Jumat, 06 Mei 2011
Definition:
Heperbilirubinemia are: increased concentrations of conjugated bilirubin was shown with jaundice ..
Etiology:
Some causes hiperbilirubin in infants BBL is:
1. Physiological factors / prematurity 2. Associated with breast milk 3. Increased production of bilirubin / hemolytic, 4. The inability to secrete bilirubin hepatic liver conjugata / deficiensi enzymes and bile duct obstruction 5. The mix of increased production and decreased excretion / sepsis 6. The presence penyalit / hipothiroidism, galaktosemia, infants with diabetic mothers. 7. Genetic predisposition to increase production.
Pathofisiologi:
Bilirubin is the breakdown products of hemoglobin derived from the destruction of red blood cells / RBCs. When RBCs damaged the right product into circulation, hemoglobin diimana broken into heme and globin.Gloobin {protein} digunaka back by the body while going diruah heme into bilirubin unkonjugata and binds to albumin.
In the liver bilirubin binding to plasma proteins and with the help of enzymes glukoronil konjugata transferase transformed into bilirubin which will ddikeluarkan through the bile duct into the intestinal tract. In the intestinal tract with the help of intestinal bacteria into urobilinogen and will ddirubah starcobilin that will give color to the faeces. Bilirubin will generally excreted through faeces in the form stakobilin and slightly through the urine in the form of urobilinogen.
Red Blood Cell
Hemoglobin
Globin heme
Iron unconjugated bilirubin
Action of acid Glucoronil glucoronil
transferase
Conjugated bilirubin
Glucoronil
Exkresi via faeces and urine
At BBL bbilirubin director can be converted into indirect bilirubin in the intestine because there are beta-glukoronidase which plays an important role to change. Bilirubin inddirek absorbed by the intestine and then go back to the liver.
The situation is influenced by a jaundice:
1. Production factors beyond yng excessive spending: the increased hemolytic 2. Impaired hepatic uptake and conjugation because imaturasi liver. 3. Impaired transport + albumin binding of bilirubin to the liver, causing more and more defiiensi albumin-free bilirubin ddalam easily pass the blood brain barrier causing kernicterus 4. Impaired hepatic excretion due to obstruction ddalam or outside the liver, due to congenital abnormalities / infection or liver damage due to other diseases.
Neonatal jaundice can be divided in two:
1. Physiological jaundice
Jaundice appeared on day 2 or 3, and looks jjelas disappeared on day 5-6 and day 10. Infants appear normal, good drink, BB ordinary ride. Aterm bilirubin levels in infants less than 12 mg / dl, the LBW 10 mg / dl, and will disappear on day 14.
Physiologic causes of jaundice such as due to lack of protein Y and, glukoronil transferase enzyme sufficient in number.
2. Pathological jaundice
a. Jaundice that appears within 24 hours of life, serum total bilirubin greater than 12 mg / dl.
b. Increased bilirubin 5 mg per cent or more in 24 hours
c. Serum bilirubin concentrations exceeded 10 mg / dl in premature infants or 12 mg / dl in infants aterm.
d. Jaundice that accompanied the process of hemolysis
e. Derek bilirubin more than mg / dl, or an increase in serum bilirubin mg / dl / h or 5 mg / dl / day.
f. Jaundice settled after 10-day-old baby in the baby aterm and 14 days in LBW.
Circumstances which are pathological jaundice mnyebabkan
1. Hemolytic disease 2. Abnormalities of red blood cells 3. Hemolysis: hematoma, polycythemia, bleeding due to trauma of the birth canal. 4. Infection 5. Metabolic disorders: hypoglycemia, galaktosemia 6. Drugs that replace bbilirubin bond with albumin, such as: sulfonaamida, salicylate, sodium bensoat, gentamicin, 7. Enterohepatic shunt is rising: the location of high intestinal obstruction, Hirschsprung, pylorus stenosis, meconium illeus.
Complication Kernicterus occurred namely brain damage due to adhesions indirect bilirubin in the brain with the clinical picture:
1. Lethargy / weakness 2. Convulsions 3. do not want to suck 4. elevated muscle tone, stiff neck and finally opistotonus 5. If the baby is alive at age further muscle spasm may occur, epistotonus, seizures 6. to deafness, speech disorders, mental retardation.
Nursing Assessment:
1. Head: visible jaundice
1. Eye: sclera visible jaundice, conjunctival anemis when pathological jaundice because hemmolisis. 2. Nose: no abnormalities 3. Mouth: mucosa of the mouth and lips look jaundice 4. Ear no deformity
2. Neck: visible jaundice, stiff neck and finally epistotonus in kernicterus.
3. Chest: symmetric, jaundice appears on the chest or not depending on the levels of bilirubin.
1. The lungs: Apne, cyanosis, dyspnea on kernikterus circumstances.Aspiksia and pulmonary effusi in hydrops fetalis 2. Cardiovascular: Edema general or reduced blood volume failed jjantung on condition of hydrops fetalis
4. Abdomen: visible jaundice, palpation sociable, distension -, can be found hepatospleno megali.
5. Kidneys: the color of dark urine with increasing concentrations of bilirubin.
6. Genitalia: there is no problem
7. Rectum: anal +,
8. Extremity: visible jaundice at all or only partially ektermitas, lethargy, muscle tone rising.
9. Backs: visible jaundice, no spinal deformity.
10. Neurology: hipotonia, tremors, moro and sucking reflexes absent, diminished tendon reflexes, seizures.
11. Endocrine: no interference with the endocrine system.
Investigations:
1. Serum bilirubin, indirect and indirect: increased bilirubin above 10 mg / dl in infants aterm or 12 mg / dl Padda LBW 2. Blood group of mother and baby, umbilical cord blood serology. 3. Hb and HCT: Hb less than 14 grams per cent and HCT less than 42 percent indicate a hemolytic process. Hb from the umbilical cord is less than 12 g / dl indication diperlukaannya exchange transfusion. 4. Total protein. 5. Blood leukocytes for monitoring the infection 6. BJ urine 7. comb test [indirect and director]
Nursing Diagnosis:
1. High risk of injury: MR, mortality b.d. increased levels of bilirubin 2. High risk of fluid volume deficiency b.d. phototerapi. 3. Damage to skin integrity b.d. effects of phototerapi. 4. The risk of disruption in body temperature regulation bd prototerapi effect 5. High risk of injury: side effects of treatment on life bd. exchange transfusion 6. High risk changing role of parents b.d. separation 7. Lack of knowledge about the condition of the dam child care at home.
Nursing care plan:
1. High risk of injury b.d. increased levels of bilirubin toxicity and complications related phototerapi.
Objective: Clients do not show symptoms of residual neurological complications phototerapi ddan continuing.
Criteria results:
Plan
Rational
1.Identifikasi presence of risk factors:
- Bruising
- Sepsis
- Delayed clamping Ord
- Mothers with DM
- Rh, ABO antagonist
- Pletora
- SGA
2.observasi BBL for the presence of hyperbilirubinemia 2-4 hours devoted the first five days of life
3.Notice and document the skin color of the head, sclera and jaundice body progressively on each shift
4. Monitor levels of bilirubin and collaboration when there are elevated levels
5.Monittor Hb, HCT ata a decrease
6.Monitor reticulocyte, when there is increased collaboration
7.phototerapi:
- According to protocol untu time, procedures, and duration.
- Monitor bilirubin levels devoted 6-12 hours under therapy
- Close your eyes with eye shield, avoid pressure on the nose
- Replace the bearing eyes at least 2 times sehhari
- Inspection of the eyes with his little lamp 8 hours once
- Maintain teraapi parenteral fluids for hydration medical kolabborasi
- Preserve the axial temperature 36.5 Celsius dderajat
8.exchange transfusion medical collaboration
- Monitoe vital signs during and after exchange transfusion
- Check in and out of blood
1.risk factors to guide nurses to be alert to the prospect of remaining one appearance of hyperbilirubinemia
2. BBL is very vulnerable to hyperbilirubinemia.
3.knowing the hiperbilirubinemi early so that remedial action can be done immediately.
4 Increased levels of bilirubin high pliers
5.presence decrease in Hb, HCT showed the presence of hemolytic
7. phototerapi function not decompose bilirubin with photoisomernya.During photooterapi to note the existence of complications such as: hipertermi, conjunctivitis, dehydration.
8. Exchange transfusion is done in case of hyperbilirubinemia due to the occurrence of pathological processes caused by excessive hemoliitik ABO antagonist.
2. High risk of fluid volume deficiency b.d. phototerapi.
Objective: Client tiidak menunjjukan signs of fluid volume deficiency
Plan Rational 1.maintanefluid intake:
- Weigh BB per day
- Measure the intake output
- Provide extra intakes orally or by IV if there is progressive loss of body weight, increased temperature, diarrhea, onsentrasi urine,
2.Output:
- Examine the number, the color of urine every 4 hours
- Review
- Excessive diarrhea
3.Kaji Hydration:
- Monitor body temperature every 4 hours
- Inspection and mucous membranes pontanel
1.Intake adequate fluid bilirubin metabolism will run perfectly and balance may occur with caairan photo that came out during therapy due to evaporation
2.Output excessive or unbalanced intake will cause interference with fluid balance.
3. Adequate hydration of body fluids show good keseimbangna indicated by body temperature 36-37 degrees Celsius and oral mucous membranes moist and fontaanela flat.
3. Damage to skin integrity b.d. effects of phototerapi.
Objective: The client does not show the integrity of skin disorders
1.Monitor damage skin integrity
2.baby's skin from the dirt after a bowel movement, bladder
3.neutral environmental temperature and axial temperature of 36.5 degrees Celsius
4.change position every 2 hours.
5. break after 24 hours phototerapi
1. Early detection of skin integrity kerusakjan
2. Faeces and urine that is acidic can irritate the skin
3. High temperatures cause dry skin so fragile skin
4. changes position to maintain adequate circulation and prevent excessive emphasis on one side
References:
1. Kathryn A. Melson, 1999, Maternal Infant Health Care Planning, second edition, Springhouse, Pennsylvania 2. Ngastiyah, 1997, Child Care Hospital, EGC, Jakarta. 3. Susan Martin Tucker, at al., 1999, Standard of Patient Care, Nursing Process, Diagnosis, and evaluation, EGC, Jakarta.
Nursing Diagnosis:
1. High risk of injury: MR, mortality b.d. increased levels of bilirubin 2. High risk of fluid volume deficiency b.d. phototerapi. 3. Damage to skin integrity b.d. effects of phototerapi. 4. The risk of disruption in body temperature regulation bd prototerapi effect
Nursing care plan:
1. High risk of injury b.d. increased levels of bilirubin toxicity and complications related phototerapi.
Objective: Clients do not show symptoms of residual neurological complications phototerapi ddan continuing.
Plan
Rational
9.Identifikasi presence of risk factors:
- Bruising
- Sepsis
- Delayed clamping Ord
- Mothers with DM
- Rh, ABO antagonist
- Pletora
- SGA
10. Assess the BBL for the presence of hyperbilirubinemia 2-4 hours devoted the first five days of life
11. Observe and document the skin color of the head, sclera and progressive body of jaundice every shift
12. Monitor levels of bilirubin and collaboration when there are elevated levels
13. Monittor Hb, HCT ata a decrease
14. Monitor reticulocyte, when there is increased collaboration
15. Give phototerapi:
- According to protocol untu time, procedures, and duration.
- Monitor bilirubin levels devoted 6-12 hours under therapy
- Close your eyes with eye shield, avoid pressure on the nose
- Replace the bearing eyes at least 2 times sehhari
- Inspection of the eyes with his little lamp 8 hours once
- Maintain teraapi parenteral fluids for hydration medical kolabborasi
- Preserve the axial temperature 36.5 Celsius dderajat
16. Perform exchange transfusion medical collaboration
- Monitoe vital signs during and after exchange transfusion
- Check in and out of blood
4.risk factors to guide nurses to be alert to the prospect of remaining one appearance of hyperbilirubinemia
2. BBL is very vulnerable to hyperbilirubinemia.
2.hiperbilirubinemi early so that remedial action can be done immediately.
3.high bilirubin levels pliers
5.decrease in Hb, HCT showed the presence of hemolytic
7. phototerapi function not decompose bilirubin with photoisomernya.During photooterapi to note the existence of complications such as: hipertermi, conjunctivitis, dehydration.
8. Exchange transfusion is done in case of hyperbilirubinemia due to the occurrence of pathological processes caused by excessive hemoliitik ABO antagonist.
2. High risk of fluid volume deficiency b.d. phototerapi.
Objective: Client tiidak menunjjukan signs of fluid volume deficiency
Plan
Rational
4.fluid intake:
- Weigh BB per day
- Measure the intake output
- Provide extra intakes orally or by IV if there is progressive loss of body weight, increased temperature, diarrhea, onsentrasi urine,
5.Output:
- Examine the number, the color of urine every 4 hours
- Review
- Excessive diarrhea
6.Kaji Hydration:
- Monitor body temperature every 4 hours
- Inspection and mucous membranes pontanel
2.Intake adequate fluid bilirubin metabolism will run perfectly and balance may occur with caairan photo that came out during therapy due to evaporation
2.Output excessive or unbalanced intake will cause interference with fluid balance.
3. Adequate hydration of body fluids show good keseimbangna indicated by body temperature 36-37 degrees Celsius and oral mucous membranes moist and fontaanela flat.
3. Damage to skin integrity b.d. effects of phototerapi.
Objective: The client does not show the integrity of skin disorders
6.Monitor damage skin integrity
7.baby's skin from the dirt after a bowel movement, bladder
8.neutral environmental temperature and axial temperature of 36.5 degrees Celsius
9.change position every 2 hours.
10. Give a break after 24 hours phototerapi
5. Early detection of skin integrity kerusakjan
6. Faeces and urine that is acidic can irritate the skin
7. High temperatures cause dry skin so fragile skin
8. position to maintain adequate circulation and prevent excessive emphasis on one side
Source :http://kumpulanmaterikeperawatan.blogspot.com
Heperbilirubinemia are: increased concentrations of conjugated bilirubin was shown with jaundice ..
Etiology:
Some causes hiperbilirubin in infants BBL is:
1. Physiological factors / prematurity 2. Associated with breast milk 3. Increased production of bilirubin / hemolytic, 4. The inability to secrete bilirubin hepatic liver conjugata / deficiensi enzymes and bile duct obstruction 5. The mix of increased production and decreased excretion / sepsis 6. The presence penyalit / hipothiroidism, galaktosemia, infants with diabetic mothers. 7. Genetic predisposition to increase production.
Pathofisiologi:
Bilirubin is the breakdown products of hemoglobin derived from the destruction of red blood cells / RBCs. When RBCs damaged the right product into circulation, hemoglobin diimana broken into heme and globin.Gloobin {protein} digunaka back by the body while going diruah heme into bilirubin unkonjugata and binds to albumin.
In the liver bilirubin binding to plasma proteins and with the help of enzymes glukoronil konjugata transferase transformed into bilirubin which will ddikeluarkan through the bile duct into the intestinal tract. In the intestinal tract with the help of intestinal bacteria into urobilinogen and will ddirubah starcobilin that will give color to the faeces. Bilirubin will generally excreted through faeces in the form stakobilin and slightly through the urine in the form of urobilinogen.
Red Blood Cell
Hemoglobin
Globin heme
Iron unconjugated bilirubin
Action of acid Glucoronil glucoronil
transferase
Conjugated bilirubin
Glucoronil
Exkresi via faeces and urine
At BBL bbilirubin director can be converted into indirect bilirubin in the intestine because there are beta-glukoronidase which plays an important role to change. Bilirubin inddirek absorbed by the intestine and then go back to the liver.
The situation is influenced by a jaundice:
1. Production factors beyond yng excessive spending: the increased hemolytic 2. Impaired hepatic uptake and conjugation because imaturasi liver. 3. Impaired transport + albumin binding of bilirubin to the liver, causing more and more defiiensi albumin-free bilirubin ddalam easily pass the blood brain barrier causing kernicterus 4. Impaired hepatic excretion due to obstruction ddalam or outside the liver, due to congenital abnormalities / infection or liver damage due to other diseases.
Neonatal jaundice can be divided in two:
1. Physiological jaundice
Jaundice appeared on day 2 or 3, and looks jjelas disappeared on day 5-6 and day 10. Infants appear normal, good drink, BB ordinary ride. Aterm bilirubin levels in infants less than 12 mg / dl, the LBW 10 mg / dl, and will disappear on day 14.
Physiologic causes of jaundice such as due to lack of protein Y and, glukoronil transferase enzyme sufficient in number.
2. Pathological jaundice
a. Jaundice that appears within 24 hours of life, serum total bilirubin greater than 12 mg / dl.
b. Increased bilirubin 5 mg per cent or more in 24 hours
c. Serum bilirubin concentrations exceeded 10 mg / dl in premature infants or 12 mg / dl in infants aterm.
d. Jaundice that accompanied the process of hemolysis
e. Derek bilirubin more than mg / dl, or an increase in serum bilirubin mg / dl / h or 5 mg / dl / day.
f. Jaundice settled after 10-day-old baby in the baby aterm and 14 days in LBW.
Circumstances which are pathological jaundice mnyebabkan
1. Hemolytic disease 2. Abnormalities of red blood cells 3. Hemolysis: hematoma, polycythemia, bleeding due to trauma of the birth canal. 4. Infection 5. Metabolic disorders: hypoglycemia, galaktosemia 6. Drugs that replace bbilirubin bond with albumin, such as: sulfonaamida, salicylate, sodium bensoat, gentamicin, 7. Enterohepatic shunt is rising: the location of high intestinal obstruction, Hirschsprung, pylorus stenosis, meconium illeus.
Complication Kernicterus occurred namely brain damage due to adhesions indirect bilirubin in the brain with the clinical picture:
1. Lethargy / weakness 2. Convulsions 3. do not want to suck 4. elevated muscle tone, stiff neck and finally opistotonus 5. If the baby is alive at age further muscle spasm may occur, epistotonus, seizures 6. to deafness, speech disorders, mental retardation.
Nursing Assessment:
1. Head: visible jaundice
1. Eye: sclera visible jaundice, conjunctival anemis when pathological jaundice because hemmolisis. 2. Nose: no abnormalities 3. Mouth: mucosa of the mouth and lips look jaundice 4. Ear no deformity
2. Neck: visible jaundice, stiff neck and finally epistotonus in kernicterus.
3. Chest: symmetric, jaundice appears on the chest or not depending on the levels of bilirubin.
1. The lungs: Apne, cyanosis, dyspnea on kernikterus circumstances.Aspiksia and pulmonary effusi in hydrops fetalis 2. Cardiovascular: Edema general or reduced blood volume failed jjantung on condition of hydrops fetalis
4. Abdomen: visible jaundice, palpation sociable, distension -, can be found hepatospleno megali.
5. Kidneys: the color of dark urine with increasing concentrations of bilirubin.
6. Genitalia: there is no problem
7. Rectum: anal +,
8. Extremity: visible jaundice at all or only partially ektermitas, lethargy, muscle tone rising.
9. Backs: visible jaundice, no spinal deformity.
10. Neurology: hipotonia, tremors, moro and sucking reflexes absent, diminished tendon reflexes, seizures.
11. Endocrine: no interference with the endocrine system.
Investigations:
1. Serum bilirubin, indirect and indirect: increased bilirubin above 10 mg / dl in infants aterm or 12 mg / dl Padda LBW 2. Blood group of mother and baby, umbilical cord blood serology. 3. Hb and HCT: Hb less than 14 grams per cent and HCT less than 42 percent indicate a hemolytic process. Hb from the umbilical cord is less than 12 g / dl indication diperlukaannya exchange transfusion. 4. Total protein. 5. Blood leukocytes for monitoring the infection 6. BJ urine 7. comb test [indirect and director]
Nursing Diagnosis:
1. High risk of injury: MR, mortality b.d. increased levels of bilirubin 2. High risk of fluid volume deficiency b.d. phototerapi. 3. Damage to skin integrity b.d. effects of phototerapi. 4. The risk of disruption in body temperature regulation bd prototerapi effect 5. High risk of injury: side effects of treatment on life bd. exchange transfusion 6. High risk changing role of parents b.d. separation 7. Lack of knowledge about the condition of the dam child care at home.
Nursing care plan:
1. High risk of injury b.d. increased levels of bilirubin toxicity and complications related phototerapi.
Objective: Clients do not show symptoms of residual neurological complications phototerapi ddan continuing.
Criteria results:
Plan
Rational
1.Identifikasi presence of risk factors:
- Bruising
- Sepsis
- Delayed clamping Ord
- Mothers with DM
- Rh, ABO antagonist
- Pletora
- SGA
2.observasi BBL for the presence of hyperbilirubinemia 2-4 hours devoted the first five days of life
3.Notice and document the skin color of the head, sclera and jaundice body progressively on each shift
4. Monitor levels of bilirubin and collaboration when there are elevated levels
5.Monittor Hb, HCT ata a decrease
6.Monitor reticulocyte, when there is increased collaboration
7.phototerapi:
- According to protocol untu time, procedures, and duration.
- Monitor bilirubin levels devoted 6-12 hours under therapy
- Close your eyes with eye shield, avoid pressure on the nose
- Replace the bearing eyes at least 2 times sehhari
- Inspection of the eyes with his little lamp 8 hours once
- Maintain teraapi parenteral fluids for hydration medical kolabborasi
- Preserve the axial temperature 36.5 Celsius dderajat
8.exchange transfusion medical collaboration
- Monitoe vital signs during and after exchange transfusion
- Check in and out of blood
1.risk factors to guide nurses to be alert to the prospect of remaining one appearance of hyperbilirubinemia
2. BBL is very vulnerable to hyperbilirubinemia.
3.knowing the hiperbilirubinemi early so that remedial action can be done immediately.
4 Increased levels of bilirubin high pliers
5.presence decrease in Hb, HCT showed the presence of hemolytic
7. phototerapi function not decompose bilirubin with photoisomernya.During photooterapi to note the existence of complications such as: hipertermi, conjunctivitis, dehydration.
8. Exchange transfusion is done in case of hyperbilirubinemia due to the occurrence of pathological processes caused by excessive hemoliitik ABO antagonist.
2. High risk of fluid volume deficiency b.d. phototerapi.
Objective: Client tiidak menunjjukan signs of fluid volume deficiency
Plan Rational 1.maintanefluid intake:
- Weigh BB per day
- Measure the intake output
- Provide extra intakes orally or by IV if there is progressive loss of body weight, increased temperature, diarrhea, onsentrasi urine,
2.Output:
- Examine the number, the color of urine every 4 hours
- Review
- Excessive diarrhea
3.Kaji Hydration:
- Monitor body temperature every 4 hours
- Inspection and mucous membranes pontanel
1.Intake adequate fluid bilirubin metabolism will run perfectly and balance may occur with caairan photo that came out during therapy due to evaporation
2.Output excessive or unbalanced intake will cause interference with fluid balance.
3. Adequate hydration of body fluids show good keseimbangna indicated by body temperature 36-37 degrees Celsius and oral mucous membranes moist and fontaanela flat.
3. Damage to skin integrity b.d. effects of phototerapi.
Objective: The client does not show the integrity of skin disorders
1.Monitor damage skin integrity
2.baby's skin from the dirt after a bowel movement, bladder
3.neutral environmental temperature and axial temperature of 36.5 degrees Celsius
4.change position every 2 hours.
5. break after 24 hours phototerapi
1. Early detection of skin integrity kerusakjan
2. Faeces and urine that is acidic can irritate the skin
3. High temperatures cause dry skin so fragile skin
4. changes position to maintain adequate circulation and prevent excessive emphasis on one side
References:
1. Kathryn A. Melson, 1999, Maternal Infant Health Care Planning, second edition, Springhouse, Pennsylvania 2. Ngastiyah, 1997, Child Care Hospital, EGC, Jakarta. 3. Susan Martin Tucker, at al., 1999, Standard of Patient Care, Nursing Process, Diagnosis, and evaluation, EGC, Jakarta.
Nursing Diagnosis:
1. High risk of injury: MR, mortality b.d. increased levels of bilirubin 2. High risk of fluid volume deficiency b.d. phototerapi. 3. Damage to skin integrity b.d. effects of phototerapi. 4. The risk of disruption in body temperature regulation bd prototerapi effect
Nursing care plan:
1. High risk of injury b.d. increased levels of bilirubin toxicity and complications related phototerapi.
Objective: Clients do not show symptoms of residual neurological complications phototerapi ddan continuing.
Plan
Rational
9.Identifikasi presence of risk factors:
- Bruising
- Sepsis
- Delayed clamping Ord
- Mothers with DM
- Rh, ABO antagonist
- Pletora
- SGA
10. Assess the BBL for the presence of hyperbilirubinemia 2-4 hours devoted the first five days of life
11. Observe and document the skin color of the head, sclera and progressive body of jaundice every shift
12. Monitor levels of bilirubin and collaboration when there are elevated levels
13. Monittor Hb, HCT ata a decrease
14. Monitor reticulocyte, when there is increased collaboration
15. Give phototerapi:
- According to protocol untu time, procedures, and duration.
- Monitor bilirubin levels devoted 6-12 hours under therapy
- Close your eyes with eye shield, avoid pressure on the nose
- Replace the bearing eyes at least 2 times sehhari
- Inspection of the eyes with his little lamp 8 hours once
- Maintain teraapi parenteral fluids for hydration medical kolabborasi
- Preserve the axial temperature 36.5 Celsius dderajat
16. Perform exchange transfusion medical collaboration
- Monitoe vital signs during and after exchange transfusion
- Check in and out of blood
4.risk factors to guide nurses to be alert to the prospect of remaining one appearance of hyperbilirubinemia
2. BBL is very vulnerable to hyperbilirubinemia.
2.hiperbilirubinemi early so that remedial action can be done immediately.
3.high bilirubin levels pliers
5.decrease in Hb, HCT showed the presence of hemolytic
7. phototerapi function not decompose bilirubin with photoisomernya.During photooterapi to note the existence of complications such as: hipertermi, conjunctivitis, dehydration.
8. Exchange transfusion is done in case of hyperbilirubinemia due to the occurrence of pathological processes caused by excessive hemoliitik ABO antagonist.
2. High risk of fluid volume deficiency b.d. phototerapi.
Objective: Client tiidak menunjjukan signs of fluid volume deficiency
Plan
Rational
4.fluid intake:
- Weigh BB per day
- Measure the intake output
- Provide extra intakes orally or by IV if there is progressive loss of body weight, increased temperature, diarrhea, onsentrasi urine,
5.Output:
- Examine the number, the color of urine every 4 hours
- Review
- Excessive diarrhea
6.Kaji Hydration:
- Monitor body temperature every 4 hours
- Inspection and mucous membranes pontanel
2.Intake adequate fluid bilirubin metabolism will run perfectly and balance may occur with caairan photo that came out during therapy due to evaporation
2.Output excessive or unbalanced intake will cause interference with fluid balance.
3. Adequate hydration of body fluids show good keseimbangna indicated by body temperature 36-37 degrees Celsius and oral mucous membranes moist and fontaanela flat.
3. Damage to skin integrity b.d. effects of phototerapi.
Objective: The client does not show the integrity of skin disorders
6.Monitor damage skin integrity
7.baby's skin from the dirt after a bowel movement, bladder
8.neutral environmental temperature and axial temperature of 36.5 degrees Celsius
9.change position every 2 hours.
10. Give a break after 24 hours phototerapi
5. Early detection of skin integrity kerusakjan
6. Faeces and urine that is acidic can irritate the skin
7. High temperatures cause dry skin so fragile skin
8. position to maintain adequate circulation and prevent excessive emphasis on one side
Source :http://kumpulanmaterikeperawatan.blogspot.com
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