Hyperbilirubinemia secondary to ABO incompatibility

t/c Sepsis

Presented by:GROUP AUTONOMY

, Aura Regene, Hazel, Jr-rey

Merry Rose, Lecel

, Charmaign, Mark Jhon

, Daniel, Elisa Jarha

, Angela Joselle

I. INTRODUCTION

Neonatal Hyperbilirubinemia or Neonatal Jaundice is one of the most common problems encountered in term newborns. Although up to 60 percent of term newborns have clinical jaundice in the first week of life. Jaundice is considered pathologic if it presents within the first 24 hours after birth.ABO incompatibility is a reaction of the immune system that occurs if two different and not compatible blood types are mixed together. ABO incompatibility disease afflicts newborns whose mothers are blood type O , and who have a baby with type A, B, or AB.

Ordinarily, the antibodies (IgG) against the foreign blood types A and B that circulate in mother's bloodstream remain there, because they are of a type that is too large to pass easily across the placenta into the fetal circulation. Some fetal red cells always leak into mother's circulation across the placental.These fetal red cells stimulate the formation of a smaller type of anti-A or anti-B antibody which can pass into the baby's circulation and there cause the destruction of fetal red cells. The increased rate of destruction of red cells causes a subsequent increase in waste product production. This excess waste product, bilirubin, can overwhelm the normal waste elimination processes and lead to jaundice, the presence of excess bilirubin.

On the other hand, sepsis in a newborn is an infection that spreads throughout the baby’s body. Sepsis occurs in less than 1 percent of newborns (1 out of every 100), but accounts for up to 30 percent of deaths in the first few weeks of life. Infection is 5-10 times more common in premature newborns and in babies weighing less than 5½ pounds than in normal-weight, full-term newborns. Complications experienced during birth, such as premature or prolonged rupture of the membranes or infection in the mother, put the newborn at increased risk of infection.

BACKGROUND OF THE STUDY

Baby Girl Autonomy is a full term baby from Pila, Laguna and delivered via NSD by her mother last July 30, 2010 at LPH and has been admitted at septic ward (PICU) last August 1, 2010 because of jaundice and fever, she has been diagnosed by hyperbilirubinemia secondary to ABO incompatibility tc sepsis. She has undergone intermittent phototherapy at her first day in Septic Intensive Care Unit then she was under intensive phototherapy when we last handled and visited her. Her mother and father blood type was O while baby Girl Autonomy blood type was A. 

RATIONALE FOR CHOOSING THE CASEThis case has been chosen by the group under following reasons:•To better understand Hyperbilirubinemia with ABO incompatibility its nature and appropriate interventions that may contribute to patient’s recovery.•To benefit the student nurses in enhancing their skills in giving care for such patient diagnose with Hyperbilirubinemia with ABO incompatibility. •To defy our capabilities in presenting such challenging case.•Be able to construct a pathophysiology.• Challenge our skills in connecting relevant details of the disease to actual care of client.

SIGNIFICANCE OF THE STUDY

To the patient  This study hopes to be most beneficial to the patient as the core purpose of this, is to aid in prompt and successful client recovery.

To the students & to the Clinical Instructor This study presents various observations and encounters upon handling the client and sustaining for her recovery. Hence, we hope to be of help to our fellow students by sharing first hand experiences about the condition.

SCOPE AND LIMITATION OF THE STUDY This study covers and focuses on the following:•A brief discussion of Hyperbilirubinemia with ABO incompatibility, its causes, manifestations and proper treatment.•A pathophysiology presented via schematic diagram format of Hyperbilirubinemia with ABO incompatibility.•A drug study of medications prescribed to patient.•Nursing Care Plans which would present nursing analysis, diagnosis, plan and appropriate interventions that would aid in patients recovery.•Discharge plan which presents follow up care and treatment after confinement.

II. CLINICAL SUMMARYEclectic Model 

1. Bio-demographic Dataa. Name : Baby Girl Autonomyb. Age : 2 days oldc. Sex : Femaled. Diagnosis : hyperbilirubinemia

secondary to ABO

incompatibility tc sepsise. Address : Pila, Lagunaf. Date of Admission : August 1, 2010g. Time of Admission : 6:54pmh. Attending Physician : Sheryl Fandino, M.D.

2. Source of Informationa. Primary Sources:•Mother•Grandmother•Nurses on Dutyb. Secondary Sources:• Patient’s records and chart 3. Chief Complaint:Onset of fever and jaundice 4. History of the Present Illness:

 According to her grandmother, when they were able to go home last Saturday, July 31, after Baby Girl Autonomy was born, Baby GA started to have fever and they have noticed that her skin became yellowish in color after 24 hours. The Pediatric Residence on Duty seen and examined her and the physician ordered to hold MGH and requested for CBC. The patient then transferred to PICU Septic ward on August 1, Sunday at exactly 6:54 pm. Afterwards, the PROD requested for Bilirubin Test and ordered to Tepid Sponge Bath the patient as well as to have intermittent phototherapy.

5. Current Health Status:

a. Body Movement:

Baby GA is fairly active and flexes her upper and lower extremities well.

b. Manner of Dressing

Baby Girl Autonomy is properly and neatly dressed by her mother.

c. Affect and Mood

She’s crying at times.

 

6. Activities of Daily Living

a. Nutrition

Baby Girl Autonomy is being directly breastfed with aspiration precaution by her mother.

b. Elimination

She only defecated twice since she was born.

c. Hygiene, Grooming and Body Odor

She has no foul odor because she usually cleaned every morning and dressed neatly by her mother.

d. Rest and Sleep

Baby GA sleeps most of the time.

7. Past Biophysical Health

a. Allergies

Baby GA has no history of any allergies noted so far.

b. Immunization

She only received Vitamin K and Hepa B vaccine immediately after birth and no immunization vaccines received so far. She’s not yet also undergone newborn screening.

c. Foreign Travel

No foreign travel so far.

d. Family Health History

Upon the interview, we’ve found out that she has a history of Hepatitis B since her uncle on father’s side has the disease.

8. Socio Cultural Pattern

a. Cultural Pattern

Her family believes in “herbolarios” and superstitions like putting wet silk on the baby’s forehead when hiccups occur.

b. Economic Pattern

Baby Girl Autonomy’s father works in a vulcanizing shop while her mother is only a housewife. They only received enough income to meet the needs of their family in everyday living.

c. Environment

They lived in a well-adjusted community along the highway in Pila, Laguna.

9. Spiritual

a. Religious Belief and Practice

Baby GA’s family is a Roman Catholic and goes to church every Sunday. They believed in “hilots” or “herbularios”.

 

Physical AssessmentGeneral Observationa. General Appearance and behavior•Weak in appearance•With yellowish discoloration of the skin•Skin warm to touch

 

b. Vital Signs

Temperature = 38.1 C

CR = 121 bpm

RR = 39 cpm

c. Height and Weight

Height (Length) = 57 cm

Weight = 2.7 kg

Complete Physical Examination (Head to Foot/ Cephalo – caudal Approach)

physical assessment landscpe.docx

Laboratory and Diagnostic ExaminationAugust 1, 2010

Test Result Normal Values Indication Significance

Neonatal Bilirubin 19.2Mg/dl

328.32 UMOL/L

1.0-10.5

17.1-180

Above normal Due to ABO incompatibility, increase destruction of RBC resulting in increase unconjugated bilirubin

Unconjugated

bilirubin

19.2Mg/dl

328 UMOL/L

0.6-10.5

10-180

Above normal Due to ABO incompatibility, increase destruction of RBC resulting in increase unconjugated bilirubin

Conjugated

Bilirubin

0

0

0-0.6

0-10

Normal

CBCTest Result Normal Values Indication Signifcance

WBC 23.5 UL 4.1-10.9 k/UL Above Normal Increase related to compensatory of immune system in response to infection

Lymphocytes 8.3RM

35.2%L

0.6-4.1

10.0-58.5%L

Above normal Increase related to the compensatory of immune system in response to infection

MID 2.8-12.0%M 0.81-24.0%M NormalGranulocytes 12.4 R3

52.8%G

2.0-7.8

37.0-92.0%G

Above normal Increase may indicate bacterial,viral, parasitic infections

RBC 5.07 M/UL 4.20-6.30M/UL Normal

Hemoglobin 17.2G/DL 12.0-18.0G/DL Normal

Hematocrit 49.0% 37.0-51.0% NormalMCU 96.7fl 80.0-97.0 fl NormalMCH 33.0pg 26.0-32.0 pg Above normal Increase related to

B12 or folic acid deficiency

MCHC 35.1 g/dl 31.0-36.0 g/dl NormalRDW 16.0% 11.5-14.5% Above normal Increase lysis RBC,

body response is to provide more RBC, sometimes immature

Platelet 307 k/ul 140-440 k/ul Normal

Initial impression and Medical Diagnosis

Hyperbilirubinemia 20 ABO incompatibility t/c sepsis

Course in the WardDay 1 August 2, 2010The shift started at 10pm, the chart was checked to gather information about the patient and if there are new doctor’s order for the patient. Vital signs were taken at 10:30pm. We recorded 370C for the temperature and 39cpm for respiration and lastly for the cardiac rate which results to 121bpm. The heplock was inserted in her right metatarsal vein. Physical assessment was done to the patient. We also reminded the patient’s mother to feed the baby with milk formula with strict aspiration precaution. She has also undergone intermittent phototherapy. Temperature was taken again at 12:30 am with body temperature of 38.10C. Because of fever, nursing managements were done such as: TSB, intermittent droplight, wrap extremities with blanket and loose clothing and note for any shaking, chills or profuse sweating. We weighed the patient which results to 2.7 kg at around 2:40am. Then, at 4am, the temperature was decreased to 370C. The cardiac rate was maintained at 121bpm and 36cpm for the respiration. At 6am, we endorsed her to the staff nurses.

Day 2 August 3, 2010The shift started at 10pm, the chart was

checked again for any new doctor’s order. The new order was to place the patient under intensive phototherapy and may have direct breastfeeding. Vital signs were taken at 12am that showed 37.20C for the temperature, 34cpm for respiration and lastly for the cardiac rate of 111bpm. The heplock was inserted at her right metacarpal vein. Physical assessment was done again to the patient. Since she was at risk for infection, we monitored her visitors as indicated, practiced standard precaution aseptic technique, observed her for any shaking, chills or profuse diaphoresis and inspected her oral cavity for white plaques. Vital signs were taken again at around 4am with the body temperature of 37.30C, 33cpm for respiration and 116bpm for cardiac rate. We weighed again the patient but the result was still the same. At 6am, we referred her accordingly to the staff nurses.

Day 3 August 4, 2010The shift started at 10 pm, the chart was checked

for progress of the condition of the patient and for new doctor’s order which indicated direct breastfeeding with aspiration precaution and continue intensive phototherapy. Vital signs were taken at 12am, temperature was 370C, 40cpm for respiration and lastly, cardiac rate of 121bpm. The heplock was still inserted at her right metacarpal vein. We also assessed her for any abnormalities or progress. We inspected her eyes for conjunctivitis, drainage and corneal abrasions due to irritation from eye patches. We also rendered interventions such as covering her eyes with eye patches while under phototherapy lights, removing her from phototherapy during feeding and providng minimal coverage only in the diaper area. We also repositioned the patient every 2 hours. Vital signs were taken again at around 4am with the body temperature of 36.30C, 35cpm for the respiration and 126bpm for cardiac rate. We weighed the patient which resulted the same. At 6am, we refer her accordingly to the staff nurses.

III. CLINICAL DISCUSSION OF THE DISEASEANATOMY AND PHYSIOLOGY

LIVER

FUNCTIONS:•Metabolism of carbohydrates, protein and fats•Production of bile salts•Bilirubin metabolism•Detoxification of endogenous and exogenous substances eg. Ammonia, steroid and vitamins ADEK•Blood reservoir•Excretion of adrenal cortex hormone•Phagocytosis by kupffer cells

GALL BLADDER

FUNCTIONS:•Stores and concentrates the (greenish liquid composed of watr, cholesterol, bile salts, electrolyte and phospholipids) produce by the liver•Important in fat emulsification and intestinal absorption of fatty acids, cholesterol and other lipids•Bile also acids in excretion of conjugated bilirubin (an end product of hemoglobin degradation) from the liver to prevent jaundice

NORMAL ANATOMY OF BILIRUBIN PRODUCTION AND ELIMINATION

NORMAL ANATOMY OF BILIRUBIN PRODUCTION AND ELIMINATION.docx

 

ANATOMY OF ABO BLOOD GROUPSYouTube - Blood groups and Blood compatibility.flv

Pathophysiology

PATHOPHYSIOLOGY---NEW....doc

Drug StudyDrug name Classification Mechanism of

actionIndication Contraindication Adverse effects Nursing

Responsibilities

Generic name: Amikacin sulfate

Brand name: AmikinDOSAGE: 17 mg IV OD

Amino glycosides Bactericidal: Inhibits protein

synthesis in susceptible

strains of gram-negative

bacteria and the functional integrity of

bacterial cell membrane

appears to be disrupted,

causing cell death.

Neonatal sepsis when other antibodies

cannot be used (often used in combination

with penicillin type drug.)

Contraindicated with glycosides renal or hepatic

disease, pre-existing hearing

loss, myasthenia,

gravis parkinsonism,

infant botulism, lactation.

-confusion-depression-lethargy-nysthagmus-headache-fever-tremor-muscle twitching-seizures-muscular weakness-nausea-vomiting-anorexia-diarrhea-weight loss-increased salivation

Assess patient for allergic reaction: rash, urticaria, pruritus and hypotension-Obtain specimen for culture and sensitivity before initiating therapy. First dose may be given before receiving results.-Monitor intake and output and daily weight to assess hydration status and renal function.-Assess patient for sign of super infection (fever, upper respiratory infection.)

Drug name Classification Mechanism of action

Indication Contraindication

Adverse effects

Nursing Responsibilities

Generic name:

AmpicillinBrand name:

PrincipenDOSAGE: 165 mg IV every 12 hours 6/6

Anti-infectives’ Bactericidal action against sensitive organisms; inhibits synthesis of bacterial cell wall easing cell death.

Treatment of a variety of infections including those of the urinary, respiratory, biliary and intestinal tracts.

Contraindicated with allergies to penicillin’s, cephalosporin’s or other allergens

Hypersensitivity: rash, fever, wheezing, and anaphylaxis.

Assess for infection (Vital signs, urine, stool and WBC) at the beginning and throughout the therapy.-Obtain a history before initiating therapy to determine previous use reaction to penicillin or cephalosporin’s.-Obtain specimens for culture and sensitivity before therapy. First dose may be given before receiving results.-Observe patient for signs and symptoms of anaphylaxia (rash, pruritus, wheezing). Discontinue the drug and notify the physician or other health care.-Assess skin for ampiciilin rash a non allergic dull red.-Report pain/ discomfort at site unusual bleeding/ bruishing, mouth sores, difficulty of breathing.

Drug name Classification Mechanism of action

Indication Contraindication Adverse effects Nursing Responsibilities

Generic name: Phenobarbital

Brand name: Luminal sodium

DOSAGE: 15 mg pptab mixed with feeding 12

hours 12/12

Antiepileptic General CNS depressant; barbiturates

inhibit impulse conduction in the

ascending RAS, depress the

cerebral cortex.

Emergency control of acute

seizures

Contraindicated with

hypersensitivity to barbiturates,

manifest or latent porphyria;

marked severe liver impairment; severe respiratory

distress-Use cautiously

with acute/chronic pain; seizure

disorders, lactation, fever,

impaired liver or renal function.

-confusion-bradycardia-pain-tissue necrosis at injection site

1. Assess patients condition before therapy and regularly, these after to monitor drug effectiveness2. Monitor respiration character rate and rhythm. Hold drug if respiration < 10 / minutes or if pupil are dilated.3. Monitor for possible drug adverse reaction.4. Assess skin color, reflexes, adventitious sounds and bowel sounds5. May cause decreases serum bilirubin concentration in neonates, in patients with congenital nonhemolytic unconjugated hyperbilirubinemia and in epileptic.

IV. NURSING CARE PLANAssessment Diagnosis Planning Intervention Rationale Evaluation

Objective:•Temp 38.10C•Warm totouch.•Weak & pale in appearance•persistent crying•With slightly dry lips

Hyperthermiarelated to direct effect of circulating endotoxin on the hypothalamus altering temperature regulation as evidenced by increase in body temp. higher than normal range

After 4hrs.ofnursinginterventions,the patient willmaintain coretemperaturewithin normalrange (370C).

(1)Monitor patient’s temperature

(2)Monitor environmental temp. limit bed linens as indicated

(3)Perform TSB, avoid use of alcohol

(4)Apply towel to provide cooling effect(5) Maintain bed rest, assist with care activity

(6) Promote surface cooling by means of undressing

(1) to evaluate degree of hyperthermia (2) Room temp or no. of blanket should be altered to maintain near-normal body temp.(3)May help reduce fever, alcohol may cause chills, actually elevating temp., alcohol is very drying to skin(4)used to reduce fever. Heat loss by conduction

5.) maximizes effectiveness of tissue perfusion and energy/oxygen conservation (6)heat loss by evaporation

After 4hrs. of nursinginterventions, thepatient wasable to maintaincore temperaturewithin normalrange from 38.10C to 370C.

Ineffective infant feeding pattern related to limited consumption of breast milk as evidenced by the mother is unable to provide adequate breast milk to her baby continuously.

NCP new (feeding pattern).doc

Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective:

•patient is in

intensive

photo therapy

for 3 days

•With single

photo therapy

•Frequent

removal of

the eye

patches

•Skin

appearing

light

to bright

yellow.

•Sclera

appearing

yellow.

•With diaper

on

Risk forcorneal irritation and skin breakdownrelated toprolonged used of phototherapy

after series of nursing interventions, the patient’s risk of acquiring corneal irritation/skin breakdown will be reduced.

(1) Maintained and

monitored baby’s eye

patches while under

phototherapy.

(2) Remove baby

from under

phototherapy and

remove eye patches

during feeding.

(4) Inspect eyes every

after phototherapy for

conjunctivitis,

drainage and corneal

abrasions due to

irritation from eye

patches.

(5) Provide

minimal coverage of the

body except for

genitals.

(6) Reposition baby

every 2hours.

(1)Protects retina fromdamage due to high intensity light.

(2) Provides visualstimulation andfacilitates attachmentbehaviors.

(4) to reduce complications and monitor the effectiveness of the management

(5) Provides maximalexposure and shielded the sensitive parts such as the eyes and genitals.

(6) to promote equal distribution of phototherapy exposure.

After series of

nursing

Interventions

Neonate was

free from injury.

As evidenced by

infant’s

eyes are free from

corneal irritation

and skin

breakdown.

V. DISCHARGE PLANMedications:•Encouraged SO to comply with medications to prevent further complications.

Environment:•Encouraged SO to keep environment clean to avoid infection.• Encouraged SO to keep environment quiet to make the patient comfortable.

Treatment:•Emphasized SO the importance of regular follow-up check-ups and as instructed by physician.•Advised SO to seek medical advice if any unusuality arises.

Health Teachings:•Advised SO to expose the patient to sunlight around 6:00am-8:00am.•Emphasized to SO the importance of proper handwashing.•Encouraged SO for proper hygiene of the patient.

Diet:•Encouraged the mother for breast feeding.Spirituality:•Encouraged SO and Family members to go to church every Sunday.•Encouraged SO to continue to seek God’s guidance and enlightenment.•Emphasized SO the importance of prayers in healing.•Encouraged SO to continue to have a positive outlook in life.

EVALUATION•The nursing procedure was rendered to the patient accordingly. Application of these procedures was done independently by the group autonomy, the knowledge, skills and attitudes of providing care for the patient.

SUMMARY YouTube - neonatal jaundice.flv

Our case study is all about Hyperbilirubinemia with ABO incompatibility. Hyperbilirubinemia also known as neonatal jaundice is a yellow discoloration of the skin of a baby due to high unconjugated bilirubin because of breakdown of RBC and immaturity of the liver, while ABO incompatibility occurs when mother blood was O, and her baby blood type was A, B, or AB.

Our patient Baby Girl Autonomy was diagnosed from Hyperbilirubinemia secondary to ABO incompatibility t/c sepsis because she experienced fever and her skin became yellowish in color after 24 hours after delivery which is a physiologic sign of jaundice, so she was admitted to septic ward (PICU). The doctor ordered complete blood count and bilirubin test. The laboratory result confirms her diagnosis Hyperbilirubinemia because of high neonatal bilirubin and high unconjugated bilirubin, also there’s high WBC and lymphocytes in her CBC that’s why she experienced fever. Our patient was also diagnosed from ABO incompatibility because her mother and father were blood type O while baby girl autonomy was blood type A. During our duty Group Autonomy rendered quality nursing care for our patient to aid quick and successful patient recovery.

CONCLUSIONTherefore, we conclude that ABO Incompatibility afflicts newborns whose mothers are blood type O can lead to destruction of RBC’s. The incresed rate of destruction of RBC’s causes a subsequent increase in bilirubin that can overwhelm the normal waste product elimination processes and lead to jaundice. This type of condition of our patient requires phototherapy as its treatment. As student nurses, we maintained the core temperature of our patient within normal range since she had a hyperthermia, practiced aseptic technique since she was at risk for infection and prtected her from any injury. We seen her at ntervals and attended her needs. At the end of our shifts, we met our goals in providing her safety and comfort. We’ve also rendered some health teachings to her family and provided them support. At the last day in the ward, still, she has jaundice but has normal normal vital signs.

RECOMMENDATION

To the students:•Study their lessons first before going to the area.•Bring complete parafernalias.•Always follow the hospital rules.•Be responsible enough as a student nurse.•Give quality nursing care to the patient. To the patient:•Encourage SO of the patient for regular check up.•Emphasize SO for the proper hygiene of the patient.•Encourage mother for breast feeding and instruct its importance.•Instruct SO to take regular medication of the patient prescribed by the physician.  

End of our Case Presentation

Thank you…