

and abilities they were bornwith, such as looking, sucking,

grasping, and listening, to

learn more about the

environment.

Stage 1 Use of reflexes Birth to 1 month Most action is reflexive

Stage 2 Primary Circular

reaction

1 to 4 months Perception of events is

centered on the body

Stage 3 Secondary Circular

reaction

4 to 8 months Acknowledges the external

environment

Stage 4 Coordination ofsecondary schemata

8 to 12 months Can distinguish a goal frommeans of attaining it

Stage 5 Tertiary Circular

reaction

12 to 18 months Tries to discover new goals

and ways to attain goals.

Stage 6 Inventions of new

means

18 to 24 months Interprets the environment by

mental image. Uses make-

believe and pretend to play


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Preconceptual Phase 2 to 4 years Uses an egocentric approach

to accommodate the demands

of an environment

Intuitive Though Phase 4 to 7 years Egocentric thinking

diminishes. Thinks of one idea

at a time. Includes others in

the environment.

Words express thoughts

Concrete Operations Phase 7 to 11 years Solves concrete problems.

Begins to understand

relationships such as size.

Understands right and left.

Cognizant of viewpoints

Formal operations phase 11 to 15 years Uses rational thinking.

Reasoning is deductive andfuturistic

Phase and Stage Description Justification

Stage 1 Use of

Reflexes

Achieved. The child was able to achieve:

rooting reflex with weak response. The child turned

her head toward the side of the face stroked;

sucking reflex because the child was able to suck

her thumb and was able to breastfeed frequently;

palmar grasp reflex with strong, immediate

response; flexion of the hands and feet were

present;

tonic neck reflex with weak response; the childs

head turned to one side and the arm and leg on the

same side extended;

babinski reflex with weak response; the big toe

rose and the remaining toes fanned out upon

stroking the sole of the foot from heel to toe;

moro reflex with quick response, where suddenextension and abduction of extremities were noted.


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ETIOLOGY

As a baby develops in the womb, a vascular connection (ductus arteriosus) between two

major blood vessels leading from the heartthe aorta and pulmonary arteryis a normal and

necessary part of your baby's blood circulation while in the womb. The ductus arteriosus diverts

blood from the lungs of the fetus while they aren't being used. The fetus receives oxygen from

the mother's circulation. But, the ductus arteriosus is supposed to close within two or three days

after birth once the newborn's heart adapts to life outside the womb. In premature infants, the

connection often takes longer to close on its own. If the connection remains open, it's referred to

as a patent ductus arteriosus.

The abnormal opening causes too much blood to circulate to the lungs and heart. If not

treated, the blood pressure in the lungs may increase (pulmonary hypertension) and the heart

may enlarge and weaken.

Congenital heart defects arise from problems early in the heart's development but there's

often no clear cause. Genetics and environmental factors may play a role.

Predisposing

Factors

Present/

AbsentRationale Justification

Being born too soon

(prematurity)

Absent Patent ductus arteriosus

(PDA) occurs more

commonly in babies

who are born too early

than in babies who bornfull term because the

infants heart was not

fully developed before

delivery.

The mothers LMP was on

April 16, 2011 and the baby was

born on Jan 15, 2012. Therefore

the baby was exactly born

9months and 1 day. Proving thatshe is not in a preterm state.


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Having other heart

defects

Absent Babies who have other

heart problems when

they're born (congenital

heart defects) are also

more likely to have a

patent ductus arteriosus.

Because other defects

such

Other than Patent Ductus

Arteriosus, no other heart defect

has been noted/diagnosed.

Family history and

other genetic

conditions.

Present If you have a family

history of heart defects,

it's more likely your

child may have a patent

ductus arteriosus. Other

genetic conditions, suchas heart problems or

chromosomal

abnormalities, also have

been linked to an

increased chance of

having a PDA.

Tracing back to the family

history, the grandmother of the

baby has myocardial infarction

in which may be a factor for her

to have PDA.

Having a female baby Present PDAs are much more

common in girls than in

boys.

The baby was born as a female

as evidenced by the presence of

only female genitalia.

Precipitating

Factors

Present/


Use of Teratogens

during pregnancy

Absent Teratogens are any

chemical, substance, or

exposure that could possibly

cause birth defects in a

developing fetus. Exposure

to teratogens seems to result

in malformations especially

when it occurs during the

fourth and tenth week of

pregnancy.

Only FeSO4 was taken by the

mother during her pregnancy

with patient Errshen.


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Smoking Present A shortage of oxygen can

have devastating effects on

your baby's growth and

development. On average,

smoking during pregnancy

doubles the chances that a

baby will be born too early

or weigh less than 5 1/2

pounds at birth. Smoking

also more than doubles the

risk of heart diseases on

infants

The mother told us that she

smoked during the first

trimester of her pregnancy;

however, she stopped smoking

when she knew that she was

pregnant.

Chromosomal

abnormalities

Absent Trisomy 21, the

chromosomal abnormality

associated with Downsyndrome, is associated

with cardiac abnormalities

in 50 percent of babies.

Chromosomal abnormalities

The infant may have PDA, but

no signs of Chromosomal

abnormalities, like simianscrease, lethargic eyes, short

neck, Brushfield spots, and

others was seen.

Maternal

infections (esp.

Rubella/German

measles)

Absent If you have rubella in the

first trimester, you have

about a 25% risk of having

a birth defect, known as

congenital rubella

syndrome. The defects can

include:

heart deformities

hearing loss

mental retardation

eye deformities

others

The mother told us that she had

no diagnosis of infections

before and during her

pregnancy.


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PHYSICAL ASSESSMENT

General Survey

The patient is 14 days old. She looked appropriate to her age. The patient has no

obvious physical deformities; her body is symmetrical and normal for her age. No body

odor or breath odor was noted. Skin integrity is interrupted due to IVTT insertion of

D5IMB 500 cc infusing @ 13cc/hr at the left metacarpal vein.

The patient was awake and was carried by the mother upon assessment. The

patient was in respiratory distress manifested by fast breathing with a respiratory rate of

100 cycles per minute. Oxygen was administered to her via face mask at 4 liters per

minute.

Vital signs

Vital Signs Upon

Admission:

4PM 8PM

Blood Pressure ---- ---- ----

Cardiac Rate 133 bpm 171 bpm 120 bpm

Respiratory Rate 54 cpm 100 cpm 58 cpm

Temperature 36.7C 38.3C 37.2C


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Skin, Hair, Nails Assessment

Skin

The skin is smooth, thin, and pale; no edema and tenderness noted. The patient has a brown

complexion in all areas. No bleeding or lesions was noted. The skin is warm to touch and has

good skin turgor. The child has a birthmark on her left leg at about 5 cm in length and 3 cm in

width. Milia was not present.

Hair

The hair is black in color, thin, and is evenly distributed. Her scalp is light brown, with no signs

of lesions. There is presence of lanugo at the back of the patient.

Nails

The nails were round, hard. Nails were intact and pale in color with a capillary refill of

3-4 seconds. The nails are clean and smooth with clubbing noted. No lesions were observed.

Head, Neck, and Regional Lymphatic Assessment

Head

The head of the patient is normocephalic and symmetrical. The head circumference of the

patient is 35 cm. The mother verbalized pag mag-utong ni siya, mamula jud ni iyang agtang

which was observed upon assessment. Upon palpation, the skull is smooth, soft, and fused except

for the fontanels. Her facial features and expressions are symmetrical and the shape of the head

is round. There are no obvious deformities. She could open and close her mouth without any

discomfort.


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Neck

Her neck is short and warm to touch. Her neck movement is coordinated; the patient can

move her head from side to side without signs of discomfort.

Regional Lymphatics

There were no visible lymph nodes upon inspection. No palpable lymph nodes were

present. There were also no abnormalities in her thyroid gland both anteriorly and posteriorly.

Eye Assessment

Upon assessment, eyebrows are thin, smooth, and symmetrically aligned. The eyelashes

are evenly distributed and curled slightly outward. No noted discharges were present in the

lacrimal apparatus. The color of her iris is dark brown. The iris and pupils were round and equal

on both sides. Pupillary reflex is not yet developed. The sclera is clear. Whenever the child cries,

tears are not present since the childs tearing ability is not yet fully developed.

Ears, Nose, Mouth, and Throat assessment

Ears

Both of her ears are symmetrical in size and are located. There is no presence of foreign

bodies, redness, deformities, or lesions. Inflammation and nodules were not visible. The external

auditory canal curves upward and is short and straight. Minimal amount of cerumen in the ear

canal was observed. The ears were physically symmetrical in size; pinna is in line with the outer

canthus of his eyes. Upon palpation, ears are smooth and no tenderness is noted. No bleeding or

masses were noted. No pain or tenderness was noted.


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Nose

Nose was located symmetrically in the midline of the face with no evidence of swelling,

bleeding, lesions, and masses. Nasal flaring was noted. No tenderness noted upon palpation.

Both left and right nares were patent, with no discharges; air could freely move in and out when

the patient breathes. The nasal septum was at the midline without perforation, lesions, or

bleeding.

Mouth

Her lips are pale and smooth. Upon inspection of the mouth, oral mucosa was pinkish and

moist. The tongue is located at the midline without lesions present. The gums were pinkish and

bleeding is absent. Her tonsils were free from inflammation. The patients teeth are not yet

developed; teeth were absent upon inspection.

Breast and Regional Nodes

The patients breasts were flat and symmetrical. Areolar areas and nipples were pale in

color. No thickening or edema was found. No fixed, firm, immobile, irregular lymph nodes were

present.

Thorax and lungs

Her respiration is irregular. Rapid, shallow breathing was noted. The patients respiratory

rate is 100 breaths in one full minute. Upon auscultation, breath sounds were low in pitch with

snoring quality, indicating rhonchi. No tenderness and masses noted upon palpation. No sputum

was present.


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Heart and Peripheral Vasculature

The patients cardiac rate was 171 beats per minute. Presence of abnormal heart sounds

was noted. Upon auscultation, machine-like murmurs were heard, which indicates heart disease.

The apical pulse is easily palpable. Her skin was warm upon palpation and capillary refill time is

3-4 seconds.

Upper Extremities

The patients upper extremities are symmetrical. Body fats are evenly distributed. Upper

extremities were pale and warm to touch. 5 fingers were present on both hands. The palm is

lighter in color than the hands.

Abdomen

Upon inspection, the abdomen is cylindrical, round, and soft. The patients

abdomen has same color with his ches. The umbilicus is medially located and shows no signs of

inflammation or abnormal discharges. Bowel sounds were heard upon auscultation. The

abdomen rises with inspirations and falls with expiration.

Genitalia

The genitals are warm, dry, smooth, and soft, with good skin turgor. Labia majora covers

labia minora. There were no discharges present.


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Lower Extremities

The patients lower extremities are symmetrical. No lesions were noted. Legs have equal

length. 5 toes were present on both legs. Cyanosis was noted; lower extremity is cold to touch

and was pale. The soles are lighter in color than the legs.

Anus

Anal patency is present; the child was able to defecate once during the shift.

Musculoskeletal System

The extremities resist when extended and return to flexed state when released. Sutures of

the head are palpable. The neck moves freely and holds the head in midline position. Clavicles

are symmetrical and intact. The spine is flexible and rounded. Palm was able to stay in both

prone and supine in a good manner without difficulty. She was able to exhibit strong hand grip

on both arms. No tenderness was visible upon moving the patient. Reflex on the upper extremity

was good. No hand tremors noted.

Neurological System

Rooting Reflex: Achieved; weak response. The child turns head toward side of face stroked.

Sucking Reflex: Achieved; the child was able to suck her thumb and was able to breastfeed

frequently.

Palmar Grasp Reflex: Achieved; flexion of hands and feet were present; the grasp was strong;

the child was able to grasp immediately.

Tonic Neck Reflex: Achieved; weak response; the childs head turned to one sid e, the arm and

leg on the same side extended.


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Stepping Reflex: Not achieved; the child wasnt able to execute this reflex since the child was

asleep and carried by the mother.

Babinski Reflex: Achieved; with weak response; upon stroking the outer sole of foot from heel

to toe, the big toe rise and the remaining toes fan out.

Moro Reflex: Achieved with quick response; sudden extension and abduction of extremities

noted.


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PATIENTS DIAGNOSIS

Definition of the complete diagnosis

Neonatal Sepsis:

A life threatening illness defined as a suspected or known plus the systemic inflammatory

response syndrome

F. J. Domino; The 5-minute Clinical Consult 2011

Neonatal sepsis is defined as a clinical syndrome of bacteremia with systemic signs and

symptoms of infection and a positive culture from central body fluid.

D.K. Guha; Guhas NEONATOLOGY Principles and Practice

Sepsis means putrefaction, i.e., the decomposition of organic matter (by bacteria or fungi)

resulting from an interaction between germs and host

J.L. Vincent; Intensive Care Medicine

Patent Ductus Arteriosus:

Patent Ductus Arteriosus (PDA) is the persistence in postural life of the normal fetal vascular

conduit between the central pulmonary and systemic arterial systems.


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M. William Schwart; Five-minute pediatric consult

Patent Ductus Arteriosus (PDA) is the failure of the ductus arteriosus to close after birth.

F. J. Domino; The 5-minute Clinical Consult 2011

A patent ductus arteriosus is a permanent defect in the muscle wall of the duct and is unlikely to

close spontaneously

A.A. Fanaroff, T. Lissauer; Neonatology at a Glance


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ANATOMY AND PHYSIOLOGY

Patent Ductus Arteriosus is a heart problem that occurs soon after birth in some babies.

In PDA, abnormal blood flow occurs between two of the major arteries connected to the heart.

Superior vena cava

Brings de-oxygenated blood from the head, neck, arm and chest regions of the body to the right

atrium.

Inferior vena cava

Brings de-oxygenated blood from the lower body regions (legs, back, abdomen and pelvis) to

the right atrium.


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Right Atrium: The right upper chamber of the heart. The right atrium receives

deoxygenated blood from the body through the vena cava and pumps it into the

right ventricle which then sends it to the lungs to be oxygenated.

Tricuspid valve:

Valves are flap-like structures that allow blood to flow in one direction. The tricuspid

valve is located between the right atrium and the right ventricle. Prevents the back flow

of blood as it is pumped from the right atrium to the right ventricle

Right ventricle

the relatively thin-walled chamber of the heart that pumps blood received from the right atrium

into the pulmonary arteries to the lungs for oxygenation. The right ventricle is shorter and

rounder than the long conical left ventricle. The chordae tendineae of the tricuspid valve of the

right ventricle are finer than the coarse strands of the chordae tendineae of the left ventricle.

Pulmonary semilunar valve:

a semilunar valve between the right ventricle and the pulmonary artery; prevents blood from

flowing from the artery back into the heart

Pulmonary artery

The pulmonary artery is the vessel transporting de-oxygenated blood from the right ventricle to

the lungs. A common misconception is that all arteries carry oxygen-rich blood. It is more

appropriate to classify arteries as vessels carrying blood away from the heart.
http://www.medterms.com/script/main/art.asp?articlekey=5974http://www.medterms.com/script/main/art.asp?articlekey=5984http://www.medterms.com/script/main/art.asp?articlekey=5984http://www.medterms.com/script/main/art.asp?articlekey=5974


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Pulmonary vein

The pulmonary vein is the vessel transporting oxygen-rich blood from the lungs to the left

atrium. A common misconception is that all veins carry de-oxygenated blood. It is more

appropriate to classify veins as vessels carrying blood to the heart.

Left Atrium

The left atrium receives oxygenated blood from the lungs through the pulmonary vein. As the

contraction triggered by the sinoatrial node progresses through the atria, the blood passes through

the mitral valve into the left ventricle.

Mitral Valve

The mitral valve separates the left atrium from the left ventricle. It opens to allow the oxygenated

blood collected in the left atrium to flow into the left ventricle. It closes as the left ventricle

contracts, preventing blood from returning to the left atrium; thereby, forcing it to exit through

the aortic valve into the aorta.

Left Ventricle

The left ventricle receives oxygenated blood as the left atrium contracts. The blood passes

through the mitral valve into the left ventricle. The aortic valve leading into the aorta is closed,

allowing the ventricle to fill with blood. Once the ventricles are full, they contract. As the left

ventricle contracts, the mitral valve closes and the aortic valve opens. The closure of the mitral

valve prevents blood from backing into the left atrium and the opening of the aortic valve allows

the blood to flow into the aorta and flow throughout the body.


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Aortic Valve:

The aortic valve separates the left ventricle from the aorta. As the ventricles contract, it opens to

allow the oxygenated blood collected in the left ventricle to flow throughout the body. It closes

as the ventricles relax, preventing blood from returning to the heart.

Aorta

The aorta is the largest single blood vessel in the body. It is approximately the diameter of your

thumb. This vessel carries oxygen-rich blood from the left ventricle to the various parts of the

body.

Chondrae Tendinae

The chordae tendineae are tendons linking the papillary muscles to the tricuspid valve in the

right ventricle and the mitral valve in the left ventricle. As the papillary muscles contract and

relax, the chordae tendineae transmit the resulting increase and decrease in tension to the

respective valves, causing them to open and close. The chordae tendineae are string-like in

appearance and are sometimes referred to as "heart strings."


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Ductus arteriosus:

The ductus arteriosus is part of the normal fetal circulatory system. This vessel connects the aorta

and the pulmonary artery. Prior to birth the ductus arteriosus allows for antegrade flow from the

right ventricle to the aorta. Following birth the ductus arteriosus normally closes

Ductus venosus:

in the fetus, the ductus venosus shunts approximately half of the blood flow of the umbilical

vein directly to the inferior vena cava. Thus, it allows oxygenated blood from the placenta to

bypass the liver. In conjunction with the other fetal shunts, the foramen ovale and ductus

arteriosus, it plays a critical role in preferentially shunting oxygenated blood to the fetal brain. It

is a part of fetal circulation.


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Foramen ovale:

Blood from the mother enters the placenta and comes in close proximity to the fetal blood that

has returned from the fetus to the placenta through the umbilical arteries . once the two

circulations are in close proximity in the placenta , the oxygen and nutrients, like sugar , protein

and fat molecules can move from maternal to fetal blood, carbon dioxide and waste products can

move from fetal to maternal blood. The maternal blood returns from the placenta to the mothers

veins for her systems to take care of the waste. The new nourished fetal blood returns to the baby

through the umbilical vein.

Fetal circulation:

- Oxygenated blood from the placenta enters the fetus through the umbilical vein

- Most of the newly oxygenated blood bypasses the liver via the DUCTUS VENOSUS and

combines with deoxygenated blood in the inferior vena cava

- Blood then joins deoxygenated blood from the superior vena cava and empties into the

right atrium

- Since pressure in the right atrium is larger than pressure left atrium, most blood will be

shunted through the foramen ovale

- Some blood does travel from the right atrium to the right ventricle through the pulmonary

trunk but most blood bypasses the pulmonary arteries and moves directly to the aorta via

the ductus arteriosus

-Deoxygenated blood returns to the placenta via the umbilical arteries originating from the

internal iliacs near the bladder


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Oxygenated blood from the placenta is transported through the umbilical vein into the

body of the fetus. Blood bypasses the liver by traveling through the ductus venosus. The ductus

venosus provides a direct communication between the umbilical vein and inferior vena cava.

Oxygenated blood from the ductus venosus combines with deoxygenated blood in the inferior

vena cava and continues to the heart.

Blood travels to the heart through the inferior vena cava and mixes with deoxygenated

blood returning from the superior vena cava. Blood enters the right atrium of the heart. Because

the fetal lungs are not functional, most blood will bypass the right ventricle and be shunted to the

left atrium via the foramen ovale. Blood will then travel into the left ventricle and be distributed

throughout the body via the aorta. Some blood will enter the right ventricle from the right atrium

and proceed into the pulmonary trunk. However, most of this blood will be shunted away from

the pulmonary arteries and into the aorta via the ductus arteriosus.

Blood then circulates through the body and returns to the placenta via the umbilical

arteries. These arteries are carrying deoxygenated blood back to the placenta .

The placenta reoxygenates blood returning from the umbilical arteries and repeats the

fetal cardiovascular cycle by recycling newly oxygenated blood to the fetus through the

umbilical vein.

Postnatal Circulatory Changes:

- With the first breath, increased alveolar oxygen pressure causes vasodilation in the

pulmonary vessels

- Obstetrical clamping induces spontaneous constriction and changes of the umbilical vein

to ligamentum teres and umbilical arteries to medial umbilical ligaments


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- Within 10 -15 hours after birth, the ductus arteriosus constricts and will become the

ligamentum arteriosum

- Increased left atrial pressure and decreased right atrial pressure causes the foramen

ovale to close and become fossa ovalis.

- The ductus venosus also constricts and will become the ligamentum venosum.

Obstetrical clamping leads to spontaneous constriction of the umbilical vessels and

eventually leads to the conversion of the ductus venosus to the ligamentum venosum. Changes

due to increased alveolar pressure in the lungs lead to anatomical and physiological alterations

in the circulatory system.

Usually within 10 -15 hours after birth, the ductus arteriosus will constrict and change to

the ligamentum arteriosum.

The umbilical vein and umbilical arteries become the ligamentum teres and medial

umbilical ligaments, respectively.

Normal Heart and Heart With Patent Ductus Arteriosus


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ETIOLOGY:

As a baby develops in the womb, a vascular connection (ductus arteriosus) between two

major blood vessels leading from the heartthe aorta and pulmonary arteryis a normal and

necessary part of your baby's blood circulation while in the womb. The ductus arteriosus diverts

blood from the lungs of the fetus while they aren't being used. The fetus receives oxygen from

the mother's circulation. But, the ductus arteriosus is supposed to close within two or three days

after birth once the newborn's heart adapts to life outside the womb. In premature infants, the

connection often takes longer to close on its own. If the connection remains open, it's referred to

as a patent ductus arteriosus.

The abnormal opening causes too much blood to circulate to the lungs and heart. If not

treated, the blood pressure in the lungs may increase (pulmonary hypertension) and the heart

may enlarge and weaken.

Congenital heart defects arise from problems early in the heart's development but there's

often no clear cause. Genetics and environmental factors may play a role.

Etiology for PDA:

Predisposing

FactorsPresent/ Absent Rationale Justification

Being born too soon

(prematurity)

Absent Patent ductus arteriosus

(PDA) occurs more

commonly in babies who

are born too early than in

babies who born full term

because the infants heart

was not fully developed

before delivery.

The mothers LMP

was on April 16,

2011 and the baby

was born on Jan 15,

2012. Therefore the

baby was exactly

born 9months and 1

day. Proving that she

is not in a preterm


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state.

Having other heart

defects

Absent Babies who have other

heart problems when

they're born (congenital

heart defects) are also more

likely to have a patent

ductus arteriosus. Because

other defects such

Other than Patent

Ductus Arteriosus, no

other heart defect has

been

noted/diagnosed.

Family history and

other genetic

conditions.

Present If you have a family

history of heart defects, it's

more likely your child may

have a patent ductusarteriosus. Other genetic

conditions, such as heart

problems or chromosomal

abnormalities, also have

been linked to an increased

chance of having a PDA.

Tracing back to the

family history, the

grandmother of the

baby has myocardialinfarction in which

may be a factor for

her to have PDA.

Having a female baby Present PDAs are much more

common in girls than in

boys.

The baby was born as

a female as

evidenced by the

presence of onlyfemale genitalia.

Precipitating FactorsPresent/


Use of Teratogens

during pregnancy

Absent Teratogens are any

chemical, substance, or

exposure that could

possibly cause birth defects

in a developing fetus.

Exposure to teratogens

seems to result in

malformations especially

Only FeSO4 was

taken by the mother

during her pregnancy

with patient Errshen.


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when it occurs during the

fourth and tenth week of

pregnancy.

Smoking Present A shortage of oxygen can

have devastating effects on

your baby's growth and

development. On average,

smoking during pregnancy

doubles the chances that a

baby will be born too early

or weigh less than 5 1/2

pounds at birth. Smoking

also more than doubles the

risk of heart diseases on

infants

The mother told us

that she smoked

during the first

trimester of her

pregnancy; however,

she stopped smoking

when she knew that

she was pregnant.

Chromosomal

abnormalities

Absent Trisomy 21, the

chromosomal abnormality

associated with Down

syndrome, is associated

with cardiac abnormalities

in 50 percent of babies.

Chromosomal

abnormalities

The infant may have

PDA, but no signs of

Chromosomal

abnormalities, like

simians crease,

lethargic eyes, short

neck, Brushfield

spots, and others was

seen.

Maternal infections

(esp. Rubella/German

measles)

Absent If you have rubella in the

first trimester, you have

about a 25% risk of having

a birth defect, known as

congenital rubella

syndrome. The defects can

include:

heart deformities

hearing loss

mental retardation

eye deformities

others

The mother told us

that she had no

diagnosis of

infections before and

during her

pregnancy.


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Etiology for Neonatal Sepsis:

Etiology Sepsis

Predisposing

Factors

Present or absent Rationale Justification

Preterm baby Absent Experimental as

well as

epidemiological

studies have shown

that low birthweight

is also a

predisposing factor

for abnormalities

such as

atherosclerosis,

cardiovascular

diseases, sepsis,

renal disease, non-

insulin diabetes,

hypertension,

obesity or the

metabolic

syndrome. Indeed,

the human fetus

The mothers LMP

was on April 16,

2011 and the baby

was delivered on

Jan. 17, 2012.

Hence the baby was

born 9 months and

a day. Proving that

she was not a

preterm baby.


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adapts to

undernutrition by

redistribution and

infection of blood

flow

infants under 3

months, whose

immune systems

haven't developed

enough to fight off

overwhelming

infections

Present Infants below 3

months have

immune systems

that are still in the

process of

maturation. Thus

being prone to

certain blood

infections

At the age of 14

days old, the

infants immune

system is still

maturing thus

making her prone to

certain infections.

Bloodstream

infection of the

mother(bacteremia)

Absent Mothers with blood

stream infection

also causes the

baby to have

infection for they

share the same

blood during fetal

development

There is no

diagnosis of the

mother about blood

stream infection.

Precipitating Present or absent Rationale Justification


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Factors

Infection Absent Newborn baby can

get infected in many

ways. Infection in

mother can be

transmitted to the

baby. After birth the

umbilical cord can

be source of

infection. Infection

of the skin can also

invade and cause

sepsis. Baby can

catch infection from

other people.

Because the

immune system of

the newborn is not

mature any infection

can potentially

cause sepsis.

Mother was not

diagnosed of

infection during

pregnancy or after

delivery.

Alcoholism Present A woman who

drinks alcohol while

Tracing to the

mothers social


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she is pregnant may

harm her

developing baby

(fetus). Alcohol can

pass from the

mothers blood into

the babys blood. It

can damage and

affect the growth of

the babys cells.

history, she

verbalized that she

has taken alcohol

during the first

trimester. After

knowing of being

pregnant, she has

stopped the alcholol

intake.

immunosuppressive

medications taken

by the mother

Absent Taking of

immunosuppressive

drugs weakens the

immune system of

the mother which

makes her prone to

infections. So if the

mother has

infections, the baby

will also share the

same fate.

Mother has not

taken any

medications aside

from FeSO4.

However she

suspects that it was

the reason for her

hematemesis during

her first 7 months of

pregnancy.

Frequent vaginal

checkups during

Absent Frequent vaginal

check-ups can

Due to financial

pressures, the


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pregnancy. cause infection to

the womens genital

area because

clinical instruments

are foreign to the

body

family only goes to

the check-up in

times of severe

symptoms such

vaginal bleeding, or

abdominal pain


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SYMPTOMATOLOGY

Symptoms Rationale Present/Absent Justification

Rapid breathing The normal respiratory rate

for infants is 40-60 breaths

per minute. Lower than

normal indicates

bradypnea; higher than

normal indicates tachypnea.

Present The respiratory rate of

the patient is 100 cycles

per minute.

Poor feeding

habits

Poor feeding occurs when

infants lack interest in

nursing or cannot obtain

the nutrition necessary for

appropriate weight gain and

other development. Infants

lacking appropriate

nutrition due to poor

feeding can suffer

significant and permanent

delays in mental and

physical development.

Absent The patient was able to

breastfeed every four

hours.

Rapid Pulse The normal pulse rate forinfants is 120-160 beats per

minute. Lower than normal

indicates bradycardia;

higher than normal

indicates tachycardia.

Present The cardiac rate of thepatient is 171 breaths per

minute, which indicates

tachycardia.

Sweating while

feeding

baby likely sweats because

he's warm while

breastfeeding. Being skin

to skin with your baby

raises body temperature,which initiates his natural

cooling system.

Present Sweat was visible upon

breastfeeding.


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PATHOPHYSIOLOGY

Superior vena cava and inferior vena cava with unoxygenated blood

Right atrium (deoxygenated blood flow in right heart)

Right ventricle

Pulmonary arteries

Lungs ( oxygenated blood)

Pulmonary veins

Left atrium

Left ventricle

Aortic valve

Aorta (mixing of blood from aorta (oxygenated) and pulmonary artery (deoxygenated blood))

distributes to the circulatory system

Superior vena cava and Inferior vena cava

- Machine like

murmur

- Fast breathing

- Poor feeding


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Pregnancy

Fetal Development( begins at the 10th week of gestation)

1st

trimester:

- Embryo increases in size to about 1 inches. Bones and muscles begin to round

Out contours of body

- Sex organs begins to form

- Beginning of fetal period

2nd

trimester:

- Hands and feet are well formed.

- Skin appears dark red

- Finger closure is possible

- Reflexes become more active

3rd

trimester:

- Generally the fetus is about 15 inches long and weighs about three pounds

- Fat is formed all over the body

- Fetal heart rate becomes quite rapid

Birth

Maternal age

SmokingIncreased parity

congenital


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Failure of ductus arteriosus to close within 10-15 hours

Blood enters systemic circulation

Through ductus bypassing

The pulmonary system

Systemic pressure greater than

Pulmonary pressure

Left to right shunting from aorta

To pulmonary artery

Right ventricular hypertrophy

If treated: if not treated

Machine like

murmur

Fast breathing

Rapid pulse

Poor feeding

Medical management

-fluid restriction-indomethacin

-cardiac catheterization

-surgical repair

Nursing management

-assessment of vital signs such as

tachycardia, tachypnea-avoid cold stress to infant- position semi-fowlers if necessary

-reduce environmental stimuli

-promote uninterrupted sleep

Bad prognosis

Poor growthPoor feeding

Increased heart size

Prolonged capillary refill time


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Doctors OrdersDATE

ORDERED DOCTORS ORDER RATIONALE REMARKS

February 3,2012

Please admit to SN ward

VSq4

BF with SAP, NPO if RR > 60

Rx:

CBC, UA, LP, 2DECHO,

Crea, Na+, k+, MCHC MCV,

Blood GSCS

To monitor closely the neonatefor any eventualities that may

occur.

Vitals signs should be checked

so that we would have abaseline record for comparison.

Also, to be able to check if

there are any abnormalities in

the persons vital statistics.

Breastfeeding is alwaysrecommended for all neonates,

however since the patient hascardiac problems, he may

develop difficulty of breathing

anytime which may lead toaspiration. If the patient has

tachypnea, the patient is

predisposed to aspiration

especially when feeding.Therefore the patient is advised

to have nothing per orem if theRR >60.

CBC is used as a broadscreening test to check for such

disorders as anemia, infection

and many other diseases. It is

actually a panel of tests thatexamines different parts of the

blood and it includes: WBC

count, RBC count,Hemoglobin, Hematocrit.- The hematocrit is used to

screen for anemia, or is

measured on a person todetermine the extent of anemia.

An anemic person has fewer or

smaller than normal red blood

DONE

DONE

DONE

DONE


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cells. A low hematocrit,

combined with other abnormal

blood tests, confirms the

diagnosis.- Lumbar puncture is done to

determine infection in themeninges. To rule out thepresence of meningitis or any

cerebral infection.

- 2DimensionalEchocardiography is used to

examine the heart. It is capable

of displaying a cross-sectional

"slice" of the beating heart,including the chambers, valves

and the major blood vessels that

exit from the left and rightventricle. For us to be able tosee presence of blockage and

any abnormalities in the

chamber.- Urinalysis is a test to check

for the presence of bacteria,

blood and pus which causeurinary tract infection.

- Serum sodium examination is

done to assess the levels of the

sodium in the blood which isespecially critical in Cardiac

Patients.

- Serum potassium examinationis done to assess the

concentration of potassium in

the blood which is critical in the

functioning of muscular organslike the heart.

- mean corpuscular volume, or

"mean cell volume" (MCV), is

a measure of the average redblood cell size that is reported

as part of a standard complete

blood count to detect anemiaand polycythemia.

- The mean corpuscular

hemoglobin concentration, orMCHC, is a measure of the


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IVF D5IMB 500 cc to run

@ 13cc/hr

Meds:

Ceftriaxone

15g IVTTq 12

Amikacin 45g

IVTT OD

Diazepam 0.6g

IVTT PRN foractive seizure

concentration of hemoglobin in

a given volume of packed red

blood cells. It is reported as part

of a standard complete bloodcount to detect if the patient is

anemic or not.- Blood Gram stain, Culture andSensitivity is to detect what

type of bacteria grows in the

infected blood of the patientand for the Doctors to know

what type of antibiotics is

responsive to the bacteria

present in the patients blood.

- Balanced Multiple

Maintenance Solution with 5%Dextrose was given to thepatient as a maintenance fluid

to increase calories, hydration

and electrolytes in the body.This specific infusion rate is

advised depending on the

weight of the patient and thecondition. Since this patient is

a cardiac patient, we cant givetoo much IV fluid because this

might lead to cardiac overload.

Ceftriaxone is a third-

generation cephalosporinantibiotic a choice drug for

treatment of bacterial

meningitis. In pediatrics, it is

commonly used in febrileinfants between 4 and 8 weeks

of age who are admitted to the

hospital to exclude sepsis and

since the patient is beingconsidered to be septic,

therefore this drug was

prescribed.Amikacin is anaminoglycoside antibiotic used

to treat different types of

bacterial infections. Amikacinis most often used for treating

DONE

DONE


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February 4,

2012

I &O q shift

O2 inhalation

@ 4LPM via

face mask PRN

for tachypnea

Refer

unusualities

Rx:

FU CBC,

FU Na+, K+ ,

S/F cranial CT

scan

severe, hospital-acquired

infections with multidrug

resistant Gram negative

bacteria. Amikacin wasprescribed to the patient to

prevent hospital ward infection.Diazepam is an anti-convulsantor anti-seizure drug given to

patient as a stand-by medication

in case the Patient will haveseizure.

- Intake and Output is

monitored because too much

fluid intake for our patient cancause cardiac overload both

orally and intravenously. While

Urine output is also monitoredto make sure the kidneys arefunctioning normally meaning

whatever is being taken inside

the body should be excreted.

- Patients with cardiac problems

may develop dyspnea anytime

thats why oxygen inhalation isconsidered as a standby

amenity for emergency

purposes.

The patient is for close watch

thus referral is necessary if any

abnormalities occur.

The laboratory tests that are still

for follow-up are really

necessary to establish thediagnosis and treatment of the

patient.

This procedure is requested torule out any other congenitalabnormalities present in the

Nervous System of the neonate

because some PDA patients can

DONE

DONE

DONE

DONE

DONE

DONE


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S/F 2DECHO

S/F LP

undecided

IVF same @

1L

Shift cefriaxme

to cefortaxime

tt. 300g IVTT

VSq4

I &O q

have concomitant neurological

defects.

This examination is still forfollow-up because it is

necessary to establish thediagnosis and treatment of thepatient.

This examination is still forfollow-up because this

procedure can detect whether

the patient has bacterial

meningitis or sepsis.

To continue to give the

nutritional and electrolyte needsof the patient and for IVmedications as well.

Ceftriaxone was shifted toCefotaxime because this drug

has a broader spectrum activity

against Gram positive andGram negative bacteria

compared to that first drug.

For close monitoring of thepatient and to check if there arechanges in the Vital signs and

sensorium of the patient.

Intake and Output is monitored

because too much fluid intakefor our patient can cause

cardiac overload both orally

and intravenously. While Urine

output is also monitored tomake sure the kidneys are

functioning normally meaning

whatever is being taken insidethe body should be excreted.

DONE

DONE

DONE

DONE

DONE

DONE

DONE


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February 5,

2012

Refer any

unusualities

Rx: FU CBC,

Na+, K+

S/F cranial CT

scan

S/F 2DECHO

S/F LP

\

Continue

monitoring of

VS

Continue IVF

at SR

Continue

meds:

CefotaximeD1

Amikacin- D2




The laboratory tests that are still

for follow-up are reallynecessary to establish thediagnosis and treatment of the

patient.

This procedure is requested to

rule out any other congenital

abnormalities present in the

Nervous System of the neonatebecause some PDA patients can


defects

This examination is still for

follow-up because it isnecessary to establish the

diagnosis and treatment of the

patient.


follow-up because this

procedure can detect whetherthe patient has bacterial


For close monitoring of the

patient and to check if there are

changes in the Vital signs and



nutritional and electrolyte needs

of the patient and for IVmedications as well.

These meds are still to becontinued to complete the

dosage to treat the severity of

the disease.

DONE

DONE

DONE

DONE

DONE

DONE

DONE

DONE


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58

February 6,

2012

I &O q shift

Refer any

unusualities

S/F cranial CT

scan

S/F 2DECHO

S/F LP

IVF @ SR

Cont meds:

CefotaximeD1

Amikacin- D2


because too much fluid intake

for our patient can cause

cardiac overload both orallyand intravenously. While Urine

output is also monitored tomake sure the kidneys arefunctioning normally meaning







rule out any other congenitalabnormalities present in theNervous System of the neonate


have concomitant neurologicaldefects


necessary to establish the


patient.


follow-up because thisprocedure can detect whether

the patient has bacterial



nutritional and electrolyte needs

of the patient and for IV

medications as well.

These meds are still to be

continued to complete thedosage to treat the severity of

the disease.

DONE

DONE

DONE

DONE

DONE

DONE

DONE


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59

February 7,

2012

I &O q shift

Refuse LP

Rx

S/F Cranial CT scan

S/F 2DECHO

shift to Heplock

Cont meds:

CefotaximeD1

Amikacin- D2







the body should be excreted

The mother refused to undergo

this procedure because they

dont have the money to pay forthis procedure. Also, the

Mother didnt think this

procedure was necessary to beundergone


rule out any other congenitalabnormalities present in the

Nervous System of the neonate

because some PDA patients canhave concomitant neurological

defects



diagnosis and treatment of thepatient.

The condition of the patient has

improved and the IV line wasremoved therefore heplock was

inserted for the medications of

the patient.


continued to complete the

dosage to treat the severity ofthe disease.

DONE

DONE

DONE

DONE

DONE

DONE


60/120

60

February 8,2012

VSq4

I &O q shift

Refer any unusualities

Rx:

S/F Cranial CT scan

S/F 2DECHO

Med:

cefotaxime- D2

AmikacinD3

VSq4





Intake and Output is monitoredbecause too much fluid intakefor our patient can cause

cardiac overload both orally

and intravenously. While Urineoutput is also monitored to

make sure the kidneys are


whatever is being taken insidethe body should be excreted.

The patient is for close watchthus referral is necessary if anyabnormalities occur.

This procedure is requested torule out any other congenital

abnormalities present in the

Nervous System of the neonatebecause some PDA patients can


defects


follow-up because it is

necessary to establish thediagnosis and treatment of the

patient.

These meds are still to becontinued to complete the

dosage to treat the severity of

the disease



changes in the Vital signs andsensorium of the patient.

DONE

DONE

DONE

DONE

DONE

DONE

DONE


61/120

61

February 9,

2012

I &O q shift

Refer unusualities

S/F cranial CT

scan

S/F 2DECHO

Meds:

CefotaximeD3

AmikacinD4

VSq4

I &O q shift












rule out any other congenitalabnormalities present in theNervous System of the neonate


have concomitant neurologicaldefects




patient.


continued to complete thedosage to treat the severity of

the disease

For close monitoring of thepatient and to check if there are





for our patient can causecardiac overload both orally

and intravenously. While Urine

output is also monitored tomake sure the kidneys are

DONE

DONE

DONE

DONE

DONE

DONE


62/120

62

February10, 2012

Refer unusualities

Rx:

S/F 2DECHO on

Thursday

Meds:

CefotaximeD6

AmikacinD5

VSq4

I &O q shift

Refer any unusualities





thus referral is necessary if anyabnormalities occur


follow-up because it isnecessary to establish the


patient.


continued to complete the

dosage to treat the severity ofthe disease


patient and to check if there arechanges in the Vital signs and






output is also monitored to

make sure the kidneys arefunctioning normally meaning





abnormalities occur

DONE

DONE

DONE

DONE

DONE

DONE


63/120

63

Date/

Time

Ordered

February

3, 2012

Diagnostic Test and

Normal Range of

Values

Urinalysis

Findings:

Color:

N: pale yellow to deep

amber

Appearance

Result

Straw( Pale

Yellow)

Clear

Clinical

Significance/Rationale

An unusual urine color is

among the most common

signs of a urinary tract

infection.

Cloudy or foamy urine may

occur occasionally due to

mild dehydration, polyuria

or phosphate in urine.

Nursing

Responsibilities

-provide the

patients mother

or significant

other with urine

container with

lead

-instruct the

watcher or

significant other

to collect sample

of urine


64/120

64

Specific Gravity

N:1.010-1.020

Albumin

Sugar

Pus cells

1.005

(Normal)

Negative

Negative

0-2

Increased in: dehydration,

fever, profuse sweating,

vomiting, diarrhea,

glycosuria, proteinuria

Decreased in:

overhydration,

hypotension, severe renal

damage, diabetes insipidus

Positive in: renal disorders,

associated with

hypertension, diabetes

mellitus

Positive in:

Hyperglycemia, diabetes

mellitus

High level of pus in urine

is an indication of Urinary

tract infection

preferably arising

-Collect specimen

from infants or

young children

into a disposable

apparatus

consisting of a

plastic bag with

an adhesive

backing around

the opening that

can be fastened to

the perineal area

or the penis to

permit voiding

directly to the

bag. Depending

on the hospital

policy, the

collected urine

can be transferred


65/120

65

Bacteria

IPD Hematology

CBC

WBC count

N: 5-10

Hemoglobin

N: 115-155

Few

8.35 x10/ uL

133.0 g/L

Numerous amount of

bacteria in urine will lead

to Urinary tract infection

Increased in: Infection,

inflammation, hematologic

malignancy, leukemia.

Decreased in: Aplastic

anemia, B12 or folate,

sepsis (decreased survival)

Increased in:

polycythemia, dehydration,

acute thermal injury

Decreased in: hemorrhage,

bleeding, anemia,

hemolytic anemia, fluid

to an appropriate

specimen

container.

-Cover all

specimens tightly,

label properly and

send immediately

to the laboratory

- identify patient

and check for the

requisition form

with the patients

identification

bracelet

-inform the

watcher or


66/120

66

Hematocrit

N: 0.36-0.48

Red Blood Cells

N: 4.20-6.10

Neutrophils

N: 55-75

0.38

3.81x10^6/uL

30%

overload, fluid retention

Low levels of hematocrit is

an indication of anemia,

acute or chronic bleeding

from the digestive tract,

Nutritional deficiencies

such as iron, folate or B12

deficiency

High level of RBC in the

urine Indicates bleeding at

some point in the urinary

tract

Increased neutrophils:

suggests infection, acute

stress, acute and chronic

inflammations

Decreased neutrophils:

suggests aplastic anemia,

drug-induced neutropenia,

significant other

of the patient that

blood needs to be

drawn from the

designated site.

- ask assistance

from the mother

or the significant

other in handling

the baby in order

for him/her to be

secured.

- the patient may

be seated or in

supine position.

The patients arm

Is in extension.


67/120

67

Lymphocytes

N: 20-35

Monocytes

N: 2- 10

Eosinophils

N: 1-8

54%

14%

2%

folate or B12 deficiency

Increased lymphocytes:

viral infection, adrenal

insufficiency disease,

chronic infection, drug and

allergic reactions,

autoimmune disease.

Decreased lymphocytes:

immune deficiency

syndrome.

Increased monocytes:

inflammation, infection,

malignancy, TB,

myeloproliferative

disorders.

Decreased monocytes:

depleted in overwhelming

bacterial infection.

Increased eosinophils:

allergic states, drug

sensitivity reaction, skin

disorders, tissue invasion

Post test

-instruct the

mother or the

watcher of the

patient to continue

compression of

the puncture site

for 25 mins or

until the bleeding

stops

-assess the

patients arm to

ensure that the

bleeding has

ceased.

-Apply adhesive

bandage if

necessary.

-if hematoma


68/120

68

PH

N: 150-400

464x10/uL

by parasites,

hypersensitivity response

to malignancy, pulmonary

infiltrative disease,

Decreased eosinophils:

acute and chronic

inflammation, stress

A highly acidic urine pH

occurs in: Acidosis,

Uncontrolled diabetes,

Diarrhea, Starvation and

dehydration, Respiratory

diseases in which carbon

dioxide retention occurs

and acidosis develops

A highly alkaline urine

occurs in: Urinary tract

obstruction, Pyloric

obstruction, Salicylate

intoxication, Renal tubular

acidosis, Chronic renal

failure

occurs or if there

is still bleeding,

ask the watcher or

the mother of the

patient to continue

compression of

puncture site or

elevate the arm


69/120

69

MCV

N:79.4-94.8

MCH

N: 25.6- 32.2

MCHC

N:32.2-35.5

99.7

34.9 pg

35.0 g/dL

Increased in: Liver

disease, megaloblastic

anemia (folate, B12

deficiencies), high WBC.

Decreased in: Iron

deficiency, thalassemia;

decreased or normal in

anemia of chronic disease.

increased in: Macrocytosis

, Megaloblastosis (Vitamin

B12 or folate deficiency),

reticulocytosis, liver

disease.

Decreased in:

Microcytosis (iron

deficiency, thalassemia).

Increased in:

hyperchromia, hemolysis

(with spuriusly high Hb or

low MCV or RBC),

Decreased in:
http://en.wikipedia.org/wiki/Reticulocytosishttp://en.wikipedia.org/wiki/Reticulocytosis


70/120

70

BLOOD CHEM

Glucose RBC

N: 4.10-6.6

Creatinine

N: 53.00-115.00

4.5

15.40 umol/L

Hypochromic anemia (iron

deficiency, thalassemia)

increased in: Diabetes

mellitus, Cushing's

syndrome, chronic

pancreatitis

Decreased in: Pancreatic

islet B cell disease with

increased insulin, diffuse

liver disease, infant of

diabetic mother, enzyme

deficiency diseases.

Increased in: Acute or

chronic renal failure;

urinary tract obstruction

Decreased in: Reduced

muscle mass


71/120

71

Sodium

N:136.00-155.00

Potassium

N: 3.5- 5.5

137.70

mmol/L

4.63 mmol/L

=989898988

2.54 mmol/L

increased in: Dehydration,

polyuria , inadequate water

intake

Decreased in: Congestive

heart failure, cirrhosis,

vomiting, diarrhea,

excessive sweating, adrenal

insufficiency, nephrotic

syndrome.

Increased in:

Hyperkalemia, acute

tubular necrosis,Cushing

syndrome(rare),Diabetic

acidosisand other forms of

metabolic acidosis, Kidney

Disorders

Decreased in:

Hypokalemia, adrenal

gland insufficiency,

Gastrointestinal disorders

associated with diarrhea Prior to taking the
http://www.nlm.nih.gov/medlineplus/ency/article/000512.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000512.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000512.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000512.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000410.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000410.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000410.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000410.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000320.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000320.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000320.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000320.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000320.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000320.htmhttp://

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