School of Health and Natural Sciences Nursing Department

Saint Mary’s University
School of Health and Natural Sciences

Nursing Department
In partial fulfillment of
the Care of mother, Child at Risk or with
Problems (Acute and Chronic) NCM 109 RLE
BILIARY ATRESIA
Submitted to:
Mrs. Joan Taroma
Mrs. Marie Curie De Pona
Mrs. Jezerel Credo
Mrs. Jenifer Joy Camacho
Mr. Mayer Tominez
Submitted by:
Pumaras, Jhanna Mei A.
Rabanal, Kryztelle Cassandrah
Ragual, Mica T.
Ramos, Angela C.
Respicio, Meryl Priss M.
Sajor, Ryan Paul M.
Silisilon Lady Alexzandrea C.
Tayaban, Summer Janie A.
Tolentino, Jamie Ann Nicole P.
Tumanut, Josephine Mae D.
BSN2B
CODE 5053
Nursing Department
TABLE OF CONTENTS
I. 3P’s 3
II. BRIEF DESCRIPTION 6
III. ANATOMY AND PHYSIOLOGY 10
IV. PATHOPHYSIOLOGY 13
V. LABORATORY RESULT AND DIAGNOSTIC STUDIES 14
VI. PHYSICAL ASSESSMENT AND ITS PHYSIOLOGICAL BASIS
Psychosocial 16
Elimination 16
Rest and Activity 18
Safe Environment 22
Oxygenation 23
Nutrition 28
VII. DRUG STUDY 29
VIII. COURSE VISIT 36
IX. NURSING CARE PLAN 45
X. REFERENCES 51
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Nursing Department
CHAPTER I
3Ps
PERSONAL PROFILE
Name: Ms. XZ
Age: 4 weeks old
Gender: Female
Birthday: March 12, 2021
Address: Zamora St., Brgy. Don Domingo Maddela (District I), Bayombong Nueva Vizcaya
Birthplace: Bayombong, Nueva Vizcaya (Region II Trauma and Medical Center)
Civil Status: child
Nationality: Filipino
Ethnicity: Tagalog
Religion: Roman Catholic
Blood Type: A+
Gestational Age at Birth: 38 Weeks AOG, Cephalic in Labor

Birth Weight: 2.4 kg
Present Weight: 4 kg
Birth Length: 49.2 cm
Present Length: 53.8 cm
Head Circumference: 34 cm
Chest Circumference: 33 cm
Abdominal Circumference: 32 cm
Name of Father: Mr. Y

Age: 23
Occupation: Courtesy Clerk/ Bagger
Educational Attainment: College Graduate
Name of Mother: Ms. W

Age: 22
Occupation: None
Educational Attainment: College Graduate
Assessment: April 9, 2021 at 9:00 am

Subjective
 “Parang nahihirapan po huminga yung anak ko” as verbalized by the client.
 “Iyak po ng iyak ung anak ko hindi makapakali “AVB by the mother
Objective
● Temperature: 36.5°C
● Blood Pressure: 85/50
● Pulse Rate: 110 bpm
● Respiratory Rate: 66 bpm
● Abdominal Distention: 38 cm
● Nasal Flaring
Date of Admission: April 9, 2021 9:00 am

Date of Discharge: April 20, 2021 12:00 noon
Baby XZ is a 4 weeks old baby whose parents are both Catholic and happily living together. She
was born on the 12th day of March, year 2021 at Region 2 Trauma and Medical Center (R2TMC). The
baby’s blood type is A+ and upon assessment, her current weight is 4kg and 53.8 cm in length. Baby XZ
is now considered a Filipino citizen and belongs to the Tagalog ethnic group. Her parents are fresh
college graduates and the mother stays at home to take care of her. The father is a courtesy clerk/ bagger
at Savemore Supermarket Bayombong Branch.
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Nursing Department
HEALTH HISTORY
I. Present Health History
Two days after the birth of baby XZ, Ms. W asked the nurse why her baby’s skin and the whites
of the eyes are yellowish. Then, it was mentioned by the nurse that it is called jaundice which is a common
and usually harmless condition in newborn babies and it usually clears up within 2 weeks in formula-fed
babies and it may last for more than 2 to 3 weeks in breastfed babies.
Then five days later, when the yellowing of the eyes and skin of baby XZ disappears. Two weeks
and four days after, when Ms. W noticed that baby XZ’s skin and the whites of her eyes were turning
yellowish again. Also, she noticed that the abdomen of the baby seems bloated, the stool of baby XZ is
pale and the color of the urine is dark yellow. Three days later, there was still the presence of jaundice,
so she notified her husband immediately and went to the hospital.
Baby XZ is a 4 weeks old baby girl who lives with her parents. She was brought to the OPD in the
hospital at 9 o’clock in the morning and her parents report that Baby XZ has yellowing of her eyes with
subsequent yellowing of her skin, poor sucking. The mother also states that the baby has dark yellow
urine and clay colored or pale stools. Upon assessment by the nurse, the baby weighed 4kg and
measured 53. 8 cm. No rashes are evident in the baby’s body.
A physical exam was performed by the pediatric doctor to assess the chief complaints of Ms. W,
the doctor feels the infant’s abdomen and it appears that baby XZ has an abdominal distention. The
doctor also examined the infant’s body for signs of jaundice, in which baby XZ has grade 1 jaundice as
of the assessment day, examined the infant’s body for other birth defects that sometimes occur along
with biliary atresia, and checked the color of the infant’s stool which is clay colored stool which indicates
that very little or no bile is reaching the intestine and a dark yellow color urine due to excessive bilirubin
in the bloodstream that passes to the kidneys and has poor weight gain which is one of the symptoms of
biliary atresia.
At 11:00 am, baby XZ was admitted to the pediatric ward for monitoring and for further
assessment. The following vital signs were recorded: BP 85/50mmHg, PR 110 bpm, RR 46 breaths per
minute, and temperature of 36.5℃.Then laboratory tests were performed to rule out other health
problems. Tests such as: Urinalysis, Complete Blood Count and Partial Thromboplastin Time (PTT). The
next day, the physician ordered Liver Function Test and Hepatobiliary Iminodiacetic Acid (HIDA) Scan.
All of the results of the laboratory tests were examined and baby XZ was diagnosed with Biliary
Atresia. The physician ordered a Laparoscopic Kasai procedure as treatment; this can help to re-
established bile flow from the liver to the intestine by joining the two directly.
II. Birth History
The pregnancy of Ms. W was unplanned. She and her partner were ambivalent when they found
out that she is pregnant because they were not expecting it but, after a few weeks Ms. W accepted her
pregnancy and they both got excited. They live in Mr. Y’s parents’ house because they are fresh college
graduates and Mr. Y is working to save up for their future plans. After knowing the pregnancy, they
immediately informed their family members of both sides. July 6, 2020 when they visited R2TMC for her
first prenatal check-up. Ms. W’s LMP is June 6, 2020 and EDC is March 12, 2021. In her first trimester,
she experienced common pregnancy symptoms like morning sickness and frequent urination. During her
second trimester when the gender of her baby was revealed they start buying things such as baby
clothes, lampin, diapers, crib and toys. March 12, 2021 she was admitted in R2TMC with an admitting
diagnosis of G1P0 (0000) 38 Weeks AOG, Cephalic in Labor. She’s already 4 cm dilated and in active
labor. When she gave birth to Ms. XZ she was very exhausted and tired due to the labor and delivery
process. Her labor lasted for 12 hours. She was discharged 2 days after being admitted with a final
diagnosis of G1 P1 (1001) pregnancy uterine term delivered via NSD. The APGAR of the baby is 7 and
the Ballard score is 40. The birth weight is 2.4 kg (5.29 lbs.) and length is 49.2 cm (19.4 inches). Head
Circumference: 34 cm, Chest Circumference: 33 cm, Abdominal Circumference: 32 cm.
The mother stated that she drank alcohol a couple of times during her pregnancy and smoke
cigarettes. On her first two days of birth, it has been reported that there is no breast milk that can be
sucked from mother's breast. Because of this, the baby had to be fed from another mother's breast milk.
The baby was immunized with the following:
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Nursing Department
Vaccine Date
Vitamin K March 12, 2021
Hepa B1 and BCG March 12, 2021
III. Family History
Ms. XZ is the first child of Mr. Y and Ms. W their family is an extended family because they live in
the family house of Mr. Y . According to the parents of Ms. XZ, both sides of the family have no history
of any genetic or hereditary disorder. Cancer, diabetes and lung problems are not present in the family.
IV. Social Health History
Ms. XZ is 4 weeks old and the first child of Mr. Y and Ms. W, they both parents smoke cigarettes
but, after the health teaching before their discharge, they decided to gradually stop their habit of smoking.
V. Feeding and Health Practices
Ms. W relays that baby XZ’s feeding pattern is 15 minutes per breast every 3 hours. From 7:30
am to 8:00 am the mother goes out to take a walk with baby XZ through the stroller, this was taught by
the nurse to help get rid of the yellowish skin of the baby.
Ms. W mentioned that she feeds her baby whenever she seems hungry and burps her each time
she switches milk. Baby XZ eliminates about 2-3 times a day in small amounts and usually eliminates
after feeding. Baby T sleeps 14-16 hours and three to four time naps each day. Baby XZ is given a bath
three times a week every morning.
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Nursing Department
CHAPTER II
BRIEF DESCRIPTION
Biliary atresia is a gastrointestinal disorder in which the biliary system is closed or absent. The
biliary system is the network of tiny tubular structures and ducts that drain bile from the liver to the small
intestine, where it helps the digestive process. Bile is a liquid secreted by liver cells, made up of
cholesterol, bile salts and waste products (including bilirubin). Biliary atresia progressively destroys the
bile ducts that carry bile from the liver to the intestine, beginning outside the liver and later affecting bile
ducts inside the liver. The damaged ducts prevent the draining of bile from the liver; as a result, bile
trapped inside the liver causes damage and scarring that can lead to cirrhosis.
Although it is relatively rare (occurring in 1 out of every 10,000 live births), biliary atresia is the
most common liver disease that requires transplantation. On average, there is one case of biliary atresia
out of every 15,000 live births. It occurs slightly more often in females than in males, and affects children
of all races.
There are two forms of biliary atresia:
● Perinatal biliary atresia. This is the most common type. It appears after birth, most often when a
baby is about 2 to 4 weeks old in which baby XZ has.
● Fetal biliary atresia. This is less common. It appears while a baby is still developing in the mother’s
womb.
There are three types of biliary atresia, classified by the level of most proximal biliary obstruction.
1. Type 1 (about 5%): The level of obstruction is within the common bile duct, with the gallbladder
containing bile. This type is sometimes associated with cystic change in some part of the
extrahepatic biliary tree.
2. Type 2 (about 2%): The level of obstruction is within the common hepatic duct with no bile in the
gallbladder but two bile-containing lumens in the proximal remnant.
● Type II a - atresia of the hepatic duct, with cystic bile ducts found at the porta hepatis
● Type II b - atresia of the cystic duct, common bile duct, and hepatic ducts
3. Type 3 (>90%): The level of obstruction is within the porta hepatis, with no visible bile-containing
proximal lumen.
In the case of baby XZ, she has the most common form which is the type III or “complete”
The exact cause of biliary atresia is not known. For some children, biliary atresia may occur
because the bile ducts did not form properly during pregnancy. For other children with biliary atresia, the
bile ducts may be damaged by the body's immune system in response to a viral infection acquired after
birth. Researchers are looking at possible causes, such as:
● Viral or bacterial infections

● Exposure to toxins
● Immune system problems
● Problem during liver and bile duct development in the womb
● A permanent change in a gene’s structure, called a genetic mutation
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Nursing Department
What is known for certain is that biliary atresia affects only newborns. It is not hereditary, not
contagious and it is not preventable.
Symptoms of biliary atresia usually begin to appear between two and six weeks after birth, and include:
● Jaundice (a yellow appearance of the skin and whites of the eyes) that does not improve within
one to two weeks
● Dark yellow or brown urine, due to excessive bilirubin in the bloodstream that passes to the
kidneys
● Pale or clay-colored (acholic) stools, an indication that very little or no bile (which gives bowel
movements their normal color) is reaching the intestine
● Enlarged liver that feels harder than normal, enlarged spleen
● Poor weight gain
Biliary atresia is a rare disorder. About one in 15,000 to 20,000 babies do not have complete bile
ducts. It seems to affect girls more than boys. Within the same family, it is common for only one child in
a pair of twins or only one child within the same family to have the disease. Asians and African-Americans
are affected more frequently than Caucasians. There does not appear to be any link to medications taken
during pregnancy.
Complications of biliary atresia include failure to thrive NIH external link and malnutrition, cirrhosis
and related complications, and liver failure. Without treatment, infants with biliary atresia would develop
cirrhosis within 6 months and liver failure within 1 year. By age 2, untreated infants would need a liver
transplant to survive or if the Kasai procedure is not successful.
Early treatment with a surgery called the Kasai procedure may slow or, in some cases, prevent
the development of cirrhosis and liver failure. Even with treatment, about half of children with biliary
atresia will need a liver transplant by age 2. Two-thirds will need a liver transplant sometime during
childhood.
Laboratories
1. Hematology for Complete Blood Count

2. Urinalysis
3. Liver Biopsy
4. Liver Function Test
5. Hepatobiliary Iminodiacetic Acid (HIDA) Scan
6. Partial Thromboplastin Time (PTT) Test
Kasai Procedure
The Kasai procedure is also known as hepatoportoenterostomy or Kasai portoenterostomy, is a
surgery performed on infants in which blocked bile ducts are bypassed to restore normal bile flow. The
flow of bile, a fluid produced by the liver that aids with digestion, can become obstructed when the ducts
do not form properly during pregnancy.
The Kasai procedure can either be performed as an open surgery (involving a large incision) or a
minimally invasive laparoscopic surgery (involving smaller incisions and specialized narrow instrument.
To perform the Kasai procedure, surgeons first carefully remove the damaged ducts outside of
the liver. They use a small segment of the patient's own intestine to replace the ducts at the spot where
bile is expected to drain. This segment not only connects to the liver, but also connects to the rest of the
intestine. The Y-shaped passageway formed by the Kasai operation allows bile to flow from the liver into
the intestine.
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Nursing Department
Pre - Operation
Once registration is complete, a surgical staff member will lead the mother and child to a
preoperative area, where a nurse will take your child's weight and height (which helps calculate the
correct anesthesia dose) and vital signs (including temperature, heart rate, and blood pressure). The
child is then prepped for surgery either in a private or semi-private room or cubicle. Because the
preoperative procedures can be scary and uncomfortable for children, the nurse may provide a mild
sedative to induce relaxation and prevent squirming or panic.
For the Kasai procedure, preoperative preparations will involve the following:
● Electrocardiogram (ECG): Used to monitor heart activity, the ECG is connected to the child's torso
via adhesive electrodes.
● Pulse Oximetry: Used to monitor blood oxygen saturation, the pulse oximeter is typically attached
to the child's big toe with a velcro strap.
● Intravenous line: Used to deliver anesthesia, medications, and fluids, the intravenous (IV) line is
usually inserted into a vein in the foot of non-walking children. It can also be inserted into the non-
dominant hand.
During the Surgery
Once the child is prepped for surgery and wheeled into the surgical suite, anesthesia is delivered.
Depending on whether the surgery is open or laparoscopic, the choices include the following:
● General anesthesia: This is a type of anesthesia delivered by IV that puts the child into an
unconscious state. It is used for open surgery but may also be chosen for laparoscopic surgery
in children with advanced liver disease.
● Regional anesthesia: This form of anesthesia was used on baby XZ to block pain signals. It may
involve a peripheral nerve block (involving an injection near a bundle of nerves) or an epidural
(involving an injection into the spine). Regional anesthesia is commonly supported by monitored
anesthesia care, a form of IV sedation used to induce a "twilight sleep."
Post - Operation
● The patient usually spends seven to ten days recovering in the hospital. During this time, the
Kasai will heal, and doctors will give your child medications to prevent ascites, or excessive fluid
build-up.
● For the first two to three days, the baby won’t be able to eat so that the internal wounds have a
better chance of healing. Nutrition will instead be delivered either through a nasogastric tube or
intravenously. The child will be monitored for flatulence and bowel movements, both of which
signal the return of normal intestinal function.
● The child may be given corticosteroid medicine. This helps decrease irritation and swelling of the
bile ducts in your child’s liver. This medicine may be given short-term or long-term.
Complications right after surgery are low. Most problems that develop are due to progression of
liver disease. After the Kasai procedure, it is common to get an infection in the bile ducts. This is usually
treated using intravenous antibiotics. Treatment may continue with oral antibiotics. But, baby XZ did not
have an infection.
Nursing Managements
Even after surgery, your child’s liver won’t be fully back to normal. Your child will need special
foods and medicine to help the liver do its work. The below care steps are needed after surgery, and
likely for a long time after. Your child will need:
● Feeding with breast milk or special formula. These provide types of fats that are easier for the
liver to absorb.
● Supplements for vitamins A, D, E, and K. These are fat-soluble vitamins.
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Nursing Department
● Antibiotic medicine. It helps prevent infection (cholangitis) caused by bacteria that travel from the
intestines into the liver and bile ducts.
● Bile acid replacement medicine. This helps improve bile flow. Your child may take this medicine
for several years.
Long Term Follow-up
The child’s health needs to be closely watched. At first, you will need to visit your child’s healthcare
provider often. As the child gets older, you may be able to visit less often. These visits may include:
● Blood tests. These are done to measure liver function and nutrition levels.
● An ultrasound exam. This uses harmless sound waves to create an image of the liver.
● Other tests. Your child may need additional kinds of tests over time. Your child’s healthcare
provider will tell you more about these.
● Vaccines. Your child will need to have vaccines against common childhood diseases. Make sure
your child gets a flu shot every year. Your child will also need vaccines for hepatitis A and B.
These are liver diseases and they can be much worse for a child who has biliary atresia.
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Nursing Department
CHAPTER III
ANATOMY AND PHYSIOLOGY
Biliary System
The biliary system also, called biliary tract or biliary tree which consists of liver, gall bladder,
pancreas, bile ducts and other associated structures. The main organs are associated with the
production, storage, transportation of bile. The main function of biliary system is to drain waste products
from the liver into the duodenum and to help in digestion with the controlled release of bile.
LIVER
A largest internal organ in the body, located on the right side of abdomen underneath the ribs and
diaphragm above of abdomen. It is normally weigh for about 1.3-3 kilogram and it is soft, pinkish-brown
and holds about 13 percent of the body blood supply.
The liver has two main lobes, which are made up of thousands of lobules. These lobules are
connected to small ducts which connects to a larger duct to form hepatic duct. The hepatic duct transports
bile produced by the liver cells to the gall bladder and duodenum.
Liver has lot of function which includes the following:

● Bile production and excretion
● Excretion of bilirubin, cholesterol, hormones and drugs
● Metabolism of fat, proteins and carbohydrates
● Enzyme activation
● Storage of glycogen, vitamins and minerals
● Synthesis of plasma proteins such as albumin and clotting factors
GALL BLADDER
It is a pear-shaped, hollow structure located underneath the liver and the right side of the
abdomen. It is connected to the liver by the hepatic duct. It is approximately 3 to 3 inches length and 1
inch in wide.
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Nursing Department
● There are several important function of the gallbladder which includes:

● To store and concentrate bile
● To respond to intestinal hormones
● To contribute to regulating the composition of bile
● To control the flow of bile into small intestine
● To contract
BILE DUCT
The bile duct is a tiny tube-like structure that connects the hepatic and cystic ducts. Its main
physiological role is to transport bile from the gallbladder and drain it into the small intestine's superior
portion (the duodenum). The biliary system includes the bile duct. The bile duct's main function is to carry
bile from the liver and gallbladder into the duodenum, which is the first part of the small intestine
pursuing the stomach. The bile it possess interacts with consumed fats and fat-soluble vitamin
supplements to allow them to be ingested by the intestine.
Bile is a dark-green or yellowish-brown fluid produced, secreted into the bile ducts and
gallbladder. It comprises of water, bile acids, cholesterol, phospholipids, bile pigments and electrolytes.
The gallbladder releases bile after eating to aid digestion and fat absorption. Bile also aids in the removal
of waste materials from the liver.
Types of bile ducts
● Intrahepatic ducts: Intrahepatic ducts are a system of smaller tubes within the liver that collect
and transport bile to the extrahepatic ducts.
● Extrahepatic ducts: The extrahepatic ducts begin as two parts, one on the right of the liver and
the other on the left. As they descend from the liver, they unite to form the common hepatic duct.
This runs directly toward the small intestine.
Integumentary System
SKIN
Skin is the largest organ of the human body. It is the outer layer of a person’s body and performs
a lot of very important functions for the body. The part skin that will be mostly affected is the right upper
quadrant. It is where the biliary system located. The skin will be open to remove the obstructed bile ducts
and gallbladder and replacing a segment of the small intestine of the child. It will sew to the liver and
serves as a new extrahepatic bile duct system.
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Nursing Department
Below are the five major functions of the skin:

 Regulates temperature in the body: The last but not least function of the skin is the fact that it helps
to regulate temperature in the body in order for the body to maintain a constant body temperature.
 A sense organ: The skin also functions as a sense organ. Thanks to the skin, we are able to detect
pain, pleasure, changes in pressure and temperature. This is another very important function of the
skin.
 Protects the body: The first function of the skin is give protection to the body tissues. The skin protects
the tissues of the body from mechanical damage and from bacteria. It also protects the body from
losing too much water through evaporation.
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Nursing Department
CHAPTER IV
PATHOPHYSIOLOGY
BILIARY ATRESIA
Risk Factor
PREDISPOSING FACTOR PRECIPITATING FACTOR

Maternal exposure to alcohol
Gender: Female and smoking
Age: Neonate
Race: Filipino Exposure to toxic substances
Exposure to virus
Deformity of the Bile

Duct
Obstruction of bile flow
Bile accumulation in the Increase pressure in the Bile cannot reach into the
liver ducts intestines
Liver became enlarged Bile will go through the No less bile pigments will
junctions below epithelial be excreted
cells lining
ABDOMINAL PALE STOOLS

DISTENTION Leak out in the blood
Increase amount of
conjugated bilirubin
Bilirubin excreted into the Yellowing of the skin

kidneys
JAUNDICE PRURITUS
DARK URINE
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Nursing Department
CHAPTER V
LABORATORY RESULT AND DIAGNOSTIC STUDIES
A. HEMATOLOGY FOR COMPLETE BLOOD COUNT, April 9, 2021, 1:00 Pm
Examination Results Units Normal Range Nursing Implication
Red blood Cell Count 3.5 millions/ mm3 3.90-5.90 Abnormal
Hematocrit 43 % 42-65 Normal
Hemoglobin 14.0 gm/dL 13.4-19.9 Normal
White Cell Count 12821 mm3 9000-30000 Normal
Differential (manual) Neutrophils 9563 mm3 1000-20000 Normal
Lymphocytes 3712 mm3 2000-11000 Normal
Monocytes 978 mm3 540-1800 Normal
Eosinophils 351 mm3 150-585 Normal
Basophils 141 mm3 0-400 Normal
Platelets 14689 μL 15000-45000 Abnormal
B. URINALYSIS, April 9, 2021, 1:30 pm
Examination Result Normal Range Nursing Implication

Abnormal
Clear, Pale,
The buildup bilirubin in the blood causes of the dark
Dark Transparent
Color color of the urine (The darker the color, the more
Yellow yellow, amber
concentrated the urine). We advise to always
yellow
hydrate the child and intake a prescribed vitamins.
Specific
1.031 1.010-1.025
gravity
pH 4.6 4.5-8 Normal
Protein Negative Negative Normal
Glucose Negative Negative Normal
Epithelial Normal
Few Few
cells
Bacteria Rare No Bacteria Normal
C. PARTIAL THROMBOPLASTIN TIME (PTT), April 9, 2021, 2:00 Pm
Test Values Range Significance

Prothrombin Time (PT) 14 sec 11-13.5 sec Abnormal
Activated Partial Prothrombin Time (APTT) 38.9 sec 25.4 - 38.4 sec Abnormal
D. LIVER FUNCTION TEST, April 10, 2021, 9:00 Am
Results Reference Unit Nursing Implication

Range
Total 7.1 6.6 – 8.3 g/dL Normal
Protein
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Nursing Department
Albumin 4.4 3.5 – 5.2 g/dL Normal

Globulin 2.9 2.4 – 3.5 g/dL Normal
Total 3.7 0.3 – 1.2 mg/dL INCREASED
Bilirubin Elevated bilirubin is a result of hemoglobin breakdown in
Direct 1.3 0.0 – 0.2 mg/dL the red blood cells. When hemoglobin is broken down,
Bilirubin bilirubin is produced, which travels through the body to
the liver to be turned into bile. This bile is then stored in
the gallbladder or eliminated in your stool. If the
gallbladder is sick or if it has a bile duct blockage, this can
cause elevated levels of bilirubin. Other conditions that
can lead to elevated bilirubin include tumors of the
gallbladder, pancreas, or bile duct.
AST 37 0 – 35 U/L Increased
(SGOT) Higher than normal levels of AST (SGOT) may indicate
that an organ or muscle that containing an enzyme
could be damaged
ALT 21 0 – 45 U/L Normal
(SGPT)
ALP 126 30 -120 U/L INCREASED
Higher than normal levels of ALP may indicate liver
damage or disease, such as a blocked bile duct, or
certain bone diseases.
E. HEPATOBILIARY IMINODIACETIC ACID (HIDA) SCAN, April 10, 2021, 9:20 am
Slow movement of radioactive tracer. Slow movement of the tracer might indicate a blockage or
obstruction, or a problem in liver function.
Gallbladder not visualized: the gallbladder is not 4 hours after the injection; it indicates that there is
either cholecystitis or cystic duct obstruction of the child.
A normal result means that the gallbladder is visualized within 1 hour of the injection and the tracer
is in the small intestine. The radioactive tracer moved freely with the bile from your liver into your
gallbladder and small intestine.
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Nursing Department
CHAPTER VI
PHYSICAL ASSESSMENT AND ITS PHYSIOLOGICAL BASIS
PERSON ASSESSMENT
PSYCHOSOCIAL
Date of Assessment: April 11, 2021
TYPE OF FAMILY: the patient lives with his father, mother, and grandparents
Extended family
SIGNIFICANT OTHERS: During the visit, both her parents were present.
Mother and father
REILIGION: Roman catholic
PRIMARY SOURCE OF HEALTH CARE Region 2 trauma and Medical Center
FINANCIAL RESOURCES: The source for financial resource of the family was the father, who is a courtesy
clerk.
GENERAL APPEARANCE: At the time of visit, the baby appears to be yellowish which is uncommon to a baby
until between 2 weeks to 6 weeks of life and her abdomen is distended. Also, she
appears tidy, and the clothing is in good condition which is appropriate to the climate.
ELIMINATION
STOOL
FINDINGS NURSING IMPLICATION
Pre-operation Pre-operation Post operation Post operation
assessment assessment assessment assessment
(April 9, 2021) (April 11, 2021) (April 12, 2021) (April 20, 2021)
FREQUENCY Approximately 2-3 Approximately 2-3 Approximately 4-5 Approximately 4-5 times During the visits, the baby eliminated for about 4
times (change times (change diapers) times (change (change diapers) to 5 times. Usually, she eliminates after feeding
diapers) diapers) by abducting her arms and legs together with
PATTERN Usually Eliminate Usually Eliminate after Usually eliminate after Usually eliminate after reddish face. The stool is soft and has minimal
after feeding feeding feeding feeding odor and the color of her stool is clay or pale
CONSISTENCY Putty Putty Soft Soft which means that there is no bile release by the
AND SHAPE
Nursing Department
PRESENCE OF Minimal odor Minimal odor Minimal odor Minimal odor liver which gives the stool a color of yellow to
UNUSUAL brown.
ODOR
COLOR Clay or pale in Clay or pale in color Yellow to brown in Yellow to brown in color
color color
ACTIVITY Abducting the arms Abducting the arms and Abducting the arms Abducting the arms and
DURING and legs with legs with reddish face and legs with reddish legs with reddish face
ELIMINATON reddish face then then subside face then subside then subside
subside
URINE
FINDINGS NURSING IMPLICATION
Pre-operation Pre-operation Post operation Post operation
COLOR Dark yellow Dark yellow Light yellow Light yellow Dark yellow urine is due to excessive bilirubin in the
AMOUNT 3 wet diapers 3 wet diapers 3 wet diapers 4-5 wet diapers bloodstream then bilirubin is filtered in the kidney and excreted
through urine.
NORMAL FINDINGS:
The color of the urine of an infant is transparent to light yellow.
It is within 4-7 wet diapers are expected daily.
ABDOMEN
Date of assessment: April 11, 2021- April 20, 2021
Pre-operation Pre-operation Post operation Post operation NURSING IMPLICATION
BOWEL All quadrants All quadrants All quadrants have All quadrants have a Diminished bowel sounds are associated with paralytic ileus.
SOUNDS have a positive have a positive a positive bowel positive bowel sounds (Source: Short, M.)
(auscultation) bowel sounds bowel sounds sounds
CONTOUR Protuberant Protuberant Protuberant Protuberant The abdomen is protuberant which means it is prominent in
UPON Abdomen is Abdomen is Abdomen is soft and Abdomen is soft and supine position and hard during the pre-operation then in the
PALPATION distended and distended and minimal tenderness without tenderness post operation it feels soft without tenderness.
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Nursing Department
hard in the right hard in the right Measure the abdominal girth
upper quadrant upper quadrant
REST AND ACTIVITY

Findings Nursing Implication
1st assessment (April 2nd assessment 3rd assessment
11, 2021) (April 12, 2021) (April 20, 2021)
CURRENT ACTIVITY Not active but Active and responsive infant Active and responsive infant 1ST assessment
LEVEL responsive infant - able turn towards moving - able turn towards moving The baby is responsive, she displayed the ability to
-able turn towards object and familiar voices object and familiar voices follow moving objects and familiar voices. The baby
moving object and - able to smile when she - able to smile when she was not active because she cannot be fed well due to
familiar voices hears familiar voices hears familiar voices poor sucking reflex that leads to poor feeding which
causes her to be passive.
2nd assessment
The baby is active and responsive. She displayed
the ability to follow moving objects and familiar
voices, smiling at parent’s faces.
3rd assessment
The baby is active and responsive. She displayed
the ability to follow moving objects and familiar
voices, and smiling at parent’s face
Between 1 to 3 months of age, infants begin the

transformation from being totally dependent to an
active and responsive one. Begin to have a social
smile when played and appear to turn towards
sounds.
ACTIVITIES OF DAILY Bathing: 8:00 am Bathing: 8:30 AM (Tepid Feeding: cry when hungry; First assessment:
LIVING Feeding: cry when sponge bath ) breastfed for 3 times and The baby was bathed at 8:00 am. Breastfed 2.
hungry; breastfed for 2 Feeding: the baby was not able to finish 1 bottles of
times and not able to able to feed for 3 days formula with the timeframe 2nd assessment:
finish 1 bottle of of visit NPO
formula-milk within the Play: enjoys watching faces
timeframe of visit of his parent Play: enjoys watching Last assessment:
faces of his parent Breast fed 3 times
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Nursing Department
Play: enjoys watching Totally dependent

faces of his parent Totally dependent The time for bathing of the baby was between 8:00 AM
to 09:30 Am as stated by the mother. For the second
Totally dependent Communication: consist of assessment, the mother was advised to do a tepid
crying; few gurgles, grunts Communication: consist sponge bath instead of typical bathing of the baby in
and coos are heard, smiles of crying; few gurgles, order to keep the wound dry. The baby usually wakes
Communication: when recognizing familiar grunts and coos are heard, up and cries when hungry. The baby’s communicating
consist of crying; few faces smiles when recognizing medium is crying, and has few grunts, gurgles or coos.
gurgles, grunts and familiar faces For the second and last assessment the baby smiles
coos are heard when happy and comfortable.
SLEEP Sleeping schedule: Sleeping schedule: Sleeping schedule: During visitation, the baby usually sleeps and wakes
7:00 AM – awake 7:30 AM – awake :00 AM – awake up when hungry. Usually, an infant tends to sleep at
*feed 8:15 AM – nap *feed about 14-16 hours a day. It has no pattern nor
8:30 AM – nap 9:30 AM – awake 8:30 AM – nap variation, it depends on the needs and surroundings of
9:30 AM – awake 10:00 AM nap 9:30 AM – awake an infant.
*feed 11:00 AM *feed
11:00 AM – nap 11:15 – nap 11:00 AM – nap
12:00 PM - awake 12:30 PM – Awake 12:00 PM - awake Usually, an infant tends to sleep at about 14-16 hours
12:30 PM – nap 1:30 PM – nap *feed a day. It has no pattern nor variation, it depends on the
1:50 PM – awake 3:00 PM – awake 12:30 PM – nap needs and surroundings of an infant.
3:00 PM – nap 5:30 PM – nap 1:00 PM - End of admission
4:00 PM - 8:30 PM 7:00 PM – awake
sleeping (due to 8:30 PM sleeping
procedure)
RESTING POSTURE Arms and legs are Arms and legs are flexed Arms and legs are flexed The baby is in normal posture. While lying in his back,
flexed the extremities are adducted towards the trunk. When
the arms and legs are extended away from the body,
then the infant is premature.
COORDINATION ASSESSMENT: Prior Good motor coordination: Good motor coordination: Good motor coordination indicates good growth and
to surgery - moves arms and legs - moves arms and legs development. The baby can actively move hands
- moves head from side to - moves head from side to towards mouth and legs, and moves head from side-
Good motor side while lying on his back side while lying on his back to-side following sounds or voices.
coordination:
- moves arms and legs
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Nursing Department
- moves head from

side to side while lying
on his back
BALANCE ASSESSMENT: Prior Cannot sit and head falls Cannot sit and head falls The baby cannot sit on his own and head falls down
to surgery down without support down without support without support. Usually, infants tend to have head
control by 4th month of life.
Cannot sit and head
falls down without
support
MUSCLE ASSESSMENT: Prior Feet and legs are symmetric Feet and legs are The assessment indicates that the baby is in a
to surgery in size, shape and movement. symmetric in size, shape wellness state. Short, broad and hyperextensible joints
Has full range of motion and movement. Has full may indicate down syndrome. Limited ROM may
Feet and legs are range of motion indicate problems ranging from mild to serious
symmetric in size, disorders.
shape and movement.
Has full range of
motion
MOTOR FUNCTION ASSESSMENT: Prior Not Assessed Gross motor: The fine and gross motor of the baby is good. Based
to surgery Ventral suspension control- on assessment, the baby is in good development of
able to lift and hold head (9 motor functions. The baby’s ability to accomplish large
Gross motor: seconds) in the same plane body movements, and ability to coordinate hand
Ventral suspension as the rest of the body. movements is in progress compared to the age of the
control- able to lift and Landau reflex and baby.
hold head (7 seconds) parachute reaction is not
in the same plane as present
the rest of the body. When the baby ages, some reflexes fade and the baby
Landau reflex and Prone position- knees are will now perform more coordinated movements.
parachute reaction is tucked under the abdomen.
not present Able to lift head and turn
easily to side
Prone position- knees
are tucked under the Sitting position- pulling the
abdomen. Able to lift baby to a sitting position
head and turn easily to shows head lag. While in
side sitting position, back
appears round and able to
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Nursing Department
Sitting position- pulling control head for about 7

the baby to a sitting seconds then drop
position shows head
lag. While in sitting Standing position- stepping
position, back appears reflex is present: baby’s
round and able to knees and hips are flexed.
control head for about
6 seconds then drop Fine motor:
Grasp reflex is still present
Standing position- but able to open arms
stepping reflex is momentarily
present: baby’s knees
and hips are flexed.
Fine motor:
Grasp reflex is still
present but able to
open arms
momentarily
PAIN ASSESSMENT Neonatal Facial Neonatal Facial Coding The baby is in pain during the 1 st and 2nd assessment
Coding System System as displayed by his facial expression and cry.
Brow bulge - 1 Brow bulge - 1 Usually, when the baby is in pain, he displays pain
Eye squeeze - 1 Eye squeeze - 0 through his facial expression, arm and leg movement
Deepening of Deepening of nasolabial and then cries. Sometimes, he will pull the sore part
nasolabial furrow - 0 furrow - 0 when it is touched.
Open lips - 1 Open lips - 1
Not in Pain
Mouth stretch Mouth stretch (horizontal or The maximal score is 8 points, considering pain ≥ 3 in
(horizontal or vertical) vertical) - 0
-1 Tongue tautening - 0 the Neonatal Facial Coding System (NFCS)
Tongue tautening - 0 Tongue protrusion - 0
Tongue protrusion - 0 Chin quivering – 1
Chin quivering – 1
Points: 3
Points: 5
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Nursing Department
SAFE ENVIRONMENT
FINDINGS Nursing Implication
1 Assessment
st
2nd Assessment 3rd Assessment
(April 11, 2021) (April 12, 2021) (April 20, 2021)
Medications: None
ALLERGY: no Food: none
known allergy Tape, iodine, latex: none
Environment: none
Pupils: are equally round Pupils: are equally round Pupils: are equally Yellowing of the white of the eyes is a common and usually harmless
and react to light and react to light round and react to light condition in newborn babies and it usually clears up within 2 weeks
Tears: not present when Tears: not present when Tears: not present when in formula-fed babies and it may last for more than 2 to 3 weeks in
crying. crying. crying. breastfed babies. For the condition of the patient, it is
Eyelids: no Eyelids: no Eyelids: no caused narrowing of the bile ducts, preventing bile from draining into
inflammation, swelling, inflammation, swelling, inflammation, swelling, the intestine from the liver. Bile then becomes trapped and
erythema, purulent erythema, purulent erythema, purulent accumulates in the liver, damaging the intrahepatic bile ducts within
EYES/VISON discharge discharge discharge the liver that causes prolonged jaundice.
Sclera and conjunctiva: Sclera and conjunctiva: Sclera and conjunctiva:
yellowish and free from yellowish and free from clear and free from
discharge, lesions, and discharge, lesions, and discharge, lesions, and
lacerations lacerations lacerations
Visual acuity: able to Visual acuity: able to Visual acuity: able to
follow moving objects follow moving objects follow moving objects
No hearing aids
HEARING There were no lesions, secretions noted on both ears. The baby was able to
immediately turn / look toward sounds or voices.
Color: yellowish Color: yellowish Color: pinkish Yellowing of the skin is a common and usually harmless condition in
Odor: no foul odor Odor: no foul odor Odor: no foul odor newborn babies and it usually clears up within 2 weeks in formula-
Lesions: absence of Lesions: absence of Lesions: absence of fed babies and it may last for more than 2 to 3 weeks in breastfed
SKIN lesions, petechiae and lesions, petechiae and lesions, petechiae and babies. For the condition of the patient, it is caused narrowing of the
bruising bruising bruising bile ducts, preventing bile from draining into the intestine from the
Texture: warm and dry Texture: soft, warm and Texture: soft, warm and liver. Bile then becomes trapped and accumulates in the
due to pruritus slightly moist slightly moist
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Nursing Department
Skin turgor: quick recoil Skin turgor: quick recoil Skin turgor: quick recoil liver, damaging the intrahepatic bile ducts within the liver that causes
Presence of scratch Presence of incision due Presence of scar due to prolonged jaundice.
marks due to pruritus to surgery surgery
Presence of scar on Presence of scar on Presence of scar on
deltoid muscle (right deltoid muscle (right deltoid muscle (right
arm) due to BCG arm) due to BCG arm) due to BCG
vaccination vaccination vaccination
VITAMIN K: March 12, 2021

VACCINATION BCG: March 12, 2021
HEPA B: March 12, 2021
OXYGENATION
FINDINGS Nursing Implication
1st Assessment 2nd Assessment 3rd Assessment 4th Assessment
No secretion is It is necessary to check the airway clearance to prevent
No secretion is No secretion is No secretion is noted compromising the air flow into the infant’s respiratory system
noted noted noted and to prevent for future complication
AIRWAY
No blockage or
CLEARANCE
No blockage or No blockage or No blockage or obstruction is noted
obstruction is noted obstruction is obstruction is
noted noted
Rhythm: Regular Rhythm: Regular Rhythm: Regular Rhythm: Regular During the 1st assessment at around 9:00 AM the respiration
Depth: Normal Depth: Normal Depth: Normal Depth: Normal rate of the patient was above the normal range due to
abdominal distension that restricts the movement of her
Position assumed: Position assumed: Position assumed: Position assumed: diaphragm.
supine position supine position supine position supine position
RESPIRATION
Both 2nd, 3rd and 4th assessment in respiration are within the
Rate of respiration Rate of respiration Rate of respiration Rate of respiration normal ranges and there were no abnormalities noted.
(awake): (awake): (awake): (awake):
9:00 AM – 66 cpm 7:30 AM – 55 cpm 7:30 AM – 52 cpm 7:30 AM – 46 cpm
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Nursing Department
10:00 AM – 45 cpm 11:30 AM – 52 10:30 AM – 48 11:30 AM – 41 cpm

cpm cpm
11:00 AM – 46 cpm 2:30 PM – 38 cpm
2:30 PM – 46 cpm 1:30 PM – 43 cpm
4:00 PM – 48 cpm 4:00 PM – 43 cpm
4:00 PM – 45 cpm 3:00 PM – 47 cpm
Rate of respiration Rate of respiration
(asleep): Rate of respiration Rate of respiration (asleep):
(asleep): (asleep):
8 PM – 49 cpm 8 PM – 48 cpm
8 PM – 46 cpm 8 PM – 45 cpm
Normal Respiration Normal Respiration
Rate: 30 -60 bpm Normal Normal Rate: 30 -60 bpm
Respiration Rate: Respiration Rate:
30 -60 bpm 30 -60 bpm
LUNG 9:00 AM - Breath sounds Breath sounds Breath sounds was It is necessary to check for the lung sounds to know if there
SOUNDS Breath sounds was was loud was loud, high- loud are any adventitious sounds that can be associated with
not too loud pitched sound diseases.
There were no There were no
There were no stridor, wheezes or There were no stridor, wheezes or
stridor or crackles crackles noted. stridor, wheezes or crackles noted.
but there is crackles noted.
wheezing noted
due to shortness of
breath. It is necessary to check for the oxygen saturation to know if
there is enough oxygen bound to the blood that will perfuse
At around 10:00 the organs and tissues.
AM until the end of
the day, breath
sounds became
loud and there were
no crackles,
wheezes and
stridor noted.
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Nursing Department
OXYGEN
SATURATION 9:00 AM - 91% 7:30 AM - 96% 7:30 AM - 97% 8:00 AM - 98%
10:00 AM – 97% 11:30 AM – 97% 11:30 AM – 96%
11:00 AM – 97% 2:30 PM – 97% 2:30 PM – 98%
4:00 PM – 98% 4:00 PM – 98% 4:00 PM – 97%
8 PM – 97% 8 PM – 97% 8 PM – 98%
11 PM - 98% 11 PM - 98% 11 PM - 98%
2 AM - 98% 2 AM - 98% 2 AM - 97%
Normal Oxygen Normal Oxygen Normal Oxygen

Saturation Saturation Saturation
Rate: 95% - 100% Rate: 95% - 100% Rate: 95% - 100%
Checking or the skin color is necessary because skin color

can reflect overall health.
During 1st and 2nd assessment, the skin of the infant is

jaundice due to accumulation of bile pigments in the blood
COLOR Jaundice Jaundice Slightly Jaundice Pinkish
and deposition into the body tissues.
During 3rd assessment, the skin color of the patient was slightly
jaundice because the procedure made to the infant as already
done and it became pinkish in the succeeding days.
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Nursing Department
Color: Light Color: Pink

Color: Pink Capillary Refill:
Color: Yellow Yellow Capillary refill assessment is essential to detect if there are
CAPILLARY Capillary Refill: less than 2 seconds
Capillary Refill: Capillary Refill: good perfusions. Pallor and prolonged refill time suggest
REFILL less than 2
less than 2 seconds less than 2 reduced blood pressure with reactive vasoconstriction
seconds
seconds
Heart rate: Heart rate:
7:30 AM – 131 7:30 AM – 136 bpm
bpm
11:30 AM – 132
Heart rate:
Heart rate: 11:30 AM – 136 bpm
7:30 AM – 130
bpm
bpm
9:00 AM – 110 bpm 2:30 PM – 135 bpm
It is necessary to monitor for the pulse rate to check for the
2:30 PM – 145
11:30 AM – 132 overall health and for baseline data
10:00 AM – 114 bpm 4:00 PM – 134 bpm
bpm
bpm 8 PM – 145 bpm
1st, 2nd, 3rd and 4th assessment was within the normal range
4:00 PM – 142
2:30 PM – 138 and there are no abnormalities noted
11:00 AM – 110 bpm Normal Pulse Rate:
PULSE bpm
bpm 8 PM – 147 bpm 70 - 190 bpm
4:00 PM – 142
4:00 PM – 148 bpm Normal Pulse
bpm
Rate: 70 - 190
8 PM – 143 bpm
8 PM – 149 bpm bpm
Normal Pulse
Normal Pulse Rate:
Rate: 70 - 190
70 - 190 bpm
bpm
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Nursing Department
Blood pressure: Blood pressure:

7:30 AM – 90/60 7:30 AM – 90/60
mmHg mmHg
11:30 AM – 95/60 11:30 AM – 95/60

mmHg mmHg
Blood pressure: Blood pressure:
BLOOD
9:00 AM – 85/50 7:30 AM – 90/60
PRESSURE 2:30 PM – 100/60 2:30 PM – 90/60 It is necessary to monitor for the blood pressure to check for
mmHg mmHg
mmHg mmHg the overall health and for baseline data
10:00 AM – 85/60 11:30 AM – 95/60
4:00 PM – 90/60 4:00 PM – 100/60 1st, 2nd, 3rd and 4th assessment was within the normal range
mmHg mmHg
mmHg mmHg and there are no abnormalities noted
11:00 PM – 85/50 2:30 PM – 90/60
8 PM – 95/60 8 PM – 90/60
mmHg mmHg
mmHg mmHg
4:00 PM – 100/60 4:00 PM – 100/60
Normal Blood Normal Blood
mmHg mmHg
Pressure: Pressure:
Systolic – 87-105 Systolic – 87-105
8 PM – 90/60 8 PM – 90/60
Diastolic 53-66 Diastolic 53-66
mmHg mmHg
Normal Blood Normal Blood

Pressure: Pressure:
Systolic – 87-105 Systolic – 87-105
Diastolic 53-66 Diastolic 53-66
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Nursing Department
NUTRITION
1st assessment 1st assessment
(April 09, 2021) (April 09, 2021)
HOSPITAL DIET Breast Feeding HOSPITAL DIET Breast Feeding
IVF’S D5imb half liter to run at 40 ugtt/min IVF’S
TISSUE TURGOR Returns to original TISSUE TURGOR Returns to original shape quickly
shape quickly
ANTHROPOMETRIC MEASUREMENTS: Date of Assessment: April 09, 2021

At Birth Present
Weight 2.4 kg (5.29 lbs) 4kg
Head Circumference 34 cm 37 cm
Chest Circumference 33 cm 35 cm
Abdominal Circumference 32 cm 38 cm
Length 49.2 cm (19.4 inches). 53. 8 cm
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Nursing Department
CHAPTER VII
DRUG STUDY
Phytomenadione (Vitamin K1)
Doctor’s Order Action Indication Contraindication Side Effects Adverse Effects Nursing Consideration
Phytomenadione - used to treat andIndicated as an - Hypersensitivity -Temporary flushing -Hypersensitivity or
prevent low levels of
antidote to anaphylaxis-like ● Monitor patients
2mg/0.2 ml certain substances
anticoagulant - Severe liver disease -taste changes constantly. Severe
solution reaction
(blood clotting
drugs of the -Dizziness reactions, including
Intravenous factors) that your coumarin type in fatalities, have occurred
Injection, Once -Rapid Heartbeat
body naturally
the treatment of during and immediately
Daily produces haemorrhage or -Sweating after IV injection (see
Brand Name threatened -Shortness of Breath ADVERSE EFFECTS).
haemorrhage, -Bluish lip/skin/nails ● Lab tests: Baseline and
AquaMEPHYTON - These substances associated with a frequent PT/INR.
Generic Name help your blood to low blood level of ● Frequency, dose, and
thicken and stop prothrombin or therapy duration are
phytonadione bleeding normally factor VII guided by PT/INR clinical
(vitamin K1) response.
breathing
episode ● Monitor therapeutic
Classification
- helps to treat and effectiveness which is
Vitamin K prevent unusual indicated by shortened
Products bleeding by PT, INR, bleeding, and
increasing the body’s clotting times, as well as
Date Started decreased hemorrhagic
production of blood
clotting factors. tendencies.
April 11, 2021
(30 mins before
surgery)
Nursing Department
Propofol
Diprivan 1.5 Low blood pressure Arterial ● Close monitoring of vital
mg/kg IV loading Short-acting, Documented (hypotension) hypotensionSevere signs
dose Diprivan
lipophilic (propofol) hypersensitivity, allergic reaction
Brand Name sedative/hypnotic Injectable egg allergy, Pauses in breathing (anaphylaxis) ● Monitor hemodynamic
; causes global Emulsion is a soybean/soy (apnea) lasting 30- status and assess for
Diprivan CNS depression, sedative- allergy 60 seconds Cardiac "flat line" dose-related
presumably hypnotic agent (asystole) hypotension.
Generic Name
through agonist used to help you -Patients with severe Pauses in breathing
propofol Rx actions on relax before and cardiac or respiratory (apnea) lasting more Bronchospasm ● Take seizure
GABAa receptors during general disorders or history of than 60 sec precautions. Tonic-
Classification Cardiac arrest clonic seizures have
Sedative-hypnotic anesthesia for epilepsy or seizures
General used in the induction surgery or other occurred following
Movement general anesthesia
Anesthesia; and maintenance of medical Seizures
Sedative hypnotic anesthesia or procedure. It is with propafol.
also used in Injection site
sedation. Inner ear reactions
Date Started critically ill (burning/stinging/pai ● Be alert to the potential
patients who n) for drug induced
April 11, 2021 Pancreatitis
require a excitation (e.g.,
breathing tube Respiratory acidosis twitching, tremor,
Fluid in the lungs hyperclonus) and take
connected to a during weaning (pulmonary edema)
ventilator. appropriate safety
measures.
Hypertriglyceridemia Phlebitis
High blood pressure ● Provide comfort
Blood clot measures; pain at the
Rash/ Itching injection site is quite
common especially when
Renal tubular
small veins are used.
Irregular heartbeat toxicity
(arrhythmia)
Cardiac output
decrease
Page 30 of 52
Nursing Department
Sevoflurane
3.3% sevoflurane Sevoflurane induces Ultane ULTANE can cause Drowsiness anxiety, chills, Assess for the mentioned
in oxygen muscle relaxation (sevoflurane) malignant breathing trouble, cautions and contraindications
and reduces pain Volatile Liquid hyperthermia. It Dizziness unusual change in (e.g. drug allergies, hepatic and
Brand Name sensitivity by altering For Inhalation is should not be used in renal impairment, etc.) to prevent
amount of urine,
Ultane tissue excitability with an anesthetic patients with known seizures, muscle any untoward complications.
a fast onset of action. drug used to sensitivity to stiffness, fast or
Generic Name It does so by induce and sevoflurane or to Prepare emergency equipment to
irregular heartbeat, maintain the airway and provide
decreasing the extent maintain general other halogenated stomach or
sevoflurane mechanical ventilation if needed.
of gap junction anesthesia in agents nor in patients abdominal pain,
Classification mediated cell-cell adult and with known or fatigue, yellowing Ensure that patients receiving
coupling and altering pediatric patients suspected eyes or skin, or dark spinal anesthesia or epidural
General the activity of the during surgery. susceptibility to urine. anesthesia are well hydrated and
Anesthetics, channels that malignant remain lying down for up to 12
Inhalation underlie the action hyperthermia. hours after the anesthesia to
Date Started potential. minimize headache.
April 11, 2021 Provide skin care to the site of

administration to reduce risk of
skin breakdown.
Provide comfort measures to
help patients tolerate drug
effects.
Monitor for adverse effects (e.g.
respiratory depression, blood
pressure changes, arrhythmias,
GI upset, skin breakdown, injury,
CNS alterations, etc).
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Nursing Department
Ceftriaxone
ceftriaxon 2ml Binds to the bacterial Ceftriaxone is a Hypersensitivity to Diarrhea, serious allergic Watch for seizures; notify
q12 hrs for 7 days cell wall membrane, prescription ceftriaxone reaction, including: physicians immediately if a
Weakness,
Brand Name causing cell death medicine used to rash, itching/swelling patient develops or increases
Rocephin treat the Premature neonates Dizziness, (especially of the seizure activity.
Generic Name Ceftriaxone works by symptoms of face/tongue/throat),
Heart palpitations,
ceftriaxone inhibiting the infections such severe dizziness, Monitor signs of
sodium and mucopeptide as intra- Pale skin, trouble breathing pseudomembranous colitis,
dextrose injection synthesis in the abdominal Headache, including diarrhea, abdominal
Classification bacterial cell wall. infection, ear pain, fever, pus or mucus in
cephalosporin The beta-lactam infection, pelvic Confusion, stools, and other severe or
antibiotics moiety of ceftriaxone inflammatory Yellowing of the prolonged GI problems (nausea,
Date binds to disease, eyes or skin vomiting, heartburn). Notify
Administered carboxypeptidases, prosthetic joint (jaundice), physicians or nursing staff
April 11, 2021 endopeptidases, and infection, immediately of these signs.
Date Ended transpeptidases in meningitis, Enlarged liver or
April 17, 2021 the bacterial sexually spleen, Monitor signs of allergic reactions
cytoplasmic transmitted Chills, fever and anaphylaxis, including
membrane. These diseases and as pulmonary symptoms
enzymes are involved surgical Back pain,
in cell-wall synthesis prophylaxis. abdominal pain, and Always wash hands thoroughly
and cell division. shock and disinfect equipment
Binding of ceftriaxone Treat a wide (whirlpools, electrotherapeutic
to these enzymes variety of devices, treatment tables, and so
causes the enzyme to bacterial forth) to help prevent the spread
lose activity; infections of infection. Use universal
therefore, the precautions or isolation
bacteria produce procedures as indicated for
defective cell walls, specific patients
causing cell death.
Instruct patient and
family/caregivers to report other
troublesome side effects
Page 32 of 52
Nursing Department
Paracetamol IV
Paracetamol IV.5 Paracetamol has indicated for the Hypersensitivity to Vomiting Hypersensitivity  Dilute prior to
q 4 hours for 3 both analgesic and short-term the active substance administration with NaCl
doses, prn antipyretic actions. It treatment of or to propacetamol neutropenia, 0.9% or glucose 5% to
thereafter inhibits eutropenian moderate pain, hydrochloride Fever make a concentration of
biosynthesis. Its half- especially not less than 1 mg/mL.
life is approximately following leukopenia,
3.5 hours. surgery, and for
Brand Name Rash  Check that the patient is
the short-term
Perfalgan It produces not taking any other
treatment of thrombocytopenia
antipyresis by medication containing
fever, when
Generic Name inhibiting the Nausea paracetamol.
administration by
hypothalamic heat- intravenous route
morphine
regulating centre. Its is clinically  Evaluate therapeutic
Classification weak anti- justified by an Constipation response.
inflammatory activity urgent need to
analgesics is related to inhibition treat pain or  Change to oral after 3
Date Started of prostaglandin hyperthermia
synthesis in the CNS days when pt. can tolerate
and/or when feeding/ Breastfeeding
April 12, 2021 other routes of
Date Ended administration
are not possible.
April 17, 2021
Colestid
Doctor’s Action Indication Contraindication Side Effects Adverse Effects Nursing Consideration
Order
5 g PO twice Forms a Used in relief of Hypersensitivity to Constipation Severe constipation Administration
daily soluble pruritus associated colestipol  Mix dry form in water/fluids
complex after with elevated levels of Hemorrhoids Stomach pain (Breastmilk) to avoid inhalation or
Brand Name binding to bile bile Bowel obstruction esophageal distress
Page 33 of 52
Nursing Department
Colestid acid, Black, bloody or

Generic increasing Used to decrease tarry stools  Take before meals
Name fecal loss of plasma half-life of
colestipol bile acid- digoxin in toxicity  Take other medications 1 hr
bound low- before or 4 hr after colestipol
Classification density Hypercholesterolemia
Bile Acid lipoprotein (adjunct to diet for
Sequestrants cholesterol Type IIa & IIb Instruct parents to monitor signs of
hyperlipidemia) allergic reactions
Date
Administered Indicated as
April 9, 2021 adjunctive therapy to
diet for the reduction
Date Ended of elevated serum
April 11, 2021 total and low-density
(12:00PM) lipoprotein (LDL)
cholesterol in patients
with primary
hypercholesterolemia
(elevated low density
lipoproteins [LDL]
cholesterol) who do
not respond
adequately to diet.
Cholbam
Doctor’s Action Indication Contraindication Side Effects Adverse Effects Nursing Consideration
Order
-
Abdominal or
CHOLBAM Treatment of bile None stomach pain Bladder pain Take with food
10 mg/kg Bile acids facilitate acid synthesis bloody or cloudy
fat digestion and Chills
PO once daily disorders Clay-colored stools urine
mix in 15 ml to absorption by (malfunction in the clay-colored stools  For infants, advise mother to
forming mixed Dark urine mix the entire capsule contents
30 ml of production of bile Diarrhea dark urine
micelles, and acid in the liver) due with one or two tablespoons
Page 34 of 52
Nursing Department
expressed facilitate absorption to a lack of a single Dizziness difficult, burning, or (15 mL to 30 mL) of infant
breastmilk of fat-soluble enzyme responsible Fever painful urination formula, expressed breast
Brand Name vitamins in the for bile acid General feeling of frequent urge to milk.
Cholbam intestine. production tiredness or urinate  Administer the mixture
Generic Name weakness lower back or side immediately
colic acid Headache pain  Monitor liver function and
capsules Endogenous bile Treatment (in Itching or rash unpleasant breath discontinue CHOLBAM if liver
acids including addition to other Light-colored stools odor function worsens while on
cholic acid enhance treatments) of Loss of appetite treatment
Classification bile flow and provide peroxisomal Nausea
Digestive the physiologic disorders (a loss of Stomach pain,
enzymes feedback inhibition function in important continuing
of bile acid parts of the cell), Unpleasant breath
Date synthesis. including Zellweger odor
Administered spectrum disorders, Unusual tiredness
April 14,2021 in patients who or weakness
and continuing show signs or Vomiting
symptoms of liver Vomiting of blood
disease, pale stools Yellow eyes or skin
due to too much fat,
or problems
resulting from not
absorbing certain
vitamins (A, D, E, K)
Page 35 of 52
Nursing Department
CHAPTER VIII
COURSE VISIT
Date and Time Doctor’s Order Nurse Order

April 9, 2021 F-Check up
9:00 am Physical exam was D-Baby XZ brought to OPD ,
performed under the pediatric parents report yellowing of
doctor her eyes with subsequent
-Check for infants abdomen yellowing of her skin, her
-Examined for signs of urine is dark yellow and clay
jaundice colored or pale stools,
-Check infants stool distended abdomen is
- evidence
A-Assess the baby
W-4kgs H-53.8 cm
Vital signs:
Temp:36.5C
-Please admit patient to BP: 85/50mmHg
pediatric ward for monitoring PR: 110bpm
and further assessment RR: 66bpm
-administer oxygen 1L /min Oxygen saturation 91%
via mask A-Hooked oxygen
R-Cooperated
10:00 am
-pls reassess oxygen A- assess oxygen saturation
saturation and vital signs and vital signs
Temp:36.5C
BP: 85/60mmHg
PR: 114bpm
RR: 45 bpm
Oxygen saturation - 97%
A-hooked oxygen via mask
11:00 am F-Admission
-Request lab for Blood test, D- Admitted a female, 4
CBC , Urinalysis and -PTT weeks old with chief complain
of yellowing of her eyes with
-please insert IVF subsequent yellowing of her
D5IMB half liter run at skin urine is dark and yellow
40drops per min and clay colored or pale
stools
-pls administer colestid 5g A-Vital signs
PO twice daily Temp: 36.5C
BP:85/50mmHg
PR: 110bpm
RR: 46cpm
Oxygen saturation:97%
A-Laboratory request
forwarded
A-Consent for hospitalization
A-Insert IVF aseptically
R-Cooperated
Nursing Department
1:00 pm- 2:00 pm -please assist the patient F-Laboratory

for Blood test, CBC , D-Start of her laboratory
Urinalysis and -PTT examination
A-Explain to the parents the
procedure
A-Tell the parents to collect
urine
A-Ready the baby for her
laboratory
A-Keep the baby on a lying
position
A-Assist them before during
and after the procedure
R-Cooperated
April 10, 2021 Request Laboratory for F-Laboratory
9:00 am- - Liver panel D-Continuation of her
-HIDA scan laboratory
A-get the vs of the baby
Temp: 36.5
BP:90/60
PR:130bpm
RR-55cpm
A-Laboratory requested
A-Explain to the parents the
procedure
A-Keep the baby in a lying
position
A-Assist them before, during
and after
R-Cooperated
April 11, 2021 Temp:36.5

7:30 am BP:90/60
PR:130bpm
RR:55cpm
Oxygen saturation: 96%
Prepare for surgery , F-Diagnosed with Biliary
9:00 am Laparoscopic Kasai Atresia
procedure D- Kasai procedure and the
-Diagnosed with Biliary patient was diagnosed with
Atresia biliary atresia
-Pls prepare consent
- A-Inform the laboratory result
A- Tell the parents about the
procedure
A-Prepare consent sign with
parents
A- Inform the operating room
A-Advise the mother not to
feed her baby before 6 hrs of
surgery
11:30 am Temp:36.7
BP:95/60
PR:132bmp
RR:52cpm
2:30 pm -pls insert Sodium Chloride Temp:36.4

half liter 40 microdrops/min BP:90/60
PR:138bpm
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Nursing Department
RR:46cpm
oxygen saturation:97%
A-insert sodium chloride
aseptically
3:00pm pls administer A-Administer atropine
atropine0.02mg/kg IM single 0.02mk/kg IM single dose 1
dose 1 hr before surgery hr before surgery
3:30 pm Phytomenadione 2mg/0.2ml -Administer Vit k via IV
solution IV once daily 30 min
before surgery
4:00pm A-Prepare the patient

-Please prepare the patient A-administer ceftriaxone,
-ceftriaxone 2ml q12 hrs for 7 diprivan , Sevoflurane,
days A-Bring patient to the
-Please administer preoperative area take height
anesthesia Propofol and weight and VS
(Diprivan) 1.5mg/kg IV as Temp:36.7
loading dose BP:100/60
- 3.3% Sevoflurane in oxygen PR:148bpm
-please clean the skin RR:45cpm
antiseptic Oxygen saturation 98%
-watch out for bleeding A-Connect
-watch out for pain - electrocardiogram
-watch out for infection - pulse oximetry
- intravenous line
A- Assist in the surgery by
monitoring the patient’s VS
checking if there are any
signs of bleeding,pain and
infection
A-Laparoscopic surgery is
used
A-Surgical incision closing
check for infection
R-Cooperated
8:00 pm -Please transfer to F-end of surgery

observation room D-Monitor the baby
-please monitor VS every A-take vs
15min Temp:36.8
-check for safety BP:90/60mmHg
-Please transfer patient to PR-134bpm
pedia if she is awake RR:54cpm
-if her VS are stable already Oxygen saturation:97%
A-The procedure is done take
the patient in the observation
room
A-Monitor the baby until
awaken from the anestesia
R-Cooperated
April 12, 2021 -Pls inform pedia ward F-Pedia ward
-pls asses vs D-The patient is now transfer
2:00 am in her room
A-VS
temp:36.5
BP:95/60
PR:138bpm
RR:45cpm
oxygen saturation:98%
A-Inform the the pedia ward
Page 38 of 52
Nursing Department
A-Tell the parents to always

wash hand and sanitize when
holding her to prevent
infection
A-Tell the mother that don’t
need to breastfeed the baby
for 3 days
A-Check the infant’s position
and educate the mother on
her positioning
A-Allow the patient to take a
rest and gain her energy
R-Cooperated
7:30 am F-post op assessment
Medications: D-Asses the patient’s
-paracetamol IV 5q 4hrs for condition
3doses prn thereafter A-get the vs of the baby
Temp:36.8
BP:90/60
PR-131bpm
RR:52cpm
A- Baby is still yellowish and
explain to the parents that it
is normal she will because
pinkish in the succeeding
days
A-record that her distended
abdomen is slightly
decreasing
A-administer paracetamol
R-Cooperated
8:00 am Doctors Visitation

Doctor check the surgical
incision
11:30 Temp:36.4
BP:95/60
PR:136bpm
RR:48cpm
2:30 pm Monitor VS
Temp:36.5
BP 100/60
PR:145bpm
RR: 47cpm
8:00pm Monitor VS
Temp:36.6
BP 95/60
PR:137bpm
RR: 46cpm
A-Educate the mother about
the sleeping pattern of the
baby so that she may rest her
body
11pm Temp:36.2
Page 39 of 52
Nursing Department
BP:90/60
PR:136bpm
RR:47
April 13,2021 -pls check the surgical F-Surgical incision
7:00 am incision D-Check the surgical incision
-please clean and change the area
gauze pad A- clean it, change the
-check for any signs of dressing ..
infection A-Educate the mother on
how to clean properly the
incision site and change the
dressing
A- Educate the mother that
she should play with the baby
to ease the pain
A-educate the mother about
the baby medicines
A-Monitor the vs
Temp:36.5
BP90/60
PR: 130bpm
RR:46cpm
R-Cooperated
9:00 am F-Bowel movement
D-the mother reported that
her baby fart
A-Monitor the baby and wait
for her poop
R-Cooperated
9:30 am -pls administer D5IMB half -Feeding
liter run for 40 D-The patient can have her
microdrops/min breastmilk already
A-Educate the mother that
-pls tell to have her she may now administer
breastmilk already feeding
-assist in giving breastmilk A- Tell the mother to be
-pls monitor vs sensitive on the incision sites
-pls monitor her bowel A-get the vs of the infant
Temp:36.5
BP90/60
PR: 130bpm
RR:46cpm
R-Cooperated
11:00 am F-bowel movement
D-The baby defacte
A-record that the baby is
already defacted
A-Record the color,amount
and consistency of the stool
-this means that the baby’s
internal organs are now
conditioned
R-Cooperated
2:00pm
Temp:36.5
BP90/60
PR: 130bpm
Page 40 of 52
Nursing Department
RR:46cpm
R-Cooperated
8:00pm Monitor VS
Temp:36.4
BP90/60
PR: 131bpm
PR:136bpm
R-Cooperated
April 14,2021 Monitor VS
7:00 am -please check the patient’s Temp:36.6
condition BP: 90/60
-pls check her skin color PR 135bpm
-pls check her urine output RR46cpm
-pls check for abdominal Oxygen saturation:98%
distention A-administer cholbam
Pls administer cholbam A-assist in breastfeeding
10mg/kg PO once daily mix A-check the baby condition
in 15 ml to 30ml of expressed -abdominal distension none
breastmilk -her yellowish skin color is
gradually decreasing
-record her urine output,
urine is clear in color
R-Cooperated
9:00 am F-Irritability
D-the mother report that the
infant is irritable
A- educate the mother that
she should play with her
infant
A- Use her favorite toy to
distract her
A-Check her surgical incision,
clean and change it
4:00 pm Monitor VS
Temp:36.6
BP: 90/60
PR 135bpm
RR46cpm
R-Cooperated
April 15, 2021 D-Monitor
7:30 am A- Monitor VS
Temp:36.6
BP: 90/60
PR:136bpm
RR46cpm
8:00 am Doctors Visitation
9:00 am -please assist in baby bath F-baby bath
-check the surgical incision D-Baby bath the baby
A-Check the surgical area
A-prepare the equipment to
be use for the bath tepid
sponge bath
A-prepare the baby
A-baby bath the baby with a
small towel
A-Tell the mother how to
properly bath her baby
Page 41 of 52
Nursing Department
A-educate about her surgical

incision during bath
A-clean and change the
gauze pad
R-Cooperated
3:30
A- Monitor VS
Temp:36.6
BP: 90/60
PR:136bpm
RR46cpm
April 16, 2021 -please check the patient’s D-Monitor and assist the
7:00 am feeding pattern mother on baby
A-get the vs
Temp:36.5
BP: 90/60
PR:135bpm
RR45cpm
A-Assist the mother on the
feeding of baby
A-Tell the mother that if she
notice something wrong just
report it to the nursing station
R-Cooperated
8:00 am -pls check the incision D-change the gauze of the

-pls clean and change the incision
gauze pad A-properly clean the surgical
-pls check for any danger incision and change the
signs gauze pad
A-Tell the mother that incase
the gauze is full of blood
report it
R-Cooperative
12:00 Monitor VS
Temp:36.6
BP: 90/60
PR:136bpm
RR46cpm
Oxygen saturation 98%
6:00 pm Get the vs

Temp:36.6
BP: 90/60
PR:136bpm
RR46cpm
Oxygen saturation97%
Promote early sleeping of the
infants
April 17,2021 A-Monitor VS every 4 hrs
7:30 am Temp:36.6
BP: 90/60
PR:136bpm
RR46cpm
Oxygen saturation 98%
A-Assess the incision site
R-Cooperated
12:30 -please check for the D-Monitor the baby
patient’s vs A-get vs
Page 42 of 52
Nursing Department
-check her condition Temp:36.5

-check her stool BP: 90/60
PR:135bpm
RR45cpm
A-Asses over all condition of
the baby
A-record and document
A- tell the mother to see if the
baby is touching the incision
site because it may be
irritable when touch
A-Monitor baby’s stool
A-record amount color and
consistency , yellowish and
she already consumes 3
diapers from 4 am to 12:30
pm
R-Cooperated
6:00 pm A-Monitor VS
Temp:36.7
BP: 90/60
PR:136bpm
RR45cpm
April 18, 2021 -please monitor the patient’s Monitor VS every 4hrs
8:00 am over all condition Temp:36.6
BP: 90/60
PR:136bpm
RR46cpm
A-monitor the infant stool
A-record the color,amount
and consistency
A-Record that the baby is
now ok
-Skin of the baby is slightly
returning to pinkish color
R-Cooperated
10:00 -please assist baby bath D-assist in baby bath

-pls give a health teach about A-assist the mother having
infection control baby bath to the baby
-check for any signs of A-Emphasize to her about
infection the incision area
A-clean and change the
surgical incision site and
gauze
A-promote handwashing
R-Cooperated
7:00 pm -pls check patient’s sleeping D-promote early bed rest for
pattern and feeding the baby
A-tell the mother to feed her
baby
A-tell the mother after feeding
put into sleep
R-Cooperated
April 19,2021 -pls monitor vs Monitor VS
7:30 am Temp:36.6
BP: 90/60
Page 43 of 52
Nursing Department
PR:136bpm
RR46cpm
11:30 D-Monitor VS
Temp:36.7
BP: 90/60
PR:135bpm
RR45cpm
A-Make the baby comfortable
A-Assess her skin if there are
any rushes
R-Cooperated
5:00 D-monitoring
A-record that the infant is
doing well
A-Health teaching about the
nutrition of the baby
R-Cooperated
April 20, 2021 Ready for discharged F-Discharged
8:00 am -please assess the patient D-asses the patient and
-please gave the prescription health teach the mother
of medicine A-get the vs
-health teach the mother Temp:36.6
-please tell to the parent the BP: 90/60
follow up check up PR:136bpm
-pls tell to watch out signs RR46cpm
and symptoms Oxygen saturation:98%
A-Record that her skin color
is pinkish
A-Tell the parents that they
are ready for discharged
A-Tell to settle their account
A-Educate the mother on the
follow up check up after a
week
-educate the mother to have
her baby sunlight in the
morning from 6 am for 10
mins.
-On how to properly handle
the baby
-Proper wound care
-Medicine of the baby
-And incase of emergency
they may call immediately
their pedia
-tell the parents to always
wash hand and sanitize to
prevent infections
R-cooperated
12:00 Discharged
Page 44 of 52
Nursing Department
CHAPTER IX
NURSING CARE PLAN
NCP 01
ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING IMPLEMENTATION RATIONALE EVALUATION
EXPLANATION
Date of assessment: “INEFFECTIVE Congenital defect during SHORT TERM: INDEPENDENT: After 1 hour of
April 09, 2021 9:00 BREATHING pregnancy After 1 hours of 1. Checking the vital implementing care
AM PATTERN implementing 1. Monitor the vital signs of the the goals were
RELATED TO Deformity of the bile care: signs every 30 patient will help met as evidenced
SUBJECTIVE: ABDOMINAL ducts minutes the health care by:
“Parang nahihirapan po DISTENSION 1. The patient’s providers to
huminga yung anak ko” SECONDARY TO Obstruction of bile flow respiration will 2. Assess respiration monitor if there SHORT TERM:
as verbalized by the BILIARY ATRESIA be within the for rate, pattern and are any
client. AS EVIDENCED BY (1) Bile accumulation in range of 30 – depth alleviations or it is 1. The patient’s
38 CM ABDOMINAL the liver 60 bpm within the normal respiration
OBJECTIVE: CIRCUMFERENCE” 3. Assess range. became 45
 Abdominal Liver became enlarge 2. The patient’s configuration of bpm and it is
Distension oxygen chest by palpation, 2. Assessing for within the range
 Abdominal Abdominal Distension saturation will auscultate for respiration is of 30 – 60 bpm
circumference – 38 at the range of breath sounds that essential to
cm Restricted movement of 95% – 100% indicate movement indicate whether 2. The patient’s
 Nasal Flaring diaphragm restriction the patients has oxygen
enough oxygen saturation
Vital signs Shortness of breath 4. Reassess for flow into the body. became 97%
 BP 85/50 mmHg oxygen saturation and it is within
 PR 110 bpm (2) Bile cannot reach into by using infant’s 3. Check if there are the range of
 RR 66 bpm the intestines pulse oximetry any crackles, 95% – 100%
 Temperature - wheezes or if
36.5℃. No bile pigments will be 5. Assess for skin breath sounds is
excreted color absent or
Oxygen saturation – diminished. It is
Pale stools 6. Promote comfort by necessary to
91%
instructing the check for
(3) Increased pressure in significant other to configuration to
the ducts lessen the activity of know if the baby’s
the infant respiration will not
be compromise
Nursing Department
Bile will go through the 7. Position the patient

junctions between supine with head 4. Assessing oxygen
epithelial cell linings slightly elevated saturation by
using infant pulse
Leak into the blood DEPENDENT: oximetry is
stream necessary to
8. Promote improve check if there is
Increase amount of oxygenation by enough oxygen
conjugated bilirubin in the giving oxygen bounded to the
blood administration to the blood that will
patient as ordered perfuse the
Yellowing of skin and by the physician organs and the
eyes tissues
9. Promote good
Jaundice nutrition like breast 5. Assessing for skin
feeding color is important
Bilirubin levels excreted to check if blood
into the kidneys receives good
oxygen that will
Dark urine perfuse the organ
and to eliminate
presence of
cyanosis.
6. Instructing the SO
to lessen the
activity of the
infant to promote
comfort and to
reduce respiratory
effort.
7. Positioning the
patient supine
with head slightly
elevated will
promote comfort
Page 46 of 52
Nursing Department
and good
respiration
8. Promote good
oxygenation by
helping the patient
to have a good
respiration and
also, oxygenation
will help to
decreased the
respiration effort
of the infant
9. Promoting for
nutrition is
necessary for the
patient to be able
to attain enough
nutrients
throughout the
period
NCP 02
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
“Imbalanced Short term goal: INDEPENDENT: a) Promote intestinal Short term goal:
Objective Cues: Nutrition: Less After 1 hour mother will be a) Encourage the mother to movement and helps to a) After 1 hour of
than body able to: breastfeed every 2-3 excrete bilirubin. nursing intervention
a) Weight less requirement hours b) To enhance intake the mother
than the related to a) Demonstrate the b) Promote pleasant and c) To monitor effectiveness demonstrated
50th disease proper latching and relaxing environment of the efforts proper latching and
percentile process” improve c) Weigh regularly and d) To identify the deviations improved sucking.
Long term goals: graph results from the norms and Outcome: partially met
d) Monitor intake and output
Page 47 of 52
Nursing Department
b) Poor establish baseline Long term goal:

sucking a) After 1 month the DEPENDENT: parameters. b) After 1 month of
reflex baby will gain Maintain IV fluid until prescribed nursing intervention
weight by the physician the baby gained
approximately 1 weight of 8.2 lbs.
pound per week Outcome: partially met
NCP 03
ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING IMPLEMENTATION RATIONALE EVALUATION

EXPLANATION
Date of assessment: “IMPAIRED Deformity of the bile ducts SHORT TERM INDEPENDENT: ● Scratching with After 1 hour of
April 11, 2021 7:40 COMFORT fingernails can nursing
AM RELATED TO After 1 hour of 1. Keep client's excoriate the intervention,
ACCUMULATION nursing fingernails short area and ● There were
SUBJECTIVE OF BILE INTO THE Increased pressure in the intervention and tell the SO increase skin no signs of
“Iyak po ng iyak ung CIRCULATION bile ducts  There will be of the patient to damage. irritability
anak ko hindi CHARACTERIZED no signs of let her wear ● Covering the from the
makapakali “AVB by BY PRURITUS DUE irritability from mitts. area with a patient.
the mother TO CHOLESTATIC the patient. nonventilated
JAUNDICE Bile will go through the 2. Encourage the dressing can After 3 days of
OBJECTIVE SECONDARY TO junctions epithelial cell lining LONG TERM mother to leave increase itching nursing
✔ Irritability AEB BILIARY ATRESIA” pruritic area sensation and intervention,
prolonged After 3 days of open to the air if warmth in the  The patient’s
crying, nursing possible. area. SO was able
grimace, and Bile leaks into the blood intervention: ● Some soaps can to verbalize
rubbing of the  The patient’s 3. Explain to the be irritating to the the
skin to the bed. SO will be SO of the patient skin and interventions
✔ Dry skin able to to use increase the for dry and
✔ Scratch marks Increased amount of verbalize the nonallergenic itching itchy skin.
bilirubin into the interventions mild soap and sensation.
bloodstream for dry and use it sparingly. ● After bathing Therefore, the goals
itchy skin. while the skin is were met.
Page 48 of 52
Nursing Department
4. Encourage the still moist, apply

mother to keep nonallergenic
Due to hydrostatic pressure the patient’s skin and alcohol-free
into the blood vessels moisturize. moisturizers.
Daily application
5. Provide of moisturizers
distraction can have the
Blood containing the techniques such persistent clinical
bilirubin drives out into the as talking and effect of relieving
going to the interstitial tissue playing to the dry skin.
patient. ● can help to
temporarily
distract the client
from the itching
Bile salt Yellowing sensation.
will of the DEPENDENT:
accumulate skin and
in the sclera of Administration of ● To minimize the
interstitial the eyes Cholestyramine effects of pruritis.
tissue (Questan)
Causes
Cholestatic
pruritogenic
jaundice
effect
Page 49 of 52
Nursing Department
CHAPTER X
REFERENCES
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Nursing Department
Leung, C. Y. (2018, July 13-14). Pediatrics & Therapeutics. Retrieved from longdom.org:
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Saint Mary’s University

School of Health and Natural Sciences

Gestational Age at Birth: 38 Weeks AOG, Cephalic in Labor

Name of Father: Mr. Y

Name of Mother: Ms. W

Assessment: April 9, 2021 at 9:00 am

Date of Admission: April 9, 2021 9:00 am

I. Present Health History

II. Birth History

Vitamin K March 12, 2021

Hepa B1 and BCG March 12, 2021

III. Family History

IV. Social Health History

V. Feeding and Health Practices

There are two forms of biliary atresia:

● Viral or bacterial infections

1. Hematology for Complete Blood Count

During the Surgery

Long Term Follow-up

Liver has lot of function which includes the following:

● There are several important function of the gallbladder which includes:

Below are the five major functions of the skin:

PREDISPOSING FACTOR PRECIPITATING FACTOR

Deformity of the Bile

Obstruction of bile flow

ABDOMINAL PALE STOOLS

Bilirubin excreted into the Yellowing of the skin

A. HEMATOLOGY FOR COMPLETE BLOOD COUNT, April 9, 2021, 1:00 Pm

Examination Results Units Normal Range Nursing Implication

Red blood Cell Count 3.5 millions/ mm3 3.90-5.90 Abnormal

Hematocrit 43 % 42-65 Normal

Hemoglobin 14.0 gm/dL 13.4-19.9 Normal

White Cell Count 12821 mm3 9000-30000 Normal

Differential (manual) Neutrophils 9563 mm3 1000-20000 Normal

Lymphocytes 3712 mm3 2000-11000 Normal

Monocytes 978 mm3 540-1800 Normal

Eosinophils 351 mm3 150-585 Normal

Basophils 141 mm3 0-400 Normal

Platelets 14689 μL 15000-45000 Abnormal

B. URINALYSIS, April 9, 2021, 1:30 pm

Examination Result Normal Range Nursing Implication

C. PARTIAL THROMBOPLASTIN TIME (PTT), April 9, 2021, 2:00 Pm

Test Values Range Significance

D. LIVER FUNCTION TEST, April 10, 2021, 9:00 Am

Results Reference Unit Nursing Implication

Albumin 4.4 3.5 – 5.2 g/dL Normal

E. HEPATOBILIARY IMINODIACETIC ACID (HIDA) SCAN, April 10, 2021, 9:20 am

REST AND ACTIVITY

Between 1 to 3 months of age, infants begin the

Play: enjoys watching Totally dependent

- moves head from

Sitting position- pulling control head for about 7

VITAMIN K: March 12, 2021

9:00 AM – 66 cpm 7:30 AM – 55 cpm 7:30 AM – 52 cpm 7:30 AM – 46 cpm

10:00 AM – 45 cpm 11:30 AM – 52 10:30 AM – 48 11:30 AM – 41 cpm

10:00 AM – 97% 11:30 AM – 97% 11:30 AM – 96%

11:00 AM – 97% 2:30 PM – 97% 2:30 PM – 98%

4:00 PM – 98% 4:00 PM – 98% 4:00 PM – 97%

8 PM – 97% 8 PM – 97% 8 PM – 98%

11 PM - 98% 11 PM - 98% 11 PM - 98%

2 AM - 98% 2 AM - 98% 2 AM - 97%

Normal Oxygen Normal Oxygen Normal Oxygen

Checking or the skin color is necessary because skin color