RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
KARNATAKA, BANGLORE.
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1 / NAME AND ADDRESS OF THE CANDIDATE / SWATHI VALAVALA#82,”SIDDAGANGA”, GROUND FLOOR, 10TH CROSS, B-BLOCK, KANAKA NAGAR, R.T.NAGAR POST.
BANGALORE.
PIN-560032
2 / NAME OF THE INSTITUTION / ACHARYA COLLEGE OF NURSING,
CHOLANAGAR, R.T.NAGAR POST.
BANGALORE-32
3 / COURSE OF THE STUDY AND SUBJECT / MSc. NURSING 1ST YEAR,
CHILD HEALTH NURSING
4 / DATE OF ADMISSION / 11-06-2012
5 / STATEMENT OF THE PROBLEM / A STUDY TO EVALUATE THE EFFECTIVENESS OF SELF INSTRUCTIONAL MODULE ON KNOWLEDGE REGARDING BILIBLANKET THERAPY AMONG STAFF NURSES IN SELECTED PEDIATRIC HOSPITALS, BANGALORE.
BRIEF RESUME OF THE INTENDED WORK
“The child is God's gift to the family. Each child is created in the special image and likeness of God for greater things; to love and to be loved .”
Mother Teresa.
6. INTRODUCTION
A neonate is also called newborn. The neonatal period is the first 4wks during Childs life. Jaundice is a yellowish discoloration of skin and white part (sclera) of the eyes by pigment of bile (bilirubin). In the newborn the degree of jaundice is normal due to the breakdown of red blood cells which releases bilirubin into the blood and due immaturity of newborn liver. Normal neonatal jaundice typically appears 2nd and 5th day of life and clears with time. Neonatal jaundice is also referred as hyperbilirubinemia and also physiological jaundice(1)
Neonatal jaundice or neonatal hyperbilirubinemia is yellowing of skin and other tissues of newborn infants. A bilirubin level of more than 85 μmol/L (5mg /dl)manifests clinical jaundice. In neonates the dermal icterus is first noted in face and as the bilirubin level rises proceeds caudal to trunk and extremities. Neonatal jaundice can be physiological or pathological type.(2)
Neonatal jaundice may have first been described in Chinese textbook 1000 years ago. In most of the infants unconjugated hyperbilirubinemia reflects normal transitional phenomenon. In some infants serum bilirubin may excessively rise which can be a cause for concern because unconjugated bilirubin is neurotoxic and can cause death in newborn and lifelong neurological sequelae in infants who survive .(3)
The incidence of neonatal jaundice is increased in infants of Eastasians and Americans , Indians and Greece. In 1985 Linn et al reported on a series in which 49 % eastasia,20%of whites,12% of black infants had serum bilirubin levels more than 170 μmol/L (10mg/dl).(4)
In neonatal jaundice the treatment modalities are phototherapy, transfusion of intravenous immune globulins, exchange transfusion ,Oral bilirubin oxidase which can reduce serum bilirubin levels, presumably by reducing enterohepatic circulation.Prophylactic treatment of Rh-negative women with Rh immunoglobulin has significantly decreased the incidence and severity of Rh-hemolytic disease. In physiological jaundice the baby usually feeds well and on physical examination reveals normal liver. The urine colour is dark while the stool colour is normal .Higher the level of bilirubin causes high pitched cry, apnea, listlessness, seizures and arched back in infants. Extremely high level of bilirubin (hyperbilirubinemia) leads to kernicterus a condition where the brain is severely damaged.(5)
Phototherapy is use of visible light for the treatment of hyper bilirubinemia in the newborn. This relatively common therapy to lower the serum bilirubin levels by transforming bilirubin into water soluble isomer that can be eliminated without conjugating in the liver. In phototherapy the blue light are used because it is more effective at breaking down of bilirubin.(6)
In phototherapy baby is subjected to light of certain wavelength (430nm-470nm) at this wavelength unconjugated bilirubin is converted to harmless,The baby needs to be completely naked apart from eyes protected genetalia and needs to be under the light as much as possible until bilirubin levels come down. During this period the mother gets frustrated as it reduces bonding time with the baby.(7)
More recently special fibreoptic blanket has been developed which can also be used in treating neonatal jaundice. Fibreoptic blanket is also called biliblanket ,which is a portable phototherapy device. Biliblanket is trademark of general datex ohmed subsidary. The name is combination of bilirubin and blanket, other names used are home phototherapy system, bilirubin blanket or phototherapy blanket.(8)
Biliblanket whole set up consists of light generator termed the light box, the fiber optic cable through which light is carried to the light pad, which is 25cm*13cm (10” * 5”) pad that attached to the baby which is wrapped around the baby or may take the form of a lighted pad upon which a baby can lie and baby can be clothed.(9)
6.1. NEED FOR THE STUDY
Signs of neonatal jaundice are seen within first 3 days of birth in 80% of preterm babies and 60% of full term babies. (10)Neonatal jaundice affects 30%-50%of newborn infants worldwide. The incidence of jaundice is much higher in preterm babies. Although the condition accounts for up to 75% of hospital readmission in the first week. Approximately 60%-70% of 4 million infants born annually in USA becomes clinically jaundiced. Over 60% of all 3.5 million healthy babies admitted in USA with hyperbillirubinemia, during first week after birth. About 60-70% of normal term neonates may develop visible jaundice and incidence is higher in preterm babies by 80%.Incidence of neonatal hype bilirubinemia in India varied from 4.3%-6.5% in all live term babies. In Karnataka about 55% of newborn suffer with neonatal jaundice.(11)
Physiological jaundice is caused due to the immaturity of newborn liver which cannot perform conjugating and removing of bilirubin completely .Neonatal jaundice can be seen in case of maternal fetal in-compatibility, the mother body will actually produce antibodies that attack the fetus blood cells .This causes break down of the RBC and thus results in increased release of bilirubin from RBC.(12)
A scalp bruises during birth called cephalic hematoma has clotted blood beneath the skin which naturally break down in increased release of bilirubin, which the new bon liver cannot manage. And also sometimes baby swallows blood during birth, swallowed blood breakdowns in intestines and absorbed, depends on the clot rise of bilirubin depends.(13)
Breastfeed babies tend to develop jaundice, which tends to last longer than in bottle feed babies. First start breastfeed is hard to provide all nutrients and fluids necessary to help their body breakdown and excrete bilirubin. Breastfeeding may sometime cause the baby’s intestine to absorb more bilirubin back in to the body than normal, which is reabsorbed to blood .It is also possible that breast milk contains unidentified but harmless substance that causes the jaundice in neonates .(14)
A retrospective study was conducted in the year (2012) of all neonates at university hospital of west India (UHWI), demographic clinical and laboratory data are collected and descriptive analysis was performed. In the study the significant neonatal jaundice at UHWI was 4.6%, there were 103 males (61%) and 67 female (39%) infants .Etiology of jaundice in infants was attributed to ABO incompatibility in 59 (35%), infection in 30 (18%), prematurity in 19 (11%),G6PD deficiency in 8 (5%), rhesus-incompatibility in 6 (3.5%) and no cause was identified in 16 (9%) infants .(15)
Phototherapy is the widely used treatment modality for neonatal jaundice. Biliblanket therapy is one of the latest phototherapy, it is a blanket which can be wrapped around a baby or may take the form of a lighted pad upon which a baby can lie. These blankets are often used in hospitals to treat neonatal jaundice but also suitable at home use .In addition to this advantage biliblanket phototherapy is so non invasive that parent can feed, hold, and clothe their children while treating the infant.(16)
Biliblanket makes quite popular with doctors, parents, insurance companies ,who otherwise has to pay for more expensive inpatient treatment .Some also consider a better option because newborns need not have to be separated from parents and does not need to lie down in the box with covered eyes.(17)
Biliblanket has got a lots of benefits like it convenient to the infant and care givers, got a compact and low weight of 3 kgs which could be portable, allows infants to be swaddled breastfeeding and bonding while receiving phototherapy .It filters away the harmful U.V and I.R lights reducing the need for eye patches ,it also allows in room darkening like no bright lights to disrupt day/night cycles of infant or family as with other phototherapy devices.(18).
A comparative study was conducted on fiber optic phototherapy with lowering serum bilirubin levels in low birth weight neonates .In the study fiberoptic phototherapy found to be effective as white lights less effective than blue lights as assed by (i) the bilirubin concentration after 24 hr of phototherapy,(ii) the duration of photo therapy ,(iii) the percentage daily decline rate and ,(iv ) overall decline rate (P<0.05)there was no failure of phototherapy and need no re-exposure was low (4.7%of total sample) with no difference in group .Finally the study states fibreoptic approach represents a modern efficient phototherapy for low birth weights infants .(19)
A retrospective study on clinical equivalence of fluorescent green and special blue lamps for neonatal jaundice was conducted among two groups of low birth weight infants with mean gestational age of 35 wk and mean birth weight of 1930 grams, who developed hyperbilirubinemia in first five days of life. Both the groups were given radiation with blue and green lamps, no statistically significant difference in plasma bilirubin was found between two groups after 24 hrs -48hrs. Therefore fluorescent green lamps provide an alternative to special blue lamps for treatment of neonatal hyperbilirubinemia.(20)
A paper presentation on rational use of phototherapy states phototherapy has been used to treat neonatal hyperbilirubinemia for more than decades. It’s only the last 10 yrs that the mechanism of action of phototherapy has emerged. As the bilirubin structural isomer is responsible for the decrement in serum bilirubin. This paper discusses current clinical recommendations for light dosage and wave length, develops new guidelines based upon on recent information of how light helps in breaking unconjugated bilirubin to simple form to excrete and reduce the bilirubin concentration(21).
In India Biliblanket a fiber optic phototherapy is used in superspeciality hospitals and minimal use in general pediatric set up. From the above literatures reviewed it was found that nurses, other health professional and parents may not have adequate knowledge regarding Biliblanket phototherapy because conventional phototherapy is very often used in treating neonatal jaundice. As it is the latest method advancing the nurses need to gain knowledge regarding it.So the researcher urged to assess and educate the staff nurses about Biliblanket therapy because nurses are the only people who spend most of the time in rendering care to the neonates.
6.2. REVIEW OF LITERATURES
A review of literatures enables one to get an insight into various aspects of the problems under study. It covers promising methodological tools, throws light on ways to improve the efficiency data collection and suggest how to increase effectiveness of data analysis and interpretation. Review of literature is an essential step in the development of the research project.
Review of literature for the present study is organized under the following
6.2.1 Review of literature regarding neonatal jaundice.
6.2.2 Review of literature regarding treatment modalities of neonatal jaundice.
6.2.3 Review of literature regarding phototherapy/ Bili blankettherapy.
6.2.1 Review of literature regarding neonatal jaundice.
A retrospective observational study was conducted among all LBW infants admitted to neonatal intensive care unit. A total of 840 infants were included in this study males (n = 407) with females (n = 433),were compared with gestational age, birth weight, race, Apgar scores at 1 and 5 mins, peak bilirubin levels, sepsis, and intraventricular hemorrhage (IVH).The results showed significant differences were detected in gestational age, sepsis, or Apgar 1 and 5. It was found that Bili in LBW infants is significantly higher in males when compared with females.(22)
Prospective, population-based study was conducted on Infants states the first month of life with severe hyperbilirubinaemia (maximum unconjugated serum bilirubin >/=510 micromol/l). 108 infants met the case definition, 106 from the UK and 2 from the Republic of Ireland. The UK incidence of severe hyperbilirubinaemia was 7.1/100 000 live births (95% CI 5.8 to 8.6). Only 20 cases presented in hospital; 88 were admitted with severe jaundice. 64 (60.4%) cases were male, and 56 (51.8%) were of ethnic minority origin. 87 (80.5%) cases were exclusively breast fed. 14 infants showed evidence of bilirubin encephalopathy, of whom 3 died. The UK incidence of bilirubin encephalopathy was 0.9/100 000 live births (95% CI 0.46 to 1.5). This is the first large, prospective, population-based study of the incidence of severe hyperbilirubinaemia in the newborn. (23)
6.2.2 Review of literature related to treatment modalities:
A retrospective study reviewed causes of jaundice, efficiency of exchange transfusion in lowering serum bilirubin concentrations. Data were compared between neonates(body weight>1500 g with out medical problems other than jaundice) who had undergone exchange transfusion via the peripheral arteries and veins method and those who had undergone exchange transfusion via the umbilical vein method. A total of 123 exchange-transfusion procedures were performed in 102 neonates in the 12-year study period: 24 were performed via the umbilical vein method and 99 via the peripheral vessels method. A total of 87 procedures were performed in 75 stable neonates and 36 in 27 unstable neonates. There was no significant difference in reduction of serum bilirubin level from circulation or the duration of procedures between the 2 methods. Exchange transfusion using peripheral arteries and veins is efficient and effective in reducing serum bilirubin from circulation and is associated with few adverse events. (24)
A study stated randomized and quasi randomized control trials comparing single volume and double volume exchange transfusions in jaundiced newborn infants were included. 20 full term babies requiring exchange transfusion for hemolytic jaundice due to ABO incompatibility were randomly allocated to receive single or double volume exchange transfusion. Base line characteristics of both groups were similar with regards to birth weight, gestational age, immediate pre exchange bilirubin level 199 (SD 33) micromol/L vs. 216 (SD 55) micromol/L. Both groups were treated equally apart from the volume of blood used for exchange transfusion. Total bilirubin levels immediately after exchange transfusion were not significantly different in either group. A change from the current practice of double volume exchange transfusions for severe jaundice in newborns infant, cannot be recommended on current evidence.(25)