Chapter VII MEDICAL AND NURSING MANAGEMENT

A.

Ideal

Medical Management Detection A physical exam is always important in assessing the level of jaundice. Jaundice first appears on the face, and, as the bilirubin level rises, spreads down the body. The yellow color is best appreciated in natural light, so doing the exam by a window is helpful. Tests that will likely be done include:

Complete blood count Measurement of levels of specific types of bilirubin Reticulocyte count

Treatment Phototherapy Phototherapy (light therapy) is the most common medical treatment for jaundice in newborns. In most cases, phototherapy is the only treatment required. It consists of exposing an infant's skin to a special blue light, which breaks bilirubin down into parts that are easier to eliminate in the stool and urine. Treatment with phototherapy is successful for most infants.

Phototherapy is usually done in the hospital, but in select cases, it can be done in the home if the baby is healthy and at low risk of complications. Infants undergoing phototherapy should have as much skin exposed to the light as possible. Infants are usually naked (or wearing only a diaper) in an open bassinet or warmer, but wear eye patches to protect the eyes. It is important to ensure that lamps do not generate excessive heat, which could scald an infant's skin. In some institutions, phototherapy blankets are used. Phototherapy should be continuous, with breaks only for feeding. Phototherapy is stopped when bilirubin levels decline to a safe level. It is not unusual for infants to still appear jaundiced after phototherapy is completed. Bilirubin levels may rebound 18 to 24 hours after stopping phototherapy, although this rarely requires further treatment. - Side effects Phototherapy is very safe, but it can have temporary side effects, including a skin rash and loose bowel movements. Therefore, the infant's skin color, body temperature, and number of wet diapers are closely monitored
Exchange

transfusion Exchange

transfusion

is

an

emergency

procedure that is done to prevent or minimize bilirubin-related brain damage. The transfusion replaces an infant's blood with donated blood in an attempt to quickly lower bilirubin levels. Exchange transfusion may be performed in infants who

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have not responded to other treatments and who have signs of or are at risk of bilirubin toxicity. Nursing Management

Hydration It is important for infants receiving phototherapy to drink adequate fluids (breast milk or formula) since bilirubin is excreted in urine and bowel movements. Breastfeeding should continue during

phototherapy, and in some cases, intravenous fluids may be necessary.

Breastfeeding Breastfed infants who are not able to consume enough breast milk, whose weight loss is excessive, or who are dehydrated may need extra expressed breast milk or formula. Mothers who supplement with formula should continue to breastfeed or pump to maintain their milk supply.

B.

Actual

Medical Management

Date & Time

Doctors Order

Rationale

September 15, 2010 2:15 pm Wt= 3.1 kg

Pls. admit under my service possible) TPR q 4 hours & record pls. (ICU is

For management

of neonatal jaundice

For monitoring of

the patients condition

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and

physiologic

status. This serves as the basis for further interventions given. To provide proper to be

Continue

breastfeeding.

nutrition.

Pls.

attach

lab

Laboratory results diseases with the

results to chart.

serve as a basis for possible associated patient.

Start with D5IMB 500 cc/hr. mL @ 16-17

Helps to expand

intravascular volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the body.

Meds: Ampicillin 150 mg q 12 hours IVTT. Gentamicin 15 mg OD IVTT.

To treat infection To treat infection

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September 15, 2010 7:05 pm

Pls. maintain temp. between 36.8-37.2C under droplight. Turn pt. to sides prone & supine

To prevent

increase in temperature To prevent

position of 2 hours.

occurrence of bed sores

September 16, 2010 jaundice

Phototherapy q 12 hours on 12 hours off

Phototherapy is

one of the treatments for neonatal jaundice.

To diagnose any

For repeat b1, b2 @ 6:00 am tomorrow

possible problem of patient.

September 16, 2010 UO- 50 cc

IVF to 120 cc q 6

Increasing IVF will

aid in decreasing fluid level of patient.

September 17, 2010 10:00 am 7:20 pm Rebound jaundice after 12 on & off exposure

For continuous phototherapy For repeat CBC, B1 and B2 @10:00 am tomorrow

To treat neonatal

jaundice

To diagnose any

problem related to the results of the patient.

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September 17, 2010 4:00 pm

IVF to ff D5IMB @ 120 cc q 6 in a soluset.

Using soluset will

monitor efficiently the fuid balance f the patient. For the AP to

September 18, 2010 10:50 pm

Pls. relay B1, B2 & CBC result once in.

study the result and diagnose problems of the patient.

September 19, 2010 9:00 pm jaundice

D/C phototherapy refer for rebound jaundice. Resume full breastfeeding

Jaundice was

already reduced.

To give proper

nutrition. To enhance blood

Vit. K, 1mg IM

clotting.

September 21, 2010 9:30 am

Complete 1 week

To treat infections.

course of antibiotics.

Management Diagnostic Tests

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Urine Analysis Urine Analysis is the chemical analysis of a patient's urine. This laboratory test evaluates the physical characteristics (color, appearance, odor, opacity and turbidity) of patients urine. It also determines the specific gravity, presence of sugar and protein, types and amount of cells and crystals present.

Date: September 15, 2010 Physical Characteristics Color: Yellow Appearance: Clear Reaction: 5.0 Specific gravity: 1.002 Chemical Findings Sugar: (-) Protein: (-) Microscopic Findings Cells: Pus cells: 1-2/hpf RBC:0-1/hpf Crystals: Amorphous urates: Few Interpretation: Pus cells are identified in the sample urine of the patient. Pus cells
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indicate a urinary tract infection anywhere from the kidneys to the urethranis present. Cloudiness in urine may be caused by either pus or chemicals, a difference determined by simple laboratory tests. Presence of RBC in urine is due to: glomerular damage, tumors, kidney trauma, urinary tract stones, and urinary tract infections. Theoretically, no red cells should be found. Common crystals seen even in healthy patients include calcium oxalate, triple phosphate crystals and amorphous phosphates. Nursing Responsibilities: Explain to significant others how to collect a clean catch specimen of at least 15 mL. Obtain a first voided morning specimen if possible.

BLOOD TYPING There are many RBC factors or types: the ABO group and the Rh factor. The ABO group contains four blood types: A, B, AB, and O. The Rh factor is another antigen. People whose RBCs have the Rh antigen are Rh positive; those without the antigen are Rh negative. The purpose of Blood typing is to determine what is the patients blood group and type.

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ABO & Rh BLOOD GROUP A B C Interpretation:

FORWARD TYPING

BLOOD TYPE

+4 0 +4

RH(+) A

After testing the blood for blood typing, patient DongHae has been found out to be Rh positive. He also belongs in Blood type A group.

HEMATOLOGY

The word hematocrit means "to separate blood", a procedure which is done following the blood draw through the proper use of a centrifuge. Hematocrit is the measurement of the percentage of red blood cells in whole blood. It is an important determinant of anemia (decreased), polycythemia (increased), dehydration (elevated), increased R.B.C. breakdown in the spleen (decreased), or possible overhydration (decreased). Hemoglobin is the main transport of oxygen and carbon dioxide in the blood. It is composed of globin a group of amino acids that form a protein and heme which contains iron atoms and imparts the red color to hemoglobin. As with Hematocrit, it is an important determinant of anemia (decreased), dehydration

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(increased), polycythemia (increased), poor diet/nutrition, or possibly a malabsorption problem.

EXAM NAME Hemoglobin Hematocrit RBC WBC -neutrophils -lymphocytes -monocytes -eusinophils -Platelet Count

RESULT 213 64 7.1 5.0 0.33 0.5 0.12 0.05 250

UNIT g/L % X10^12/L X10^9/L

NORMAL VALUES 110-150 35-47 4.0-5.5 5.1-10 0.5-0.65 0.25-0.40 0.03-0.05 0.01-0.03

X10^9/L

150-400

Interpretation: Patient DongHae has been found to have high hematocrit level of 64, the normal range is 35-47 %. it usually indicates dehydration, but diminishes if normal fluid balance is restored. Some other infrequent causes of elevated hematocrit are lung disease, certain tumors, a disorder of the bone marrow known as polycythemia rubra vera. A low WBC count (leucopenia) may indicate bone marrow failure, possibly due to infection, tumor, fibrosis, presence of cytotoxic substance, collagen-vascular diseases (such as lupus erythematosus, disease of the liver or spleen), or radiation.

Nursing Responsibilities:
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Explain to the significant others that the tests are done to detect any hematologic disorders

Use gloves when collecting and handling all specimens. Transport the specimen to the laboratory as soon as possible after the collection.

Do not allow the blood sample to clot, of the results will be invalid. Place the specimen in a biohazard bag.

BLOOD CHEMISTRY A byproduct of the breakdown of hemoglobin from red blood cells in the liver, bilirubin is a good indication of the liver's function. Excreted into the bile, bilirubin gives the bile its pigmentation. Elevated in liver disease, mononucleosis, hemolytic anemia, low levels of exposure to the sun and toxic effects to some drugs, decreased levels are seen in people with an inefficient liver, excessive fat digestion, and possibly a diet low in nitrogen bearing foods.

EXAM NAME DBIL TBIL Indirect TBIL

RESULT 0.47 H 14.93 H 14.46 H

UNIT mg/dL mg/dL mg/dL

NORMAL VALUES 0-0.2 0.2-1 0.2-0.8

Interpretation:

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When bilirubin levels are high, the skin and whites of the eyes may appear yellow (jaundice). Jaundice may be caused by liver disease (hepatitis), blood disorders (hemolytic anemia), or blockage of the tubes (bile ducts) that allow bile to pass from the liver to the small intestine. Too much bilirubin

(hyperbilirubinemia) in a newborn baby can cause brain damage (kernicterus), hearing loss, and problems with the muscles that move the eye, physical abnormalities, and even death. Therefore, some babies who develop jaundice may be treated with special lights (phototherapy) or a blood transfusion to lower their bilirubin levels. Nursing Responsibilities: define and explain the test to the significant others state the specific purpose of the test explain the procedure discuss test preparation, procedure, and posttest care some blood chemistry tests will have specific requirements such as dietary restrictions or medication restrictions. CBC PLATELET COUNT This is done to aid in diagnosing anemia, certain cancers of the blood and monitor blood loss and infection. Also, to diagnose and/or monitor bleeding and clotting disorders. EXAM NAME RESULT NORMAL VALUES

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WBC Count -segmenters -lymphocytes -monocytes -eosinophil count -basophils Hemoglobin Hematocrit Platelet

12.6 0.30 0.58 0.08 0.02 0.02 180 0.54 345

5-10x10 na/L 0.55-0.65 0.25-0.35 0.03-0.06 0.02-0.04 0.03-0.06 140-170 0.40-0.50 150-350

Interpretation: Patient DongHae has been found to have an increased level of White Blood Cells, which indicates an infection. Hemoglobin level is also slightly elevated, but can still be considered in normal level.

Therapy Phototherapy is used as a primary treatment for Neonatal Jaundice and was used for Patient Baby DongHae until observed jaundice was reduced to near normal as possible.

Pharmacologic Management

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Date ordered

Name of Drug Ampicillin

Dosage/ Order 150 mg q12 IVTT 15 mg OD IVTT.

September 15, 2010 2:15 pm Gentamicin

September 16, 2010

Phototherapy

q 12 hours on 12 hours off

September 19, 2010 9:00 pm

Vit. K

1 gm, IM

DRUG STUDY

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Brand Name: Ampicillin Generic name: Ampicillin Sodium Classification: Anti-infectives; Penicillin Indications: Respiratory tract or skin and skin-structure infections. GI infections or UTIs. Bacterial meningitis or septicemia. Uncomplicated gonorrhea. To prevent endocarditis in patients having dental, GI, and GU procedures.

Contraindications:

Contraindicated in patient hypersensitive to drug or other penicillins. Use cautiously in patient with other drug allergies (especially to cephalosporins) because of possible cross-sensitivity, and in those with mononucleosis because of high risk of maculopapular rash.

Dosage: 150 mg q120 IVTT Mechanism of Action: inhibits cell-wall synthesis during bacterial multiplication. Adverse Reactions: CNS: lethargy, hallucinations, seizures, anxiety, confusion, agitation, depression, dizziness and fatigue. CV: vein irritation, thrombophlebitis GI: diarrhea, nausea and vomiting, abdominal pain, glossitis, stomatitis, gastritis, enterocolitis, pseudomembranous colitis, black hairy tongue.

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GU: intestinal nephritis, nephropathy,vaginitis HEMATOLOGIC: anemia, thrombocytopenia, thrombocytopenic, purpura,

eosinophilia, leukopenia, hemolytic anemia, agranulocytosis. SKIN: pain at injection site. OTHER: hypersensitivity reactions, overgrowth of nonsusceptible organisms. Nursing Responsibilities with Rationale: Assess patient about allergic reactions to penicillin. This is to prevent causing adverse reactions such as hypersensitivity. Obtain specimen for culture and sensitivity test before giving first dose. This is to identify if correct treatment has been initiated. Assess for any ampicillin rashes; a dull, red, itchy, flat or raised rashes. These signs and symptoms may indicate allergic reaction and need to stop the therapy. Assess sodium level because each gram of ampicillin contains 2.9 mEq of sodium. Assess for the adverse reactions that may occur. This is to prevent the casualties to worsen. Health Teaching: Instruct patient to report adverse reactions promptly. Tell patient to report discomfort at I.V. injection site. Advise patient to notify prescriber if a rash, fever, chills develops.

Rationale: To treat infection

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Brand Name: Gentamicin

Generic name: Gentamicin Sulfate Classification: Antibiotics; Aminoglyscoside Indications: Serious infections caused by sensitive strains of Pseudomonas aeruginosa, Escherichia coli, Proteus Klebsiella, or Straphylococcus. To prevent endocarditis before GI or GU procedure or surgery.

Contraindications: Contraindicated aminoglycosides.. Use cautiously in neonates, infants, elderly patients, and patient with impaired renal function or neuromuscular disorder. Dosage: 15 mg q80 IVTT Mechanism of Action: inhibits protein synthesis by binding directly to 30S ribosomal subunits; bactericidal. Adverse Reactions: CNS: dizziness, fever, headache, lethargy, encephalopathy, confusion, seizure, numbness, peripheral neuropathy, vertigo, ataxia, tingling. CV: hypotension GI: nausea and vomiting GU: nephrotoxicity, possible increase in urinary excretion of casts. to patients hypersensitive to drug or other

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HEMATOLOGIC: agranulocytosis.

eosinophilia,

anemia,

leukopenic,

thrombocytopenia,

MUSCULOSKELETAL: muscle twitching, myasthenia gravis-like sybdrome. SKIN: rash, urticaria, pruritus, injection site pain. OTHER: anaphylaxis Nursing Responsibilities with Rationale: Obtain specimen for culture and sensitivity test before giving first dose. This is to identify if correct treatment has been initiated. Assess for sign and symptoms of superinfections(especially of upper respiratory tract), such as continued fever, chills and increased pulse rate. Signs of superinfection may indicate resistance to drug. Assess for anaphylaxis: rash, urticaria, pruritius, chills, fever or joint pains. These signs and symptoms may indicate allergic reaction and need to stop the therapy. Assess renal function before and during therapy: urine output, BUN, and creatinine, monitor for nephrotoxicity. Health Teaching:

Instruct patient to report adverse reactions promptly report adverse reactions, such as dizziness, vertigo,tingling or muscle twitching.

Tell patient to report discomfort at I.V. injection site. Advise patient to notify prescriber if a rash develops or if Signs & Symptoms of superinfection occur.

Rationale: To treat infection

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Brand Name: Vitamin K Generic name: Phytonadione Classification: Antihemorrhagic Indications: Recommended Dietary Allowance Hypoprothrombinemia caused by vitamin K malabsorption, drug therapy, or excessive vitamin A dosage. Hypoprothrombinemia caused by effect of oral anti coagulants.

Contraindications: Contraindicated to patients hypersensitive to drug.

Dosage: 1 mg IM Mechanism of Action: an antihemorrhagic factor that promotes hepatic formation of active coagulation factors. Adverse Reactions: CNS: dizziness CV: flushing, transient hypotension after I.V administration, rapid and weak pulse. SKIN: diaphoresis, erythema OTHER: anaphylaxis or anaphylactoid reactions, usually after excessively raid I.V administration; pain, swelling, and hematoma at injection site. Nursing Responsibilities with Rationale:

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Assess the label for administration route restriction. For I.M. use in adult and children, give in outer thigh or deltoid region. Subcutaneous route is preferred to avoid hematoma formation.

With I.M or subcutaneous use, allergic reaction may occur. Monitor PT and INR to determine dosage effectiveness. If sever bleeding occur give fresh frozen plasma or whole blood immediately

Watch for flashing, weakness, tachycardia, and hypertension; condition may progress to shock.

For hemorrhagic disease in infants, phytonadione cause less adverse reaction that other vitamin K analogue.

Health Teaching: Explain the purpose of the drug.

Rationale: To prevent hemorrhagic disease of newborn.

Nursing Management

Encouraged the mother to continue breastfeeding Baby DongHae since bilirubin is excreted in urine and bowel movements. Breastfeeding should continue during phototherapy, and in some cases, intravenous fluids may be necessary.

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Monitored closely the patient especially the infant's skin color, body temperature, and number of wet diapers because phototherapy has side effects like loose bowel movement and skin rashes.

Encouraged the mother to always secure Baby DongHae for his safety. Advised the significant others to follow and comply with the prescribed medication. PROGNOSIS

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Poo r Duration of Illness Onset Precipitating Factors Willingness to Compliance of Treatment

Fair

Good

Justification The patient manifested neonatal jaundice 3 days after his birth; however, they seek for medical assistance only after 7 days. The manifestation only took place 3 days after.

It is good since there is no involvement of any risk factor except that it is found to be a normal process happening on newborn. The patients mother is willing to comply with the treatment for the recovery of her son, thats why she follows what the physician is instructing her. His condition is common to almost 50% of the newborn and Baby DongHae is not aware of this because that he is still young. His parents see to it that his room is always clean. However, external factors can contribute in making it to be not totally clean. Support system from his family is good since they show their love and care for Baby DongHae by always securing his safety.

Age

Environment

Family Support

The patients prognosis is fair because they were only able to seek medical assistance after 7 days. For most babies, jaundice usually resolves without treatment within 1 to 2 weeks. However, the parents were willing to comply for any treatment that will be given by the physician.

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Discharge Planning

General Condition of client upon discharge Upon discharge, the patient was lying and sleeping on his crib with her mother and other significant others around ready to be instructed with home instructions for the full recovery and improvement of the health status of Baby DongHae given by the student nurse.

Method - Instructed the significant others to take the following home medication as ordered by the physician. - Explained to the significant others the drug names as well as the right route and dosage. - Informed the significant others about the side effects that may occur brought by the medication. - Encouraged the significant others to comply and follow religiously the right timing in taking the medication. Exercise/Environment

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- Instructed significant others to avoid risk factors that may harm Baby DongHae. - Encouraged significant others to always keep in mind of the safety and security of the patient. Treatment - Instructed to comply with the physicians prescribed medication such as the antibiotic to treat infections. Hygiene - Instructed significant others to bathe Baby DongHae everyday. - Advised significant others to change soaked diaper into new one. Outpatient - Advised significant others to visit or have a follow up check-up with the attending physician. - Advised to call and notify the attending physician for any abnormalities or complications that may further occur. Diet - Encouraged to continue breastfeeding.

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- Encouraged mother to eat nutritious foods that would help in her breastfeeding.

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