NURSING CARE REPORT OF Mrs.

Is BABY WITH
MEDICAL DIAGNOSIS
HYPERBILIRUBINEMIA IN TERATAI WARD (BABYS
WARD)
BANJARMASIN ULIN GENERAL HOSPITAL

By:
HJ. MINA HAYATI
SRN. 011017 D3 KI
BANJARMASIN MUHAMMADIYAH HEALTH COLLEGE
INTERNATIONAL OF NURSING DIPLOMA PROGRAM
2014

BACKGROUND
According to data Demographic Survey and
Indonesian Healthy (2012), the infant
mortality 34 / 1,000 live births. Among
this number, 19 / 1.000 occurred in the
neonatal period from birth until the age of
28 days
According to medical record data in
Banjarmasin Ulin General Hospital on
January 2013 - February 2014, the amount
of baby with hyperbilirubinemia in all units
is 417 infant.

DEFINITION
According to Maryunani and Nurhayati
(2009), hyperbilirubin is a condition in
newborn which the total serum bilirubin
levels 10 mg% at full term and 15 mg% in
preterm, resulting jaundice of the skin,
sclera, mucous, and urine.

ETIOLOGY
1. Destruction of red blood cells
(hemolysis of red blood cells), for
example: Incompatibility of the
rhesus and sepsis
2. Impaired of metabolism, for
example: premature, immature of
cepalenhepar
3. Impaired excretion of bilirubin

PATHOPHYSIOLOGY
Hemoglobi
n

Heme

Globin
Biliverdin

Feco

Increased erythrocytes destruction (impaired of bilirubin conjugation

/ impaired bilirubin transport / increased enterohepatic cycle)
abnormal Hb and erythrocytes
Risk
Overload bilirubin broken
damage of
Liver unable to did
skin
conjugation
integrity
Increased bilirubin conjugated on the
blood
Icterus on the sclera, neck, and body, Increased indirect bilirubin
12mg/dl
Phototherapy
Indication
Risk for Injury

Deficit fluid volume

Temperature
impaired

SIGNS AND SYMPTOMS

Skin Jaundice (yellow)
Sclera jaundice
Incresed bilirubin serum which 10 mg% at full
term neonatus and 15 mg% in preterm neonatus
Decrese activity and hypotonia
Weight loss of 5% in 24 hours caused by low
intake
Fever
Tremors
Weak sucking reflexes or dont want to dirnk milk
Liver enlargement
High-pitched cry (kernicterus)

COMPLICATION
According to Lyndon (2014), complication of
hyperbilirubinemia are:
Kern icterus (biliary encephalopathy) is a
brain damage as a result of indirect bilirubin
in the brain
Lethargy
Seizures
Doesnt want to suck
Increased muscle tone, stiff neck ,
epistonus, and cyanosis.

NURSING CARE REPORT

CLIENTS IDENTITY
Name : Baby of Mrs. I
Sex
: Male
Date of Birth : Sunday, May 6th, 2014 at
13.50 pm
Date of Assessment
: Thursday, May 8th,
2014
Medical Diagnosis : Hyperbilirubinemia
Main Complaint : Mrs. I said that her baby
just
wanted to drink a little
and
her babys body looked yellow.

PROBLEM PRIORITY
Damage skin integrity related to
pigmentation changed (jaundice),
radiation, erythema.
Risk for injury
Risk for deficit fluid volume

IMPLEMENTATION
Nursing Diagnosis 1st :
Damage Skin Integrity Related To
Pigmentation Changed (Jaundice), Radiation,
Erythema.
Assessing the skin condition and recording any
change of skin conditions such as rush, irritation,
etc.
Changing the baby's position every 3 hours.
Keeping the baby's skin always clean, not wet and
giving baby oil.
Maintaining the crib always dry, clean, free from
folds and changing immediately the sheet and
babys diaper when wet or dirty.

Continue....
Nursing Diagnosis 2nd :
Risk For Injury
Assessing babys vital signs.
Measuring the baby's body weight every day.
Maintaining babys intake like giving milk
repeatedly as babys needs with the syringe.
Measuring fluid intake-output.
Assessing defecating and urinating frequency.
Monitoring signs of dehydration (mocus
membranes, skin turgor, and CRT).
Giving appropriate fluids.

Continue....
Nursing diagnosis 3rd :
Risk For Deficit Fluid Volume
Assessing and recording skin color from head,
sclera and body every shift.
Putting the baby under phototherapy light
with distance 45 cm.
Letting the baby naked but protecting the
babies eyes and genital during phototherapy.
Monitoring any complication like:
hyperthermia, conjunctivitis, dehydration
during phototherapy.
Colaborating to check value of bilirubin level.

EVALUATION

Nursing Diagnosis 1st: Sunday, May

11th, 2014
Damage Skin Integrity Related To Pigmentation
Changed (Jaundice), Radiation, Erythema.
S: Mrs. I said that her baby body is yellow color
O: - The baby was putted in the crib, phototherapy was
stopped at 09.30 pm because babys condition
become better.
- The babys skin looked moist, clean and there is not
rush or irritation anymore.
A: The problem of damage skin integrity had been
solved.
P: Intervention was stopped

Nursing Diagnosis 2nd: Monday, May

12th, 2014
Risk For Injury
Risk factors:
Mrs. I said that her baby drink a breast milk.
Baby vital signs :
T : 36,8C
HR : 140 times/min
RR : 40 times/min
The baby looked active in the bed.
The babys skin turgor is < 2 second.
The baby skin and lips mocus looked moist.
The baby defecated 1 time in this morning.
A: The problem of deficit body fluid volume had been
solved
P: Intervention was stopped

Nursing diagnosis 3rd: Tuesday, May

13rd, 2014

Risk For Deficit Fluid Volume

Risk Factors :
Mrs. I said that her babys body yellow color had
been reduced.
The babys skin and sclera jaundice looked
reduced.
The baby looked dry in the sun by his mother at
the morning during 1 hour.
The baby looked wearing diaper and eye cover
during drying under sunlight.
A : The problem of risk for injury had been solved
P : Intervention was stopped

CONCLUSION
Evaluation of nursing care that given is good
enough because the tree of diagnosis that
appears could be resolved and client could
go home with doctors permission.