Download - Hyperbilirubinemia Case Presentation
CASE PRESENTATION
Hyperbilirubinemia
Personal Data
Name: Baby Girl L Age: 27 days Date of Birth: October 22, 2009 Address: B24 B186 Street Maricaban
Pasay City
History of Present Illness
Born, preterm, baby girl delivered to a 18 years old, G2P1 (1001) via NSD. Maturity Index is 31-32 weeks AOG, APGAR Score 9,9, Amniotic Fluid is clear.
Day of birth, placed in incubator, monitored with pulse oxymeter and put on NPO diet. Infused IVF with D5water at 80cc/kg/day and amino steril 6%.
2nd hour of life had apnea episode. 1st day of life, stable and maintained on NPO and
given antibiotic. 2nd day of life, she manifested jaundice 4th day of life manifested and increased in jaundice
and was placed under phototheraphy.
Family History
The mother of BGL had no history of diabetes mellitus, hypertension and asthma in their family. A non-smoker but considered as second hand smoker because her husband consumes atleast 1 pack of cigarettes per day. She said that during her early month of pregnancy (1st - 2nd month) she used to drink alcohol but after she found out about her pregnancy she immediately stop drinking. She had not been exposed to any medications except for vitamins. She usually eat foods rich in preservatives and she doesn’t eat vegetables. During her pregnancy she still do house hold chores that makes her stressful but most of the time she just takes a rest and sleep.
Physical Assessment
Anthropomentric measurement as follows:
GA: 31-32 weeks HC: 25.5 cm CC: 23.5 cm AC: 21 cm Wt: 1.18 kg L: 34 cm T – 37.1 C
Physical Assessment
Preterm Term
Posture Lies in a relaxed attitude, limbs more extended; the body size is small, and the head may appear somewhat larger in proportion to
the body size
Has more subcutaneous fat tissue and rests in a more flexed attitude
Ear Ear cartilages are poorly developed, and the ear may fold
easily;
Ear cartilages are well formed
Sole Appears more turgid and may have only fine wrinkles
Well and deeply creased
Female Genetalia Clitoris is prominent, and labia majora are poorly developed
Labia majora is fully developed, and the clitoris is not as
prominentLanugo Hair is fine and leathery, and the
lanugo may cover the back and upper arm
Less lanugo
Scarf Sign Elbow may easily be brought across the chest with little or no
resistance
Elbow may be brought to the midline of the chest , resisting
attempts to bring the elbow past the midline
Neuromuscular Maturity
Posture – slight or moderate flexion of the knees
Square Window (wrist) – 90 degrees Arm Recoil - incomplete / partial
flexion Popliteal Angle – 180 degrees Scarf Sign – elbow between opposite
anterior axillary line and midline of the thorax
Ballard’s Assesment Physical Maturity
-1 0 1 2 3 4 5Skin Sticky, friable,
transparentGelatinous, red,
trancslucentSmooth, pink,
visible veinSuperficial,
peeling &/or rash, few veins
Cracking, pale area, rare veins
Parchment, deep cracking, no
vessels
Leathery, cracked, wrinkled
Lanugo None sparse Abundant Thinning Bald areas Mostly bald
Plantar creases
Heel to toe No crease Faint red marks Anterior transverse crease only
Creases ant. 2/3 Creases cover entire sole
Breast imperceptible Barely percept. Flat areola, no bud
Stippled areola, 1-2 mm bud
Raised areola, 3-4 mm bud
Full areola, 5-10 mm bud
Eyes/Ear Lids fuses loosely Lids open, Pinna flat, stays
folded
Slightly curved pinna, soft with
slow recoil
Well-curved pinna, soft but
ready recoil
Formed and firm with instant
recoil
Thick cartilage, ear stiff
Female genitals
Prominent clitoris, labia flat
Prominent clitoris, small labia minora
Prominent clitoris,
enlarging minora
Majora and minora equally
prominent
Majora large, minora small
Clitoris and minora
completely covered
Ballard’s Assesment Physical Maturity
Diagnostic test
October 22, 2009 Culture and Sensitivity; Blood
(Bactec) Culture: No growth after 5 days of incubation
Interpretation:
Diagnostic test
CHEST X-RAYResult: The lung fields are clear with normovascular
patterns. The heart is normal in size and configuration Bony walls and thorax are unremarkable Soft tissue densities are w/in normal Comment: Normal Chest
Interpretation:
Diagnostic test
Normal (female) Result
Leukocytes 4.1-10.9 6
Erythrocytes 3.8-5.5 6
Hemoglobin 12-15.2gm/dL 17.5
Hematocrit 37-46% 52
Thrombocytes 140-450 482
Lymphocytes 20-50% 52.300
Hematology
Diagnostic test
October 25, 2009CLINICAL CHEMISTRY Total Bilirubin 10 mg/dl .2-13 Direct Bilirubin 2 mg/dl
0-.4 Indirect Bilirubin 8mag/dl 0-1.1 Sodium 147 mg/dl
137-145
Interpretation:
Diagnostic test
October 30, 2009CLINICAL CHEMISTRY
Total Bilirubin Neonates 3.6 mg/dl 0-12 Direct Bilirubin 1.2 0-0.2 Indirect Bilirubin 2.4 0-1.1
Interpretation: There is an increase in Bilirubin Neonates because of hemolysis.
Disease entity
Predisposing factors: age 18 yrs.old
Precipitating factors: alcohol drinker, second hand smoker , unhealthy diet
Contributing factors: sedentary lifestyle, exposed to pollution, stress
Disease entity
Signs and symptoms: maturity index (31-32 weeks), low birth weight(1180g), small birth length(34 cm), transparent skin, more lanugo, wrinkled skin, less vernix caseosa, poor sucking reflex, poikilothermia, labia minora is more prominent than labia majora,
Pre-term
Disease Entity
Increase sequestration of RBC containing Fetal HGB by the spleen
Release of HGB and dissolution into heme and globin portions
heme
Globin
Converted into unconjugated bilirubin
LIVERHGB formation
Increased accumulation of concentration of bile in the blood
Be used for HGB formation
Jaundice
conjugated bilirubin
DRUG CLASSIFI-CATION
FREQUENCY, ROUTE, DOSE
INDICATION CONTRAINDICATION
ADVERSE EFFECTS
NURSING RESPONSIBILI-
TIES
AMINOPHYLLINE
XANTHINE;
BRONCHODILATOR
I.V. 3 MG +2CC STERILE WATER;
OD;
Relief for bronchospasm
HYPERSENSITIVITY TO XANTHINE
USE CAUTIOUSLY
WITH NEONATES AND INFANTS. Before giving loading dose,
make sure patient hasn’t
had recent theophylinne
therapy.Monitor VS
THEOPHYLLINE
XANTHINE,
BRONCHODILATOR
I.V. 25.7 mg/ 5 Ml 0.6 mL OD
RELIEF FOR BRONCHO-
SPASM
DON’T USE EXTENDED RELEASE
FORMS OF ACUTE BRONCHOSPASM
NAUSEA AND VOMITING,
IRRITABILITY, RESTLESNESS,
FLUSHING
USE CAUTIOUSLY IN NEONANATES, MONITOR VS
Treatment and Management
DRUGCLASSIFICATION
FREQUENCY, ROUTE, DOSE INDICATION
CONTRAINDICATION
ADVERSE EFFECTS
NURSING RESPONSIBILITI
ES
CLUSIVOL Multi-vitamins
PO 0.2 mL OD Nutritional supplement,
Hypersensitivity, Nausea and vomiting
Use cautiously in patients with respiratory inefficiency
Ferrous (Ferlin Drops)
Hema-tinics
PO 0.5 OD For iron deficiency
Contraindication in patients with
hemosiderosis hemolytic anemia
Nausea and Vomiting,
black stool
Between meals are preferable
NURSING CARE PLAN
CUES BACKGROUND KNOWLEDGE
NURSING DIAGNOSIS
OBJECTIVES
Objective:>31-32 weeks AOG>weak suck> 22 cc OGT tolerated
Premature babies are babies born before the target gestational age which is 37-38 weeks. Since they are born prematurely most of their organs are still developing. They must make the same adjustment towards their
Imbalanced Nutrition due to Immaturity
After 8 hours of nursing interventions, patient will be able to receive adequate nourishment to maintain balance.
undeveloped body systems but with functional immaturity proportional to the stage of development reached at the time of birth.Nutrition is the combination of processes by which the living organism receives and utilizes the materials necessary for its growth .
INTERVENTION RATIONALE
Independent:>use orogastric feeding>use appropriate milk formula and amount >assess readiness to nipple feed Dependent:>maintain parenteral fluid nutrition therapy as ordered >administer medications as prescribed by the physician
>patient has weak suck>to avoid feeding intolerance
>to recognize the sucking ability and the coordination of swallowing and breathing
>gives additional nourishment and renews body fluid
>food supplements are necessary to support the child’s nutrition
EVALUATION
After 8 hours of nursing interventions, patient received an adequate amount of calories and essential nutrients.
NURSING CARE PLAN
CUES BACKGROUND KNOWLEDGE
NURSING DIAGNOSIS
OBJECTIVES
Objective:>dry, flaky skin>thin, parchment-like skin>skin turgor test (slow skin recoil)
Premature babies are babies born before the target gestational age which is 37-38 weeks. Since they are born prematurely most of their organs are still developing. They must make the same adjustment towards their undeveloped body systems but with functional immaturity proportional to the stage of development reached at the time of birth.
Risk for Imbalanced Fluid Volume related to immature characteristics of preterm infants
After 8 hours of nursing interventions, patient will be able to exhibit adequate hydration status
Requirements of water are related to caloric consumption and loss through perspiration. The daily consumption of fluids by infants ranges from 10-15% of his body weight. The quantity of water absorbed in the bloodstream changes considerably in order to maintain homeostasis within the intracellular and vascular compartments
INTERVENTION RATIONALE
Independent:>minimize use of adhesives>monitor intake and laboratory results>monitor urine output, especially the frequency, amount and characteristics>apply lotion or oil over the body>regulate parenteral fluids>assess signs of hydration Dependent:>maintain parenteral fluid nutrition therapy as ordered
>to preserve skin integrity>shows evidence IF there is dehydration>it may indicate the low body fluid levels
>prevent subsequent drying of the skin>to avoid dehydration and overhydration>to recognize if there is dehydration or overhydration
>gives additional nourishment and renews body fluid
EVALUATION
After 8 hours of nursing interventions, patient exhibited evidence of fluid balance.