IDENTIFICATION DATA:

 Name of the baby: B/O Nalini Sahoo

 Registration no: 1608051447
 Father’s name: c/o sandip sahoo
 Mother’s name: Nalini Sahoo
 Bed no: photo therapy 2
 Name of the ward: NICU
 Chronological age: 06 days
 Developmental age: neonates
 Sex: Male.
 Informant: Mother
 Religion: Hindu.
 Address: Nayaghar, Bhubaneswar.
 Date of admission: 29/01/2019
 Diagnosis: Hyperbilirubinemia
 Date of discharge: 2/01/2019

CHIEF COMPLAIN:

 Yellowish discoloration of the skin.

 Icterus present.

HISTORY OF PRESENT ILLNESS:

Present medical history:

Neonates having yellow discoloration of the whole skin, nails and sclera.

History of past illness: nothing significant

Past medical history: Nothing significant

Maternal History-
Antenatal history: The age of the mother during pregnancy is 24years old. The baby is the 1st child
of the parents. The mother had a regular check up. She had received 2 doses of TT. During
pregnancy adequate weight gain is achieved. The mother received good diet and had taken Iron and
Folic acid tablets. She had not exposed to any radiation.

Natal History: The Baby was born by normal vaginal delivery. The child’s weight at birth
was 3kg. The child cried immediately after birth. There were no specific complication present.

Post natal history: the child passed urination and meconium within 12hours. No congenital
anomalies are present after birth.

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IMMUNIZATION HISTORY:
AGE NAME OF VACCINE VACCINE TAKEN REMARKS
At birth  OPV ‘O’ Dose  TAKEN No
 BCG  Taken complication
 Vitamin K
injection

DEVELOPMENTAL MILESTONE:

Book picture Patient picture

1. NEW BORN 1ST MONTH

FINE MOTOR: Follows only the mother’s face
and only follow bright light.
GROSS MOTORS: Head Lags
LANGUAGE: Cries Startles to noise Head lags.
SOCIAL SkILL: Turns head toward the sound.
Follows only face

FAMILY HISTORY:

Name of the Age Sex Education Occupation Relationship Remarks

Family Member with patient
Sandip Sahoo 29 Yrs M B.SC PASS SERVICE FATHER
Nalini Sahoo 24 Yrs F H.S.PASS House Wife Mother
Lata Sahoo 52 Yrs F House Wife Grand Asthma since
Mother last 6 yrs
B/O Nalini sahoo 6 days Boy - Patient Pathological
baby jaundice

Family Tree:

1st Generation

2nd Generation

Key point:

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 Male:

Female:

Dead:

Patient:

Socioeconomic Status:

The socioeconomic Status of the family is satisfactory. They are from joint Family. Father is a
service man. They have a good relationship with neighbour and relatives.

ASSESSMENT:

1. Vital Sign:
On Admission:-
Pulse Rate-100bts/min
Respiration Rate: 39 brs/min
Temp-98 degree F
2. Anthropometric Measurement:

SL NO PARAMETERS IN CHILD EXPECTED REMARKS

1 Weight 2.8kg 2.5-3.9 Kg Anthropometric
2 Length 48-53 cm 50 cm measurements
3 Head Circumference 33-37 cm 34 cm are appropriate
4 Chest Circumference 30-33cm 35cm as per age
PHYSICAL ASSESSMENT:

 Physical Assessment (Head to toe)

Head:
 Shape - oval, Moulding - little
 fontanels – Anterior (shape- Dimond) & ( Diameter- 2cm )
Posterior (shape- Tringle) & (diameter – 2cm )
 Birth Trauma- no , Forceps marks- no
 Caput succedaneum - little

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Hair:
 Colour- black, Texture- smooth, silky.
Face:
 Symmetry- symmetrical, Swelling – no.
 Abnormal Movement – no
 Color – yellowish
Ears:
 Position -normal, Size -normal, Shape- normal
 Cartilage formation- good , any discharge- no
 Other - no
Eyes:
 Position (slant, hypertelorism)- Symmetric, Discharge- no
 Redness - no, Colour of sclera- yellow
 Papillary reflex to light- active.
Nose:
 Patency- good , Flaring- no, Nasolabial folds- normal
 Discharge- no , Others- no:
 Lips- pink ,no cleft , Symmetrical facial movements- present
 Palate- normal, no cleft, tongue- no tie , Secretions- no
 Others- no
Skin:
 Colour- yellow, Texture- smooth , Lanugo- presnt.
 Vernix- present, Skin turgor- good, Milia- no
 Birth marks- no , Dehydrations- no
 Edema/Puffiness -no
 Nails –formed, yellow color nails
Neck:
 Webbing- no, Masses-no
 Range of motions- good
 Dryness- no, Others- no

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Chest:
 Shape - symmetric
 Chest movement- good,symmetric
 Respiratory rate- normal, Retraction/Grunting --no
 Apnea- no , Breath sounds- normal.
 Breast tissue- palpable, Capillary refill time- 2sec
 Others- normal
Cardiovascular:
 Heart rate- good, Unusual rhythm/murmurs --no
 Cyanosis (acrocyanosis) - no.
Abdomen:
 Distention-no
 Liver, Spleen: not Palpable
 Umbilicus : normal ,no sign of infection.
 Extremities & Back:
 Upper extremities (Digits, symmetry) symmetry,10digit
 Lower extremities (Digits, symmetry)symmetry,10 digit
 Barlow maneuver, Club foot- no
 Erb sign- no , Plantar creases- good
 Genetalia:
Male: testis descends in the scorturm. Prominent rugae and deep pigmentation.
Neurological Assessment:
Reflexes of neonate:
 Rooting reflex
 Sucking reflex
 Swallowing reflex
 Gagging reflex
 Glabelar reflex
 sneezing & coughing reflex
 doll’s eye reflex
 blinking reflex

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  moro reflex
Assessment of Gestational age:
 Via date - 37 weeks. Via ultrasound - 37 weeks.
 Via examination (using NBS ) - 37 weeks.
INITIAL ASSESSMENT :
New Ballard Score :
 Physical maturity.
 Neurologic criteria
Physical maturity.
 SOLE CREASE: Baby having deep crease over anterior one- third of sole or no deep crease.
The sole may be full of superficial creases.
 GENITALIA: in case of my baby testis are descended, prominent rugae and deep
pigmentation. .
 BREAST NODULES: breast nodules are fully developed. Size of breast nodules are- above
5mm.
 EAR: Ear cartilage are well developed. And recoil is present.
 HAIR: Black shiny hairs are present.
GROWTH & DEVELOPMENT ASSESSMENT

BOOK PICTURE PATIENT PICTURE

PHYSIOLOGICAL GROWTH VITAL SIGN
PULSE-110-150 B/MIN
RESP – 35+-10 B/MIN PR-100 BTS/Min
Breath through nose. Resp- 40brs/min
Blood pressure 80/50 & 20/10 mm Hg Temp- 980 F
PHYSICAL GROWTH
 Birth to 4 months ¾ kg weight gain
 Length increase about 3 cm/months
during 1st 3 months of age
 Head circumference about 2cm/months
during 1st 3 months of age
NEW BORN 1st MONTH :-
I. FINE MOTORS- Follows only the
mother’s face and only follow
bright light According to appropriate age child developed
II. GROSS MOTORS-Head leg his milestone
III. LANGUAGE-Cries startles to
noise

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 IV. SOCIAL SKILL-Follows only by
face
HYPERBILIRUBINEMIA

Definition:

The term hyperbilirubinemia refers to an excessive level of accumulated bilirubin in the

blood and is characterized by jaundice or icterus, a yellowish discoloration of the skin, sclera
and nails. Hyperbilirubinemia is a common finding in the newborn.

Incidence :

Approximately 60% of term and 80% of preterm babies develop jaundice in the first week of
life, and about 10% of breastfed babies are still jaundiced at 1 month.

Risk factors:

Risk factor of hyperbilirubinemia were –

 Blood group incompatibility
 G6PD deficiency
 Sepsis babies
 Male sex babies.

In case of my patient the baby developed hyperbilirubinemia within 30-72 hrs. That is
physiological jaundice.

PHYSIOLOGIC JAUNDICE (non-pathologic unconjugated hyperbilirubinemia):

Term Infants:
•50-60 % of all newborns are jaundiced in the first week of life.
•Total serum bilirubin peaks at age 3–5 d (later in Asian infants).
•Mean peak total serum bilirubin is 6 mg/dL (higher in Asian infants).

ETIOLOGY:

BOOK PICTURE PATIENT PICTURE

1. Increased lysis of RBCs (i.e., increased Decreased hepatic uptake and conjugation
hemoglobin release) of bilirubin.
•Isoimmunization (blood group
incompatibility: Rh, ABO and minor blood
groups)
•RBC enzyme defects (e.g., G6PD
deficiency, pyruvate kinase deficiency)
•RBC structural abnormalities (hereditary
spherocytosis, elliptocytosis)
•Infection (sepsis, urinary tract infections)
•Sequestered blood (e.g.,
cephalohematoma, bruising, intracranial

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 hemorrhage)

2 .Decreased hepatic uptake and

conjugation of bilirubin
•Immature glucuronyl transferase activity
in all newborns: term infants have 1% of
adult activity, preterm infants have 0.1%.
•Gilbert Syndrome
•Crigler Najjar Syndrome (Non-hemolytic
Unconjugated Hyperbilirubinemia):
inherited conjugation defect (very rare)
•Pyloric stenosis (mechanism is unknown)
•Hypothyroidism
•Infants of Diabetic Mothers (polycythemia
is also common)
•Breastmilk Jaundice (pregnanediol inhibits
glucuronyl transferase activity)
3. Increased enterohepatic reabsorption
•Breast feeding jaundice (due to
dehydration from inadequate milk supply)
•Bowel obstruction
•No enteric feedings

Pathophysiology:
From reticuloendothelial system bilirubin levels

Enters into the plasma to the liver

Billirubin bind tightly with albumin

Only billirubin is transferred across the cell membrane into the hepatocyte

Then billirubin is primarily bound with ligandin with in the cell and this binding
prevents its backflow into circulation

This intracellular billirubin transferred to smooth endoplasmic reticulum for

conjugation

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The conjugation added with uridine diphosphate glucurony transferase (UDPG-
T)

Produced monoglucuronide in first 48 hrs of life

Billirubin diglucorunide

Excreate through urine and stool

CLINICAL FEATURES:

BOOK PICTURE PATIENT PICTURE

 Phase one- 1st few days  Yellow discolraisation of the skin and
– Lethargy, hypotonia, poor sclera, nails
suck, high pitched cry  Inability to suck
 Phase two- end of 1st week  High pitched cry.
– Irritable, hypertonia,
retrocollis, opisthotonus
 Phase three- after 1st week
– Stupor, coma, shrill cry

 Yellow discolraisation of the skin and

sclera, nails

DIAGONSTIC FINDINGS:
BOOK PICTURE PATIENT PICTURE
 In case of my child serum bilirubin is
 Serum bilirubin, both direct and don on 8/08/2016
indirect , and total bilirubin.  Bilirubin direct- 0.2 mg/dl
 ABO and Rh blood grouping of ( 0.1-0.4)
mother as well as baby.  Bilirubin total- 14.0mg/dl
 Hemoglobin and peripheral smear. ( 0.2-1.2)
 Reticulocyte count.
 Coombs test of mother as well as
mother.
 Blood culture.
 Liver function test.
 G6PD enzyme studies.
 Non invasive monitoring for
measuring the level of bilirubin are-
 Ingram icterometer.
 Transcutaneous

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 bilirubinometer.
 End tibia cardon monoxide.

MANAGEMENT:-

BOOK PICTURE PATIENT PICTURE

1. Medical Management:
 PHOTOTHERAPY= In case of my child –
It consists of the application of Photo therapy is continued.
fluorescent light to the infant’s exposed
skin. Light promotes bilirubin excretion
by photoisomerization, which alerts the
structure of bilirubin to a soluble form
( lumirubin) for easier excretion.
 EXCHANGE BLOOD TRANSFUSION=
It is the reliable method to reduce
serum bilirubin in case of severe
bilirubinemia to prevent kernicterus
and correct anaemia.
 DRUG THERAPY IN NEONATAL
JAUNDICE=
In case of neonatal jaundice drug is less
effective. Some time few drugs are
used. These are-
 Phenobarbitone
 Cholestyramine.
 Metallopophyrins.

1. Supportive management:
 History collection
 Physical Examination
 Vital sign are checked
 To Take adequate breast milk in dietary
intake
 Proper Knowledge is given to the child’s
mother.
 Advice to give exclusive breast feeding.
COMPLICATIONS:-

BOOK PICTURE PATIENT PICTURE

 Bilirubin encephalopathy.
 Kernicterus Nothing Significant

Plan of care-
 Keep the baby warm.

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  Exclusive breastfeeding.
 Immunization taken as per schedule.
 Vitamin K injection 1gm IM given.
PREVENTION:
a) Pregnancy, labour, and delivery-
 Test all the pregnant women for ABO, Rh typing.
 Check the total bilirubin level.
 Umbilical cord blood test serum bilirubin, haemoglobin or haematocrit
measurements do not aid in the prediction of severe hyperbilirubinemia.
b) Breastfeeding-
 Encourage the mother to breastfeed their babies 8-12 times a day in the first
2-3 days of life.
 Encourage the ingestion of colostrums to increased stooling which prevent
reabsorption of bilirubin.
 Educate the parents regarding sign of adequate hydration.
PROGNOSIS

Early recognition and treatment of hyperbilirubinemia prevent unnecessary medical

therapies, parent infant separation, breast feeding disruption and possibly failure, and
severe brain damage.

NURSING DIAGNOSIS:-

 Impaired parent infant attachment related to disease condition

( neonatal hyperbilirubinemia) as evidenced by admitted in SNCU.
 Risk for deficient fluid volume related to phototherapy.
 Risk for impaired skin integrity related to the side effect of phototherapy.
 Interupted breast feeding related to the phototherapy as evidenced by mother’s
verbalization.
 Interrupted family process related to the hospitalization of the baby in SNCU as
evidenced by family member’s verbalization
 Knowledge deficit related to hyperbilirubinemia as evidenced by frequent
questioning about the eye shiled and the treatment also.
 Risk for decreased sensorineural stimulation related to the side effect of the
phototherapy

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 ASSESSMENT NURSING GOAL INTERVENTION Implementation EVALUATION
DIAGNOSIS
1)  To provide  Consistent care
SUB. DATA:- Impaired parent Parent infant consistent care to is provided to Parent infant
Mother says that infant attachment attachment develop sense of develop sense relation and
she does not stay
related to disease will be security. of security. attachment is
with her child due
to photo therapy condition ( neonatal improved  To provide  Information of improved.
procedure. hyperbilirubinemia) information of the the baby is
as evidenced by body to her provided to her
Obj. DATA:- I admitted in SNCU. parents. parents
observed that  To encourage the  Encouragement
Baby & Mothers
attachment not
mother to feed as is given to
properly much as possible mother to
maintained due to during her visit to continue
admission in SNCU the nursery feeding as much
 To minimize as possible.
isolation by touch
eye contact.

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2)
SUB. DATA:- Risk for deficient Normal fluid  To assess the fluid  Assessment is Risk for fluid
Mother says that fluid volume related volume level volume level by done. deficit is
baby can’t breast
to phototherapy. will be checking skin  The frequency, decreased.
feed from his
ownself. maintained tourgor. amount, colour
 To evaluate the of urine and
Obj. DATA:- frequency, stool are
I observed that amount, colour of evaluated.
baby totaly can’t
urine and stool  Intake and
breast feed.
 To maintain intake output chart is
and output chart. maintained.
 To encourage the  Mother is
mother to give encouraged to
breast feeding as give adequate
per body’s breast feeding.
demand

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ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION EVALUATION
DIAGNOSIS
3)  To assess the  Assessed the
SUB. DATA:- Risk for impaired Skin integrity skin condition. skin condition Risk for impaired
skin integrity will be  To observe  Frequent skin integrity is
related to the side maintained frequently for observation is reduced.
effect of prescence of done for any
phototherapy. any rashes, rashes ,
dryness and dryness of skin
excoriation. and
 To clean the excoriation
skin of the baby
with warm
water.
4) Interrupted breast Breastfeeding  To encourage the  Mother is
SUB DATA:- feeding related to will be mother to give encouraged to Effective breast
Mother says that breast feeding to give
the phototherapy as improved feeding is
her baby. breastfeeding to
she can’t breast evidenced by improved.
 To allow her her baby.
feed her child mother’s mother in the unit.  Mother is
properly. verbalization.  To advice her allowed in the
mother to hold her unit
Obj. DATA:- baby and give  Advice is given
I observed that feeding. regarding care
mother can’t chance  To remove the eye and
all the time for shield while breastfeeding.
breast feed to her feeding.  While feeding
child due to eye shield are
phototherapy. removed

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5)  All information
SUB DATA:- Interrupted family Normal family  To give all of the baby is Family member’s
Family members
process related to process will information of given to her anxiety level is
says that they are
worried about the the hospitalization be improved. the baby to her family. decreased to
baby’s of the baby in SNCU family members  Baby’s some extent.
hospitalization as evidenced by  To explain about prognosis is
family member’s baby’s explained to
Obj. DATA:- verbalization prognosis. her family.
I observed that
family members are
 To give  Psychological
very tensed about psychological support is
the baby’s support to her given.
hospitalization. family.
 To involve her
mother in the
care of her baby
if possible.

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  Assessed the
6) Knowledge deficit The level of  To assess the level of Now the parent’s
SUB. DATA:- related to knowledge level of knowledge are know
Mother asking hyperbilirubinemia will be knowledge regarding the something
various question
as evidenced by improved. regarding the treatment. regarding the
regarding
hyperbilirubinemia frequent treatment.  Proper treatment.
Obj. DATA:- questioning about  Proper information is
I observed that the eye shiled and information is given.
mother is various the treatment also. given  Psychological
qurious to know
 Psychological support is
about phototherapy
& about eye shiled
support is given. given.

16
7)
SUB DATA:- Risk for decreased  All precautions
sensorineural Risk for  To maintain all are Risk for
stimulation related decreased precautions maintained. decreased
to the side effect of sensorineural during  Eyes are sensorineural
the phototherapy stimulation phototherapy. protected with stimulation is
will be  To protect the eye shield. reduced
reduced. baby’s eye with  Testes are
eye shield. protected with
 To protect the gauze.
baby’s testes  Body
with gauze. temperature is
 To maintain maintained.
body  The distance
temperature. between
 To maintain the surface of
distance fluroscent
between lamp and
surface of infant
fluroscent lamp ismaintained.
and infant.

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HEALTH EDUCATION:-

 To advice the mother to give exclusive breastfeeding.

 To advice the mother always cover the eye and genitelia to prevent damage.
 Keep warm the baby always.

Prognosis:

Sl Characteristics 06/08/2016 07/08/2016 08/08/2016

No Day 1 Day 2 Day 3

1 Out Look Baby Look Child Look, Slide Child Look, Fresh
Restless, Irritate better

2 Physical  Skin and Same as before Better than before

Examination sclera are
yellowish in
color.
 Poor
sucking

Vital sign PR-100 bts/min PR-110 bts/Min PR-100 bts/Min

RR-44bss/min RR-48 bss/min RR-40bss/min
3 Temp-99 Deg F Temp-98 Deg F Temperature: 97 deg F

Medication Only supportive Same as before

management.
4 Phototherapy is Same as before
given

Investigation
5 Serum bilirubin No Serum bilirubin and
total and direct direct bilirubin is test

Summary

B/O Nalini sahoo, 6 days old baby diagnosed with hyperbilirubinemia admitted to this
hospital and undergone various phototherapy and investigation. Then at last child recovered
and discharged on 10/08/2016

Conclusion

I learned many things regarding hyperbilirubinemia. Now I can able to manage the child and
able to provide nursing care to the child.

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Bibliography

1) Dutta Parul : ‘Pediatric Nursing’;2nd Edition, New Delhi: Jaypee Brothers medical
publishers:2010
2) Lippincatt,’Manual Nursing Practice’,8th Edition, New Delhi: Jaypee Brothers medical
publishers;2007
3) R.Marlow;’Text Book of pediatric Nursing’,1st Edition;Philadelphia,Elsalvier
publication
4) Wong’s ; essentials of pediatric nursing, 8th edition; Noida: Elsevier publisher; 2009
5) www.medline.co.in

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 CASE STUDY
ON
NEONATAL JAUNDICE

Submitted to: Submitted by:

Mr. Sugumar.S Dakshina Sarkar

HOD, Pediatric Nursing, M.Sc nursing, 1st year

SUM Nursing College, SUM Nursing College,

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BBSR. BBSR.

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