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 CASE
This 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 SUMMARY
Eclectic Model
1. Bio-demographic Data
 
a. Name : Baby Girl Autonomy
b. Age : 2 days old
c. Sex : Female
d. Diagnosis : hyperbilirubinemia secondary to
ABO
incompatibility tc sepsis
e. Address : Pila, Laguna
f. Date of Admission : August 1, 2010
g. Time of Admission : 6:54pm
h. Attending Physician : Sheryl Fandino, M.D.
2. Source of Information
a. Primary Sources:
•Mother
•Grandmother
•Nurses on Duty
b. 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 Assessment
General Observation
a. 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
Examination
August 1, 2010
Test Result Normal Values Indication Significance

Neonatal Bilirubin 19.2Mg/dl 1.0-10.5 Above normal Due to ABO

incompatibility,
328.32 UMOL/L 17.1-180 increase
destruction of
RBC resulting in
increase
unconjugated
bilirubin
Unconjugated 19.2Mg/dl 0.6-10.5 Above normal Due to ABO
incompatibility,
bilirubin 328 UMOL/L 10-180 increase
destruction of
RBC resulting in
increase
unconjugated
bilirubin

Conjugated 0 0-0.6 Normal

Bilirubin 0 0-10
 CBC
Test 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 0.6-4.1 Above normal Increase related to the
compensatory of
35.2%L 10.0-58.5%L immune system in
response to infection
MID 2.8-12.0%M 0.81-24.0%M Normal
Granulocytes 12.4 R3 2.0-7.8 Above normal Increase may indicate
bacterial,viral, parasitic
52.8%G 37.0-92.0%G 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% Normal
MCU 96.7fl 80.0-97.0 fl Normal
MCH 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 Normal
RDW 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 Ward
Day 1 August 2, 2010
The 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, 2010
The 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 37.3 0C, 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, 2010
The 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 36.3 0C,
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 DISEASE
ANATOMY 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 GROUPS
YouTube - Blood groups and Blood compatibility.flv
Pathophysiology

PATHOPHYSIOLOGY---NEW....doc
 Drug name
Drug Study
Classification Mechanism of Indication Contraindication Adverse effects Nursing
action Responsibilities

Generic name: Amino glycosides Bactericidal: Neonatal sepsis Contraindicated -confusion Assess patient for
Amikacin sulfate Inhibits protein when other with glycosides -depression allergic reaction:
Brand name: Amikin synthesis in antibodies renal or hepatic -lethargy rash, urticaria,
DOSAGE: 17 mg IV OD susceptible cannot be used disease, pre- -nysthagmus pruritus and
strains of gram- (often used in existing hearing -headache hypotension
negative combination loss, -fever -Obtain specimen
bacteria and the with penicillin myasthenia, -tremor for culture and
functional type drug.) gravis -muscle sensitivity before
integrity of parkinsonism, twitching initiating therapy.
bacterial cell infant botulism, -seizures First dose may be
membrane lactation. -muscular given before
appears to be weakness receiving results.
disrupted, -nausea -Monitor intake and
causing cell -vomiting output and daily
death. -anorexia weight to assess
-diarrhea hydration status and
-weight loss renal function.
-increased -Assess patient for
salivation sign of super
infection (fever,
upper respiratory
infection.)
 Drug name Classification Mechanism of Indication Contraindicati Adverse Nursing Responsibilities
action on effects

Generic name: Anti-infectives’ Bactericidal Treatment of a Contraindicate Hypersensitivi Assess for infection (Vital
Ampicillin action against variety of d with allergies ty: rash, fever, signs, urine, stool and
Brand name: sensitive infections to penicillin’s, wheezing, and WBC) at the beginning
Principen organisms; including those cephalosporin’ anaphylaxis. and throughout the
DOSAGE: 165 mg inhibits of the urinary, s or other therapy.
IV every 12 hours synthesis of respiratory, allergens -Obtain a history before
6/6 bacterial cell biliary and initiating therapy to
wall easing cell intestinal determine previous use
death. tracts. 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 Indication Contraindication Adverse effects Nursing
action Responsibilities
Generic name: General CNS Emergency Contraindicated -confusion 1. Assess patients
Phenobarbital Antiepileptic depressant; control of acute with -bradycardia condition before
Brand name: Luminal barbiturates seizures hypersensitivity -pain therapy and regularly,
sodium inhibit impulse to barbiturates, -tissue necrosis these after to
DOSAGE: 15 mg pptab conduction in the manifest or latent at injection site monitor drug
mixed with feeding 12 ascending RAS, porphyria; effectiveness
hours 12/12 depress the marked severe 2. Monitor
cerebral cortex. liver impairment; respiration character
severe respiratory rate and rhythm.
distress Hold drug if
-Use cautiously respiration < 10 /
with minutes or if pupil
acute/chronic are dilated.
pain; seizure 3. Monitor for
disorders, possible drug adverse
lactation, fever, reaction.
impaired liver or 4. Assess skin color,
renal function. reflexes, adventitious
sounds and bowel
sounds
5. May cause
decreases serum
bilirubin
concentration in
neonates, in patients
with congenital
nonhemolytic
unconjugated
hyperbilirubinemia
and in epileptic.
Assessment IV. Diagnosis NURSING CARE PLAN
Hyperthermia
Planning
After 4hrs.of
Intervention
(1)Monitor patient’s
Rationale
(1) to evaluate
Evaluation
After 4hrs. of
Objective: related to nursing temperature degree of nursing
•Temp 38.10C direct effect of interventions, hyperthermia interventions, the
•Warm to circulating the patient (2)Monitor (2) Room temp or patient was
touch. endotoxin on will environmental temp. no. of blanket able to maintain
•Weak & pale the maintain core limit bed linens as should be altered core temperature
in hypothalamus temperature indicated to maintain near- within normal
appearance altering within normal normal body temp. range from
•persistent temperature range (370C). (3)Perform TSB, (3)May help reduce 38.10C to 370C.
crying regulation as avoid use of alcohol fever, alcohol may
•With slightly evidenced by cause chills,
dry lips increase in actually elevating
body temp. temp., alcohol is
higher than very drying to skin
normal range (4)Apply towel to (4)used to reduce
provide cooling fever. Heat loss by
effect conduction
(5) Maintain bed rest,
assist with care 5.) maximizes
activity effectiveness of
tissue perfusion
(6) Promote surface and energy/oxygen
cooling by means of conservation
undressing
(6)heat loss by
evaporation
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: Risk for after series of (1) Maintained and (1)Protects retina After series of
corneal nursing from
monitored baby’s eye nursing
•patient is in irritation and interventions, damage due to high
skin patches while under intensity light. Interventions
intensive the patient’s
breakdown risk of phototherapy. Neonate was
photo therapy related to (2) Provides visual
acquiring (2) Remove baby free from injury.
for 3 days prolonged stimulation and
corneal from under As evidenced by
used of facilitates
•With single irritation/skin phototherapy and infant’s
phototherapy attachment
breakdown remove eye patches eyes are free from
photo therapy behaviors.
will be
during feeding. corneal irritation
•Frequent reduced. (4) to reduce
(4) Inspect eyes every and skin
removal of complications and
after phototherapy for breakdown.
the eye monitor the
conjunctivitis, effectiveness of the
patches
drainage and corneal management
•Skin abrasions due to
appearing irritation from eye
light patches.
to bright (5) Provides maximal
(5) Provide
yellow. exposure and
minimal coverage of the
shielded the
•Sclera body except for sensitive parts such
appearing genitals. as the eyes and
genitals.
yellow.

•With diaper (6) to promote equal

(6) Reposition baby
on distribution of
every 2hours.
phototherapy
exposure.
V. DISCHARGE PLAN
Medications:
•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.
CONCLUSION
Therefore, 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…