ADAMSON UNIVERSITY

COLLEGE OF NURSING

HYPERBILIRUBINEMIA
PRESENTED TO THE FACULTY OF COLLEGE OF NURSING

SUBMITTED BY:

DANSO PRECIOUS OPHELIA

NOVEMBER 25, 2016

 TABLE OF CONTENT
I. Back ground of the Study ------------------------------------------------------------2
II. Objectives ------------------------------------------------------------------------------3
III. Introduction --------------------------------------------------------------------------- 4
A. Definition of case4
B. Etiology5-6
C. Incidence7
D. General signs and symptoms7
E. Nursing theory.8

IV. Patients Data9

A. Patient data.9
B. Nursing history9-10-11
C. Course in the ward.12
V. Anatomy and Physiology.13-14
VI. Pathophysiology.15-16-17-18-19
VII. Laboratory
Examinations..20-21
VIII. Drug study22
IX. Nursing care plan23-24-25-26
X. Discharge planning 27
XI. Implications of the study to the following areas.28
A. Nursing Research.28
B. Nursing Education...28
C. Nursing Practice..28
XII. Bibliography.29
I. Back ground of the Study
D.P is a 17year old G1P1 mother who delivered via NSD last December 25, 2015
at home; she is from Accra Ghana, resides in Tema community 10 and a
Presbyterian . She rushed her 3 days old premature baby girl to the emergency unit
of Ridge hospital due to yellowish discoloration of the skin, eyes and tongue of her

baby. the physician ordered and requested CBC, B1 and B2further assessments

were made and he has been diagnosed with Hyperbilirubinemia, The baby was
then transferred to the neonatal intensive care unit and was placed under intensive
phototherapy.

II. Objectives of the case study

General Objective:

This case study aims to present to the readers the nature of Hyperbilirubinemia, the
origin and the effects it does on the neonate body. It also encompasses the proper
approach in a patient with this kind of disease. This study aims to broaden the
knowledge of the readers about this condition.

Specific Objectives:

To improve knowledge on:

1) The fundamental information about Hyperbilirubinemia including its risk

factors, etiology, signs and symptoms, and treatment.
2) The pathophysiology of the disease
3) To enhance skills on:
 4) The appropriate approach to a newborn patient undergoing systemic changes
and adaptation
5) Formulating nursing care plans and independent nursing interventions
to care for fully dependent patient.
6) Different types of medical treatment necessary for hyperbilirubinemia

To modify attitude on:

7) Caring a newborn patient with hyperbilirubinemia
8) Confidence in managing patients with this kind of condition

III. Introduction

A. DEFINITION

HYPERBILIRUBINEMIA

Is a condition in which there is too much bilirubin in the blood. When red blood
cells break down, a substance called bilirubin is formed. Babies are not easily able
to get rid of the bilirubin and it can build up in the blood and other tissues and
fluids of the baby's body. Before birth, the placenta, the
organ that nourishes the developing baby, removes the bilirubin from the infant so
that it can be processed by the mother's liver. In newborn babies a degree of
jaundice is normal. It is due to the immaturity of the newborn's liver (which cannot
effectively metabolize the bilirubin and prepare it for excretion into the urine).
Normal neonatal jaundice typically appears between the 2nd and 5th days of life
and clears with time. Because bilirubin has a pigment or coloring, it
causes yellowish staining of the skin and whites of the newborn's eyes (sclera) by
pigment of bile (bilirubin) which called jaundice. Jaundice is not a disease but is a
symptom of an elevated blood bilirubin level. Jaundice is not painful, but serious
complications can occur if elevated bilirubin levels are not treated in a timely
manner. Jaundice is a marker used to identify those infants who may be at risk for
developing severe hyperbilirubinemia. Severe hyperbilirubinemia can be toxic to
the nervous system of infants, potentially causing brain damage.

B.Etiology

The majority of bilirubin is produced from the breakdown of Hb into

unconjugatedbilirubin (and other substances).

Unconjugated bilirubin (indirect reacting) binds to albumin in the blood for

transport to the liver, where it is taken up by hepatocytes and conjugated with
glucuronic acid by the enzyme uridine diphosphogluconurate
glucuronosyltransferase (UGT) to make it water-soluble.

The conjugated bilirubin (direct reacting) is excreted in bile into the duodenum. In
adults, conjugated bilirubin is reduced by gut bacteria to urobilin and excreted.
Neonates, however, have sterile digestive tracts. They do have the enzyme -
glucuronidase, which deconjugates the conjugated bilirubin, which is then
reabsorbed by the intestines and recycled into the circulation. This is called
enterohepatic circulation of bilirubin.

I.Physiological jaundice:

It is common in newborn babies. It usually becomes noticeable during the baby's

first three to five days of life. It disappears as the baby's liver matures. This type of
jaundice is not harmful. This is the type of jaundice seen in my patien.

C. Incidence
 Global

Source: Canadian pediatric surveillance program

Severe hyperbilirubinemia is the most common cause of neonatal readmission to

hospital even though, in the majority of cases, risk factors can be identified before
discharge. Severe neonatal hyperbilirubinemia and kernicterus continue to be
reported worldwide in otherwise healthy term infants. We conducted this study to
estimate the incidence of severe neonatal hyperbilirubinemia and to determine
underlying causes, improved knowledge of which would be valuable to help identify
strategies for risk reduction.

Hyperbilirubinemia affects 60% of full-term infants and 80% of preterm infants in

the first 3 days after birth.

What are the risk factors for jaundice seen in my patient?

Preterm babies
Newborns with feeding difficulties/poor feeding
Mother with diabetes

D. General signs and symptoms.

The general signs and symptoms seen on my patient are: yellow
skin, sclera and tongue

TREATMENT
The following were used as a treatment on my patient
Phototherapy

Phototherapy is a treatment that is done by placing a baby under a special light

while the baby wears only protective eye patches and a diaper. The light is blue-
green in color, and works by changing the molecule structure of bilirubin so it can
be excreted in the urine and stool. It is used day and night, with frequent changing
of the baby's position to expose all of the skin to the light. The physician will draw
blood periodically to monitor the bilirubin levels.

Feeding/hydration:

By encouraging frequent feeding with breast milk or formula, newborns will

produce more stool and urine, and thus eliminate bilirubin more rapidly from the
body. Newborns may need to be fed up to 12 times per day, thus ensuring proper
hydration and elimination. In certain instances, newborns may require observation
in a hospital to receive intravenous fluids and closer monitoring of bilirubin levels.

E. Nursing theory

Sister Callista Roys adaptive model

Roys adaptive model of nursing sees an individual as a set of interrelated systems,

biological, psychological, and social. The individual will try to maintain a balance
between each of this system and the outside world. However, there is no absolute
level of balance. We all strive to live with in a band where we can cope adequately;
the adaptation model is the range of adaptability within which the individual can
deal effectively with new experiences.

IV. Patients Data

A. Patient data

Patient Name: Baby K.K

AGE: 3days old
SEX: female
Birthdate: December 25, 2015
 Address: Tema community 10, Accra, Ghana
Date of Admission: December 28, 2015
Time of Admission: 11:00AM
Admitting Diagnosis: Hyperbilirubinemia

SOURCE OF INFORMATION
Primary Source: Mother
Secondary Source: patients chart.

B.Nursing history
Chief Complaint: my baby has a yellowish discoloration of skin, eyes
and tongue for 3days as verbalized by the mother.

HISTORY OF PRESENT ILLNESS

According to patients mother, when baby boy K.k was born, she noticed that
her babys skin became yellowish in color for 3days. The pediatric resident on duty
see and examined him and the physician ordered and requested CBC and B1,
B2.the patient then admitted to NICU on December 28, 2015 at exactly 11:00AM.
Afterwards, the PROD requested for bilirubin test and has continuous
phototherapy.

PAST HISTORY

The mother of the baby had no history of liver disease, asthma or hypertension in
their family, but was diagnosed with gestational diabetes. She and her boyfriend
use to smoke about two packs of cigarettes per day and drinks alcohol almost every
day but she stopped this lifestyle after she found out about her pregnancy. She
keeps herself busy by doing the house hold chores that makes her stressed but
most of the time she takes a rest or sleep; she has dynamic taste and interest for
food except vegetables. She sleeps well and was not exposed to any medication
except vitamins during her pregnancy.

Developmental history
trust vs. mistrust (oral-sensory, infancy, 02 years)
The first stage of Erik Erikson's theory centers on the infant's basic needs being
met by the parents and this interaction leading to trust or mistrust. Trust as defined
by Erikson is an essential truthfulness of others as well as a fundamental sense of
one's own trustworthiness. The infant depends on the parents, especially the
mother, for sustenance and comfort.
OB, FEEDING AND IMMUNIZATION HISTORY
Delivered via NSD, Breastfeeding and had Vitamin K, Hepa B and BCG
vaccines.
Physical Examination History
General Appearance slightly yellowish skin color and
sclera,tongue
- with dry skin
- with good sucking reflex
- afebrile
Head Normocephalic
- symmetrical in shape
- no masses, no lesions
- Non bulging and non-depressed
anterior and posterior fontanels
- No signs of caput succedaneum and
cephalhematoma
Hair evenly distributed over the scalp
- with black, straight and thick hair
Eyelids - lids close symmetrically
- with eyeshield
 - no edema, and no discharges
Sclera slightly yellowish
Iris symmetrical in size
- round and black
Pupils Symmetrical in size
- round and dark brown in color
- PERRLA (Pupils Equally Round
And Reactive Light and
Accommodation)
Ears - equal in size
- auricles are smooth and symmetrical
- pinna recoils after it is folded
Nose the external nose is symmetrical and
straight
- color is the same with the entire face
- lesions and tenderness were both
absent
- nasal mucosa was pinkish
- both left and right nares were patent
- nasal septum is intact and in midline
without deviations
- cilia present in internal nares
- absence of nasal discharge
- no signs of nasal flaring
Mouth
- dry oral mucous membrane
- frenulum intact at midline
- tongue was located at the midline,
yellow in color, slightly dry and furry
with whitish coating
- tongue moves freely
- uvula is in midline
Neck neck movement was coordinated and
difficulty in moving was not noted
- free from lumps and no tenderness
Thorax no masses and tenderness upon
palpation
 - no adventitious breath sounds upon
auscultation on both left and right lung
fields
- negative retractions
Breast round in shape, no lumps, no masses
- areola dark brown in color - nipples
round, equal in size
Abdomen same color of the body
- globular, soft without distention
- bowel sounds in all quadrant
skin pinch goes back quickly
Upper extremities good range of motion was noted
- no lesions, no presence of
abnormalities, no tenderness
- can flex and extend arms without
difficulty
Lower extremities skin uniform in color
- good range of motion was noted - no
lesions, no presence of abnormalities,
no tenderness
- can flex and extend legs without
difficulty
Genitalia Testicles have not fully descended into
the scrotum yet
Elimination With patent anus
Reflexes Are present such as moro, babinski,
rooting, sucking, and plantar grasp
reflex

C.Course in the ward

Date Time Vital Sign Observation

December 28,2016 11:00am T 36.3 oC - with yellowish skin color,

P 130 bpm tongue and sclera

- With good skin turgor
R 38 cpm
- with good sucking reflex
- Afebrile
5:00pm T 36.5 oC - with negative (-)
adventitious breath
P 131 bpm
sounds upon auscultation
R 42 cpm
on both bilateral lung
fields

10:00pm T 36.8 oC - fairly active

- with good sleeping habit
P 134 bpm

R 39 cpm

Date Time Vital Sign Observation

December 29, 2015 10:00PM T 36.3 oC - with slightly yellowish skin

color, tongue and sclera
P 130 bpm
- With good skin turgor
R 38 cpm - with good sucking reflex
- Afebrile
- with negative (-)
2:00AM T 36.5 oC
adventitious breath
P 131 bpm
sounds upon auscultation
R 42 cpm on both bilateral lung
fields
- fairly active
6:00AM T 36.8 oC
- with good sleeping habit
 P 134 bpm

R 39 cpm

Date Time Vital Sign Observation

December 30, 2015 10:00am T 36.3 oC - with slightly yellowish skin

color and sclera
P 130 bpm
- With good skin turgor
R 38 cpm - with good sucking reflex
- Afebrile
- with negative (-)
2:00pm T 36.5 oC
adventitious breath
P 131 bpm
sounds upon auscultation
R 42 cpm on both bilateral lung
fields
- fairly active
6:00pm T 36.8 oC
- with good sleeping habit
P 134 bpm

R 39 cpm
V. Anatomy and Physiology
VI. Pathophysiology
NORMAL PHYSIOLOGY

RBCS lifespan of 120

RBC would become fragile or prone

Cellular content would be released

Macrophages will phagocytized it

Hemoglobin will split into

Heme Globins

Iron Biliverdin Breakdown into amino amino acids

reuse as protein synthesis
Will go to the bone Reduct into Bilirubin (indirect, unconjugated) fat
marrow for new RBC
production

Transport to the liver with the help of albumin

The liver enzyme ( biliverdin reductase) will

convert unconjugated to conjugated bilirubin

The bacteria will convert conjugated bilirubin to

urobilinogen
That excrete with the feces and some of it in
urine
 HISTORY

Mother Diagnosed with gestational diabetes during pregnancy

PRECIPITATION FACTOR
PREDISPOSING FACTOR
Diabetes mother
3 days old
preterm

CHIEF COMPLAINT

Yellowish discoloration of babys skin, eyes and tongue for 3days

LABORATORY AND DIAGNOSTIC EXAM RESULT

Neonatal Bilirubin 20.5 mg/dl 1.0-10.5mg/dl Increased

Unconjugated bilirubin 18.56 mg/dl 0.6-10.5mg/dl Increased

Conjugated bilirubin 1.5mg/dl 0-0.6 mg/dl Increased

Hemoglobin 11.0 g/dl 13-19g/dl Decrease

White Blood Cells (WBC)17.9-4.5 10.5 x10.9/L Increase

Hematocrit 33% 42-59% Decrease

CLINICAL SIGNIFICANCE

A bilirubin test is used to detect an increased level in the blood. It

may be used to determine the cause of hyperbilirubinemia and
help diagnose conditions such as liver disease, hemolytic anemia
and blockage of the bile ducts
 CLINICAL MANIFESTATIONS/SIGN AND SYMPTOMS

Yellow eyes, skin, tongue and urine.

NURSING CARE PLAN

Risk for Injury related to abnormal blood profile as evidenced by increase

bilirubin level of 1.59mg/dl
Risk for injury related to prematurity
Risk for fluid imbalance related to prolonged exposure to
phototherapy

X.Discharge Planning ( METHODS )

Medication
No home medications
Instruct to give multivitamins for optimum recovery and health
Environment
Keep an environment conducive to health for the rapid recovery of infants.
Emphasize the idea of keeping a clean environment to avoid infection.
Treatment
Encourage the mother to let the baby be monitored by the health care provider till
complete recovery is met.
Health teaching
Emphasize the need for compliance and cooperation of the mother in helping
treat the infant.
Encourage breast feeding to help the baby gain resistance and protection
from diseases in the future.
Emphasize that the baby is on a trust vs. mistrust stage: the needs must be
met for a healthy emotional development.
Out patient
Remind the mother for a follow up after one week to evaluate the recovery of the
infant.
Diet
Encourage the mother to breast feed the baby up to two years.
An increase in feeding will help a faster gain in the weight of the baby.
Spiritual
Encourage the mother to pray for the babys fast recover.
Give words of encouragement.

XI. Implication of case study to the following:

Nursing research

This study will supply helpful information on how to treat infants with
hyperbilirubinemia especially to health care providers, students, nurses, and
other individuals who plan to perform a study in this case.

Nursing education

This will aid researchers and students with knowledge and information about hat
hyperbilirubinemia is; help them assess better with their own understanding and
insight about the illness and modify the wrong facts that they believe in.
This study will give them more efficient knowledge and skills about
hyperbilirubinemia and assure them a better competency regarding this illness.

Nursing practice

This study will not only enhance own knowledge and skills of this illness, but also
instruct them the proper way to serve and cater the patients needs to alleviate
this condition.

XII. Bibliography
Adams, A. (2006). Breathing in the Newborn, 5th edition. California. Page 5
http://www.lpch.org/DiseaseHealthInfo/HealthLibrary/hrnewborn/hyperb.
html
http://www.nlm.nih.gov/medlineplus/ency/article/001559.htm
Fundamentals of Maternal and Child Nursing, London, Ladewig, Ball and
Bindler, 2nd ed., Vol. 1, pp. 835
844 Nursing Drug Guide, Lippincotts, 2009, pp. 126, 101, 246, 948
Essential Nursing Care for Children and Young People: Theory, Policy and Practice
Chris Thurston
Routledge, 14 Mar 2014 - Medical - 472 pages