cp jaundice chapter vii

7/31/2019 CP Jaundice Chapter VII

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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.
http://www.righthealth.com/topic/Complete%20blood%20count?as=clink&ac=&afc=3626845248http://www.righthealth.com/topic/Complete%20blood%20count?as=clink&ac=&afc=3626845248http://www.righthealth.com/topic/Complete%20blood%20count?as=clink&ac=&afc=3626845248


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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 (ICU is

possible)

TPR q 4 hours &

record pls.

For management

of neonatal jaundice

For monitoring of

the patients condition

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Continue

breastfeeding.

Pls. attach lab

results to chart.

Start with D5IMB

500 mL @ 16-17

cc/hr.

Meds:

Ampicillin 150 mg q

12 hours IVTT.

Gentamicin 15 mg

OD IVTT.

and physiologic

status. This serves as

the basis for further

interventions to be

given.

To provide proper

nutrition.

Laboratory results

serve as a basis for

possible diseases

associated with the

patient.

Helps to expand

intravascular volume;

corrects an underlyingimbalance in fluids

and electrolytes, and

compensates the loss

in the body.

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

position of 2 hours.

To prevent

increase in

temperature

To prevent

occurrence of bed

sores

September 16, 2010

jaundice

Phototherapy q

12 hours on 12 hours

off

For repeat b1, b2

@ 6:00 am tomorrow

Phototherapy is

one of the treatments

for neonatal jaundice.

To diagnose any

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.

September 18, 2010

10:50 pm

Pls. relay B1, B2 &

CBC result once in.

For the AP to

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

Vit. K, 1mg IM

Jaundice was

already reduced.

To give proper

nutrition.

To enhance blood

clotting.

September 21, 2010

9:30 am

Complete 1 week

course of antibiotics.

To treat infections.

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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Interpretation:

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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ABO & Rh BLOOD

GROUP

FORWARD TYPING BLOOD TYPE

A +4 RH(+)

B 0 A

C +4


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

malabsorption problem.

EXAM NAME RESULT UNIT NORMAL VALUES

Hemoglobin 213 g/L 110-150

Hematocrit 64 % 35-47

RBC 7.1 X10^12/L 4.0-5.5

WBC 5.0 X10^9/L 5.1-10

-neutrophils 0.33 0.5-0.65

-lymphocytes 0.5 0.25-0.40

-monocytes 0.12 0.03-0.05

-eusinophils 0.05 0.01-0.03-Platelet Count 250 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.


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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 RESULT UNIT NORMAL VALUES

DBIL 0.47 H mg/dL 0-0.2

TBIL 14.93 H mg/dL 0.2-1

Indirect TBIL 14.46 H mg/dL 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.


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 12.6 5-10x10 na/L

-segmenters 0.30 0.55-0.65

-lymphocytes 0.58 0.25-0.35

-monocytes 0.08 0.03-0.06

-eosinophil count 0.02 0.02-0.04-basophils 0.02 0.03-0.06

Hemoglobin 180 140-170

Hematocrit 0.54 0.40-0.50

Platelet 345 150-350

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 Dosage/ Order

September 15, 2010

2:15 pm

Ampicillin 150 mg q12 IVTT

Gentamicin 15 mg OD IVTT.

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 to patients hypersensitive to drug or other

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.

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HEMATOLOGIC: eosinophilia, anemia, leukopenic, thrombocytopenia,

agranulocytosis.

MUSCULOSKELETAL: muscle twitching, myasthenia gravis-like sybdrome.

SKIN: rash, urticaria, pruritus, injection site pain.

OTHER: anaphylaxis


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, andcreatinine, 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.


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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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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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Poor

Fair Good Justification

Duration of

Illness

The patient manifested neonatal jaundice3 days after his birth; however, they seek

for medical assistance only after 7 days.

Onset The manifestation only took place 3 days

after.

PrecipitatingFactors

It is good since there is no involvement ofany risk factor except that it is found to bea normal process happening on newborn.

Willingness toCompliance of

Treatment

The patients mother is willing to complywith the treatment for the recovery of herson, thats why she follows what the

physician is instructing her.

Age

His condition is common to almost 50% ofthe newborn and Baby DongHae is notaware of this because that he is stillyoung.

Environment

His parents see to it that his room isalways clean. However, external factorscan contribute in making it to be not totallyclean.

Family Support

Support system from his family is good

since they show their love and care forBaby DongHae by always securing hissafety.


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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.

cp jaundice chapter vii

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