Diagnosis: Neonatal Sepsis   Chief complaint/History of Present…

Diagnosis: Neonatal Sepsis

 

Chief complaint/History of Present Illness:  Rennie is a 28-day-old female presenting to ER during the night with presenting complaint of apneic episodes approximately 2/day with changing color to blue. Apneic episodes lasts 1-2 minutes, resolves with stimulation, chest rub, or gentle shaking.  Apneic episodes not associated with vomiting/spit ups. Baby completely recovers to her baseline with stimulation.  Baby always sleeps on her back, no family history of SIDS.  The current episode started more than 1 week ago. The problem occurs intermittently.  The problem has not changed since onset. Nothing relieves the symptoms. Nothing aggravates the symptoms. Pertinent negatives include no fever, no stridor, and no intake of a foreign body.  She had a lumbar puncture and chest X-ray as well as venous blood gases and lytes done in ER.  Urinalysis and culture have been done.   Ceftriaxone 380mg IV was given in ER after culture obtained.

 

Personal/Social History:  Family (mom and dad) lives/stays sometimes in a friend’s place (who does not let the baby’s dad in) and a homeless shelter (the dad stays in a shelter and is allowed to bring family in).  Mother says she is a medical assistant, currently unemployed.  Both parents smoke, they state they do not smoke around the baby.

 

PMH:   Born 39 weeks, C/S (FTP) 8lbs. 8oz, no birth/nursery complications. Medical history significant for GERD, hiccups, and weight loss thought to be due to lactose intolerance, she has since been placed on soy formula with rice cereal added to the formula.  Has been in ED for umbilical bleeding (resolved), GERD (improved on Zantac), thrush (put on nystatin) and conjunctivitis (resolved).   

 

Allergies: NKA

 

Weight: 3.81 kg

 

VS:

T:  36.6 (97.8)                              

P:  164

R:  58

BP:  80/42   

O2 sats:  95% on room air

 

Nursing Assessment: 

Gen:  Asleep, comfortable, reactive to stimulation. 

Resp: no congestion or nasal discharge, Slightly increased WOB, nasal flaring, no retractions, lungs clear bilaterally A&P, no wheezing. 

CV:   RRR, brachial and femoral pulses 2+  equal bilat, cap refill <3s. 

GI: Abd:  Soft, active BS, small amount spit up.   

MS: Ext:  WNL, no edema or cyanosis, moves all extremities equally. 

Neuro: normal grasp and suck, normal tone, normal strength. 

Skin: mild diaper rash, cold wet diaper. IV infusing 24 g. D5 1/2 NS with 20 mEq. KCL at 15 ml/hr per pump, in right hand. Site without redness or edema. Pain  FLACC 1/10    PEWS 1

Radiology Reports: Chest X-Ray IMPRESSION: Mild strandy and hazy pulmonary opacities diffusely within both lungs. This patient remains within the upper age range of the neonatal period and neonatal pneumonia remains within the differential diagnosis. Bronchiolitis related to a viral infection is an additional possibility.

 

Radiology Reports: Complete Abdominal Ultrusound: The liver is homogeneous in echogenicity. No focal hepatic mass or intrahepatic ductal dilatation is identified. The gallbladder is not abnormally distended. There are no gallstones, wall thickening or pericholecystic fluid. The common duct measures less  than 1 mm. No significant sonographic abnormality of the pancreatic head, neck or body is identified. The spleen is homogeneous in echogenicity, measuring 4.2 cm in length. The right kidney is normal in echogenicity relative to liver. The right kidney measures 4.7 cm in length. Corticomedullary differentiation is preserved. There is no right-sided renal mass, calculus or hydronephrosis. The left kidney measures 4.5 cm in length. Corticomedullary differentiation is preserved. There is no left-sided renal mass, calculus or hydronephrosis. The bladder is partially distended with urine and demonstrates a small amount of debris.

Doppler evaluation demonstrates normal monophasic hepatopetal flow within the main portal vein. The visualized portions of the aorta and IVC demonstrate normal gray scale and color Doppler appearance.

Normal renal lengths for age range from 4.0 to 6.0 cm.

IMPRESSION:

1. Small debris in bladder.

2. Otherwise normal abdominal ultrasound.

 According the patient’s information, what are 2 nursing diagnosis and 1 at risk diagnosis? 

Explanation & Answer

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