Neonatal Case Study

Neonatal Case Study

Introduction

The presenting clinical problem for the newborn (Jennifer) discussed in case study two is neonatal jaundice. This is a discoloration of the skin often occurring in newborns due to high bilirubin levels. This paper will discuss the pathophysiology of this presenting clinical problem as it relates to Jennifer, analyze the presenting data, and apply the principles of family-centered care.

The pathophysiology of the presenting clinical problem

Neonatal jaundice often takes place due to the simultaneous occurrence of two phenomena. The first is the elevation of bilirubin production arising from the increased breakdown of fetal erythrocytes. This outcome is often due to the shortened lifespan of fetal erythrocytes as well as a higher mass of erythrocyte in the neonate (Hansen, 2017). Secondly, the condition occurs due to low hepatic excretory capacity arising from the diminished concentration of the binding protein ligandin in the hepatocyte as well as because of low glucuronyl transferase, which is an enzyme often responsible for binding bilirubin to glucuronic acid. The low glucuronyl transferase makes bilirubin water-soluble, a state commonly known as conjugation.

Fundamentally, bilirubin is generated in the reticuloendothelial system, often as the final product of heme catabolism. Additionally, bilirubin is produced through oxidation-reduction reactions. Initially, biliverdin is formed from heme as a result of the heme oxygenase reaction leading to the release of carbon monoxide and iron (Hansen, 2017). While the iron is conserved for reuse, the carbon monoxide is excreted through the lungs. Next, biliverdin, which is water-soluble, is reduced to bilirubin that has a hydrophobic nature. The unconjugated bilirubin is transferred into the plasma bound to albumin tightly. However, binding to other erythrocytes and proteins occur. Nevertheless, the physiologic role is limited. The bilirubin binding to the albumin often increases postnatally and reduced in ill infants. When the bilirubin reaches the liver, it is transported into the liver cells. At this point, the bilirubin binds to ligandin (Hansen, 2017). Furthermore, the uptake of bilirubin into the hepatocytes often surge in correspondence with increasing concentration levels of ligandin. At birth, the concentration of ligandin is very low. However, over the first few weeks after birth, the concentration increases fast.

Bilirubin is often bound to conjugated glucuronic acid occurring in the hepatocyte endoplasmic reticulum. This outcome is facilitated in a reaction in which the uridine diphosglucuronyltransferase acts as a catalyst (Hansen, 2017). The formation of monoconjugates occurs first before they predominate in newborns. The conjugation of bilirubin is critical as it transforms a water-insoluble bilirubin molecule into a water-soluble one. This change is essential because it allows for the excretion of the conjugated bilirubin into the bile. At the point of birth, uridine diphosphoglucuronyltransferase is often very low. After bilirubin is excreted and transferred to the intestines, it is reduced to colorless tetrapyrroles in the colon by microbes. While this is the case, the unconjugated bilirubin might be reabsorbed back into the circulation, which then increases the aggregate plasma bilirubin pool (Hansen, 2017). The uptake, conjugation, excretion, deconjugation, and reabsorption cycle is, in most cases, extensive in neonates.

As claimed in the case study, several factors increase the risk for neonatal jaundice. One of these, according to Tavakolizadeh et al. (2018), is the preterm rupture of membranes. According to the researchers, while there is no direct association between the preterm rupture of membranes, the condition affects some of the parameters often involved in the health of infants and fetuses. However, spontaneous labor and delivery have a direct effect on the degree of bilirubin. Seyedi et al. (2017) show that due to the induction involved, the serum bilirubin is increased significantly. Jaundice, according to Shimokaze et al. (2015), often leads to respiratory distress.

Treatment and nursing/midwifery management

It is revealed in the case study that Jennifer is now three days old, which is 72 hours. In this case, the midwife should consider dehydration or sufficiency of milk supply, infection, hemolysis, polycythemia, and breakdown of extravasated blood, for example, cephalohematoma and bruising. As relayed by Booth, Dyke, Allen, and York (2017), the midwife should corroborate the initial manifestation of significant jaundice by testing or measuring the level of bilirubin. He or she should accomplish this objective by using a blood gas analyzer within six hours of the initial clinical suspicion of the condition that Jennifer currently has. In the case that the midwife notes that the level of bilirubin exceeds the treatment threshold, then he or she should administer phototherapy using an overhead unit (Booth, Dyke, Allen, & York, 2017). The midwife should take caution not to use a biliblanket as the first line of treatment. The midwife should then repeat the bilirubin level measurement after six hours of treatment.

He or she should also monitor the patient’s response to treatment by measuring the serum bilirubin level after every 2 hours in the course of her treatment (Booth, Dyke, Allen, & York, 2017). The midwife should continue administering the phototherapy until he or she established that the measured bilirubin is at the 50μmol/liter level below the treatment threshold point. Once phototherapy is stopped, the midwife ought to repeat a bilirubin level at 12 hours. The chief aim is to check for rebound hyperbilirubinemia. Where the midwife notes that the bilirubin level is still at the 50μmol/liter level below the treatment threshold, he or she could now discontinue the routine monitoring of bilirubin (Booth, Dyke, Allen, & York, 2017). However, if the professional identifies that the bilirubin concentration has risen within the 50μmol/liter of the intervention threshold, the midwife should repeat the level after a further six to12 hours. However, the interval depends on the rate at which the rise in the bilirubin level is occurring.

As the client is preterm, there are chances that she will experience prolonged conjugated jaundice. This is due to a lack of external feeding. If prolonged jaundice indeed occurs, the midwife should consider performing additional investigations (Booth, Dyke, Allen, & York, 2017). These assessments should consider blood culture, coagulation screening, cholesterol and triglycerides, plasma amino acids, cortisol, ferritin, hepatitis A, B, and C serology, congenital infection serology, liver ultrasound scan, confirmation of IRT screening outcomes, Gal-1-PUT, and urine organic acids (Booth, Dyke, Allen, & York, 2017).

Assessment data

In the case study, it is revealed that the client is sleepy and needs to be woken for feeds. Zhang, Zhou, Li, and Cheng (2017) demonstrates that babies who experience neonatal hyperbilirubinemia show sleep spindle abnormalities. This is primarily because of the high concentration of the bilirubin cause neurotoxicity, which jeopardize the brain sleep function. The case study also shows that the client has a heart rate of 130. According to Brignole et al. (2017), the normal heart rate is often between 60 and 100 beats per minute. This means that the client’s heart rate, at 130, is exceedingly high. The chief cause of this is that the high bilirubin level depresses the heart. Thus, the heart has to beat faster in an attempt to alleviate the effect of the bilirubin. The respiratory rate of Jennifer is 40, yet the normal rate should be between 12 ad 20 breaths per minute. Hyperbilirubinemia tends to induce respiratory alterations in the neonates due to changes in the metabolic or thermal function (Champlain Maternal Newborn Regional Program, 2015). The case study also notes that the Sp02 is 95% in room air while her temperature is 36.6c, but these outcomes are within the recommended limits. Nevertheless, Jennifer’s TSB is at 250 micromoles per liter. This is a vivid indication that the albumin-bound bilirubin has crossed the blood-brain hyperosmolality in the client.

Family-centered care

The case study reveals that her family lives in Queensland and that the client’s parents are anxious because their other children had had neonatal jaundice. At the same time, it is revealed that the parents feel isolated and are keen to return to their other children. They also want to know when visiting hours are for the parents. There are several principles of family-centered care that apply in this scenario. The most relevant, however, as related by Ramezani et al. (2015), is that the midwife should consider providing a room for the family within the care facility in which they can also bring the other two children so that they can be close to Jennifer. The essence is to have the parents interact with the neonate, control infections, reduce expenses for the family, and make them feel as if they are at home, hence eliminate the feelings of loneliness.

Conclusion

It is indeed unfortunate that Jennifer has jaundice caused by excessive bilirubin, which is then causing mild respiratory distress. Nevertheless, if the midwifery treatment option highlighted in this paper is followed to the latter, the client will recover swiftly. Additionally, the family-centered care doctrine discussed in this paper must be applied to ensure a quick recovery. It is essential to keep in mind that, where the family members interact with a neonatal regularly, it follows that an infant will most possibly endure quick recovery. Furthermore, it is critical to note that family-centered care tends to improve the family’s perception of the intervention process.

References

Booth, D., Dyke, M., Allen, R., & York, S. (2017). Joint Trust Guideline for the Management of Neonatal Jaundice. Retrieved from http://www.nnuh.nhs.uk/publication/download/neonatal-jaundice-jcg0013-v3-1/

Brignole, M., et al. (2017). Mechanism of syncope without prodromes with normal heart and a normal electrocardiogram. Heart Rhythm, 14(2), 234-239.

Champlain Maternal Newborn Regional Program (2015). Newborn Hyperbilirubinemia. Retrieved from http://www.cmnrp.ca/uploads/documents/Hyperbilirubinemia_Self_Learning_Module_updated_July_2015_FINAL.pdf

Hansen, W. (2017). Neonatal Jaundice. Medscape. Retrieved from https://emedicine.medscape.com/article/974786-overview

Ramezani, T. et al. (2014). Family-centered care in the neonatal intensive care unit: a concept analysis. International journal of community-based nursing and midwifery, 2(4), 268.

Seyedi, R., e al. (2017). The Effect of the Use of Oxytocin in Labor on Neonatal Jaundice: A Systematic Review and Meta-Analysis. International Journal of Pediatrics, 5(12), 6541-6553.

Shimokaze, T. et al. (2015). Premature rupture of membranes and neonatal respiratory morbidity at 32–41 weeks’ gestation: A retrospective single‐center cohort study. Journal of Obstetrics and Gynaecology Research, 41(8), 1193-1200.

Tavakolizadeh, R. et al. (2018). Maternal risk factors for neonatal jaundice: a hospital-based cross-sectional study in Tehran. European Journal of Translational Myology, 28(3), 7618.

Zhang, L., Zhou, Y., Li, X., & Cheng, T. (2017). Hyperbilirubinemia influences sleep-wake cycles of term newborns in a non-linear manner. PloS one, 12(1).