|Noticing – Gathering Cues & Coming to Know the Patient
Provide a synopsis/summary of the salientinformation you have learned about your patient – as an individual patient and as a person
|Synopsis of Patient:
Patient was a 4-day old infant who came in with a diagnosis of polycythemia and a second diagnosis of hyperbilirubinemia. However, they were asymptomatic at the time of admission to the pediatric unit. The patient was placed in an incubator under an order to receive phototherapy to treat their hyperbilirubinemia.
The patients mother and brother have a history of G6PD. Patient was of Asian descent, which increases the risk of developing G6PD (Frank, 2005). Written report from the physician also noted there had been delayed cord clamping at the time of the infant’s birth, however the reasons remain unclear as to why. Routine bloodwork was drawn and it was noted that the infant is also likely G6PD deficient.
Both parents were highly attentive to the patient throughout the day. Patient was also breast fed, while the mother adhered to a strictly vegetarian diet. Throughout the day, the infant slept well between feeds, cuing themselves and fed well. The patient did not exhibit any signs of pain when assessed.
Medications and IV:
Vitamin D: 400 IU given PO once a day. Vitamin D is usually given to neonates as many babies are found to be vitamin D deficient, largely due to the lack of sun exposure. To combat this, 400 unites of vitamin D is recommended daily for women who are pregnant or breastfeeding, particularly if the infant is less than 6 months of age (Wu, 2014, p.1).
D5W 0.45% NaCl- peripheral IV which was set to 2ml/hr. For babies the recommended dosage is 20 to 100 ml per 24 hours per kg of body weight. Typically, this solution is indicated for the treatment of hypertonic extracellular dehydration, where the intake of fluids by normal routes (ex. Mouth) is not possible.
Vitals were stable and within normal ranges. No significant findings when conducting the head to toe exam. Urine output during the shift was 2.6 cc/hr. Skin turgor was good.
Bilirubin: 230 (increased)
Red cell distribution: 16.0 (increased)
Platelet count: 118 (low)
Blood glucose: 3.6 (low)
|Interpreting – Clinical Reasoning
Describe the relationships between the pieces of information and why they are significant for your patient at this time.
Identify the possible alternatives to choose from in caring for your patient.
|Significance of Findings
– The detailed family history of G6PD (a common enzyme deficiency) increases the likelihood that the child will develop the deficiency as well as a contributing factor (along with polycythemia) for why they were likely experiencing neonatal hyperbilirubinemia (Frank, 2005). In comparison the general population, the prevalence of neonatal hyperbilirubinemia is twice as likely (Frank, 2005). The risk for developing G6PD is further increased because their sibling also experienced neonatal jaundice and is G6PD deficient.
– The significance of delayed cord clamping (30-180 seconds after delivery) has been found to increase rates of both hyperbilirubinemia, transient tachypnea, as well as polycythemia (Mercer, 2001, p. 403). While delayed cord clamping has shown some indication in reducing the risk of anemia in some infants, it has been found to increase hematocrit, hemoglobin and the risk of jaundice requiring phototherapy (Saba, Majeed, & Bukhari, 2012, p.309).
– The lab work also indicated increased bilirubin levels of greater than the 95thpercentile (Richardson & O’Malley, 2017). This is a significant finding because with a diagnosis of polycythemia, common lab abnormalities include low blood glucose and hyperbilirubinemia. In this case, the hyperbilirubinemia is caused by the higher turnover rate in the number of red blood cells (Walter, 2017). Because of this, it likely explains why the patients red cell distribution was elevated at 16.0. In this case, the hemoglobin and red blood cell count was expected to be truly elevated due to their diagnosis of polycythemia.
Options for care
Because of the variability in obtaining measurements of hematocrit (Hct) between capillary and venous samples, standard guidelines indicate that a diagnosis of polycythemia is based upon peripheral venous samples. This was done twice daily (or q 12hrs) on my patient in the evening and morning as his venous Hct was 0.653 at his highest level. Standard published guidelines indicate that when family history, ethnic, and timing of the presentation of jaundice suggest the possibility of G6PD, appropriate lab testing should be performed on the infant. Since my patient falls into all three categories it was important that this blood work was done.
Management of polycythemia seems to be controversial in the literature, however, all infants should be monitored for complications such as hyperbilirubinemia and hypoglycemia. In neonatal patients, research has indicated that treatment largely focuses on the management of the jaundice, as well as the prevention of kernicterus (Richardson & O’Malley, 2017). To care for this patient and based of standard published guidelines, an order for phototherapy is required. Standard guidelines also indicate the polycythemia infants should also have their bilirubin and blood glucose levels monitored frequently (NHS- Worcestershire, 2015, p.3).
As the extra red blood cells (polycythemia) break down, it is not uncommon for an infant to have yellowing of the skin for a short period of time (Walter, 2017). Since the patient was currently experiencing hyperbilirubinemia, the most common treatment is phototherapy. As the infants skin absorbs a specific spectrum of blue range light, unconjugated bilirubin is converted through photo oxidation and excreted in both the stool and urine (Muchowski, 2014, p. 874). It has also been indicated that phototherapy is effective at both preventing and reducing and increase in bilirubin levels (source).
As the patient did not have a bilirubin level approaching 15-20mg/dL, there was no need to explore an exchange transfusion. This option for care is typically used in cases where the cause of hyperbilirubinemia is due to blood group incompatibility, rather than physiologic jaundice (source).
What are the pharmacological management options, why these are appropriate?
In many cases, polycythemia has no lasting effects. As the patient was asymptomatic when admitted for polycythemia, recommendations for treatment are as follows (Sankar, Agarwal, Deorari, & Paul, 2010, p.1120):
1. If the infant has a hematocrit (Hct) value of over 75%: Partial Exchange Transfusion (PET) is recommended to improve cerebral blood flow, cardiac function, and capitally perfusion. In these cases, normal saline or ringer’s lactate are the preferred crystalloids (de Waal, Baerts, & Offringa, 2006, p.8).
2. Hct value is between 70% and 75%: Conservative management with fluids may be ensured by parenteral (IV) or enteral (supervised feedings). This encourages hemodilution and a decrease in viscosity of the blood. However, this treatment should be reviewed on a case-by-case basis for preterm infants.
3. Hct values between 65% and 70%: Monitoring for symptoms and re-estimation of hematocrit values.
|Responding – Decision Making
Describe the decisions you made in caring for your patient, the factors that influenced your decisions, and how you determined the priorities of your care.
Describe any adjustments or changes you made to your care based on follow-up assessment of your patient
|The most appropriate action(s) and what I did:
1. My main priorities for today’s shift were to ensure that the infant was kept under the lights of the phototherapy for as much as possible throughout the day with as much skin as possible exposed (Stokowski, 2011, p. 14). With this it was important to monitor the infants level of activity, in that increased levels of unconjugated bilirubin in the brain could lead to the infant exhibiting decreased levels of consciousness or becoming increasingly lethargic (Walter, 2017). Therefore, visually assessing the child through the incubator, as well as in the mother’s arms when breastfeeding was an important priority.
2. As the infant was under phototherapy it was also important to monitor the infant’s temperature as well as that of the incubator every 1 to 2 hours. With this the infant is at risk for hypothermia when out of the incubator and at risk for hyperthermia when under the phototherapy unit (Stokowski, 2011, p. 19).
3. My second priority was to monitor the infants’ ins/and outs. I could accomplish this by charting how often and how long each of the feeds were for the infant. As well, I could collect and weigh each diaper to calculate a urine output. As the infant had lost weight it is important to take into consideration their hydration level and oral intake. Urine output for the patient for most the night shift had been considerably low, with having had only one diaper since the IV fluids had been reduced. It was important that I watched the infants’ hydration levels, as adequate hydration is needed to help with absorption and excretion of conjugated bilirubin as it passes through the liver. With this, known side effects of phototherapy include dehydration due to insensible water loss, dark yellow urine, watery diarrhea, and retinal damage (Stokowski, 2011, p. 19).
1. The expected outcome of the phototherapy was to deliver light within a narrow spectrum to help reduce bilirubin. When assessing the infants’ skin colour and sclera there were no signs of jaundice. It was also important to note that while the average total serum bilirubin level usually peaks to about 5 to 6mg/dL on the third or fourth day of life, it declines thereafter. In this case, the infant’s bilirubin levels had peaked the night before, but on the fourth day after having been placed under phototherapy, the levels began to decline. This is consistent with other healthy newborns experiencing physiological jaundice during the first week of life (Porter & Dennis, 2002, p.602).
2. The expected outcome was that the infant’s temperature would not fluctuate throughout the day. As infants are prone to temperature instability, this can be more evident in infants under closed care systems (Stokowski, 2011, p. 19). Tachycardia, restlessness, or plethora are signs that indicate an infant may be overheating due to the increase ambient air temperature (Stokowski, 2011, p. 19). In this case, the infant exhibited none of those signs.
3. The expected outcome of also monitoring my patients’ intake and output also yielded important information. Throughout most my shift, the infants’ urine output was only 1.4cc/hr, which hovered along the lower end of the output curve. However, by the 10th hour, the urine output had jumped up to 2.6cc/hr, which was within a normal limit considering the infant had fed well throughout my shift and was on 2ml/hr of IV fluid which had just been creased from 3ml/hr the day before.
|Reflecting – Learning through Experience
Respond to one of the following:
“I learned about myself . . .”
“I learned about nursing . . .”
| Learning through experience
Today I felt I learned quite a bit on how to care for infants and the importance of supporting both the infant and parents in caring for their child. While both polycythemia and hyperbilirubinemia are new conditions for me, I learned in nursing that sometimes patient and their families own experiences can help facilitate optimal care. In this case, the family has previously experienced a similar event when their first child was born with similar symptoms and has also been admitted to the pediatric unit. With the prolonged and unexpected stay of their second child, the patient’s mother had expressed feeling guilt towards not being there to support her first born who had just started school and having to focus all her attention on her hospitalized child. Similar feelings have been noted to be common, with one qualitative study pointing out that with extended hospitalization stays, parental concern for their other children increases in relation to their emotional safety, their health and other care (Calcagno & de Oliverira, 2012, p.169).
Talking throughout the day with the parents, it was evident how important it was for the mother to feel and be involved as much as possible with caring for her child as it helped keep her optimistic in being able to take her baby home and perform the same tasks. This feeling is consistent in the literature with parents of children being cared for in hospital emphasizing the importance of making them feel involved (Dahav & Sjostrom- Strand, 2017, p.365).
With caring for young patients, I felt it was important to always keep at the forefront how vital it is to keep the parents involved in all aspects of care, largely because the parent’s perception of the situation can also influence patient care. When a child is that young, they are dependent on the people around them, it is important for nurses to provide not only health teaching, emotional support but reminders that self-care is important to. Through this I encouraged my patients mother to take a shower, while I watched over the patient and giver her comfort knowing her needs mattered too. This seemed to make the mother feel more at relaxed. This encouragement is supported in the literature, in that through promoting self-care, family bonds become strengthened as they feel they are better able to assist the child when their own physical and emotional needs have been met (Calcagno & de Oliverira, 2012, p.170).
Gomes, G.C. & de Oliveira, P.K. (2012). Family experience in the hospital during child hospitalization. Rev Gaucha Enfrem,33(4), 165-171. Retrieved from http://www.scielo.br/pdf/rgenf/v33n4/en_21.pdf
Dahav, P. & Sjostrom-Strand, A. (2017). Patients’ experiences of their child being admitted to a paediateic intensive care unit: a qualitative study- like being in another world. Scandinavian Journal of Caring Science, 32(1), 363-370. Retrieved from https://onlinelibrary.wiley.com/doi/epdf/10.1111/scs.12470
de Waal, K.A., Baerts, W., & Offringa, M. (2006) Systematic review of the optimal fluid for dilutional exchange transfusion in neonatal polycythemia. Arch Dis Child Fetal Neonatal Ed; 91(1), 7–10. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2672658/
Frank, J. (2005). Diagnosis and management of G6PD deficiency. Am Fam Physician, 72(7), 1277-1282. Retrieved from https://www.aafp.org/afp/2005/1001/p1277.html
Mercer, J.S. (2001). Current best evidence: a review of the literature on umbilical cord clamping.J Midwifery Women’s Health, 46(6), 402-12. Retrieved from https://www.sciencedirect.com/science/article/pii/S1526952301001969
Muchowski, K.E.(2014) Evaluation and treatment of neonatal hyperbilirubinemia. American Academy of Family Physicians, 89 (11), 873-878. Retrieved from https://www.mcgill.ca/familymed/files/familymed/hyperbilirubinemia_in_newborns.pdf.
Porter, M.L., & Dennis, B.L.(2002).Hyperbilirubinemia in the term newborn. American Family Physician, 65(4), 599-606.Retrieved from https://www.aafp.org/afp/2002/0215/p599.html
Saba, K. Majeed, T. Bukhari, M.H. (2012). Early vesus delayed umbellical cord clamping leads to neonatal anemia. Annals of King Edward Medical University,18(3), 309-315). Retrieved from http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.679.2702&rep=rep1&type=pdf
Sankar, J.M., Ramesh, A., Deorari, A., & Paul, V.K. Management of polycythemia in neonates. Indian Journal of Pediatrics, 77(1), 1117-1121. Retrieved from http://medind.nic.in/icb/t10/i10/icbt10i10p1117.pdf
Walter, A. (2017). Perinatal polycythemia and hyperviscosity syndrome. Merck Manual. Retrieved from https://www.merckmanuals.com/en-ca/professional/pediatrics/perinatal-hematologic-disorders/perinatal-polycythemia-and-hyperviscosity-syndrome
Wu, Z. (2014). Vitamin D supplementation in neonates. BMJ Quality Improvement Reports, 1-3 Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4645901/pdf/bmjqir-3-u203171-w1436.pdf