Hyperbilirubinemia

CASE PRESENTATION
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 Has more subcutaneous fat tissue and rests
extended; the body size is small, and the in a more flexed attitude
head may appear somewhat larger in
proportion to the body size

Ear Ear cartilages are poorly developed, and Ear cartilages are well formed
the ear may fold easily;

Sole Appears more turgid and may have only Well and deeply creased
fine wrinkles
Female Genetalia Clitoris is prominent, and labia majora are Labia majora is fully developed, and the
poorly developed clitoris is not as prominent

Lanugo Hair is fine and leathery, and the lanugo Less lanugo
may cover the back and upper arm

Scarf Sign Elbow may easily be brought across the Elbow may be brought to the midline of
chest with little or no resistance 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

Ballard’s Assesment
Physical Maturity

-1 0 1 2 3 4 5
Skin Sticky, friable, Gelatinous, red, Smooth, pink, Superficial, Cracking, pale Parchment, deep Leathery,
transparent trancslucent visible vein peeling &/or area, rare veins cracking, no cracked,
rash, few veins vessels wrinkled

Lanugo None sparse Abundant Thinning Bald areas Mostly bald

Plantar Heel to toe No crease Faint red marks Anterior Creases ant. 2/3 Creases cover
creases transverse entire sole
crease only

Breast imperceptible Barely percept. Flat areola, no Stippled areola, Raised areola, Full areola, 5-10
bud 1-2 mm bud 3-4 mm bud mm bud

Eyes/Ear Lids fuses loosely Lids open, Slightly curved Well-curved Formed and Thick cartilage,
Pinna flat, stays pinna, soft with pinna, soft but firm with instant ear stiff
folded slow recoil ready recoil recoil

Female Prominent clitoris, Prominent Prominent Majora and Majora large, Clitoris and
genitals labia flat clitoris, small clitoris, minora equally minora small minora
labia minora enlarging prominent completely
minora covered
Diagnostic test

October 22, 2009

 Culture and Sensitivity; Blood (Bactec)
 Culture:
 No growth after 5 days of incubation

Interpretation:
Diagnostic test

CHEST X-RAY
Result:
 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

Hematology
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
Diagnostic test

October 25, 2009

CLINICAL 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, 2009

CLINICAL 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 LIVER

HGB formation
unconjugated bilirubin
conjugated bilirubin
Be used for HGB
Increased accumulation formation
of concentration of bile
in the blood

Jaundice
 Treatment and Management
NURSING
CLASSIFI- FREQUENCY, ADVERSE
DRUG INDICATION CONTRAINDICATION RESPONSIBILI-
CATION ROUTE, DOSE EFFECTS
TIES

USE CAUTIOUSLY
WITH NEONATES
AND INFANTS.
XANTHINE Before giving
I.V. 3 MG +2CC
; Relief for HYPERSENSITIVITY loading dose, make
AMINOPHYLLINE STERILE WATER;
BRONCHO bronchospasm TO XANTHINE sure patient hasn’t
OD;
DILATOR had recent
theophylinne
therapy.
Monitor VS

NAUSEA AND
XANTHINE DON’T USE
RELIEF FOR VOMITING, USE CAUTIOUSLY
, I.V. 25.7 mg/ 5 Ml 0.6 EXTENDED RELEASE
THEOPHYLLINE BRONCHO- IRRITABILITY, IN NEONANATES,
BRONCHO mL OD FORMS OF ACUTE
SPASM RESTLESNESS, MONITOR VS
DILATOR BRONCHOSPASM
FLUSHING
 CLASSIFI FREQUENCY, CONTRAINDICATIO ADVERSE NURSING
DRUG INDICATION
CATION ROUTE, DOSE N EFFECTS RESPONSIBILITIES

Use cautiously in
Multi- Nutritional Nausea and
CLUSIVOL PO 0.2 mL OD Hypersensitivity, patients with
vitamins supplement, vomiting
respiratory inefficiency

Contraindication in
Nausea and
Ferrous (Ferlin For iron patients with Between meals are
Hema-tinics PO 0.5 OD Vomiting, black
Drops) deficiency hemosiderosis hemolytic preferable
stool
anemia
NURSING CARE PLAN
CUES BACKGROUND NURSING OBJECTIVES
KNOWLEDGE DIAGNOSIS
Objective: Premature babies Imbalanced After 8 hours of
>31-32 weeks AOG are babies born Nutrition due to nursing
>weak suck before the target Immaturity interventions,
> 22 cc OGT gestational age patient will be able
tolerated which is 37-38 to receive adequate
weeks. Since they nourishment to
are born maintain balance.
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.
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 >patient has weak suck
>use appropriate milk formula and >to avoid feeding intolerance
amount
>assess readiness to nipple feed >to recognize the sucking ability and the
  coordination of swallowing and breathing
Dependent:
>maintain parenteral fluid nutrition >gives additional nourishment and
therapy as ordered renews body fluid
 
>administer medications as prescribed by >food supplements are necessary to
the physician 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 NURSING OBJECTIVES
KNOWLEDGE DIAGNOSIS
Objective: Premature babies are Risk for Imbalanced After 8 hours of
>dry, flaky skin babies born before the Fluid Volume nursing
>thin, parchment- target gestational age
which is 37-38 weeks. related to interventions,
like skin Since they are born immature patient will be able
>skin turgor test prematurely most of characteristics of to exhibit adequate
(slow skin recoil) their organs are still preterm infants hydration status
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.
 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
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
EVALUATION
After 8 hours of nursing interventions, patient exhibited evidence of fluid balance.
RATIONALE
>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