casepre sepsis um
TRANSCRIPT
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Colegio de San Juan de Letran Calamba
School of Nuroing
Case Presentation:
SEPSIS NEONATORUM
Presented by:
Casunuran, Cherry AnnCatapang, Czarina May
Causing, Immaulate FayeCiarell, Ciar
Corcuera, Dan Ryan
Corpuz, Lady AnilinCortez, Daserie RoseDe Jesus, Eileen JaneDe Leon, Ma. ClaritaDeocareza, Alfrenan
Diche, SatinaEmata, Arlene JoyErcia, Alphine Gael
Ercia, Alvie GaelFaraon, Ara Denise
Presented to:
Ms. Eufemia Cortado
September
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I. INTRODUCTION
A. Background of the Study
Neonatal sepsis, also termed Sepsis neonatorum in simplest way of defining it,
refers to a group of physical and laboratory findings that occur in response to
invasive infection within the first 30 days of life, this is may be a bacterial or viral
etiology.
This may arise from congenital infection (common among premature babies and
to those babies wherein their mother suffered from infections while they are
pregnant), early onset infection (most common on prolonged labor) and late onset
infection which is caused by environmental factors.
Neonatal sepsis is also known as "sepsis neonatorum." The infection may
involve the infant globally or may be limited to just one organ (such as the lungs
with pneumonia). It may be acquired prior to birth (intrauterine sepsis) or after birth
(extra uterine sepsis). Viral (such as herpes, rubella [German measles]), bacterial
(such as group B strep) and more rarely fungal (such as Candida) causes may be
implicated.
During labor, several indicators may raise concern regarding the possibility ofneonatal sepsis. Abnormalities of fetal heart rate, maternal fever, premature
separation of the placenta from the uterine wall, or foul smelling/cloudy amniotic fluid
all indicate a high-risk labor and delivery. These situations will commonly prompt
consultation with the pediatrician or neonatologist regarding the potential for delivery
and/or postpartum complications.
Any infant who fails to make a smooth transition from intrauterine to extra uterine
life should be considered at high risk for sepsis. Close monitoring of vital signs (heart
rate, respiratory rate and effort, skin color, temperature, and "vigor") is a crucial part
of the evaluation of the newborn. Infants may manifest neonatal sepsis by subtle
signs such as poor feeding, jaundice, unusual rashes, or more obvious indicators
such as seizures, projectile vomiting, or abdominal distention.
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B. Focus on Incidence of Disease
Neonatal sepsis occurs in 0.5 to 8.0 per 1000 live births. It is the third leading
cause of neonatal deaths. Occurrence can be classified into low birth weight
(weighing less than 2500 grams) and very-low-birth-weight (weighing less than 1500
grams). In which, 81% percent were low birth weight and 63.6% were very-low-birth-
weight. Neonatal sepsis occurs in a 2:1 ratio, with a higher occurrence in males and
in neonates with congenital anomalies.
In the Philippines 8,000 newly born babies die from sepsis. In May 2003, 23
neonatal deaths could be attributed alone. According to the Annual Statistics of the
Philippine General Hospital (2002), neonatal sepsis accounts for 58.8% of deaths in
the country. It is the second major cause of disability by a slim margin to jaundice,
affecting 24.2% and 25.6% of the population respectively.
The census in the National Childrens Hospital (NCH) Intensive Care Unit during
one month (July 2010 to August 2010) was 61 patients having neonatal sepsis.
Having a total of 61 days, the average of patients having neonatal sepsis is 1 per
day.
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II. CLINICAL SUMMARY / CLINICAL ABSTRACT
A. Personal Data
Personal Data
Name: Baby G.P.B. Gender: Male Status: Newborn
Address: #3604 Amihan Compound, Halang, Calamba, Laguna
Birthday: August 19, 2011 Birthplace: Calamba Age:
Date of Admission:August 21, 2011 8:10pm
Diagnosis: t/c Sepsis Neonatorum
B. History of Present Illness
b.1 Past Medical History
No previous illnesses &/or operations
b.2 Present Medical History
Chief complaint: fever
Born cesarean section upon delivery, mother was diagnosed with
toxemia; BP 160/90 mmHg
Secondary (+) flaring episode
(+) jaundice noted
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III. ASSESSMENT
A. Physical Assessment
HEAD TO TOEASSESSMENT
NORMAL FINDINGS FINDINGS
Skin
Color in Caucasianinfants usually pink;varies with other ethnicbackgrounds.
Pigmentation increasesafter birth.
Skin may be dry.
Acrocyanosis of handsand feet normal for 24hours; may develop"newborn rash"(erythema toxicumneonatorum).
Small amounts of lanugo
and vernix caseosa stillseen.
Rashes over the surface of the face Pathologic Jaundice
- usually appears early, up to 24 hours after birth;represents a process ongoing before birth
Nursing interventions:
Identify conditions predisposing to hyperbilirubinemia, especiallypositive coombs test (test on cord blood for presence ofmaternal antibodies).
Prevent progression or complications of jaundice.
Assess jaundice levels (visually, lab tests) as needed.
Prevent conditions that contribute to development ofhyperbilirubinemia (e.g., cold stress, hypoxia, acidosis,hypoglycemia, dehydration, infection).
Provide adequate hydration. Implement phototherapy if ordered; use of blue lights overhead
or in blanket-device wrapped around infant.
Fontanels Anterior: diamond shaped
Posterior: triangularShould be flat and open.
NORMAL
Ears Should be even with
canthus of eyes.NORMAL
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Cartilage should bepresent and firm
Eyes
May be irritated bymedication instillation,
some edema/dischargepresent.
NORMAL
Breast Nodule of tissue present
Normal breath sounds
heard.
NORMAL
Male genitalia Testes descended or in
inguinal canal
Rugae cover scrotum
NORMAL
Legs
Bowed
No click or displacementof head of femurobserved when hipsflexed and abducted
NORMAL
Feet Flat
Soles covered withcreases in fully matureinfant
NORMAL
Muscle tone
Predominantly flexed
Occasional transienttremors of mouth andchin
Newborn can turn headfrom side to side in proneposition
Needs head supportedwhen held erect or lifted
NORMAL
Cry Loud and vigorous.
Heard when infant is NORMAL
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hungry, disturbed, oruncomfortable.
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B. Identification and Application of appropriate theory
b.1 Gordons11 Functional Health Pattern of Assessment
Gordons Assessment Health PatternNorms and Standards
During Hospitalization
Health Perception and HealthManagement- Compliance with medication
regimen, use of health-promotionactivities such as regular exercise,annual check-ups. Perception ofbeing healthy.
According to the mother, herbaby was born in the hospital.She was told that her babybecame yellow and that heneeds treatment. They followedthe right therapeuticmanagement and followed thedoctors order regarding thetreatment of her baby.
Nutrition and Metabolism- Normal Pattern of food and fluid
consumption relative to metabolicneed and pattern; indicators of localnutrient supply.
According to the mother, everynow and then, she breastfeedsher baby. She also follows therule that after breastfeeding, theinfant must be allowed to burp.
Elimination- Frequency of bowel movements is
at least once every 2 days andurination is about 1-2L per day
The mother told that shechanges the diaper 2-3 times aday. The urine and stool aretogether. The urine has a yellowcolor. The stool was black incolor, large in amount and has asoft consistency.
Activity and Exercise- Exercise, hobbies. May include
cardiovascular and respiratorystatus, mobility, and activities ofdaily living.
Not applicable to the patient.
Cognition and Perception- Vision, hearing, taste, touch, smell,
pain perception and managementshould be normal; cognitive
functions such as language,memory, and decision making areintact.
Not applicable to the patient.
Sleep and Rest- Sleep pattern should be normal with
hours ranging from 7-9.
The mother said that her babyssleep pattern was normal. Thebaby was relaxed althoughthere are times that her baby
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would suddenly wake up.
Self-Perception and Self Concept- Body comfort, body image, feeling
state, attitudes about self,perception of abilities, objective
data such as body posture, eyecontact, voice tone.
Not applicable to the patient.
Roles and Relationship- Perception of current major roles
and responsibilities; satisfied withfamily, work, or social relationships.
Not applicable to the patient.
Sexuality and Reproduction- Number and histories of pregnancy
and childbirth; difficulties withsexual functioning; satisfaction withsexual relationship.
According to the mother, it washer third time getting pregnant.All her children are alive andwell.
Coping on Stress Tolerance- Clients usual manner of handling
stress, available support systems,perceived ability to control ormanage situations
The mother said that herhusband and family are theirmain support. They visit thehospital every now and then.
Values and Beliefs- Religious affiliation, what client
perceives as important in life, value-belief conflicts related to health,special religious practices.
According to the mother, theyare of a Roman Catholicreligion.
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b.2 Developmental Theory
Erik Erickson: Trust vs. MistrustAge Range: Birth to 18 MonthsBasic strength: Drive and Hope
Erikson also referred to infancy as the Oral Sensory Stage (as anyone might whowatches a baby put everything in her mouth) where the major emphasis is on themother's positive and loving care for the child, with a big emphasis on visual contact andtouch. If we pass successfully through this period of life, we will learn to trust that life isbasically okay and have basic confidence in the future. If we fail to experience trust andare 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.
Sigmund Freud: Oral stageAge Range: Birth to 1 YearErogenous Zone: Mouth
During the oral stage, the infant's primary source of interaction occurs throughthe mouth, so the rooting and sucking reflex is especially important. The mouth is vitalfor eating, and the infant derives pleasure from oral stimulation through gratifyingactivities such as tasting and sucking. Because the infant is entirely dependent uponcaretakers (who are responsible for feeding the child), the infant also develops a sense
of trust and comfort through this oral stimulation.
The primary conflict at this stage is the weaning process--the child must becomeless dependent upon caretakers. If fixation occurs at this stage, Freud believed theindividual would have issues with dependency or aggression. Oral fixation can result inproblems with drinking, eating, smoking or nail biting.
Jean Piaget: SensorimotorAge Range: Birth to about age 2
During this stage, the child learns about himself and his environment throughmotor and reflex actions. Thought derives from sensation and movement. The childlearns that he is separate from his environment and that aspects of his environment--his parents or favorite toy -- continue to exist even though they may be outside thereach of his senses. Teaching for a child in this stage should be geared to thesensorimotor system. You can modify behavior by using the senses: a frown, a stern orsoothing voice -- all serve as appropriate techniques.
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b.3 Nursing Theory
Nightingales Environmental Theory
As for the theoretical framework, Florence Nightingales Environmental theory suits
best the condition of the patient. The patient is in the state of having sepsis neonatorum
and the main priority with this is to avoid further spread infection throughout the system
of the patient by providing him a safe and clean environment. With Nightingales theory
which states that the act of utilizing the environment of the patient to assist him in his
recovery is what nursing does. As she linked health with the five environmental factors
that includes: fresh or pure air, pure water, efficient drainage, cleanliness and light.
Combining these factors would help to alleviate the condition of the patient especiallythat he is in the state where he could not do things on his own. Furthermore, since the
patient has an infection given that he has a fever, providing a clean environment around
him would help him for his recovery. A quiet environment is also a factor. Providing the
client with the right diet by ensuring that he will be able to tolerate his Doppler feeding
will also help his recovery since this is a necessity for a patient to easily get well.
Therefore, in its simplest term, with the integral parts of nursing, and the factors that
promotes a good environment to the patient, recovery could be achieved or at least
alleviation of what he feels most especially the patient will be free from harm or injury
and also the spread of infection could be more prevented.
C. Diagnostics
August 21, 2011
Diagnostics Normal Result Analysis
HEMATOL
OGY
WBC 5 - 10x10 9/1 8.5 Normal
Neutrophils 0.51 - 0.67 0.60 Normal
Lymphocytes 0.21 - 0.35 0.40
LymphocytosisIncreased lymphocytecount in response topresence of infection.
HematocritM 39 - 54F 36 - 48
50 Normal
HemoglobinM = 130 180 g/LF = 120 -160 g/L
166g/L Normal
Platelet Count 150 400x10 g/L 315 Normal
Blood Type B positive Normal
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Total Bilirubin 1.0 10.5 Mg/dl 17.6Hyperbilirubinemia
Indirect bilirubinoutweighs Direct bilirubin
Direct Bilirubin 0.0 0.6 Mg/dl 0.3
Indirect Bilirubin 1.0 10.5 Mg/dl 17.3
IV. ANATOMY AND PHYSIOLOGY
A baby's immune system is not fully developed until
he/she is about six months-old. In the meantime, pregnant
mothers pass immunoglobulin antibodies from their
bloodstream, through the placenta, and to the fetus. These
antibodies are an essential part of the fetus's immune
system. They identify and bind to harmful substances, such
as bacteria, viruses, and fungi that enter the body. This
triggers other immune cells to destroy the foreign substance.
Immunoglobulin G (IgG) is the only antibody that crosses
the placenta to the fetus during pregnancy. IgG antibodies are the smallest, but most
abundant antibodies, making up 75-80% of all the antibodies in the body. They are
present in all body fluids and they are considered to be the most important antibodies
for fighting against bacterial and viral infections. These antibodies help protect the fetus
from developing an infection inside the womb.
Immediately after birth, the newborn has high levels of the mother's antibodies in the
bloodstream. Babies who are breastfed continue to receive antibodies via breast milk.
Breast milk contains all five types of antibodies, including immunoglobulin A (IgA),
immunoglobulin D (IgD), immunoglobulin E (IgE), IgG, and immunoglobulin M (IgM).
This is called passive immunity because the mother is "passing" her antibodies to her
child. This helps prevent the baby from developing diseases and infections.
During the next several months, the antibodies passed from the mother to the infantsteadily decrease. When healthy babies are about two to three months old, the immune
system will start producing its own antibodies. During this time, the baby will experience
the body's natural low point of antibodies in the bloodstream. This is because the
maternal antibodies have decreased, and young children, who are making antibodies
for the first time, produce them at a much slower rate than adults.
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Once healthy babies reach six months of age, their antibodies are produced at a
normal rate.
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V. PATHOPHYSIOLOGY
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VI. MEDICAL MANAGEMENT ANALYSIS
A. Intravenous TherapyB alanced Multiple Maintenance Solution with 5% Dextrose (D5IM)
Action Adverse Reactions Nursing Responsibilities
The solution is administeredby intravenous infusion forparenteral maintenance ofroutine daily fluid andelectrolyte requirementswith minimal carbohydratecalories
PediatricUse:The safetyand effectiveness in
the pediatricpopulation are basedon the similarity of theclinical conditions ofthe pediatric and adultpopulations. Inneonates and verysmall infants thevolume of fluid mayaffect fluid andelectrolyte
balance.Frequentmonitoring of serumglucose concentrationsis required whendextrose is prescribedto pediatric patients,particularly neonatesand low birth weightinfants.
Reactions which may occurbecause of the solution orthe technique ofadministration include febrileresponse, infection at thesite of injection, venousthrombosis or phlebitisextending from the site ofinjection, extravasation andhypervolemia. If an adversereactiondoes occur,
discontinue the infusion,evaluate the patient,institute appropriatetherapeuticcountermeasures and savethe remainder of the fluid forexamination if deemednecessary.
Clinical evaluation andperiodic laboratorydeterminations arenecessary to monitorchanges in fluid balance,electrolyteconcentrations, and acid-base balance duringprolonged parenteraltherapy or whenever thecondition of the patient
warrants suchevaluation.
Caution must beexercised in theadministration ofparenteral fluids,especially thosecontaining sodium ions,to patients receivingcorticosteroids orcorticotropin.
Solutions containingacetate should be usedwith caution, as excessadministration may resultin metabolic alkalosis.
Solutions containingdextrose should be usedwith caution in patientswith known subclinical orovert diabetes mellitus.
Do not administer unlesssolution is clear andcontainer is undamaged.Discard unused portion.
In very low birth weightinfants, excessive orrapid administration ofdextrose injection may
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result in increased
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B. MedicationsName of
drugClassification
Therapeuticaction
Indication Contraindication Side effectsNursing
Responsibilities
Ampicillin 410mgIV q 12
Ampicilin61.5mgIV OD
Anti-infective Bactericidalaction
Binds tobacterialcell wall,resulting incell death
Treatment of thefollowinginfections:
skin structureinfections,
soft tissueinfection,
otitis media,
sinusitis,
respiratoryinfection and
SEPTICEMIA
Hypersensitivityto penicillins
USECAUTIOUSLYIN: severerenalinsufficiency
CNS: seizures
GI:pseudomembranous colitis,
diarrhea, nauseaand vomiting
DERM: rashes,urticaria
HEMAT: blooddycrasias
MISC: allergicreactionincludinganaphylaxis andserum sickness,superinfection
assess patientfor infection
obtain historybefore
initiatingtherapy todetermineprevious useand reactionsto penicillins
observepatient forsigns andsymptoms ofanaphylaxis
assess skinfor ampicillinrash
laboratory testconsiderations: may causeincreasedAST and ALT
may cause afalse-positivedirect Coombstest result
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VII. PLANNING
A. List Daily Nursing Problems
DAY NO. IDENTIFIED NURSING PROBLEMS PRIORITIZATION
1 Risk for further infection
Interrupted breast feeding
Skin integrity as evidenced of
disruption of the skin (epidermis)
Since the baby had already an infection, our firstpriority is to prevent further infection to thenewborn. The next priority would be the interrupted
breast feeding, because a newborn only needsmilk from the mother since it has all the nutrients anewborn needs including colostrum which givesthe newborn immunization to fight the infection,then the skin integrity.
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VIII. NURSING CARE PLAN
Assessment Diagnosis Planning Intervention Rationale Evaluation
Objective :
Bradycardia(104bpm)
Lab tests:Total
Bilirubin(17.6mg/dl)
Lymphocytes (.40) Skin rashes
Crackles(left posteriorpart)
On phototherapy witheyeshield in place
Risk forfurtherinfectionrelated toinadequate
secondarydefense asevidenced bylymphocytosis
Short-termGoal:After 8 hrs. ofnursingintervention, the
clients motherwill be able to:a. Preventthe risk fromfurtherinfection to thebaby
b. Identifyinterventionsto prevent /reduce theinfection
Long-term
GoalAfter days ofnursingintervention, thepatient will beable to:a. Maintainthe normallevel oflymphocytes
b. Be free
INDEPENDENT:-Close vital signsmonitoring
- Assess umbilical sitefor any signs ofinfection
- Monitor visitors asindicated
-Wash hands beforeand after each careactivity, even glovesare used
-Instruct mother intechniques to protectthe integrity of skin ofthe baby, care forlesions
-Promote childhoodimmunization program
-to monitorabnormal signsthat can lead toother problem
-to prevent risk offurther infectionon the wound site
-To preventexposure of client
-Reduces risk ofcrosscontamination
-To preventspread of furtherinfection
-For the baby tobe free / immuneto furtherdiseases likeHepatitis B
After 8 hours of nursinginterventions, themother was able toverbalize / perform
techniques to preventthe spread of infection
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from infectionc.Have thenormal level ofbilirubin forjaundice to notoccur
COLLABORATIVE:-Administer antibioticsas prescribed -To prevent
spread of furtherinfection
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Nursing Care PlanAssessment Diagnosis Planning Intervention Rationale Evaluation
Subjective:
Objective: Interrupted
breastfeeding
related to
neonates present
illness as
evidenced by
separation of
mother to infant.
Short-term:
After 3 hours of
nursing
intervention and
health teachings
the mother will
identify and
demonstrate
techniques to
sustain lactation
until breastfeeding
is initiated
Long Term:
After 3 days of NI,
the mother shall
still be able toidentify and
demonstrate
techniques to
sustain lactation
and identify
techniques on
how to provide the
newborn with
breast milk.
1. Assessmothersperception andknowledge aboutbreastfeeding andextent of
instruction thathas been given.
2. Give emotionalsupport to motherand acceptdecision regardingcessation/continuation ofbreast feeding.
3. Demonstrateuse of manualpiston-type breastpump.
4. Reviewtechniques forstorage/use ofexpressed breastmilk
5. Determine if aroutine visitingschedule or
1. To know what
the mother
already knows
and needed to
know.
2. To assist
mother to
maintain
breastfeeding as
desired.
3. aid in feeding
the neonate with
breast milk
without the mother
breastfeeding the
infant.
4. To provide
optimal nutrition
and promote
continuation of
breastfeeding
process
5. So that infant
will be hungry/
The mother shall
be able to identify
and demonstrate
techniques to
sustain lactation
and identify
techniques on
how to provide the
newborn with
breast milk.
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advance warningcan be provided
6. Provideprivacy, calmsurroundingswhen mother
breast feeds.
7. Recommendfor infant suckingon a regular basis
8. Encouragemother to obtainadequate rest,maintain fluid andnutritional intake,and schedulebreast pumpingevery 3 hourswhile awake
ready to feed
6. To promote
successful infant
feeding
7. Reinforces that
feeding time is
pleasurable and
enhances
digestion.
8. to sustain
adequate milk
production and
breast feeding
process
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Nursing Care PlanAssessment Diagnosis Planning Intervention Rationale Evaluation
Subjective:
Objectives:>Jaundice
>Skin rashes>Crackles>Bradycardia>Lymphocytosis
Impaired skinIntegrity related todisruption of skinsurface(epidermis)as evidence skin
rashes.
After 8hrs. ofNursingIntervention, thepatient will reduceskin rashes.
Independent:>Vital signsmonitored andrecorded.
>Instruct therelatives forproper hygiene aswell thesurroundings ofthe patient.
Dependent:>Administeredprescribed medssuch as ascorbicacid and
furosemide.
>Changes in vitalsigns may indicateinfection.
>Proper hygieneprevent infectionand complication.A cleanenvironmentoccurrence of anydiseases.
>Vitamin Cprovides woundhealing anddiureticsdecreases renal
vascularresistance andmay increaserenal blood flow.
After 8hrs. ofnursingintervention, thegoal is partiallymet through
demonstration ofproper skinhygiene andcompliance withtreatment andmedication.
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IX. DISCHARGE PLAN
Medications
Medications ordered by the Physician must be well administered on time.
Select a drug class that has the greatest effectiveness, fewest side effects
and best chance of acceptance by the patient.
Environment
Environment free from pollutants and stress that may trigger to the complication of
the patients condition.
Provide a quiet and peaceful environment for the patient to be more relaxed.
Provide therapeutic environment such as stretching bed linens & arrangingobjects on bed.
Treatment
Continue medications as ordered by the physician.
Reinforce importance of follow-up care to the parents of the newborn.
Parents must continue to follow treatment regimen of physician in order to
prevent relapse of the disease.
Health Teaching
Encourage the mother to have a regular check-up for her baby.
Tailor information according to the parents ability to understand.
Parents must also know importance of proper hand washing because it
the best known method of preventing many diseases.
Out- patient
Instruct the guardian of the client that they should report for possible
complications of the newborn.
Encourage to recommend follow up check up as noted by the physician.
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Diet
Diet must be recommended by the physician. Since the client is a newborn.
Spiritual/Sexual
Encourage the guardian to enhance their faith in God and uplift their desire to be
able to surpass the condition of their baby.