The Care Provided for a Premature Infant and Their Family - Essay Example

NURSING CARE FOR NEONATAL JAUNDICE CRITICAL ANALYSIS INTRODUCTION This essay will critically analyze the nursing care provided to a neonate suffering from jaundice that the author will call as Baby John to comply with the Code of Conduct of the Nursing and Midwifery Council (2004) to use pseudonym in discussing patient’s information in literatures like this. The essay will objectively analyze the appropriateness of nursing interventions provided in the treatment of jaundice in neonates within the author’s 12 hour shift. Patient’s Profile and Relevant Medical Information Baby John is male. He was born at 33 weeks and five days, weighing 2.336 kg and delivered through an emergency caesarian section in cephalic presentation due to cord prolapsed. He was admitted to Neonatal Intensive Care Unit (NICU) due to pre-maturity, poor condition at birth requiring resuscitation, respiratory distress and presumed sepsis. A birth is considered premature if delivery time is three or more weeks early of the normal 40 weeks pregnancy; hence babies born closer to thirty-two weeks like Baby John will have problems on eating, breathing and warming themselves (WebMD, 2007). Infant respiratory syndrome that he experienced usually occurs in premature babies born earlier than 37 weeks requiring mechanical ventilation to avoid fatality (Professional Guide to Diseases, 2007). He is presumed to suffer sepsis due to a rupture to his mother’s membranes at 30 weeks. Membranes contain amniotic fluid, commonly known as “water bag”, that protect babies in the uterus from outside contaminants; hence its rupture puts babies at risk from bacteria that enters the uterus through the mother’s vagina (Estad, 2006). Baby John arrived at NICU with a temperature of 36 degree Celsius and was noted to have a cut at the left gluteal area which was accidentally cut by the attending doctor during his delivery via caesarian section. He had positional talipes treated through massage and manual foot stretches. He had blood glucose of 1.8 millimoles per liter (mmol/L). Normal blood glucose level for babies within two hours old is 2mmol/L and below increasing to 3mmol/l within three days; hence babies with 2.5 mmol/.L glucose level must be provided treatment (Canadian Pediatric Society, 2004). Patient’s Medical Condition Baby John is diagnosed with hyperbilirubinemia which is an increased level of serum bilirubin (Porter & Dennis, 2002), an accumulated yellow pigment from the break down of hemoglobin (MedHelp, 2007) which is a common cause of jaundice among neonates. The increase in bilirubin is related to the increase in red blood cell breakdown and the inability of the immature liver to conjugate bilirubin which causes the infant’s skin to appear yellow within the first week of life. (Preud’ Homme, 2006). Baby John’s laboratory results showed a high serum bilirubin ratio. CAUSES OF NEONATAL JAUNDICE A baby with jaundice appears yellow starting from the head down to the feet. This symptom usually starts during the first 48 hours of life. Breaking down of red blood cells is the main cause of jaundice among neonates who are born with generous supply of red blood cells. Bilirubin is formed in the process of red blood cell breakdown which is transported to the liver for processing before eliminated from the neonate’s body. However, excessive production of bilirubin among neonates results to inability of their livers to process it for elimination from their bodies resulting to jaundice. (MFMER, 2007). Premature babies, like Baby John., are susceptible to jaundice since their livers are not fully developed unlike full term babies. Severe bruising, blood infection and incompatibility between mothers and neonates’ bloods are other factors that cause jaundice among neonates (MFMER, 2007). Production of more blood cells results from bruises during birth which consequently increases formation of bilirubin. An infection or sepsis in the baby’s blood further slows down the process of bilirubin resulting to higher risk of jaundice. Different blood types between mother and baby results to faster break down of higher amount of red blood cells for the latter when it receives antibodies from the placenta. These factors are present in Baby John particularly severe bruising since he had a cut at his left gluteal area during caesarian section delivery as well as presumed sepsis. ANALYSIS OF NURSING INTERVENTIONS The following are the nursing interventions provided to Baby John for treatment of jaundice and the author’s analysis. 1. Intravenous (IV) and Nasogastric (NGT) Feeding Intervention Baby John was put in an IV fluid commencing at 60 mls/kg per day which was added 30mls/kg/day increasing it to 180 mls/kg per day during fifth day. Fluid intake at day five was provided through bottle or NGT limited to two hourly feeds. He also started a low risk protocol feeding of 2mls/kg per day an hour of Nutriprem 2 via NGT while keeping intravenous fluids of 10% dextrose. The increase number of feeds for Baby John is necessary to increase elimination of waste to fasten excretion of bilirubin from his kidneys. Also, it is also beneficial for his hypothermic condition when he was brought to NICU. Dehydration or hypothermia slows down the ability of premature baby’s waste elimination which decreases the time that bilirubin exits from his body (Porth, 2006). Further, “at least 150 ml/kg per 24 hours’ (Rennei and Roberton, 2002, p. 427) should be administered to pre-term babies. Frequent feeds provided Baby John more calories resulting to more bowel movement; hence increasing the amount of bilirubin excreted from his stool or urine (MFMER, 2007). Also, neonate like Baby John who is undergoing both incubation and phototherapy require constant watch over the balance in his fluids since phototherapy can increase his loss of fluids either through sweats or urines to eliminate bilirubin; hence there is a need for an increase in oral and IV fluid (Rennie, 2002, p. 429). His fluids has been increased accordingly to about 30ml/kg/day and maintained on 180 ml/kg/day on the fifth day onwards. 2. Breastfeeding Intervention Baby John was offered breast milk during third day of nursing care. His mother started producing milk on the second day but did not want to breast feed him yet and just fed him milk through a bottle. Also, she started producing more milk only on fourth day of nursing care hence formula milk was mostly fed to him prior to that day. Breast feeding of Baby John is one effective intervention given the benefits of breast milk. Breast feeding can cause yellowing in the baby’s skin however the risk is far lower compared to its benefits. The complete nutrients of breast milk are crucial in the making premature babies gain weight rapidly hence the hesitance and inability of Baby John’s mother to breast fed him and produce breast milk right away is detrimental to his growth. Dehydration might result if breast feeding starts late among neonates which will directly result to increase in bilirubin level worsening jaundice (MFMER, 2007). Higher frequency of breast feeding in a day encourages neonates to increase bowel movement which releases bilirubin outside of his body system decreasing the occurrence of jaundice. American Academy of Pediatrics (AAP) recommends to provide at least eight breast feedings per day for preterm neonates, like Baby John., to prevent increase in hyperbilirubinemia or total serum bilirubin (TSB) levels (Paradigm Health, 2003). The delay in his breastfeeding contributed to the increase of his TSB levels resulting to jaundice. It should be noted that mothers who delivered through caesarian section normally experience delay in producing breast milk. AAP further said that routine water dextrose supplementation “will not prevent hyperbilirubinemia nor decrease TSB” (Paradigm Health, 2003, p. 28). 3. Intervention to Correct Hypoglycemia Baby John’s blood glucose is checked every four to six hours. A bolus of 10% dextrose was administered to him to correct hypoglycemia. This intervention is necessary to control his hypoglycemia as well as correct his hypothermic state. Administering bolus of 10% dextrose to Baby John is an “effective approach” (Hashim & Guillet, 2002) to correct his hypoglycemia. On the other hand, hypothermia is one of the risk factors for hypoglycemia (BRCP, 2003) since pre-term neonate’s utilization of glucose is higher than what is normally required; hence the amount of glycogen available in his body is not enough to meet such requirements resulting to hypoglycemia (McGowan, 2007). As discussed earlier, dehydration or hypothermia can lead to increase in bilirubin level in neonates that worsens jaundice. 4. Phototherapy Intervention Started overhead phototherapy light for Baby John as his bilirubin level increases above treatment line. His eyes were covered with a patch while being nursed through phototherapy to protect damage in his retina. Also, he is left to wear only his nappies to maximize exposure of his skin to the light. Phototherapy light was stopped after two of his blood results posted below treatment line. However, it was recommended again after his bilirubin level shoots up to about three squares above the treatment line during an evening blood test. Phototherapy is an effective intervention for lowering the level of bilirubin of Baby John which changes its form that can easily be eliminated from his kidneys (MFMER, 2007). Leaving him with only his nappies while in phototherapy is an effective approach since it is better to leave more skin exposed to phototherapy to effectively break down bilirubin for easy elimination (ACG, 2006). It is due to this action that Baby John’s SBR results were positive or below treatment line for two consecutive tests. However, stopping phototherapy after these tests worked against his treatment to recover from jaundice. The author believes that phototherapy should have been continued even after his blood results were positive given that the result was just one to two squares below treatment line which means that it is very likely that his bilirubin level will rise again. Continuing phototherapy could have arrest any further increase in his bilirubin level. As foreseen, Baby John’s bilirubin level shoots up again above treatment line after an evening blood test. Continuing phototherapy could not be harmful to baby John since it does not prevent him from being fed either through breast milk or formula milk; hence he can easily be removed from overhead phototherapy for feeding without disrupting his treatment (ACG, 2006). On the other hand, the author believes that combining the use of two phototherapy devices can help lower Baby John’s bilirubin level. Nursing care could have wrapped him in a bili blanket, which is another phototherapy device, while he is taken out of the overhead phototherapy for feeding. The combine use of these two types of phototherapy devices “can reduce bilirubin level by more than 40% in 24 hours” (Rennie, p 428, 2002). Also, there are generally no significant risks involved in phototherapy (Porth, 2007). Baby John’s eyes were covered with a patch to protect his retina from the light. Also, increase fluid feeds provided to him is effective intervention while he is in phototherapy to prevent dehydration or hypothermia (Porth, 2007). 5. Nursing in an Incubator Intervention Baby John was nursed in an incubator for four hours of life. Incubation of hypothermic pre-term infant with his weight is recommended at temperature of 33.8 to 34.6 degrees Celsius to stabilize his temperature (BCRC, 2003). Stabilizing his temperature is a necessary intervention to arrest his hypothermic condition which can worsen his jaundice. Also, energy consumption in preterm infant is lessened when he is in an incubator with a neutral temperature (Paradigm Health, 2003) which lessens level of blood glucose consumption. This is important to for Baby John who had history of hypoglycemia and hypothermia are birth which are both crucial risk factors contributing to his condition of jaundice; hence being in an incubator is an effective intervention to support his treatment. 6. Intervention of Antibiotic to Treat Sepsis Baby John was provided antibiotics due to presumed sepsis until blood culture posted negative. The treatment of sepsis through antibiotic intervention is appropriate and directly affects the ability of Baby M.G. to recover from jaundice since it may be it can be symptom of septicaemic illness (Johnston. P, Flodo, K. & Spinks, K. (2004). Infection is another factor that causes jaundice, hence treating it lowers the risk of increasing bilirubin level of Baby John. 7. Closely monitoring of Bilirubin levels Baby John’s bilirubin levels were closely monitored during the first 24 hours of his life which is a standard recommendation for pre term neonates who have jaundice. Also, since his medical profile at birth is highly at risk for increasing level of bilirubin like being born premature, with rupture in membrane, hypothermic and hypoglycemic. Thus, it is efficient nursing care to closely monitor his bilirubin levels. Also, monitoring the levels of his TSB led care providers to determine what appropriate nursing care or treatment should be provided to him such as phototherapy. 8. Nursing Baby into a Normal Cot After Incubation Baby John was nursed into a normal cot from an incubator as his temperature stabilized during the fourth day. He was in full feeds and had his IV discontinued. Also, he was cuddled by his father during the fifth day of nursing care. Infants that have been nursed through an incubator are traditionally transferred to open cots as their temperature normalizes implementing measure such as putting a warmer to maintain their body heat (Gray & Flennady, 2002). The author believes that the intervention of putting Baby John into a normal cot without a warmer after incubation is inappropriate. He is still premature and putting him in a cot warmer will help maintain his temperature. On the other hand, putting him in an open cot generally has been good for him in terms of social aspect since it encouraged bonding with his parents particularly his mother. It is emotionally traumatic for mothers to see their babies put in an incubator and then in phototherapy particularly for pre-term babies. It is found out that “maternal perceptions on their infants may influence infant development” (Gray, 2002); hence putting importance on the social aspect component of nursing of neonates in NICU through measures supporting bonding of neonates with their parents as well as providing parents appropriate and timely information regarding the progress of their neonates. Putting Baby John to a normal cot allowed his mother to nurse him regularly since it is more accessible compared to the time while he was in an incubator. Study by Swedish researchers states that “a father providing skin to skin contact with his newborn immediately after caesarian birth offers that same calming and comforting effect as a mother” (Gray, 2002) which makes the intervention to cuddle Baby John by his father effective. However, the author believes that parent contact should have started immediately after his delivery and even while he is in phototherapy; hence it is more socially supportive for him if a bili blanket was used so that even if his parents cuddles him away from overhead phototherapy he is still getting the benefits of phototherapy. CONCLUSION The nursing interventions for jaundice provided to Baby John are within the standard nursing process for preterm neonates with jaundice. However, the interventions should have been stretched further to ensure maintaining the level of his bilirubin below treatment line particularly the intervention of phototherapy. Also, bonding with his parents has been implemented late in his treatment which is against the recommendation of proven medical studies. RECOMMENDATION Given the above conclusions of the author, the following are his recommendations: 1. Complementing use of phototherapy devices such as over head phototherapy and bili blanket. This type of intervention would have dropped his bilirubin level significantly. This should be part of the routine in using phototherapy to treat jaundice for neonates while addressing their need to bond with their parents outside of the overhead phototherapy device. Further, the author recommends commencing this double phototherapy intervention regardless of how high is the level of bilirubin of a baby with jaundice as long as proper fluid management is observed for the neonate. 2. Additional 30ml/kg/day of extra fluid should be administered to compensate the fluid lost through the skin of Baby John or for other neonates with same medical condition. 3. Encourage bonding between mother and neonate by encouraging mother to do breast feeding or oral feeding to the neonate even if he is under phototherapy. The baby will still be in continuous therapy and bonding with his mother. 4. Also, encourage bonding between father and neonate by immediately allowing the father to hold the baby while he is being treated for hypothermia by using kangaroo cuddling. 5. Implement measures providing social support to parents of neonates under NICU to ease their emotional trauma and guide them to continue caring for their babies while being treated. Information provision related to the medical condition of the baby, the rationale behind treatment interventions provided as well as helping parents process whatever questions or doubts they have on these interventions to help ease their mind and assure them of the safety of their babies. REFERENCES 1. Canadian Pediatric Society (2004). Checking blood glucose in newborn babies. Retrieved on 10 October 2007 from http://www.caringforkids.cps.ca/babies/Glucose.htm . 2. WebMD (2007). Children’s Health: Premature Infant, An Overview. Retrieved on 12 October 2007 from http://children.webmd.com/tc/premature-infant-overview?page=1&2. 3. 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Retrieved on 29 October 2007 from website http://www.rcp.gov.bc.ca/guidelines/ThermoregulationJuly2003Final.pdf. 15. Clinical Management Guidelines (2003). Paradigm Health. 4th Edition. 16. Hashim, M.J. & Guillet, R. (2002). Common Issues in the Care of Sick Neonates. American Academy of Family Physician. Volume 66, No. 9. Retrieved on 25 October 2007 from website http://www.aafp.org/afp/20021101/1685.html 17. Johnston, P., Flodo, Kirstie & Spinks, K. (2004). The Newborn Child. 9th Edition. Churchill Livingstone. Retrieved on 29 October 2007 from website http://www.paradigmhealth.com/PDF/Guidelines/ParadigmHealth%20Neonatal%20Clinical%20Management%20Guidelines-%20Fourth%20Edition%20(Complete%20Edition).pdf 18. Gray, PH. & Flennady, V. (2002). Cot Nursing vs. Incubator Care for Preterm Infant. National Institute of Child Health and Human Development. Cochrane Neonatal Care Homepage. Retrieved on 30 October 2007 from website http://www.nichd.nih.gov/cochrane/Gray/Gray.htm Read More