RAJIVE GANDHIUNIVERSITY OF HEALTH SCIENCES BENGALURU

KARNATAKA

SYNOPSIS PERFOMA FOR REGISTRATION OF

SUBJECT FOR DISSERTATION

Mrs. Rosebi Joseph

First Year Msc Nursing

Obstetrical and Gynecological Nursing

Year 2010-2011

BRITE COLLEGE OF NURSING ,BENGALURU

RAGIVE GANGHIUNIVERSITY OF HEALTH SCIENCE

BENGALURU,KARNATAKA

PERFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. / NAME AND ADDRESS OF
CANDIDATE / Mrs.ROSEBI JOSEPH
I YEAR M.SC NURSING
BRITE COLLEGE OFNURSING
SY.NO:69,B W S S B COLONY
CHIKKAGOLLARAHATTY
BENGALURU-91
2. / NAME AND ADDRESS OF THE
COLLEGE / BRITE COLLEGE OF NURSING
SY.NO:69,B W S S B COLONY
CHIKKAGOLLARAHATTY
BENGALURU-91
3. / COURSE AND STUDY AND SUBJECT / FIRST YEAR M.SC NURSING
OBSTETRICS AND GYNAECOLOGICAL NURSING.
4. / DATE OF ADMISSION / 01.10.2010
5. / TITLE OF THE TOPIC / A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME REGARDING NEONATAL JAUNDICE AMONG PRIMIGRAVIDA MOTHERS IN A SELECTED HOSPITAL AT BENGALURU

6.BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“Health should mean a lot more than escape from death,or for

that matter escape from disease”

-K.PARK

Pregnancy and child birth are special event in women’s lives,and indeed in the lives of their families1. Proper care of the newborn babies forms the foundation for the subsequent life not only in terms of qualitative outcome without any medical and physical disabilities newborn is an important link in the chain of events from conception to adulthood.2

Newborn undergo many profound physiological changes at birth. Because they have been released from a warm,darkened liquid filled environment,which has met all of their needs,into chills gravity by based,outside world.3

Neonatal mortality rate can be defined as neonatal deaths of infants weighing above 1000gm during first 28 days after birth per 1000 live birth. Current neonatal mortality rate in India is 43.4 per 1000 live births. Almost 50% of neonatal deaths occur within first one week of life and majourity of within the first 24 hours of life4.

Neonatal jaundice is the yellowing of skin and other tissues of a newborn infant. A bilirubin level of more than 85 umol/l (5mg/dl) manifests clinical jaundice in neonates whereas in adults a level of 34 umol/l (2mg/dl) would look icteric. In newborns,jaundice is detected by blanching the skin with digital pressure or that it reveals underlying skin and subcutaneous tissue. Jaundice newborns have an apparent icteric sclera,and yellowing of the face,extendind down onto the chest.this condition is common in upwords of 70% of newborns.

An elevated serum bilirubin level may be toxic to the central nervous system causing neurological impairement even in a healthy term newborn. The total serum bilirubin concentration level has been used as the releavant criterion or management of hyperbilirubinemia in newborns. Phototherapy changes bilirubin through structural photoisomerization into water soluble lumirubin that is excreted in the urine. The effectiveness of phototherapy is related to the areas of skin exposed and the radiant energy and wavelength of light. There is no standardized method for delivering phototherapy. Phototherapy units differ widely,as do the types of lamps used in these units. Units can be freestsnding or as a part of a radiant warmer device. Fiberoptic units have been developed that deliver light from a high intensity lamp to a fiberoptic blanket.27,28,29.

Newborn infants who develop hyperbilirubinemia may require therapeutic intervention(eg:phototherapy) within first 24 to 72 hours of life during hospitalization. Home phototherapy may be used as an alternative to hospital phototherapy for early discharge or prevention of re-admission in term infants with elevated TSB(Total Serum Bilirubin) without the presence of hemolytic disease or any other pathologic process.

Peer reviewed literature has demonstrated that the management of neonatal jaundice (TSB 12-18mg/dl) with home phototherapy to be safe,effective method of lowering of TSB and allows for discharge home with the mother for continued bonding. Because devices available for home phototherapy may not provide the same degree of irradiance or surface area exposure as those available in the hospital,home phototherapy should be used only in infants whose bilirubin levels are in the optional photoyherapy range,it is not appropriate for infants with higher bilirubin concentration.

The 2004 American Academy Of Paediatrics,clinical practice guidelines specifices that providing conventional phototherapy either in the hospital or at home is an option at TSB levels that are 2-3mg/dl below the intensive therapy levels but only in infants without risk factors. Infants with high bilirubinemia and any risk factors do not have the option for home phototherapy and require intensive phototherapy in the hospital setting.27,28

NEED FOR THE STUDY

Currently infant mortality rate at national level is 67.6% per 1000 live births where as neonatal mortality rate is 43.4 per 1000 live births. The most important cause of neonatal death in the community is due to neonatal infections.5

Neonatal jaundice is a disorder that affects nearly 50% of all newborns to at least a small degree. The yellow coloration of the skin and sclera of the eyes is due to the accumulation of bilirubin in adipose tissue and its adherence to collagen fibers. In neonatal jaundice, the excess bilirubin is not due to an abnormal level of red blood cell destruction. It is due to the inability of the young liver cells to conjugate bilirubin, or make it soluble in bile, so that it can be excreted and removed from the body by the digestive tract. This inability is corrected, usually within one week, as the liver cells synthesize the conjugation enzymes. If uncorrected, sufficiently high bilirubin concentrations can cause brain damage. Frequent feedings of a newborn with jaundice increase gastrointestinal tract motility and decrease the likelihood of reabsorbing significant amounts of bilirubin in the small intestine. Radiation from sunlight alters the chemical form of bilirubin, making is easier for the liver to excrete.

Despite recent attention to newborn health much remains to be done to achieve sustained high courage of effective interventions,especially in poor communities where most newborn all born and die in the first week of life. Primigravidae may be due to early marriage,which is culturally,and religiously acceptable in some areas they may have poor knowledge regarding neonatal jaundice. The other further which may lead to poor knowledge,are low socio economic status,low education and career aspiration residence in a single parent home and poor family relationship. Mothers are having low knowledge,on neonatal care which impacts the care given to their newborn.6

Here the investigator felt the need of provision of information and adequate knowledge regarding the neonatal jaundice which will help to improve the knowledge of mother to adopt and maintain healthy practice thereby reducing the neonatal mortality and morbidity.

Hence the investigator is interested to assess the effectiveness of structured teaching programme regarding neonatal jaundice among primigravida mothers.

.REVIEW OF LITERATURE

Review of literature is a systematic identification,local or scruting and summary of written materials that contain information on research problem.

This chapter deals with the literatures related to knowledge of primigravida mothers regarding neonatal jaundice and the effectiveness of structured teaching programme. In present study,review of literature will Fall on:

1.Review of literature related to neonatal jaundice.

2.Review of literature related to the study.

Review of literature related to neonatal jaundice:

Madlon-kay,Diane.j:7Neonatal jaundice is the yellowing of the skin and other tissues of a newborn infant. A bilirubin level of more than 85umol/l (5mg/dL) manifests clinical jaundice in neonates whereas in adults a level of 34umol/l (2mg/dL) would look icteric. In newborns jaundice is detected by blanching the skin with digital pressure so that it reveals underlying skin and subcutaneous tissue. Jaundice newborns have an apparent icteric sclera, and yellowing of the face, extending down onto the chest. This condition is common in upwards of 70% of newborns.In neonates the dermal icterus is first noted in the face and as the bilirubin level rises proceeds caudal to the trunk and then to the extremities.

Wood S(2007,March):17Neonatal jaundice is caused by a buildup of bilirubin in the baby's blood. Sometimes, for a variety of reasons, the infant's liver isn't able to process bilirubin, resulting in jaundice, according to MedlinePlus. Infant jaundice often doesn't require treatment, beyond frequent feedings. If the problem persists, the next steps phototherapy, according to MedlinePlus.In phototherapy, the infant is treated with special lights. The baby's body absorbs the light, helping break down and eliminate the bilirubin. In severe cases, an exchange transfusion (the baby's blood is replaced with fresh blood) or intravenous immunoglobulin may be required. Phototherapy replaced phenobarbital as a treatment for jaundice more than 50 years ago.

According to Lynn.C.Garfunkel, Jeffry Kaczorowski,Cynthia Christy(2002):8 Jaundice tends to develop because of two factors - the breakdown of fetal haemoglobin as it is replaced with adult haemoglobin and the relatively immature hepatic metabolic pathways which are unable to conjugate and so excrete bilirubin as quickly as an adult. This causes an accumulation of bilirubin in the blood (hyperbilirubinemia), leading to the symptoms of jaundice.If the neonatal jaundice does not clear up with simple phototherapy, other causes such as biliary atresia, PFIC, bile duct paucity, Alagille's syndrome, alpha 1 and other pediatric liver diseases should be considered. The evaluation for these will include blood work and a variety of diagnostic tests. Prolonged neonatal jaundice is serious and should be followed up promptly.

Dobbs,R H;R J Cremer:9,10Breastfeeding jaundice" or "lack of breastfeeding jaundice," is caused by insufficient breast milk intake,9 resulting in inadequate quantities of bowel movements to remove bilirubin from the body. This can usually be ameliorated by frequent breastfeeding sessions of sufficient duration to stimulate adequate milk production. Passage of the baby through the vagina during birth helps stimulate milk production in the mother's body, so infants born by caesarean section are at higher risk for this condition.

Amato M ,Inaebnit D:11Infants with neonatal jaundice are treated with colored light called phototherapy. Physicians randomly assigned 66 infants 35 weeks of gestation to receive phototherapy. After 15±5 the levels of bilirubin, a yellowish bile pigment that in excessive amounts causes jaundice, were decreased down to 0.27±0.25mg/dl/h in the blue light. This suggests that blue light therapy helps reduce high bilirubin levels that cause neonatal jaundice.

Stokowski LA,Ennever JF,Sobel MC Donagh AF,Speck WT:Phototherapy works through a process of isomerization that changes trans-bilirubin into the water-soluble cis-bilirubin isomer.12,13In phototherapy, blue light is typically used because it is more effective at breaking down bilirubin (Amato, Inaebnit, 1991). Two matched groups of newborn infants with jaundice were exposed to intensive green or blue light phototherapy. The efficiency of the treatment was measured by the rate of decline of serum bilirubin, which in excessive amounts causes jaundice, concentration after 6, 12 and 24 hours of light exposure. A more rapid response was obtained using the blue lamps than the green lamps. However, a shorter phototherapy recovery period was noticed in babies exposed to the green lamps.Green light is not commonly used because exposure time must be longer to see dramatic results.Ultraviolet light therapy may increase the risk of or skin moles, in childhood. While an increased number of moles is related to an increased risk of skin cancer(14,15,16).

Thomas JT, Muller P,Wikinson CS:18 Since the mid-20th century, however, it has been replaced by phototherapy, which treats the baby with light. Since phenobarbital improves liver function, one possible approach is to give it to mothers just before they give birth to help prevent jaundice. However, there's been insufficient research to support such treatment, according to a 2007 Cochran review of the literature.

Rosenfeld J19 reported that infants with cord bilirubin levels less than 2.0 mg/dL have only a 4 percent chance of developing hyperbilirubinemia and a 1.4 percent chance of needing phototherapy. However, if serum cord bilirubin levels are more than 2.0 mg/dL, the infant has a 25 percent chance of developing subsequent hyperbili-rubinemia Rataj J et al reported that if cord bilirubin was under 1 mg% the jaundice occurred in 2.4% newborns, where as 89% of the infants with cord bilirubin above 2.5 mg% becamejaundiced.

Knudsen A20found that if cord bilirubin was below 20 mumol/l, 2.9% became jaundiced as opposed to 85% if cord bilirubin was above 40 mumol/l. Furthermore, 57% of jaundiced in-fants with cord bilirubin above 40 mumol/l required phototherapy, but only 9% if cord bilirubin was 40 mumol/l or lower (p less than 0.003)

Alpay et al21observed thata serum bilirubin >6mg/dl on the first day of life had 90% sensitivity of predicting a subsequent TSB >17mg/dl between 2nd and 5th day of life. At this critical serum bilirubin value, the negative predictive value was 97.9%. No cases with TSB of <6mg/dl in the first 24 hours required phototherapy treatment value of measuring cord bilirubin concentration in ABO-incompatibility has been investigated by Riesenberg et al who found that all infant with cord bilirubin level s higher than 68mumol/l, developed severe jaundice. The study done by Seidman et al found that the risk of significant hyperbilirubinemia was 1.6% in cases whose bilirubin level was <5 mg/dL at 24 hours of life, whereas that risk was 6.6% in cases whose bilirubin level was 5 mg/dL at 24 hours of life.

Knudsen A:22The maternal and umbilical cord bilirubin concentration at delivery, a yellow skin colour on the first post-natal day, an increase in the yellow skin colour during the first 24 h or postnatal life, and carbon monoxide excre-tion are all associated with the later development of neo-natal jaundice in the healthy, mature newborn infant.

Review of literature related to the study

Based on the AAP(2004) guidelines,23 mothers should:

* Be encouraged to breastfeed.

* Supplementation with formula or water is not recommended.

* Breastfeed 8 to 12 times per day especially for the first few days.

* Seek breastfeeding support as needed.

* Monitor output to gauge successful breastfeeding hydration.

* Keep follow-up appointments with clinician based on infant's risk factors.

* Receive written patient education materials pertaining to jaundice.

* Ask questions.

* Know who and when to call.

* Report increasing jaundice at once.

* Know that a blood test is the best way to determine bilirubin level.

* Be aware that putting their infant in sunlight, inside or outside, is NOT considered a safe and reliable treatment for jaundice.

According to Bestable,2008:24 it is importantthat more be known about the maternal experience with neonatal jaundice in order to inform the development of appropriate postpartum educational strategies. There are numerous studies pertaining to the risk factors, identification, and treatment strategies for hyperbilirubinemia, ABE, and kernicterus;, but little is known about the contemporary American mother's perspective of having an infant with neonatal jaundice; The purpose of this study, therefore, was to fill that gap in the nursing literature by describing the lived and educational experience of mothers having an infant with neonatal jaundice.

Bhutani et al 2006,George 2005:25When mothers receive inappropriate or conflicting infant care advice neonatal outcomes may be adversely impacted. Providing consistent and accurate education is foundational to the role of the nurse. It is essential, therefore, that nurses caring for women and infants learn the evidence about newborn jaundice, adhere to the guidelines from professional organizations such as AAP(2004) and provide their patients with accurate education in both written and verbal formats before discharge as available through organizations such as AAP, Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN,2006 ), CDC, March of Dimes, and PICK if the harmful effects of hyperbilirubinemia and kernicterus are to be avoided. Identification of barriers to such education for parents should be a priority in nursing research.

Martel 1999:26The current practice of discharging mothers and infants 24 to 48 hours following birth, however, results in bilirubin levels peaking at home rather than in the hospital, thus shifting the primary responsibility for early detection and treatment of neonatal jaundice to the postpartum mother. Home phototherapy is now available due to the advent of fiberoptics in the early 1990s; this practice has become feasible, safe, and acceptable for treating infants with hyperbilirubinemia. It is essential that mothers, as the primary caretaker, have a clear understanding of how to recognize neonatal jaundice and how to respond appropriately, since early recognition and prompt treatment decrease the likelihood of development of the potentially permanent sequelae of kernicterus .

PROBLEM STATEMENT

A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME REGARDING NEONATAL JAUNDICE AMONG PRIMIGRAVIDA MOTHERS IN A SELECTED HOSPITAL AT BANGALORE.

6.3.OBJECTIVES

  • To assess the level of knowledge on neonatal jaundice among primigravida mothers.
  • To determine the level of knowledge of the primigravida mothers on neonatal jaundice after structured teaching programme.
  • To associate the findings based on the demographic variables of the knowledge of the primigravida mothers on neonatal jaundice before and after the structured teaching programme.

6.3.1. HYPOTHESIS

H0.There will be a significant difference between the pre and post test knowledge on neonatal jaundice among primigravida mothers after the structured teaching programme.

H1.There will be a significant association between the demographic variables and post test scores of the respondent.

6.4.OPERATIONAL DEFINITIONS

  • Assess:

It refers to examine the knowledge level regarding neonatal jaundice.

  • Effectiveness:

It refers to determining the extent to which teaching programme has brought about the result extended and is measured in terms of significant knowledge gained in the post test.

  • Structured teaching programme:

It refers to the systematically developed information designed to teach the antenatal mothers on newborn care by lecture cum discussion and by using handouts,charts and flash cards.

  • Neonate:

The infant from birth to four weeks(<28 days)of birth.

  • Neonatal jaundice:

Newborn babies suffer from a slight yellow tinge of the skin and eyes caused by a type of jaundice is called neonatal jaundice.

  • Primigravida mothers:

Mothers who are pregnant for the first time.3

6.5.ASSUMPTIONS

1.Primigravida mothers may have some knowledge regarding neonatal jaundice.