Original Article
Rev. Latino-Am. Enfermagem 2014 Mar.-Apr.;22(2):255-61 DOI: 10.1590/0104-1169.3101.2410
www.eerp.usp.br/rlae
Nursing diagnoses of newborns with sepsis in a Neonatal Intensive Care Unit
Ana Paula de Souza Santos1 Maria de Lourdes Costa da Silva2 Nilba Lima de Souza3 Gabriela Miranda Mota4 Débora Feitosa de França5
Objectives: to elaborate the Nursing Diagnoses of newborns with sepsis in a neonatal intensive care unit and characterize the profile of the neonates and their mothers. Method: a crosssectional and quantitative study, with a sample of 41 neonates. A physical examination and consultation of the hospital records were undertaken, using an instrument. The elaboration of the Nursing Diagnoses followed a process of diagnostic inference and was based on the North American Nursing Diagnosis Association 2012-2014. Results: the mothers were around 25 years old, had a low average number of pre-natal consultations, and various complications during the pregnancy; and the newborns were predominantly premature and with very low birth weights. Five Nursing Diagnoses predominated, and all the neonates presented Risk of Shock and Risk of fluid volume imbalance. Conclusion: the Nursing Diagnoses of the neonates with sepsis can guide the formulating of specific assistential plans. The study contributes to the generation of new knowledge and found various relationships between the Nursing Diagnoses and the variables selected in the characterization of the neonates, which deserve to be elucidated in greater detail based on further research on the issue. Descriptors: Nursing Diagnosis; Infant, Newborn; Sepsis; Neonatal Nursing.
1
RN, Specialist in Neonatal Intensive Care, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil.
2
Doctoral student, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil. Assistant Professor, Departamento de Enfermagem, Universidade
3
PhD, Professor, Departamento de Enfermagem, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil.
Federal do Rio Grande do Norte, Natal, RN, Brazil. 4
RN, Specialist in Neonatal Intensive Care, Hospital da Polícia Militar Coronel Pedro Germano, Natal, RN, Brazil.
5
RN, Maternidade Escola Januário Cicco, Universidade Federal do Rio Grande do Norte, Natal, RN, Brasil.
Corresponding Author: Ana Paula de Souza Santos Rua Dom Bosco, 758 Bairro: Emaús CEP: 59148-450, Parnamirim, RN, Brasil E-mail: [email protected]
Copyright © 2014 Revista Latino-Americana de Enfermagem This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC). This license lets others distribute, remix, tweak, and build upon your work non-commercially, and although their new works must also acknowledge you and be non-commercial, they don’t have to license their derivative works on the same terms.
256
Rev. Latino-Am. Enfermagem 2014 Mar.-Apr.;22(2):255-61.
Introduction
of the research for nursing because it integrates the range of studies linked to the NDs, given that the
Neonatal sepsis, or Primary Infection of the
operationalization of diagnostic systems contributes to
Bloodstream (BSI) is a clinical syndrome characterized
the construction of accurate clinical reasoning, facilitates
by a systemic inflammatory response, with or without
communication between the health professionals, and
evidence of a suspected or confirmed infection. It is one
allows the development of the profession(10-11).
of the more frequent infectious pictures in the neonatal
Based on this context, the study aimed to elaborate
period, and is the one which most raises morbidity and
the NDs of newborns with sepsis in a NICU, according
mortality(1-2).
to the North American Nursing Diagnosis Association
BSI can develop as early-onset, when diagnosed in the first 48 hours of the newborn’s (NB) life and in
(NANDA-I) 2012-2014(12) and to characterize the profile of the mothers and the affected neonates.
the presence of a perinatal risk factor for infection. In the late-onset form, the diagnosis is made after the
Method
first 48 hours, and the incidence is related to the care environment, notably in the Neonatal Intensive Care Unit (NICU)(3). The Nurse with the NB with this illness is, often, the professional who observes the first signs and
A cross-sectional and quantitative study was undertaken in the Neonatal ICU of the Januário Cicco Maternity School, a state center of excellence in highrisk maternal-infant care.
symptoms of the infection, which makes her important
The inclusion criteria for the sample were: neonates
for early diagnosis and intervention, by advocating in
interned in the NICU with a diagnosis of sepsis during the
the name of the child and ensuring timely diagnostic
data collection period, May – August 2012. The NBs who
complementation and empirical antibiotic therapy(4-5).
met these criteria were recruited through consecutive
In this aspect of the care, the Systematization of
convenience, by listing consecutively all the population
Nursing Care (SNC) presupposes the organization of the
accessible. The exclusion criteria were: neonates with
work regarding the method, personnel and instruments,
congenital heart defect, and those for whom the diagnosis
and makes possible the operationalization of the Nursing
of the illness was ruled out. The sample calculation
Process, a methodological tool made up of five inter-
resulted in 41 neonates, with a confidence interval of
related stages: Nursing History, Nursing Diagnosis (ND),
95% (CI 95%) and a margin of error of 5%.
Planning, Implementation and Evaluation(6-7). Through
For data collection, a complete physical examination
the ND, the nurse uses clinical reasoning and judgment
of the NB was used, in line with the recommended
and concludes the surveying of data referent to the
techniques and neonatal specific characteristics(2,13), and
patient’s state of health, allowing the standardization
consultation of the hospital records.
and individualization of the care(8). After intensive searching of the literature available,
The data collected was guided by an instrument developed
based
on
another
model
applied
in
only 11 works were detected whose focus was on the
neonatology and already validated in the literature
NDs in Neonatology. The Nursing studies regarding
The form is composed of two main parts: the first
.
sepsis are limited to few publications(4-5,9). Only two
contains maternal characteristics (identification, socio-
works address the NDs of NBs with specific illnesses,
demographic data and obstetric data) and neonatal
there being no studies regarding the NDs of neonates
characteristics (identification, occurrences of the birth,
with sepsis.
birth data and anthropometric data); the second has
(14)
The undertaking of the study on the above-
information related to the NB’s nursing history, which
mentioned issue is based on the point of view that the
includes the psycho-biological needs (oxygenation,
NDs consist of knowledge which is relevant for the guiding
hydration, nutrition, elimination, sleep and rest, motility,
of the decision-making of the nurses who care for these
shelter, skin and mucous membrane integrity, physical
patients. The research is also justified because it aims to
integrity, thermal, neurological, hydro-electrolytic and
meet the compulsoriness of SNC in line with legislation(7)
immunological regulation, perception, environment) and
and, thus, can contribute to the implementation of
the psycho-social needs (safety, love, communication).
SNC in NICU, to the improvement of the care, and
Subsequently, the instrument was submitted for
to the reduction of mortality from neonatal sepsis in
content validation by four nurses who are specialists in
the long term. Emphasis is given to the importance
neonatal care, in hospital infections, and/or in nursing
www.eerp.usp.br/rlae
257
Santos APS, Silva MLC, Souza NL, Mota GM, França DF. diagnoses. Their recommendations were accepted and
Grande do Norte (RN) (58.5%). The majority were in
reflected in the instrument’s improvement. The pre-
a stable relationship (87.8%). The mean age was 24.9
test was undertaken with septic newborns from another
(SD±6.7 years), while 70.7% were aged between 19
institution similar to the place of the study and did not
and 35 years old.
result in alterations to the form.
There was a mean of 4.4 pre-natal consultations
So as to characterize the mothers, the following variables
were
chosen:
where
they
were
(SD±2.3) and only 19.5% had attended more than
from,
six. The recurrent gestational complications were
marital status, age, number of pre-natal consultations
Urinary Tract Infection (UTI) (31.7%), Pregnancy-
attended, and complications during the pregnancy. And
Specific
to characterize the neonates: place of birth, sex, type of
and
birth, gestational age (GA), weight at birth, Apgar scores,
had a mean equivalent to 37.4 hours ± 29 hours.
need for resuscitation at birth, the next event (discharge
A history of drug use was ascertained in 17.1%,
from NICU, transference to another hospital, or death)
namely crack cocaine. Genital infections occurred in
and the types of clinical manifestations of the neonatal
12.2%, such as chorioamnionitis, candidiasis, and
sepsis. These variables were defined as independent and
bacterial vaginosis. Syphilis affected 14.6% of the
allowed the identification of the defining characteristics,
women, most of whom received no or inadequate
the related factors, and the risk factors which involve
treatment.
the NDs elaborated, considered dependent variables.
Hypertensive
amniotic
Disorders
membrane
rupture
(PSHD)
(29.2%)
(24.4%),
which
Regarding the neonatal characteristics, 95.1%
The process of the elaboration of the NDs followed
of the NBs were born in the locale of the study; and
the stages of the process of reasoning and diagnostic
there was no significant predominance in the sample
inference proposed in the literature(6): analysis of the
in relation to females (46.3%) or males (53.7%) and
grouping of indicators; lists of suspected problems;
to the type of birth, either vaginal (48.8%) or surgical
discarding of similar diagnoses; choice of more specific
(51.2%). The mean GA was 31 weeks (SD ± 5 weeks,
diagnostic labels; declaration of the problems and their
2 days), in which 51.2% of the premature babies had
causes; and identification of strong points, resources and
between 23 and 30 weeks of GA, making up 78% of
areas of improvement. After all the NDs were formulated,
the pre-term births. The mean weight at birth was 1475
the process was followed for adaptation of the nomination,
g, totalling 85.4% of the NBs with low weight at birth
supported in the NANDA-I 2012-2014 Taxonomy
(LBWN); and weight ≤1500 g represented 56.1% of this
.
(12)
All the data collected was organized in databases constructed in the Excel software and was submitted to descriptive statistics using the Statistical Package for the Social Sciences (SPSS) version 20. The
descriptive
analysis
of
the
total. The Apgar score in the 5th minute had a mean of 7.2 (SD±2). Little over half of the neonates needed tracheal intubation (53.7%) as a resuscitation manoeuvre. Most
quantitative
of the sample progressed to discharge from the NICU
variables involved calculations of the mean, the median
to the shared accommodation (75.6%) and six cases
and standard deviation, and that of the categorical
died (14.6%).
variables was undertaken through absolute and relative frequencies, with a level of significance of 5% and CI
Figure 1 shows the clinical manifestations of the sepsis presented by the NBs.
95%. The frequency relationships between the NDs
Table 1 shows the measurements of central
and the variables listed in the characterization of the
tendency and of dispersion of the total of the NBs, the
neonates were studied.
defining characteristics, the related factors and the risk
The study had prior approval by the Research Ethics
factors detected in the NBs with BSI.
Committee of the Onofre Lopes University Hospital,
It should be clarified that the presentation of
under Decision 16576, and received authorization from
the NDs and the discussion about them is limited
the parents and guardians of the NBs, through signing
only to those registered in Table 2, which presents
the Terms of Free and Informed Consent.
the distribution of the thirteen NDs with percentages
Results With relation to the maternal characteristics, a little over half were from the rural areas of the State of Rio
www.eerp.usp.br/rlae
over 20%. Emphasis is placed on the first five NDs, observed in more than 60% of the NBs. After Table 2, Table 3 is shown, with the percentages of the defining characteristics, related factors, and risk factors of the five prevalent NDs.
258
Rev. Latino-Am. Enfermagem 2014 Mar.-Apr.;22(2):255-61. Shock
14.6% 19.5%
Thermal instability
24.4%
Convulsion
29.3%
Bleeding
34.1%
Apnea
36.6%
Hyperglycemia
43.9%
Abdominal distension Intolerance to feeding
61.0%
Lethargy, hypertonia
65.9%
Respiratory distress
65.9% 0%
20%
40%
60%
80%
100%
Figure 1 - Distribution of the clinical manifestations of neonatal sepsis in 41 newborns. Natal, RN, Brazil, 2012
Table 1 - Measurements of the Nursing Diagnoses, defining characteristics, related factors and risk factors of 41 NBs with sepsis, according to NANDA-I 2012-2014, Natal, RN, Brazil, 2012 Total
Mean
Standard Deviation
Median
Confidence Interval 95%
Nursing Diagnoses
31
8.4
3.1
8
7.5-9.4
Defining Characteristics
62
8.3
4.8
7
6.8-9.8
Related Factors
37
4.2
3.3
3
3.2-5.3
Risk Factors
40
5.7
4.5
4
4.2-7.1
Variables
Table 2 - Nursing Diagnoses of 41 NBs with sepsis, according to NANDA-I 2012-2014, Natal, RN, Brazil, 2012 Nursing Diagnoses
n
%
Confidence Interval 95%
1. Risk of shock
41
100
91.4-100
2. Risk of fluid volume imbalance
41
100
91.4-100
3. Gastrointestinal motility dysfunction
32
78.0
63.3-88.0
4. Neonatal jaundice
26
63.4
48.1-76.4
5. Impaired gaseous Exchange
25
61.0
45.7-74.3
6. Inefficient respiratory pattern
22
53.7
38.7-67.9
7. Risk of bleeding
22
53.7
38.7-67.9
8. Risk of ineffective renal perfusion
22
53.7
38.7-67.9
9. Risk of developmental delays
19
46.3
32.1-61.3
10. Reduced cardiac output
13
31.7
19.6-47.0
11. Hypothermia
10
24.4
13.8-39.3
12. Risk of impaired bonding
10
24.4
13.8-39.3
13. Ineffective airway clearance
9
22.0
12.0-36.7
Table 3 - Frequent Nursing Diagnoses and defining characteristics, related factors and risk factors of 41 NBs with sepsis, NANDA-I 2012-2014, Natal, RN, Brazil, 2012 Nursing diagnosis 1. Risk of shock
2. Risk of fluid volume imbalance
n
%
Risk factor: Sepsis
Defining characteristic and/or Related factor or Risk factor
41
100.0
Risk factor: Hypovolemia
17
41.5
Risk factor: Hypoxemia
17
41.5
Risk factor: Sepsis
41
100.0
(continue...)
www.eerp.usp.br/rlae
259
Santos APS, Silva MLC, Souza NL, Mota GM, França DF. Table 3 - (continuation) Nursing diagnosis 3. Gastrointestinal motility dysfunction
4. Neonatal jaundice
5. Impaired gaseous Exchange
n
%
Defining characteristic: increase of gastric residue
Defining characteristic and/or Related factor or Risk factor
29
70.7
Defining characteristic: Abdominal distension
21
51.2
Defining characteristic: Regurgitation
6
14.6
Defining characteristic: Difficulty in eliminating feces
6
14.6
Defining characteristic: Abdominal pain
6
14.6
Related factor: Prematurity
12
29.3
Defining characteristic: Yellow-orange skin
26
63.4
Defining characteristic: Abnormal blood profile (hemolysis, serum bilirubin>2mg/dl)
26
63.4
Related factor: Age of neonate between 1 and 7 days
26
63.4
Defining characteristic: Dyspnea
34
82.9
Defining characteristic: Cyanosis
25
61.0
Defining characteristic: Hypoxemia
9
22.0
Defining characteristic: Tachycardia
7
17.1
Defining characteristic: abnormal arterial pH
7
17.1
Related factor: Ventilation-perfusion mismatch
14
34.1
Discussion
for late-onset sepsis, as it determines prolonged hospitalization(2,21).
The maternal profile revealed that a significant
An Apgar score at the 5th minute of ≤7 presented a
percentage of the mothers are from cities in the rural parts
percentage lower than the results of other studies(17,19).
of the state where the study was held, which is due to the
Perinatal asphyxia is understood as a disorder of impaired
service in the locale where the research took place being
gaseous exchange which results in fetal hypoxemia and
a center of excellence in high-risk perinatal care.
The
hypercapnia and can predispose to early-onset sepsis,
mothers’ mean age was considered ideal, as it is outside
due to neutropenia and to the reduction of medullary
the maternal age ranges of the child at risk at birth(15).
reserves of neutrophils(2,20,22).
In relation to the variable of pre-natal consultations,
Concerning
the
clinical
manifestations
of
the
a substantial proportion of the mothers had attended less
illness, it is appropriate to emphasize the non-specific
than six consultations, below the number of six which is
symptomatic pattern in the neonates. The initial clinical
stipulated by the Ministry of Health(16). One cohort study
signs may be confused with other illnesses, such as
indicated that attending less than six consultations
serious congenital heart defect(2).
led to a risk ten times higher of progressing to neonatal sepsis(17).
In this study, the most common symptoms of BSI in the neonates were respiratory discomfort, lethargy
Among the complications during the pregnancy,
and/or hypoactivity, and intolerance to feeding. This
UTI was predominant. UTIs are a risk factor for neonatal
information agrees with the literature only in regard
BSI, as they predispose to the ascending migration
to the respiratory and gastrointestinal symptoms; and
of microorganisms to the cervix. This results in pre-
other studies report a prevalence of apnea and fever
term labor and birth, low birth weight NBs, premature
or bradycardia, and hyperglycemia, principally among
amniotic membrane rupture and chorioamnionitis(17).
those below 32 weeks(17,22-23).
It is known that premature rupture of membranes
Five NDs were frequent in more than 60% of the NBs
(PROM) ≥18h is an important predictive factor for early-
and belong to the Domains: Safety/protection (Physical
onset sepsis(2), which represented 14.6% of the cases, a
injury Class), Nutrition (Hydration and Metabolism
number within the range observed by other studies(17-18).
Classes) and Elimination and exchange (Gastrointestinal
The data on prematurity and very low birth weight
function and Respiratory function Classes)(12). In the
babies (VLBWB), that is, those whose weight was
authors’ view, this data points to the probable health
≤1500 g, endorsed previous studies, which reported
needs to be prioritized in the nursing care plan for NBs
rates of sepsis inversely proportional to the weight and
with sepsis. The NDs which are little recurrent indicate
to the GA(19-20). These patients present immunological
only individual characteristics of the neonates with the
deficiencies predisposing them to have a risk of infection
infection.
which is 8 to 11 times greater, when compared to full-
All the NBs presented the NDs of Risk of Shock and
term NBs. The birth weight is a risk factor, above all
Risk of fluid volume imbalance due to the presence of the
www.eerp.usp.br/rlae
260
Rev. Latino-Am. Enfermagem 2014 Mar.-Apr.;22(2):255-61.
risk factor “Sepsis”(12). In serious BSI, the clinical picture
Conclusion
can culminate in septic shock, resulting in the worsening of the organic dysfunctions, hypotension, metabolic acidosis, oliguria, poor perfusion, and thrombocytopenia . (1)
In this study, five NDs predominated in the sample of NBs with neonatal sepsis, distributed in the
In this study, the Apgar score in the 5th minute
domains Safety/protection, Nutrition and Elimination
≤7 was related to the triad of NDs: Dysfunctional
and exchange: Risk of shock; Risk of fluid volume
gastrointestinal motility, Risk of Bleeding, and Risk of
imbalance;
Developmental delay.
Neonatal jaundice and Impaired gaseous exchange. The
Dysfunctional
gastrointestinal
motility;
Perinatal asphyxia causes gastrointestinal effects,
NDs found reflected the health needs of the infected
such as an increased risk of tissue ischemia and
neonates and may lead to the formulation of specific
necrotizing enterocolitis(22). In addition to this, it has
nursing care measures within the domains of the NDs.
hematological effects such as disseminated intravascular
Various
significant
and
the
neonatal
the low production of coagulation factors and platelets.
characteristics,
Depending on the extent of the hypoxemia/hypoxia, the
converge for the generation of new knowledge. However,
asphyxiated NBs may suffer brain injury, with a risk of
these relationships deserve to be thoroughly elucidated
delays in neurodevelopment and sequelae in 15 to 45%
through further research with greater statistical rigor on
of the survivors
the same issue, so as to ascertain if there is significant
which
NDs
outlined
between
.
different
were
coagulation (DIC) due to the injury of blood vessels and
(22)
the
relationships encourage
discussion
and
More than 70% of septic extremely premature
association between the events reported. Some of the
neonates and VLBWB demonstrate the ND Risk of
findings could not be grounded on details and compared,
bleeding. The platelet count increases in line with the GA
due to the absence of similar studies and to the limitation
and the thrombocytopenia (platelets
Rev. Latino-Am. Enfermagem 2014 Mar.-Apr.;22(2):255-61 DOI: 10.1590/0104-1169.3101.2410
www.eerp.usp.br/rlae
Nursing diagnoses of newborns with sepsis in a Neonatal Intensive Care Unit
Ana Paula de Souza Santos1 Maria de Lourdes Costa da Silva2 Nilba Lima de Souza3 Gabriela Miranda Mota4 Débora Feitosa de França5
Objectives: to elaborate the Nursing Diagnoses of newborns with sepsis in a neonatal intensive care unit and characterize the profile of the neonates and their mothers. Method: a crosssectional and quantitative study, with a sample of 41 neonates. A physical examination and consultation of the hospital records were undertaken, using an instrument. The elaboration of the Nursing Diagnoses followed a process of diagnostic inference and was based on the North American Nursing Diagnosis Association 2012-2014. Results: the mothers were around 25 years old, had a low average number of pre-natal consultations, and various complications during the pregnancy; and the newborns were predominantly premature and with very low birth weights. Five Nursing Diagnoses predominated, and all the neonates presented Risk of Shock and Risk of fluid volume imbalance. Conclusion: the Nursing Diagnoses of the neonates with sepsis can guide the formulating of specific assistential plans. The study contributes to the generation of new knowledge and found various relationships between the Nursing Diagnoses and the variables selected in the characterization of the neonates, which deserve to be elucidated in greater detail based on further research on the issue. Descriptors: Nursing Diagnosis; Infant, Newborn; Sepsis; Neonatal Nursing.
1
RN, Specialist in Neonatal Intensive Care, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil.
2
Doctoral student, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil. Assistant Professor, Departamento de Enfermagem, Universidade
3
PhD, Professor, Departamento de Enfermagem, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil.
Federal do Rio Grande do Norte, Natal, RN, Brazil. 4
RN, Specialist in Neonatal Intensive Care, Hospital da Polícia Militar Coronel Pedro Germano, Natal, RN, Brazil.
5
RN, Maternidade Escola Januário Cicco, Universidade Federal do Rio Grande do Norte, Natal, RN, Brasil.
Corresponding Author: Ana Paula de Souza Santos Rua Dom Bosco, 758 Bairro: Emaús CEP: 59148-450, Parnamirim, RN, Brasil E-mail: [email protected]
Copyright © 2014 Revista Latino-Americana de Enfermagem This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC). This license lets others distribute, remix, tweak, and build upon your work non-commercially, and although their new works must also acknowledge you and be non-commercial, they don’t have to license their derivative works on the same terms.
256
Rev. Latino-Am. Enfermagem 2014 Mar.-Apr.;22(2):255-61.
Introduction
of the research for nursing because it integrates the range of studies linked to the NDs, given that the
Neonatal sepsis, or Primary Infection of the
operationalization of diagnostic systems contributes to
Bloodstream (BSI) is a clinical syndrome characterized
the construction of accurate clinical reasoning, facilitates
by a systemic inflammatory response, with or without
communication between the health professionals, and
evidence of a suspected or confirmed infection. It is one
allows the development of the profession(10-11).
of the more frequent infectious pictures in the neonatal
Based on this context, the study aimed to elaborate
period, and is the one which most raises morbidity and
the NDs of newborns with sepsis in a NICU, according
mortality(1-2).
to the North American Nursing Diagnosis Association
BSI can develop as early-onset, when diagnosed in the first 48 hours of the newborn’s (NB) life and in
(NANDA-I) 2012-2014(12) and to characterize the profile of the mothers and the affected neonates.
the presence of a perinatal risk factor for infection. In the late-onset form, the diagnosis is made after the
Method
first 48 hours, and the incidence is related to the care environment, notably in the Neonatal Intensive Care Unit (NICU)(3). The Nurse with the NB with this illness is, often, the professional who observes the first signs and
A cross-sectional and quantitative study was undertaken in the Neonatal ICU of the Januário Cicco Maternity School, a state center of excellence in highrisk maternal-infant care.
symptoms of the infection, which makes her important
The inclusion criteria for the sample were: neonates
for early diagnosis and intervention, by advocating in
interned in the NICU with a diagnosis of sepsis during the
the name of the child and ensuring timely diagnostic
data collection period, May – August 2012. The NBs who
complementation and empirical antibiotic therapy(4-5).
met these criteria were recruited through consecutive
In this aspect of the care, the Systematization of
convenience, by listing consecutively all the population
Nursing Care (SNC) presupposes the organization of the
accessible. The exclusion criteria were: neonates with
work regarding the method, personnel and instruments,
congenital heart defect, and those for whom the diagnosis
and makes possible the operationalization of the Nursing
of the illness was ruled out. The sample calculation
Process, a methodological tool made up of five inter-
resulted in 41 neonates, with a confidence interval of
related stages: Nursing History, Nursing Diagnosis (ND),
95% (CI 95%) and a margin of error of 5%.
Planning, Implementation and Evaluation(6-7). Through
For data collection, a complete physical examination
the ND, the nurse uses clinical reasoning and judgment
of the NB was used, in line with the recommended
and concludes the surveying of data referent to the
techniques and neonatal specific characteristics(2,13), and
patient’s state of health, allowing the standardization
consultation of the hospital records.
and individualization of the care(8). After intensive searching of the literature available,
The data collected was guided by an instrument developed
based
on
another
model
applied
in
only 11 works were detected whose focus was on the
neonatology and already validated in the literature
NDs in Neonatology. The Nursing studies regarding
The form is composed of two main parts: the first
.
sepsis are limited to few publications(4-5,9). Only two
contains maternal characteristics (identification, socio-
works address the NDs of NBs with specific illnesses,
demographic data and obstetric data) and neonatal
there being no studies regarding the NDs of neonates
characteristics (identification, occurrences of the birth,
with sepsis.
birth data and anthropometric data); the second has
(14)
The undertaking of the study on the above-
information related to the NB’s nursing history, which
mentioned issue is based on the point of view that the
includes the psycho-biological needs (oxygenation,
NDs consist of knowledge which is relevant for the guiding
hydration, nutrition, elimination, sleep and rest, motility,
of the decision-making of the nurses who care for these
shelter, skin and mucous membrane integrity, physical
patients. The research is also justified because it aims to
integrity, thermal, neurological, hydro-electrolytic and
meet the compulsoriness of SNC in line with legislation(7)
immunological regulation, perception, environment) and
and, thus, can contribute to the implementation of
the psycho-social needs (safety, love, communication).
SNC in NICU, to the improvement of the care, and
Subsequently, the instrument was submitted for
to the reduction of mortality from neonatal sepsis in
content validation by four nurses who are specialists in
the long term. Emphasis is given to the importance
neonatal care, in hospital infections, and/or in nursing
www.eerp.usp.br/rlae
257
Santos APS, Silva MLC, Souza NL, Mota GM, França DF. diagnoses. Their recommendations were accepted and
Grande do Norte (RN) (58.5%). The majority were in
reflected in the instrument’s improvement. The pre-
a stable relationship (87.8%). The mean age was 24.9
test was undertaken with septic newborns from another
(SD±6.7 years), while 70.7% were aged between 19
institution similar to the place of the study and did not
and 35 years old.
result in alterations to the form.
There was a mean of 4.4 pre-natal consultations
So as to characterize the mothers, the following variables
were
chosen:
where
they
were
(SD±2.3) and only 19.5% had attended more than
from,
six. The recurrent gestational complications were
marital status, age, number of pre-natal consultations
Urinary Tract Infection (UTI) (31.7%), Pregnancy-
attended, and complications during the pregnancy. And
Specific
to characterize the neonates: place of birth, sex, type of
and
birth, gestational age (GA), weight at birth, Apgar scores,
had a mean equivalent to 37.4 hours ± 29 hours.
need for resuscitation at birth, the next event (discharge
A history of drug use was ascertained in 17.1%,
from NICU, transference to another hospital, or death)
namely crack cocaine. Genital infections occurred in
and the types of clinical manifestations of the neonatal
12.2%, such as chorioamnionitis, candidiasis, and
sepsis. These variables were defined as independent and
bacterial vaginosis. Syphilis affected 14.6% of the
allowed the identification of the defining characteristics,
women, most of whom received no or inadequate
the related factors, and the risk factors which involve
treatment.
the NDs elaborated, considered dependent variables.
Hypertensive
amniotic
Disorders
membrane
rupture
(PSHD)
(29.2%)
(24.4%),
which
Regarding the neonatal characteristics, 95.1%
The process of the elaboration of the NDs followed
of the NBs were born in the locale of the study; and
the stages of the process of reasoning and diagnostic
there was no significant predominance in the sample
inference proposed in the literature(6): analysis of the
in relation to females (46.3%) or males (53.7%) and
grouping of indicators; lists of suspected problems;
to the type of birth, either vaginal (48.8%) or surgical
discarding of similar diagnoses; choice of more specific
(51.2%). The mean GA was 31 weeks (SD ± 5 weeks,
diagnostic labels; declaration of the problems and their
2 days), in which 51.2% of the premature babies had
causes; and identification of strong points, resources and
between 23 and 30 weeks of GA, making up 78% of
areas of improvement. After all the NDs were formulated,
the pre-term births. The mean weight at birth was 1475
the process was followed for adaptation of the nomination,
g, totalling 85.4% of the NBs with low weight at birth
supported in the NANDA-I 2012-2014 Taxonomy
(LBWN); and weight ≤1500 g represented 56.1% of this
.
(12)
All the data collected was organized in databases constructed in the Excel software and was submitted to descriptive statistics using the Statistical Package for the Social Sciences (SPSS) version 20. The
descriptive
analysis
of
the
total. The Apgar score in the 5th minute had a mean of 7.2 (SD±2). Little over half of the neonates needed tracheal intubation (53.7%) as a resuscitation manoeuvre. Most
quantitative
of the sample progressed to discharge from the NICU
variables involved calculations of the mean, the median
to the shared accommodation (75.6%) and six cases
and standard deviation, and that of the categorical
died (14.6%).
variables was undertaken through absolute and relative frequencies, with a level of significance of 5% and CI
Figure 1 shows the clinical manifestations of the sepsis presented by the NBs.
95%. The frequency relationships between the NDs
Table 1 shows the measurements of central
and the variables listed in the characterization of the
tendency and of dispersion of the total of the NBs, the
neonates were studied.
defining characteristics, the related factors and the risk
The study had prior approval by the Research Ethics
factors detected in the NBs with BSI.
Committee of the Onofre Lopes University Hospital,
It should be clarified that the presentation of
under Decision 16576, and received authorization from
the NDs and the discussion about them is limited
the parents and guardians of the NBs, through signing
only to those registered in Table 2, which presents
the Terms of Free and Informed Consent.
the distribution of the thirteen NDs with percentages
Results With relation to the maternal characteristics, a little over half were from the rural areas of the State of Rio
www.eerp.usp.br/rlae
over 20%. Emphasis is placed on the first five NDs, observed in more than 60% of the NBs. After Table 2, Table 3 is shown, with the percentages of the defining characteristics, related factors, and risk factors of the five prevalent NDs.
258
Rev. Latino-Am. Enfermagem 2014 Mar.-Apr.;22(2):255-61. Shock
14.6% 19.5%
Thermal instability
24.4%
Convulsion
29.3%
Bleeding
34.1%
Apnea
36.6%
Hyperglycemia
43.9%
Abdominal distension Intolerance to feeding
61.0%
Lethargy, hypertonia
65.9%
Respiratory distress
65.9% 0%
20%
40%
60%
80%
100%
Figure 1 - Distribution of the clinical manifestations of neonatal sepsis in 41 newborns. Natal, RN, Brazil, 2012
Table 1 - Measurements of the Nursing Diagnoses, defining characteristics, related factors and risk factors of 41 NBs with sepsis, according to NANDA-I 2012-2014, Natal, RN, Brazil, 2012 Total
Mean
Standard Deviation
Median
Confidence Interval 95%
Nursing Diagnoses
31
8.4
3.1
8
7.5-9.4
Defining Characteristics
62
8.3
4.8
7
6.8-9.8
Related Factors
37
4.2
3.3
3
3.2-5.3
Risk Factors
40
5.7
4.5
4
4.2-7.1
Variables
Table 2 - Nursing Diagnoses of 41 NBs with sepsis, according to NANDA-I 2012-2014, Natal, RN, Brazil, 2012 Nursing Diagnoses
n
%
Confidence Interval 95%
1. Risk of shock
41
100
91.4-100
2. Risk of fluid volume imbalance
41
100
91.4-100
3. Gastrointestinal motility dysfunction
32
78.0
63.3-88.0
4. Neonatal jaundice
26
63.4
48.1-76.4
5. Impaired gaseous Exchange
25
61.0
45.7-74.3
6. Inefficient respiratory pattern
22
53.7
38.7-67.9
7. Risk of bleeding
22
53.7
38.7-67.9
8. Risk of ineffective renal perfusion
22
53.7
38.7-67.9
9. Risk of developmental delays
19
46.3
32.1-61.3
10. Reduced cardiac output
13
31.7
19.6-47.0
11. Hypothermia
10
24.4
13.8-39.3
12. Risk of impaired bonding
10
24.4
13.8-39.3
13. Ineffective airway clearance
9
22.0
12.0-36.7
Table 3 - Frequent Nursing Diagnoses and defining characteristics, related factors and risk factors of 41 NBs with sepsis, NANDA-I 2012-2014, Natal, RN, Brazil, 2012 Nursing diagnosis 1. Risk of shock
2. Risk of fluid volume imbalance
n
%
Risk factor: Sepsis
Defining characteristic and/or Related factor or Risk factor
41
100.0
Risk factor: Hypovolemia
17
41.5
Risk factor: Hypoxemia
17
41.5
Risk factor: Sepsis
41
100.0
(continue...)
www.eerp.usp.br/rlae
259
Santos APS, Silva MLC, Souza NL, Mota GM, França DF. Table 3 - (continuation) Nursing diagnosis 3. Gastrointestinal motility dysfunction
4. Neonatal jaundice
5. Impaired gaseous Exchange
n
%
Defining characteristic: increase of gastric residue
Defining characteristic and/or Related factor or Risk factor
29
70.7
Defining characteristic: Abdominal distension
21
51.2
Defining characteristic: Regurgitation
6
14.6
Defining characteristic: Difficulty in eliminating feces
6
14.6
Defining characteristic: Abdominal pain
6
14.6
Related factor: Prematurity
12
29.3
Defining characteristic: Yellow-orange skin
26
63.4
Defining characteristic: Abnormal blood profile (hemolysis, serum bilirubin>2mg/dl)
26
63.4
Related factor: Age of neonate between 1 and 7 days
26
63.4
Defining characteristic: Dyspnea
34
82.9
Defining characteristic: Cyanosis
25
61.0
Defining characteristic: Hypoxemia
9
22.0
Defining characteristic: Tachycardia
7
17.1
Defining characteristic: abnormal arterial pH
7
17.1
Related factor: Ventilation-perfusion mismatch
14
34.1
Discussion
for late-onset sepsis, as it determines prolonged hospitalization(2,21).
The maternal profile revealed that a significant
An Apgar score at the 5th minute of ≤7 presented a
percentage of the mothers are from cities in the rural parts
percentage lower than the results of other studies(17,19).
of the state where the study was held, which is due to the
Perinatal asphyxia is understood as a disorder of impaired
service in the locale where the research took place being
gaseous exchange which results in fetal hypoxemia and
a center of excellence in high-risk perinatal care.
The
hypercapnia and can predispose to early-onset sepsis,
mothers’ mean age was considered ideal, as it is outside
due to neutropenia and to the reduction of medullary
the maternal age ranges of the child at risk at birth(15).
reserves of neutrophils(2,20,22).
In relation to the variable of pre-natal consultations,
Concerning
the
clinical
manifestations
of
the
a substantial proportion of the mothers had attended less
illness, it is appropriate to emphasize the non-specific
than six consultations, below the number of six which is
symptomatic pattern in the neonates. The initial clinical
stipulated by the Ministry of Health(16). One cohort study
signs may be confused with other illnesses, such as
indicated that attending less than six consultations
serious congenital heart defect(2).
led to a risk ten times higher of progressing to neonatal sepsis(17).
In this study, the most common symptoms of BSI in the neonates were respiratory discomfort, lethargy
Among the complications during the pregnancy,
and/or hypoactivity, and intolerance to feeding. This
UTI was predominant. UTIs are a risk factor for neonatal
information agrees with the literature only in regard
BSI, as they predispose to the ascending migration
to the respiratory and gastrointestinal symptoms; and
of microorganisms to the cervix. This results in pre-
other studies report a prevalence of apnea and fever
term labor and birth, low birth weight NBs, premature
or bradycardia, and hyperglycemia, principally among
amniotic membrane rupture and chorioamnionitis(17).
those below 32 weeks(17,22-23).
It is known that premature rupture of membranes
Five NDs were frequent in more than 60% of the NBs
(PROM) ≥18h is an important predictive factor for early-
and belong to the Domains: Safety/protection (Physical
onset sepsis(2), which represented 14.6% of the cases, a
injury Class), Nutrition (Hydration and Metabolism
number within the range observed by other studies(17-18).
Classes) and Elimination and exchange (Gastrointestinal
The data on prematurity and very low birth weight
function and Respiratory function Classes)(12). In the
babies (VLBWB), that is, those whose weight was
authors’ view, this data points to the probable health
≤1500 g, endorsed previous studies, which reported
needs to be prioritized in the nursing care plan for NBs
rates of sepsis inversely proportional to the weight and
with sepsis. The NDs which are little recurrent indicate
to the GA(19-20). These patients present immunological
only individual characteristics of the neonates with the
deficiencies predisposing them to have a risk of infection
infection.
which is 8 to 11 times greater, when compared to full-
All the NBs presented the NDs of Risk of Shock and
term NBs. The birth weight is a risk factor, above all
Risk of fluid volume imbalance due to the presence of the
www.eerp.usp.br/rlae
260
Rev. Latino-Am. Enfermagem 2014 Mar.-Apr.;22(2):255-61.
risk factor “Sepsis”(12). In serious BSI, the clinical picture
Conclusion
can culminate in septic shock, resulting in the worsening of the organic dysfunctions, hypotension, metabolic acidosis, oliguria, poor perfusion, and thrombocytopenia . (1)
In this study, five NDs predominated in the sample of NBs with neonatal sepsis, distributed in the
In this study, the Apgar score in the 5th minute
domains Safety/protection, Nutrition and Elimination
≤7 was related to the triad of NDs: Dysfunctional
and exchange: Risk of shock; Risk of fluid volume
gastrointestinal motility, Risk of Bleeding, and Risk of
imbalance;
Developmental delay.
Neonatal jaundice and Impaired gaseous exchange. The
Dysfunctional
gastrointestinal
motility;
Perinatal asphyxia causes gastrointestinal effects,
NDs found reflected the health needs of the infected
such as an increased risk of tissue ischemia and
neonates and may lead to the formulation of specific
necrotizing enterocolitis(22). In addition to this, it has
nursing care measures within the domains of the NDs.
hematological effects such as disseminated intravascular
Various
significant
and
the
neonatal
the low production of coagulation factors and platelets.
characteristics,
Depending on the extent of the hypoxemia/hypoxia, the
converge for the generation of new knowledge. However,
asphyxiated NBs may suffer brain injury, with a risk of
these relationships deserve to be thoroughly elucidated
delays in neurodevelopment and sequelae in 15 to 45%
through further research with greater statistical rigor on
of the survivors
the same issue, so as to ascertain if there is significant
which
NDs
outlined
between
.
different
were
coagulation (DIC) due to the injury of blood vessels and
(22)
the
relationships encourage
discussion
and
More than 70% of septic extremely premature
association between the events reported. Some of the
neonates and VLBWB demonstrate the ND Risk of
findings could not be grounded on details and compared,
bleeding. The platelet count increases in line with the GA
due to the absence of similar studies and to the limitation
and the thrombocytopenia (platelets
