MAKATI MEDICAL CENTER

COLLEGE OF NURSING

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A Case Presentation on the Care of an Infant with Hyperbilirubinemia

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In Partial fulfillment of the Course Requirements of NCM102- Related Experience

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Submitted to:

Mrs. Gretel Viray, RN

Submitted by:

Leader:
Fernandez, Jeatrish Elica C.
Members:
Arejola, Catherine Danielle L.
Ching, Kayceline M.
Dela Rosa, Ma. Christine S.
Lagarico, Risza A.
Lim, Hana Cheska F.
Limfueco Alexis
Manapsal, Danielle Anne A.
Salenga, Immanuel
Torres, Arryl Patrick

December 15, 2010

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TABLE OF CONTENTS

CHAPTER I Page

Introduction…………………………………………………………………….3-7

Purpose and Objectives…………………………………………………8

Significance of the Study……………………………………………….9-10

Scope and Limitations………………………………………………….11

Background of the Study……………………………………………….12-13

CHAPTER II

Review of Related Literature…………………………………………………..14-24

CHAPTER III

Client Presentation……………………………………………………………..25-27

Concept Map…………………………………………………………………...

Nursing Care Plans……………………………………………………………..28-35

CHAPTER IV

Case Analysis and Interpretation……………………………………………….36-47

CHAPTER V

Summary of Findings, Conclusions and Recommendations…………………..48-53

APPENDICES

A. Pathophysiology in Schematic Diagram…………………………………….

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 CHAPTER I

INTRODUCTION

A baby is God's opinion that life should go on. Never will a time come when the most

marvelous recent invention is as marvelous as a newborn baby. The finest of our precision

watches, the most super-colossal of our supercargo planes don't compare with a newborn baby in

the number and ingenuity of coils and springs, in the flow and change of chemical solutions, in

timing devises and interrelated parts that are irreplaceable.

According to Pilliteri (2010), Hyperbilirubinemia leads to jaundice, or yellowing of the

skin. This occurs on the second or third day of life in about 50% of all newborns, as a result of

breakdown of fetal red blood cells or also known as physiologic jaundice. The infant’s skin and

the sclera of the eyes appear noticeably yellow. This happens because the high red blood cells

count built up in utero is destroyed, and heme and globin are released. Globin is a protein

component that is reused by the body and is not a factor in the developing jaundice. Heme is

further broken down into iron (which is also reused and not involved in the jaundice) and

protoporphyrin. Protoporphyrin is a further broken down into indirect bilirubin. Indirect bilirubin

is fat soluble cannot be excreted by the kidneys in this state. For removal of the body it is

converted by the liver enzyme glucuronyl transferase into direct bilirubin, which is water

soluble. This is incorporated into stool and then excreted in the feces. Many newborns have such

immature liver function that indirect bilirubin cannot be converted into direct form; it therefore

remains indirect. As long as building of indirect bilirubin remains in the circulatory system, the

red coloring of the blood cells covers the yellow tint of the bilirubin. After the level of this

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indirect bilirubin has risen to more than 7mg/100ml, however, bilirubin permeates the tissue

outside the circulatory system and causes the infant to appear jaundice.

An infant who are prone to extensive bruising carefully for jaundice, because bruising

leads to hemorrhage of blood into the subcutaneous tissue or skin. A cephalhematoma is a

collection of blood under periosteum of the skull bone. As the bruising in these location heals

and the red blood cells are hemolyzed, additional indirect bilirubin is released and can be another

cause of jaundice.

If intestinal obstruction is present and stool cannot be evacuated, intestinal flora may

breakdown bile into its basic components, leading to the released of indirect bilirubin into the

blood stream again. Early feeding of newborns promotes intestinal movements and excretion of

meconium and helps prevent indirect bilirubin build-up from this source.

The level of jaundice in the newborns may be judge grossly by estimating the extent to

which it has progress to that surface of the infant’s body, as it is noticed first in the head and then

spreads to the rest of the body.

Transcutaneous bilirubinometry devices are available to measure skin tone for jaundice

and help in estimating jaundice levels. Although this devices rarely replace from serum

measurements, they can use to the infants who need serum bilirubin determinations. The

technique for obtaining a serum bilirubin specimen by heel puncture. Treatment for physiologic

jaundice or the routine rise in the bilirubin in newborns is rarely necessary, except for measures

such as early feeding to speed passage of feces through the intestine and prevent reabsorption of

bilirubin from the bowel.

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 Above normal indirect bilirubin levels are potentially dangerous because, if enough

bilirubin (about 20mg/100ml) leaves the blood stream, it can interfere with the chemical

synthesis of brain cells, resulting in permanent cell damage, a condition termed kernicterus. If

this occurs permanent neurologic damage, including cognitive challenge, may result.

There is no set levels at which indirect serum bilirubin requires treatment, because other

factors, such as age maturity and breastfeeding status, affect this determination. If the level rises

to more than 10/12mg/100ml, treatment is usually considered. Phototherapy is a common

therapy. If this is necessary the incubator and light source can be moved to the mother’s room so

that the mother is not separated from her baby. Some infants need continued therapy after

discharged and receive phototherapy at home.

Compared with the formula-fed babies, a small proportion of breastfed babies have more

difficulty in converting indirect bilirubin to direct bilirubin, because breast milk contains

pregnanediol, which depressed the action of glucuronyl transferase. However breast milk alone

can cause enough jaundice to warrant therapy.

Signs and symptoms of infant jaundice usually appear between the second or fourth day

of life and include yellowing of the skin, yellowing of the eyes. They are too sleepy, and they are

difficult to arouse - either they don't wake up from sleep easily like a normal baby, or they don't

wake up fully, or they can't be kept awake. They have a high-pitched cry, and decreased muscle

tone, becoming hypotonic or floppy) with episodes of increased muscle tone (hypertonic) and

arching of the head and back backwards. As the damage continues, they may develop fever, may

arch their heads back into a very contorted position known as opisthotonus or retrocollis. If

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severe hyperbilirubinemia is not treated, it can cause mental retardation, hearing loss, behavior

disorders, cerebral palsy, or death (Adam,2006).

The nursing management of the newborn are require astute observation for jaundice and

careful review of possible risk factor for hyperbilirubinemia. The nurse should collaborate with

the other health team members to identify who may require follow up early discharge and

educate the parents about jaundice and normal time frame for its resolution. Monitor the weight

of the client, its skin turgor and the age of the baby as much as possible and monitor the vital

signs of the baby (Orshan, S., 2010).

During the study period, the main cause of admission in 144 (32%) neonates of the 446 admitted

neonates was hyperbilirubinemia. Seventy neonates fulfilled inclusion criteria. Two patients

were excluded from the study because of subsequent positive blood culture and refusal by

parents for blood sampling. Remaining 68 newborn infants were assigned randomly to the two

groups. Of the 68 neonates enrolled in this study, 33 patients in the control group received

phototherapy and placebo, while 35 neonates in the study group received phototherapy and

clofibrate. There was no significant difference in gender, weight, age at admission and cesarean

section rate between the two groups. Sixty-five percent of neonates were first offspring. Ninety-

seven percent (66 newborns) of the studied newborns were exclusively breast-fed.

Mean total serum bilirubin levels at the time of admission were as follows (mean± SD): 20.05 ±

2.82 mg/dL (95% confidence interval: 19.54-22.04 mg/dL) in the study group and 19.72 ± 1.79
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mg/dL (95%confidence interval: 19.12-20.54 mg/dL) in the control group (P= 0.57). Mean

duration of phototherapy was significantly shorter in the study group in comparison with control

group [mean ± SD: 64.32 ± 12.48 hours (95% confidence interval: 60-81.6 hours) vs. 87.84 ±

29.76 hours (95% confidence interval: 79.2-108 hours), P< 0.001]. The results of laboratory tests

of patients in the two groups are shown in. None of the patients in the present study required

exchange transfusion.

None of the babies receiving clofibrate developed vomiting or diarrhea. We noted only one case

of rebound hyperbilirubinemia, which was from the control group, during the follow-up of

neonates. White blood cell count, BUN and creatinine levels were normal 1 week after discharge

(Maisels MJ, 2005).

PURPOSE OF THE STUDY

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 This case study aims to present the nursing care of the client who underwent elective

caesarean section. Specifically, this study seeks to achieve the following objectives:

1. Identify factors that led to the development of the problem.

2. Analyze the relationship of factors leading to the development of the problem.

3. Discuss the relevant interventions that were utilized to resolve problems.

4. Explain the patient’s response toward the interventions.

SIGNIFICANCE OF THE STUDY

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The result of the case study will be beneficial to the following:

To the client, as an indirect recipient, the findings of the study will serve as a

guide to enhance further the health of the client.

To the family, the study will serve as a guide for the family on how to provide

care to the baby and enhance their knowledge about the changes that happens after

delivery and the adaptation of the baby to extra-uterine life, to achieve a better health

condition.

To the health care providers, the findings of this study will provide more

knowledge on improving the health of the client especially the newborns and other future

client’s with the same case.

To the students, the study will serve as a guide to enhance their knowledge and

skills in providing care to the newborn, and making interventions appropriate for the

condition of the newborn.

To the clinical instructors, the findings of this study may be used as a basis for

evaluating the student’s performance by identifying the student’s strengths and

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 weaknesses in analyzing and formulating the case history and be able to recommend and

make improvements.

To the future researchers, the findings of this study will provide the future

researchers the knowledge about the case and may be used as a reference for comparing

this study to their own research. This will also serve as a basis for improvement in their

research and in providing health care and meeting the needs of the client.

SCOPE AND LIMITATION OF THE STUDY

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 The researchers utilized a retrospective B type of study wherein this approach focused on

the utilization of the nursing care process to provide appropriate care to a live full term baby boy

delivered via elective caesarean section. This study involves assessment of the newborn to

identify actual and potential problems that may be encountered by the newborn. The patient was

also unable to handle by the researchers at the Newborn Services Unit of one of the tertiary

hospital in Makati City, from December 02 to 04 of 2010 during 0600H-1200H shift. This is the

case of baby boy Licaros who was born on November 27, 2010 at 0654H.

The scope of the study was focused on the case on of a live full term baby boy delivered

via elective caesarean section, utilizing the nursing process in meeting the needs of the patient

taking into consideration the core competencies standards of nursing practice. Methods for data

gathering includes observation for empirical data, physical assessment for examining the overall

status of the newborn and reviewing the chart of the newborn to verify the condition of the

patient and orders given by the attending paediatrician and staff nurse.

The limitations of this study include time constraint since the researcher was not be able

to handle the patient because the clinical instructor was the one who gave the case to the

researcher for study. The researchers were able to communicate with the other medical staffs

such as the staff nurse regarding only the client’s status and latest vital signs. Another limitation

is that the researchers are still in the stage of observation hence; they did not have a chance to

interview the mother of the newborn and to implement health teaching. Also the researchers

depend only to the chart of the patient.

BACKGROUND OF THE STUDY

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 This study was conducted at the Nursery Department located at the 5th floor of a selected

tertiary hospital in Makati City. It has a vision of “to be an internationally recognized medical

center dedicated to excellence in health care” and a mission of “with patient wellness in mind,

they provide high-quality health care services through integrated specialty centers operated by

highly qualified physicians and nurses, as well as technical and management staff, who are

sustained by well-developed research and training programs and enabled by state-of-art

professional equipment and specialized tools.” The hospital is a mother-baby friendly hospital

and it provides the ultimate care for the baby from birth to discharge.

Its department has its division. These are the discharge room, breastfeeding area, well

newborn I, admission room, well newborn II, potentially septic room, area management room,

nurse’s lounge, doctor’s lounge, milk preparation room, pantry; and further more circumcision

room, neonatal intensive care unit II and II, step down room, out born NICU, doctor’s

conference room and linen room wherein student nurses are not allowed to enter.

It provides services and procedures like, routine admission care, circumcision, earlobe

puncture, Newborn Hearing Screen: Otoacoustic Emission Test and Newborn Screening. Aside

from the said services and procedures, it has also lactation counselors wherein mothers are being

taught about the importance of breastfeeding of newborns which makes it the primary care for

rooming-in services.

This department follows an ordered flow. Upon admission of the baby from the delivery

room, the health care team will assess the neonate for any abnormalities. If there are

complications identified, the neonate will be endorsed to the Neonatal Intensive Care Unit

(NICU). Well neonates are admitted to Newborn Section for routine care. It provides state of the

art facilities and equipment for the newborn that helps the healthcare providers in rendering safe

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and quality services, such as: radiant warmer, bassinette, suction machines and more. Visitors of

the nursery may view their babies using the “Show My Baby” card. Only the infant’s mother is

allowed to enter the breastfeeding room during feeding time.

The researcher chose this case for it is found interesting for the reason that this will

provide them a learning opportunity. Moreover, it imposes a challenge to them to know more

regarding the selected case – A care of a Newborn with Hyperbilirubinemia. Furthermore, it is

believed that this will give them additional information about the chosen topic and the

appropriate interventions needed to be performed.

CHAPTER II

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 REVIEW OF RELATED LITERATURE

This chapter will identify significant theoretical concepts about hyperbilirubinemia as well as

understanding the current knowledge that are related to the study.

DEFINITION

http://www.lpch.org/DiseaseHealthInfo/HealthLibrary/hrnewborn/hyperb.html

Hyperbilirubinemia is a condition in which there is too much bilirubin in the blood.

When red blood cells break down, a substance called bilirubin is formed. Babies are not easily

able to get rid of the bilirubin and it can build up in the blood and other tissues and fluids of the

baby's body. Before birth, the placenta -- the organ that nourishes the developing baby --

removes the bilirubin from the infant so that it can be processed by the mother's liver.In newborn

babies a degree of jaundice is normal. It is due to the immaturity of the newborn's liver (which

cannot effectively metabolize the bilirubin and prepare it for excretion into the urine). Normal

neonatal jaundice typically appears between the 2nd and 5th days of life and clears with time.

Because bilirubin has a pigment or coloring, it causes yellowish staining of the skin and whites

of the newborn's eyes (sclerae) by pigment of bile (bilirubin) which called jaundice. Jaundice is

not a disease but is a symptom of an elevated blood bilirubin level. Jaundice is not painful, but

serious complications can occur if elevated bilirubin levels are not treated in a timely manner.

Jaundice is a marker used to identify those infants who may be at risk for developing severe

hyperbilirubinemia. Severe hyperbilirubinemia can be toxic to the nervous system of infants,

potentially causing brain damage.

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ETIOLOGY

http://www.nlm.nih.gov/medlineplus/ency/article/001559.htm

The majority of bilirubin is produced from the breakdown of Hb into unconjugated

bilirubin (and other substances). Unconjugated bilirubin (indirect reacting) binds to albumin in

the blood for transport to the liver, where it is taken up by hepatocytes and conjugated with

glucuronic acid by the enzyme uridine diphosphogluconurate glucuronosyltransferase (UGT) to

make it water-soluble. The conjugated bilirubin (direct reacting) is excreted in bile into the

duodenum. In adults, conjugated bilirubin is reduced by gut bacteria to urobilin and excreted.

Neonates, however, have sterile digestive tracts. They do have the enzyme β-glucuronidase,

which deconjugates the conjugated bilirubin, which is then reabsorbed by the intestines and

recycled into the circulation. This is called enterohepatic circulation of bilirubin.

Physiologic hyperbilirubinemia occurs in almost all neonates. Shorter neonatal RBC

life span increases bilirubin production; deficient conjugation due to the deficiency of UGT

decreases clearance; and low bacterial levels in the intestine combined with increased hydrolysis

of conjugated bilirubin increase enterohepatic circulation. Bilirubin levels can rise up to 18

mg/dL by 3 to 4 days of life (7 days in Asian infants) and fall thereafter. Breastfeeding

jaundice is a type of exaggerated physiological jaundice seen in breastfed infants in the first

week of life, especially in those that are not nursing often enough. Breastfeeding increases

enterohepatic circulation of bilirubin in some infants who have decreased milk intake and who

also have dehydration or low caloric intake. The increased enterohepatic circulation also may

result from reduced intestinal bacteria that convert bilirubin to nonresorbed metabolites. Breast

milk jaundice is another common, usually non-harmful form of newborn jaundice. It is different

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from breastfeeding jaundice. Such jaundice appears in some healthy, breastfed babies after the

first 5 to 7 days of life and peaks at about 2 week. It may last at low levels for a month or more.

It is thought to be caused by an increased concentration of β-glucuronidase in breast milk,

causing an increase in the deconjugation and reabsorption of bilirubin in the intestines.

Inadequate intake jaundice is distinct from breast milk jaundice occurs if a newborn is not

getting enough breast milk. This is more likely to occur in babies who have difficulty with

breastfeeding due to physical problems (prematurity, cleft lip or palate, tongue-tie) or a mother's

insufficient milk supply.

Pathologic hyperbilirubinemia in term infants is diagnosed if jaundice appears in the

first 24 h, after the first week of life, or lasts > 2 wk, total serum bilirubin (TSB) rises by > 5

mg/dL/day, TSB is > 18 mg/dL and infant shows symptoms or signs of a serious illness. Some of

the most common pathologic causes are immune and nonimmune hemolytic anemia, hematoma

resorption, sepsis and hypothyroidism. The increased production of bilirubin levels in infants can

be related to bruising and mild injuries from the birth process, mother and infant's blood types

incompatibility (the mother's immune system may attack the infant's red blood cells) and

inherited causes of red blood cell breakdown (such as deficiency of an enzyme called glucose-6-

phosphate dehydrogenase [G6PD).

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SIGNS AND SYMPTOMS

Adams, A. (2006). Breathing in the Newborn, 5th Edition. California. Page 5

Signs and symptoms of infant jaundice usually appear between the second or fourth day

of life and include yellowing of the skin, yellowing of the eyes. They are too sleepy, and they are

difficult to arouse - either they don't wake up from sleep easily like a normal baby, or they don't

wake up fully, or they can't be kept awake. They have a high-pitched cry, and decreased muscle

tone, becoming hypotonic or floppy) with episodes of increased muscle tone (hypertonic) and

arching of the head and back backwards. As the damage continues, they may develop fever, may

arch their heads back into a very contorted position known as opisthotonus or retrocollis. If

severe hyperbilirubinemia is not treated, it can cause mental retardation, hearing loss, behavior

disorders, cerebral palsy, or death.

EPIDEMIOLOGY

David, H.E. (2010). Care of a newborn: A handbook of primary care. Washington, USA. Page

60

The overall incidence of jaundice in the newborn is 65%. It affects 50% term newborns

and 80% of premature newborns. Elevated bilirubin levels have been associated with several

factors during the newborn period, including the following: low birth weight, breastfeeding,

prematurity, sepsis, Delivery inquiring instrumentation, history of maternal Diabetes, and Asian

Descent. Other factors have been identified inconsistently, such as epidural anesthesia and

oxytoxin during labor.

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DIAGNOSTIC TEST

Hertz, D. (2005). “Care of the newborn: A Handbook for Primary Care” Philadelphia: USA

In addition to a complete history and thorough physical examination, laboratory testing is

a key component in the evaluation of the jaundiced infant. A basic laboratory evaluation is

indicated for all infants and an expanded evaluation for selected infants. A basic evaluation

should include the following: a fractionated bilirubin level that includes direct (conjugated) and

unconjugated bilirubin measurements; a complete blood count with peripheral smear and

differential noting any nucleated red blood cells; a retuculocyte count; maternal blood type, Rh

status, and antibody screen; and, if ABO incompatibility is suspected, the infant’s blood type, Rh

status, and direct and indirect Coombs should be assessed. The direct Coombs test, also known

as the Direct Antiglobulin test or “DAT,” determines if IgG antibodies are attached to red blood

cells. A positive direct Coombs does not identify the type of antibody or specific antigen;

therefore, it is impossible to determine if it is against the Rh, ABO, or some other red blood cell

antigen group. The indirect Coombs tests for specific plasma antibodies that are not attached to

red blood cells. Further, established newborn metabolic newborn metabolic screening tests

(particularly to detect hypothyroidism and galactosemia) should be sent as a part of basic

laboratory studies.

Additional studies may be indicated on the basis of the history (both maternal and perinatal) and

physical examination of the infant. The level of albumin in the baby's blood may also be

checked. Low albumin levels may increase the risk of damage from excessive jaundice.

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MEDICAL MANAGEMENT

Phototherapy: This treatment remains the standard of care, most commonly using

fluorescent white light. (Blue light is most effective for intensive phototherapy.) Phototherapy is

the use of light to photoisomerize unconjugated bilirubin into forms that are more water-soluble

and can be excreted rapidly by the liver and kidney without glucuronidation. It provides

definitive treatment of neonatal hyperbilirubinemia and prevention of kernicterus. Phototherapy

is an option when unconjugated bilirubin is > 12 mg/dL (> 205.2 μmol/L) and may be indicated

when unconjugated bilirubin is > 15 mg/dL at 25 to 48 h, 18 mg/dL at 49 to 72 h, and 20 mg/dL

at > 72 h. Phototherapy is not indicated for conjugated hyperbilirubinemia. Because visible

jaundice may disappear during phototherapy, though serum bilirubin remains elevated, skin color

cannot be used to evaluate jaundice severity. Blood taken for bilirubin determinations should be

shielded from bright light, because bilirubin in the collection tubes may rapidly photo-oxidize.

Exchange transfusion: This treatment can rapidly remove bilirubin from circulation and

is indicated for severe hyperbilirubinemia, which most often occurs with immune-mediated

hemolysis. The transfusion replaces an infant's blood with donated blood in an attempt to quickly

lower bilirubin levels. Exchange transfusion may be performed in infants who have not

responded to other treatments and who have signs of or are at risk of bilirubin toxicity. Small

amounts of blood are withdrawn and replaced through an umbilical vein catheter to remove

partially hemolyzed and antibody-coated RBCs as well as circulating Igs. These then are

replaced with uncoated donor RBCs. Only unconjugated hyperbilirubinemia can cause

kernicterus, so if conjugated bilirubin is elevated, the level of unconjugated rather than total

bilirubin is used to determine the need for exchange transfusion.

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Specific indications are serum bilirubin ≥ 20 mg/dL at 24 to 48 h or ≥ 25 mg/dL at > 48 h and

failure of phototherapy to result in a 1- to 2-mg/dL (17- to 34-μmol/L) decrease within 4 to 6 h

of initiation or at the first clinical signs of kernicterus regardless of bilirubin levels. If the serum

bilirubin level is > 25 mg/dL when the neonate is initially examined, preparation for an exchange

transfusion should be made in case intensive phototherapy fails to lower the bilirubin level. An

alternative approach uses the weight of the neonate in grams divided by 100 to determine the

bilirubin level (in mg/dL) at which exchange transfusion is indicated. Thus, a 1000-g neonate

would receive an exchange transfusion at a bilirubin level of ≥ 10 mg/dL, and a 1500-g neonate

would receive an exchange transfusion at a bilirubin level of ≥ 15 mg/dL.

Most often, 160 mL/kg (twice the infant's total blood volume) of packed RBCs is exchanged

over 2 to 4 h; an alternative is to give 2 successive exchanges of 80 mL/kg each over 1 to 2 h. To

do an exchange, 20 mL of blood is withdrawn and then immediately replaced by 20 mL of

transfused blood; this procedure is repeated until the total desired volume is exchanged. For

critically ill or premature infants, aliquots of 5 to 10 mL are used to avoid sudden major changes

in blood volume. The goal is to reduce bilirubin by nearly 50%, with the knowledge that

hyperbilirubinemia may rebound to about 60% of pretransfusion level within 1 to 2 h. It is also

customary to lower the target level by 1 to 2 mg/dL in conditions that increase the risk of

kernicterus (eg, fasting, sepsis, acidosis). Exchange transfusions may need to be repeated if

bilirubin levels remain high. Finally, there are risks and complications with the procedure, and

the success of phototherapy has reduced the frequency of exchange transfusion.

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 Blood type incompatibility: Infants with hyperbilirubinemia due to incompatibility with

their mother's blood may be given intravenous immunoglobulin (IVIG). Intensive phototherapy

is used as a first line treatment.

NURSING MANAGEMENT

Jackson C. et.al (2007). Maternal, fetal, neonatal physiology. United Staes of America:

Elsevier Inc.

Various techniques have been used to manage neonates with indirect hyperbilirubinemia.

Strategies have included prevention, use of pharmacologic agents, exchange transfusion and

phototherapy. Prevention has focused on early initiation of feedings and frequent breastfeeding

to decrease enterohepatic shunting, promote establishment of normal bacterial flora, and

stimulate intestinal activity. Specific pharmacologic agents have been used to prevent

hyperbilirubinemia or reduce bilirubin levels.

Pharmacologic agents have been used in the management of hyperbilirubinemia to

stimulate the induction of hepatic enzymes and carrier proteins, to interfere with heme enzymes

and carrier proteins, to interfere with degradation, or to bind bilirubin in the intestines to

decrease enterohepatic reabsorption.

Lowdermilk, D. et.al, (2006). Maternity nursing 7th edition. Missouri: Mosby, Inc.

The management of hyperbilirubinemia will depend to some extent on the cause, but

ultimately on the level of bilirubin and the condition of the neonate. If the neonate is less than 38

weeks’ gestation, or has hemolysis or other medical problems, the bilirubin level for initiating

phototherapy may be somewhat lower than if the neonate is full-term, healthy, and does not have

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any type of haemolytic disease. Very high or rapidly rising bilirubin levels may need to be

controlled with and exchange transfusion, in which case feedings would be temporarily

interrupted for the procedure. Neonates who are treated only with phototherapy should continue

to be breastfed or receive other milk feedings since good caloric intake improves the

effectiveness of phototherapy.

RISK FACTORS

Avery, G., MacDonald, M.G. (2005). Avery's neonatology: Pathophysiology & management of
the newborn.(6th ed.). Philadelphia: Lippincott William and Wilkins.

Infants who do not consume enough breastmilk are at risk for jaundice, especially if the

infant loses an excessive amount of weight because of difficulty feeding or if the mother does not

have an adequate milk supply. In babies whose bilirubin blood levels reach hazardous levels,

bilirubin may cross to the brain and cause reversible damage (called early acute bilirubin

encephalopathy) or permanent damage (called kernicterus). Frequent monitoring and early

treatment of infants at high risk for jaundice can help to prevent severe hyperbilirubinemia.

Babies with any of the following risk factors need close monitoring and early jaundice

management: A baby with a brother or sister that had jaundice is more likely to develop

jaundice. A baby who is not eating, wetting, or stooling well in the first few days of life is more

likely to get jaundice. A baby who has bruises at birth is more likely to have jaundice. A bruise

forms when blood leaks out of a blood vessel and causes the skin to look black and blue. Then,

when the bruise begins to heal, red blood cells die. Bilirubin is made when red blood cells break

down. The healing of large bruises may cause high levels of bilirubin, and the baby may become

22
jaundiced. A baby who is yellow in the first 24 hours of life may get dangerously jaundiced. A

baby born to an East-Asian or Mediterranean family is at a higher risk of becoming very

jaundiced. Also, jaundice is harder to see in babies with darker skin tones. Some families inherit

conditions (such as G6PD), and their babies are more likely to become jaundiced. Babies born

before 37 weeks, or 8 ½ months, of pregnancy may become jaundiced because their liver may

not be fully developed. The young liver may not be able to get rid of so much bilirubin. If too

many red blood cells break down at the same time, the baby can become very yellow or may

even look orange. Women with an O blood type or Rh negative blood factor might have babies

with higher bilirubin levels. A mother with Rh incompatibility should be given Rhogam.

PREVENTION

http://www.nlm.nih.gov/medlineplus/ency/article/001559.htm

In newborns, some degree of jaundice is normal and probably not preventable. The risk

of significant jaundice can often be reduced by feeding babies at least 8 to 12 times a day for the

first several days and by carefully identifying infants at highest risk. Also all pregnant women

should be tested for blood type and unusual antibodies. If the mother is Rh negative, follow-up

testing on the infant's cord is recommended. This may also be done if the mother blood type is

O+, but it not necessarily required if careful monitoring takes place. Careful monitoring of all

babies during the first 5 days of life can prevent most complications of jaundice. Ideally, this

includes considering a baby's risk for jaundice, checking bilirubin level in the first day or so and

scheduling at least one follow-up visit the first week of life for babies sent home from the

hospital in 72 hours.

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 Prevention of severe hyperbilirubinemia is important in avoiding serious complications.

Infants who are at risk for hyperbilirubinemia need close surveillance and follow-up. The

following information applies to infants who are healthy and late preterm or older (greater than

or equal to 35 weeks of gestation).

Screen — Experts recommend that all infants have bilirubin blood testing before going home.

This is especially true for infants who are jaundiced before 24 hours of age or are jaundiced

below the level of the umbilicus (navel).

Monitor — Parents and healthcare providers should monitor the infant closely if jaundice

develops. Hyperbilirubinemia is usually easy to prevent and treat initially, but the complications

can be serious and irreversible if treatment is delayed. You should contact your child's healthcare

provider immediately if you are concerned about worsening jaundice.

Treat promptly — Infants with elevated bilirubin levels should be treated by a qualified doctor

or nurse to safely reduce bilirubin levels and prevent the risk of brain damage. Parents and

healthcare providers should not delay treatment for any reason.

24
 CHAPTER III

CLIENT PRESENTATION

This is a case of baby L., a live full term baby boy; appropriate to gestational age, with an

Apgar score of 9, 10; delivered via elective caesarian section, last Nov. 27, 2010 at 0654H in a

private tertiary hospital.

Maternal History revealed that baby L. was born to Ms. A.J.V., a 34 year old, Gravida 1

Para 0 (T=0, P=0, A=0, L=0) at AOG of 38 4/7 weeks by last menstrual period. Ms. A.J.V had

regular prenatal check-ups. She was taking regular prenatal medication.

During the 1st trimester Ms. A.J.V was noted to have gestational Diabetes Mellitus and was

managed with insulin. During the pregnancy, the mother was found to have HSP virus type II

wherein no treatment was given.

Nov. 27, 2010 patient was admitted to the Nursery. Patient was received cuddled by the

delivery room nurse, Identification Band was checked and was located at right hand and right

leg. Sex was also verified. Upon delivery, baby had a good cry and good activity. Patient was

then placed safely and comfortably under the radiant warmer. Apgar score was 9, 10 at 1 & 5

minutes respectively. Amniotic fluid was clear. With (+) secretions, (-) dyspnea Risk for

ineffective airway clearance related to presence of oropharyngeal secretions was identified.

Secretions were immediately suctioned via the nose and mouth.

25
 Initial vital signs were taken and revealed that: temperature was 36.5°C (Normal Values:

36.5-37.5°C) taken rectally, apical pulse rate was 149 beats per minute (Normal Values: 120-160

bpm) and respiratory rate was 44 cycles per minute (Normal Values: 30-60 cpm). Blood pressure

was: 69/28 mmHg (36), (Normal Values: 75-50/45-25).with the temperature of 36.5 o C Risk for

Hypothermia related to immature thermoregulating mechanism was identified. The

following interventions were done; kept the baby dry, the baby was kept warm by swaddling,

and the infant was given mittens, booties and bonnet.

Physical Examination was also done and revealed the following results: a.) general

appearance - good activity, good color, good tone and good cry; b.) Skin – no lesion/s; no

jaundice; c.) Head and neck – no caput, no molding, no cephalhematoma; d.) Eyes – no

discharge; e.) Ears and nose – patent; no discharge; f.) Mouth, pharynx – no cleft lip, no cleft

palate, no tongue tied; g.) Chest – equal/chest expansion; h.) Lungs – clear breath sounds; j.)

Heart – no murmurs; i.) Genitalia – grossly male; j.) Trunk and spine – straight; k.) Anus –

patent; l.) Extremities – grossly symmetrical and m.)Reflexes - intact

Infant’s temperature was allowed to stabilize before the initial cleaning was done. Cord

care and cord clamping was also done aseptically, Hepa B vaccine 0.05 ml was given

intramuscularly on the anterolateral thigh, 0.1 ml of vitamin K given at the right anterolateral

thigh and Terramycin was applied in the eye. BCG was given at the right buttocks (intradermal).

Infant was then dressed and swaddled comfortably, and kept under the radiant warmer.

26
With (+) newly clamped cord Risk for infection related to inadequate secondary defenses

was identified. Interventions done were doing cord care and keeping the cord dry and exposed.

Anthropometric measurements were also taken: head circumference was 35.5 cm

(Normal Values 33-35 cm), chest circumference was 34 cm (Normal Values 31-33 cm),

abdominal circumference was 32 cm (Normal Values 28-32 cm:), body length was 52 cm

(Normal Values 48-52 cm) and weight was 3374 grams (Normal values: 2500-4000 g).

On Nov. 30, 2010 client was diagnosed with hyperbilirubinemia with the laboratory results of

Total Bilirubin = 16.74 mg/dL, Direct bilirubin = 0.72 mg/dL, and Indirect bilirubin = 16.02

mg/dL. The patient had good skin turgor but with jaundice. Patient was given a double

phototherapy treatment using bilibed thus Risk for injury related to properties of

phototherapy and effects on body regulatory mechanism was identified. Interventions done

were the infant was turned and that the eyes and genitals were covered.

Dec. 04, 2010 the client’s condition improved and was roomed in.

27
 NURSING CARE PLAN
Nursing Diagnosis # 1: Risk for ineffective airway clearance related to presence of
oropharyngeal secretions.

Goal: To maintain airway clearance

Expected Outcome: At the end of 15 minutes – 30 minutes of nursing intervention, Client will show no
signs of ineffective airway clearance as evidenced by:
• Respiratory rate within 30-60cpm
• (-) cyanosis; Good skin color (pink-pale)
• Clear breath sounds
• (-) secretions in mouth and nose

INTERVENTIONS RESPONSE

PROMOTIVE/PREVENTIVE:
1. Monitor vital signs. 1. Vital signs were taken. (December 3, 2010)
Rationale: To obtain baseline data. • T- 36.5 ºC
• RR- 44 breaths/min
• HR- 149beats/min
• BP - 69/28 mmHg
2. Assess for characteristic of breath sounds.
2. Clear breath sounds; no crackles, no wheezes,
Rationale: To see if the baby is breathing rales, no chest retractions
normally.

3. Note for presence of secretions. 3. Moderate, clear whitish secretions noted.

Rationale: To see if there’s a blockage in the
airway clearance.

4. Keep infant’s mouth and nose clear from

4. Oral secretions have been lessened
any obstruction.
and/or diminished and with no form of
Rationale: To see if there’s a blockage in the
airway clearance. foreign body in the oral opening

5. Provide oxygen when needed as ordered

by the doctor 5. Oxygen will be provided when needed.
Rationale: To prevent alteration of gas exchange.

6. Perform suctioning when needed.

Rationale:To remove the internal secretion. 6. The newborn was suctioned.Moderate, clear
whitish secretions was seen.
NURSING CARE PLAN

28
Nursing Diagnosis # 2: Risk for aspiration related to immature cardiac esophageal sphincter.

Goal: To prevent aspiration of the new born

Expected Outcome: At the end of 8 hours nursing interventions the patient will be able to manifest the
following:
• Respiratory rate within 30-60cpm
• (-) cyanosis; Good skin color (pink-pale)
• (-) choking or gagging
• (-) regurgitation
• (-) difficulty in breathing
• Clear breath sounds
• (-) secretions in mouth and nose

INTERVENTIONS RESPONSE
PROMOTIVE/PREVENTIVE:
1. Assess infant’s breathing and feeding 1. The baby showed no signs of difficulty in
pattern breathing, with a RR of 44 breaths/min. The baby
Rationale: To see if there are any signs of displayed no signs of choking or gagging while
respiratory distress and to avoid aspiration while being fed.
feeding.
2. Monitor vital signs, especially respiratory 2. Vital signs were taken.
rate, every 4 hours. Report any deviations. • T- 36.5 ºC
Rationale: To obtain baseline data. • RR- 44breaths/min
• HR- 149 beats/min
3. Check the mouth and nose for any • BP – 69/28 mmHg
secretions
3. The baby showed no difficulty in breathing,
Rationale: To maintain airway clearance
had clear breath.

4. Auscultate lungs for irregular breath

4 the baby’s lungs was checked and showed no
sounds
signs of difficulty in breathing. The baby has clear
Rationale: To distinguish if the client has normal breath sounds.
breath sounds.
5. Slowly feed the infant. 5. The baby consumed feeding without choking.
Rationale: To avoid choking and entry of feeding
into the airway.

6. Assess infant’s skin color and activity 6. (-) cyanosis; good skin turgor with
Rationale: To make sure that the baby isn’t going jaundice.
through any respiratory distress.

29
CURATIVE: 7. (+) burp
7. Burp the infant between feedings.
Rationale: To make sure that the baby isn’t going
through any respiratory distress.
8. The baby consumed feeding with ease and
8. Position infant in a semi-fowler’s did not show signs of choking or
position. aspiration.
Rationale: To provide the baby with ease in
swallowing. To avoid choking and entry of
feeding into the airway. 9. No regurgitation experienced.
9. If regurgitation is present put the infant in
a vertical position and tap the back (for
burping).
Rationale: To prevent further regurgitation that
could lead to aspiration.

NURSING CARE PLAN

30
Nursing Diagnosis # 3: Risk for injury related to physical properties of phototherapy and effects
on body regulatory mechanism.

Goal: To protect infant from injury

Expected Outcome: At the end of nurse-client interaction, the client will manifest:

• Normal vitals sigs

• Patient’s skin color will be normal
• Normal bilirubin level
INTERVENTIONS RESPONSE

1. Note the infant’s age. 1.Client’s age is noted. The baby is 6 days old.
Rationale: May aids in diagnosing underlying
cause in connection with the appearance of 2. The patient’s color is normal (Pink)
jaundice.

2. Monitor vital signs

3. Assist with phototherapy treatment.

Rationale: To allow for utilization of alternate
pathways for bilirubin excretion

4. Have the infant completely undressed

Rationale: To expose the entire skin in
phototherapy

5. Keep the eyes and genitals covered

Rationale: To protect them from the constant
exposure to high intensity light

6. Develop a systemic schedule of turning the

infant

NURSING CARE PLAN

31
Nursing Diagnosis # 4: Risk for infection R/T inadequate secondary defences

Goal: To protect infant from infection

Expected Outcome: At the end of 8 hours nursing interventions, the client will be prevented
from infection as manifested by:

• Normal vital signs

• No redness around the cord
• Be free from other complications
INTERVENTIONS RESPONSE
PROMOTIVE
1. Maintain daily cord care.
1. Cord care was monitored.
2. Monitor Vital signs especially the
temperature 2. December 3, 2010
Rationale: Fever is the first sign of infection 0800H =44 cpm, 125 bpm, 36.1 ͦC
1200H = 48 cpm, 147 bpm, 35.9 ͦC
3. Provide care to the newborn.
3. Applied hand washing before giving the
4. Monitor the area at the base of the
cord care.
umbilical cord for any swelling or redness.
4. The umbilical cord was kept dry
PREVENTIVE
2. Use prescribed solution when doing cord
care (70% ethyl alcohol or povidone iodine). 5. Mother agreed to wash hands and clean
her baby’s cord using alcohol and cotton.
3. Apply proper strokes when doing cord care.

4. Stress proper hygiene before doing cord care

(Hand washing).

5. Change clothes, mittens, bonnet, booties,

blanket, and bed cover everyday.

6. Fold the diaper below the umbilical cord to

prevent it from being wet.

REHABILATIVE
1. Educate the mother on performing proper

32
 cord care

2. Instruct the mother to wash hands before

doing cord care to prevent transmission of
microorganisms.

33
 NURSING CARE PLAN
Nursing Diagnosis # 5 : Risk for Hypothermia related to immature thermoregulating
mechanism.
Goal: To maintain body temperature within normal range.
Expected Outcome: After 8 hours of nursing intervention the client will:
• Temperature within normal range (36.5-37.5)
• (-) cyanosis
• Skin warm to touch

INTERVENTIONS RESPONSE

PREVENTIVE:
1. Determine if present condition results
from exposure to environmental factors,
surgery, infection, physiologic and
trauma.
Rationale: Helps to determine the scope of
interventions that maybe needed.
2. Note client’s age.
1. The condition was determined. The
resulting factors are environmental and
physiologic.
2. Client’s age is noted. The baby is 6 days
old.
3. The temperature was assessed.
T: 36.1 Cͦ at 0800H (December 3, 2010)
ͦ at 1200H (December 3, 2010)
T: 35.9 C

4. Jaundiced skin color

Rationale: It can directly impact ability to
maintain/regulate body temperature and respond 5. Good suck noted
to environmental changes.

3. Assess temperature with low register

thermometer.

PROMOTIVE:
4. Cover infant’s head with knit cap, place
under adequate blankets.

Rationale: Heat loss in newborn is greatest

through head and by evaporation and convection.

5. Let the baby wear mittens, bonnet, and

booties.
Rationale: Heat loss in newborns is greatest
through head and by evaporation and convection.

34
 6. Swaddle the baby

7. When using instrument such as

stethoscope, warm it first.

8. Warm your hands before touching the

baby.

9. Observe signs of cyanosis

10. Encourage mother to breastfeed the baby

Rationale: Breastfeeding encourage transmission
of heat from mother to the baby and increases
metabolism which produces heat.

35
 CHAPTER IV

Case Analysis and Interpretation

NDx#1: Risk for ineffective airway clearance related to presence of oropharyngeal

secretions.

NANDA Definition: Inability to clear secretions or obstructions from the respiratory

tract to maintain airway patency. Maintaining a patent airway is vital to life. Coughing is the

main mechanism for clearing the airway. However, the cough may be ineffective in both normal

and disease states secondary to factors such as pain from surgical incisions/ trauma, respiratory

muscle fatigue, or neuromuscular weakness. Other mechanisms that exist in the lower

bronchioles and alveoli to maintain the airway include the mucociliary system, macrophages, and

the lymphatic. Factors such as anesthesia and dehydration can affect function of the mucociliary

system. Likewise, conditions that cause increased production of secretions (e.g., pneumonia,

bronchitis, and chemical irritants) can overtax these mechanisms. Ineffective airway clearance

can be an acute (e.g., postoperative recovery) or chronic (e.g., from cerebrovascular accident

[CVA] or spinal cord injury) problem. Elderly patients, who have an increased incidence of

emphysema and a higher prevalence of chronic cough or sputum production, are at high risk.

Cues that supported this diagnosis are the following: Initial vital signs: HR = 149bpm;

Temperature = 36.5 ͦC; RR = 44cpm; BP = 69/28 mmHg, Monitoring of the RR (December 3,

2010) 0800H =44 cpm, 1200H = 48 cpm, six days old, good and loud cry, good skin turgor with

jaundice, good perfusion, good body movement, breath sounds clear, heart sounds clear and

regular, no dyspnea, APGAR = 9,10 Suctioning done, presence of moderate clear whitish

secretions, delivered via elective caesarean section, gastric lavage done, weight = 3374 grams,
36
chest circumference = 34 cm, AOG = 38 4/7 weeks by LMP; 38 weeks by MI, good rooting,

sucking, and gag reflex.

The formulated goal in the plan of care was to maintain airway clearance. The following

interventions were done to achieve the said goal: Maintain daily cord care, Monitor Vital signs,

Assess for characteristic of breath sounds, Note for presence of secretions, Keep infant’s mouth

and nose clear from any obstruction, Provide oxygen when needed as ordered by the doctor,

Perform suctioning when needed.

The following evaluations were achieved through the help of the said interventions. Vital

signs were taken. (December 3, 2010) T- 36.5 ºC; RR- 44 breaths/min ; HR- 149beats/min; BP

- 69/28 mmHg, clear breath sounds; no crackles, no wheezes, rales, no chest retractions,

moderate, clear whitish secretions noted, oral secretions have been lessened and/or diminished

and with no form of foreign body in the oral opening, oxygen will be provided when needed, the

newborn was suctioned, moderate, clear whitish secretions was seen.

37
Nursing Diagnosis # 2: Risk for aspiration related to immature cardiac sphincter.

Risk for aspiration is defined as at risk for entry of gastrointestinal secretions,

oropharyngeal sections, or solids or fluids into tracheobronchial passages. (Doenges et al., 2008)

Relatively immaturity of their body systems, newborns require a great deal of physical

care. Promotion of parental attachment and assimilation of the infant into the family are also of

vital importance. (Handbook of Neonatal Intensive Care, 6th edition. Gardner, 2006)

A term newborn who is to be breastfed may be fed immediately after birth. It is

universally agreed upon that breast milk is the preferred method of feeding a newborn, because it

provides numerous health benefits to both a mother and an infant, it remains the ideal nutritional

source for infants through the first year of life. Colostrum a thin, watery, yellow fluid composed

of protein, sugar, fat, water, minerals, vitamins, and maternal antibodies. For the first 3 or 4 days

after birth, colostrums production continues. Because of its high in protein and fairly low in

sugar and fat, colostrum is easy to digest and capable of providing adequate nutrition for a

newborn. Breastfeeding should always be recommended unless the babies are too weak to suck

as in the preterm and other high risk infants in which case mother’s milk may be given by

dropper or gavage. There is no need for daily weighing especially of healthy term infants. The

nurse evaluates the infant’s ability to suck, swallow and breathe in a coordinate manner. Some

newborns choke or gag during the first feeding, others may become dusky or cyanotic because

they become apneic while they are feeding. (Foundations of Maternal-Newborn Nursing, 4th

Edition. Murray and Mc Kinnly, 2006)

38
 Although a newborn’s stomach holds about 60 to 90 mL, a newborn has limited ability to

digest fat and starch because the pancreatic enzymes, lipase and amylase remains deficient for

the first few months of life. A newborn regurgitates easily because of an immature cardiac

sphincter between the stomach and esophagus (Pillitteri. 2007)

Cues that supported this diagnosis are the following: Initial vital signs of heart rate of 149

beats per minute; temperature of 36.5 degrees Celsius; respiratory rate of 44 cycles per minute;

blood pressure of 69 over 28 mmHg; monitoring of respiratory rate December 3, 2010 0800H

respiratory rate is 44 cycles per minute and at 1200H respiratory rate is 48 cycles per minute;

newborn is six days old; good and loud cry; Good perfusion; good skin turgorm good body

movement, normal clear breath sounds, heart sounds clear and regular, no dyspnea, gastric

lavage done, suctioning done, with the apgar score of 9 in the 1st minute and 10 in the 5th minute,

presence of moderate clear whitish secretions, delivered via elective cesaerian, fed via

breastfeeding and cup feeding (glucose water every 2 hours), good suck, cuddled by mother

while breastfeeding, no regurgitation seen, and was burped every after feeding.

The formulated goal in the plan of care was to prevent aspiration of the newborn. The

following interventions were done to achieve the said goal; Assess infant’s breathing and feeding

pattern, Monitor vital signs, especially respiratory rate, every 4 hours. Report any deviations.

Check the mouth and nose for any secretions, To maintain airway clearance, Auscultate lungs for

irregular breath sounds, Slowly feed the infant. Assess infant’s skin color and activity, Burp the

infant between feedings. Position infant in a semi-fowler’s position. If regurgitation is present

put the infant in a vertical position and tap the back (for burping).

39
 The following evaluations was achieved through the help of the said interventions; The

baby showed no signs of difficulty in breathing, with a RR of 44 breaths/min. The baby

displayed no signs of choking or gagging while being fed. Vital signs were taken. T- 36.5 ºC,

RR- 44breaths/min , HR- 149 beats/min, BP – 69/28 mmHg . The baby showed no difficulty in

breathing, had clear breath.. the baby’s lungs was checked and showed no signs of difficulty in

breathing. The baby has clear breath sounds. The baby consumed feeding without choking. (-)

cyanosis; good skin turgor with jaundice. (+) burp . The baby consumed feeding with ease and

did not show signs of choking or aspiration. No regurgitation experienced.

40
Nursing Diagnosis # 3: Risk for injury related to properties of phototherapy and effects on

body regulatory mechanism

The nursing management of the newborn are require astute observation for jaundice and

careful review of possible risk factor for hyperbilirubinemia. The nurse should collaborate with

the other health team members to identify who may require follow up early discharge and

educate the parents about jaundice and normal time frame for its resolution. Monitor the weight

of the client, its skin turgor and the age of the baby as much as possible especially the vital signs

of the baby (Orshan, S., 2010). Orshan, S.A. (2010). Maternity, newborn, and women’s health

nursing: comprehensive care. Flourida: USA. Page 963

Various techniques have been used to manage neonates with indirect hyperbilirubinemia.

Strategies have included prevention, use of pharmacologic agents, exchange transfusion and

phototherapy. Prevention has focused on early initiation of feedings and frequent breastfeeding

to decrease enterohepatic shunting, promote establishment of normal bacterial flora, and

stimulate intestinal activity. Specific pharmacologic agents have been used to prevent

hyperbilirubinemia or reduce bilirubin levels.

Pharmacologic agents have been used in the management of hyperbilirubinemia to

stimulate the induction of hepatic enzymes and carrier proteins, to interfere with heme enzymes

and carrier proteins, to interfere with degradation, or to bind bilirubin in the intestines to

decrease enterohepatic reabsorption. Jackson C. et.al (2007). Maternal, fetal, neonatal

physiology. United Staes of America: Elsevier Inc.

41
 The management of hyperbilirubinemia will depend to some extent on the cause, but

ultimately on the level of bilirubin and the condition of the neonate. If the neonate is less than 38

weeks’ gestation, or has hemolysis or other medical problems, the bilirubin level for initiating

phototherapy may be somewhat lower than if the neonate is full-term, healthy, and does not have

any type of haemolytic disease. Very high or rapidly rising bilirubin levels may need to be

controlled with and exchange transfusion, in which case feedings would be temporarily

interrupted for the procedure. Neonates who are treated only with phototherapy should continue

to be breastfed or receive other milk feedings since good caloric intake improves the

effectiveness of phototherapy. Lowdermilk, D. et.al, (2006). Maternity nursing 7th edition.

Missouri: Mosby, Inc.

Cues that supported this diagnosis are as follows. Initial vital signs: HR = 149bpm;

ͦ RR = 44cpm; BP = 69/28 mmHg. Monitoring of the RR December 3,

Temperature = 36.5 C;

2010. 0800H =44 cpm, 125 bpm, 36.1 ͦC 1200H = 48 cpm, 147 bpm, 35.9 ͦC, Good and loud

cry, Good skin turgor with jaundice, Good activity, Good prefusion, Good body movement, Six

days old, Placed in a double phototherapy using bilibed. Laboratory results: Total Bilirubin =

16.74 mg/dl. Direct bilirubin = 0.72 mg/dl. Indirect bilirubin = 16.02 mg/dl. Delivered via

elective caesarean section. AOG = 38 4/7 weeks by LMP; 38 weeks by MI. Good rooting,

sucking, and gag reflex.

The main goal is to protect infant from injury: the following interventions were done to

fully meet the main goal, Note the infant’s age. Monitor vital signs. Assist with phototherapy

treatment. Have the infant completely undressed. Keep the eyes and genitals covered. Develop

a systemic schedule of turning the infant. The following interventions were evaluated and the

42
evaluations were Client’s age is noted. The baby is 6 days old. The patient’s color is normal

(Pink)

43
NDx#4: Risk for infection related to inadequate secondary defenses.

NANDA Definition: At increased risk for being invaded by pathogenic organisms

Persons at risk for infection are those whose natural defense mechanisms are inadequate to

protect them from the inevitable injuries and exposures that occur throughout the course of

living. Infections occur when an organism (e.g., bacterium, virus, fungus, or other parasite)

invades a susceptible host. Breaks in the integument, the body’s first line of defense, and/or the

mucous membranes allow invasion by pathogens. If the host’s (patient’s) immune system cannot

combat the invading organism adequately, an infection occurs. Open wounds, traumatic or

surgical, can be sites for infection; soft tissues (cells, fat, muscle) and organs (kidneys, lungs)

can also be sites for infection either after trauma, invasive procedures, or by invasion of

pathogens carried through the bloodstream or lymphatic system. Infections can be transmitted,

either by contact or through airborne transmission, sexual contact, or sharing of intravenous (IV)

drug paraphernalia. Being malnourished, having inadequate resources for sanitary living

conditions, and lacking knowledge about disease transmission place individuals at risk for

infection.

Cues that supported this diagnosis are the following: Initial vital signs: HR = 149bpm;

ͦ RR = 44cpm; BP = 69/28 mmHg, Monitoring of the vital signs:

Temperature = 36.5 C;

(December 3, 2010) 0800H =44 cpm, 125 bpm, 36.1 ͦC 1200H = 48 cpm, 147 bpm, 35.9 C,
ͦ Six

days old, Good and loud cry, Good skin turgor with jaundice, Good perfusion, Good body

movement, Breath sounds clear,Heart sounds clear and regular, No dyspnea, APGAR = 9,10,

Newborn care was done like sponge bath and cord dressing, (+) cord stamp, dry, Given vitamin

K (phytomedionekanakion ample 10mg/ml) 0.1ml of 10mg/ml ampule at right anterolateral thigh

44
( intramuscular), Given Hepa B vaccine 0.05 ml intramuscularly on the anterolateral thigh, Given

BCG at the right buttocks (intradermal) Blood typing done, Newborn Screening done, Placed in

a double phototherapy using bilibed, Fractionated bilirubin done, Suctioning done, Presence of

moderate clear whitish secretions, Delivered via elective caesarean section, Gastric lavage done,

Fed via breastfeeding and cupfeeding (glucose water, every 2 hours), Elimination = 1 stool, 1

urine (December 3, 2010), AOG = 38 4/7 weeks by LMP; 38 weeks by MI, Good rooting,

sucking, and gag reflex.

The formulated goal in the plan of care was to prevent aspiration of the newborn. The

following interventions were done to achieve the said goal: Maintain daily cord care, Monitor

Vital signs especially the temperature, Provide care to the newborn,Monitor the area at the base

of the umbilical cord for any swelling or redness, Use prescribed solution when doing cord care

(70% ethyl alcohol or povidone iodine), Apply proper strokes when doing cord care, Stress

proper hygiene before doing cord care (Hand washing), Change clothes, mittens, bonnet, booties,

blanket, and bed cover everyday, Fold the diaper below the umbilical cord to prevent it from

being wet, Educate the mother on performing proper cord care, Instruct the mother to wash

hands before doing cord care to prevent transmission of microorganisms.

The following evaluations was achieved through the help of the said interventions: Cord care

ͦ
was monitored, (December 3, 2010) 0800H =44 cpm, 125 bpm, 36.1 C,1200H = 48 cpm, 147

ͦ Applied hand washing before giving the cord care, The umbilical cord was kept
bpm, 35.9 C,

dry, Mother agreed to wash hands and clean her baby’s cord using alcohol and cotton.

45
NDx#5:Risk for Hypothermia related to immature thermoregulating mechanism.

Hypothermia in newborn: Newborn baby is a homoeothermic, but his ability to stay

warm may easily be overwhelmed by extremes of environmental temperatures. Neonatal

hypothermia often due to lack of attention by health care providers continues to be a very

important cause of neonatal deaths.

A newborn is more prone to develop hypothermia because of large surface area per unit of

body weight. A low birth weight baby has decreased thermal insulation due to less subcutaneous

fat and reduced amount of brown fat. Brown fat is the site of heat production. It is localized

around the adrenal glands, kidneys, nape of neck; inter scapular area and axillary region.

Metabolism of brown fat results in heat production. Blood flowing through the brown fat

becomes warm and through circulation transfers heat to other parts of the body. This mechanism

of heat production is called non-shivering thermogenesis. Thermal balance: Newborn loses heat

by evaporation particularly soon after birth (due to evaporation of amniotic fluid from skin

surface), conduction (by coming in contact with cold objects-cloth, tray etc.), convection (by air

currents in which cold air replaces warm air around baby-open windows, fans) and radiation (to

colder solid objects in vicinity-walls). The process of heat gain is by conduction, convection and

radiation in addition to non-shivering thermogenesis.

(http://medical-dictionary.thefreedictionary.com/neonatal+hypothermia)

46
 Cues that supported this diagnosis are the following: Initial vital signs: HR = 149bpm;

ͦ RR = 44cpm; BP = 69/28 mmHg, Monitoring of the vital signs:

Temperature = 36.5 C;

(December 3, 2010)0800H =44 cpm, 125 bpm, 36.1 ͦC, 1200H = 48 cpm, 147 bpm, 35.9 ͦC, Good

and loud cry, Good skin turgor with jaundice, Good body movement, Good perfusion, Breath

sounds clear, Heart sounds clear and regular, No dyspnea,APGAR = 9,10, Six days old,

Delivered elective caesarean section, Environmental temperature: 28 ͦC, cold environment,

Routine newborn care was done like sponge bath and cord dressing, AOG = 38 4/7 weeks by

LMP; 38 weeks by MI, Good rooting, sucking, and gag reflex

The formulated goal in the plan of care was to prevent hypothermia of the newborn. The

following interventions were done to achieve the said goal: Determine if present condition

results from exposure to environmental factors, surgery, infection, physiologic and trauma, Note

client’s age, Assess temperature with low register thermometer, Cover infant’s head with knit

cap, place under adequate blankets, Let the baby wear mittens, bonnet, and booties, Swaddle the

baby, When using instrument such as stethoscope, warm it first, Warm your hands before

touching the baby, Observe signs of cyanosis, Encourage mother to breastfeed the baby.

The following evaluations was achieved through the help of the said interventions: The

condition was determined, the resulting factors are environmental and physiologic, client’s age is

noted, the baby is 6 days old, the temperature was assessed. T: 36.1 ͦC at 0800H (December 3,

ͦ at 1200H (December 3, 2010), jaundiced skin color, good suck noted.

2010) T: 35.9 C

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 CHAPTER V

SUMMARY OF FINDINGS, CONCLUSION AND RECOMMENDATION

I. Factors that led to the development of the problem

• Transition to extra uterine living

• Age

• Birthing history

• Apgar Score

• Environment

• Maternal History

II. Interrelationship of the factors that led to the development of the problem

The identified factor that may lead to the development of a problem of a well

newborn is the transition to extra uterine living. It reveals that the newborn is at her

second day of life. Transitions by nature are challenging, but this is never truer than it is

for transition from intrauterine to extra uterine life. In fact, the essence of life depends on

this successful transition. Successful transition requires the initiation of spontaneous

breathing; significant cardiopulmonary changes, including the shift from fetal to postnatal

circulation; and a variety of other important adaptations, including but not limited to,

thermoregulatory and metabolic adjustments. With minutes of being exposed to the

environment, the newborn is observed and rated to an Apgar score, a newborn total score

is under 4 is in serious danger and needs resuscitation.

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III. Significant Interventions Rendered

Nursing Diagnosis #1 : Risk for ineffective airway clearance related to presence of

oropharyngeal secretions.

• Monitor vital signs.

• Assess for characteristic of breath sounds.

• Note for presence of secretions.

• Keep infant’s mouth and nose clear from any obstruction.

• Provide oxygen when needed as ordered by the doctor

• Perform suctioning when needed.

Nursing Diagnosis # 2: Risk for aspiration related to immature cardiac esophageal sphincter.

• Assess infant’s breathing and feeding pattern

• Monitor vital signs, especially respiratory rate, every 4 hours. Report any deviations.

• Check the mouth and nose for any secretions

• Auscultate lungs for irregular breath sounds

• Slowly feed the infant.

• Assess infant’s skin color and activity

• Burp the infant between feedings.

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 • Position infant in a semi-fowler’s position.

• If regurgitation is present put the infant in a vertical position and tap the back (for

burping).

Nursing Diagnosis # 3 : Risk for injury related to properties of phototherapy and effects on
body regulatory mechanism

• Turn the baby every two hours to avoid burning

• Cover the eyes and genitals

• Always watch the baby

• Always check the baby’s condition

Nursing Diagnosis # 4: Risk for infection R/T inadequate secondary defenses

• Maintain daily cord care.

• Provide care to the newborn.

• Monitor the area at the base of the umbilical cord for any swelling or redness.

• Use prescribed solution when doing cord care (70% ethyl alcohol or povidone iodine).

• Apply proper strokes when doing cord care.

• Stress proper hygiene before doing cord care (Hand washing).

• Change clothes, mittens, bonnet, booties, blanket, and bed cover every day.

Nursing Diagnosis # 5: Risk for Hypothermia related to immature thermoregulating mechanism.

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• Keep the baby warm and dry

• Monitor the vital signs especially the temperature

• Determine if present condition results from exposure to environmental factors, surgery,

infection, physiologic and trauma.

• Note client’s age.

• Assess temperature with low register thermometer.

• Cover infant’s head with knit cap, place under adequate blankets.

• Let the baby wear mittens, bonnet, and booties.

• Swaddle the baby

• When using instrument such as stethoscope, warm it first.

• Warm your hands before touching the baby.

• Dress the newborn with mittens, gloves and bonnet

• Place the neonate in a radiant warmer

IV. Effectiveness of the responses

• The patient did not manifest signs of aspiration

• The patient did not manifest hypothermia

• There are no signs of infection noted

• The patient did not manifest signs of ineffective airway

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Conclusion and Recommendation

Based from the summary of findings, the researchers concluded that the factors that led to

the development of the problem were age, sexual activity, environment, and her sedentary

lifestyle.

The researchers would like to recommend the following:

For the patient:

• To verbalize her concerns about the noticeable discomfort within her body system.

• To change her lifestyle in order to avoid related conditions from precipitating.

For the family members:

• To give more attention and improve their sensitivity towards the health conditions of the

client.

• To provide necessary information regarding the condition of the patient or other family

members having the same case.

• To give enough time to give the best care for the client and be considerate enough in

meeting the client’s needs.

• To participate in the rehabilitation of the patient in continuing to care for the development

of the patient.

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For the student nurses:

• To become aware of the difficulties that they may encounter in making the said case such

as limited interaction time with the patient and the patient’s compliance to nursing

activities and gathering of data.

• So that they will work hard and hand-in-hand with other members of the health care

team.

• This will also be a basis of their experience in clinical duty in using their skills and

knowledge on the matter.

For the clinical instructors:

• To aid them in evaluating the student’s learning in the said case.

• For them to be able to assist their students in rendering the appropriate intervention in

meeting the needs of the patient.

For the health care team:

• They should render more quality safe nursing care to the patient and further enhance the

patient and significant other’s knowledge regarding his present condition through proper

health education.

• They must also inform every health care team as soon as possible when there is any

significant finding on the condition of the patient.

• To incorporate health teaching and enhance patient’s awareness on the disease processes.

• For the health care team provider to have holistic approach to client as a person.

For the future researchers:

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• That they utilize this research as a baseline data for the enhancement of quality and safe

nursing care they may provide to their patient. In addition, a similar research study should

me more comprehensive and analysis.

• The findings in this study will also supplement any similar research that could aid for the

better understanding of the case.

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