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CHAPTER 1
PRELIMINARY
1.1. Background
In the United States, as many as 65% of newborns suffering from icterus in birthst
week. In Malaysia, a survey in 1998 in government hospitals and health centers under the
Ministry of Health to get 75% of newborns suffering from icterus in the first week of
life. In Indonesia, the incidence of neonatal icterus in term infants in some education
among others RSCM Hospital, Hospital Dr. Sardjito, RS Dr. Soetomo, RS Dr. Kariadi
varied from 13.7% to 85%. (MOH, 2004).
Icterus is a yellow color that appears on the skin and mucous membranes due to
increased bilirubin. Usually begin to appear in the serum bilirubin levels> 5 mg / dL.
Icterus usually physiological, but in some cases it can cause problems; The most feared is
the bilirubin encephalopathy. Babies who have bilirubin encephalopathy / kernicterus
will experience the growth and development disorders such as mental retardation,
cerebral palsy and hearing loss (MOH, 2004). This situation can be prevented, include:
1) promotion and support of breastfeeding with adePuate intake; 2) Perform a systematic
assessment bilirubin levels; 3) follow-lowering kadarbilirubin with phototherapy or
exchange transfusion; and 4) the National Institutes of Health is developing a drug
research to meghambat production of bilirubin (Nursanti, 2011).
One of the neonatal health care program is monitoring the incidence of neonatal
icterus. Focus action on this program is early detection by seeing the appearance of
yellowing of the skin and encourage the baby to continue breastfeeding. (MOH, Books
Charts Integrated Management of Childhood Illness (IMCI), 2008).
CHAPTER 2
DISCUSSION
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2.1.2 Classification
Divided into two types, namely:
1. Physiologic icterus is icterus arising on the second day and the third day with
bilirubin levels within normal limits and did not cause morbidity in infants.
2. Pathological Icterus
Pathological icterus is icterus with bilirubin levels above normal.
Icterus is likely to become pathological or neonatal icterus sebgai considered are:
a. Icterus occurs in the first 24 hours after birth.
b. Increased bilirubin concentration of 5mg% or more every 24 hours.
c. Serum bilirubin concentration as 10mg% in preterm neonates and 12.5% in term
neonates.
d. Icterus is accompanied by the process of hemolysis (blood incompatibility,
G6PD enzyme deficiency and sepsis).
e. Icterus is caused by newborn infants less than 2000gr caused by maternal age
under 20 years old or over 35 yahun and teenage pregnancy, gestation less than
36 weeks, asphyxia, hypoxia, respiratory distress syndrome, infection,
hipoglierosmolikemia, hiperkopnia, hiperosmolitas blood.
2.1.3 Etiology
1) Hemolysis increased the Rh blood incompatibility, ABO, other blood group,
G6PD enzyme deficiency, closed bleeding, and sepsis.
2) Interference processes hepatic uptake and conjugation of the liver caused by
immaturity, lack of substrate for conjugation of bilirubin, hepatic dysfunction due
to acidosis, hypoxia, and infections or absence of enzyme glukorinil tranferase
(criggler Najjar syndrome). Another cause is a deficiency of the protein Y in the
liver that plays an important role in bilirubi uptake into liver cells.
3) Impaired transport of bilirubin in the blood is bound to albumin was then
appointed to the liver, bilirubin binding to albumin can be affected drugs eg
5
2.1.4 Pathophysiology
Bilirubin is a product solver hemoglobin derived from red blood cell
hemolysis / RBC. When RBC broken then prroduknya will enter the circulation,
where the hemoglobin breaks into heme and globin. Globin reused by the body while
the heme is converted to bilirubin inkonjugata and binds to albumin. Genesis are often
found is when there is the addition of bilirubin in the liver streptococcus excessive. It
can be found when there is an increase in erythrocyte destructed, polycythemia,
shortened life of erythrocytes fetus / infant, meningkatanya bilirubin from other
sources, or the presence of an increase in the enterohepatic circulation.
Impaired uptake of bilirubin plasma occurs when levels of protein Z, and
protein Y are bound by other anion, for example, in infants with acidosis or with
anoxic / hypoxic determined interference conjugation liver (deficiency of the enzyme
glucuronyl transferase) or infants suffering from disorders of excretion, eg, patients
with hepatitis neonatal or obstruction bile intra / extra hepatic. At a certain degree,
bilirubin can be toxic and damage brain tissue. The toxicity is mainly found in
bilirubin indirect bilirubin indirek.Sifat allow pathologic effects on brain cells when
bilirubin can penetrate the blood-brain barrier. Abnormalities that occur in the brain
called kernicterus / biliary encephalopathy.
Ease of bilirubin through the blood-brain barrier is not only dependent on high
levels of bilirubin but it depends also on the state of the neonate's own. Indirect
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bilirubin will easily through the blood-brain barrier in infants if there is a state of
immaturity, LBW. Hypoxia, hypoglycemia, and central nervous system disorders due
to trauma or infection.
Hem Globi
e n
Indication fototerapi
Biliverdin
Ikterus neonatorum
Disorder
Risk injuri internal elimination
alvi diarrhea
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2. Vomiting, anorexia, fatigue, dark urine color, the color of pale stools
(Suriadi & Yulianni, 2006)
2.1.6 Complications
Complications that may occur in neonatal icterus by Suriadi & Yulianni, 2006:
1. Bilirubin encephalopaty (serious complications)
2. Kernicterus; neurological damage; cerebral palsy; mental retardation,
hyperactivity, slow speech, no muscle coordination, and the shrill cries.
2.1.7 Management
1. Common actions
a. Checking blood group Mothers (Rh, ABO) and others at the time of
pregnancy.
b. Prevent birth trauma, administration of the drug in pregnant women or
newborns that can cause icterus, infections and dehydration.
c. Early feeding with the amount of fluid and calories are in accordance with the
needs of the newborn.
d. Illumination is Puite in place bai treated.
e. Treatment of a factor if not known.
2. Accelerate the metabolism and expenditure bilirubin
a. Early feeding. Early neonatal feeding can reduce the occurrence of physiologic
icterus in neonates, because with early feeding it happens facilitation and
meconium bowel movements more Puickly removed, so that the enterohepatic
circulation of bilirubin is reduced.
b. Giving gelatin. The mechanism is by blocking or reducing the enterohepatic
circulation of bilirubin.
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5) Collaboration
Monitor laboratory tests as indicated
1. Bilirubin direct and indirect
Rationale: musty icterus show reduced or absent
2. Start phototherapy using a fluorescent lamp that is placed over the baby
Rationale: bilirubin oxidation causes the photo on an extensive network
of subcutaneous, so the water soluble bilirubin Enhancing the
capabilities that enable rapid excretion of bilirubin in feces and urine
3. Provide a blindfold when phototherapy underway
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2.2.4 Evaluation
a. In term infants at the age of 3 days indirect bilirubin levels below 12 mg /
dl, bilirubin levels in preterm infants <10 mg / dl.
b. No signs of dehydration, good turgor.
Age : 7 days
Gender : Female
Person in charge
Dad / Mom : Mr. A / Mrs . W
Age : 30 years / 27 years
Address : Sirepah , Balong Bendo , Sidoarjo
Religion : Moeslem
Job :-
Medical Diagnose : SMK + icterus Neonatorum
B. Health History
1. Main Complaint : No result.
2. History of Pregnancy and Childbirth
Pre Natal : States G2 P11002 with 30/31 weeks gestation , treatment during
pregnancy is no result , TT immunization no result , complications during
pregnancy are no result.
Natal :
Babies born in emergency unit Dr. Soetomo hospital, childbirthing: SC with
indication amniotic murky and placenta the previa totalis.
Post Natal :
A baby born on may 30th 2016 at 06: 15: 00 with weight 1235 grams , the long
body 43 cm , circle head 27 cm, circle chest 24 cm , mekonium out < 24 hours ,
baby treated at NICU on may 30th 2016 at 06: 37 temperatures 36.5 c , HR 150
time/ minutes , RR 40 times / minutes.
APGAR Score 11 51
Heat rate 1 2
Respiration 1 1
Tonus Muscle 1 1
Reflecs 1 1
Skin color 1 1
Total APGAR Score 5 6
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4. Personal Hygiene
Baby every morning at 04:30am always wiped, every tubs and chapter always
replaced its diapers, always oral hygiene by using Enystatin .
5. Activities
Weak grasp reflex , Babinski reflex is not gripping fingers , moro reflex is weak,
the attitude of the extension baby , the baby is not moving on.
G. Psychosocial
Mother's behavior toward infants : No Result
H. Physical Examination
General appearance: Baby weak
Temperature : 36.6 C
Pulse : 146 beats/min
Breathing : 46 beaths/min
1. Head
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13. Skin
Reddish, dry, turgor skin is good.
I. Examination of supporting
Chemical examination clinic June 04th 2016 at 10: 27: 46
Examination Result Unit Normal value
Albumin 3.4 g/dL 3.4 5.0
Direct bilirubin 0.52 mg/dL 0.00 0.20
Total bilirubin 11.19 mg/dL 0.2 1.00
CRP 0.1 mg/dL 0.00 0.90
J. Therapy Provided
1. Installed infusion : D5 - Ns 12.5 % 60 cc / 24 hours via pump
2. ASI / PASI 8 cc personde every 2 hours ( 12 x 8 cc / 24 hours )
3. Phototherapy conducted on June 5th, 2016 1 x 24 hours
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DATA ANALYSIS
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ASI/PASI 8 cc
personde every 2 Most of bilirubin can not be bound
Installed phototherapy
1x24 hours Less risk of fluid volume
Installed infusion D5 -
Ns 12.5 % 60 cc / 24
hours via pump
Balance fluid 50 cc
BB 1220 gram
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2. Nursing Diagnose
1. On June 5, 2016
Risk of internal injury related with increase in serum bilirubin caused
red blood cell breakdown and excretion of bilirubin disorders
2. On June 5, 2016
The risk of lack of fluid volume associated with secondary air loss from phototherapy
3. Nursing Intervention
1. Risk of injury (internal) associated with secondary increase in serum bilirubin of red
blood cell breakdown and excretion of bilirubin disorders
Goal : The taxable income carried over 3x24 hour nursing action baby free from injury
Criteria outcome : bilirubin <10 mg / dL
General good condition
Good moro reflex
Good sucking and rooting reflex
Intervention:
1) Keep warm and dry babys incubator, monitor skin and temperature every 4 hours.
R / Cold stress release acids potentially weak side association competing on the
albumin, thereby increasing bilirubin.
2) Observation phototherapy light of baby
R / Detecting evidence / degree of icterus.
3) Assess progress of baby behavior
R / Behavioral changes associated with kernicterus.
4) Collaboration for evaluation laboratory appropriate indications
R / Increased indirect bilirubin 13-15 mg / dl on premature babies.
5) Start phototherapy using flouresan light bulbs above the baby
R / Causes photo bilirubin oxidation on networks after subcutaneous thereby
enhancing the ability of air
6) Give cover eye to the baby
R / Preventing the possibility of damage to the retina and conjunctiva of high
intensity beam
7) Change the baby position at least 2 hours
R / Journey toward balanced from the skin surface fluorescence rays, preventing
exposure excessive and emphasis specific body parts
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4. Implementation Of Nursing
Date June 5th, 2016
Diagnose 1
At 03:30 pm .
1. Maintaining warmth baby with replace nested and if wet blanket .
Response : babys acral dry warm red .
At 03:32 pm.
2. Turn on phototherapy lamps 1x24 hours above baby incubator
At 03:33 pm.
3. placed eye cover on baby
At 05:00 pm
4. Change the baby position every 2 hours
At 08:00 am
1. Measure babys vital sign
At 08:05 am
2. Replace wet baby's diaper with new diaper
At 08:08 am
3. Change the baby position to right side
Diagnose 2
At 08:10 am
1. Weighing diapers
Balance 50 cc
At 08:11 am
2. Change the formula milk with breast milk
At 08:11 am
3. Give ASI 8cc x 12/24 hours.
Date June 8th, 2016
Diagnose 1
At 04:25 am
1. Measure the baby's vital signs
Temperature of 37.5 C HR 142 beats / min RR 40 times / min
At 04:30 am
2. Wiping and diapering the baby
At 04:35 am
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Diagnose 2
At 04:36 am
1. Give breastfeeding 15 cc personde
At 04:40 am
2. Weighing the baby, the result is 1320 grams
5. Evaluation Of Nursing
Date June 5th, 2016
Diagnose 1
S: -
O: Acral warm, infant hypothermia
A: The problem still occurs
P: Interventions continued
S: -
O: temperature 36.8 C HR 149 beats / min RR 48 / min, infant hypothermia, not visible
redness
A: The problem still occurs
P: Interventions continued
Diagnose 2
S: -
O: Balance liPuid 50 cc, 8 cc personde breastfeeding, infant diarrhea, dehydration
A: The problem still occurs
P: Interventions continued
Diagnose 2
S: -
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O: ASI 15 cc personde, BB 1320 grams, the baby no diarrhea, no abrasions on the skin
genitalia
A: The problem still occurs
P: Interventions continued
CHAPTER 3
COVER
3.1 Conclussion
Icterus is a yellowing of the sclera, skin or other tissue due to accumulation
of bilirubin in the body or the accumulation of bilirubin in the blood of more than 5
mg/dl within 24 hours, indicating the occurrence of functional disorders of the
liver, biliary system, or the hematologic system. Icterus itself is physiological, but
can become pathological. Icterus is caused by elevated levels of bilirubin so that it
can lead to kernicterus due to accumulation of unconjugated in brain cells. This
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3.2 Recommendation
Icterus is one of the health problems that often arise in neonates and infants,
therefore, the role of health workers, mothers and other related agencies in
addressing and finding solutions to problems need to be done so that the incidence
of icterus have occurred not continue to.
Bibliography