A- Assessment D- diagnosis P- Plan I-Mplementing e- evaluation

PHOTOTHERAPY

I. Introduction:

Nearly 70% of term and 80% of preterm infants develop Jaundice during the First week of life.
Jaundice is the frequent diagnosis and reason of post discharge readmission in any neonatal
set-up. While hyperbilirubinemia occurs in all of them, Phototherapy as a treatment modality
has become the backbone of unconjugated hyperbilirubinemia in the neonate. It's noninvasive
in nature and have fewer side effects as reported until now.

II Definition:

Photo therapy consists of the application of fluorescent light to the infant's exposed skin, light
promotes bilirubin excretion by photoisomerization which alters the structure of bilirubin to
soluble form (humirubin) for easier excretion.

III. Nursing care and procedure for photo therapy:

1. Undress the baby completely.

2. The baby's eyes are shielded by an opaque mask to prevent exposure to the light.

3. The eye shield should be properly sized and correctly positioned to cover the eye completely
but prevent any occlusion of the nares.

4. The baby's eyelids are closed before the mask is applied, because the corneas may become
excoriated if they come in contact with the dressing.

5. On each nursing shift the eyes are checked for evidence of discharge, excessive pressure on
the lids or corneal irritation.

6. Eye shields are removed during feedings, which provide the opportunity to provide visual
and sensory stimulation.

7. During breastfeeding switch off the photo therapy unit.

8. Provide frequent breast feeding.

9. Turn the baby after each feed to expose maximum surface area of baby to light.

10. Keep baby at a distance of 45 cm from the light source.

11. A special light - permeable photo therapy diaper, or bikini diaper fashioned with a face
mask may be used to cover the genitalia and buttocks.

12. Keep diaper area dry and clean because skin in this area is prone to break down.

13. Babies who are in an open crib must have a protective plexiglas shield between them and
the fluorescent light to minimize the amount of un desirable ultraviolet light reaching their skin
and to protect them from accidental bulb breakage.

14. Monitor temperature every two to four hour or more frequently if fluctuation in
temperature is noted.
15. Maintaining the baby in a flexed position with rolled blankets along the sides of the body
helps maintain heat and provides comfort.

16. Maintain thermoneutrality - measure incubator or isolate temperature as well as infant's

light affects the cambient temperature.

17. Do not expose the thermistor probe to the light without the probe's being covered with
opaque tape

18. Adequate fluid intake should be provided either orally or intravenously, vasodilation
increases the insensible water loss and there is excess stool loss from occasional diarrhea,
keep urine specific gravity below 1.015. (Breastfeeding or 10-20% extra fluids are provided)

19. Ensure that the baby passes adequate urine (6-8 times per day)

20. Weight is taken at least once a day.

21. Ensure that serum bilirubin levels are obtained as prescribed. The diminishing icterus, i.e.
the lowering of unconjugated bilirubin from cutaneous tissue does not reflect the serum
bilirubin concentration.

22. Discontinue photo therapy when serum bilirubin returns to a safe value as per unit
protocol.

23. Monitor clinically for rebound bilirubin rise within 24 hours after stopping phototherapy for
babies with hemolytic disorders.

24. Accurate charting is another important nursing responsibility that includes:

* time that photo therapy is started and stopped.

* proper shielding of the eyes, and covering of the testes (genitals)

* type of fluorescent lamp (by manufacture)

* number of lamps.

* distance between surface of lamps and infant (should be not less than 45 cms)

* use of photo therapy in combination with an incubator or open bassinet.

* photometer measurement of light intensity.

* occurrence of side effect.

* length of time the bulbs have been used.

* the effectiveness of light of the wave length decreases after 800 hours, of use; thus bulbs
should be changed at the correct time. A record of hours of use is essential.

* record vital signs every 2 hourly.

* maintain feeding chart, weight chart, regularly

* serum bilirubin is monitored at least every 12 hours

* record weight daily.

IV Side effects of phototherapy:

Photo therapy is not a harmless intervention. It can produce adverse effects on the baby and
may disturb medical and nursing personnel

a. Lethargy

b. Loose green stool-weigh often and compensate

c. Increased insensible water loss- provide more frequent extra breastfeeding

d. Dark Urine.

e. Temperature elevation.

f. Skin changes - greenish colour, rash due to capillary dilation - skin rashes - no need to
discontinue photo therapy.

g. Turn infant on abdomen for short period of time and will cease priapism (persistent
abnormal erection of penis)

h. Retina damage: prevented by shielding the eyes.

i. Hypo or hyperthermia: Monitor temperature frequently.

j. Increased metabolic rate, dehydration, and electrolyte disturbances such as hypocalcemia.

k. Frequent stooling can cause perineal irritation therefore meticulous skin care especially
keeping the skin clean and dry is essential.

l. Bronze - baby syndrome - in which the serum, urine and skin turn grayish brown several
hours after the infant is placed under the light. This reaction is probably caused by retention of
a bilirubin break down product of phototherapy, possibly copper porphyrin. The syndrome
almost always occurs in infants who have elevated conjugated hyperbilirubinemia and some
degree of cholestasis. The browning generally resolves following discontinuation of
phototherapy.

m. Photo therapy has been shown to affect short terms behavior of the term infant, which has
been attributed to maternal separation. This least discussed and often overlooked aspect, is
the most common side effect, so one should encourage the mother to breastfeed and interact
with her baby regularly during phototherapy.

V Caution:

1. Do not use photo therapy without trying to find the cause of Jaundice.

2. Photo therapy results in dehydration and iatrogenic hyperthermia /hypothermia.

3. Blue light may interfere with monitoring of cyanosis. Blue light cause nausea, giddiness and
headache which may affect /disturb the staff.

4. In direct hyperbilirubinemia, photo therapy results in Bronze baby syndromes (green colour)

5. Nurse should wear sunglass and cover the hair with a cap or bandana, when caring for an
infant under blue light for her own protection.

6. If the nurses skin is sensitive to the lights a screening substance may be used to prevent
tanning of exposed area.
VI. Conclusion:

Phototherapy continues to be the preferred method of treatment for neonatal

hyperbilirubinemia by virtue of its safety and non-invasive nature. Effective nursing care
during Phototherapy and appropriate use of phototherapy has significantly reduced the need
for exchange blood transfusion. It is convenient and inexpensive. It is used even in small
hospitals and nursing homes.

HEAD CIRCUMFERENCE AND SHOULDERS

At NICU PA!!

NEONATAL SEPSIS

Def:

Nursing Responsibilities

HYPERTHERMIA, FLUID VOLUME DEFICIT, INEFFECTIVE TISSUE PERFUSION, INTR.

BREASTFEEDING

1. Monitor VS as ordered

2. Provide warmth to neonate via warmer or droplight and wrap with towel or wide cloth.

3. Monitor closely the abnormal signs showing through physical and mental behaviour.

4. Provide TSB if not contraindicated.

5. Monitor closely, provide stimulation to the baby during assessment.

6. Promote proper hygiene, hand washing technique and sterility such as handwashing,
ABHR, using sterile equipments at bedside and limit interaction with neonates.

7. Administer antipyretics as ordered.

8. Provide Oral Care such as moistening the lips or dry areas to prevent injury due to
dryness.

9. Replace IVF or monitor IV line as ordered.

10. Monitor quality and strength of peripheral pulses. To asses pulse that may become
weak or thready, because of sustained hypoxemia

11. Assess respiratory rate, depth, and quality to note for an increased respiration that
occurs in response to direct effects of endotoxins on the respiratory center in the
brain, as well as developing hypoxia, stress. Respirations can become shallow as
respiratory insufficiency develops creating risk of acute respiratory failure.

12. Assess skin for changes in color, temperature and moisture. To assess for
compensatory mechanisms of vasodilation

13. Elevate Head of Bead To promote circulation /venous drainage

 14. Elevate affected extremities with edema once in a while To reduce edema

15. Provide a quiet, restful atmosphere, Conserves energy and lowers O2 demand9. To
maximize O2

16. Administer oxygen as ordered, availability for cellular uptake

17. Assess mother’s perception and knowledge about breastfeeding and extent of
instruction that has been given, To know what the mother already knows and needed
to know

18. Give emotional support to mother and accept decision regarding cessation/
continuation of breast feeding. To assist mother to maintain breastfeeding as desired.

19. Demonstrate use of manual piston-type breast pump. Aid in feeding the neonate with
breast milk without the mother breastfeeding the infant.

20. Review techniques for storage/use of expressed breast milk awake To provide optimal
nutrition and promote continuation of breastfeeding process

21. Determine if a routine visiting schedule or advance warning can be provided that
infant will be hungry/ ready to feed.

22. Provide privacy, calm surroundings when mother breast feeds. To promote successful
infant feeding.

23. Recommend for infant sucking on a regular basis Reinforces that feeding time is
pleasurable and enhances digestion

24. Encourage mother to obtain adequate rest, maintain fluid and nutritional intake, and
schedule breast pumping every 3 hours while. to sustain adequate milk production
and breast feeding process

June 26, 2008

S- ØO-warm to touch, (+) tachycardia and tachypnea, (+) edema on extremities latest Hct
result 0.64%. Urine output 5 grams in an hour (diaper’s weight). Vital signs taken and
recorded are as follows:RR-63 bpmCR-175 bpmTemp- 38.5o

CA-Fluid volume deficit related to failure of regulatory mechanismP-After 3 hours of nursing

intervention the patient will be able to maintain fluid volume at a functional level as evidenced
by individually adequate urinary output with normal specific gravity, stable vital signs, moist
mucous membranes, good skin turgor and prompt capillary refill and resolution of edema.I-
Monitored and recorded vital signs-Noted for the causative factors that contribute to fluid
volume deficit-Provided TSB -Provided oral care by moistening lips & skin care by providing
daily bath - Administered IV fluid replacement as ordered-Monitored laboratory results.-
Washed hands before and after giving care.- Stretched bed linens.

E-Goal partially met, after 3 hours the patient has stable vital signs but still has edema and
inadequate urine output. The edema d disappears on the 3rd day of interaction.

June 29, 2008

S- ØO-Seen baby in crib with ongoing IVF of D5IMB 113 cc via soluset at 9-10 ugtts/min
infusing well on his left hand. He is less active and afebrile. With weak peripheral pulses and
(+) edema. Vital signs taken and recorded are as follows:RR-48 bpmCR-132 bpmTemp- 36o

CA-Ineffective tissue perfusion related to impaired transport of oxygen across alveolar and on
capillary membraneP-After 3 hours of nursing intervention the patient will demonstrate
increased perfusion as evidenced by warm and dry skin, strong peripheral pulses, normal vital
signs, adequate urine output and absence of edema I-Monitor neonate’s condition.-Monitor
Vital signs-Note quality and strength of peripheral pulses-Assess respiratory rate, depth, and
quality-Assess skin for changes in color, temperature and moisture-Elevate Head of Bead-
Elevate affected extremities with edema once in a while-Provide a quiet, restful atmosphere

E-Goal partially met, after 3 hours the patient has stable vital signs and adequate urine output
but still has edema. The edema d

July 01, 2008

S- ØO-Seen baby in crib with ongoing IVF of D5IMB 98 cc via soluset at 7-8 ugtts/min infusing
well on his left hand. He is active and afebrile. He has good cry, good suck and demanded
feedings. Vital signs taken and recorded are as follows:RR-45 bpmCR-135 bpmTemp- 36.8o

CA-Interrupted breastfeeding related to neonate’s present illness as evidenced by separation

of mother to infantP-After 3 hours of nursing intervention and health teachings the mother will
identify and demonstrate techniques to sustain lactation until breastfeeding is initiatedI-
Assessed mother’s perception and knowledge about breast feeding and extent of instruction
that has been given.- Gave emotional support to mother -Encouraged use of manual piston-
type breast pump.-Reviewed techniques for storage/use of expressed breast milk- Determined
if a routine visiting schedule or advance warning can be provided- Provided privacy, calm
surroundings when mother breast feeds.- Recommended infant sucking on a regular basis-
Encouraged mother to obtain adequate rest, maintain fluid and nutritional intake, and
schedule breast pumping every 3 hours while awake

E-Goal met after 3 hours of nursing intervention the mother had identified and demonstrated
techniques to sustain lactation and identified techniques on how to provide the newborn with
breast milk.

In common clinical usage, neonatal sepsis specifically refers to the

presence of a serious bacterial infection(SBI) (such
as meningitis, pneumonia, pyelonephritis, or gastroenteritis) in the setting of
fever. Criteria with regards to hemodynamic compromise or respiratory
failure are not useful clinically because these symptoms often do not arise in
neonates until death is imminent and unpreventable.

It is difficult to clinically exclude sepsis in newborns less than 90 days old that
have fever (defined as a temperature > 38°C (100.4°F). Except in the case of
obvious acute viral bronchiolitis, the current practice in newborns less than
30 days old is to perform a complete workup including complete blood
count with differential, blood culture, urinalysis, urine culture,
and cerebrospinal fluid(CSF) studies and CSF culture, admit the newborn to
the hospital, and treat empirically for serious bacterial infection for at least
48 hours until cultures are demonstrated to show no growth. Attempts have
been made to see whether it is possible to risk stratify newborns in order to
decide if a newborn can be safely monitored at home without treatment
despite having a fever. One such attempt is the Rochester criteria.