Pediatric Nursing in Neonatal Jaundice

Introduction

In nursing, children and young people nurse (CYP) nurse belong to the branch of child nursing. They have the role to assess and plan nursing care for children and young people along with offer them care before and after surgical operation. Moreover, CYP nurses have the role to monitor young patient’s health and administer them medications for treatment (Reynolds et al., 2021). In this study, the role of the CYP nurse while caring for a baby in the Neonatal care who is suffering from jaundice is to be discussed. For this purpose, the assessment and planning of care made for the baby will be informed. The nursing diagnosis made by use of different techniques will be discussed. The nursing intervention made by the CYP nurse and its outcome for the baby will be explained.

Case Scenario

According to the NMC Code of Practice, no personal data or identity of the patient is to be revealed in public so that their confidentiality and privacy is maintained (NMC, 2018). Thus, to maintain confidentiality and privacy of the patient, the pseudonym B is to be used to indicate the baby. B is a 2 days old baby boy of Mrs T who presented yellowish discolouration of the body and eye within 1-day duration after his birth. B was delivered through normal vaginal birth at the 36th week of pregnancy. His body weight is 2.8 kg with APGAR 9 in 1 minute. His blood sugar level is more than 46mg which is monitored every 24 hours. The discolouration of the body with yellowish hint after first day of birth was primarily detected by the nurse when handing over the baby for breastfeeding to his mother.

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B was reported to be lethargic when his mother tried to wake him during feeds but expressed no difficulty in feeding or presence of fever and abnormal urine output. His bowel output was slightly pale than normal on the 3rd of the examination. The family history of the baby reports no members from the mother and father’s side has suffered neonatal jaundice. They family history also shows no records of haemolytic disorder as hereditary condition, anaemia or bile stones. The mother and father of the baby are both 34 years old and have enhanced access of family support with good financial condition. B was provided only BCG vaccination in the last 24 hours.

Assessment and Planning of Care

As a CYP nurse, the assessment and planning of care for B are to be made at the earliest to resolve his current hindered health issue of body discolouration leathery and pale bowel. The initial clinical decision made for B through physical examination is that the boy is suffering from jaundice. This is because the increased level of bilirubin in the blood which is a yellowish substance formed after the breakdown of the red blood cells travels to the digestive tract, liver and gall bladder. The bilirubin is tried to be moved from the liver to reach the kidneys to be excreted out. However, failure to leave the liver cells in neonates due to it increased production in the body compared to adults leads to the development of bilirubin in the blood as seen in the case of B which is symptom of jaundice (Mitra and Rennie, 2017). The nature of jaundice that has occurred to B may be regarded as physiological jaundice because such jaundice develops within 2-3 days from birth as seen in the case of B (NHS, 2018).

In order to develop detailed health examination of B, the ABCDE assessment model is been used. This is because ABCDE (Airway, Breathing, Circulation, Disability and Exposure) assessment model has the key purpose to identify and stabilise the health problem of the patient to avoid its spread to vital system. It is beneficial as it makes the patient avoid developing clinically worsen state and avoid the need for more complex treatment (resus.org.uk, 2019). According to ABCDE assessment, airway obstruction is emergency condition as it may led to deliver hindered amount of oxygen to the brain, heart, kidney and other organs. It would eventually hinder their ability to functional effectively and make them damaged in extreme condition that may be responsible for the death of the patient (resus.org.uk, 2019). The key symptoms of airway obstruction are neonates is laboured breathing, gagging, choking and others (Brits et al., 2018). Since B expressed none of the symptoms, thus airway obstruction assessment is not made.

In the study by Specq et al. (2016), it is mentioned that increased bilirubin in serum of the newborns is related to cause decline in the lung functioning of the individuals. This is because increased presence of bilirubin in the blood leads to support neurotoxicity due to which hindered breathing may be experienced. Thus, the breathing assessment of B is made by checking his oxygen saturation in the blood and counting the number of breaths per minute. This is because hindered breathing leads to lower the concentration of inspired oxygen in the blood (Tiwari et al., 2021). The oxygen saturation of B is 98% and he is breathing at the rate of 50 breaths/ minute. In neonates, the normal respiratory rate is between 30-60 breaths/minute and the normal oxygen saturation level is more than 95% (Moshiro et al., 2019). Thus, B indicates no issues with breathing due to jaundice.

In circulation assessment, the overall efficiency of the blood been carried through the vein and arteries are examined (resus.org.uk, 2019). The blood pressure of B examined through blood pressure monitor is 64/30 and his heart rate is 156 beats per minute. The normal blood pressure of neonates is 64/41 and the normal heart rate of neonatal is 100-200 beats per minutes (Vrancken et al., 2018). This indicates that B is suffering from low blood pressure, but his heart rate is normal. The disability assessment is made to determine patient’s conscious level and blood glucose level (resus.org.uk, 2019). The patient’s consciousness is checked through AVPU method which is alert, responding to Vocal stimuli, responding to painful stimuli with the help of Glasgow Coma Scale score (Tønsager et al., 2020). The score 3 in Glasgow Coma Scale indicates deep brain coma or unconsciousness and 15 indicate fully awake patient (Tønsager et al., 2020). Baby B scored 15 on the Glasgow Coma Scale which indicates that he is fully conscious. The exposure assessment is overall physical assessment of the exposed body (Tønsager et al., 2020). In case of B, the exposure assessment indicates that the baby has developed yellow coloration of skin over the entire body. The body temperature examined is 36.5℃ which is normal. Thus, the two key issues to be focused in care plan for B is lowering his bilirubin level to resolve jaundice and increase his blood pressure level.

Nursing Diagnosis

In neonates, the jaundice mainly appears 2-3 days within the birth and is prone to occur more in premature babies who are given birth before 37th week of pregnancy (NHS, 2019). The premature babies in the neonatal stage are prone to suffer from jaundice because of their immature liver which is not developed enough to support removal of bilirubin from the blood (Mojtahedi et al., 2018). In case of B, it is seen that he was given normal birth prematurely as he was delivered on 36th week of the pregnancy unexpectedly instead on the 38th week of pregnancy. Thus, his premature birth may have led his liver to remain underdeveloped which may have led to increased bilirubin level in the blood. In order to make nursing diagnosis for neonatal jaundice for B, the bilirubin level in the blood is examined through blood test. The bilirubin level in B is 18 mg/dL as identified on the second day. The normal indirect bilirubin level of the neonatal is within 13 mg/dL (Brits et al., 2018). Thus, it indicates that baby B has increased level of bilirubin in the blood which is indicative of jaundice.

One of the causes of neonatal jaundice is incompatibility in the blood group between the mother and the baby. It means that if the mother has blood type O whereas the newborn blood type A or B. This is because in such condition the immune system of reach in making antibodies against the red blood cells of the bay, in turn causing to destroy them to support increased bilirubin secretion (Abbas et al., 2020). Thus, during nursing diagnosis of B, the blood group of both the mother and B is checked which informed that both have O positive blood type, indicating the jaundice is caused mainly due to inefficiency of premature liver to move bilirubin to kidney to be excreted and not due to difference in blood group.

The nursing diagnosis for neonatal jaundice indicates that skin examination along with additional physical examination of the baby is to be made determine the extent of impact of jaundice on their health (Dharel and Bhattarai, 2017). As mentioned during the initial assessment, the bowel of B is found to pale in colour. The bowel in jaundice patient become pale in colour as increased amount of bilirubin stay in the bloodstream and is not excreted out through the bowel leading to its discolouration (Mitra and Rennie, 2017). Thus, physical examination of skin and bowel colouration does indicate the B is suffering from jaundice. The jaundice in neonates is to be treated because increased level of bilirubin in the blood may cause damage to the brain cells of the baby makes them feel less active and in rare condition may show seizures (NHS, 2018). The seizures may later lead the babies to develop mental retardation and cerebral palsy as worsen condition which are rare (Alfouwais et al., 2018). Thus, effective management of jaundice for B is to be made to support his enhanced health and well-being.

The study by Yu et al. (2019) mentioned that increased level of bilirubin in the serum during neonatal jaundice acts as contributor to increased antioxidant capacity in the blood. This leads to lower the blood pressure of the individuals by inhibiting and inactivating the reactive oxygen species synthesis in the vascular cells. Thus, the circulation efficiency of the neonatal baby B is determined. The health assessment of B indicated that he has low blood pressure which is to be managed. This is because low blood pressure in new-borns makes them be at risk of organ failure due to poor delivery of oxygen to the organs that leads them to terminate functioning effectively (Menon and Amanullah, 2017). Thus, the CYP nurse of B diagnosed that blood pressure is another factor to be considered in caring for B.

Care Goals

The two care goals are:

Manage jaundice of B by reducing his bilirubin level below 13 mg/dL

Normalise low blood pressure level from 30 to 41

Interventions

The key intervention for B made to manage his jaundice is phototherapy. The Phototherapy is the treatment made with the help of a specialised light where it light is focussed on the body of the infant to support photo-oxidation that helps in lowering raised bilirubin level in bloodstream (NICE, 2019). The neonates are to be placed naked apart from nappy under for the phototherapy and required to be nurse isolated for maintaining effective amount of thermal neural environment to support enhanced body temperature is maintained (Mreihil et al., 2018). The position of the phototherapy for neonatal jaundice is required to 30.5cm apart at the maximum for the patient to avoid any harm (Mreihil et al., 2018). This is because closer placement of the photo light may lead to cause overheating, water loss and others which would worsen the baby’s health condition (Mreihil et al., 2018). Thus, for B, the phototherapy been appropriately provided to ensure him to overcome jaundice and the nurse is to support in this context by ensuring the baby remain clean along with effective skin exposure as required in the process.

During phototherapy for neonatal jaundice, the eye of the neonates is to be covered because they may be damaged due to overexposure of the lights making the child develop hindered sight (Arnolda et al., 2018). Thus, B’s eyes are to be covered with the help of eye protector by nurses while providing phototherapy to avoid damage. The study by Blumovich et al. (2020) informed that phototherapy led to reduce the increased serum bilirubin by converting it into structural bilirubin photo isomers and photo-oxidation products that are able to be excreted out from the body with the requirement of biotransformation in the liver to the passed to the kidney for excretion. The type of phototherapy intervention to be made for B for resolving his neonatal jaundice is to be determined by the health professionals and the process is to be supported by CYP nurses by assisting the professionals in setting up the equipment. Moreover, the CYP nurses are required to monitor the serum bilirubin level of the infant before during and after the phototherapy to ensure their enhanced health.

The role of the children and young people (CYP) nurses in phototherapy is that they are to continuously monitor the hydration level of the baby that is their total urine output before and after the process (Slusher and Vaucher, 2020). This is because during phototherapy, there is risk of subclinical dehydration in infants out of increased exposure to light as such condition leads to evaporation of increased water from the blood (NICE, 2019). In addition, phototherapy may lead to hindered intake of breast milk by the infants which interfere with adequate urine output by the body (NICE, 2019). As argued by McDonagh and Lightner (2020), normal urine output for the infants are to be adequately maintained. This is because it indicates effective release of toxins from the body and enhanced hydration is maintained. The normal urine output for neonates is nearly 2 ml/kg/hour (NICE, 2019). The CYP nurse caring for B has the role to monitor and maintain normal urine output for B to ensure his well-being and good health.

The other of CYP nurse to be executed for B during phototherapy is ensuring adequate nutrition is provided to the infant to retain normal body weight and the body temperature remains normal (NICE, 2019). This is because babies are able to lose heat in rapid manner compared to the adults (NICE, 2019). Moreover, premature babies are found to lack enough fat in their body which also acts as hindrance for managing normal body temperature for them (NICE, 2019). The presence of hindered body temperature would led neonate face adversities towards health such as hypothermia and others (NICE, 2019). Thus, nurses caring for B during phototherapy are to monitor the body temperature of B at the interval of 1 hours to avoid any adversities to be controlled. Moreover, the CYP nurse caring for B is also responsible to ensure he is feed at proper intervals to ensure his nutrient content in the body remain normal that is essential for maintain healthy body weight. In managing low blood pressure of B, the nurses are to use pharmacotherapy. According to it, the dopamine is the common inotropic drug to be administered to premature babies to normalise their blood pressure to normal. This is because dopamine makes the heart muscles contract more intensely to raise the overall blood pressure to normal (Abiodun et al., 2018). The CYP nurse in administering dopamine to B is to be follow the prescribed dose mentioned by the health professional.

Evaluation of interventions

The evaluation of the impact of phototherapy on B for reducing his raised bilirubin level mentions that his hydration level, nutrition content in the body and temperature remain steady to normal before, during and after the process. At the end of first day of phototherapy, B’s serum bilirubin level was 17mg/dL which is lowered by 1 mg/dL as before the initiation of the process it was 18 mg/dL. The next day the serum bilirubin level in B is reduced to 15 mg/dL and by the third day it reached 12.6 mg/dL that is considered to be normal. This indicates that the phototherapy intervention was successful in reducing increased bilirubin level in B and helped to gradually overcome jaundice by the end of the 3rd day leading to the fulfilment of the goal as per timeline. The blood pressure level in B is also raised to 64/40 from 64/30 after the administration of dopamine. This indicates positive impact on controlling the blood pressure is achieved within the set timeline for the baby B.

The evaluation of the care intervention for B led to me reflect on my role as a CYP nurse is that I have enhanced knowledge regarding the way to communicate with the family members of the infants to avoid panic. This is evident as I was able to make Mrs T remain calm when jaundice was detected for B by mentioning the care to be provided and its impact along with efficiency to resolve the problem. Moreover, I also identified that I have enhanced efficiency in monitoring neonatal vitals as required for any intervention. This is evident as the health professional caring for B praised me regarding the way I kept health records of B through monitoring in each time interval and day as mentioned during and after his photography for jaundice. I also expressed enhanced role is understanding the way health history of patient is to be collected to support enhanced health analysis and identification of cause of the problem. However, the drawback faced was that I lacked enough efficiency in positioning the neonate in the phototherapy equipment in effective way. The information from the episode of care that can be transferred to other areas of practice regarding the way patient monitoring is to be made with accuracy. The other aspect which can be transferred is the way to make the patient and their family members remain clam and way to remain patient as a nurse in care during challenging situation.

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Conclusion

The above discussion mentions that B is a 2-day old baby who is expressing symptoms of yellowish skin with lethargy to breastfed. His mother and the nurse detected regarding his condition on the secondary while being changed for breastfeeding. The initiation assessment made through physical examination of B indicated that he is suffering from jaundice. The ABCED assessment used for health assessment of B to detect if the health condition has led to alteration in airway, breathing, circulation, disability and exposure in health. In case of B, it was seen that he has enhanced breathing capability and no disability but has high bilirubin (18mg/dL) and low blood pressure (64/30). The intervention such as phototherapy is used for overcoming neonatal jaundice and dopamine is administered to raise the blood pressure which resulted B to develop 12.6 mg/dL serum bilirubin level and 64/40 blood pressure level at the end of the care that indicate success of the intervention.

References

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Abiodun, M.T., Oluwafemi, R.O. and Badejoko, O., 2018. A randomized controlled trial of the impact of dopamine on outcome of asphyxiated neonates. Nigerian Journal of Paediatrics, 45(2), pp.86-90.

Alfouwais, N.M., Seada, L.S., Alahmadi, R.Y., Alassiri, A.A., Alenazi, A.A. and Aljuaeed, M.S., 2018. Assessment of knowledge, attitude and practice of Saudi parents towards neonatal jaundice (NNJ): A cross-sectional study. The Egyptian Journal of Hospital Medicine, 70(9), pp.1686-1694.

Arnolda, G., Chien, T.D., Hayen, A., Hoi, N.T.X., Maningas, K., Joe, P., Cavallin, F., Trevisanuto, D. and Moccia, L., 2018. A comparison of the effectiveness of three LED phototherapy machines, single-and double-sided, for treating neonatal jaundice in a low resource setting. PloS one, 13(10), p.e0205432.

Blumovich, A., Mangel, L., Yochpaz, S., Mandel, D. and Marom, R., 2020. Risk factors for readmission for phototherapy due to jaundice in healthy newborns: a retrospective, observational study. BMC pediatrics, 20, pp.1-6.

Brits, H., Adendorff, J., Huisamen, D., Beukes, D., Botha, K., Herbst, H. and Joubert, G., 2018. The prevalence of neonatal jaundice and risk factors in healthy term neonates at National District Hospital in Bloemfontein. African journal of primary health care & family medicine, 10(1), pp.1-6.

Brits, H., Adendorff, J., Huisamen, D., Beukes, D., Botha, K., Herbst, H. and Joubert, G., 2018. The prevalence of neonatal jaundice and risk factors in healthy term neonates at National District Hospital in Bloemfontein. African journal of primary health care & family medicine, 10(1), pp.1-6.

Dharel, D. and Bhattarai, A., 2017. Maternal perception about neonatal jaundice in eastern Nepal: a qualitative study. Health Prospect: Journal of Public Health, 16(1), pp.1-6.

McDonagh, A.F. and Lightner, D.A., 2020. Mechanism of phototherapy of neonatal jaundice. Regiospecific photoisomerization of bilirubins. In Optical Properties and Structure of Tetrapyrroles (pp. 297-310). de Gruyter.

Menon, S. and Amanullah, N., 2017. Maternal and neonatal determinants of neonatal jaundice–a case control study. Journal of Medical Science and clinical Research, 5(03), pp.19659-19665.

Mitra, S. and Rennie, J., 2017. Neonatal jaundice: aetiology, diagnosis and treatment. British Journal of Hospital Medicine, 78(12), pp.699-704.

Mojtahedi, S.Y., Izadi, A., Seirafi, G., Khedmat, L. and Tavakolizadeh, R., 2018. Risk factors associated with neonatal jaundice: a cross-sectional study from Iran. Open access Macedonian journal of medical sciences, 6(8), p.1387.

Moshiro, R., Mdoe, P. and Perlman, J.M., 2019. A global view of neonatal asphyxia and resuscitation. Frontiers in pediatrics, 7, p.489.

Mreihil, K., Benth, J.Š., Stensvold, H.J., Nakstad, B., Hansen, T.W.R., Norwegian NICU Phototherapy Study Group, Norwegian Neonatal Network, Scheck, O., Nordin, S., Prytz, A. and Hochnowski, K., 2018. Phototherapy is commonly used for neonatal jaundice but greater control is needed to avoid toxicity in the most vulnerable infants. Acta Paediatrica, 107(4), pp.611-619.

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resus.org.uk 2019, The ABCDE Approach, Available at: https://www.resus.org.uk/library/abcde-approach [Accessed on: 24 May 2021]

Reynolds, J., Sivaramakrishnan, A., Broe, R., Kingshott, R. and Elphick, H., 2021. Evaluating a nurse-led sleep support intervention to reduce melatonin prescribing in children and young people. Nursing children and young people, 33(3).pp.56-78.

Slusher, T.M. and Vaucher, Y.E., 2020. Management of neonatal jaundice in low-and middle-income countries. Paediatrics and international child health, 40(1), pp.7-10.

Specq, M.L., Bourgoin-Heck, M., Samson, N., Corbin, F., Gestreau, C., Richer, M., Kadhim, H. and Praud, J.P., 2016. Moderate hyperbilirubinemia alters neonatal cardiorespiratory control and induces inflammation in the nucleus tractus solitarius. Frontiers in physiology, 7, p.437.

Tiwari, M.S.S., Pothen, M.B. and Jain, P., 2021. Emergency Disaster Preparedness and Response: Role and challenges of Neonatal Nurse in Indian Hospitals. European Journal of Molecular & Clinical Medicine, 7(11), pp.6682-6691.

Tønsager, K., Krüger, A.J., Ringdal, K.G. and Rehn, M., 2020. Data quality of Glasgow Coma Scale and Systolic Blood Pressure in scientific studies involving physician‐staffed emergency medical services: Systematic review. Acta Anaesthesiologica Scandinavica, 64(7), pp.888-909.

Vrancken, S.L., van Heijst, A.F. and de Boode, W.P., 2018. Neonatal hemodynamics: from developmental physiology to comprehensive monitoring. Frontiers in pediatrics, 6, p.87.

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Appendices
Appendix 1
Care Plan
Care Plan of B
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