DISEASE

PORTION
JAUNDICE
Definition:
An excessive level of accumulated bilirubin in blood and is characterised by “hyper
bilirubinemia” or “Icterus”.this may be as the result of increased unconjugated and
conjugated bilirubin level above normal.

Jaundice comes from the French word “Jaune” which means yellow.

Jaundice is the clinical term used for the yellowish discoloration of the mucus
membrane and skin due to increase serum bilirubin level more than 4-5 mg/dl in the
new born.
Prevalence
Signs of Neonatal Jaundice are seen within the first three days of birth in 80% of
preterm babies and 60% of full-term infants
 Jaundice persisting beyond 14 days of age (prolonged jaundice) can (rarely) be a sign of serious
underlying liver disease (Hussein, 1991). Jaundice persists beyond 14 days in 15-40% of breastfed
infants, depending on the series studied (Hannam, 2000). A prospective study of all 7139 term
infants born at King’s College Hospital (London) between January 1997 and June 1998 (Hannam,
2000) found 154 with prolonged jaundice, one of which had conjugated hyperbilirubinaemia (0.14
per 1000 live births).
Another study of 3661 babies in Sheffield (Crofts, 1999) found 127 who were jaundiced at 28 days, of
which 125 were breastfed (9.2%).
Although preterm infants, whose livers are more immature, have prolonged jaundice
more commonly than term infants (Fenton, 1998) there appear to be no studies of
incidence in this group (Lucas, 1986).
 Etiology
Signs of Neonatal jaundice are seen within the first three days of birth in 80% of preterm
babies and 60% of full term infants.The journal of Paediatrics reports a retrospective
study,which observed that the incidence of Jaundice is higher in breast feed babies than in
the formula feed ones.

Causes of jaundice:
         Physiological jaundice
         Pathological jaundice associated with liver disease
         Rh and ABO incompatibilty
         Inherited cause of hemolytic disease i.e.glucose 6 phospate dehydrogenase
deficiency
         Erythroblastosis Fetalis
         Breast milk jaundice
         Jaundice due to sepsis
         Hemolysis due to drugs (quinine),poison(snake venom)
         Congenital biliary atresia and obstructive jaundice
         Inborn errors of metabolism:Galactosemia,Hypothyroidism,glucuronyl
transferase deficiency

Types of jaundice:

I.Physiological jaundice:
It is common in newborn babies. It usually becomes noticeable during the baby's first three
to five days of life. It disappears as the baby's liver matures. This type of jaundice is not
harmful.

II.Hemolytic jaundice:
This type of jaundice develops when there is Rh incompatibility and ABO in compatibility
between the mother and the fetus.

            Rh incompatibility occurs when the mother is Rh negative and the fetus is Rh
positive, having inherited gene for the Rhesus factor from his/her parents

            ABO incompatibility may present if the mother has blood group “O” and baby has
type “A “or “B” .then the mother makes Anti A or Anti B type anti bodies of the IgG glass and
cross the placenta causing destruction of the baby’s red blood cells.

III.Pathological Jaundice:

In some situation however there is so much billirubin in baby’s blood that it can be harmful
.This condition is called Pathological Jaundice.If the level of bilirubin becomes very high ,it
may affect some of the baby ‘s brain cells. This may cause a baby to be les active.In rare
cases ,a baby may have seizures (convulsions).Pathological jaundice may lead to
 deafness ,cerebral palsy and /or mental retardation. Pathologic jaundice can occur in
children or adults. It arises for many reasons ,including blood incompatibilities, blood
diseases, genetics syndromes ,hepatitis , cirrhosis ,bile duct blockage ,other liver diseases
,infections ,or medications.

IV. Jaundice of prematurity:

This occurs frequently in premature babies since they take longer to adjust to excreting
bilirubin effectively.

V. Breast Milk Jaundice:

In 1% to 2% breast fed babies, jaundice can be caused by substances produced in their
other’s breast milk that can cause the billirubin level rise above 20 mg.These substances
can revent the excertion of bilirubin through the intestines.It starts at 4 to 7 days and
normally lasts from 3 to 10 weeks. The cause is thought to be inadequate milk intake
,leading to dehydration or low caloric intake.It is a type of physiologic or exaggerated
physiologic jaundice.

VI. Not enough breast milk Jaundice:

This may occur because the baby is not getting enough milk.This is because sometimes the
mother’s milk takes a longer than average time to “come in”, or because the baby is poorly
latched on and thus not getting the milk which is available.

VII. Inadequate Liver Function:

Jaundice may be related to inadequate liver function due to infection like TOCH and sepsis
or other factors.

In other aspect of classification, according to the onset and

duration of the jaundice it can be classified into:

I.         Within 36 hours:
Usually pathological jaundice appears within 36 hours of life. This may involve
haemolytical jaundice usually due to Isoimmunisation, G6PD deficiency and other
congenital infections.

II.         After more than 36 hours:

Usually the jaundice appearing after more than 36 hours of life are physiological
jaundice or may be pathological jaundice due to drugs or sepsis.

III.         Prolonged jaundice(more than 2-3 weeks):

     The jaundice appears for more than 3 weeks in pre term and more than 2 weeks
in term infant .It may be conjugated or unconjugated. About more than 15% of the
cases seems to be conjugated jaundice.
This type of jaundice might occur due to
         Bile duct obstruction
         Endocrine disorder(hypothyroidism)
         Metabolic disorder(Galactesemia)
         Breast milk
         TORCH infection
         Viral hepatitis α-antitrypsin deficiency, cystic fibrosis.
In my patient, PROLONGED JAUNDICE is present leading
toinadequate liver function with the relevant cause
of TORCH positive, and Hypothyroidism

Pathophysiology:
Bilirubin is one of the breakdown product of haemoglobin result from Red Blood
Cell(RBC) destruction.When RBC is destroyed ,the breakdown product are release
into the blood circulation where haemoglobin splits into two fraction:hame and globin.
The globin (protein) portion is used by the body and the heme is converted to
conjugated bilirubin, an insoluble substance to albumin.
In liver ,the bilirubin is detached from the albumin molecule in presence of enzyme
glucornyl transferase is conjugated with glucuronic acid to produce a highly
soluble ,conjugated bilirubin glucoronide ,whivh is then excreted into the bile.In the
intestine ,bacterial action reduces the conjugated bilirubin to urobilirobinogen ,the
pigment that gives the stool its characteristics color.Most of reduce bilirubin is
excreted through feces.
Normally, the body is able to maintain a balance between the destruction of RBCs
and the use and excretion of the byproducts.However, when developmental
limitation or a pathologic process interferes with this balance; bilirubin accumulates
into tissue to produce jaundice.
                                    
                       

Signs and symptoms of jaundice

The symptoms of jaundice are extreme weakness, headache , and fever ,loss of appetite
,severe constipation ,nausea ,and yellow discoloration of the eyes ,tongue ,skin and urine
The patient may also feel a dull pain in the liver region.Obstructive jaundice may be
associated with intense itching.

In my patient,the yellowish discoloration of the sclera,skin and tongue is present.

Diagnosis:

      a.    History Taking: Positive family history of jaundice and anaemia,Previous babies with                  
jaundice
     b.    Family history of neonatal or early infant deaths due to liver disease suggesting                            
Galactesemia.
     c.    Maternal drugs such as sulphonamides or antimalarial drugs causing haemolysis in baby
    d.    Physical examination findings: Presence of yellowish staining of sclera ,skin and mucus      
membrane.
    e.    A blood test will confirm the raised bilirubin level and other tests such as those for hepatitis
and haemolysis are also done on the blood.
  Blood serum bilirubin
  Complete blood count
  Liver function test and bilirubin
  Prothombin time
  Bleeding time
  Clotting time

      f.     Urine and fecal test(urobilinogen)

    g.    Ultrasound scanning of the liver and bile ducts for signs of obstruction,which often can
give  useful information on the pancreas gland.
     h.    Endoscpic retrograde cholangiopancreotography
     i.      Ct scanning also helps to diagnose obstructive jaundice accurately

Investigation done in my patient:

Investigation item                                 findings                  normal range
                                            2069/03/27
WBC                                                   9800/cu mm              (4,000-11,000)
Polymorph                                           54   
Lymphocytes                                       46
Hb                                                        8.7gm%                          (13.5-17.5)
Total protein                                         6.5                            (6-8gm%)
Albumin                                                 3.2                           (3.5-5.2 gm %)
Bilirubin (Total)                                      16.6                         (0.4-0.8mg%)
Bilirubin (conjugate)                              11.2                          (0.4mg%)
Alkaline phosphate                               1220
SGPT                                                    655
                                     URINE EXAMINATION
Macroscopic                                       Color  light yellow
                                              
pH                                                      Acidic
Sugar                                                 Nil
Appearance                                       clear
Albumin                                              Nil
Microscopic
Puscell                                               NIl
RBC                                                   Nil
Cast                                                   Nil
Crystal                                                Nil
Epithelial cells                                    Nil
Bacteria                                              Nil

                                      2069/3/28
Thyroid function Test

T3                                                       5.42                              (4.2-8.1pmol/l)

T4                                                       14.9                              (10.0-28.2pmol/l)
TSH                                                    6.76microunit/ml           (0.4-4.6mIU/ml)
Ultrasonography :
Liver :normal
Gall Bladder: Normal
Kidney: Bilateral mild hydronephrosis,loss of CMD(corticomedullary differentiation)
Impression :? Medico renal disease
                                                069/3/29
Ultrasonography :
Liver :normal
Gall Bladder: Normal
Kidney: right lateral hydronephrosis with echogenicity of bilateral kidney
Impression : Right in thinned out Renal Parenchyma CMD layered
                Hb electrophoresis
Hgb                                        6.4gm%
PCV                                       21.7%
RBC                                      27,900,00cmm
WBC                                     12800/cmm
Platelets                                184000
Retics                                     4.0
MP corrected                          2%
HbF                                         0.8%
HbA2                                       3.6% 
 Hb Electrophoresis: Normal banded Speen;Normal Hb Electroporesis

                                     
                                         069/04/1
Ultrasonography :
Liver :7.8 mm with normal echotexture
Spleen: 7.2 mm with normal texture 
Kidney: Mild dilatation at right kidney
Impression : spleenomegaly
                      Mild hydronephrosis

                                    
                                   069/04/03
Hb                                      4.8

                                     
                                     069/04/04
Cholesterol                       174mg%                                150-250mg%
Total Protein                     6.2                                          6-8g%
Albumin                            4.1                                          3.5-5.2
Bilirubin Total                   21.1                                         0.4-0.9mg%
Bilirubin Congugate          15.3                                         0.4gm%
SGPT                                 285
SGOT                                  208
PT                                       18 sec                                     (12 sec)
APTT                                   26sec                                       (23sec)

Anti HCV test                       NON REACTIVE

HbsAg                                  NON REACTIVE
TORCH IgM Antibody test result(Method ELISA)
Toxoplasma gondii                                 NEGATIVE
Rubella Virus                                          NEGATIVE
Cytomegalovirus                                     NEGATIVE
 Herpes Simplex Virus I                           NEGATIVE
Herpes Simples Virus II                          NEGATIVE
TORCH IgG Antibody test result(Method ELISA)
Toxoplasma gondii                                 778                       <50iu span="span">
Rubella Virus                                          283                       <10iu span="span">
Cytomegalovirus                                     10.3                       <0 .5iu=".5iu" span="span">
Herpes Simplex Virus I                           148                         <5 .0iu=".0iu" span="span">
Herpes Simples Virus II                          1.6                          <5 .0iu=".0iu" span="span">

Preventions of Jaundice:
Although jaundice cannot be totally prevented but recognition and treatment are important in
preventing bilirubin levels from rising to dangerous levels.If your baby’s color id turning more
yellow , promptly call your baby’s physician.
         Feed babies frequently and don’t let them become dehydrated
         With jaundice,the important thing to prevent kernicterus –toxic levels of bilirubin
accumulating in the brain. Early identification and treatment of jaundice will usually prevent
kernicterus, whatever the cause.
Treatment of Jaundice:
Most jaundice needs no treatment,but when it does,the given below treatments are possible:
      1.    Encourage frequent nursing ,at least 8-10 times per day and avoid pacifiers.
    2.    Avoid supplementation of mother’s milk with water  or glucose water.If supplementation
needed due to some reason then give expressed breast milk of formula feeding
approximately   30ml/feeding for term and near term infants.
      3.    Halted breast feeding until bilirubin level drop in case of prlonged jaundice
     4.    Phototherapy (light therapy) is  considered very safe and effective.Placing the baby under
blue “bililights” lights – naked in a bassinet,with his eyes covered – will often do the trick
because ultraviolet light changes the bilirubin to a form that your baby can more easily
dispose of in his urine.
      5.    Fibre optic blanket:another option involves wrapping the baby in a fibre optic blanket
called a bili-blanket or bili-pad
   Phototherapy is usually effective,but if a baby develops a severe case of jaundice ,or his
bilirubin levels continue to rise despite phototherapy treatment ,he may need to be admitted
to the intensive care unit for a blood transfusion called an “exchange transfusion”.

If left untreated ,Hyperbilirubinemia due to Neonatal Jaundice can result in mental

retardation,cerebral palsy, behavioural problems,hearing loss or even loss of life.

Nursing consideration of child with jaundice :

     1.      Routine physical assessment of baby chould be done by observing the color of
the sclera and the skin            ,including palms,soles and mucus membrane at
regular intervals under natural lights

     2.      Reorganization anf differentiation of type of jaundice and early refferal

     3.      Provide supportive care

         Early breast feeding
         Optimal thermal environment
         Sterile saline soaked dreesing in umbilical cord for possible exchange transfusion
         Maintain intake/output chart accurately
         Fluid volume correction
         Assist in medical therapies such as collection and sending of investigations

     4.      Monitor vital signs and record accurately

    5.      Emotional support:parents need constant reassurance,clear explanation about

infant’s condition in                  understanding level

    6.      Prevent blood incompatibility:

         Encourage pregnant women to seek early antenatal care
         Determine blood group
         Administer RHoGAM to Rh-negative mother at delivery or during abortion

   7.      Identify infants at risk for hyperbilirubinimia and kernicterus:

         Observe color of amniotic fluid at time of rupture of membrane and delivery
         Early detection and early referal to physician
         Early detection of risk conditions(acidosis,hypoxia,and hypothermia) that decreased
the risk of kernicterus

    8.      Care of baby receiving phototherapy

         Assure effectiveness irradiance by placing the babay to machine at distance of 45
cm change bulbs every 2000hours of used,periodic checks of spectrum of irradiance
produced by sifferent photo therapy units
         Provide eye protection:ensure the closure of the lids before applying shield and
check eye fordischarge,irritation and pressure as well.Gently clean the infant’s eye
strile cotton or soft gauze moistened with sterile water or saline,starting with the
inner canthus of the eye on moving outward in a single,smooth stroke.A separate
cleaning pad should be used for each eye.
         Change the position of the baby frequently(every three hourly)
         Monitor vital signs every 4 hourly
         Assess skin exposure :the largest area of the infant’s body,the trunk should be
positioned in the center of the light,where irradiance highest and change position as
per need.Remove diapers for intensive phototherapy when the serum bilirubin level
approaching high level.
         Assess and adjust thermo regulation devices
         Promoting elimination and skin integrity

     9.      Maintain hydration
         Assess early sign of dehydration
         Ensure that the baaby is fed
         Encourage mother to breast fed at least every three hourly.If baby receiving
intravenous fluid or expressed breast milk ,increasethe volume of fluid by 10% of
total daily volume per day as long as the baby is under photo therapy
         Maintain intake output chart
         Promoting parent –infant interaction:unless jaundice is severe,photo therapy can
safely to interrupt at feeding time,allow parental visits and encourage skin to skin
contact
         Monitoing bilirubin levels:The most significant decline in bilirubin level occurs in the
first 4-6 hours after initiating photo therapy so assess bilirubin periodically
         Proper recording of duration and type of therapy

     10.  Care of baby receiving exchange transfusion

         Give infant nothing by mouth prior to procedure(usually for 3-4 hours)
         Check donor prior transfusion
         Assist physician during tranfusion
         Monitor optimal body temperature during procedure
         Observe signs of exchange transfusion reactions
         Keep resustication equipment ready at bed side(baby size)
         Apply aterile dressing to catheter site and check for bleeding
         Keep nrecording accurately(amount of blood infused anf withdrawn)
         Observe for complications
         Observe for signs of central nervous system depression such as
lethargy,hypotonia,poor sucking,convulsions,high pitched cry
         Observe for hypothermia,dehydration and diarrhoea and bronze-baby syndrome
         Observe for cord bleeding and infections

    11.  Follow up care and visit:periodic assessment of baby’s

condition,breastfeeding,observe for signs of anaemia and provide ferrous sulphate
supplementation at 2-3 month period

   12.  Parent teaching on:disease,treatment,homecare,nutritional care,signs of

severity,infections etc.

Complications:
         a.      Acute bilirubin encephalopathy
         b.      Kernicterus
         c.       Abnormal motor movement
        d.      Behavior disorder
        e.      Sensor neural hearing loss

NURSING MANAGEMENT:
Assessment:
During patient's assessment, I observed following things:
Patient's general condition.
Vital signs.
Nutritional status
Anxiety level of parents.
 NURSING DIAGNOSIS:
         Imbalanced Nutrition:Less than Body requirements related to inadequate intake
and                diarrhoea
         Impaired skin integrity related to hyperbilirubinemia and diarrhoea
         Anxiety related to change in health status(patient’s mother)
                     Fluid volume deficit r/t poor absorption
          Potential for altered growth-due to liver disease
          Altered Growth and Development r/t chronic illness
          Health Maintenance Altered, need for family to monitor for symptoms of increased liver
dysfunction

NURSING
CARE PLAN
SN Nursing Nursing goal Nursing intervention Rationale Evaluation
diagnosis

1. Imbalanced The client will - Record the number -Variations help identify fluctuating My goal was met the
Nutrition:Less maintain and quality of faecal intravascular volumes or changes in risk for fluid deficit was
than Body adequate vital signs associated with immune minimized.
requirements infantile body response to inflammation
-Monitor skin turgor
related to fluids -indicators of adequacy of peripheral
inadequate intake circulation and cellular hydration
and                 -Monitor intake output -Monitor intake and output (I &O);note
diarrhoea urine color and concerntration and
-Give water between specific gravity
breastfeeding or giving -Indicators of return of peristalsis and
a bottle readiness to begin oral intake

-Reduces risk of gastric irritation and

vomiting to minimize fluid loss

2.  Impaired skin The integrity -Useful in monitoring effectiveness of My goal was partially
integrity related to of the baby medication,progression of met. The patient was
hyperbilirubinemia skin can be - Assess skin color healing.Changes in characteristics of quiet relieved by the
and diarrhoea maintained every 8 hours pain may indicate developing therapy but not
abcess /peritonitis,requiring prompt controlled.
medical evaluation and intervention.
-Monitor direct and
-Being informed about progress of
indirect bilirubin
 situation provides emotional support,
-Change position every helping to decrease anxiety
2 hours -Relief of pain facilitates cooperation
-Massage the area that with other therapeutic interventions,
stands out -Refocuses attention, promotes
relaxation, and may enhance coping
abilities. 
-Keep your skin clean -Decreases discomfort of early
and moisture intestinal peristalsis and gastric
irritation/vomiting.

3. Anxiety related to -to relieve -examine the level of Understanding promotes cooperation My goal was met the
change in health anxiety anxiety with therapeutic regimen, enhancing patient party was less
status(patient’s healing and recovery process anxious and well
mother) oriented about his
-Give information about
disease condition.
the disease process
and actions -to gain trust from the patient party
-reassure the patient
party
-Enhance the patient
general activity

4. Fluid volume maintain fluid -document and - Useful in My goal was fully met,
deficit r/t poor and monitor :intake and assess for signs of blood transfusion done,
 absorption electrolyte output,  specific gravity, dehydration, assess for fluid overload, haemodynamically
balance daily weights, daily stabilized.
abdominal girth -regular vital sign helps to rule out any
measurements, deviation normal body functions as
well as presence of infection in body
-check vitals, monitor -to maintain haeomostatic equilibrium
for signs of tachycardia - to assess the proper liver function
or new murmurs, and kidney function

 -blood transfusion -to assess the peripheral circulation

-Check laboratory
studies for electrolyte
imbalances,

-Capillary refill less than

3 seconds and urine
output.
5. Potential for Infant/ child -Monitor growth curve- Chart above information, be able to My goal was partially
altered growth- grow monitor weight on identify and   report abnormalities and met. The patient party
due to liver following regular basis. reassess was well instructed for
disease growth curve the continuous growth
-assess range of motion, gross and
while monitoring.
-Assure that ADEK fine motor skills
maintaining
appropriate vitamins taken on
nutritional regular basis, monitor
lab values.
 status
-Instruct regarding
methods to increase
calories: medium chain
triglyceride formula,
additional formula
supplementation.
6. Knowledge deficit Parents -Teach parents about Proper knowledge about the disease My goal was met. The
R/T Homecare understand medications including helps to promote cooperation with parents were well
Instructions home care purpose, dose, therapeutic regimen, enhancing conscious about the
instructions.  patient and caring.
administration, side healing and recovery process as well
effects and signs and as coping abilities.
symptoms to report. -regular follow up helps for regular
monitoring of the child’s health status.
-Teach parents
importance of
compliance relating to
testing, medications
and follow-up visits.
Teach parents to
identify, verbalize and
report changes in
child’s health status.

8. Health Family/ -Review with parents Early instruction about the My goal was met. The
Maintenance Parents the signs and complications due to   altered body patient party was well
Altered ,need for familiar with symptoms of worsening function helps in early identification conscious about the
family to monitor symptoms of liver function including: and treatment if present child and no any
for symptoms of complication shows
worsening change in stool color,
increased liver up. Though,blood
liver function. ascites, peripheral
dysfunction transfusion was done.
edema,
hepato/spleenomegaly,
anorexia, urine color,
lethargy, jaundice, -early management help to gain good
bleeding, and pruritus. prognosis if any complication prevails.

-Educate regarding -the early identification helps in

complications of end effective management.
stage liver disease.

-Attempt to identify of
signs and symptoms of
bleeding with treatment
of vitamin K or perhaps
even a transfusion
APPLICATION OF NURSING THEORY
 
                       By applying nursing theory of  Faye Glenn Abdellah's Theory,
holistic care was given to my patient from the day of my visit.

"Nursing is based on an art and science that mould the attitudes, intellectual
competencies, and technical skills of the individual nurse into the desire and
ability to help people , sick or well, cope with their health needs." -
Abdellah                      

“Although Abdellah spoke of the patient-centered approaches, she wrote of nurses

identifying and solving specific problems. This identification and classification of problems
was called the typology of 21 nursing problems. Abdellah’s typology was divided into three
areas:
(1) the physical, sociological, and emotional needs of the patient;
 (2) the types of interpersonal relationships between the nurse and the patient; and
(3) the common elements of patient care.

Adbellah and her colleagues thought the typology would provide a method to evaluate a
student’s experiences and also a method to evaluate a nurse’s competency based on
outcome measures.”

(Tomey & Alligood, Nursing theorists and their work 4th ed., p. 115).

Abdellah’s Typology of 21 Nursing Problems are as follows:

1. To promote good hygiene and physical comfort

2. To promote optimal activity, exercise, rest, and sleep
3. To promote safety through prevention of accidents, injury, or other trauma and through the
prevention of the spread of infection
4. To maintain good body mechanics and prevent and correct deformities
5. To facilitate the maintenance of a supply of oxygen to all body cells
6. To facilitate the maintenance of nutrition of all body cells
7. To facilitate the maintenance of elimination
8. To facilitate the maintenance of fluid and electrolyte balance
9. To recognize the physiologic responses of the body to disease conditions
10. To facilitate the maintenance of regulatory mechanisms and functions
11. To facilitate the maintenance of sensory function
12. To identify and accept positive and negative expressions, feelings, and reactions
13. To identify and accept the interrelatedness of emotions and organic illness
14. To facilitate the maintenance of effective verbal and nonverbal communication
15. To promote the development of productive interpersonal relationships
16. To facilitate progress toward achievement of personal spiritual goals
17. To create and maintain a therapeutic environment
18. To facilitate awareness of self as an individual with varying physical, emotional, and
developmental needs
19. To accept the optimum possible goals in light of physical and emotional limitations
20. To use community resources as an aid in resolving problems arising from illness
21. To understand the role of social problems as influencing factors in the cause of illness

HEALTH EDUCATION TO THE CLIENT AND FAMILY

REGARDING HEALTH MAINTAINANCE
             
               Health teaching plays an important role to prevent disease, promote health
as well as to cure diseases more rapidly without any complications. One of the most
important roles of nurse is to provide health education. So, I provided health teaching
to family as well as patient objectives of health education are as follows:
-To promote health
-To motivate for early diagnosis and treatment
-To help limitation of disability
-To help in rehabilitation.

         Keeping these objectives in mind, I gave informal teaching and information to
patient and family.

-Nutrition: The importance of nutritious food and balanced diet. He was advised to
take plenty of fluids and soft hygienic foods.

-Infection prevention: I gave teaching on importance of personal hygiene and the role
of hygiene in infection control

-Rest and exercise: Adequate sleep is necessary for the patient.

- breast feeding
-Supplementary foods
 -immunization
-Personal hygiene
-About disease
-Medications
-Follow up.

                                  
CONCLUSION
         Case study is one of the most important parts of nursing practice. It is the best
method of learning case study concerned with the individualized care which helps to
provide holistic nursing care including physiological, psychological, social and
cultural traditional beliefs.
         According to our B.N. 1st year curriculum, I had taken a case of Jaundice,
named Shishir Kuwar for case study. During this period of case study, at first, I had
collected relevant health history from the patient as well as his family members.
Then I had done complete physical examination of my patient. I gathered lots of facts
and formulated nursing diagnosis. I applied knowledge from the basic sciences,
nursing theories and other related courses, to plan and implement nursing care. I
had studied the normal developmental task of infant and correlate it with my patient.
He meets these entire normal developmental tasks.
         I had also studied about disease its type, epidemiology, etiological factors,
Pathophysiology, clinical manifestations, diagnostic test, therapeutic and nursing
management including Prognosis, Prevention and Possible Complications.
         I had provided different diversion therapy to the patient for stress
management.           
         Finally patient’s general condition was improved day by day and I am satisfied
from this case study and the goals set were fully met.

References
      1.      AZ of Practical Paediatrics,Baral Manindra.R,HISI Offset
printers1st edition,2007,page 234-238
      2.      Nursing 2012 Drug Handbook,Kluwer Wolters,Lippincott Williams and wikins, 32
edition page 780,1169,273,1466.
      3.      http://www.whereincity.com
      4.      Child health Nursing,uprety kamala,pradipa printing and publishing 1st edition pg no:
200-208
      5.       http://www.medindia.net
      6.       http://www.drugs.com
      7.  Internet: www.google.com.np