HIGH-RISK RELATED TO PHYSIOLOGIC FACTORW

1. HIGH-RISK RELATED TO PHYSIOLOGIC FACTORW Hyperbilirubinemia

2. Hyperbilirubinemia The term refers to an excessive level of accumulated bilirubin in the blood. Characterized by jaundice, or icterus, a yellowish discoloration of the skin, sclera, and nails. It is a common finding in the newborn and in most cases is relatively benign, but in extreme cases, it can indicate a pathologic state.

3. Pathophysiology Normally the body is able to maintain a balance between the destruction of RBC and the use or excretion of products Destruction of RBC= heme+ globin. Globin (protein) portion is used by the body. Heme portion is converted to unconjugated bilirubin: an insoluble substance bound to albumin. In the liver: the unconjugated bilirubin with the presence of the enzyme glucuronyl transferase is conjugated with glucuronic acid to produce a highly soluble substance, conjugated bilirubin. Which is then excreted into the bile. In the intestine , bacterial action reduces the conjugated bilirubin to urobilinogen, the pigment that gives stool its characteristic color. Most of reduced bilirubin is excreted through the feces; a small amount is eliminated in the urine

4. Pathophysiology When developmental limitation or a pathologic process interferes with this balance, bilirubin accumulates in the tissues to produce jaundice. Causes of Hyperbilirubinemia in the newborns: Physiologic factors (prematurity). Excess production of bilirubin (hemolytic disease, bruises). Disturbed capacity of the liver to secrete conjugated bilirubin (enzyme deficiency, bile duct obstruction). Combined overproduction and under secretion (sepsis). Some disease states (hypothyroidism)

5. Hyperbilirubinemia Types of Unconjugated Hyperbilirubinemia: table 9-4 p:286 Physiological jaundice. Breast-feeding associated jaundice (early onset). Breast milk jaundice( late onset). Hemolytic disease.

6. Diagnostic evaluation The degree of jaundice is determined by serum bilirubin measurements. (invasive method) Normal values of unconjugated bilirubin are 0.2 to 1.4 mg/dl. In newborn see table 9-5,p/: 289. Evaluation of jaundice depend on: Serum bilirubin level (TSB).. Timing of the appearance of clinical jaundice. Gestational age at birth. Age in days since birth. Family history including maternal Rh factor.

7. Diagnostic evaluation Evidence of hemolysis. Feeding method. Infant's physiologic status. The progression of serial serum bilirubin levels. Noninvasive monitoring of bilirubin: Transcutaneous bilirubinometry: via cutaneous reflectance measurements. Hour-specific serum bilirubin level (nomogram). Carbon monoxide indices in exhaled breath: monoxide is produced when RBCs are broken down and the use of a transcutaneous bilirubin meter.

8. Diagnostic evaluation Criteria's for pathologic jaundice Appearance of jaundice within 24 hours of birth. Persistent jaundice after 1(term neonate) or 2(preterm) weeks. Total serum bilirubin (TSB) levels12 to 13 mg/dl. Increase in serum bilirubin 5mg/dl/day. Direct bilirubin 105 to 2 mg/dl.

9. Complication A syndrome of sever brain damage resulting from the deposition of unconjugated bilirubin in brain cells called: Bilirubin encephalopathy: Kernicterus: the yellow staining of the brain cells. The damage occurs when the serum concentration reaches toxic levels, regardless of cause. Factors that enhance the development of bilirubin encephalopathy include: Metabolic acidosis. Lowered serum albumin levels. Intracranial infection as meningitis. Increase in blood pressure. Signs: CNS depression. or excitation .decrease activity, lethargy; irritability, hypotonia, and seizures. Later signs: cerebral palsy, mental retardation, deafness.

10. Therapeutic management The primary goals of treatments are: Prevent bilirubin encephalopathy. Reverse the hemolytic process. The main form of treatment involves: 1. the use of phototherapy. 2. Pharmacologic management with Phenobarbital has centered primarily on the infant with hemolytic disease. its action are to: Hepatic glucuronyl transferase synthesis __increase bilirubin conjugation and hepatic clearance of the pigment in the bile. Protein synthesis __increase albumin for more bilirubin binding sites. 3. Full term infant also benefit from early initiating of feeding and frequent breast-feeding: increased intestinal motility, decreasing enter hepatic shunting, establish normal bacterial flora in the bowel.

11. Therapeutic management Phototherapy Phototherapy: consists of the application of fluorescent light to the infant's exposed skin. Light promotes bilirubin excretion by alters the structure of bilirubin to a soluble form for easier excretion. The infant's skin must be fully exposed to an adequate amount of the light source. Best results occur within the first 24-48 hours of treatment. Prognosis: severe brain damage (bilirubin encephalopathy)

12. Nursing consideration Assessment: Observing the infant's skin color from head to toe and sclerae and mucus membranes in natural daylight Blood samples are also taken for the measurement of bilirubin in the laboratory. while blood is drawn, phototherapy lights are turned off. Family history. Type of delivery Method of feeding.

13. Nursing consideration Nursing diagnoses: Body temperature, risk for imbalanced related to use of phototherapy. Fluid volume, risk for deficient related to phototherapy. Family processes, interrupted, related to situational crisis, prolonged hospitalization of infant, or rehospitalization for therapy injury, risk for, related for phototherapy.

14. Nursing consideration Planning: the goals: Infant will receive appropriate therapy I needed to reduce serum bilirubin levels. Infant will experience no complications from therapy. Family will receive emotional support. Family will be prepared for home phototherapy (if prescribed).

15. Nursing consideration Implementation: NCP of the Newborn chapter 8. and NCP of the high-risk newbornp:277. Nursing care for infant under Phototherapy: Repositioned frequently to expose all body surface areas to the light. Frequent serum bilirubin levels every 4-12 hours are necessary. The infant's eyes are shielded by an opaque mask The infant's eyelids are closed before the mask is applied. On each nursing shift the eyes are checked Eye shield are removed during feeding. Temperature is closely monitored

16. Nursing consideration Accurate charting is important nursing responsibility and includes: Times that phototherapy is started and stopped. Proper shielding of the eyes. Type of fluorescent lamp. Number of lamps. Distance between surface of lamps and infant (should be no less than 18 inches. Use of phototherapy in combination with an incubator or open bassinet. Occurrence of side effects .as: loose, greenish stools, transient skin rashes, hyperthermia, increase metabolic rate, dehydration, electrolyte disturbances as hypocalcemia Oily lubricant or lotions are not used on the skin in order to prevent increased heat Additional fluid volume needed.