NURSING CARE REPORT BABY OF Mrs. I WITH MEDICAL DIAGNOSISHYPERBILIRUBINEMIA IN TERATAI WARD (BABY’S WARD)

BANJARMASIN ULIN GENERAL HOSPITAL

By:HJ. MINA HAYATI

SRN. 011017 D3 KI

BANJARMASIN MUHAMMADIYAH HEALTH COLLEGEINTERNATIONAL OF NURSING DIPLOMA PROGRAM

2014

BACKGROUND

• According to data Demographic Survey and Indonesian Healthy (2012), the infant mortality ≥ 34 / 1,000 live births which 19 / 1.000 occurred in the neonatal period from birth until the age of 28 days.

• According to medical record data in Banjarmasin Ulin General Hospital on January 2013 until February 2014, the amount of baby with hyperbilirubinemia in all units is 417 / 938 infant live births.

DEFINITION

According to Maryunani and Nurhayati (2009), hyperbilirubin is a condition in newborn which the total serum bilirubin > 10 mg% at full term infants

and > 15 mg% in preterm infants, resulting jaundice of the skin, sclera, mucous, and urine.

ETIOLOGY

• Destruction of red blood cells (hemolytic)• Impaired of bilirubin metabolism• Impaired of bilirubin excretion

PATHOPHYSIOLOGY

Heme

Hemoglobin

Globin

FecoBiliverdin

Risk for Injury

Icterus on the sclera, neck, and body, Increased bilirubin total > 10mg/dl

Increased erythrocytes destruction (impaired of bilirubin conjugation / impaired bilirubin transport / increased enterohepatic cycle) abnormal Hb and erythrocytes

Overload bilirubin broken

Liver unable to do conjugation

Increased bilirubin conjugated on the blood

Phototherspy Indication

Deficit fluid volume Temperature impaired

Risk damage of skin

integrity

SIGNS AND SYMPTOMS

• Skin Jaundice• Sclera icteric• Increased serum bilirubin levels > 10 mg% for the full

term infants and > 15 mg% for the preterm infants.• Loss weight to 5% for 24 hours caused by low of

calorie intake• Fever• Weak sucking reflexes or doesn’t want to drink milk• Seizures• Liver enlargement

COMPLICATIONS

According to Lyndon (2014), complications of hyperbilirubinemia are:•Kern icterus (biliary encephalopathy)•Lethargy•Seizures•Doesn’t want to suck •Increased muscle tone, stiff neck , epistonus, and cyanosis

NURSING CAREREPORT

CLIENT’S IDENTITY

Name : Baby of Mrs. ISex : MaleDate of Birth : Sunday / May 6th, 2014 at 01.50 pmDate of Assessment : Thursday / May 8th, 2014 Medical Diagnosis : Hyperbilirubinemia

Main ComplaintMrs. I said that her baby just wanted to drink a little and her baby’s body looked yellow.

PROBLEM PRIORITY

Risk for injury

Risk for deficit fluid volume

Damage skin integrity related to pigmentation changed (jaundice), radiation, erythema.

IMPLEMENTATION

Assessing the skin condition and recording any change of skin conditions such as rush, irritation, etc.

Changing the baby's position every 3 hours.

Keeping the baby's skin always clean, not wet and giving baby oil.

Maintaining the crib always dry, clean, free from folds and changing immediately the sheet and baby’s diaper when wet or dirty.

1st DIAGNOSIS Damage skin integrity related to pigmentation changed (jaundice), radiation, erythema

Continue....

Assessing baby’s vital signs. Measuring the baby's body weight every

day. Maintaining baby’s intake like giving milk

repeatedly as baby’s needs with the syringe.

Measuring fluid intake-output. Assessing defecating and urinating

frequency. Monitoring signs of dehydration (mocus

membranes, skin turgor, and CRT). Giving appropriate fluids.

2nd DIAGNOSIS Risk for deficit fluid volume

Continue....

Assessing and recording skin color from head, sclera and body every shift.

Putting the baby under phototherapy light with distance ± 45 cm.

Letting the baby naked but protecting the babies eyes and genital during phototherapy.

Monitoring any complication like: hyperthermia, conjunctivitis, dehydration during phototherapy.

Colaborating to check value of bilirubin level.

3rd DIAGNOSISRisk for injury

EVALUATION

1st Nursing Diagnosis: Sunday / May 11th, 2014

S :•Mrs. I said that her baby’s yellow color looked reducedO :•The baby’s yellow skin looked reduced.•The baby’s skin looked moist, clean and there is not rush and irritation anymore.•Phototherapy was stopped at 09.30 pm because baby’s condition better and his jundice was reduced and then the baby was moved from photherapy box to the crib.A : The problem of damage skin integrity had been solved.P : Intervention was stopped

Damage skin integrity related to pigmentation

changed (jaundice), radiation, erythema.

2nd Nursing Diagnosis: Monday / May 12th, 2014

Risk factors:•Mrs. I said that her baby drinks breast milk.•Baby vital signs :•T : 36,8◦C•HR : 140 times/min•RR : 40 times/min•The baby looked active in the bed.•The baby’s skin turgor is < 2 second.•The baby skin and lips mocus looked moist.•The baby defecated 1 time in this morning.A : The problem of deficit body fluid volume had been solvedP : Intervention was stopped

Risk for deficit fluid

volume

3rd Nursing Diagnosis: Tuesday / May 13rd, 2014

Risk Factors:•Mrs. I said that her baby’s body yellow color had been reduced.•The baby’s skin and sclera jaundice looked reduced.•The baby looked dry in the sun by his mother at the morning during 30 hours at 08.30-09.00 a.m.•The baby looked wearing diaper and eye cover during drying under sunlight.A : The problem of risk for injury had been solvedP : Intervention was stopped

Risk for injury

CONCLUSION

Evaluation of nursing care given is good enough because all of nursing

diagnosis had been solved and client can go home

with the doctor’s permission.

Evaluation of nursing care given is good enough because all of nursing

diagnosis had been solved and client can go home

with the doctor’s permission.

Risk for injury

Risk for injuryDamage

skin integrity

Damage skin

integrityRisk for deficit

fluid volume

Risk for deficit fluid volume