OBJECTIVES

A. General Objective After this case presentation, the students will be able to deal and care for patients with ABO incompatibility integrally by applying their knowledge, skills, and positive attitude.

B. Specific Objectives At the end of the case presentation, students will be able to: Skills Deal patients with ABO incompatibility utilizing the nursing process. Accomplish a nursing history intensively through a systematic physical assessment, guided interview and efficient organization of data to gain significant information necessary in identifying appropriate nursing diagnosis. Formulate plan of care related to nursing diagnosis identified. provide proper care and nursing intervention associated with recommended treatments for ABO incompatibility. Perform an evaluation of the intervention rendered based on the plan formulated. Knowledge Discuss ABO incompatibility. Synthesize and summarize literature relevant to the discussion of the condition. Acquire sufficient information about the condition, its causes, preventive measures, and treatment. Recognize its signs and symptoms. Review the anatomy and physiology of the system affected. Relate the identified signs and symptoms to the pathophysiology of the condition. Identify and enumerate the management needed depending on the severity of ABO incompatibility. Interpret the significance of laboratory results to the signs and symptoms manifested by the patient. 1

Distinguish the prescribed medication, its mechanism of action, its indication and nursing responsibilities prior to medication administration.

Enumerate and integrate nursing theories and core competencies applicable to a specific nursing intervention.

Attitude Gain respect and trust from the significant others as well as from other health care team members through dedicated service in providing humble and simple care to patients with ABO incompatibility. Harness compassion and express empathy in caring for patients with ABO incompatibility throughout the nursing Process as embodied in the institutions mission-vision statement. Assimilate and live Vincentian Anthonian core values as integrated in rendering interventions and health teachings to the significant others to ensure full cooperation and compliance of treatment.

INTRODUCTION

Neonatal Hyperbilirubinemia or neonatal jaundice is the most common condition that requires medical attention in newborns. About 50% of term and 80% of preterm babies develop jaundice. In the Annual Statistics of the Philippine General Hospital of 2010, about 25.6% of delivered neonates had jaundice. Jaundice occurring on the 3rd to 4th day of life is usually harmless and is called physiologic jaundice. In most cases, the fundamental problem is early jaundice which is visible during the first 24 hours of life and is often called pathologic jaundice which requires closer examination and monitoring. In relation to this case discussion, the cause of jaundice is ABO incompatibility. According to Jane Palmer (2011), a midwife, a childbirth educator and lactation consultant, who focuses to improve pregnancy, birth and parenting options for families, ABO incompatibility is a common and a general mild type of hemolytic disease in babies. The term hemolytic disease means that red blood cells are broken down more quickly than usual which can cause jaundice, anemia and in very severe cases can cause death. During pregnancy, this breakdown of red blood cells in the baby may occur if the mother and babys blood types are incompatible and if these different blood types come into direct contact with each other, antibodies are formed.

The result of recent studies of Nadir, Syeda Javaria (2011), a researcher and one of the author in the publication of Journal of Pharmaceutical Sciences and Research, show some evidence that photo therapy is effective in treating neonatal jaundice and they recover more rapidly if they are full term and having no associated disease. It is concluded that phototherapy has a very effective role in the prevention and control of jaundice either in initial stage or in complicated cases. Hygienic conditions should be improved in hospitals to avoid and prevent the associated diseases with jaundice (like urticaria, sepsis, etc.) which a baby can acquire after birth. New advanced techniques i.e Billiblanket & Fibre optics should be introduced in our country to enhance the effectiveness of the phototherapy. However in some studies, close monitoring of the affected neonate is essential, and exchange transfusion is occasionally required. In addition, the spectrum of the disease has altered as new treatments, particularly improved intravenous immunoglobulin (IVIG), are being evaluated and introduced to reduce the need for exchange transfusion in the reduced number of severe cases. This review will aim to place HDN in the context of contemporary neonatal services, systematically evaluate its various presentations, and review the evolving role of these new treatments. This case study hopes to be most beneficial to the significant others of the newborns as the core purpose to aid in prompt and successful client recovery and understand somehow its significance to prevent further complications. To the students and clinical instructors, this study presents various observations and encounters upon handling the client and sustains recovery.

ANATOMY AND PHYSIOLOGY

ABO BLOOD GROUPS

INTRAUTERINE CIRCULATION 4

During pregnancy, the fetal circulatory system works differently than after birth: The fetus is connected by the umbilical cord to the placenta, the organ that develops and implants in the mother's uterus during pregnancy. Through the blood vessels in the umbilical cord, the fetus receives all the necessary nutrition, oxygen, and life support from the mother through the placenta. Waste products and carbon dioxide from the fetus are sent back through the umbilical cord and placenta to the mother's circulation to be eliminated. The new well nourished fetal blood returns to the baby through the umbilical vein and goes to the liver, splits in to three branches, one of which connects to the inferior vena cava (a major vein connected to the heart). In this way the well nourished blood reaches the fetal heart to be sent to the rest of the body. Schematic Diagram of Intrauterine Circulation

Uterine artery of the mother

Carries oxygenated blood

Placenta

Blood vessels of the umbilical cord

Nutrition, Oxygen & Life Support

Through the umbilical vein of the fetus

Goes to the liver

Splits into 3 branches

New well nourished fetal blood

Fetal heart

Rest of the body

Inside the fetal heart: 5

 Blood enters the right atrium, the chamber on the upper right side of the heart. Most of the blood flows to the left side through a special fetal opening between the left and right atria, called the foramen ovale. Blood then passes into the left ventricle (lower chamber of the heart) and then to the aorta, (the large artery coming from the heart). From the aorta, blood is sent to the head and upper extremities. After circulating there, the blood returns to the right atrium of the heart through the superior vena cava. About one-third of the blood entering the right atrium does not flow through the foramen ovale, but, instead, stays in the right side of the heart, eventually flowing into the pulmonary artery.

Inside the fetal heart

Foramen Ovale

Blood

Right Atrium

Left Ventricle

Aorta

Head & Upper Extremities

EXTRAUTERINE CIRCULATION With clamping of the cord, the detachment from the placenta and the first breaths of air the baby takes at birth, the fetal circulation changes. By removing the placenta reservoir, the baby's venous resistance/blood pressure goes up. By filling the lungs with air, the blood pressure in the lung arteries goes down. This eventually leads to the closing of the two areas for shunting, the

Clamping of arteriosus patent foramen ovale (PFO) and the patent ductusthe cord, (PDA). detachment from the placenta & 1st breaths of air Because the ductus arteriosus (the normal connection between the aorta and the pulmonary
artery) is no longer needed, it begins to constrict and close off. The circulation in the lungs increases and more changes into the left atrium of the heart. Fetal circulation blood flows This increased pressure causes the foramen ovale to close and blood circulates normally.

Babys Extrauterine Circulation Schematic Diagram of venous resistance/blood pressure goes up

6

Filling the lungs with air

Blood pressure in the lung arteries goes down

Patent Foramen Ovale (PFO)

Closing of the 2 areas for shunting Circulation in the lungs increases & more blood flows into the left atrium Increased Pressure

Patent Ductus Arteriosus (PDA)

Constricts

Close Off Close foramen ovale

BILIARY SYSTEM Functions of Liver: Carbohydrates, metabolism. Production of bile salts Bilirubin metabolism Detoxification of endogenous and proteins and fats

exogenous substances (Ammonia, steroid and vitamins ADEK) Blood reservoir 7

 Excretion of adrenal cortex hormone Phagocytosis by kupffer cells

Functions of Gallbladder: It is a small organ that aids mainly in by

fat digestion and

concentrates bile produced

the liver. In humans the loss of the gallbladder is usually easily tolerated. Stores and concentrates the bile (greenish liquid composed of water, 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.

Bilirubin Production and Elimination: Bilirubin is a reddish-yellow pigment found in bile. This pigment is produced during the breakdown of heme, a component of red blood cells. Initially, the compound is in a state known as unconjugated or indirect. The unconjugated form of the compound is not water soluble, and binds to albumin so that it can travel through the body to the liver, where it is treated with an enzyme (glucuronyl transferase) which turns it into conjugated or direct bilirubin. In this water soluble phase, the pigment moves into the bile. The body normally expresses bilirubin through the urine and stool, keeping levels in the body relatively stable leading to neurological problems. Buildups can also result in the development of jaundice.

ABO INCOMPATIBILITY (Hemolytic Disease of the Newborn)

ABO incompatibility is an immune system reaction that occurs when blood from two different and incompatible blood types are mixed together. In ABO hemolytic disease of the newborn also known as ABO HDN maternal IgG antibodies with specificity for the ABO blood group system pass through the placenta to the fetal circulation where they can cause hemolysis of fetal red blood cells which can lead to fetal anemia and HDN.

A. Blood Type Compatibility All people fit into one of four blood types -- A, B, AB and O. Everyone is compatible with some blood types but not all of them as follows:
People with blood type A are compatible with donor organs (or blood) from a person with

type A or O blood.
People with blood type B are compatible with blood type B or O. People with blood type AB are compatible with blood types A, B, AB or O. They are known

as universal recipients.
People with blood type O are compatible only with blood type O person. People with type

O blood are known as universal donors because all blood types are compatible with type O blood. B. Causes Environmental exposure 9

Anti-A and anti-B antibodies are usually IgM and do not pass through the placenta, but some mothers "naturally" have IgG anti-A or IgG anti-B antibodies, which can pass through the placenta. Exposure to A-antigens and B-antigens, which are both widespread in nature, usually leads to the production of IgM anti-A and IgM anti-B antibodies but occasionally IgG antibodies are produced. Fetal-maternal transfusion

Some mothers may be sensitized by fetal-maternal transfusion of ABO incompatible red blood and produce immune IgG antibodies against the antigen they do not have and their baby does. For example, when a mother of genotype OO (blood group O) carries a fetus of genotype AO (blood group A) she may produce IgG anti-A antibodies. The father will either have blood group A, with genotype AA or AO, or more rarely, have blood group AB, with genotype AB. Miscarriage, trauma and birth, and sometimes maternal and fetal blood mix for unknown reasons Blood transfusion It would be very rare for ABO sensitization to be caused by therapeutic blood transfusion as a great deal of effort and checking is done to ensure that blood is ABO compatible between the recipient and the donor. A, B, and O are the three major blood types. The types are based on small substances (molecules) on the surface of the blood cells. In people who have different blood types, these molecules act as immune system triggers (antigens). Each person has a combination of two of these surface molecules. Type O lacks any molecule. The different blood types are: Type A (AA or AO molecules) Type B (BB or BO molecules) Type AB (one A and one B molecule) Type O People who have one blood type form proteins (antibodies) that cause their immune system to react against other blood types. Being exposed to another type of blood can cause a reaction. This is important when a patient needs to receive blood (transfusion) or have an organ transplant. The blood types must be matched to avoid an ABO incompatibility reaction. C. Moderating factors In about a third of all ABO incompatible pregnancies maternal IgG anti-A or IgG anti-B antibodies pass through the placenta to the fetal circulation leading to a weakly positive direct

10

Coombs test for the neonate's blood. However, ABO HDN is generally mild and short-lived and only occasionally severe because: Immmunoglobulin G (IgG) anti-A (or IgG anti-B) antibodies that enter the fetal circulation from the mother find A (or B) antigens on many different fetal cell types, leaving fewer antibodies available for binding onto fetal red blood cells. Fetal RBC surface A and B antigens are not fully developed during gestation and so there are a smaller number of antigenic sites on fetal Red Blood Cells (RBC). Elevated isohemagglutinins. Antepartum intestinal parasitism or third-trimester immunization with tetanus toxoid or pneumococcalvaccine may stimulate isoantibody titer to A or Bantigens. Maternal isoantibody exists naturally and is independent of prior exposure to incompatible fetal blood group antigens. First-born infants have a 40-50% risk for symptomatic disease. Progressive severity of the hemolytic process in succeeding pregnancies is a rare phenomenon. D. Symptoms Manifested From the Textbook by the Patient Hyperbilirubinemia Rationale If a baby and mother have different blood types, sometimes the mother produces antibodies that destroy the newborn's red blood cells. This causes a sudden buildup of bilirubin in the baby's blood. Jaundice Anemia Fever Hematuria E. Exams and Tests Physical Examination It is a head-to-toe or cephalocaudal assessment of patients to gather significant data about signs or manifestations that can be observed objectively. Serum Bilirubin It is due to sudden buildup of bilirubin in the body as a breakdown product of blood hemolysis

11

Bilirubin is the breakdown product of heme catabolism. Heme is found in hemoglobin, a principal component of RBC. As the Red Blood Cell destruction continues the level of bilirubin in the blood increases. Complete blood count (CBC)

It is also known as full blood count (FBC) or full blood exam (FBE) or blood panel, is a test panel requested by a doctor or other medical professional that gives information about the cells in a patient's blood. It can also show damaged to red blood cells or anemia.

F. Diagnosis Routine antenatal antibody screening blood tests (indirect Coombs test) do not screen for ABO HDN. If IgG anti-A or IgG anti-B antibodies are found in the pregnant woman's blood, they are not reported with the test results, because they do not correlate well with ABO HDN. Diagnosis is usually made by investigation of a newborn baby who has developed jaundice during the first day of life. Blood type and Rh factor in the mother and the infant Increased reticulocyte count Direct Coombs' test (direct antiglobulin test). Because there is very little antibody on the red blood cell(RBC), the direct Coomb's test is often only weakly positive at birth and may become negative by 2-3 days of age. Blood smear. microspherocytes, polychromasia proportionate to the reticulocyte response, and normoblastosis above the normal values for gestational age Indirect hyperbilirubinemia G. Possible Complications Kidney failure Liver failure Death H. Treatment/Management Neonatal jaundice caused by ABO HDN is usually successfully treated with phototherapy, unless the ABO HDN is uncommonly severe. Treatment of moderate or severe HDN caused by ABO antibodies is similar to that for Rh disease. Treatment may include: Antihistamines Drugs used to treat allergic reactions Steroids 12

 Drugs used to treat swelling and allergies Intravenous Fluids Fluids given through a vein. Medicines to raise blood pressure if it drops too low Exchange transfusion It is a medical treatment in which apheresis is used to remove one person's red blood cells or platelets and replace them with transfused blood products.

Intravenous Immunoglobulin (IVIG) By blocking neonatal reticuloendothelial Fc receptors, and thus decrease hemolysis of

the antibody-coated RBCs, high-dose IVIG (1 g/kg over 4h) has been shown to reduce serum bilirubin levels and the need for blood exchange transfusion with ABO or Rh hemolytic diseases. Phototherapy It is the process of using light to eliminate bilirubin in the blood. Your baby's skin and blood absorb these light waves. These light waves are absorbed by your baby's skin and blood and change bilirubin into products, which can pass through their system. An infant liver processes little bilirubin in utero because the mothers circulation does this for an infant. With birth, exposure to light apparently triggers the liver to assume this function. Additional light supplied by phototherapy appears to speed the conversion potential of the liver. In phototherapy, an infant is continuously exposed to specialized light such as quartz halogen, cool white daylight, or special blue fluorescent light. Reasons to Use Phototherapy The primary reason a newborn needs phototherapy is excessively high bilirubin levels or levels that get too high too fast. Any of these can be caused by infection, liver ailments, prematurity or metabolic disease. Almost all healthy babies develop jaundice in the first few days of life, but very few require phototherapy. Bilirubin in present in bile in the body and has a dark yellow color. It is a by-product of the breakdown of old red blood cells. The immature liver of a newborn is less efficient at breaking down the bilirubin. This causes a buildup of bilirubin, leading to the yellow color of the skin (jaundice). Phototherapy helps the baby to metabolize the excess bilirubin in her blood. According to WebMD, a study from Johns Hopkins University in 2002 showed that bilirubin is an antioxidant that protects babies' cells from damage. I. Nursing interventions Keep infant warm and dry. Monitor skin and body temperature frequently. 13

Monitor laboratory studies as indicated such as hematology, and direct and indirect Initiate phototherapy per protocol, using fluorescent bulbs placed above the infant Discontinue breastfeeding for 24-48 hours as indicated. Assist mother as needed Assist with preparation and administration of exchange transfusion if needed. Regarding in phototherapy, apply patches to closed eyes. Inspect eyes every 2 Monitor fluid intake and output; weigh infant twice a day. Note signs of dehydration

bilirubin. or bili blanket. with pumping of breasts and reestablishment of breastfeeding.

hours when patches are removed for feedings. e.g. reduced urine output, depressed fontanels, dry or warm skin with poor turgor and sunken eyes). Increased oral fluid intake by at least 25%.

VITAL INFORMATION
Name Sex Age Address Civil Status Date and Time Admitted Religion Ward Chief complaint Anthropometric Measurement Baby Boy V.I.C Male 3 days old Milibili, Roxas City Newborn Nov. 23, 2011 - 4:30 pm Roman Catholic St. Catherine Laboure Room 332 Jaundice Weight = 2.8 kg Head circumference = 33 cm Chest circumference = 31 cm Abdominal Circumference = 30 cm Diet Admitting Diagnosis Final Diagnosis Height = 51 cm Milk Formula Acute Hyperbilirubinemia 2 to ABO incompatibility, T/c Neonatal Sepsis Neonatal Sepsis, Early Onset (Pseudomonas stutzeri) Severe Hyperbilirubinemia 2 ABO Incompatibility Attending Physicians S/P IVIG transfusion Dr. C. and Dr. C.

CLINICAL ASSESSMENT
A. Nursing History 14

Three days prior to admission, baby boy V.I.C was born via Normal Spontaneous Vaginal Delivery (NSVD) by a HILOT, with a loud cry and pinkish in color as narrated by the mother. Vaccines and Terramycin eye ointment were not administered. Initial temperature and APGAR evaluation were not taken. Umbilical cord was not cut aseptically. Skin to skin contact to the mother was initiated. He was then kept warm in a blanket and kept rested in crib. Milk formula was given after birth. Breastfeeding was only initiated two (2) days after, due to insufficient production of the mothers breast milk. The passage of meconium was reported five (5) hours after birth. Two days prior to admission, facial and peripheral jaundice was noted by the mother. He was afebrile with good sucking reflex. Particular observations noted were neglected and thus, appropriate interventions were not rendered. One day prior to admission, November 23, 2011, generalized jaundice was already observed, hence, was brought for check up to Roxas City Health Office and to be given a Bacillus Calmette Guerin (BCG) vaccination. Upon thorough examination by the medical officer, he was referred to Roxas Memorial Provincial Hospital (RMPH) for admission. Several laboratory tests were ordered thereafter. Unfortunately, their desired pediatrician was not affiliated in the said hospital. So, they decided to be admitted at St. Anthony College Hospital (SACH).

15

92
B. Family Genogram

1930
82

1939
73

1942
70

R.C

S .C

A .C

1978
34

19 8 3
29

1986
26

1987
25

1989
23

1991
21

1990
22

D.C 1981
31

B.C 1984
28

R.B

C.B

Ca .B

S .B

B.B

I.C

M.B
LEGEND:

DEATH

2011
1m
16

Bb.

PATTERNS OF FUNCTIONING Nutritional History a. Drinking and Eating Pattern. HOME HOSPITAL

Baby boy V.I.C was given milk after birth due Baby boy V.I.C is in NPO upon admission. Milk to inability of the mother to produce breastmilk. formula was resumed in the evening of It is on his second day breastfeeding was admission, and was ordered to withhold initiated. breastfeeding.

b. Breathing Pattern HOME HOSPITAL

According to his mother, Baby boy V.I.C did He has regular breathing pattern with a not experience any breathing problems when respiratory rate of 54 - 60 bpm. No signs of he was at home. respiratory distress noted.

c. Circulation Temperature Apical rate Respiration rate IVF 36 C 130 bpm 56 bpm D5W 500 cc x 11 cc/

Daily Activity Patterns: a. Rest and Sleeping Patterns HOME Baby boy V.I.C sleeps at long intervals when he was at home without any disturbance. He cries when his diaper is soaked and if hes hungry. HOSPITAL He sleeps at short intervals due to some hospital procedures like turning patterns, changing of diapers and medication administration.

b. Personal Hygiene HOME HOSPITAL

He was being bathe by her mother daily in a Baby boy V.I.C was not bathe all throughout quick and fast manner in order to avoid hospitalization. Hence, diaper is still changed 17

hypothermia. He was also given manzanilla whenever soaked, and umbilical cord is also after it. Then, cleaning of umbilical cord was done using 70% isopropyl alcohol. Diaper is immediately changed whenever soaked. cleaned everyday.

Elimination Patterns a. Bowel Movement FREQUENCY Home Once or twice a day. Hospital Defecates once for the whole shift. PROBLEMS/DIFFICULTIES Home Hospital

No problems presented during our care.

b.

Urination FREQUENCY Home Hospital He has urine output of 150 cc for the whole shift. PROBLEMS/DIFFICULTIES Home Hospital

His diaper was being changed at least 2-3 times a day.

No other problems noted during our care.

BRIEF CULTURAL, ECONOMIC, ENVIRONMENTAL AND RELIGIOUS BACKGROUND

Cultural Health His family believes in herbolarious and superstitions like putting wet silk on the babys forehead when hiccups occur. Economic Status They belong in the middle class of family in this society. His father works as a mechanical engineer while his mother graduated as Bachelor of Science in Nursing but unfortunately, she was not yet a registered nurse. Currently, she works as a medical representative. Their monthly income is within 20,00025,000 pesos. Environmental Pattern Their house is located near the highway in Brgy. Milibili, Roxas City and their backyard is wide enough for plantation of vegetables. Religious Background

18

 Baby boy V.I.C was not yet baptized. His parents are not binded by the sacrament of marriage but they are living together. They are both Roman Catholic and seldom attends mass during Sundays. -

CLINICAL INSPECTION
A. Vital Signs Upon Admission Temperature 36.7C Respiratory rate 57 bpm Apical pulse 145 bpm

During our Care November 23, 2011 Time 8:00 8:30 9:00 9:30 10:00 November 24, 2011 Time 4:00 6:00 8:00 10:00 Temperature (C) 36.6 36.7 36.9 36.7 Respiratory rate (bpm) 56 54 55 54 Apical pulse (bpm) 136 134 135 136 Temperature (C) 36 36.4 36.5 36.6 36.7 Respiratory rate (bpm) 60 58 57 54 56 Apical pulse (bpm) 130 132 134 134 133

Height: 51 cm = 20.08 inches

Weight: 2.8 kg = 6.17 lbs

PHYSICAL ASSESSMENT
General Appearance Baby boy V.I.C was placed in a crib and exposed to phototherapy and was covered by eye shield. He has an IVF of D5W 500cc x 11cc/hour infusing well at right metacarpal vein at the level of 350cc. He was afebrile, cried loudly, with good suck. Generalized jaundice noted. Cephalocaudal (Head to Toe) Body parts Method of Assessment 19 Findings Interpretation

Skin

Inspection

(-) Cyanosis With good skin turgor (+) Cool skin

Normal Due to ineffective heat thermoregulation of the body that results to hypothermia. Due to the destruction of RBC that will result into increase bilirubin in the blood. Normal

Generalized jaundice

Head

Inspection

Normocephalic Head Circumference = 33 cm Non-bulging and non depressed anterior and posterior fontanels Hair evenly distributed No signs of caput succedaneum and cephalohematoma

Eyes

Inspection

No discharges present. Absence of periorbital edema (+) Blink reflex

Normal

Due to the (+) Icteric sclerae destruction of RBC that will result into increase bilirubin in Ears Inspection External ear is lined with the outer canthus of the eyes. No discharges noted. Nose Inspection (+) Moro/startle reflex Presence of minimal amount of Milia. Nares are bilateral. 20 Normal the blood. Normal

 No signs of nasal flaring. Nasal septum is in the midline Mouth Inspection No discharges observed. Has a good suck Tongue is pink and lower palate is intact. Lips is pink with moist mucosa No thrush noted. (+) Sucking reflex Normal

(+) Rooting reflex (+) Swallowing reflex (+) Extrusion reflex Throat & Neck Inspection Palpation Inspection Unable to support the head. No palpable lymph nodes. Chest Circumference = 31 cm. It is smaller than the head. RR = ranges from 54 - 60 bpm Clavicles are straight and symmetric side to side. No chest retractions presented. Nipples are symmetrical. Auscultation Abdomen Inspection No rales, wheezing and murmur heard. Abdominal Circumference = 30 cm Umbilicus is dry and brown in color with no signs of infection. Palpation Back Inspection (+) Soft and protuberant abdomen (+) Lanugo Spines are flat in the lumbar 21 Normal Normal Normal

Chest, breast and axilla

Normal

& sacral areas. (+) Incurbation reflex Absence of scoliosis and Extremities Inspection kyphosis. Arms and legs are short. Hands are plump and clenched into fist. (+) Darwinian reflex/ palmar grasp (+) Babinski reflex (+) Tonic neck reflex Normal

(+) Magnet reflex

GROWTH AND DEVELOPMENT

Piagets Theory of Cognitive Development SENSORIMOTOR (From birth to age 2)

Baby boy V.I.C interacts and learns about his environment by relating his sensory experiences such as hearing and touch. During at home, he rattles when he hears a loud noise and even to his parents voice. He presented sucking and grasping reflexes and can recognize that a parent remains the same person who cuddled him. Freuds Psychosexual Theory ORAL STAGE (Early infancy to 1st 18 months of life)

Baby boy V.I.C explores his world by using his mouth, especially his tongue.

Eriksons Psychosocial Theory TRUST VS MISTRUST (Early infancy-birth through 1st year)

In this stage, Baby boy V.I.C needs much care and attention. If his parents give him enough love and attention, he will develop basic trust but if not, he may view his world as uncaring, learns to become mistrustful and have difficulty in dealing with the second stage.

COURSE IN THE WARD

22

Date / Time / Side Notes 5:25 pm T = 37 C CR = 131 bpm RR = 58 bpm (+) General jaundice o o o

Orders Nov. 23, 2011 Please admit to 332 under the service of Dr. L.C. NPO temporarily. Labs: Chest X ray Antero - posterior lateral (APL) view Urinalysis Medicus laboratory results taken at out patient department (OPD) to chart Serum Na & K o o o o o o o D5W 500 cc @ 11, use solu set. Cefotaxime 150 mg IV drip for 30 mins q12 No skin test (NST) Gentamycin 14 mg IVTT, retrograde push Once a day (O.D) Bili light (Phototherapy) exposure. Cover eyes & perineum while on therapy. V/S q2 & record. MIO q shift. Refer as needed (prn). Attending physician (AP) informed. Change intravenous fluids (IVF) to D5 IMB @ 11 cc/ Discontinue Gentamycin Start Ampicillin 150 mg slow IVTT q12, No Skin Test (NST) D10 IMB = D50W 10cc + D5IMB 83 cc x 8 @ 10 12 cc/

6:10 pm

o o o

6:20 pm On Nothing per orem (NPO) 6:25 pm Temperature = 36 C Total Bilirubin ((TB) = Indirect Bilirubin (B1) = Direct Bilirubin (B2) =

o o

o o o o o

Hold electrolyte. For Blood C/S For extensive photo exposure using overhead phototherapy & Bilibed. Refer to Dr. E.C. for further evaluation & management. AP made orders. Prescribe Intravenous Immunoglobulin (IVIG) 500mg # 1 vial. Inform Dr. E.C if available. Transfuse IVIG 1 vial 500 mg to run for 3 via infusion pump. Flush with PNSS 10 15 ml after IVIG infusion. Give Lasix 3 mg IV after IVIG infusion. Hold mainline IVF while

8:05 pm

o o

9:10 am Still jaundice Afebrile, good suck Clear breath sounds No murmur

IVIG is going on. Nov. 24, 2011 o Continue extension photo (Bili Light & overhead photo). o o o o Continue meds. For repeat indirect bilirubin (B1), direct bilirubin (B2), total bilirubin (TB) tomorow. Suggest to resume feeding. Please turn patient side to side & prone q2. 23

o 9:25 am 6:35 pm 9:00 pm 9:20 pm o o o o o

Stand by fresh whole blood type O. Pending result repeat bilirubin. May have milk formula 1:2 dilution 1 2 ounces q 2 - 3 per demand. Repeat TB, B1, B2 tomorow morning. Regulate D10IMB @ 11 12 cc/ IVF to follow D5 IMB as follows D50W 11 cc + D5IMB 91 cc = 102 cc x 8 @ 12 13 cc/ for 3 cycles. Nov. 25, 2011 Plase relay laboratory results once in

9:15 am jaundice Good suck 2:20 pm jaundice Repeat TB = 23 mg/dl

o o o o

Continue photo and Bilibed. Continue meds. Add Ursofalk 250 mg/ cap = 1 cap 9 paper tab. Give 1 paper tab O.D p.o (mix with milk). Repeat TB, B1, B2 tomorow am. Nov. 26, 2011 Continue photo therapy and bilibed. Continue IV meds. Please follow up repeat bilirubin.

9:05 am jaundice Afebrile Good suck 10:55 am jaundice Good suck 7 am Good suck 7:50 am jaundice TB = 16 g/dl 7:45 am jaundice Good suck 1:35 pm

o o o

IVF to follow D5 IMB 240 cc x 24 - 10 cc/

o o o

Nov. 27, 2011 IVF to follow D5 IMB 240 cc x 24 - 10 cc/ Continue meds. Continue phototherapy and bilibed. Nov. 28, 2011 IVF to follow D5 IMB 500 cc x 10 cc/

o o o o

Continue IV meds. Continue photo and bilibed. Dr. C. signing out for the service. Suggestion: Continue IV meds to day 7. May resume blue light until tomorow. Just continue overhead photo, until discharged. Consume stock of ursofalk. 24

 For hearing test, for high risk hyperbilirubenemia May delay immunization after 3 months old after IVIG therapy. Nov. 29, 2011 o Discontinue bilibed. o o 9:40 am o o 9:50 am 11:20 am o o o o o Continue overhead photo. Repeat TB, B1,B2. Nov. 30, 2011 May go home (MGH) this pm, if with no problem. Summarize bill. Please inform Dr. E.C. For hearing test c/o Dr. J.V. As follow up c/o medicus. For discharge anytime. Return to clinic anytime.

6:50 am

LABORATORY AND DIAGNOSTIC DATA

Medicus Diagnostic Center Date: Nov. 23, 2011 Hematology: Hematology is the branch of biology (physiology), pathology, clinical laboratory, internal medicine, and pediatrics that is concerned with the study of blood, the blood of forming organs, and blood diseases. Hematology includes the study of etiology, diagnosis, treatment, prognosis, and prevention of blood diseases. Name of Examination WBC Result 13.5 x 10^9/L Normal values 4.5-11.0 Significance As a compensatory mechanism of the body against pathogens (Neonatal RBC Hemoglobin Hematocrit 3.86 10^12/L 122.4 g/L 0.36 vol. fr. 4.6-6.2 135-180 0.40- 0.56 Sepsis) It is caused by the faster than normal breakdown of the babys red blood cells caused by the mothers antibodies. Radiography It is the use of X-rays to view a non-uniformly composed material such as the human body. By using the physical properties of the ray an image can be developed which displays areas of different density and composition. Chest X ray, APL Dr. C. Impression: 25

Essentially (-) cardiopulmonary findings

Bilirubin Test A bilirubin test measures the amount of bilirubin in a blood sample. Date Nov. 23, 2011 Nov. 24, 2011 Nov. 25, 2011 Nov. 26, 2011 Nov. 30, 2011 Result Signifance Total Bilirubin 566.71 umol/L ABO Incompatibility. 437.04 umol/L It indicates increase levels of bilirubin 407.2 umol/L due to increased hemoglobin 274.5 umol/L N - 139.5 umol/L breakdown. Normal Value: O 176 umol / L Date Nov. 23, 2011 Nov. 24, 2011 Nov. 25, 2011 Nov. 26, 2011 Nov. 30, 2011 Result Signifance Indirect Bilirubin 31.71 mg/dl ABO Incompatibility. 42.2 umol/dl It indicates increased level of stored 39.59 umol/dl bilirubin processed by the liver. 27.36 umol/dl N 13.52 umol/dl Normal Value: 3.4 13.7 umol / dl Result Signifance Direct Bilirubin 27.64 umol/L ABO Incompatibility. 19.18 umol/L It indicates increase levels of bilirubin in 11.37 umol/L the blood stream as a result of 8.7 mg/L N 4.40 umol/L hemolysis. Normal Value: 0 5 umol / L Bacteriology It is the study of bacteria. This subdivision of microbiology involves the identification, classification, and characterization of bacterial species Bacteriology Name of specimen: Blood Organism Identified: o Confluent P. Stutzeri Sensitive to: o o o o o Amoxicillin / Penicillin / Ctrimoxazole Piperacillin Cefurxime Meropenem Imipenem

Date Nov. 23, 2011 Nov. 24, 2011 Nov. 25, 2011 Nov. 26, 2011 Nov. 30, 2011

26

Non-modifiable risk factor: Mothers blood type=O Fathers blood type=A VICs blood type= A

PATHOPHYSIOLOGY
Modifiable risk factor: Home delivery by untrained hilot

RBC- 3.86 10^12/L Hgb-122.4 g/L

Fetal RBC destruction

Hct- 0.36 vol. fr.

Heme

Hemoglobin

Globin

Oxygen Iron

Photophorphyri n

Goes back to circulation, utilized as amino acid

Used by body for oxygenati on

Used by marrow for producti on of RBC

Bilivedin Converted to unconjugated bilirubin bounded to albumin Albumin detached from unconjugated bilirubin Unconjugated bilirubin not converted to conjugated bilirubin Unconjugated bilirubin not excreted Direct Bilirubin 19.18 umol/L Bilirubin goes to the liver

Disease process LEGEND: Lab. results Treatme nt

Factors Sympto ms

Absence of glycorynyl transferase produced by the liver

Goes to skin and sclera (+ )Jaundice and icteric sclera Ursodi ol

Indirect Bilirubin: 422 umol/L 27 Total Bilirubin: 566.71 umol/L

IGIV

Photothera py

MEDICAL MANAGEMENT
Generic Name Drug class Dosage Indications Contraindications Adverse reaction Cefotaxime Sodium Antibiotic (Cephalosporin) 150 mg IV drip for 30 mins ANST Q12 Neonatal Sepsis Hypersensitivity Nausea, vomiting, diarrhea, anorexia, abdominal pain, flatulence, pseudomembranous colitis, bone marrow depression, ranging from rash Mechanism of Action to fever, pain at injection site It binds to one or more of the penicillin-binding proteins (PBPs) which inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell wall, thus inhibiting biosynthesis and arresting cell wall Nursing Responsibilities assembly resulting in bacterial cell death. Observe the 10 rights of giving medications. Monitor the laboratory results (hematology). Discontinue if hypersensitivity reaction occurs. Inform significant others that the patient may experience stomach upset such as diarrhea. Monitor for adverse reactions. Urge them to report if there is severe diarrhea, difficulty breathing, pain and swelling at injection site.

Generic Name Drug class Dosage Indications Contraindications Adverse reaction Mechanism of Action Nursing Responsibilities

Ampicillin Sodium Antibiotic (Penicillin) 150 mg IVTT slow ANST Q12 Neonatal Sepsis Hypersensitivity Glossitis, stomatitis, gastritis, sore throat, nausea, vomiting, diarrhea, rash, fever, wheezing, anemia, phlebitis Ampicillin exerts bactericidal action on both gram positive and gram negative organisms by inhibiting the synthesis of bacterial cell wall. Observe the 10 rights of giving medications. Slowly administer the drug. Inform significant others that the patient may experience these side effects: nausea, vomiting and GI upset. Monitor for adverse reactions. Urge them to report unusal bleeding or bruising, mouth sores, rash, fever, severe diarrhea and difficulty breathing.

Generic Name

Gentamicin Sulfate 28

Drug class Dosage Indications Contraindications Adverse reaction Mechanism of Action Nursing Responsibilities

Antibiotic (Aminoglycoside) 14 mg IVTT retrograde push OD Neonatal Sepsis Hypersensitivity Ototoxicity, nausea, vomiting, anorexia, leucopenia, purpura, rash, fever, apnea Bactericidal: Inhibits protein synthesis in susceptible strains of gramnegative bacteria; appears to disrupt functional integrity of bacterial cell membrane, causing cell death. Observe the 10 rights of giving medications. Monitor for side effects. Inform significant others that the patient may experience nausea, vomiting, headache and dizziness. Monitor serum concentrations. Observe for difficulty breathing, rash or skin lesions and severe headache.

Generic Name Drug class Dosage Indications Contraindications Adverse reaction Mechanism of Action

Intravenous Immune globulin (IVIG) Vaccines & Immunologicals 1 vial 500 mg to run for 3 via infusion pump ABO Incompatibility Hypersensitivity Tenderness, urticaria, angioedema, nausea, vomiting, chills, fever, chest tightness Human normal immunoglobulin is derived from donations of pooled human plasma. It contains antibodies, mainly immunoglobulin G (IgG), to various bacteria and viruses present in the general population such as hepatitis A, measles, mumps, rubella and varicella. It has a distribution of IgG subclasses that is very close to that of the normal human plasma. It is therefore, used to provide passive immunization against such diseases and shown to decrease bilirubin level in the body. Observe 10 rights in giving medications. Observe for any symptoms during IV administration. Adverse effects appear to be related to the rate of infusion. Monitor the vital signs specifically temperature and respiratory rate.

Nursing Responsibilities

Generic Name Brand Name Drug class Dosage Indications Contraindications Adverse reaction

Furosemide Lasix Loop diuretic 3 mg IV ABO Incompatibility (IVIG transfusion) Hypersensitivity Dizziness, vertigo, paresthesia, thrombophlebitis, rash, pruritus, urticaria, 29

nausea, vomiting, oral and gastric irritation, urinary bladder spasm, Mechanism of Action Nursing Responsibilities leukemia, thrombocytopenia It inhibits reabsorption of sodium and chloride from the proximal and distal tubules and ascending limb of the loop of Henle, leading to a sodium-rich diuresis. Observe 10 rights in giving medications. Monitor serum electrolytes, liver and renal function. Monitor intake and output. Measure and record weight to monitor fluid changes. Inform significant others that the patient may experience these side effects: increased volume and frequency of urination, dizziness, drowsiness.

Generic Name Brand Name Drug class Dosage Indications Contraindications Adverse reaction Mechanism of Action Nursing Responsibilities

Ursodiol Ursofalk Gallstone-solubilizing drug 250 mg/cap 1 cap9 paper tabs one paper tab O.D P.O. ABO Incompatibility (Risk for impaired liver function) Hypersensitivity Headache, pruritus, rash, dry skin, sweating, diarrhea, rhinitis, cough A naturally occurring bile acid that aids in the excretion of bilirubin from the body. Observe 10 rights in giving medications. Inform significant others that the patient may experience these side effects: diarrhea, rash and headache. Observe for nausea, vomiting, abdominal pain and yellowing of the skin or eyes.

Intravenous Fluids: Drug Name Drug class Dosage Indications Contraindicatio ns Adverse reaction Mechanism of Action 5% Dextrose in Water (D5W) Isotonic Intravenous Solution 500cc @ 11cc/hr Fluid & electrolyte maintenance, and NPO. Hypersensitivity Hyperglycemia, increased intracranial pressure, hypokalemia, and fluid volume overload. It is an electrolyte-free and an isotonic solution that supplies 170 cal/L and free water that aids in renal excretion of solutes. It also dilutes plasma electrolyte concentration. 30

Nursing Responsibilitie s

Observe the 10 rights of giving medications. Monitor for signs of hyperglycemia such as bounding pulse and shortness of breath. Monitor intravenous fluid level hourly. Calculated and regulated the flow rate accurately.

Drug Name Drug class Dosage Indications Contraindicatio ns Adverse reaction Mechanism of Action Nursing Responsibilitie s

Balanced

Multiple

Maintenance

Solution

with

5%

Dextrose/ Euro-Ion in D5W (D5IMB) Hypertonic Intravenous Solution 500cc @ 11cc/hr NPO, and insensible fluid loss (phototherapy) Hypersensitivity Allergic-type reactions including anaphylactic symptoms & lifethreatening or less severe asthmatic episodes It pulls fluids from the cells and interstitial compartment into the blood vessel. Observe the 10 rights of giving medications. Monitor intravenous fluid level hourly. Observe for adverse reactions. Monitor intake and output. Measure and record weight to monitor fluid changes. Calculated and regulated the flow rate accurately.

Drug Name Drug class Dosage Indications Contraindicatio ns Adverse reaction Mechanism of Action Nursing Responsibilitie s

D10IMB (D50W 10cc + D5IMB 83cc) Hypertonic Intravenous Solution 93cc x 8hrs @ 10-12cc/hr NPO, and insensible fluid loss (phototherapy) Hypersensitivity Allergic-type reactions including anaphylactic symptoms & lifethreatening or less severe asthmatic episodes It provide glucose to the body and pulls fluid from the cells and from interstitial compartment into the blood vessels. Observe the 10 rights of giving medications. Monitor intravenous fluid level hourly. Observe for adverse reactions. Measure and record weight to monitor fluid changes. Calculated and regulated the flow rate accurately. 31

 Monitor intake and output.

32

MEDI MAP
Risk factors: Home delivery with Hilot Mothers blood type=O Fathers blood type=A Baby boy V.I.Cs blood type=A

Pathophysiology: It occurs when a mother is blood type O and her infant is either blood type A,B or AB. Because in blood groups there are naturally occurring anti-A and anti-B antibodies, these naturally occurring antibodies may cross the placental barrier. This situation can occur because of a tear in the membrane of the placenta separating the maternal blood from the fetal blood (trauma). With birth, progressive jaundice, usually occurring within the first 24 hours of life. This is due to RBC destruction and indirect bilirubin released.

Laboratory and Diagnostic Test Hematology Bactriology Radiography Bilirubin test

ABO INCOMPATIBILITY

Nursing interventions: Keep infant warm and dry. Monitor skin and body temperature frequently. Monitor laboratory studies as indicated such as hematology, and direct and indirect bilirubin. Initiate phototherapy per protocol, using fluorescent bulbs placed above the infant or bili blanket. Discontinue breastfeeding for 24-48 hours as indicated. Assist mother as needed with pumping of breasts and reestablishment of breastfeeding. Assist with preparation and administration of exchange transfusion if needed. Regarding in phototherapy, apply patches to closed eyes. Inspect eyes every 2 hours when patches are removed for feedings. Monitor fluid intake and output; weigh infant twice a day. Note signs of dehydration e.g. reduced urine output, depressed fontanels, dry or warm skin with poor turgor and sunken eyes). Increased oral fluid intake by at least 25%.

Signs & symptoms: Hyperbilirubinemia Jaundice

Medical Management: Cefotaxime Sodium 150 mg IV drip for 30 mins ANST Q12 Ampicillin Sodium 150 mg IVTT slow ANST Q12 Gentamicin Sulfate 14 mg IVTT retrograde push OD Intravenous Immune globulin (IVIG) 1 vial 500 mg to run for 3 via infusion pump Furosemide 3 mg IV

Prevention: Early breastfeeding. Phototherapy Exchange transfusions

33

CONCEPT MAP

Ineffective peripheral tissue perfusion r/t destruction of red blood cells

4. Interrupted breast-feeding r/t discontinuation of breast milk

TREATMENT Cefotaxime Sodium 150 mg IV drip Ampicillin Sodium 150 mg IVTT Gentamicin Sulfate 14 mg IVTT

Ineffective peripheral tissue perfusion r/t destruction of red blood cells ASSESSMENT r/t the destruction of 2. Infection Subjective: bodys primary verbalized by Ga yellow siya as defense system the mother. Objectives: (+)Generalized jaundice (+) Icteric sclerae Laboratory Results: Hematology: RBC = 3.86 10^12/L breast-feeding r/t 4. Interrupted Hemoglobin = 122.4 g/L discontinuation Hematocrit = 0.36 vol. fr. of breast milk Serum Bilirubin: Total bilirubin = 566.71 umol/L Indirect bilirubin = 422 umol/L Direct bilirubin = 27.64 umol/L TREATMENT IVIG 1 vial 500 mg x 3 hours Lasix 3 mg IV Bili light (phototherapy) exposure

2. Infection r/t the destruction of bodys primary defense system

ASSESSMENT Objectives: Temp. = 36C Home delivery by untrained hilot

Laboratory results: Hematology WBC = 13.5 x 10^9/L

ABO INCOMPATIBILITY CC: Jaundice

ASSESSMENT Subjective: Altered thermoregulation: 3. Ginpauntat ni doctor ang pagpabreastHypothermia r/t as verbalized feeding ko sa akon bata,ineffective heat regulatory process in the body by the mother. Objectives: Breastmilk was shifted to milk formula.

5. Risk for corneal irritation and skin breakdown related to prolonged 5.used for phototherapy Risk of corneal irritation and skin
breakdown related to prolonged used of phototherapy ASSESSMENT Objectives: (+) Intensive photo-therapy for 7 days Frequent removal of the eye patches Skin appearing light to bright yellow. (+) Icteric sclera

3. Altered thermoregulation: Hypothermia r/t ineffective heat regulatory process in the body Assessment Objective: Temp. = 36C (+) Cool skin

34

Assessment

Nursing Diagnosis

Planning

Intervention / Rationale

Theory / Implication

Core Competency

Core Values

Evaluation

Subjective: Ga yellow

Ineffective peripheral tissue

To provide adequate peripheral

Dependent: Transfused IVIG 1 The 3 cs of Lydia Safe and Commitment to

Goal met as evidenced by jaundice with the following serum bilirubin 35

siya as verbalized by the mother.

perfusion r/t destructio n of red blood

tissue perfusion and lessen the severity of jaundice as evidenced by decreased bilirubin level in blood and reduction of jaundice within 24 hours of care.

vial 500 mg x 3 hours using syringed pump as ordered. It is a normal human immunoglobulin that has been shown to reduce serum bilirubin levels

Hall The theory contains 3 independent but interconnected circles; it includes the core, care and cure. Wherein the cure is the attention given by the healthcare provider. These are the interventions or actions geared on treating or curing the patient from whatever illness or disease he may be suffering from.

Quality Nursing Care

Vincentian Excellence

results the next day: Total bilirubin = 437.04 umol/L Indirect bilirubin = 395.91 umol/L Direct bilirubin = 19.18 umol/L

Objective: (+)Generalized jaundice (+) Icteric sclerae Laboratory Results: Hematology: RBC = 3.86 10^12/L Hemoglobin = 122.4 g/L Hematocrit = 0.36 vol. fr.

cells

Safe and Quality Nursing Care

Commitment to Vincentian Excellence

Administered Lasix 3 mg IV after IVIG transfusion as ordered. It inhibits reabsorption of sodium and chloride from the proximal and distal tubules and ascending limb of

36

the loop of Henle, Serum Bilirubin: Total bilirubin = 566.71 umol/L Indirect bilirubin = 422 umol/L Direct bilirubin = 27.64 umol/L Exposed on bili light (phototherapy) as ordered. It eliminates bilirubin in the blood by converting it into products than can pass through the system. leading to a sodium-rich diuresis which aids in the excretion of direct bilirubin. The 3 Cs of Lydia Hall The theory contains 3 independent but interconnected circles; it includes the core, care and cure. Wherein the cure is the attention given by the healthcare provider. These are the interventions or actions geared on treating or curing the patient from 37 Management of Resources and Environment Commitment to Vincentian Excellence

whatever illness or disease he may be suffering from.

Nightingales Environmental Independent: Provided a calm and quiet environment conducive for rest. To conserve energy and lowers tissue perfusion demand. Theory She stated that environmental settings appropriate for the gradual restoration of the patient's health is necessary, and that external factors associated with the patient's surroundings affect the persons life or biologic and physiologic processes, and his 38 Management of Resources and Environment Compassionat e Service

development.

Faye Glenn Abdellahs TwentyOne Nursing Monitored vital signs including the cardiac rate To monitor patient from any changes in his status. Elevated VS may indicate poor circulation and oxygenation. Problems One of her Typology of Twenty-One Nursing Problem is to facilitate the maintenance of elimination and fluid balance, and to recognize the pathologic responses of the Monitor intake and output To monitor for fluid balance and organ function. body to disease condition.

Safe and Quality Nursing Care

Commitment to Vincentian Excellence

Safe and Quality Nursing Care

Commitment to Vincentian Excellence

39

Assessment

Nursing Diagnosis

Planning

Intervention / Rationale

Theory / Implication

Core Competency

Core Values

Evaluation

Objectives: Temp = 36C Home delivery by untrained hilot

Infection r/t the invasion of pathogens

To prevent or reduce further progression of infection with in hospital stay.

Dependent: Administered Cefotaxime 150 mg IV drip for 30 minutes as ordered. It binds to one or more of the penicillin-binding proteins (PBPs) which inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell wall, thus inhibiting biosynthesis and arresting cell wall The 3 cs of Lydia Hall The theory contains 3 independent but interconnected circles; it includes the core, care and cure. Wherein the cure is the attention given by the healthcare provider. These are the interventions or actions geared on treating or curing the patient from whatever illness or disease he may be Safe and Quality Nursing Care Commitment to Vincentian Excellence

Goal partially met. Baby boy V.I.C was discharged last November 30, 2011 without any signs of infection. However, there is no latest laboratory results that can prove if the infection progressed or regressed.

Laboratory results: Hematology WBC = 13.5 x 10^9/L Bacteriology: Organism Identified: Confluent

40

P. Stutzeri

assembly resulting in bacterial cell death.

suffering from.

Administered Ampicillin 150 mgs. slow IVTT as ordered. It exerts bactericidal action on both gram positive and gram negative organisms by inhibiting the synthesis of bacterial cell wall. Safe and Quality Nursing Care Commitment to Vincentian Excellence

Administered Gentamycin 14 mg IVTT retrograde push as ordered. It inhibits protein 41 Safe and Quality Nursing care Commitment to Vincentian Excellence

synthesis in susceptible strains of gram-negative bacteria; appears to disrupt functional integrity of bacterial cell membrane, causing cell death.

Transfused IVIG 1 vial 500 to run for 3 hours using syringe pump as ordered. It contains antibodies, mainly immunoglobulin G (IgG). It is therefore, used to provide passive immunization against such diseases. Safe and Quality Nursing Care Commitment to Vincentian Excellence

42

Independent: Monitored vital signs; including temperature. To check for the presence of hyperthermia, which is a common signs of infection. Virginia Hendersons 14 Basic Human Needs Henderson viewed health as a quality of life and is very basic for a person to function fully. As a vital need, a person needs to maintain his normal body temperature. And for a care provider to know the vital status of a client, there is a need for a vital signs monitoring especially the 43 Safe and Quality Nursing Care Commitment to Vincentian Excellence

temperature.

Performed hand hygiene before and after every procedure. To prevent transmission of microorganisms that could add to current infection.

Faye Glenn Abdellahs TwentyOne Nursing Problems One of her Typology of Twenty-One Nursing Problem is to promote safety through prevention of accident, injury,

Safe and Quality Nursing Care

Commitment to Vincentian Excellence

Cleaned the umbilical cord using 70% isopropyl alcohol regularly and every after changing of diaper. To lessen or eradicate bacterial growth in the area and prevents

or other trauma and through the prevention of the spread of infection.

Research

Commitment to Vincentian Excellence

44

another occurrence of infection.

Assessment

Nursing Diagnosis

Planning

Intervention / Rationale

Theory/ Implication

Core Competency

Core Values

Evaluation

Objective: Temp. = 36C (+) Cool skin

Altered thermoregulation: Hypothermi a r/t ineffective heat regulatory process in the body

To normalize body temperature within normal range of 36.5 to 37.5C after 4 hours of nursing interventions.

Independent: Placed in a droplight, overhead light and radiant warmer. It increases body temperature through the heat given by the artificial warmers Florence Nightingales Environmental Theory. She stated that environmental settings appropriate for the gradual restoration of the patient's health is Turned off the air conditioner. To provide a warm and heater room necessary, and that external factors associated with the patient's surroundings affect Management of Resources and Environment Management of Resources and Environment Commitment to Vincentian Excellence

Goal met as evidenced by body temperature of 36.7C after 2 hours of nursing intervention.

Compassionat e Service

45

temperature.

the persons life or biologic and physiologic processes, and his development.

Monitored vital signs, especially temperature. Closely monitoring of vital signs, especially the temperature gives us significant information about the clients current condition and vital status. Virginia Hendersons 14 Basic Human Needs Henderson viewed health as a quality of life and is very basic for a person to function fully. As a vital need, a person needs to maintain his normal body temperature. And for a care provider to know the vital status of a client, there is a

Safe and Quality Nursing Care Commitment to Vincentian Excellence

46

need for a vital signs monitoring especially the temperature.

Assessment

Nursing Diagnosis

Planning

Intervention / Rationale

Theory / Implication

Core Competency

Core Values

Evaluation

Subjective: Ginpauntat ni doctor ang pagpabreastfeeding ko sa akon bata, as verbalized by the mother.

Interrupted breastfeeding r/t pregnanidi ol component of the breastmilk

After 4 hours of nursing interventions, the mother will be able to show understandding about the interruption of breastfeeding and will be able to give milk formula per

Independent: Educated the mother about the effects of breastmilk to the baby. Breast milk contains pregnanediol that interferes in the conversion of indirect bilirubin. Henderson viewed health as a quality of life and is very basic for a person to function fully. As a vital need, a person must eat and drink Virginia Hendersons 14 Basic Human Needs Health Education Social Commitment

Goal met. The mother gives an s 26 milk formula to the infant per demand and burped thereafter.

Objective: Breastmilk was shifted to milk

47

formula.

demand.

Educated the mother about the importance of supplemental feeding for the baby. During the first six months of life, milk is the primary source of nutrients of the baby. They are given no other than but milk.

adequately to achieve optimum level of wellness. Health Education Social Commitment

Encouraged to give supplemental feeding per demand. Supplemental feeding is necessary for the infant as a source of nutrients since 48 Health Education Co responsibility

breast milk is contraindicated.

Assessment

Nursing Diagnosis

Planning

Intervention / Rationale

Theory / Implication

Core Competency

Core Values

Evaluation

Objectives: (+) Intensive phototherapy for 7 days Frequent removal of the eye patches Skin appearin g light to bright yellow.

Risk for corneal irritation and skin breakdown related to prolonged used of phototherap y

To prevent acquiring of corneal irritation and skin breakdown within the shift.

Independent: Maintained and monitored babys eye patches while under phototherapy. Protects retina from damage due to high intensity light. Dorothea Orems Self Care Deficit Theory Dorothea Orem stated that the clients must perform self care activities in order to live independently and to maintain a healthy life Provided minimal coverage of the body except for genitals and eyes. Provides maximal development. However, as health care provider, nursing is helping clients to establish or identify ways to Safe and Quality Nursing Care Commitment to Vincentian Excellence Safe and Quality Nursing Care Commitment to Vincentian Excellence

Goal met. Able to free from injury as evidenced by infants eyes are free from corneal irritation and skin breakdown.

49

(+) Icteric sclera

exposure and shielded the sensitive parts such as the eyes and genitals.

perform self care activities.

Safe and Repositioned baby every 2 hours. To promote equal distribution of phototherapy exposure. Quality Nursing Care

Commitment to Vincentian Excellence

Faye Glenn Instructed mother to remove baby from under phototherapy and remove eye patches during Abdellahs TwentyOne Problems One of her Typology of Twenty-One 50 Health Education Social Commitment

feeding. Provides visual stimulation and facilitates attachment behaviors.

Nursing Problems is to promote the development of productive interpersonal relationships.

51

DIISCHARGE PLANNING
Medication
Advise the family of the client to continue the medication as prescribed by the physician. Cefixime {Ultraxime} 25mg/ml 0.7 ml BID x 1 wk E zinc drops .3 mL OD Clusivol drops .3 mL OD to start at 2 weeks old Ursofalk 250mg/cap 1 cap paper tabs to consume stocks. Emphasize to the folks about compliance and strict adherence to dosage and the time of intake of the medicines to attain the desired therapeutic effects. Explain the medications how they work, there side effects, and precautions. Instruct the family of the patient not to alter doses of medications and emphasize the importance of continuous medication.

Exercise
Instruct the mother to massage babys lower extremities and turn side to side. Educate the mother that exercise for babies, especially in the newborn period, consists solely of feeding. Educate the mother that during those first few weeks when the baby is too young for rigorous exercise, they can still begin demonstrating healthy habits by participating in the following activities together: Take your baby for a walk in the stroller. Put your baby on the floor beside you and practice stretching. Play, talk, and cuddle with your baby regularly. Carry baby in a sling or carrier while exercising.

Treatment
Emphasized to parents the importance of regular follow-up check-ups and as instructed by physician. Instruct the mother to clean the umbilical cord with 70% isopropyl alcohol every change of diaper. Make sure that the cord is kept clean and dry.

Home Teaching
Advised parents to expose the patient to sunlight around 6:00am-8:00am. Teach parents of the patient the importance of hand washing to avoid the spread of infection. Emphasize to folks about proper hygiene for baby. Advised to have a clean, quiet, well ventilated room conducive to rest and relaxation. Emphasize the need for compliance and cooperation of the mother in helping treat the infant. Encourage the breastfeeding to help the baby gain resistance and protection from diseases in the future. 52

Emphasize that the baby is on a trust vs mistrust stage; the needs must be met for a healthy emotional development.

Out Patient
Instruct the mother to return to their attending physician for scheduled follow up visit. Inform the mother regarding future check-ups and treatment and the importance of compliance to the scheduled procedures to maintain and monitor the clients health Advise family to report to the physician if any recurrence or severity of symptoms, any adverse effects to the medication, and any development of complications. Remind the mother that baby boy V.I.C is for hearing test under Dr. J.V.

Diet
Encourage the mother to breastfeed the baby up to 2 years. An increase in feeding will help a faster gain in the weight of the baby.

Spirituality
Remind the parents the importance of baptism and marriage. Encourage the family to strengthen their faith to Almighty Father and to hear mass every Sunday. Encourage the mother to always seek a spiritual advice.

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JOURNEY
At first its like weve been thrown into an unknown vast universe and everyone seems alien to one another. But just like any stories, theres just things that doesnt end from where they were, because we believe that fate or destiny whatever you may call it led us to a path where we would all collide. Not only in a mere sense of finding a companion to be with, nor flaunting a strong or superficial personality, but weve had been bumped to each other for a profound purpose. We dont know what exactly that purpose is just yet, but maybe its a quest that we have to find out to ourselves. Stranger we may seem to each other at the start. But as days, situations, circumstances and confrontations had passed by we became classmates, friends, best friends, team and a group. We had our shortcomings and misunderstandings but we consider those as spices of our student life, it wouldve been a boring life if everything is perfect, sometimes we need a little drama to add excitement in our student life and in fact it helped us a lot to become the persons who we are now. Whatever it is that had been said and done are already part of our past, it made us strong, affective, mature and a rational person. Its difficult to describe the journey of BSN 4B. Its like putting a giraffe in a small box. Although were known for being clamorous and boisterous over random things, still we manage to do it gracefully. Theres been countless times that our unity as a group has been challenged, be it on a light or heavy matter. But at the end of the day, after a little fussy commotion we are able to keep up to it harmoniously. This journey has been a physically, spiritually, mentally and emotionally roller-coaster ride. However, the best part of this is that we have the option if we prefer to root out or develop the things that has been imparted and gained. Moving on to the attitudes well, we bet that youll never get enough of us since weve got the best of both worlds, we can be enigmatically expressive, responsible juvenile and humorously serious at the same time. I know its crazy, but thats how it is. Maybe the reason why we get along with each other is because most of us have a shallow level of happiness which is great because we easily laugh at random things even the lamest jokes of our classmates. This may be our last journey for this year and the reason why its been worthwhile is because of the persons weve been with, they are at the beginning strangers that turned out to be our best of friends who are fearless enough to sprinkle some drama, gave big splashes of love, roll some compliment and throw a big bolt of fun! And were overwhelmingly ambiguous to what may happen to the next chapter.

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ACKNOWLEDGEMENT

A Students Gratitude
Words are never enough, To express how much we thank you. For guiding us, when times are rough And for sharing some laughter too. For teaching us what we need to know, For the values instilled that we have to grow. For always reaching out a helping hand For your patience in lecturing until we understand For motivating us to give our best in everything, For giving us confidence to face whatever life may bring, For leading us in the vocation we aspire And most of all for being there to inspire. We feel lucky, we feel blessed, It is because of you weve become our best. Where we are now and wherever we may be, We owe to you, our mentors gratefully. You enlighten our way when we are lost, And in our success, you are the cause You opened up our hearts and minds, And theres no one compared to you we could ever find.

55

BIBLIOGRAPHY
BOOKS: Mosbys Pocket Dictionary of Medicine, Nursing and Health Professions, 5th Edition Nurses Pocket Guide; Diagnosis, Prioritized Interventions and Rationales, 11th Edition Springhouse Nurses Drug Guide, 2007 Theoretical Foundations of Nursing: The Philippine Perspective

INTERNET: http://www.scribd.com/doc/2761875/NurseReviewOrg-Hyperbilirubinemia http://www.scribd.com/doc/36925627/hyperbilirubinemia http://www.fi.edu/learn/heart/blood/red.html

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