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fulfillment of the Course Requirements of NCM102- Related Experience __________________________________________________ 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
TABLE OF CONTENTS
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…………………………………….
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
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.
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
There was no significant difference in gender. Two patients were excluded from the study because of subsequent positive blood culture and refusal by parents for blood sampling.72 ± 1. 2010). the main cause of admission in 144 (32%) neonates of the 446 admitted neonates was hyperbilirubinemia. cerebral palsy..severe hyperbilirubinemia is not treated. hearing loss. Monitor the weight of the client. while 35 neonates in the study group received phototherapy and clofibrate. Remaining 68 newborn infants were assigned randomly to the two groups. 33 patients in the control group received phototherapy and placebo.79 6 . Sixty-five percent of neonates were first offspring. weight.05 ± 2. Ninetyseven percent (66 newborns) of the studied newborns were exclusively breast-fed. it can cause mental retardation. Of the 68 neonates enrolled in this study. 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.2006). S.04 mg/dL) in the study group and 19.82 mg/dL (95% confidence interval: 19. The nursing management of the newborn are require astute observation for jaundice and careful review of possible risk factor for hyperbilirubinemia. behavior disorders. its skin turgor and the age of the baby as much as possible and monitor the vital signs of the baby (Orshan. During the study period.54-22. or death (Adam. age at admission and cesarean section rate between the two groups. Mean total serum bilirubin levels at the time of admission were as follows (mean± SD): 20. Seventy neonates fulfilled inclusion criteria.
BUN and creatinine levels were normal 1 week after discharge (Maisels MJ. PURPOSE OF THE STUDY 7 . None of the babies receiving clofibrate developed vomiting or diarrhea. We noted only one case of rebound hyperbilirubinemia. The results of laboratory tests of patients in the two groups are shown in.6 hours) vs.001]. 87.76 hours (95% confidence interval: 79.2-108 hours). 2005). Mean duration of phototherapy was significantly shorter in the study group in comparison with control group [mean ± SD: 64. P< 0.54 mg/dL) in the control group (P= 0.84 ± 29.32 ± 12. None of the patients in the present study required exchange transfusion.48 hours (95% confidence interval: 60-81. White blood cell count.12-20.57). during the follow-up of neonates. which was from the control group.mg/dL (95%confidence interval: 19.
Specifically. Discuss the relevant interventions that were utilized to resolve problems. SIGNIFICANCE OF THE STUDY 8 .This case study aims to present the nursing care of the client who underwent elective caesarean section. this study seeks to achieve the following objectives: 1. Explain the patient’s response toward the interventions. 2. Identify factors that led to the development of the problem. 4. 3. Analyze the relationship of factors leading to the development of the problem.
To the family. 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. the findings of the study will serve as a guide to enhance further the health of the client. 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 the clinical instructors. To the students. and making interventions appropriate for the condition of the newborn. the findings of this study may be used as a basis for evaluating the student’s performance by identifying the student’s strengths and 9 . To the health care providers. the study will serve as a guide to enhance their knowledge and skills in providing care to the newborn. to achieve a better health condition.The result of the case study will be beneficial to the following: To the client. as an indirect recipient.
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. To the future researchers.weaknesses in analyzing and formulating the case history and be able to recommend and make improvements. SCOPE AND LIMITATION OF THE STUDY 10 . This will also serve as a basis for improvement in their research and in providing health care and meeting the needs of the client.
Methods for data gathering includes observation for empirical data. Another limitation is that the researchers are still in the stage of observation hence. This is the case of baby boy Licaros who was born on November 27. The patient was also unable to handle by the researchers at the Newborn Services Unit of one of the tertiary hospital in Makati City. 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. BACKGROUND OF THE STUDY 11 . The scope of the study was focused on the case on of a live full term baby boy delivered via elective caesarean section. they did not have a chance to interview the mother of the newborn and to implement health teaching. from December 02 to 04 of 2010 during 0600H-1200H shift. utilizing the nursing process in meeting the needs of the patient taking into consideration the core competencies standards of nursing practice. This study involves assessment of the newborn to identify actual and potential problems that may be encountered by the newborn. Also the researchers depend only to the chart of the patient.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. 2010 at 0654H. 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. 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.
This study was conducted at the Nursery Department located at the 5th floor of a selected tertiary hospital in Makati City. nurse’s lounge. breastfeeding area. step down room. 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. milk preparation room. pantry. Its department has its division. routine admission care. This department follows an ordered flow. the health care team will assess the neonate for any abnormalities. 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. potentially septic room. who are sustained by well-developed research and training programs and enabled by state-of-art professional equipment and specialized tools. area management room. as well as technical and management staff. It provides state of the art facilities and equipment for the newborn that helps the healthcare providers in rendering safe 12 . well newborn II. well newborn I. earlobe puncture. Newborn Hearing Screen: Otoacoustic Emission Test and Newborn Screening. Well neonates are admitted to Newborn Section for routine care. and further more circumcision room. Upon admission of the baby from the delivery room. It provides services and procedures like. out born NICU. These are the discharge room. Aside from the said services and procedures. they provide high-quality health care services through integrated specialty centers operated by highly qualified physicians and nurses. If there are complications identified.” The hospital is a mother-baby friendly hospital and it provides the ultimate care for the baby from birth to discharge. the neonate will be endorsed to the Neonatal Intensive Care Unit (NICU). doctor’s conference room and linen room wherein student nurses are not allowed to enter. neonatal intensive care unit II and II. admission room. doctor’s lounge. circumcision.
Visitors of the nursery may view their babies using the “Show My Baby” card. The researcher chose this case for it is found interesting for the reason that this will provide them a learning opportunity. such as: radiant warmer. it is believed that this will give them additional information about the chosen topic and the appropriate interventions needed to be performed. Furthermore. suction machines and more. Only the infant’s mother is allowed to enter the breastfeeding room during feeding time. it imposes a challenge to them to know more regarding the selected case – A care of a Newborn with Hyperbilirubinemia. Moreover. CHAPTER II 13 . bassinette.and quality services.
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). 14 . but serious complications can occur if elevated bilirubin levels are not treated in a timely manner. Severe hyperbilirubinemia can be toxic to the nervous system of infants. a substance called bilirubin is formed. it causes yellowish staining of the skin and whites of the newborn's eyes (sclerae) by pigment of bile (bilirubin) which called jaundice. Before birth. Jaundice is a marker used to identify those infants who may be at risk for developing severe hyperbilirubinemia. Normal neonatal jaundice typically appears between the 2nd and 5th days of life and clears with time. Jaundice is not painful.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.lpch. 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. When red blood cells break down. Because bilirubin has a pigment or coloring.org/DiseaseHealthInfo/HealthLibrary/hrnewborn/hyperb.html Hyperbilirubinemia is a condition in which there is too much bilirubin in the blood.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. the placenta -. potentially causing brain damage. Jaundice is not a disease but is a symptom of an elevated blood bilirubin level. DEFINITION http://www.
It is different 15 .gov/medlineplus/ency/article/001559. which deconjugates the conjugated bilirubin. Shorter neonatal RBC life span increases bilirubin production. Breastfeeding increases enterohepatic circulation of bilirubin in some infants who have decreased milk intake and who also have dehydration or low caloric intake. conjugated bilirubin is reduced by gut bacteria to urobilin and excreted. Breast milk jaundice is another common. and low bacterial levels in the intestine combined with increased hydrolysis of conjugated bilirubin increase enterohepatic circulation. In adults.ETIOLOGY http://www. The increased enterohepatic circulation also may result from reduced intestinal bacteria that convert bilirubin to nonresorbed metabolites. Physiologic hyperbilirubinemia occurs in almost all neonates. usually non-harmful form of newborn jaundice. This is called enterohepatic circulation of bilirubin. especially in those that are not nursing often enough.nlm. which is then reabsorbed by the intestines and recycled into the circulation.htm The majority of bilirubin is produced from the breakdown of Hb into unconjugated bilirubin (and other substances). deficient conjugation due to the deficiency of UGT decreases clearance. Neonates. where it is taken up by hepatocytes and conjugated with glucuronic acid by the enzyme uridine diphosphogluconurate glucuronosyltransferase (UGT) to make it water-soluble. They do have the enzyme β-glucuronidase. however.nih. Unconjugated bilirubin (indirect reacting) binds to albumin in the blood for transport to the liver. Breastfeeding jaundice is a type of exaggerated physiological jaundice seen in breastfed infants in the first week of life. The conjugated bilirubin (direct reacting) is excreted in bile into the duodenum. Bilirubin levels can rise up to 18 mg/dL by 3 to 4 days of life (7 days in Asian infants) and fall thereafter. have sterile digestive tracts.
16 . It may last at low levels for a month or more. hematoma resorption. Such jaundice appears in some healthy. total serum bilirubin (TSB) rises by > 5 mg/dL/day. 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.from breastfeeding jaundice. TSB is > 18 mg/dL and infant shows symptoms or signs of a serious illness. sepsis and hypothyroidism. tongue-tie) or a mother's insufficient milk supply. Inadequate intake jaundice is distinct from breast milk jaundice occurs if a newborn is not getting enough breast milk. or lasts > 2 wk. This is more likely to occur in babies who have difficulty with breastfeeding due to physical problems (prematurity. Some of the most common pathologic causes are immune and nonimmune hemolytic anemia. The increased production of bilirubin levels in infants can be related to bruising and mild injuries from the birth process. after the first week of life. Pathologic hyperbilirubinemia in term infants is diagnosed if jaundice appears in the first 24 h. cleft lip or palate. 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-6phosphate dehydrogenase [G6PD). breastfed babies after the first 5 to 7 days of life and peaks at about 2 week.
either they don't wake up from sleep easily like a normal baby. They have a high-pitched cry. Page 60 The overall incidence of jaundice in the newborn is 65%. Other factors have been identified inconsistently. Breathing in the Newborn. and decreased muscle tone. history of maternal Diabetes. prematurity. USA. including the following: low birth weight. behavior disorders. or they don't wake up fully. 5th Edition.SIGNS AND SYMPTOMS Adams. they may develop fever. H. They are too sleepy.E. sepsis. California. may arch their heads back into a very contorted position known as opisthotonus or retrocollis. It affects 50% term newborns and 80% of premature newborns. Delivery inquiring instrumentation. EPIDEMIOLOGY David. If severe hyperbilirubinemia is not treated. A. As the damage continues. Page 5 Signs and symptoms of infant jaundice usually appear between the second or fourth day of life and include yellowing of the skin. it can cause mental retardation. such as epidural anesthesia and oxytoxin during labor. and Asian Descent. and they are difficult to arouse . yellowing of the eyes. Elevated bilirubin levels have been associated with several factors during the newborn period. breastfeeding. becoming hypotonic or floppy) with episodes of increased muscle tone (hypertonic) and arching of the head and back backwards. or death. 17 . hearing loss. cerebral palsy. (2010). (2006). or they can't be kept awake. Care of a newborn: A handbook of primary care. Washington.
The direct Coombs test. the infant’s blood type. Additional studies may be indicated on the basis of the history (both maternal and perinatal) and physical examination of the infant. established newborn metabolic newborn metabolic screening tests (particularly to detect hypothyroidism and galactosemia) should be sent as a part of basic laboratory studies. and direct and indirect Coombs should be assessed. and. laboratory testing is a key component in the evaluation of the jaundiced infant. therefore. Rh status. ABO. A basic laboratory evaluation is indicated for all infants and an expanded evaluation for selected infants. if ABO incompatibility is suspected. (2005). Low albumin levels may increase the risk of damage from excessive jaundice. a retuculocyte count. 18 . it is impossible to determine if it is against the Rh. Rh status. maternal blood type.” determines if IgG antibodies are attached to red blood cells. The level of albumin in the baby's blood may also be checked.DIAGNOSTIC TEST Hertz. Further. also known as the Direct Antiglobulin test or “DAT. “Care of the newborn: A Handbook for Primary Care” Philadelphia: USA In addition to a complete history and thorough physical examination. The indirect Coombs tests for specific plasma antibodies that are not attached to red blood cells. or some other red blood cell antigen group. D. a complete blood count with peripheral smear and differential noting any nucleated red blood cells. and antibody screen. A positive direct Coombs does not identify the type of antibody or specific antigen. A basic evaluation should include the following: a fractionated bilirubin level that includes direct (conjugated) and unconjugated bilirubin measurements.
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. and 20 mg/dL at > 72 h. skin color cannot be used to evaluate jaundice severity. 18 mg/dL at 49 to 72 h. most commonly using fluorescent white light.2 μmol/L) and may be indicated when unconjugated bilirubin is > 15 mg/dL at 25 to 48 h. which most often occurs with immune-mediated hemolysis. (Blue light is most effective for intensive phototherapy. because bilirubin in the collection tubes may rapidly photo-oxidize. so if conjugated bilirubin is elevated. though serum bilirubin remains elevated. the level of unconjugated rather than total bilirubin is used to determine the need for exchange transfusion. Because visible jaundice may disappear during phototherapy. Blood taken for bilirubin determinations should be shielded from bright light.MEDICAL MANAGEMENT Phototherapy: This treatment remains the standard of care.) 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. The transfusion replaces an infant's blood with donated blood in an attempt to quickly lower bilirubin levels. 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. It provides definitive treatment of neonatal hyperbilirubinemia and prevention of kernicterus. Phototherapy is an option when unconjugated bilirubin is > 12 mg/dL (> 205. Only unconjugated hyperbilirubinemia can cause kernicterus. 19 . Phototherapy is not indicated for conjugated hyperbilirubinemia. These then are replaced with uncoated donor RBCs. Exchange transfusion: This treatment can rapidly remove bilirubin from circulation and is indicated for severe hyperbilirubinemia.
an alternative is to give 2 successive exchanges of 80 mL/kg each over 1 to 2 h. For critically ill or premature infants. 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. It is also customary to lower the target level by 1 to 2 mg/dL in conditions that increase the risk of kernicterus (eg. Most often. If the serum bilirubin level is > 25 mg/dL when the neonate is initially examined. with the knowledge that hyperbilirubinemia may rebound to about 60% of pretransfusion level within 1 to 2 h. there are risks and complications with the procedure.to 34-μmol/L) decrease within 4 to 6 h of initiation or at the first clinical signs of kernicterus regardless of bilirubin levels. and a 1500-g neonate would receive an exchange transfusion at a bilirubin level of ≥ 15 mg/dL. Finally. a 1000-g neonate would receive an exchange transfusion at a bilirubin level of ≥ 10 mg/dL. 20 . aliquots of 5 to 10 mL are used to avoid sudden major changes in blood volume. Exchange transfusions may need to be repeated if bilirubin levels remain high. To do an exchange. The goal is to reduce bilirubin by nearly 50%. sepsis. this procedure is repeated until the total desired volume is exchanged. 160 mL/kg (twice the infant's total blood volume) of packed RBCs is exchanged over 2 to 4 h. preparation for an exchange transfusion should be made in case intensive phototherapy fails to lower the bilirubin level.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. Thus.to 2-mg/dL (17. fasting. acidosis). and the success of phototherapy has reduced the frequency of exchange transfusion. 20 mL of blood is withdrawn and then immediately replaced by 20 mL of transfused blood.
and stimulate intestinal activity. Inc. healthy. and does not have 21 . United Staes of America: Elsevier Inc. Prevention has focused on early initiation of feedings and frequent breastfeeding to decrease enterohepatic shunting. Strategies have included prevention. Lowdermilk. or has hemolysis or other medical problems. Intensive phototherapy is used as a first line treatment. use of pharmacologic agents. Pharmacologic agents have been used in the management of hyperbilirubinemia to stimulate the induction of hepatic enzymes and carrier proteins. et.Blood type incompatibility: Infants with hyperbilirubinemia due to incompatibility with their mother's blood may be given intravenous immunoglobulin (IVIG). promote establishment of normal bacterial flora. The management of hyperbilirubinemia will depend to some extent on the cause. Maternity nursing 7th edition. Missouri: Mosby. to interfere with heme enzymes and carrier proteins. fetal. (2006). but ultimately on the level of bilirubin and the condition of the neonate. Specific pharmacologic agents have been used to prevent hyperbilirubinemia or reduce bilirubin levels.al (2007). neonatal physiology. or to bind bilirubin in the intestines to decrease enterohepatic reabsorption. the bilirubin level for initiating phototherapy may be somewhat lower than if the neonate is full-term. Maternal. et. NURSING MANAGEMENT Jackson C. to interfere with degradation.al. If the neonate is less than 38 weeks’ gestation. D. Various techniques have been used to manage neonates with indirect hyperbilirubinemia. exchange transfusion and phototherapy.
in which case feedings would be temporarily interrupted for the procedure. G.any type of haemolytic disease. Then. 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. Philadelphia: Lippincott William and Wilkins. Frequent monitoring and early treatment of infants at high risk for jaundice can help to prevent severe hyperbilirubinemia. 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.. MacDonald. wetting. when the bruise begins to heal. M. red blood cells die. A bruise forms when blood leaks out of a blood vessel and causes the skin to look black and blue. RISK FACTORS Avery. Bilirubin is made when red blood cells break down. A baby who has bruises at birth is more likely to have jaundice.). 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. In babies whose bilirubin blood levels reach hazardous levels. A baby who is not eating. and the baby may become 22 . or stooling well in the first few days of life is more likely to get jaundice. The healing of large bruises may cause high levels of bilirubin.(6th ed.G. Very high or rapidly rising bilirubin levels may need to be controlled with and exchange transfusion. (2005). Avery's neonatology: Pathophysiology & management of the newborn. Infants who do not consume enough breastmilk are at risk for jaundice. bilirubin may cross to the brain and cause reversible damage (called early acute bilirubin encephalopathy) or permanent damage (called kernicterus).
jaundice is harder to see in babies with darker skin tones. but it not necessarily required if careful monitoring takes place.nlm.jaundiced. or 8 ½ months. Women with an O blood type or Rh negative blood factor might have babies with higher bilirubin levels. Babies born before 37 weeks. and their babies are more likely to become jaundiced.gov/medlineplus/ency/article/001559. A baby who is yellow in the first 24 hours of life may get dangerously jaundiced. the baby can become very yellow or may even look orange. A mother with Rh incompatibility should be given Rhogam. Careful monitoring of all babies during the first 5 days of life can prevent most complications of jaundice. Also all pregnant women should be tested for blood type and unusual antibodies. 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. If too many red blood cells break down at the same time. Also. this includes considering a baby's risk for jaundice. Some families inherit conditions (such as G6PD). If the mother is Rh negative. A baby born to an East-Asian or Mediterranean family is at a higher risk of becoming very jaundiced.nih. of pregnancy may become jaundiced because their liver may not be fully developed. This may also be done if the mother blood type is O+. The young liver may not be able to get rid of so much bilirubin.htm In newborns. Ideally. follow-up testing on the infant's cord is recommended. 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. 23 . PREVENTION http://www.
Parents and healthcare providers should not delay treatment for any reason. This is especially true for infants who are jaundiced before 24 hours of age or are jaundiced below the level of the umbilicus (navel). 24 . You should contact your child's healthcare provider immediately if you are concerned about worsening jaundice.Prevention of severe hyperbilirubinemia is important in avoiding serious complications. Hyperbilirubinemia is usually easy to prevent and treat initially. Monitor — Parents and healthcare providers should monitor the infant closely if jaundice develops. Infants who are at risk for hyperbilirubinemia need close surveillance and follow-up. but the complications can be serious and irreversible if treatment is delayed. The following information applies to infants who are healthy and late preterm or older (greater than or equal to 35 weeks of gestation). 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. Screen — Experts recommend that all infants have bilirubin blood testing before going home.
J. 27. appropriate to gestational age. last Nov. A.V had regular prenatal check-ups. the mother was found to have HSP virus type II wherein no treatment was given. A. 10 at 1 & 5 minutes respectively. With (+) secretions. A. 2010 at 0654H in a private tertiary hospital.. with an Apgar score of 9. Patient was then placed safely and comfortably under the radiant warmer. delivered via elective caesarian section. was born to Ms. 27. A=0. Maternal History revealed that baby L. She was taking regular prenatal medication. a 34 year old.V.. a live full term baby boy.CHAPTER III CLIENT PRESENTATION This is a case of baby L. Upon delivery.J. Identification Band was checked and was located at right hand and right leg.J. 25 . Apgar score was 9. L=0) at AOG of 38 4/7 weeks by last menstrual period. (-) dyspnea Risk for ineffective airway clearance related to presence of oropharyngeal secretions was identified. 10. Amniotic fluid was clear. During the pregnancy. Nov. Ms. During the 1st trimester Ms. Sex was also verified. 2010 patient was admitted to the Nursery. Patient was received cuddled by the delivery room nurse. Secretions were immediately suctioned via the nose and mouth. Gravida 1 Para 0 (T=0. baby had a good cry and good activity.V was noted to have gestational Diabetes Mellitus and was managed with insulin. P=0.
Physical Examination was also done and revealed the following results: a.with the temperature of 36. the baby was kept warm by swaddling. c. no molding.) Anus – patent. booties and bonnet. Cord care and cord clamping was also done aseptically.intact Infant’s temperature was allowed to stabilize before the initial cleaning was done. d.) Trunk and spine – straight. no discharge.05 ml was given intramuscularly on the anterolateral thigh. BCG was given at the right buttocks (intradermal).good activity. i. (Normal Values: 75-50/45-25).) Genitalia – grossly male.) Eyes – no discharge. l.1 ml of vitamin K given at the right anterolateral thigh and Terramycin was applied in the eye.5°C) taken rectally. e. no cephalhematoma.) Lungs – clear breath sounds.5°C (Normal Values: 36.) Extremities – grossly symmetrical and m.) Chest – equal/chest expansion. good color. and kept under the radiant warmer. Hepa B vaccine 0. b. g. 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). h. kept the baby dry. The following interventions were done.) Mouth. j.) general appearance . no tongue tied. Blood pressure was: 69/28 mmHg (36). good tone and good cry.) Ears and nose – patent.) Heart – no murmurs. j.Initial vital signs were taken and revealed that: temperature was 36.5 o C Risk for Hypothermia related to immature thermoregulating mechanism was identified. no cleft palate. f. k.) Skin – no lesion/s. no jaundice.5-37. pharynx – no cleft lip.)Reflexes . Infant was then dressed and swaddled comfortably. and the infant was given mittens. 26 . 0.) Head and neck – no caput.
74 mg/dL. 04. 2010 client was diagnosed with hyperbilirubinemia with the laboratory results of Total Bilirubin = 16. 2010 the client’s condition improved and was roomed in.02 mg/dL. The patient had good skin turgor but with jaundice.72 mg/dL. abdominal circumference was 32 cm (Normal Values 28-32 cm:). Anthropometric measurements were also taken: head circumference was 35. body length was 52 cm (Normal Values 48-52 cm) and weight was 3374 grams (Normal values: 2500-4000 g). Interventions done were doing cord care and keeping the cord dry and exposed. 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. 27 . Direct bilirubin = 0.5 cm (Normal Values 33-35 cm).With (+) newly clamped cord Risk for infection related to inadequate secondary defenses was identified. chest circumference was 34 cm (Normal Values 31-33 cm). 30. On Nov. and Indirect bilirubin = 16. Interventions done were the infant was turned and that the eyes and genitals were covered. Dec.
and/or diminished and with no form of Rationale: To see if there’s a blockage in the foreign body in the oral opening airway clearance. Clear breath sounds. 6. clear whitish secretions noted.69/28 mmHg 2. Monitor vital signs. 3. 4.5 ºC • RR. Oxygen will be provided when needed. NURSING CARE PLAN 28 . RESPONSE 1. (December 3. Moderate. Rationale: To obtain baseline data.44 breaths/min • HR. Provide oxygen when needed as ordered by the doctor Rationale: To prevent alteration of gas exchange. 2010) • T. Keep infant’s mouth and nose clear from 4. Vital signs were taken. 5. Rationale:To remove the internal secretion. no chest retractions 2. Goal: To maintain airway clearance Expected Outcome: At the end of 15 minutes – 30 minutes of nursing intervention. no wheezes. 5. Rationale: To see if there’s a blockage in the airway clearance. no crackles. 3.Moderate. The newborn was suctioned. Good skin color (pink-pale) • Clear breath sounds • (-) secretions in mouth and nose INTERVENTIONS PROMOTIVE/PREVENTIVE: 1. Note for presence of secretions.36. Oral secretions have been lessened any obstruction. clear whitish secretions was seen.NURSING CARE PLAN Nursing Diagnosis # 1: Risk for ineffective airway clearance related to presence of oropharyngeal secretions.149beats/min • BP . Assess for characteristic of breath sounds. rales. Perform suctioning when needed. Client will show no signs of ineffective airway clearance as evidenced by: • Respiratory rate within 30-60cpm • (-) cyanosis. 6. Rationale: To see if the baby is breathing normally.
Slowly feed the infant.36. Check the mouth and nose for any secretions Rationale: To maintain airway clearance 3.5 ºC Rationale: To obtain baseline data. 5. Auscultate lungs for irregular breath sounds Rationale: To distinguish if the client has normal breath sounds. 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. Rationale: To avoid choking and entry of feeding into the airway. Assess infant’s breathing and feeding 1. 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. 29 . (-) cyanosis. The baby consumed feeding without choking. rate. especially respiratory 2. 4. The baby has clear breath sounds. Monitor vital signs. 5.149 beats/min • BP – 69/28 mmHg 3. The baby showed no signs of difficulty in pattern breathing. 6. with a RR of 44 breaths/min. feeding.Nursing Diagnosis # 2: Risk for aspiration related to immature cardiac esophageal sphincter. Report any deviations. had clear breath.44breaths/min • HR. 4 the baby’s lungs was checked and showed no signs of difficulty in breathing. 6. 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. 2. The baby showed no difficulty in breathing. Vital signs were taken. good skin turgor with jaundice. Assess infant’s skin color and activity Rationale: To make sure that the baby isn’t going through any respiratory distress. • RR. every 4 hours. • T.
Position infant in a semi-fowler’s position. 8. No regurgitation experienced. Rationale: To provide the baby with ease in swallowing. The baby consumed feeding with ease and did not show signs of choking or aspiration. If regurgitation is present put the infant in a vertical position and tap the back (for burping). 7. Burp the infant between feedings. Rationale: To make sure that the baby isn’t going through any respiratory distress. Rationale: To prevent further regurgitation that could lead to aspiration.CURATIVE: 7. To avoid choking and entry of feeding into the airway. 9. NURSING CARE PLAN 30 . (+) burp 8. 9.
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. 1.Client’s age is noted. The baby is 6 days old. 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 . the client will manifest: • • • Normal vitals sigs Patient’s skin color will be normal Normal bilirubin level INTERVENTIONS RESPONSE 1. 2. Note the infant’s age. Assist with phototherapy treatment. Rationale: May aids in diagnosing underlying cause in connection with the appearance of 2. Have the infant completely undressed Rationale: To expose the entire skin phototherapy in 5. Rationale: To allow for utilization of alternate pathways for bilirubin excretion 4. The patient’s color is normal (Pink) jaundice. Monitor vital signs 3.
Maintain daily cord care. PREVENTIVE 2. 4. bonnet. 5. Stress proper hygiene before doing cord care (Hand washing). Apply proper strokes when doing cord care. and bed cover everyday.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. Monitor Vital signs especially temperature Rationale: Fever is the first sign of infection 3. 6. Educate the mother on performing proper 32 • • • RESPONSE 1. Applied hand washing before giving the cord care. 36. Use prescribed solution when doing cord care (70% ethyl alcohol or povidone iodine).9 ͦC 3. .1 ͦC 1200H = 48 cpm. the 2. 2010 0800H =44 cpm. December 3. REHABILATIVE 1. 125 bpm. 35. Cord care was monitored. Mother agreed to wash hands and clean her baby’s cord using alcohol and cotton. 2. mittens. Monitor the area at the base of the umbilical cord for any swelling or redness. 3. 147 bpm. 4. Provide care to the newborn. The umbilical cord was kept dry 5. the client will be prevented from infection as manifested by: Normal vital signs No redness around the cord Be free from other complications INTERVENTIONS PROMOTIVE 1. booties. Change clothes. 4. blanket. Fold the diaper below the umbilical cord to prevent it from being wet.
33 .cord care 2. Instruct the mother to wash hands before doing cord care to prevent transmission of microorganisms.
9 C at 1200H (December 3. Expected Outcome: After 8 hours of nursing intervention the client will: • Temperature within normal range (36. Jaundiced skin color 5. 2. place under adequate blankets. Client’s age is noted. and booties. 3. The temperature was assessed. Rationale: Heat loss in newborn is greatest through head and by evaporation and convection. 5. The baby is 6 days old. Rationale: It can directly impact ability to maintain/regulate body temperature and respond to environmental changes. surgery. physiologic and trauma. Determine if present condition results from exposure to environmental factors. RESPONSE 1. Good suck noted PROMOTIVE: 4.5) • (-) cyanosis • Skin warm to touch INTERVENTIONS PREVENTIVE: 1. T: 36.NURSING CARE PLAN Nursing Diagnosis # 5 : Risk for Hypothermia related to immature thermoregulating mechanism. Note client’s age. 34 . Rationale: Helps to determine the scope of interventions that maybe needed. Cover infant’s head with knit cap. Goal: To maintain body temperature within normal range. The resulting factors are environmental and physiologic. 2010) ͦ 4. infection. 3.5-37.1 C at 0800H (December 3. 2. Rationale: Heat loss in newborns is greatest through head and by evaporation and convection. The condition was determined. 2010) ͦ T: 35. Assess temperature with low register thermometer. bonnet. Let the baby wear mittens.
Warm your hands before touching the baby. When using instrument such as stethoscope. 9. Encourage mother to breastfeed the baby Rationale: Breastfeeding encourage transmission of heat from mother to the baby and increases metabolism which produces heat.6. 35 . warm it first. 8. Swaddle the baby 7. Observe signs of cyanosis 10.
gastric lavage done. no dyspnea. 1200H = 48 cpm. six days old. ͦ 2010) 0800H =44 cpm.g.. heart sounds clear and regular. 36 .10 Suctioning done. or neuromuscular weakness. good perfusion. weight = 3374 grams. respiratory muscle fatigue. breath sounds clear. presence of moderate clear whitish secretions. bronchitis. and chemical irritants) can overtax these mechanisms. RR = 44cpm. Ineffective airway clearance can be an acute (e. pneumonia. postoperative recovery) or chronic (e. NANDA Definition: Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency. and the lymphatic. Cues that supported this diagnosis are the following: Initial vital signs: HR = 149bpm. Maintaining a patent airway is vital to life. Monitoring of the RR (December 3. who have an increased incidence of emphysema and a higher prevalence of chronic cough or sputum production. macrophages. Temperature = 36.. BP = 69/28 mmHg. are at high risk. Other mechanisms that exist in the lower bronchioles and alveoli to maintain the airway include the mucociliary system. Factors such as anesthesia and dehydration can affect function of the mucociliary system. good and loud cry.g. Coughing is the main mechanism for clearing the airway. the cough may be ineffective in both normal and disease states secondary to factors such as pain from surgical incisions/ trauma.5 C.. Likewise. good skin turgor with jaundice. delivered via elective caesarean section.CHAPTER IV Case Analysis and Interpretation NDx#1: Risk for ineffective airway clearance related to presence of oropharyngeal secretions. from cerebrovascular accident [CVA] or spinal cord injury) problem. However.g. good body movement. APGAR = 9. conditions that cause increased production of secretions (e. Elderly patients.
AOG = 38 4/7 weeks by LMP. HR. RR. oral secretions have been lessened and/or diminished and with no form of foreign body in the oral opening. Note for presence of secretions. The formulated goal in the plan of care was to maintain airway clearance. clear whitish secretions was seen. moderate. good rooting. moderate. Provide oxygen when needed as ordered by the doctor. 38 weeks by MI. no chest retractions.36. Perform suctioning when needed. Keep infant’s mouth and nose clear from any obstruction. clear breath sounds. rales. no wheezes. 2010) T. BP 69/28 mmHg. the newborn was suctioned. (December 3. oxygen will be provided when needed.5 ºC. and gag reflex. clear whitish secretions noted. no crackles. Monitor Vital signs. Vital signs were taken.149beats/min. 37 . The following interventions were done to achieve the said goal: Maintain daily cord care. Assess for characteristic of breath sounds.44 breaths/min .chest circumference = 34 cm. sucking. The following evaluations were achieved through the help of the said interventions.
Promotion of parental attachment and assimilation of the infant into the family are also of vital importance. because it provides numerous health benefits to both a mother and an infant.. (Doenges et al. vitamins. it remains the ideal nutritional source for infants through the first year of life. 2006) A term newborn who is to be breastfed may be fed immediately after birth. 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. water. 6th edition. Some newborns choke or gag during the first feeding. others may become dusky or cyanotic because they become apneic while they are feeding. 2008) Relatively immaturity of their body systems. or solids or fluids into tracheobronchial passages. minerals. Risk for aspiration is defined as at risk for entry of gastrointestinal secretions. The nurse evaluates the infant’s ability to suck. There is no need for daily weighing especially of healthy term infants. newborns require a great deal of physical care. oropharyngeal sections. colostrums production continues. Gardner. Colostrum a thin. swallow and breathe in a coordinate manner. fat. For the first 3 or 4 days after birth. yellow fluid composed of protein. (Handbook of Neonatal Intensive Care. watery. It is universally agreed upon that breast milk is the preferred method of feeding a newborn.Nursing Diagnosis # 2: Risk for aspiration related to immature cardiac sphincter. 4th Edition. Murray and Mc Kinnly. sugar. and maternal antibodies. Because of its high in protein and fairly low in sugar and fat. (Foundations of Maternal-Newborn Nursing. colostrum is easy to digest and capable of providing adequate nutrition for a newborn. 2006) 38 .
normal clear breath sounds. Position infant in a semi-fowler’s position. Check the mouth and nose for any secretions. no dyspnea. and was burped every after feeding. with the apgar score of 9 in the 1st minute and 10 in the 5th minute. fed via breastfeeding and cup feeding (glucose water every 2 hours). Monitor vital signs. delivered via elective cesaerian. suctioning done. presence of moderate clear whitish secretions. good skin turgorm good body movement. especially respiratory rate. gastric lavage done. no regurgitation seen. good and loud cry. Assess infant’s skin color and activity. 2007) Cues that supported this diagnosis are the following: Initial vital signs of heart rate of 149 beats per minute. The formulated goal in the plan of care was to prevent aspiration of the newborn. blood pressure of 69 over 28 mmHg. temperature of 36. Assess infant’s breathing and feeding pattern. respiratory rate of 44 cycles per minute. cuddled by mother while breastfeeding. Report any deviations. The following interventions were done to achieve the said goal. monitoring of respiratory rate December 3. lipase and amylase remains deficient for the first few months of life.Although a newborn’s stomach holds about 60 to 90 mL. every 4 hours. To maintain airway clearance.5 degrees Celsius. 2010 0800H respiratory rate is 44 cycles per minute and at 1200H respiratory rate is 48 cycles per minute. Good perfusion. good suck. a newborn has limited ability to digest fat and starch because the pancreatic enzymes. heart sounds clear and regular. Slowly feed the infant. newborn is six days old. 39 . A newborn regurgitates easily because of an immature cardiac sphincter between the stomach and esophagus (Pillitteri. Burp the infant between feedings. Auscultate lungs for irregular breath sounds. If regurgitation is present put the infant in a vertical position and tap the back (for burping).
40 . with a RR of 44 breaths/min. The baby showed no difficulty in breathing.149 beats/min.The following evaluations was achieved through the help of the said interventions.5 ºC. T. HR. (+) burp . the baby’s lungs was checked and showed no signs of difficulty in breathing. had clear breath.44breaths/min . The baby displayed no signs of choking or gagging while being fed. The baby showed no signs of difficulty in breathing. BP – 69/28 mmHg . No regurgitation experienced.36. The baby has clear breath sounds. (-) cyanosis. good skin turgor with jaundice. The baby consumed feeding without choking. RR. The baby consumed feeding with ease and did not show signs of choking or aspiration.. Vital signs were taken.
Pharmacologic agents have been used in the management of hyperbilirubinemia to stimulate the induction of hepatic enzymes and carrier proteins. Specific pharmacologic agents have been used to prevent hyperbilirubinemia or reduce bilirubin levels. Maternal. S. United Staes of America: Elsevier Inc. and women’s health nursing: comprehensive care. fetal. Orshan. Prevention has focused on early initiation of feedings and frequent breastfeeding to decrease enterohepatic shunting. 41 . and stimulate intestinal activity.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. its skin turgor and the age of the baby as much as possible especially the vital signs of the baby (Orshan. Monitor the weight of the client. newborn. to interfere with heme enzymes and carrier proteins. 2010). exchange transfusion and phototherapy.al (2007). Maternity. or to bind bilirubin in the intestines to decrease enterohepatic reabsorption.A. promote establishment of normal bacterial flora. Flourida: USA. use of pharmacologic agents. Page 963 Various techniques have been used to manage neonates with indirect hyperbilirubinemia. Jackson C. S. 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. (2010). to interfere with degradation. neonatal physiology. et.. Strategies have included prevention.
Very high or rapidly rising bilirubin levels may need to be controlled with and exchange transfusion. RR = 44cpm. Have the infant completely undressed. Note the infant’s age. in which case feedings would be temporarily interrupted for the procedure.9 ͦC. The main goal is to protect infant from injury: the following interventions were done to fully meet the main goal. If the neonate is less than 38 weeks’ gestation. healthy. Good and loud cry. Maternity nursing 7th edition. D. BP = 69/28 mmHg. Missouri: Mosby. Laboratory results: Total Bilirubin = 16. Placed in a double phototherapy using bilibed. Lowdermilk. (2006).74 mg/dl. 38 weeks by MI. the bilirubin level for initiating phototherapy may be somewhat lower than if the neonate is full-term. Delivered via elective caesarean section.72 mg/dl. ͦ 2010.02 mg/dl. and does not have any type of haemolytic disease.The management of hyperbilirubinemia will depend to some extent on the cause. Cues that supported this diagnosis are as follows.al. but ultimately on the level of bilirubin and the condition of the neonate. Good skin turgor with jaundice. Keep the eyes and genitals covered. Initial vital signs: HR = 149bpm. Good rooting. 0800H =44 cpm.1 ͦC 1200H = 48 cpm. Develop a systemic schedule of turning the infant. The following interventions were evaluated and the 42 . Good prefusion. 35. Direct bilirubin = 0. Indirect bilirubin = 16. Inc. Assist with phototherapy treatment. et. Good body movement. Six days old.5 C. AOG = 38 4/7 weeks by LMP. 36. and gag reflex. 125 bpm. sucking. Good activity. 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. Monitoring of the RR December 3. 147 bpm. or has hemolysis or other medical problems. Monitor vital signs. Temperature = 36.
The patient’s color is normal (Pink) 43 .evaluations were Client’s age is noted. The baby is 6 days old.
BP = 69/28 mmHg. and/or the mucous membranes allow invasion by pathogens. soft tissues (cells. 147 bpm. and lacking knowledge about disease transmission place individuals at risk for infection. invasive procedures. traumatic or surgical. Open wounds.1ml of 10mg/ml ampule at right anterolateral thigh 44 . fungus. Cues that supported this diagnosis are the following: Initial vital signs: HR = 149bpm. Given vitamin K (phytomedionekanakion ample 10mg/ml) 0.5 C. No dyspnea.. or by invasion of pathogens carried through the bloodstream or lymphatic system. either by contact or through airborne transmission. or sharing of intravenous (IV) drug paraphernalia. 2010) 0800H =44 cpm. virus. sexual contact. 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. (+) cord stamp. Newborn care was done like sponge bath and cord dressing.1 ͦC 1200H = 48 cpm.g. fat. bacterium. Infections occur when an organism (e.Heart sounds clear and regular. Six ͦ days old. Infections can be transmitted.10.NDx#4: Risk for infection related to inadequate secondary defenses. can be sites for infection. dry. Monitoring of the vital signs: ͦ (December 3. If the host’s (patient’s) immune system cannot combat the invading organism adequately. 125 bpm. Good and loud cry. APGAR = 9. Good body movement. 35. Breath sounds clear. Good perfusion. RR = 44cpm. having inadequate resources for sanitary living conditions. the body’s first line of defense. Being malnourished.9 C. Good skin turgor with jaundice. an infection occurs. 36. Breaks in the integument. lungs) can also be sites for infection either after trauma. or other parasite) invades a susceptible host. muscle) and organs (kidneys. Temperature = 36.
Applied hand washing before giving the cord care. 147 ͦ bpm. sucking. mittens. The umbilical cord was kept ͦ dry. The following evaluations was achieved through the help of the said interventions: Cord care was monitored. 125 bpm. 35. 45 . Given BCG at the right buttocks (intradermal) Blood typing done.05 ml intramuscularly on the anterolateral thigh. Presence of moderate clear whitish secretions. Educate the mother on performing proper cord care. Fractionated bilirubin done. Stress proper hygiene before doing cord care (Hand washing).9 C.Monitor the area at the base of the umbilical cord for any swelling or redness. Change clothes. Monitor Vital signs especially the temperature. Gastric lavage done. 38 weeks by MI. and gag reflex. Good rooting. Given Hepa B vaccine 0. Fed via breastfeeding and cupfeeding (glucose water. every 2 hours).1 C. Instruct the mother to wash hands before doing cord care to prevent transmission of microorganisms. blanket. Apply proper strokes when doing cord care. booties. Fold the diaper below the umbilical cord to prevent it from being wet. 2010). Elimination = 1 stool. Mother agreed to wash hands and clean her baby’s cord using alcohol and cotton. Newborn Screening done. AOG = 38 4/7 weeks by LMP.( intramuscular). Use prescribed solution when doing cord care (70% ethyl alcohol or povidone iodine). Suctioning done. Delivered via elective caesarean section. 1 urine (December 3. The following interventions were done to achieve the said goal: Maintain daily cord care. Provide care to the newborn. bonnet. The formulated goal in the plan of care was to prevent aspiration of the newborn. and bed cover everyday. Placed in a double phototherapy using bilibed. 2010) 0800H =44 cpm. (December 3. 36.1200H = 48 cpm.
but his ability to stay warm may easily be overwhelmed by extremes of environmental temperatures. Hypothermia in newborn: Newborn baby is a homoeothermic. inter scapular area and axillary region.thefreedictionary. Brown fat is the site of heat production. nape of neck. A low birth weight baby has decreased thermal insulation due to less subcutaneous fat and reduced amount of brown fat. This mechanism of heat production is called non-shivering thermogenesis.com/neonatal+hypothermia) 46 . tray etc. 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. Metabolism of brown fat results in heat production. convection and radiation in addition to non-shivering thermogenesis. convection (by air currents in which cold air replaces warm air around baby-open windows.). conduction (by coming in contact with cold objects-cloth. It is localized around the adrenal glands. fans) and radiation (to colder solid objects in vicinity-walls). Blood flowing through the brown fat becomes warm and through circulation transfers heat to other parts of the body. kidneys. Thermal balance: Newborn loses heat by evaporation particularly soon after birth (due to evaporation of amniotic fluid from skin surface). The process of heat gain is by conduction.NDx#5:Risk for Hypothermia related to immature thermoregulating mechanism. (http://medical-dictionary.
36. 1200H = 48 cpm. jaundiced skin color. good suck noted.1 ͦC at 0800H (December 3. ͦ 47 .APGAR = 9. Observe signs of cyanosis. place under adequate blankets. Note client’s age. Warm your hands before touching the baby. 125 bpm. Delivered elective caesarean section. warm it first. Environmental temperature: 28 ͦC. 147 bpm. Good body movement. Good rooting. client’s age is noted. The following evaluations was achieved through the help of the said interventions: The condition was determined. Good perfusion. surgery. No dyspnea. Let the baby wear mittens. Good skin turgor with jaundice. 2010)0800H =44 cpm. 2010). and booties. When using instrument such as stethoscope. Encourage mother to breastfeed the baby.Cues that supported this diagnosis are the following: Initial vital signs: HR = 149bpm. infection. Good ͦ ͦ and loud cry. physiologic and trauma. Monitoring of the vital signs: ͦ (December 3. 2010) T: 35. Six days old. 38 weeks by MI. Cover infant’s head with knit cap.10. the temperature was assessed. The following interventions were done to achieve the said goal: Determine if present condition results from exposure to environmental factors.1 C. BP = 69/28 mmHg. Swaddle the baby.5 C. the baby is 6 days old. Assess temperature with low register thermometer. 35.9 C at 1200H (December 3. Heart sounds clear and regular. AOG = 38 4/7 weeks by LMP. Temperature = 36. the resulting factors are environmental and physiologic. T: 36. RR = 44cpm. sucking. cold environment.9 C. bonnet. Routine newborn care was done like sponge bath and cord dressing. and gag reflex The formulated goal in the plan of care was to prevent hypothermia of the newborn. Breath sounds clear.
and a variety of other important adaptations. including the shift from fetal to postnatal circulation. a newborn total score is under 4 is in serious danger and needs resuscitation. Transitions by nature are challenging. the essence of life depends on this successful transition. but this is never truer than it is for transition from intrauterine to extra uterine life. With minutes of being exposed to the environment. 48 .CHAPTER V SUMMARY OF FINDINGS. Successful transition requires the initiation of spontaneous breathing. thermoregulatory and metabolic adjustments. In fact. 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. including but not limited to. It reveals that the newborn is at her second day of life. the newborn is observed and rated to an Apgar score. Factors that led to the development of the problem • • • • • • Transition to extra uterine living Age Birthing history Apgar Score Environment Maternal History II. significant cardiopulmonary changes. CONCLUSION AND RECOMMENDATION I.
Note for presence of secretions. • • • • • • Monitor vital signs. Significant Interventions Rendered : Risk for ineffective airway clearance related to presence of Nursing Diagnosis #1 oropharyngeal secretions. Keep infant’s mouth and nose clear from any obstruction.III. every 4 hours. • • • • • • • Assess infant’s breathing and feeding pattern Monitor vital signs. Nursing Diagnosis # 2: Risk for aspiration related to immature cardiac esophageal sphincter. Assess infant’s skin color and activity Burp the infant between feedings. Check the mouth and nose for any secretions Auscultate lungs for irregular breath sounds Slowly feed the infant. especially respiratory rate. Assess for characteristic of breath sounds. Provide oxygen when needed as ordered by the doctor Perform suctioning when needed. 49 . Report any deviations.
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. blanket. Change clothes. booties. 50 . Monitor the area at the base of the umbilical cord for any swelling or redness.• • Position infant in a semi-fowler’s position. bonnet. Nursing Diagnosis # 5: Risk for Hypothermia related to immature thermoregulating mechanism. If regurgitation is present put the infant in a vertical position and tap the back (for burping). Apply proper strokes when doing cord care. Provide care to the newborn. and bed cover every day. mittens. Use prescribed solution when doing cord care (70% ethyl alcohol or povidone iodine). Stress proper hygiene before doing cord care (Hand washing).
bonnet. surgery. warm it first. Swaddle the baby When using instrument such as stethoscope. Let the baby wear mittens. Warm your hands before touching the baby. infection. • • • • • • • • • Note client’s age. place under adequate blankets. and booties.• • • Keep the baby warm and dry Monitor the vital signs especially the temperature Determine if present condition results from exposure to environmental factors. 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 51 . gloves and bonnet Place the neonate in a radiant warmer IV. Assess temperature with low register thermometer. physiologic and trauma. Dress the newborn with mittens. Cover infant’s head with knit cap.
52 . To change her lifestyle in order to avoid related conditions from precipitating. The researchers would like to recommend the following: For the patient: • • To verbalize her concerns about the noticeable discomfort within her body system. • To participate in the rehabilitation of the patient in continuing to care for the development of the patient. sexual activity. • To provide necessary information regarding the condition of the patient or other family members having the same case. environment. and her sedentary lifestyle.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. • To give enough time to give the best care for the client and be considerate enough in meeting the client’s needs. For the family members: • To give more attention and improve their sensitivity towards the health conditions of the client.
• • To incorporate health teaching and enhance patient’s awareness on the disease processes. • They must also inform every health care team as soon as possible when there is any significant finding on the condition of the patient.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. 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. For the health care team provider to have holistic approach to client as a person. • So that they will work hard and hand-in-hand with other members of the health care team. For the future researchers: 53 . • This will also be a basis of their experience in clinical duty in using their skills and knowledge on the matter.
In addition.• That they utilize this research as a baseline data for the enhancement of quality and safe nursing care they may provide to their patient. 54 . 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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