Jumat, 24 Juni 2011

Nursing In Hiperbilirubin Clients

When the baby is still in the womb (still in the form of a fetus), then the task of removing bilirubin from the blood of fetuses carried by the placenta. Heart / liver of the fetus does not have to waste bilirubin. When the baby is born, then this task immediately taken over by a liver / her liver. Because his liver is not used to it, then do not be surprised if it turns out it can take weeks for adjustments. During the baby’s liver works hard to eliminate bilirubin from the blood, of course, the remaining amount of bilirubin will continue to accumulate in the body. Since bilirubin is yellow, so if there are huge numbers, he can “stain” the skin and other body tissues which is owned by your baby. Hyperbilirubinemia is an increase in bilirubin levels in infants. When the baby’s body to replace red blood cells and other body tissues with a new one, then the disposal of this process will usually be removed by the liver / liver. Bilirubin is one result of such disposal.

A. Basic Concepts

1. Definition
Physiologic jaundice is jaundice that arise on the day of the second and third with no pathological basis, levels do not exceed levels that jeopardize or have the potential to be “kernicterus” and does not cause any morbidity in infants. Pathological jaundice are having basic pathological jaundice or bilirubin levels reach a value called hiperbilirubin.

2. Bilirubin Metabolism
To get an adequate understanding of the problem of jaundice in neonates, to know a little about the metabolism of bilirubin in neonates. Bilirubin is a product that is toxic and must be issued by the body. Most of the bilirubin is derived from blood hemoglobin degradation and partly from the hem free or eritropoesis ineffective. Bilirubin formation was initiated by the oxidation process that produces biliverdin and several other substances. Biliverdin is reduced and this is a free bilirubin or bilirubin IX alpha. This substance is difficult to dissolve in water but soluble in fat, therefore had the difficult nature of the lipophilic and easily excreted through biological membranes such as the placenta and blood brain barrier. Free bilirubin is then fused with albumin and transported to the liver. In the hepatic uptake mechanism occurs, so that bilirubin is bound by the receptor liver cell membrane and into the liver cell. As soon as there is in the heart cells, occur persnyawaan with ligandin (protein-Y) Z protein and other liver glutathione which took him to the liver endoplasmic reticulum, where the process of conjugation. This procedure arise thanks to the glukotonil transferase enzyme which then produces the form of indirect bilirubin. Type of bilirubin is soluble in water and at certain levels can be excreted through the kidneys. Most of these conjugated bilirubin hepatikus dikeskresi through ducts into the digestive tract and subsequently became urobilinogen and come out with feces as sterkobilin. In the intestinal mucosa partially absorbed by the intestine and re-formed the enterohepatic absorption process.

Most of the neonates had elevated levels of indirect bilirubin in the first days of life. This happens because the presence of certain physiological processes in neonates. The process is partly due to high levels of neonatal erythrocytes, erythrocyte life span is shorter (80-90 days) and not yet mature liver function. Elevated bilirubin levels occurred at day 2-3 and reached a peak on days 5-7, then will drop back in the day to 10-14 bilirubin levels were generally not exceed 10 mg / dl in term infants and less than 12 mg / dl in infants less months. In this state of elevated bilirubin is still considered normal and therefore is called physiologic jaundice. Problems will arise if this is too much bilirubin production or decreased liver conjugation so that cumulation in the blood. Increased levels of bilirubin can cause excessive cell damage t3 body, eg brain cell damage that will result in residual symptoms on the day later.

3. Etiology
The cause of jaundice in newborns can stand alone or can be caused by several factors :
a. Excessive production
This baby exceeds its ability to remove it, eg an increase in hemolysis on blood inkompabilitas Rh, ABO, blood type other hand, deficiency of the enzyme G-6-AT, pyruvate kinase, enclosed hemorrhage and sepsis.

b. Disturbance processes “uptake” and hepatic conjugation
These disorders can be caused by immturitas liver, lack of substrates for conjugation of bilirubin, impaired liver function, due to acidosis, hypoxia and the absence of infection or glukoronil transferase enzyme (Criggler-Najjar syndrome) or other causes of Y protein deficiency in the liver which plays an important role in the “uptake “bilirubin into hepatic cells.

c. Impaired transport
Bilirubin in the blood bound to albumin was then appointed to the liver. Institute of bilirubin with albumin can be influenced by drugs such as salicylates, and sulfaforazole. Albumin deficiency causes more there is a free indirect bilirubin in the blood that is easy to attach to brain cells.

d. Disorders in the excretion
These disorders can occur due to obstruction in the liver or outside the liver. Abnormalities outside the liver usually caused by a congenital abnormality. Obstruction in the liver is usually from infections / liver damage by other causes.

4. Pathophysiology
Genesis is often found when there is the addition of bilirubin in streptucocus hepatic bebab too excessive. It can be found when there is increased destruction of erythrocytes, polycythemia, shortened erythrocyte age fetus / infant, increased bilirubin from other sources, or the presence of increased enterohepatic circulation. Impaired plasma bilirubin uptake occurs when the levels of protein and protein-Z-Y is bound by other anions, for example in infants with acidosis or with anoksia / hypoxia, determined disorder hepatic conjugation (glukuronii transferase enzyme deficiency) or excretion of infants suffering from disorders such as neonatal hepatitis patients or bile duct blockage intra / extra hepatic. In some degree, this bilirubin will be toxic and damaging brain tissue. Toxicity was mainly found in indirect bilirubin. Which allows the indirect nature of this pathological effect on brain cells when bilirubin was able to penetrate the blood brain barrier. Abnormalities that occur in the brain is called kernikterus or biliary encephalopathy. Easy least bilirubin through the blood brain barrier was not only depends on the high levels of bilirubin, but depends also on the state of their own neonates. Indirect bilirubin will easily through the blood brain barrier in infants if there are circumstances immaturity. Low birth weight, hypoxia, hypercarbia, hypoglycemia and central nervous system disorders due to trauma or infection.

5. Signs and Symptoms
- Skin looks bright yellow to orange (in infants with indirect bilirubin).
- Anemia
- Petekie
- Enlargement of the spleen and liver
- Bleeding closed
- Impaired breathing
- Impaired circulation
- Neurological disorders

6. Management
The main objective is to control for serum bilirubin levels did not reach the value that may cause kernikterus / biliary encephalopathy, as well as treating the direct cause of jaundice. Conjugated bilirubin can more quickly take place this can be done by stimulating the formation of glukuronil transferase with the administration of drugs such as luminal or Facebook. Giving substrate that can inhibit the metabolism of bilirubin (plasma or albumin), reducing the enterohepatic circulation (giving kolesteramin), light therapy or transfusion hikan, an act which also can control the rising levels of bilirubin. Cessation or review of radiation was also carried out if there side effects light therapy, among others: enteritis, hyperthermia, dehydration, skin disorders (rash tick bite), drinking problems, lethargy and irritability. Side effects are temporary and sometimes radiation can be continued while the accompanying state of repair.

7. Prognosis
New Hiperbilirubin will affect the form if indirect bilirubin have been through the brain barrier, patients may suffer kernikterus or biliary encephalopathy, the symptoms of encephalopathy in neonates may be very mild and only shows drinking problems, lethargy and hipotonia, then baby may spasm, spastic and found opistotonis. At the stadium might get a atitosis didan found opistotonis. At the stadium might get a atitosis ditai hearing loss or mental retardation later in the day.

B. Nursing

1. Nursing Assessment
a. Hospital chart
Chaos / hemolytic disorders (Rh or ABO incompabilitas), policitemia, infection, hematoma, bruising, hepatic or metabolic disorders, obstruction persists, a mother with diabetes.

b. Physical examination

- Yellow
- Pallor
- Urine concentrated
- Lethargy
- Decrease in muscle strength (hipotonia)
- Decrease sucking reflex
- Itching
- Tremor
- Convulsio (stomach cramps)
- Crying with high tone

c. Psychological examination
The effects of sick babies; restless, uncooperative / difficult co-operative, a foreign feeling.

d. Assessment of knowledge and the patient’s family

Causes and treatment, follow-up treatment, foster kinship with the other babies who suffer from jaundice, the level of education, lack of reading and lack of willingness to learn.
2. Nursing Diagnosis
1).The risk elevated levels of bilirubin in the blood associated with physiological conditions / pathological
Objectives / Criteria
No increase in hyperbilirubinemia
Action Plan
a.Monitor vital signs
b.Monitor serum bilirubin
c.Monitor if there is vomiting, muscle stiffness or tremor
d.Colaboration therapy with medical team
e.Give extra drink
f.Colaboration with the medical team for providing phototherapy

2). The risk of disruption associated with nutritional needs lazy suck
Objectives / Criteria
Nutritional needs are met
Action Plan
a.Berikan drinking through a sonde (expressed breast milk or PASI)
b.Lakukan oral hygiene and mouth with a wet cotton basting
c.Monitor intake and output
d.Monitor body weight per day
e.Observasi turgor and mucous membranes

3). Risks associated with changes in body temperature side effects phototherapy
Objectives / Criteria:
The body temperature remained normal
Action Plan:
a.Monitor vital signs every 4 hour
b.Aambient temperature and use of isolation
c.Give additional drinking

4). Risk of trauma-related visual sensory perception side effects phototherapy
Objectives / Criteria:
Not an interruption in the retina during development
Action Plan:
1.Kaji side effects of phototherapy
Baby 2.Letakkan 45 cm from the light source / lamp
3.Done phototherapy close your eyes and genitals with a material opaque
4.Monitor reflex eye with a flashlight when the baby is rested and state control eye every 8 hours
5.Close your eyes when given a drink or when not under the light
6.Observasi and note the use of lights

5. The risk of skin integrity disruption associated with side effects phototherapy
Objectives / Criteria:
During the baby’s skin care is not impaired skin integrity
Action Plan:
a.Observasi condition and color of skin integrity
b.Clean immediately if your baby defecate or urinate
c.Using lotion on the buttocks area
d.Keep loom is clean and dry
e.Overing lying and massage

6. Parental anxiety associated with lack of knowledge about the objectives, procedures for installing and side effects of phototherapy
Objectives / Criteria:
Parents understand the objectives, procedures and side effects of phototherapy
Action Plan:
1.Give counseling to parents about the goals, procedures and side effects of phototherapy
2.Give mental support
3.Colaboration parents in phototherapy procedure

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