NURSING CARE TO BABY

WITH Icterus NEONATORUM

DIPLOMA 3 PROGRAM STUDY OF SOETOMO

1/09/2016
NURSING SURABAYA
2016/2017
 Written By:

Ekanailatul Wafiroh
Nurya Kumala
Melinda kartika Sari
Tika Ayu Wardhany
Christine Grace Tamalawe
MEDICAL CONCEPT TO BABY
WITH ICTERUS NEONATORUM

Definitions
Icterus neonatorum is increased levels of bilirubin in
the extravascular tissue, so that the skin, conjunctiva,
mucosal and other body tool yellow (Ngastiyah,
2000).
Classification
Divided into two types, namely:
1.Physiological Icterus is Icterus arising on the second day and the third day
with bilirubin levels within normal limits and did not cause morbidity in
infants.
2.Pathological Icterus
Pathological Icterus is Icterus with bilirubin levels above normal.
Icterus is likely to become pathological or neonatal Icterus as considered are:
1. Icterus occurs in the first 24 hours after birth.
2. Increased bilirubin concentration of 5mg% or more every 24 hours.
3. Serum bilirubin concentration as 10mg% in preterm neonates and
12.5% in term neonates.
4. Icterus is accompanied by the process of hemolysis (blood
incompatibility, G6PD enzyme deficiency and sepsis).
5. Icterus is caused by newborn infants less than 2000gr caused by
maternal age under 20 years old or over 35 years and teenage
pregnancy, gestation less than 36 weeks, asphyxia, hypoxia,
respiratory distress syndrome, infection, hipoglicemia.
Etiology
1.Hemolysis increased the Rh blood incompatibility, ABO, other blood
group, G6PD enzyme deficiency, closed bleeding, and sepsis.
2.Interference processes hepatic uptake and conjugation of the liver caused
by immaturity, lack of substrate for conjugation of bilirubin, hepatic
dysfunction due to acidosis, hypoxia, and infections or absence of enzyme
glukorinil tranferase (criggler Najjar syndrome). Another cause is a
deficiency of the protein Y in the liver that plays an important role in
bilirubi uptake into liver cells.
3.Impaired transport of bilirubin in the blood is bound to albumin was then
appointed to the liver, bilirubin binding to albumin can be affected drugs
eg salicylates, sulfatfurazole. Albumin deficiency causes more presence of
indirect bilirubin in the blood that is free and easy to attach to cells of the
brain.
4. Disorders in the secretion caused by obstruction in the liver
or outside the liver is usually due to infection.
5. The gastrointestinal tract obstruction (functional or
structural) can lead to neonatal Icterus due to the addition of
unconjugated bilirubin derived from enterahepatik.
6. Icterus breast milk (ASI). Breast milk Icterus is Icterus
neonatal unconjugated which peaked late (the day of 6-14).
Can be distinguished from other causes by a rapid reduction
of bilirubin levels when substituted with formula milk for 1-2
days. Most of the ingredients contained in breast milk (beta
glucoronidase) will break down bilirubin into a form that is
soluble in fat, so that the indirect bilirubin will increase, and
will then be absorbed by the intestine.
Pathophysiology
Bilirubin is a product solver hemoglobin derived from red blood
cell hemolysis / RBC. When RBC broken then prroduknya will
enter the circulation, where the hemoglobin breaks into heme and
globin. Globin reused by the body while the heme is converted to
bilirubin inkonjugata and binds to albumin. Genesis are often
found is when there is the addition of bilirubin in the liver
streptococcus excessive. It can be found when there is an increase
in erythrocyte destructed, polycythemia, shortened life of
erythrocytes fetus / infant, meningkatanya bilirubin from other
sources, or the presence of an increase in the enterohepatic
circulation.
 Impaired uptake of bilirubin plasma occurs when levels of protein Z,
and protein Y are bound by other anion, for example, in infants with acidosis or
with anoxic / hypoxic determined interference conjugation liver (deficiency of
the enzyme glucuronyl transferase) or infants suffering from disorders of
excretion, eg, patients with hepatitis neonatal or obstruction bile intra / extra
hepatic. At a certain degree, bilirubin can be toxic and damage brain tissue. The
toxicity is mainly found in bilirubin indirect bilirubin indirect. Caracteristic of
pathologic effects on brain cells when bilirubin can penetrate the blood-brain
barrier. Abnormalities that occur in the brain called kernIcterus / biliary
encephalopathy.
Ease of bilirubin through the blood-brain barrier is not only dependent
on high levels of bilirubin but it depends also on the state of the neonate's own.
Indirect bilirubin will easily through the blood-brain barrier in infants if there is
a state of immaturity, LBW. Hypoxia, hypoglycemia, and central nervous
system disorders to trauma or infection.
Clinical Manifestations
1.Looks Icterus: the sclera, nails, or skin and membrane
mukosa.Icterus that appears in the first 24 hours caused by
hemolytic disease of the newborn, sepsis, or mother with
diabetic or infection. Icterus that appears on the second day or
the third day, and reached the peak on the third day until the
seventh day is usually a physiological Icterus
2.Vomiting, anorexia, fatigue, dark urine color, the color of pale
stools. (Suriadi & Yulianni, 2006)
Examination and Assessment Clinic at Neonatorum Icterus
1.How to vote by neonatal Icterus clinic with methods Kremer
It is best done in the light of the sun and by pressing a little skin to be
observed to eliminate the influence of color because the circulation of
blood. There are several ways to determine the degree of Icterus is a risk
of kernIcterus by means of clinical (Kremer) is carried out under
ordinary light (daylight). Clinical assessment degree of neonatal Icterus
with methods Kremer (Marni & Massy Raharjo, 2012)
2.Diagnostic tests neonatal Icterus
a. Coombs tests on the umbilical cord of newborns: Indirect
Coombs test positive result indicates a positive Rh antibodies,
anti-A and anti-B in the Capital region. The positive result of
Coombs test direk indicate sensitization (Rh-positive, anti-A,
anti-B) HR from neonates.
b. Mother and baby blood group ABO incompatibility
identified.
c. Total bilirubin: blood levels (conjugated) meaningful if
it exceeds 1.0 - 1.5 mg / dL, which may be associated
with sepsis. Levels indirect (unconjugated) should not
exceed an increase of 5 mg / dL in 24 hours or not
more than 20 mg / dL in term infants, or 14 mg / dL in
preterm infants (depending on weight).
d. Total serum protein: less then levels of 3.0 g / dL
indicates a decrease in bonding capacity, especially
preterm infants.
e. Full blood count: hemoglobin (Hb) may be low (less
than 14 g / dL for hemolysis hematocrit (Ht) may
increase (greater than 65%) in polistemia, decrease
(less than 45%) with excessive hemolysis and anemia.
f. Glucose: dextrosit levels may be less than 45% full
blood glucose less than 30 mg / dL or test serum
glucose less than 40 mg / dL when the newborn
hypoglycemia and start using fat stores and releases a
weak acid.
g. Urinalysis to determine the reducing agent
(galactosemia)
Complications
Complications that may occur in neonatal Icterus by
Suriadi & Yulianni, 2006:
1.Bilirubin encephalopaty (serious complications)
2.Kern Icterus; neurological damage; cerebral palsy;
mental retardation, hyperactivity, slow speech, no
muscle coordination, and the shrill cries.
Management
1.Common actions
a. Checking blood group Mothers (Rh, ABO) and others
at the time of pregnancy.
b. Prevent birth trauma, administration of the drug in
pregnant women or newborns that can cause Icterus,
infections and dehydration.
c. Early feeding with the amount of fluid and calories are
in accordance with the needs of the newborn.
d. Illumination is quite in place bai treated.
e. Treatment of a factor if not known.
2. Accelerate the metabolism and expenditure bilirubin
a. Early feeding. Early neonatal feeding can reduce the
occurrence of physiologic Icterus in neonates, because
with early feeding it happens facilitation and meconium
bowel movements more quickly removed, so that the
enterohepatic circulation of bilirubin is reduced.
b. Giving gelatin. The mechanism is by blocking or
reducing the enterohepatic circulation of bilirubin.
c. Giving phenobarbital. Efficacy of phenobarbital was
held microsomal enzyme induction, so that the
conjugation of bilirubin faster.
3. Therapy sunshine
Only an additional therapy. Usually
recommended after the baby has admitted to the
Hospital. It can be dried for half an hour with a
different position. Conducted between the hours of
7:00 to 9:00 am. Because this is the time where
ultraviolet light is quite effective in reducing levels of
bilirubin. Avoid positions that make the baby look
directly at the sun as it can damage the eyes.
4. The light therapy with phototherapy
Carried out for 24 hours or at least until bilirubin levels in the
blood return to normal.
5. The exchange transfusion
The most appropriate way to treat neonatal Icterus
neonatorum is the
exchange transfusion.
6. Therapy
a. Action to immediately tackle Icterus neonatal Icterus is
usually indirect (unconjugated) in infants, using indicators
of physical signs and laboratory mainly bilirubin levels in
infants is by taking action irradiation (phototherapy), or
exchange transfusion. When Icterus neonatorum is direk
(conjugated) it can be cultivated by administration of
UDCA (Urso deaxycholic acid).
b. Causal therapy is carried out simultaneously is intended to
eliminate the causes of diseases like primary varies greatly
among others:
1. Treatment of drug intoxication, chemicals, toxins from
animal / food / herbs / supplements, is to immediately
terminate or avoid, and sedapatnya issued a material
cause of intoxication, and gastric lavage or giving
antidotes.
2. Therapy to overcome the infection as a cause of Icterus.
3. Symptomatic therapy is the giving drugs to overcome
or alleviate the symptoms that arise as a result of illness
such as fever selin Icterus.
 4. Treatment is supportive, to improve and maintain optimal patient's
general condition and needs, including providing adequate
nutrition, fluids and electrolytes, as well as oxygen.
5. The surgical therapy; typically geared to cases such as tumors,
congenital defects, bile duct obstruction, gallstones, and effort with
liver transplants.
6. Preventive measures
The precautions taken by way of avoiding drinking alcohol, avoid
kesanguinitas is hereditary, and provide vaccination against
hepatitis virus A and B.
7. Prognosis
When unconjugated bilirubin levels higher can cause toxicity in the
form of bilirubin encephalopathy brain resulting in permanent
disability and even death can result. Increased conjugation of
bilirubin can lead to long-term biliary cirrhosis and liver failure
cause.
Education and Follow-up
a.Adequacy of nutritional needs, fluid, electrolyte, feeding on
the mother passed though Icterus associated breast milk.
b.Just taking the drugs as prescribed.
c.Avoid non-prescription drugs, herbal and supplements.
d.Avoid drinking alcohol and hepatotoxic drugs.
e.Newborns with Icterus well if given string enough sun to
reduce levels of bilirubin in the blood.
f. If there is a change in symptoms aggravating the immediate
consultation with the treating physician (Klidagdo, 2012).
 CONCEPT OF NURSING
TO BABY WITH ICTERUS NEONATORUM

A. ASSESSMENT
1. Identity
Occurs more often in boys than girls. Perhaps preterm infants, preterm
infants small for gestational age (SGA), or infants with intrauterine
growth retardation (IUGR), or large for gestational age infants (LGA),
such as the baby from mother with diabetes (Mitayani, 2009).
2. Medical history
a. Disease History Now
History of present illness is about the symptoms of Icterus, it is stated in
detail the moment when the onset of Icterus, whether permanent,
intermittent, gain weight in a short time, and asked other accompanying
symptoms such as fever, pale, gastrointestinal complaints are nausea,
vomiting, decreased appetite , enlarged abdomen, upper right abdominal
pain, itching, pale stools like putty, dark color urine, bleeding, stiffness
in ekstermitas, decreased consciousness, excessive sleep. Another
question related to babies with neonatal Icterus is hard drinking
awareness apathy, lethargy, muscle tone changed, shrill crying.
b. Formerly Disease History
Pre Natal
Mothers with diabetes mellitus, taking certain medications, such as
salicylates, sulfonami blood on rubella, cytomegalovirus during delivery
with vacuum extraction, induction, oxytocin and deceleration binding
cord or other birth trauma.
Natal
Preterm labor, birth with vacuum extraction, induction pksitosin,
slowing spending umbilical cord, or birth trauma.
Post natal
Birth trauma can occur in connection with a cold stress, asphyxia,
hypoxia, acidosis, hypoglycemia, hypoproteinemia.
c. Family Health History
With a history of Icterus neonatorum mothers in pregnancy, liver
disease, fibrosiskristik, metabolism errors at birth (galactosemia), or
blood diskarasiasi sfeosititas, and deferusi glucose-6 phosphate
dehydrogenase (G-6PD).
3. Nutrition History
Maternal factors, such as maternal diabetes; digest drugs (eg salicylates,
sulfonamides oral in late pregnancy or nitrofurantoin (Furadantin);
inkompatibilotas Rh / ABO; infectious diseases eg rubella,
cytomegalovirus, syphilis, toxoplasmosis).
4. Physical examination
a. General appearance: Fatigue, lethargy, coma
b. Vital signs
Temperature: 36.5 C - 37.5 C
Nadi: 140-160x / min
Breathing: 40x / min
c. Anthropometric data such as weight and height, circle head, a thick
layer of fat under the skin, as well as the upper arm circles.
d. Inspection Head to toe
Head: shape, state of hair, facial edema or not
Eyes: cleanliness, sclera Icterus or not, conjunctival pallor or not
Nose: hygiene, respiratory nostril
Ears: cleanliness, shape, whether or not there is cerumen
Mouth: cleanliness, suction reflex, swallow
Neck: thyroid gland, lymph nodes, enlargement of the jugular veins, stiff
neck
Chest
Heart: precordial bulge, pulsation, cardiac Icterus, vibration, heart sounds.
Lungs: maximum chest expansion, no breast development is lagging,
additional breath sounds
Abdomen: shape, bowel, if there is a mass, liver enlargement, ascites.
Genitalia: whether closed labia mayora labia minora, the cleanliness of the
genitalia, eliminations process fast with soft stool characteristics, brown for
spending bilirubin. Process eliminations dark urine.
Ekstermitas: muscle tone, muscle spasm, edema

2. NURSING DIAGNOSIS
a. Risk of injury (internal) are associated with increased serum bilirubin
secondary to breakdown of red blood cells and impaired excretion of
bilirubin
b. The risk of a lack of fluid volume associated with water loss (insensible
water loss) secondary of phototherapy
3. NURSING INTERVENTION
Risk of injury (internal) are associated with increased serum bilirubin
secondary to breakdown of red blood cells and impaired excretion of
bilirubin.
Objective: after the action for 3x24 hour nursing babies free from injury.
Criteria results: in term infants at the age of 3 days indirect bilirubin
levels below 12 mg/dl, bilirubin levels in preterm infants < 10 mg/dl
intervention:
1) Keep the babies warm and dry; monitor the temperature of the skin
and often
Rationale: cold stress potentially releasing fatty acids that
compete on the bond to albumin, thereby increasing the levels of
bilirubin circulating free (unbound).
2) Observe baby in natural light, consider the sclera and oral mucosa,
skin yellowing soon
Rationale: detecting evidence of the degree of Icterus
3) Consider the age of the baby at the beginning of Icterus, distinguish
the type of Icterus physiology, pathology, dank because breast milk.
Rational: physiological Icterus between the first and second day of life,
Icterus because milk appear between the fourth and sixth day of life is
usually only 1% -2%, pathological Icterus appears within the first 24
hours of life and may lead to the development of kern Icterus /
enselopati bilirubin.
4) Monitor the progress of the infant to behavioral change
Rationale: behavioral changes associated with kern Icterus usually
occurs between days 3 and 10 of life and is rare before 36 hours of life.
5) Collaboration
a) Monitor laboratory tests as indicated
Bilirubin direct and indirect
Rationale: musty Icterus show reduced or absent
b) Start phototherapy using a fluorescent lamp that is placed over the
baby
Rationale: bilirubin oxidation causes the photo on an extensive network
of subcutaneous, so the water soluble bilirubin Enhancing the
capabilities that enable rapid excretion of bilirubin in feces and urine
c) Change the baby's position frequently, at least every 2 hours
Rationale: to prevent decubitus

The risk of lack of fluid volume associated with water loss

(insensible water loss) secondary of phototherapy
Objective: after the act of nursing for 3x24 hours the problem
resolved
Criteria results: there are no signs of dehydration, good turgor.
Intervention
1) Monitor output client
Rationale: output excessive or unbalanced intake will cause fluid
balance disturbances.
2) Inform the family about the importance of breastfeeding than milk
formula
Rationale: order intake remains balanced
3) Collaboration on fluid administration
Rationale: to prevent dehydration and lack of fluid volume
EVALUATION
1. In term infants at the age of 3 days indirect bilirubin levels below
12 mg / dl, bilirubin levels in preterm infants <10 mg / dl.
2. No signs of dehydration, good turgor.
 2.3 Nursing in Infants Icterus Neonatorum
The Rooms : Baby
No. Reg : 12.50.78.16
Assessment Date : June 5, 2016 , 15:00 Pm
MRS Date : May 29, 2016 , At 07:02:29 am
ASSESSMENT
A. Identity
Baby Names : By . W
Age : 7 days
Gender : Female
Person in charge
Dad / Mom : Mr. A / Mrs . W
Age : 30 years / 27 years
Address : Sirepah , Balong Bendo , Sidoarjo
Religion : moslem
Job : -
Medical Diagnosis : LBW / SMK + Icterus Neonatorum
B. Health History
1. Main Complaint : No result
2. History of Pregnancy and Childbirth
Pre Natal : States G2 P11002 with 30/31 weeks gestation , treatment
during pregnancy is no result , TT immunization not result, no result of
complications pregnancy assesment.
Natal :
Babies born in emergency unit Dr. Soetomo hospital, childbirthing : sc
with indication amniotic murky and placenta the previa totalis.
Post Natal :
A baby born on may 30 2016 at 06: 15: 00 with weight 1235 grams , the
long body 43 cm , circle head 27 cm, circle chest 24 cm , meconium
out < 24 hours , baby treated at NICU on may 30 2016 at 06: 37
temperatures 36.5C , HR 150 time/ minutes , RR 40 times / minutes.
APGAR Score to 11 and 51 = 5 6
APGAR Score 11 51
Heat rate 1 2
Respiration 1 1
Tonus Muscle 1 1
Refleks 1 1
Skin color 1 1
Total APGAR Score 5 6

C. Disease History Now

On May 31 2016 at 7:02 baby moved in the baby's room with a
temperature of 36.6 C , HR 148 / min, RR 39 / min . Was assisted by
the baby by physicians with a kind of childbirth SC. Babies suffering
from Icterus since June 4 2016.
D. Family History : No result
E. Immunization History : No result
F. The pattern of the function of health
1. Fluid intake / nutrition
ASI / PASI : 8 cc personde every 2 hours ( 12 x 8 cc / 24 hours )
Infusion : D5 - Ns 12.5 % 60 cc / 24 hours via pump
2. Elimination
Urine elimination : 50 cc / 4 hours
Bowel elimination : characteristic soft , distinctive smell of feces
3. Rest and Sleep
Sleep duration : 20 hours
State of sleep : Quiet , crying if thirsty
4. Personal Hygiene
Baby every morning at 04:30 am always wiped, every tubs and chapter always
replaced its diapers, babies are always performed oral hygiene by using
Enystatin .
5. Activities
Weak grasp reflex , Babinski reflex is not gripping fingers , moro reflex is
weak , the attitude of the extension baby , the baby is not moving on.
G. Psychosocial
Mother's behavior toward infants : No result
H. Physical Examination
General State
1. Head
Nothing Caput succadenum, fronto- occipito 27 cm , state heads clean
, no swelling , no lesion , thin hair .
2. Eyes
Symmetrical shape, clean, nothing anemic conjunctiva and sclera
Icterus , there are no abnormalities in the eye .
3. Nose
There is a hole nose, nothing respiratory pierced nose , no polyps , no
secretions .
4. Lips
Dark red lip color , lip mucosa dry , clean tongue , gums clean, no
inflammation , no stomatitis , no lesions , feeble rooting reflex , sucking
reflex is weak .
5. Ear
Symmetrical shape , layout aligned against the ear , the ear elastic ,
nothing cerumen , the color of dark red ears .
6. Neck
No enlargement of the thyroid gland , no enlargement of the jugular veins , no
redness , no blisters skin , weak swallowing reflex .
7. Chest
Symmetrical shape , redness , circle chest 26 cm , regular respiratory rhythm ,
maximum chest expansion , clean breath sounds .
8. Abdomen
Nothing injuries , redness , there is tenderness , bowel sounds 19 times / min ,
the umbilical cord is not loose , no bleeding on the cord , there are no signs of
umbilical cord infection .
9. The state of the back
Nothing spina bifida , nothing dicubitus , No bruised the emphasis back.
10. Genetalia
Closed labia mayora labia minora , clitoris stand , no skin abrasions , nothing
mushroom .
11. Anal
The anal canal is not blocked, the anal is not ruddy , the skin around the anus
blisters .
12. Extremities
Hand
The movement of weak hands , nothing injuries / edema , weak grasp reflex
Under
The movement of weak legs , no edema , no wounds , leg skin dry , do not grip
the finger Babinski reflex .
13. Leather
Reddish skin color reddish , dry , turgor skin good.
I. Examination of supporting
Chemical examination clinic June 04 2016 at 10: 27: 46

Examination Result Unit Normal value

Albumin 3.4 g/Dl 3.4 5.0

Direk bilirubin 0.52 mg/Dl 0.00 0.20

Total bilirubin 11.19 mg/Dl 0.2 1.00

CRP 0.1 mg/Dl 0.00 0.90

Diagnostic examination at Juni 04 2016
Kind of Hematologi Normal Result

WBC/Lecco L = 3.8 10.6 9420 x 103/ L

P = 3.6 11
HGB/Hb L = 13.2 17.39 14.7 g/Dl
P = 11.7 15.5
HCT/PVC L = 40 52 42 %
P = 35 47
PLT/Thrombo 150 400 31840 x 103/ L

Kind chemistry

Bilirubin direk 0.00 0.2 0.52 mg/dL

Bilirubin total 0.1 1 11.19 mg/dL

Examination Chemistry Clinic Juni 07 2016 at11:14:31WIB
Parameter Result Normal
value
Bilirubin 0.52 0.00 0.2
direk
Bilirubin 4,35 0.1 1
total
J. Therapy Provided
1. Installed infusion : D5 - Ns 12.5 % 60 cc / 24 hours via pump
2. ASI / PASI 8 cc personde every 2 hours ( 12 x 8 cc / 24 hours )
3. Phototherapy conducted on June 5, 2016 1 x 24 hours
 As Much As This,
Thank You For Your
Attention
Wassalamualaikum
Warahmatullah
Wabarakatuh