Sepsis is a condition in which the body is fighting a severe infection that has spread via the bloodstream. If a patient becomes "septic," they will likely have low blood pressure leading to poor circulation and lack of perfusion of vital tissues and organs. This condition is termed "shock." This condition can develop either as a result of the body's own defense system or from toxic substances made by the infecting agent (such as a bacteria, virus, or fungus).
Causes
Many different microbes can cause sepsis. Although bacteria are most commonly the cause, viruses and fungi can also cause sepsis. Infections in the lungs (pneumonia), bladder and kidneys (urinary tract infections), skin (cellulitis), abdomen (such as appendicitis), and other areas (such as meningitis) can spread and lead to sepsis. Infections that develop after surgery can also lead to sepsis.
Nursing Assessment
- The main complaint: The client comes with a yellow body, lethargy, convulsions, did not want to suck, weak.
- History of present illness: In the beginning it is not clear, and jaundice on the second day, but the incidence of jaundice it lasts more than 3 weeks, accompanied by lethargy, loss of reflexes of rooting, stiffness in the neck, increased muscle tone as well as asphyxia or hypoxia.
- History of disease first: Mother patients had abnormal liver or liver damage due to obstruction.
- History of family illness: A parent or family has a history of diseases associated with liver or blood.
- Prenatal History: History of blood incompatibility, exchange transfusion or a history of light therapy in the previous baby, pregnancy complications, drugs given to the mother during pregnancy / delivery, delivery by action / complication.
- Neonatal History: In clinical jaundice in neonates can be seen immediately after birth or several days later. Jaundice that appears highly dependent on the cause of jaundice itself. Babies suffering from respiratory distress syndrome, crigler-Najjar syndrome, neonatal hepatitis, pyloric stenosis, hyperparathyroidism, post-natal infections and others.
Nursing Diagnosis for Sepsis and Nursing Interventions for Sepsis
- High risk of injury (internal) related to liver damage secondary physiotherapy
Marked by :- Baby's skin looks yellowish
- injury did not occur
- Monitor bilirubin levels before starting treatment with light, report if there is an increase
- Inspection of the skin, urine every 4 hours to see the color yellow, report what happened.
- Knowing the bilirubin level and assist the effectiveness of therapy
- Knowing how much bilirubin levels.
- Anxiety related to ignorance about the disease and the therapy given to infants.
Goal :
Parents know about treatment
Nursing Intervention :- Assess family knowledge about infant jaundice treatment
- Give an explanation of: Causes of jaundice, the process of therapy, and treatment.
- Give an explanation of each will take action.
- Talk about the baby and programs that will be done during the hospital.
- Create a close relationship with the family during treatment.
Rational :- Provide input for the nurse before doing education to the family's health
- By understanding the causes of jaundice, which provided family therapy programs may accept any measures that are given to their babies.
- Information is obviously very important in helping to reduce family anxiety
- Communication openly in solving one problem can reduce the anxiety of the family.
- An intimate relationship can increase the participation of families in caring for a baby jaundice.