PROFORMA FOR REGISTRATION OF



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

|1. |NAME OF THE CANDIDATE AND ADDRESS | |

| | |MS. PRITI RANI BHARDWAJ |

| | |NOOR COLLEGE OF NURSING, |

| | |BHOOPSANDRA MAIN ROAD, |

| | |BANGALORE –560 094. |

|2. |NAME OF THE INSTITUTION | |

| | |NOOR COLLEGE OF NURSING. |

| | |NO.5, NOOR BUILDING, RMV 2ND |

| | |STAGE, BHOOPSANDRA MAIN ROAD, BANGALORE – 560 094. |

|3. |COURSE OF STUDY AND SUBJECT | |

| | |M.Sc. NURSING I YEAR |

| | |PAEDIATRIC NURSING. |

|4. |DATE OF ADMISSION TO COURSE |01-06-2011 |

|5. |TITLE OF THE TOPIC |A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING |

| | |PROGRAMME REGARDING KNOWLEDGE ON NEONATAL JAUNDICE AMONG STAFF|

| | |NURSES IN SELECTED HOSPITAL BANGALORE. |

6. BRIEF RESUME OF THE INTENDED WORK

6.0 INTRODUCTION

“Having a baby’s sweet face so close to your own, for so long a time as it takes to nurse, is a great tonic for a sad soul”

-------ERICA JAMES

With the birth of every child, man may calculate that God is still hopeful about the world He Created. But healthy survival of the children is threatened at every moment. Child health problems are shocking and alarming throughout the world, especially in the developing countries. Expert and empathetic approach is essential to minimize these problems and to reduce the inexcusable causes of childhood morbidity mortality and disability.1

New born are considered to be tiny and powerless and more of all treasure to the nation, completely dependent on others for their adaptation in the external environment within one minute of birth the normal newborn adapts from dependant fetal existence to an independent one capable of oxygenation and carry on physiological processes. Understanding and appreciating this transition are vital to the assessment and care of newborn babies.2

During this process of the physiological process or adaptation for its survival of the infants life or neonates have to face many life threatening problems such as asphyxia, hypothermia, hyperthermia, infections and neonatal jaundice etc. So the assessment and care of newborn is very essential.3

Among these problems neonatal jaundice is the commonest problem among infants in neonatal period. The word jaundice is derived from the French word Jaune which means Yellow. Clinical jaundice manifests as yellowness of the skin of the face when the serum bilirubin level exceeds 5mg/dl. As the degree of jaundice increases, there is a cephalocaudal progression of the yellowness of the skin.when the trunk of the baby is distinctly yellow stained, the serum bilirubin levels is likely to range between 10 to 15mg/dl. The yellow staining of the palms and soles indicates that serum bilirubin level has exceeded 15mg/dl.4

Neonatal jaundice affects 60%of full term infants and 80% of preterm infants, bilirubin level greater than 5mg/dl in the first week of life and about 6% of term babies will have bilirubin levels exceeding 15mg/dl. Neonatal jaundice is a yellowing of the skin and other tissues of a newborn infant with a bilirubin level of more than 5mg/dl.5

Infants jaundice is restricted to the face and part of the trunk and above the umbilicus all have the bilirubin level less than 12mg/dl. Infants whose palm and sole are yellow have serum bilirubin level over 15mg/dl.6

Bilirubin is a yellowish red pigment formed during breakdown of red blood cells. It is normally present in the blood in small quantities when there is excessive red blood cell breakdown the bilirubin level in the blood goes up and it also gets deposited in tissues impacting a yellow colour to the skin.7

In normal benign jaundice tends to develop because of two factors, the breakdown of fetal hemoglobin as it is replaced with adult hemoglobin and the relatively immature hepatic metabolic pathways which are unable to conjugate and so excrete bilirubin as quickly as adult. This causes an accumulation of bilirubin in the blood leading to the symptoms of jaundice.8

Focuses on the importance of monitoring and identifying those early discharged infants who are at risk for developing complications of jaundice, by utilizing standing orders in monitoring babies within 24hours of discharged, bilirubin level can be assessed in the home setting, required interventions can be implemented and unplanned emergency room visits and hospital readmissions can be saved.9

Caring for these newborns those are acutely ill is paramount important and also challenging today. It requires a high-tech nursing care, to implement this, the nurses caring for these children need to be knowledgeable and should possess adequate skill.

6.1 NEED FOR THE STUDY

More than 40% of the population of our country falls in the age spectrum covered by pediatrics. Infants (0-1 years) constitute 2.82% of the total population in India. Infants are a sensitive group that requires care from efficient and competent persons to meet their special needs. They demands special concern for survival. It is the responsibility of the nurse to fulfill the demands of the newborn.10

Neonatal jaundice is a common problem affecting over half of all full term and most of the preterm infants. Jaundice is noticed during the first week of life after birth. Healthcare providers need to be familiar with the diagnosis and management of jaundice to prevent brain, vision and hearing damage. Treatment of choice for jaundice remains close observation and frequent feeding followed by phototherapy and finally exchange transfusion for sense or refractory.9

The WHO reveals the source of incidence of hypebilirubinemia is 50 to 60,000 neonates reported 2% has total serum bilirubin levels over 20mg/dl, the total serum bilirubin level in normal range is0.3 to 1mg/dl.0.15%had levels over 25 mg/dl and 0.01% has over 30mg/dl. Thus we can expect 50,000 in chat 6000 and 400 new borns with bilirubin levels of greater than 20mg/dl and 30mg/dl. Hyperbilirubinemia is one of the most common problems encountered in newborns. Historically, management guidelines were derived from studies on bilirubin toxicity in infants with hemolytic disease. More recent recommendations support the use of less intensive therapy in healthy newborns with jaundice.11

Each year in India over one million new born dies before they complete their first month of life, accounting for 30% of the world’s neonatal death India’s current neonatal mortality rate of 40 per thousand live births represents 1.2 million children who die each year. Neonatal mortality is higher in rural areas at 50 per thousand live births. The neonatal mortality rate also varies considerably among Indian states. Orissa and Madhya Pradesh have the highest neonatal mortality rates of 61(rural 63, urban 42) and 59 (rural 63, urban 40) per 1000 live births respectively. In Uttar Pradesh the rate is 53/1000(rural 56, urban 39) and 31/1000(rural 33, urban 21) in west Bengal. Kerala has the lowest neonatal mortality of 10/1000(rural 10, urban 9), followed by Punjab 29/1000(rural 32, urban19).The Government of India is committed to reduce the neonatal mortality rate to approximately 20/1000 live births by 2015.12

Two-thirds of infant deaths in India occur in the first month of life. Approximately three-quarters of Indian neonatal deaths occur within one week of birth while 90% occur within the first 2 weeks of life. A major challenge in Indian rural areas is that most of the births take place at home, assisted by untrained personnel. As well as the risks associated with the use of traditional birth attendants, the environment into which a child is born also influences survival. It is, therefore important to know about risk factors and prevention of neonatal jaundice.13

In UK incidence of severe hyperbilirubinemia was 7.1/ 100000 live births. Only 20 cases presented in hospital; 88 were admitted with severe jaundice. Co- morbidity included hemolysis, dehydration, infection and bruising. 14 infants showed evidence of bilirubin encephalopathy ,of which 3 died. The UK incidence of bilirubin encephalopathy was 0.9/100000 live births.14

In United States, 4.3% of 47,801 infants had total serum bilirubin (TSB) levels in a range in which phototherapy was recommended by the 2005 American Academy of Pediatrics(AAP) guidelines, and 2.9% had values in a range in which the 2005 AAP guidelines suggest considering phototherapy.15

A study undertaken to evaluate the etiological factors responsible for neonatal jaundice in Shimla, India among 164 neonates. The findings shows that 105(64%) developed clinical jaundice. 68( 64.5%) were boys and 37(35.2%) were girls. Serum hyperbilirubinemia was found in 38 cases(23.1%). In 12(11.4%), no cause could de determined for the jaundice. Physiological jaundice was determined in 67 (63.7%) cases could be determined. Sepsis associated with jaundice was found in 11 (10.5%) cases.16

The study on Neonatal surgical jaundice revisited shows nearly 25 – 50 % of all new borns and a much higher percentage of premature babies develop hyperbilirubinemia. It also consider a possibility of extra hepatic biliary atresia early. During management of a case of direct hyperbilirubinemia as surgical intervention results in a better out come.17

A study conducted on Exchange transfusion for neonatal jaundice in Nigeria to determine the indication for exchange blood transfusion(EBT) in neonatal jaundice and what proportion of EBT was possibly avoidable among 1686 babies admitted in the neonatal unit. The study findings shows that90 (5.3%) had BBT. Fourteen (15.6%) were inborn while 76(84.4%) were out born babies. Fifty six (62.2%) babies were primarily for neonatal jaundice while 34(37.8%) developed neonatal jaundice (NNJ) during admission. Thirty six (40%) of the babies had phototherapy for more than 24 hours prior to EBT either because they were of very low birth weight or NNJ was detected very early therapy was commenced. Sixty-eight (75.6%) babies had single EBT while the remaining 22 (24.4%) had two sessions of EBT. The study concluded that EBT rate in the center was high. With more effective phototherapy, EBT could be avoided in most of the babies, who initially had phtotherapy for more than 24 hours before EBT and repeated EBT sessions.18

The study on Management of neonatal hyperbilirubinemiashows among the total of 114 Newborns in Karnataka. The study revealed that 33.3% (38/114) underwent exchange transfusion by push-pull and 66.7% (76/114) iso volumetric technique. When these two techniques are compared, 59.2% in iso volumetric and 57.9% in push-pull group had more than 40% reduction in bilirubin level. In neonatal hyperbilirubinemia exchange transfusion reduces the bilirubin level rapidly by about 40%.The iso volumetric and push pull techniques are comparable in efficiency.19

The study on Jaundice- the newborn babies shows the yellow discoloration of the skin and sclera that results from raised levels of bilirubin in the blood. Neonates it appears when serum bilirubin concentration reach 85- 120 mol/l with cephalo caudal progression as levels increase. Asian and Native American babies usually have higher bilirubin levels than Caucasian infants whereas babies of African origins have lower levels. Preterm babies are more likely to develop jaundice. Pathological jaundice in newborn appears within 24 hours of birth. Rh D incompatibility can occur when a women with Rh negative blood type is pregnant with a fetus with Rh positive blood type. This is commonest among Caucasians about 15%, 8% in Africans and 1% in Asian population.20

There are so many complications related to the neonatal jaundice such as mortality, hearing loss, incidence of kernicterus, adverse events caused by hospitalizations as parent infant bonding, failure of treatment, length of hospital stay and need for transfusion. Kernicterus refers to the yellow staining of the deep nuclei of the brain, which includes symptoms such as athetoid cerebral palsy, hearing loss, failure of upward gaze and dental enamel dysplasia. By educating the staff nurses about neonatal jaundice and its complications they can do interventions in clinical area to prevent complications.21

For successful management, the staff nurses should have adequate knowledge on early detection, level of serum bilirubin and interventions. The overall aims of the study is to provide information about neonatal jaundice to prevent complications of neonatal jaundice by staff nurses. Considering the above study findings the researcher understood that the staff nurses need to be specially trained.

The investigator while working in neonatal intensive care unit (NICU) had cared for the babies with jaundice. Most of the babies treated with phototherapy and some babies with exchange transfusion to reduce the bilirubin level. From there the investigator found that neonatal jaundice is very common and become very serious to cause death in neonates from inadequate interventions. So the investigator felt the need for the study.

6.2 Review of Literature

It refers to an integral component of any study or research projects. It enhances the depth of the knowledge and inspires a clean insight into course of the problem. Literature review throws light on the studies and their reports about the problem under the studies.

The studies related to the topic are organized and presented under the following headings.

A. Study related to incidence and prevalence of neonatal jaundice.

B. Studies related to risk factors of neonatal jaundice.

C. Studies related to management of neonatal jaundice.

D. Studies related to complications of neonatal jaundice.

E. Studies related to effectiveness structured teaching programme.

A. Study related to incidence and prevalence of neonatal jaundice.

A cross-sectional study was conducted to identify and incidence and prevelance related to st “Redcell pyruvate deficiency in neonatal jaundice in India” among 218 neonates. The study shows that 7 of the 218 cases of neonates were PK( pyruvatef kinase) deficient with 30-40%

reduction in PK activity. The study concluded that the prevalence of PK deficiency in Indian neonatal jaundice case is 3.2%, which is relatively high. This emphasis the need for screening neonatal hyperbilirubinemia cases in India for PK deficiency prevalence-estimated people managing neonatal jaundice incidence-annual diagnosis.22

A study was conducted on incidence, course and prediction of hyperbilirubinemia among 23 term newborns and 37 in the near term groups. The study was conducted with the aim to compare the serum bilirubin levels among the groups. The study found that on the first 4 days values did not significantly differ between the groups, whereas on the 5th and 7th days values were significantly higher in the near term groups. The study recommended that regular monitoring of the serum bilirubin will help in early diagnosis and treatment.23

A prospective study among 1238 full-term Chinese newborn infants was conducted to determine the incidence of neonatal jaundice and associated factors. A significantly more severe degree of hyperbilirubinaemia was present in infants whose ABO blood group was incompatible with that of their mothers and those who were deficient in the enzyme glucose-6-phosphate dehydrogenase (G6PD). Among the remainder, clinical jaundice was present in 87% and 23.9% had a peak serum bilirubin (SB) concentration greater than 204 mumo l/l. Factors that were found to have an association with a higher peak SB concentration included: male infants; elder siblings who had a history of neonatal jaundice; and breast-fed infants with or without supplementation with formula feed. Factors that were found to have no significant association with the peak SB concentration were: gestational age; birth weight; the mode of delivery of the infants; maternal consumption of Chinese herbs and syntocinon induction or augmentation of labour.24

A population-based prospective study was conducted to estimate the incidence of neonatal jaundice and hyperbilirubinemia in a poor urban community among 1690 in Karachi, Pakistan ao. Clinical assessments of jaundice were assigned by a physician and recorded using an adapted Kramer scale. Blood for plasma bilirubin was obtained if parents consented. The study findings reveled that Bilirubin was measured in 125 of 466 (27%) jaundiced newborns. Overall detected rate of hyperbilirubinemia (bilirubin >5 mg/dl) among 1690 newborns was 39.7/1000 live births (95% CI 29.3-47.6). Rate of plasma bilirubin levels in the range of 15-20 mg/dl was 13/1000 live births (95% CI 7.6-18.4); levels >20 mg/dl were observed in 3.5/1000 live births (95% CI 0.4-5.5). The proportion of newborns with bilirubin > or =15 mg/dl was significantly higher among those assigned a Kramer score of 4-5 compared to those receiving a score of 1-3 (P-value 0.00004). The study concluded that untreated severe neonatal jaundice, causing potential neurological squeal, exists in developing countries such as Pakistan. WHO guidelines are needed for screening and appropriate management of neonatal jaundice in developing countries.25

B. Studies related to risk factors of neonatal jaundice.

A study was conducted on 50 pregnant mothers and their 52 newborns in western Uttar Pradesh for Several maternal and fetal factors which are responsible for neonatal jaundice, which is a common observation in large number of newborns. In addition newborns with congenital or chromosomal abnormalities were excluded. Serum concentrations of bilirubin of all neonates were measured on days 1, 3 and 5. It was found to be lower on day 1, with a peak at day 3. The area under serum bilirubin level-time curve for each neonate was also calculated. Fetal sex and birth weight were not found to significantly affect the neonatal hyperbilirubinemia. Newborn of bipara mothers were found to have significantly lower (P < 0.05) serum bilirubin level on day 1 as compared to primipara mothers only but higher (P < 0.05) on day 3 as compared to either primi or multipara mothers. Yet, of serum bilirubin curve was significantly higher (P < 0.05) in newborns of bipara mothers than others. Significantly (P < 0.05) higher serum bilirubin on day 1 was also observed in preterm neonates than full term ones. However, maternal haemoglobin and mode of delivery were not shown to affect the neonatal bilirubin levels in these newborns.26

A prospective study was conducted to identify the role of genetic factors in occurance of neonatal jaundice. Totally 109 umblical cord blood samples were collected for the screening of G-6-PD activity. According to G-6-PD activity and G71R or A388 G genotype, the genotypes were allocated into different groups. The study concluded that UGTIAI G71IR gene mutation combined with G-6-PD deficiency or A388G gene mutation combined with G-6-PD deficiency play a co-ordinate role in the development of neonatal hyperbilirubinemia.28

A study was conducted on epidemiology of clinical hyperbilirubinemia in United Arab Emirates. Total 2300 live births were prospectively studied. In this 85(3.7%) were developed hyperbilirubinemia of these, 22 were premature, 22 had ABO hemolytic disease of the newborn, 8 had G6PD deficiency, 7 had breast milk jaundice, 5 were born to mothers with diabetes mellitus and 1 had Rh incompatibility. No specific factor was identified in 20(24%).29

A study was conducted to determine etiological spectrum as well as clinical profile of chronic hepatobiliary disorders in children 45 children with chronic hepatobiliary among 105 children with liver diseases referred to the childs clinic in Bidar, Karnataka. All underwent detailed history and clinical examination. Clinical and laboratory features as well as causes of chronic hepato biliary disorders were studied. The study reveals that the common causes were biliary atresia in 11 (25%) patients, neonatal hepatitis and Wilson's disease in 6 (13%) patients each, glycogen storage disorder (GSD) and idiopathic hepatitis in 5 patients (11%) each, Hepatitis B in 2 (5%), Hepatitis C in 1 (2%), Hepatitis B and C in 1 (2%), Caroli's disease in 2 (5%), autoimmune hepatitis in 2 (5%); sclerosing cholangitis, viral hemophagocytosis and thalassemia major in 1 (2%) patient each. Common clinical presentations were jaundice in 32 (71%), dark urine in 19 (42%), fever in 13 (29%), failure to thrive in 7 (16%), splenomegaly in 21 (47%) and hepatomegaly in 32 (71%). Also children with neonatal cholestasis presented in 1s' year of life, those with idiopathic liver disease and GSD presented within 1st 5 years of life and those with Wilson's disease. Autoimmune hepatitis, Caroli's disease presented between 5-10 years of age and viral hepatitis was seen in 2nd decade of life (p < 0.001). The study concluded that the study has commonest cause of chronic hepatobiliary disorders in children is neonatal hepatitis. Metabolic liver disease usually presents in 1st 5 years of life whereas chronic viral hepatitis has a presentation in adolescence.30

C. Studies related to management for neonatal jaundice.

A study was conducted on effect of light on total micro-bilirubin values in vitro in Taipei. 616 capillary blood samples were collected from jaundiced newborn infant. These samples were randomly divided into three groups. One group contained 133 samples and would receive phototherapy with blue light. Another group contained 202 samples would receive room light or white light. The final groups contained 215 samples and wer left in a dark room. The total bilirubin levels were checked at 0,2,4,6,24,48 hrs. there was a significant decrease in bilirubin in the first group exposed to phototherapy after 2 hours, but no change occurred in 2nd &3rd group. After 6 hrs there was significant change bilirubin level in the white light group but not in the 3rd group. It took 48hrs to record a change in the dark room group’s bilirubin level.31

A study conducted as Phototherapy of the newborn a predictive model for the outcome. The work aims at finding a predictive model for the decrement of blood bilirubin followed conventional phototherapy. It is possible to predict the total blood bilirubin of the patient under phototherapy by knowing its birth weight, bilirubin level at the beginning of treatment, duration of exposition, and irradiance. Besides, it is possible to infer the time necessary for a given decrement of bilirubin, under approximately constant irradiance.32

A study conducted on Treatment of physiological and pathological neonatal jaundice. If hyperbilirubinemia necessitates, treatment involves phototherapy and /or exchange transfusion of donor blood. In cases of pathological jaundice the underlying cause must also be treated. Parental involvement is important to minimize the trauma of having a sick baby and its effect on bonding.33

A comparative study was conducted to assess the effectiveness of various phototherapy system in lowering serum bilirubin levels among 140 preterm infants. Efficacy was assessed by comparing highest serum bilirubin levels, duration of treatment, and numbers of infants requiring exchange transfusion. The results confirm that that fibroptic phototherapy, both wallaby and Biliblanket, had the same effectiveness of conventional phototherapy. The data suggested that combined phototherapy should be the method of choice in treating hyperbilirubinemia in very preterm infants.34

D. Studies related complications of neonatal jaundice.

A study on sensorineural hearing loss in infants with neonatal jaundice in Lagos:

a community based study among 234 infants . The study shows that Fourteen (6%) of the 234 infants with neonatal jaundice (NNJ) had sensorineural hearing loss (SNHL). The study concluded that SNHL is prevalent among infants with NNJ.35

A prospective study conducted on Magnetic resonance imaging (MRI) in Kernicterus in Karache, Karnataka. The study that shows kernicterus is a disease entity with very high rate of mortality in neonates. The children who survive are left with neurological deficits such as choreoathetosis, sensorineural deafness and mental retardation. Magnetic imaging of the brain in this condition has specific findings which aid in the accurate diagnosis of the condition, along with clinical and biochemical criteria. Reports have shown involvement of the globus pallidus, putamen and less commonly thalamus.36

A study was conducted to determine the complication of post-phototherapy bilirubin rebound in neonates. Subjects included 232 inborn neonates needing phototherapy for hyperbilirubinemia. Standard guidelines were used to start and stop phototherapy. Rebound bilirubin was measured 24+/-6 h after stopping phototherapy. Significant bilirubin rebound (SBR) was defined as post-phototherapy bilirubin level needing reinstitution of phototherapy. Among 245 neonates with hyperbilirubinemia, post-phototherapy bilirubin estimation was done in 232 neonates. A total of 17 (7.3%) neonates developed SBR. In neonates with SBR, bilirubin increased by 2.3 mg/dL (95% CI 1.6-3.0) after stopping phototherapy. Risk factors for SBR included birth at >35 weeks of gestation (RR 4.3, 95% CI 1.5-12.0), birthweight60 h of age (RR 3.3, 95% CI 1.2-9.0). Post-phototherapy discharge and follow-up planning is recommended.37

A retrospective cohort study was conducted to assess the risk of skin cancer in persons treated with neonatal phototherapy for jaundice in Grampian Region, Scotland, UK Main outcome measures were Incidence ratios, standardized for age, sex, calendar period and socio-economic position. The study revealed that After excluding neonatal deaths (n=435), the cohort comprised 77,518 persons. 5868 Received neonatal phototherapy, providing 138,000 person-years at risk (median follow-up, 24 years). Two cases of melanoma occurred in persons exposed to neonatal phototherapy versus 16 cases in unexposed persons, yielding a standardized incidence ratio of 1.40 (95% CI, 0.17 to 5.04; p=0.834). No cases of squamous cell or basal cell carcinoma of skin were observed in exposed persons. Author concluded by saying although there is no statistically significant evidence of an excess risk of skin cancer following neonatal phototherapy, limited statistical power and follow-up duration mean it is not possible categorically to rule out an effect. However, taken in conjunction with the results of the only other study to investigate risk of melanoma following neonatal phototherapy, evidence available so far does not suggest a major cause for concern.38

E. Studies related to structured teaching programme

A study was conducted on Visual assessment of jaundice in term and late preterm infants Nurses assessment of jaundice extent was only moderately correlated with bilirubin concentration. The correlation was particularly weak among infants ................
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