Question

11. Apgar scoring is a method of newborn assessment used in the immediate post birth period, at 1 and 5 minutes. Indicate the Apgar score of the following newborns:

a.    BB Smith, at 1 minute after birth:

·      Heart rate 160 beats/min

·      Respiratory effort – good, crying vigorously

·      Muscle tone – active movement, well flexed

·      Reflex irritability – cries with stimulus to soles of feet

·      Color – body pink, feet and hands cyanotic

                                               i.     Score:

                                             ii.     Interpretation:

b.    BG Doe at 5min after birth:

·      Heart rate – 102 beats/min

·      Respiratory effort – slow, irregular with weak cry

·      Muscle tone – some flexion of extremities

·      Reflex irritability – grimace with stimulus to soles of feet

·      Color – pale

                                               i.     Score:

                                             ii.     Interpretation:

12. Parents of BB Marion are concerned about the color of their baby who has developed hyperbilirubinemia at 30hours of age, and the need to put the baby under special lights. “My uncle was yellow just like our baby and he died of liver cancer!”

a.    Describe how the nurse should respond to the parents’ concern.

b.    Identify the expected assessment findings and physiologic effects related to hyperbilirubinemia.

c.     List the precautions and care measures that are required by the nurse caring for a newborn under phototherapy in order to prevent injury to the newborn yet maintain the effectiveness of the treatment.

Answer 1

1.

A. The apgar score is 10 the condition is excellent

B. Apgar score is 6. Interpretation moderately depressed. Need further treatment.

2.

A. There is nothing to worry it's physiological jaundice. The infantile liver may not respond properly the doctor should be informed when

• Your baby's skin becomes more yellow
• The skin on your baby's the abdomen, arms or legs looks yellow
• The whites of your baby's eyes look yellow
• Your baby seems listless or sick or is difficult to awaken
• Your baby isn't gaining weight or is feeding poorly
• Your baby makes high-pitched cries
• Your baby develops any other signs or symptoms that concern you

B.

High levels of bilirubin that cause severe jaundice can result in serious complications if not treated.

Acute bilirubin encephalopathy

Bilirubin is toxic to cells of the brain. If a baby has severe jaundice, there's a risk of bilirubin passing into the brain, a condition called acute bilirubin encephalopathy. Prompt treatment may prevent significant lasting damage.

Signs of acute bilirubin encephalopathy in a baby with jaundice include:

• Listlessness
• Difficulty waking
• High-pitched crying
• Poor sucking or feeding
• Backward arching of the neck and body
• Fever

Kernicterus

Kernicterus is the syndrome that occurs if acute bilirubin encephalopathy causes permanent damage to the brain. Kernicterus may result in:

• Involuntary and uncontrolled movements (athetoid cerebral palsy)
• Permanent upward gaze
• Hearing loss
• Improper development of tooth enamel

Prevention

The best preventive of infant jaundice is adequate feeding. Breast-fed infants should have eight to 12 feedings a day for the first several days of life. Formula-fed infants usually should have 1 to 2 ounces (about 30 to 60 milliliters) of formula every two to three hours for the first week.

C.

• Commence phototherapy once TSB/SBR is greater than the appropriate reference range for neonate’s gestation/weight and presence of risk factors.
• Neonates should be nursed naked apart from a nappy under phototherapy and will need to be nursed in an Isolette to maintain an appropriate neutral thermal environment. (Link to:” Ward Management of a Neonate” and “Isolette use in Paediatric Wards”) In severe cases, the nappy may need to be removed and a urine bag applied to maximise skin exposure.
• Positon phototherapy units no more than 30.5cm from the patient. neoBLUE® LED phototherapy unit can be positioned as close as 15cm to patient. Refer to specific phototherapy units manufacturing guidelines for more details
• Expose as much of the skin surface as possible to the phototherapy light. To maximise skin exposure, dress the baby in a nappy and their protective eye covers only.
• Cover the eyes with appropriate opaque eye covers e.g. Natus Biliband® Eye Protector (available from Butterfly ward).
• Ensure eye covers are removed 4-6 hourly for eye care during infant cares or feeding. Observe for discharge/infection/damage and document any changes.
• Daily fluid requirements should be reviewed and individualised for gestational and postnatal age.
• Maintain a strict fluid balance chart.
• Breast feeds may need to be limited to 20 minutes if bilirubin level is high to minimise amount of time out of the lights
• Monitor vital signs and temperature at least 4 hourly, more often if needed
• Cover lipid lines with light resistant, reflective tape to avoid peroxidation
• Ensure that phototherapy unit is turned off during collection of blood for TSB/SBR levels, as both conjugated and unconjugated bilirubin are photo-oxidized when exposed to white or ultraviolet light.
• Observe for signs of potential side effects.