Group 6 BSN II Monna Patricio Maribeth Cerillo Annalou Laurel Marilou Jalla Nonelyn Hernandez Richard Paul Gonzales

s Butch Ogerio

General Objectives
After establishing the nurse patient interaction and providing care to the client and by a thorough assessment and careful study of the clients condition. Students will gain knowledge and develop skills enhance attitude through the utilization of the nursing process on the care management of patient with Hyperbilirubinemia disorder.

Specific Objectives
To define what is Hyperbilirubinemia disorder. Present a theoretical framework for the study in relation to a nursing approach applied to a patient with hyperbilirubinemia disorder. To know the nursing history, personal data, health history and physical and functional assessment. To present the anatomy and physiology To expound the normal physiology and pathophysiology of the case To present the laboratory examinations carried out duty for the client, including its findings.. To discuss the pharmacological management of the disease. To lay at hand the nursing care plan and the bounds to which the end are accomplished. To evaluate the quality of nursing care rendered to the patient To enhance the knowledge and skills in the delivery of the nursing process Show a Discharge Planning that the client may use upon discharge to the hospital.

I. Introduction

Background of the study

High levels of serum bilirubin in the neonatal period have long been associated with the development of kernicterus, a rare condition characterized by hypertonicity, poor feeding, and high-pitched cry. Kernicterus was a frequent complication of hyperbilirubinemia caused by Rh incompatibility, a condition that also led to severe hemolytic anemia, and, in some cases, fetal demise due to hydrops fetalis. Over the past decades, improved obstetric and neonatal care has reduced the incidence of high bilirubin levels and kernicterus. Hydrops fetalis and severe hemolytic anemia caused by maternal-fetal Rh incompatibility have been dramatically reduced by the use of RhoGam. Post-natal phototherapy has further reduced the incidence of hyperbilirubinemia.

Rationale for choosing the Case

We have chosen this case to gain more information about the occurrence of such illness, its causative factors, and preventive actions and how to care for a patient with such condition.

Significance of the Study

The significance of this study is to enhance/gain knowledge, to develop skills and to apply the right attitudes of the student nurses in rendering and giving care to the patient with hyperbilirubinemia, its importance and implication. This study will serve as guidelines in assessing and providing proper nursing care to patient with the same problem or disease.

These are other significance of the study that would support the above statement:
To define and understand what is hyperbilirubinemia disorder. To know the nursing history, personal data, health history and physical and functional assessment of the patient To expound the anatomy and physiology and pathophysiology of the case To present the laboratory examinations carried out duty for the client, including its findings. To discuss the pharmacological management of the disease. To lay at hand the nursing care plan and the bounds to which the end are accomplished. To enhance the knowledge and skills in the delivery of the nursing process Show a Discharge Planning that the client may use upon discharge to the hospital.

Scope of Limitation
The study will only focus on hyperbilirubinemia which is indicative to the clients health condition and its underlying nursing care relevant for the client within the three weeks duty at Quezon Medical Center

What is hyperbilirubinemia?
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. This is called hyperbilirubinemia. Because bilirubin has a pigment or coloring, it causes a yellowing of the baby's skin and tissues. This is called jaundice. Depending on the cause of the hyperbilirubinemia, jaundice may appear at birth or at any time afterward.

Risk Factors:
1. Race- Asian,

Native Americans, Mediterranean 2. Complications during pregnancy 3. Non-optimal Breast feeding 4. Birth Trauma, bruising, and cephalahematomas 5. Infections and sepsis 6. Prematurity 7. Genetic factors such as G6PD deficiency and a family history of sibling who was jaundiced as a neonate 8. Drug exposure 9. Blood type incompatibility

What are the symptoms?

Yellow eyes Yellow skin Anemia Enlarged spleen Tiredness Fatigue Dark urine

What Causes?
During pregnancy, the placenta excretes bilirubin. When the baby is born, the baby's liver must take over this function. There are several causes of hyperbilirubinemia and jaundice, including the following: Physiologic jaundice Physiologic jaundice occurs as a "normal" response to the baby's limited ability to excrete bilirubin in the first days of life. Breast milk jaundice About 2 percent of breastfed babies develop jaundice after after the first three to five days. It peaks about two weeks of age and can persist up to three to 12 weeks. Breast milk jaundice is thought to be caused by a maternal factor in the breast milk that increases the reabsorption of bilirubin through the intestinal tract. The process is called enterohepatic circulation.

Breastfeeding failure jaundice It is caused by failure to initiate breastfeeding, resulting in dehydration, decrease urine production and accumulation of bilirubin. Late preterm infants, those who are born between 34 weeks and 36 weeks, are more susceptible to this problem. They do not have the coordination and the strength to maintain a successful breastfeeding. Jaundice from hemolysis Jaundice may occur with the breakdown of red blood cells due to hemolytic disease of the newborn (Rh disease), having too many red blood cells, or bleeding. Jaundice related to inadequate liver function Jaundice may be related to inadequate liver function due to infection or other factors

Diagnostic Procedures:
Direct and indirect bilirubin levels These reflect whether the bilirubin is bound with other substances by the liver so that it can be excreted (direct), or is circulating in the blood circulation (indirect). Red blood cell counts Blood type and testing for Rh incompatibility (Coomb's test)

Treatment
Specific treatment for hyperbilirubinemia will be determined by your baby's physician based on:
Your baby's gestational age, overall health, and medical history Extent of the disease Your baby's tolerance for specific medications, procedures, or therapies Expectations for the course of the disease Your opinion or preference

Treatment depends on many factors, including the cause of the hyperbilirubinemia and the level of bilirubin. The goal is to keep the level of bilirubin from increasing to dangerous levels. Treatment may include: Phototherapy Since bilirubin absorbs light, jaundice and increased bilirubin levels usually decrease when the baby is exposed to special blue spectrum lights. Phototherapy may take several hours to begin working and it is used throughout the day and night. The baby's position is changed to allow all of the skin to be exposed to the light. The baby's eyes must be protected and the temperature monitored during phototherapy. Blood levels of bilirubin are checked to monitor if the phototherapy is working. Fiberoptic blanket Another form of phototherapy is a fiberoptic blanket placed under the baby. This may be used alone or in combination with regular phototherapy.

Exchange transfusion to replace the baby's damaged blood with fresh blood Exchange transfusion helps increase the red blood cell count and lower the levels of bilirubin. An exchange transfusion is done by alternating giving and withdrawing blood in small amounts through a vein or artery. Exchange transfusions may need to be repeated if the bilirubin levels remain high. Adequate hydration with breastfeeding or pumped breast milk The American Academy of Pediatrics recommends that, if possible, breastfeeding be continued. Breastfed babies receiving phototherapy who are dehydrated or have excessive weight loss can have supplementation with expressed breast milk or formula. Treating any underlying cause of hyperbilirubinemia, such as infection

Prevention
a. Increase oral intake, breast feeding instructions and support b. Early diagnosisi. Detect hemolysis by measuring Carbon Monoxide exhaled ii. Arrange follow-up after early discharge to check neonate c. Synthetic metalloporphyrins may inhibit production of bilirubin (not approved for use) 2. Phototherapy 3. Exchange Transfusion

II. Cilinical Summary

General Data Profile

Name: Ptient X Age: 0 Sex: Female Civil Status: Infant Nationality: Filipino Religion: Catholic Birthday: February 18, 2011 Birthplace: Lucena city Address: Ipil II Lucena city, Quezon Province Chief Complaint: Yellowish discolorisation Diagnosis: Hyperbilirubinemia

PSYCHOCIAL THEORY ACCORDING TO ERIK ERIKSON

STAGE AGE CENTRAL TASK INDICATORS OF POSITIVE RESOLUTION INDICATORS OF NEGATIVE RESOLUTION
Strangers

Infant

0 18 month s

Trust vs. Mistrust Satisfying needs on infant on time Care must be consistent and adequate. Give experiences that will add security

According to this theory, middle adulthood focuses on care and security of an infant.

General Assessment
Parameters General Appearance Skin Hair Nails Normal Findings Actual Findings

Skull & Face Eyes

Ears Mouth Muscoloskeletal (Upper & Lower Extrimities) Abdomen

Laboratory Diagnostic Procedure

COMPLETE BLOOD COUNT Hemoglobin 180 (F) 120 160 g/l (M) 140 180 g/l Hematocrit 0.54 (F) 0.36 0.47 (M) 0.40 0.54 RBC 5.8 (F) 4.0 5.2 (M) 4.5 5.8 10 ^ 12 / l WBC 12.6 5.0 10.0 10 ^ g/l Platelet 150 500 10 ^ g/l MCV 80 - 94 Fl ( 80 -94 u ^ 3 MCH 1.67 1.92 (27 31 uug MCHC 33% 19.22 22.3 mmol/l (31 36 %) Reticolocyte count Coagulation 5 12 min (L & W) time 2 5 min (cap) BT 1 3 (duke) ESR (F) 0 -20 mm/hr (M) 0 20 mm/hr Blood Group Type/RH Neutrophils Juvenile Stab Segmenters Lymphocytes Monocytes Eusinophils Basophils Prothrombin time Patient Control Activity INR APTT Patient Control Ratio SCHILLING DIFFERENTIAL COUNT 0.50 0.70 0.0 0.05 0.03 0.05 0 . 55 0. 32 0.10 0.03 0. 50 0..56 0.20 0.40 0.02 0.08 0.01 0.04

sec Sec 70 100 % times normal

sec Sec

TESTS

SI UNITS

CONVENTIONAL

Bilirubin, total Direct Indirect Protein, total Albumin Globulin A/G Ratio Sodium Potassium Chloride Magnesium Amylase Calcium LDH

17.1 2.9 14.2

0 -1.0 mg/dl 0 0.5mg/dl 0 0.5 mg/dl 60 80 g/l 35 55g/l 23 35g/l 13.5 14.8 mmol/L 3.5 5.3 mmol/L 98 107 mmol/L 1.3 2.5mLq/L 0 86 u/L 8.5 10.5 mg/dl (M) 80 285 (F) 103 227 IU/L 10 150 u/L 25 192 u/L 0 24.0 IU/L 2.7 4.5 mg/dl (M) 97.0 157.6 (F)103.2 149.5 mg/L

17.1 2.9 14.2

0 1.0mg/dl 0 0.5 mg/dl 0 0.5mg/dl 6.0-8-0g/dl 3.5-5.5g/dl 2.3-3.5g/dl 1.1-2.2:1 135-148mmol/L 3.5-5.3mmol/L 98-107mmol/L 1.3-2.5mEgL 0.864/L 8.5-10.5mg/dL (M)80-285u/L(F)103227u/L 10 150u/L 25 192u/L 0 24.0 IU/L 2.7 4.5 mg/dl (M) 970 1576 (F) 1032 1495 mg/L

Lipase cPK CK MB Phosphorus C3

TESTS Bilirubin, total Direct Indirect Protein, total Albumin Globulin A/G Ratio Sodium Potassium Chloride Magnesium Amylase Calcium LDH

18. 0 3.0 15.0

SI UNITS 0 -1.0 mg/dl 0 0.5mg/dl 0 0.5 mg/dl 60 80 g/l 35 55g/l 23 35g/l 13.5 14.8 mmol/L 3.5 5.3 mmol/L 98 107 mmol/L 1.3 2.5mLq/L 0 86 u/L 8.5 10.5 mg/dl (M) 80 285 (F) 103 227 IU/L 10 150 u/L 25 192 u/L 0 24.0 IU/L 2.7 4.5 mg/dl (M) 97.0 157.6 (F)103.2 149.5 mg/L

18.0 3.0 15.0

CONVENTIONAL 0 1.0mg/dl 0 0.5 mg/dl 0 0.5mg/dl 6.0-8-0g/dl 3.5-5.5g/dl 2.3-3.5g/dl 1.1-2.2:1 135-148mmol/L 3.5-5.3mmol/L 98-107mmol/L 1.3-2.5mEgL 0.864/L 8.5-10.5mg/dL (M)80-285u/L(F)103227u/L 10 150u/L 25 192u/L 0 24.0 IU/L 2.7 4.5 mg/dl (M) 970 1576 (F) 1032 1495 mg/L

Lipase cPK CK MB Phosphorus C3

Anatomy and Physiology

Anatomy of the Liver

Function
Bile production and excretion Excretion of bilirubin, cholesterol, hormones and drugs. Metabolism of fats, proteins and carbohydrates. Enzyme activation. Synthesis of plasma proteins, such as albumin and globulin, and clotting factors. Blood detoxification and purification.

Anatomy of the Kidney

Function
Removing wastes and water from the blood. Balancing chemicals in your body. Releasing hormones. Helping control blood pressure. Helping to produce red blood cells. Producing vitamin D, which keeps the bones strong and healthy.

Drug

Action

Indication

Contraindicati on Allergies to penicillins, Cephalosporins. Renal disorders

Adverse effect
CNS: Lethargy, hallucinations ,seizures CV: Heart failure GI: Glossitis, stomatitis, gastritis, sore mouth, furry tongue, nausea, vomiting, diarrhea, abdominal pain GU: Nephritis.

Nsg. Considerations

Ampicill Bacterecida Treatment in l action of infections against caused by sensitive susceptible organisms; strains of inhibits Shigella, synthesis of Salmonella, bacterial cell S. Typhosa, wall, causing E. COLI, cell death. Haemophilus influenza, Proteus mirabilis, Gram positive organisims. Meningitis.

History: Allergies to penicillin, cephalosporins, or renal disorders. Physical: Culture infected area, assess skin color, adventitious sounds and bowel sounds. Check IV site carefully for signs and symptoms of thrombosis or drug reaction.

Discharge Plan

Medication
Name of drugs Time

Ampicillin 85mg IVP

8am 4pm

Environment
Therapeutic environment, that was free of pollution, stress and conducive to relaxation have an adequate rest and sleep. Properly ventilated environment. Non-stimulating environment. Non crowded environment.

Treatment
Adherence to proper treatment regimen by following medication instructions and consulting a health care provider when needed.

Health Teachings
Keeping the back dry. Proper hygiene. Clean environment. Newborn screening. Complete immunization. Proper cord care. Proper hand washing. Importance of changing of diaper to prevent from rash. Instructed proper perineal care. OPD Check-up
Follow up check up after 7 days at QMC OPD @ 8AM with Laboratory result of repeat CBC and TB B1 and B2.

Diet Breast feeding with SAP

Thank you!!!