1

CHAPTER 1
PRELIMINARY

1.1. Background

Neonatal icterus is a common problem encountered in the treatment of normal

newborns, particularly in Asia, namely the appearance of yellow skin and sclera because
of the occurrence of hyperbilirubinemia to infants aged 72-120 hours and will return to
normal after 7-10 days (Nursanti, 2011). Icterus in newborns in the first week occurred in
60% of term infants and 80% of preterm infants. This is a physiological condition. Even
so, most infants will develop severe icterus that need to check and correct governance in
preventing morbidity and mortality. (Suradi & Letupeirissa, 2013).

In the United States, as many as 65% of newborns suffering from icterus in birthst
week. In Malaysia, a survey in 1998 in government hospitals and health centers under the
Ministry of Health to get 75% of newborns suffering from icterus in the first week of
life. In Indonesia, the incidence of neonatal icterus in term infants in some education
among others RSCM Hospital, Hospital Dr. Sardjito, RS Dr. Soetomo, RS Dr. Kariadi
varied from 13.7% to 85%. (MOH, 2004).

Icterus is a yellow color that appears on the skin and mucous membranes due to
increased bilirubin. Usually begin to appear in the serum bilirubin levels> 5 mg / dL.
Icterus usually physiological, but in some cases it can cause problems; The most feared is
the bilirubin encephalopathy. Babies who have bilirubin encephalopathy / kernicterus
will experience the growth and development disorders such as mental retardation,
cerebral palsy and hearing loss (MOH, 2004). This situation can be prevented, include:
1) promotion and support of breastfeeding with adePuate intake; 2) Perform a systematic
assessment bilirubin levels; 3) follow-lowering kadarbilirubin with phototherapy or
exchange transfusion; and 4) the National Institutes of Health is developing a drug
research to meghambat production of bilirubin (Nursanti, 2011).

Optimal breastfeeding management is the act of breastfeeding infants appropriate,

include: 1) early initiation of breastfeeding in the first hour; 2) management of
breastfeeding (breast milk) is optimal, at least 10-12 times per day without the provision
of water or other food additives; 3) feeding with the correct position so that it can be
ascertained ASI transfer effectively; 4) prevent the loss of birth weight of less than 8%.
(Gartner,2001).
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One of the neonatal health care program is monitoring the incidence of neonatal
icterus. Focus action on this program is early detection by seeing the appearance of
yellowing of the skin and encourage the baby to continue breastfeeding. (MOH, Books
Charts Integrated Management of Childhood Illness (IMCI), 2008).

1.2 Problem Formulation

1.2.1 How Medical Concepts Icterus Neonatorum?

1.2.2 How Nursing Concepts Icterus Neonatorum?

1.2.3 How Nursing in Infants Icterus Neonatorum?

1.3 General Purpose

1.3.1 Knowing Medical Concepts Icterus Neonatorum

1.3.2 Knowing Concept of Nursing Icterus Neonatorum

1.3.3 Knowing Nursing in Infants Icterus Neonatorum

1.4 Specific Objectives

1.4.1 Knowing Definition of Neonatorum

1.4.2 Knowing Classification of Icterus Neonatorum

1.4.3 Knowing The Etiology of Icterus Neonatorum

1.4.4 Knowing Pathway Icterus Neonatorum

1.4.5 Knowing Pathophysiology Icterus Neonatorum

1.4.6 Knowing Clinical Manifestations Icterus Neonatorum

1.4.7 Knowing Examination And Assessment Clinic at Icterus Neonatorum

1.4.8 Knowing Diagnostic Examination Icterus Neonatorum

1.4.9 Knowing Complications Icterus Neonatorum

1.4.10 Knowing Icterus Treatment Neonatorum

1.4.11 Knowing Assessment of Icterus Neonatorum

1.4.12 Knowing Diagnose Nursing Icterus Neonatorum

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1.4.13 Knowing Intervension Nursing Icterus Neonatorum

1.4.14 Knowing Evaluation of Icterus Neonatorum

1.4.15 Knowing Nursing in Case of Icterus Neonatorum

CHAPTER 2
DISCUSSION
 4

2.1 Medical Concept

2.1.1 Definitions
Icterus neonatorum is increased levels of bilirubin in the extravascular tissue, so that
the skin, conjunctiva, mucosal and other body tool yellow (Ngastiyah, 2000).

2.1.2 Classification
Divided into two types, namely:
1. Physiologic icterus is icterus arising on the second day and the third day with
bilirubin levels within normal limits and did not cause morbidity in infants.
2. Pathological Icterus
Pathological icterus is icterus with bilirubin levels above normal.
Icterus is likely to become pathological or neonatal icterus sebgai considered are:
a. Icterus occurs in the first 24 hours after birth.
b. Increased bilirubin concentration of 5mg% or more every 24 hours.
c. Serum bilirubin concentration as 10mg% in preterm neonates and 12.5% in term
neonates.
d. Icterus is accompanied by the process of hemolysis (blood incompatibility,
G6PD enzyme deficiency and sepsis).
e. Icterus is caused by newborn infants less than 2000gr caused by maternal age
under 20 years old or over 35 yahun and teenage pregnancy, gestation less than
36 weeks, asphyxia, hypoxia, respiratory distress syndrome, infection,
hipoglierosmolikemia, hiperkopnia, hiperosmolitas blood.

2.1.3 Etiology
1) Hemolysis increased the Rh blood incompatibility, ABO, other blood group,
G6PD enzyme deficiency, closed bleeding, and sepsis.
2) Interference processes hepatic uptake and conjugation of the liver caused by
immaturity, lack of substrate for conjugation of bilirubin, hepatic dysfunction due
to acidosis, hypoxia, and infections or absence of enzyme glukorinil tranferase
(criggler Najjar syndrome). Another cause is a deficiency of the protein Y in the
liver that plays an important role in bilirubi uptake into liver cells.
3) Impaired transport of bilirubin in the blood is bound to albumin was then
appointed to the liver, bilirubin binding to albumin can be affected drugs eg
 5

salicylates, sulfatfurazole. Albumin deficiency causes more presence of indirect

bilirubin in the blood that is free and easy to attach to cells of the brain.
4) Disorders in the secretion caused by obstruction in the liver or outside the liver is
usually due to infection.
5) The gastrointestinal tract obstruction (functional or structural) can lead to
neonatal icterus due to the addition of unconjugated bilirubin derived from
enterahepatik.
6) Icterus breast milk (ASI). Breast milk icterus is icterus neonatal unconjugated
which peaked late (the day of 6-14). Can be distinguished from other causes by a
rapid reduction of bilirubin levels when substituted with formula milk for 1-2
days. Most of the ingredients contained in breast milk (beta glucoronidase) will
break down bilirubin into a form that is soluble in fat, so that the indirect bilirubin
will increase, and will then be absorbed by the intestine.

2.1.4 Pathophysiology
Bilirubin is a product solver hemoglobin derived from red blood cell
hemolysis / RBC. When RBC broken then prroduknya will enter the circulation,
where the hemoglobin breaks into heme and globin. Globin reused by the body while
the heme is converted to bilirubin inkonjugata and binds to albumin. Genesis are often
found is when there is the addition of bilirubin in the liver streptococcus excessive. It
can be found when there is an increase in erythrocyte destructed, polycythemia,
shortened life of erythrocytes fetus / infant, meningkatanya bilirubin from other
sources, or the presence of an increase in the enterohepatic circulation.
Impaired uptake of bilirubin plasma occurs when levels of protein Z, and
protein Y are bound by other anion, for example, in infants with acidosis or with
anoxic / hypoxic determined interference conjugation liver (deficiency of the enzyme
glucuronyl transferase) or infants suffering from disorders of excretion, eg, patients
with hepatitis neonatal or obstruction bile intra / extra hepatic. At a certain degree,
bilirubin can be toxic and damage brain tissue. The toxicity is mainly found in
bilirubin indirect bilirubin indirek.Sifat allow pathologic effects on brain cells when
bilirubin can penetrate the blood-brain barrier. Abnormalities that occur in the brain
called kernicterus / biliary encephalopathy.
Ease of bilirubin through the blood-brain barrier is not only dependent on high
levels of bilirubin but it depends also on the state of the neonate's own. Indirect
 6

bilirubin will easily through the blood-brain barrier in infants if there is a state of
immaturity, LBW. Hypoxia, hypoglycemia, and central nervous system disorders due
to trauma or infection.

Production human resources in bbl Etiology

increased Pathway
Hemolysis increase in inkompabilitas Rh
blood, ABO
Hemolysis increase in inkompabilitas Rh
Age human resources increased
blood, ABO
Deficiency an enzyme G6PD
Imaturitas hepar
The breakdown of hemoglobin
Deficiency protein y and z
increased

Hem Globi
e n
Indication fototerapi
Biliverdin

Rays with high

Bilirubin indirek intensity
increase in the blood

Ikterus neonatorum

The eye the skin is Body

dry ,
isomerasi Subcutaneos
In the blood bilirubin affected by temperature bilirubin
reddish fat still thin
fastened by albumin the rays increased indirect
be direk

The number Risk bodily fluids

Disorder Hipotermi
of albumin of evaporatebod
integrity
low injury
the skin in excretion by
to the
hepar to gall
eyes
Disorder
Some bilirubin liPuid
not could be tied balance
PATHWAY A fluid excretion
bile inthe intestin
increased
Bilirubin diffuses to
sawar blood the brain
Intestinal peristalsis
increased
Kern ikterus

Disorder
Risk injuri internal elimination
alvi diarrhea
 7

2.1.5 Clinical Manifestations

1. Looks icterus: the sclera, nails, or skin and membrane mukosa.icterus that appears
in the first 24 hours caused by hemolytic disease of the newborn, sepsis, or
mother with diabetic or infection. Icterus that appears on the second day or the
third day, and reached the peak on the third day until the seventh day is usually a
physiological icterus
 8

2. Vomiting, anorexia, fatigue, dark urine color, the color of pale stools
(Suriadi & Yulianni, 2006)

2.1.6 Examination and Assessment Clinic at Neonatorum Icterus

1) How to vote by neonatal icterus clinic with methods Kramer
It is best done in the light of the sun and by pressing a little skin to be observed
to eliminate the influence of color because the circulation of blood. There are
several ways to determine the degree of icterus is a risk of kernicterus by
means of clinical (Kremer) is carried out under ordinary light (daylight).
Clinical assessment degree of neonatal icterus with methods Kremer
(Marni & Massy Raharjo, 2012)

The area The level

Outside icterus of
of a figure bilirubin

1 head and neck 5

2 regions 1 (+1) a body of the upper part of 9

regions 1, 2 ( + ) a body of the bottom and a
3 11
limb
regions 1, 2, 3 (+) Arms and the leg under
4 12
shallow
regions 1, 2, 3, 4 (+) hands and feet
5 > 12.5

2) Diagnostic tests neonatal icterus

a. Coombs tests on the umbilical cord of newborns: Indirect Coombs test
positive result indicates a positive Rh antibodies, anti-A and anti-B in the
Capital region. The positive result of Coombs test direk indicate
sensitization (Rh-positive, anti-A, anti-B) HR from neonates.
b. Mother and baby blood group ABO incompatibility identified.
c. Total bilirubin: blood levels (conjugated) meaningful if it exceeds 1.0 - 1.5
mg / dL, which may be associated with sepsis. Levels indirect
(unconjugated) should not exceed an increase of 5 mg / dL in 24 hours or
not more than 20 mg / dL in term infants, or 14 mg / dL in preterm infants
(depending on weight).
 9

d. Total serum protein: less daari levels of 3.0 g / dL indicates a decrease in

bonding capacity, especially preterm infants.
e. Full blood count: hemoglobin (Hb) may be low (less than 14 g / Dl for
hemolysis hematocrit (Ht) may increase (greater than 65%) in polistemia,
decrease (less than 45%) with excessive hemolysis and anemia.
f. Glucose: dextrosit levels may be less than 45% full blood glucose less
than 30 mg / dL or test serum glucose less than 40 mg / dL when the
newborn hypoglycemia and start using fat stores and releases a weak acid.
g. Urinalysis to determine the reducing agent (galactosemia)

2.1.6 Complications
Complications that may occur in neonatal icterus by Suriadi & Yulianni, 2006:
1. Bilirubin encephalopaty (serious complications)
2. Kernicterus; neurological damage; cerebral palsy; mental retardation,
hyperactivity, slow speech, no muscle coordination, and the shrill cries.

2.1.7 Management
1. Common actions
a. Checking blood group Mothers (Rh, ABO) and others at the time of
pregnancy.
b. Prevent birth trauma, administration of the drug in pregnant women or
newborns that can cause icterus, infections and dehydration.
c. Early feeding with the amount of fluid and calories are in accordance with the
needs of the newborn.
d. Illumination is Puite in place bai treated.
e. Treatment of a factor if not known.
2. Accelerate the metabolism and expenditure bilirubin
a. Early feeding. Early neonatal feeding can reduce the occurrence of physiologic
icterus in neonates, because with early feeding it happens facilitation and
meconium bowel movements more Puickly removed, so that the enterohepatic
circulation of bilirubin is reduced.
b. Giving gelatin. The mechanism is by blocking or reducing the enterohepatic
circulation of bilirubin.
 10

c. Giving phenobarbital. Efficacy of phenobarbital was held microsomal enzyme

induction, so that the conjugation of bilirubin faster.
3. Therapy sunshine
Only an additional therapy. Usually recommended after the baby has admitted to
the Hospital. It can be dried for half an hour with a different position. Conducted
between the hours of 7:00 to 9:00 a.m. because this is the time where ultraviolet
light is Puite effective in reducing levels of bilirubin. Avoid positions that make
the baby look directly at the sun as it can damage the eyes.
4. The light therapy with phototherapy
Carried out for 24 hours or at least until bilirubin levels in the blood return to
normal.
5. The exchange transfusion
The most appropriate way to treat neonatal icterus neonatorum is the exchange
transfusion.
6. Therapy
a. Action to immediately tackle icterus neonatal icterus is usually indirect
(unconjugated) in infants, using indicators of physical signs and laboratory
mainly bilirubin levels in infants is by taking action irradiation
(phototherapy), or exchange transfusion. When icterus neonatorum is direk
(conjugated) it can be cultivated by administration of UDCA (Urso
deaxycholic acid).
b. Causal therapy is carried out simultaneously is intended to eliminate the
causes of diseases like primary varies greatly among others:
1. Treatment of drug intoxication, chemicals, toxins from animal / food /
herbs / supplements, is to immediately terminate or avoid, and sedapatnya
issued a material cause of intoxication deng, and lain-lain.an lavage or
administration of antidotes.
2. Therapy to overcome the infection as a cause of icterus.
3. Symptomatic therapy is the administration of drugs to overcome or
alleviate the symptoms that arise as a result of illness such as fever selin
icterus, seizures.
4. Treatment is supportive, with tjuan improve and maintain optimal patient's
general condition and needs, including providing adePuate nutrition,
fluids and electrolytes, as well as oxygen.
 11

5. The surgical therapy; typically geared to cases such as tumors, congenital

defects, bile duct obstruction, gallstones, abnormal upaya spleen and liver
transplants.
6. Preventive measures
The precautions taken by way of avoiding drinking alcohol, avoid
kesanguinitas is hereditary, and provide vaccination against hepatitis virus
A and B.
7. Prognosis
When unconjugated bilirubin levels higher can cause toxicity in the form
of bilirubin encephalopathy brain resulting in permanent disability and
even death can result. Increased conjugation of bilirubin can lead to long-
term biliary cirrhosis and liver failure cause.
8. Education and Follow-up
a. AdePuacy of nutritional needs, fluid, electrolyte, feeding on the mother
passed though icterus associated breast milk.
b. Just taking the drugs as prescribed.
c. Avoid non-prescription drugs, herbal supplements sertag unclear.
d. Avoid drinking alcohol and hepatotoxic drugs.
e. Newborns with icterus well if given string enough sun to reduce levels of
bilirubin in the blood.
f. If there is a change in symptoms aggravating the immediate consultation
with the treating physician (Klidagdo, 2012).

2.2 Concept of Nursing

2.2.1 Assessment
a. Identity
Occurs more often in boys than girls. Perhaps preterm infants, preterm infants
small for gestational age (SGA), or infants with intrauterine growth retardation
(IUGR), or large for gestational age infants (LGA), such as the baby's mother
diabetes (Mitayani, 2009).
b. Medical history
1) Disease History Now
 12

History of present illness is about the symptoms of icterus, it is stated in

detail the moment when the onset of icterus, whether permanent, intermittent,
gain weight in a short time, and asked other accompanying symptoms such as
fever, pale, gastrointestinal complaints are nausea, vomiting, decreased
appetite , enlarged abdomen, upper right abdominal pain, itching, pale stools
like putty, dark color urine, bleeding, stiffness in ekstermitas, decreased
consciousness, excessive sleep. Another Puestion related to babies with
neonatal icterus is hard drinking awareness apathy, lethargy, muscle tone
changed, shrill crying, and seizures.
2) Formerly Disease History
a. Pre Natal
Mothers with diabetes mellitus, taking certain medications, such as
salicylates, sulfonami blood on rubella, cytomegalovirus during delivery
with vacuum extraction, induction, oxytocin and deceleration binding cord
or other birth trauma.
b. Natal
Preterm labor, birth with vacuum extraction, induction pksitosin, slowing
spending umbilical cord, or birth trauma.
c. Post natal
Birth trauma can occur in connection with a cold stress, asphyxia,
hypoxia, acidosis, hypoglycemia, hypoproteinemia.

3) Family Health History

With a history of icterus neonatorum mothers in pregnancy, liver disease,
fibrosiskristik, metabolism errors at birth (galactosemia), or blood diskarasiasi
sfeosititas, and deferusi glucose-6 phosphate dehydrogenase (G-6P).
c. Nutrition History
Maternal factors, such as maternal diabetes; digest drugs (eg salicylates,
sulfonamides oral in late pregnancy or nitrofurantoin (Furadantin);
inkompatibilotas Rh / ABO; infectious diseases eg rubella, cytomegalovirus,
syphilis, toxoplasmosis).
d. Physical examination
 13

1) General appearance: Fatigue, lethargy, coma

2) Vital signs
Temperature: 36.5 C - 37.5 C
Nadi: 140-160x / min
Breathing: 40x / min
3) Anthropometric data such as weight and height, circle head, a thick layer of fat
under the skin, as well as the upper arm circles.
4) Inspection Head to toe
a. Head: shape, state of hair, facial edema or not
Eyes: cleanliness, sclera icterus or not, conjunctival pallor or not
Nose: hygiene, respiratory nostril
Ears: cleanliness, shape, whether or not there is cerumen
Mouth: cleanliness, suction reflex, swallow
b. Neck: thyroid gland, lymph nodes, enlargement of the jugular veins, stiff
neck
c. Chest
Heart: precordial bulge, pulsation, cardiac icterus, vibration, heart
sounds.
Lungs: maximum chest expansion, no breast development is lagging,
additional breath sounds
d. Abdomen: shape, bowel, if there is a mass, liver enlargement, ascites.
e. Genitalia: whether menutuoi labia majora labia minora, the cleanliness of
the genitalia, BAB process fast with soft stool characteristics, brown for
spending bilirubin. Process BAK dark urine.
f. Ekstermitas: muscle tone, muscle spasm, edema

2.2.2 Nursing Diagnose

1. Risk of injury (internal) are associated with increased serum bilirubin
secondary to breakdown of red blood cells and impaired excretion of bilirubin
2. The risk of a lack of fluid volume associated with water loss (insensible water
loss) secondary of phototherapy

2.2.3 Nursing Intervention

 14

a. Risk of injury (internal) are associated with increased serum bilirubin

secondary to breakdown of red blood cells and impaired excretion of bilirubin.
Objective: after the action for 3x24 hour nursing babies free from injury.
Criteria results: in term infants at the age of 3 days indirect bilirubin levels
below 12 mg / dl, bilirubin levels in preterm infants <10 mg / dl
intervention:
1) Keep the babies warm and dry; monitor the temperature of the skin and
often
Rationale: cold stress potentially releasing fatty acids that compete on the
bond to albumin, thereby increasing the levels of bilirubin circulating free
(unbound).
2) Observasu baby in natural light, consider the sclera and oral mucosa, skin
yellowing soon
Rationale: detecting evidence of the degree of icterus
3) Consider the age of the baby at the beginning of icterus, distinguish the
type of icterus physiology, pathology, dank because breast milk.
Rational: physiological icterus between the first and second day of life,
icterus because milk appear between the fourth and sixth day of life is
usually only 1% -2%, pathological icterus appears within the first 24
hours of life and may lead to the development of kern icterus / enselopati
bilirubin.
4) Monitor the progress of the infant to behavioral change
Rationale: behavioral changes associated with kern icterus usually occurs
between days 3 and 10 of life and is rare before 36 hours of life.

5) Collaboration
Monitor laboratory tests as indicated
1. Bilirubin direct and indirect
Rationale: musty icterus show reduced or absent
2. Start phototherapy using a fluorescent lamp that is placed over the baby
Rationale: bilirubin oxidation causes the photo on an extensive network
of subcutaneous, so the water soluble bilirubin Enhancing the
capabilities that enable rapid excretion of bilirubin in feces and urine
3. Provide a blindfold when phototherapy underway
 15

Rationale: to prevent the possibility of damage to the retina and

conjunctiva
4. Change the baby's position frePuently, at least every 2 hours
Rationale: to prevent decubitus
b. The risk of lack of fluid volume associated with water loss (insensible water
loss) secondary of phototherapy
Objective: after the act of nursing for 3x24 hours the problem resolved
Criteria results: there are no signs of dehydration, good turgor.
Intervention
1) Monitor output client
Rationale: output excessive or unbalanced intake will cause fluid balance
disturbances.
2) Inform the family about the importance of breastfeeding than PASI
Rationale: order intake remains balanced
3) Collaboration on fluid administration
Rationale: to prevent dehydration and lack of fluid volume

2.2.4 Evaluation
a. In term infants at the age of 3 days indirect bilirubin levels below 12 mg /
dl, bilirubin levels in preterm infants <10 mg / dl.
b. No signs of dehydration, good turgor.

2.3 Nursing Care To Baby With Icterus Neonatorum

The Rooms : Baby
No. Reg : 12.50.78.16
Assessment Date : June 5th, 2016 , 15:00 Pm
MRS Date : May 29th, 2016, At 07:02:29 am
1. ASSESSMENT
A. Identity
Baby Names : By . W
 16

Age : 7 days
Gender : Female
Person in charge
Dad / Mom : Mr. A / Mrs . W
Age : 30 years / 27 years
Address : Sirepah , Balong Bendo , Sidoarjo
Religion : Moeslem
Job :-
Medical Diagnose : SMK + icterus Neonatorum
B. Health History
1. Main Complaint : No result.
2. History of Pregnancy and Childbirth
Pre Natal : States G2 P11002 with 30/31 weeks gestation , treatment during
pregnancy is no result , TT immunization no result , complications during
pregnancy are no result.
Natal :
Babies born in emergency unit Dr. Soetomo hospital, childbirthing: SC with
indication amniotic murky and placenta the previa totalis.

Post Natal :
A baby born on may 30th 2016 at 06: 15: 00 with weight 1235 grams , the long
body 43 cm , circle head 27 cm, circle chest 24 cm , mekonium out < 24 hours ,
baby treated at NICU on may 30th 2016 at 06: 37 temperatures 36.5 c , HR 150
time/ minutes , RR 40 times / minutes.

APGAR Score to 11 and 51 = 5 6

APGAR Score 11 51
Heat rate 1 2
Respiration 1 1
Tonus Muscle 1 1
Reflecs 1 1
Skin color 1 1
Total APGAR Score 5 6
 17

C. Disease History Now

On May 31th 2016 at 7:02 baby moved in the baby's room with a temperature of
36.6C , HR 148 / min, RR 39 / min . Was assisted by the baby by physicians with
a kind of childbirth SC. Babies suffering from icterus since June 4th 2016.
D. Family History : No result
E. Immunization History : No result
F. The pattern of the function of health
1. Fluid intake / nutrition
ASI / PASI : 8 cc personde every 2 hours ( 12 x 8 cc / 24 hours )
Infusion : D5 - Ns 12.5 % 60 cc / 24 hours via pump
2. Elimination
Urine elimination : 50 cc / 4 hours
Bowel elimination : characteristic soft , distinctive smell of feces
3. Rest and Sleep
Sleep duration : 20-24 hours
State of sleep : Puiet , crying if thirsty

4. Personal Hygiene
Baby every morning at 04:30am always wiped, every tubs and chapter always
replaced its diapers, always oral hygiene by using Enystatin .
5. Activities
Weak grasp reflex , Babinski reflex is not gripping fingers , moro reflex is weak,
the attitude of the extension baby , the baby is not moving on.

G. Psychosocial
Mother's behavior toward infants : No Result
H. Physical Examination
General appearance: Baby weak
Temperature : 36.6 C
Pulse : 146 beats/min
Breathing : 46 beaths/min
1. Head
 18

Nothing Caput succadenum, fronto-occipito 27 cm, state heads clean, no swelling,

no lesion, thin hair.
2. Eyes
Symmetrical shape, clean, pink conjunctiva and icterus sclera.
3. Nose
There is a hole nose, nothing respiratory pierced nose, no polyps, no secretions.
4. Lips
Dark red lip color, dry mucosa, clean tongue, gums clean, no inflammation, no
stomatitis, no lesion, feeble rooting reflex, sucking reflex is weak.
5. Ear
Symmetrical shape, layout aligned against the ear, the ear elastic, nothing cerumen,
the color of dark red ears.
6. Neck
No enlargement of the thyroid gland, no enlargement of the jugular veins, no
redness, no blisters skin, weak swallowing reflex.
7. Chest
Symmetrical shape, redness, circle chest 26 cm, regular respiratory rhythm,
maximum chest expansion, clean breath sounds.
8. Abdomen
Tenderness, bowel sounds 19 times/min, the umbilical cord is not lose, no bleeding
on the cord, there are no signs of umbilical cord infection.
9. Backbone
Nothing spina bifida, nothing dicubitus, no bruised the emphasis back.
10. Genitalia
Not covering the labia mayora labia minora, clitoris stand, no skin abrasions,
nothing mushroom.
11. Anal
The anal canal is not blocked, anal is not ruddy, the skin around the anus blisters.
12. Extremities
Upper :
The movement of weak hands, nothing injuries/edema, weak grasp reflex.
Lower:
Movement of weak is legs, no edema, no wounds, leg skin dry, do not grip the
finger Babinski reflex .
 19

13. Skin
Reddish, dry, turgor skin is good.

I. Examination of supporting
Chemical examination clinic June 04th 2016 at 10: 27: 46
Examination Result Unit Normal value
Albumin 3.4 g/dL 3.4 5.0
Direct bilirubin 0.52 mg/dL 0.00 0.20
Total bilirubin 11.19 mg/dL 0.2 1.00
CRP 0.1 mg/dL 0.00 0.90

Diagnostic examination at June 04 2016

Kind of Hematologi Normal Result
WBC/Leucosit L = 3.8 10.6 P = 3.6 11 9420 x 103/ L
HGB/Hb L = 13.2 17.39 P = 11.7 14.7 g/dL
15.5
HCT/PVC L = 40 52 P = 35 47 42 %
PLT/Thrombo 150 400 31840 x 103/ L
Kind chemistry
Bilirubin direct 0.00 0.2 0.52 mg/dL
Bilirubin total 0.1 1 11.19 mg/dL

Examination Chemistry Clinic June 07th 2016 at11:14:31WIB

Parameter Result Normal value
Bilirubin direct 0.52 0.00 0.2
Bilirubin total 4.35 0.1 1

J. Therapy Provided
1. Installed infusion : D5 - Ns 12.5 % 60 cc / 24 hours via pump
2. ASI / PASI 8 cc personde every 2 hours ( 12 x 8 cc / 24 hours )
3. Phototherapy conducted on June 5th, 2016 1 x 24 hours
 20

DATA ANALYSIS
 21

Grouping Of Data Etiology Nursing Problem

DS : - neonatal icterus Risk of internal injury
DO :
Temperature 36.6 C
HR 146 times/minute
RR 46 times/minute Bilirubin in the blood is bound to
Total bilirubin 11.19 albumin
mg/dL
Albumin 3.4 g/dL
weak general state Number of low albumin

ASI/PASI 8 cc
personde every 2 Most of bilirubin can not be bound

hours (12x8 cc/24

jam) Bilirubin diffuses into the blood brain
Installed infusion : barrier
D5 - Ns 12.5 % 60
cc/24 hours via pump
Kern Icterus

Risk of internal injury

DS : - Indication fototerapi Risk of less fluid body

DO :
volume
Temperature 37 C
Subcutaneous fat is still thin
HR 142 times/minute
RR 40 times/minute
The baby's skin dry
Body fluids evaporate
Mucosal dry lips

Installed phototherapy
1x24 hours Less risk of fluid volume

Installed infusion D5 -
Ns 12.5 % 60 cc / 24
hours via pump

Balance fluid 50 cc
BB 1220 gram
 22

2. Nursing Diagnose
1. On June 5, 2016
Risk of internal injury related with increase in serum bilirubin caused
red blood cell breakdown and excretion of bilirubin disorders
2. On June 5, 2016
The risk of lack of fluid volume associated with secondary air loss from phototherapy

3. Nursing Intervention
1. Risk of injury (internal) associated with secondary increase in serum bilirubin of red
blood cell breakdown and excretion of bilirubin disorders
Goal : The taxable income carried over 3x24 hour nursing action baby free from injury
Criteria outcome : bilirubin <10 mg / dL
General good condition
Good moro reflex
Good sucking and rooting reflex
Intervention:
1) Keep warm and dry babys incubator, monitor skin and temperature every 4 hours.
R / Cold stress release acids potentially weak side association competing on the
albumin, thereby increasing bilirubin.
2) Observation phototherapy light of baby
R / Detecting evidence / degree of icterus.
3) Assess progress of baby behavior
R / Behavioral changes associated with kernicterus.
4) Collaboration for evaluation laboratory appropriate indications
R / Increased indirect bilirubin 13-15 mg / dl on premature babies.
5) Start phototherapy using flouresan light bulbs above the baby
R / Causes photo bilirubin oxidation on networks after subcutaneous thereby
enhancing the ability of air
6) Give cover eye to the baby
R / Preventing the possibility of damage to the retina and conjunctiva of high
intensity beam
7) Change the baby position at least 2 hours
R / Journey toward balanced from the skin surface fluorescence rays, preventing
exposure excessive and emphasis specific body parts
 23

2. Risk of a lack of fluid volume patronizing a secondary water loss of

phototherapy
Goal : After nursing actions during 3x24 hours the client
improved and fulfilled fluid volume
Criteria outcome : There was no sign of dehydration
The baby's skin moist
Mucosa moist lip
Heavy weight rises
Intervention :
1. Assess the baby output
R / Output causing excessive fluid balance disturbances
2. Explain to the parents the importance of breastfeeding
R / Intake remain balanced with output
3. Collaboration with the doctor in giving fluid
R / Prevent dehydration

4. Implementation Of Nursing
Date June 5th, 2016
Diagnose 1
At 03:30 pm .
1. Maintaining warmth baby with replace nested and if wet blanket .
Response : babys acral dry warm red .

At 03:32 pm.
2. Turn on phototherapy lamps 1x24 hours above baby incubator
At 03:33 pm.
3. placed eye cover on baby
At 05:00 pm
4. Change the baby position every 2 hours

Date June 6th, 2016

Diagnose 1
 24

At 08:00 am
1. Measure babys vital sign
At 08:05 am
2. Replace wet baby's diaper with new diaper
At 08:08 am
3. Change the baby position to right side

Date June 7th, 2016

Diagnose 1
At 08:00 am .
1. Measure babys vital sign
Temperature of 36.7 C HR 120 Times / min RR 42 times / min
At 08:05 am
2. Remove diapers and wipes the baby
At 08:08 am
3. Change the baby position being right obliPue

Diagnose 2
At 08:10 am
1. Weighing diapers
Balance 50 cc
At 08:11 am
2. Change the formula milk with breast milk
At 08:11 am
3. Give ASI 8cc x 12/24 hours.
Date June 8th, 2016
Diagnose 1
At 04:25 am
1. Measure the baby's vital signs
Temperature of 37.5 C HR 142 beats / min RR 40 times / min
At 04:30 am
2. Wiping and diapering the baby
At 04:35 am
 25

3. Monitor laboratory results after the baby is doing phototherapy

Direct 0:51 bilirubin mg / dL
Total bilirubin 4:35 mg / dL

Diagnose 2
At 04:36 am
1. Give breastfeeding 15 cc personde
At 04:40 am
2. Weighing the baby, the result is 1320 grams

Date June 9th, 2016

Diagnose 2
At 04:36 am
1. Giving ASI personde 15 cc
At 04:45 am
2. Wiping and diapering the baby
At 4:50 am
3. Measure the baby's vital signs
Temperature of 37.2 C HR 140 beats / min RR 45 times / min

5. Evaluation Of Nursing
Date June 5th, 2016
Diagnose 1
S: -
O: Acral warm, infant hypothermia
A: The problem still occurs
P: Interventions continued

Date June 6th, 2016

Diagnose 1
 26

S: -
O: temperature 36.8 C HR 149 beats / min RR 48 / min, infant hypothermia, not visible
redness
A: The problem still occurs
P: Interventions continued

Date June 7th, 2016

Diagnose 1
S: -
O: temperature 36.7 C HR 120 beats / min RR 42 / min,
A: The problem still occurs
P: Interventions continued

Diagnose 2
S: -
O: Balance liPuid 50 cc, 8 cc personde breastfeeding, infant diarrhea, dehydration
A: The problem still occurs
P: Interventions continued

Date June 8th, 2016

Diagnose 1
S: -
O: temperature 37.5 C HR 142 beats / min RR 40 / min, total bilirubin 4.35 mg / dL,
direk
0:51 bilirubin mg / dL
A: The problem does not occur
P: Intervention terminated

Diagnose 2
S: -
 27

O: ASI 15 cc personde, BB 1320 grams, the baby no diarrhea, no abrasions on the skin
genitalia
A: The problem still occurs
P: Interventions continued

Date June 9th, 2016

Diagnose 2
S: -
O: ASI 15 cc personde, temperature 37.2 C HR 140 beats / min RR 45 times / min
A: The problem does not occur
P: Intervention terminated

CHAPTER 3
COVER

3.1 Conclussion
Icterus is a yellowing of the sclera, skin or other tissue due to accumulation
of bilirubin in the body or the accumulation of bilirubin in the blood of more than 5
mg/dl within 24 hours, indicating the occurrence of functional disorders of the
liver, biliary system, or the hematologic system. Icterus itself is physiological, but
can become pathological. Icterus is caused by elevated levels of bilirubin so that it
can lead to kernicterus due to accumulation of unconjugated in brain cells. This
 28

form of therapy for icterus assortment, including light therapy (phototherapy),

exchange transfusion, drug therapy, feed infants and sunlight therapy.

3.2 Recommendation
Icterus is one of the health problems that often arise in neonates and infants,
therefore, the role of health workers, mothers and other related agencies in
addressing and finding solutions to problems need to be done so that the incidence
of icterus have occurred not continue to.

Bibliography

Asmadi. 2008. Konsep Dasar Keperawatan . Jakarta : EGC.

Marmi S.ST dan Kukuh Rahardjo. 2012. Asuhan Neonatus, Bayi, Balita, dan Anak Pra
Sekolah. Cetakan Pertama. Yogyakarta : Pustaka Pelajar.
Mutayani. 2009. Asuhan Keperawatan Maternitas. Jakarta : Salemba Medika.
Ngastiyah. 2000. Perawatan Anak Sakit. Jakarta : EGC.
Surasmi, dkk. 2003. Perawatan Bayi Resiko Tinggi. Cetakan Pertama. Jakarta : EGC.
Sariadi dan rita Yuliani. 2006. Asuhan Keperawatan Pada Anak. Edisi 1. Jakarta : Fajar
Inter Pratama.
 29

Widagdo. 2012. Tatalaksana Masalah Penyakit Anak dengan Ikterus. Jakarta : CV

Sagung Seto.