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.