RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE,KARNATAKA.

SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 NAME OF THE

CANDIDATE AND

ADDRESS

MR. ARUNJITH KG

1ST YEAR M.Sc. NURSING STUDENT,

RATHNA COLLEGE OF NURSING,

B.M.ROAD, HASSAN,KARNATAKA

2 NAME OF THE

INSTITUTION

RATHNA COLLEGE OF NURSING

B.M ROAD, HASSAN

3 COURSE OF STUDY

AND SUBJECT

MASTER OF SCIENCE IN NURSING

CHILD HEALTH NURSING

4 DATE OF ADMISSION

TO THE COURSE

31. 05. 2010

5 TITLE OF THE TOPIC “ASSESS THE KNOWLEDGE AND KNOWLEDGE ON PRACTICE AMONG STAFF NURSES WORKING IN PEDIATRICS HOSPITALS REGARDING MANAGEMENT NEONATAL JAUNDICE”.

5.1 STATEMENT OF THE

PROBLEM

“A STUDY TO ASSESS THE KNOWLEDGE AND KNOWLEDGE ON PRACTICE OF STAFF NURSES REGARDING MANAGEMENT OF NEONATAL JAUNDICE IN SELECTED PEADIATRIC HOSPITALS AT HASSAN WITH A VIEW TO DEVELOP AN INFORMATION BOOKLET”.

6. BRIEF RESUME OF THE INTENDED WORK.

1

INTRODUCTION

"Children are our most valuable natural resource."1

(Herbert Hoover, 31st U.S. President ,1929-1933)

Jaundice is the most common condition that requires medical attention in

newborns. The yellow coloration of the skin and sclera in newborns with jaundice is the

result of accumulation of unconjugated bilirubin. In most infants, unconjugated

hyperbilirubinemia reflects a normal transitional phenomenon. However, in some infants,

serum bilirubin levels may excessively rise, which can be cause for concern because

unconjugated bilirubin is neurotoxic and can cause death in newborns and lifelong

neurologic sequelae in infants who survive kernicterus. For these reasons, the presence of

neonatal jaundice frequently results in diagnostic evaluation.2

Neonatal jaundice may have first been described in a Chinese textbook 1000

years ago. Medical theses, essays, and textbooks from the 18th and 19th centuries contain

discussions about the causes and treatment of neonatal jaundice. Several of these texts

also describe a lethal course in infants who probably had Rh isoimmunization. In 1875,

Orth first described yellow staining of the brain, in a pattern later referred to as

kernicterus.2

Jaundice is a yellow color in the skin, the mucous memberanes, or the eyes. The

yellow pigment is from bilirubin a by product of old red blood cells.3

Neonatal jaundice is a yellowing of the skin and other tissues of a newborn infant.

A bilirubin level of more than 85 umol/l (5 mg/dL) manifests clinical jaundice in

neonates whereas in adults 34 umol/l (2 mg/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, extend down on to the chest. This condition is common in upwards

on of 70% of newborn.4

Jaundice comes from the French word jaune, which means yellow. When it is

said that a baby is jaundiced, it simply means that the color of his skin appears yellow.

2

Jaundice in the infant appears first in the face and upper body and progresses downward

toward the toes. Premature infants are more likely to develop jaundice than full-term

babies.5

No baby should develop brain damage from untreated jaundice. If a baby gets

too jaundiced, the baby can be treated with phototherapy. That is, the baby can be put

under blue lights most of the day. The blue lights do not bother the baby. They are warm

and probably feel good. If the baby gets very, very jaundiced, the doctor can do an

exchange transfusion.6

The aim of clinical assessment is to distinguish physiological from pathological

jaundice. The sign which helps to differentiate pathological jaundice of neonates from

physiological jaundice of neonates are presence of intrauterine retardation, stigma of

intrauterine infections (cataracts, microcephaly, hepatosplenomegaly), cephalhematoma,

bruising, signs of intra ventricular hemorrhage etc. History of illness is noteworthy.

Family history of jaundice and anemia, family history of neonatal or early infant death

due to liver disease, maternal illness suggestive of viral infection (fever, rash or

lymphadenopathy), Maternal drugs ( Sulphonamides, anti-malarials causing hemolysis in

G-6-PD deficiency) are suggestive of pathological jaundice in neonates.7

In neonates, 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 an adult. This causes an accumulation of bilirubin in the blood , leading to the

symptoms of jaundice.7

Severe neonatal jaundice may indicate the presence of other conditions

contributing to the elevated bilirubin levels, of which there are a large variety of

possibilities . These should be detected or excluded as part of the differential diagnosis to

prevent the development of complications. They can be grouped into the following

categories:7

Jaundice is a common physiologic problem seen in both term and preterm

infants. Normal transitional changes in bilirubin metabolism lead to physiological

3

jaundice in many infants. In some infants these normal changes at birth may be

exaggerated, such as occurs with immaturity, or may interact with health alterations

(pathologic jaundice), resulting in the accumulation of excess bilirubin and development

of hyperbilirubinemia. Caregivers must appreciate the processes and the basis for

physiologic jaundice and hyperbilirubinemia and recognize infants at risk for these

disorders. This article reviews neonatal bilirubin metabolism as a basis for understanding

the causes and treatment of physiologic jaundice and hyperbilirubinemia arising from 6.1 NEED FOR THE STUDY

Each year in India over one million newborns die before they complete their first

month of life, accounting for 30% of the world's neonatal deaths. India’s current neonatal

mortality rate of 20 per 1000 live births .Asian male babies and Native American ones are

reported to be most affected by Neonatal Jaundice13.4 million babies need treatment for

jaundice every year;9National (NNPD)

Signs of Neonatal Jaundice are seen within the first three days of birth in 80% of

preterm babies and 60% of full-term infants . The Journal of Pediatrics reports a

retrospective study, which observed that the incidence of Jaundice is higher in breast- fed

babies than in the formula- fed ones. Asian male babies and Native American ones are

reported to be most affected by Neonatal Jaundice. They are followed by Caucasian

infants who in turn are followed by African Neonates.10

Jaundice is the most common condition requiring medical attention in newborn

infants. About 50 percent of term and 80 percent of preterm infants develop jaundice in

the first week of life. Jaundice also is a common cause of readmission to the hospital after

4

early discharge of newborn infants. Jaundice usually appears two to four days after birth

and disappears one to two weeks later, usually without the need for treatment.11)

195, Incidence of neonatal jaundice in India is 60% of term neonates and 80% of

preterm.12

Hyperbilirubinemia is the commonest morbidity in the neonatal period and 5-10%

of all newborns require intervention for pathological jaundice. Neonates on exclusive

breastfeedinghave a different pattern of physiological jaundice as compared to artificially

fed babies. Guidelines from American Academy of Pediatrics (AAP) for management of

jaundice in a normal term newborn have been included in the protocol.

Separateguidelineshave been provided for the management of jaundice in sick term

babies, preterm and low birth weight babies, for jaundice secondary to hemolysis and for

prolonged hyperbilirubinemia. Although hour specific bilirubin charts are available,

thesehave to be validated in Indian infants before they are accepted for widespread use.13

The maximum risk of hyperbilirubinemia is Kernicterus because of accumulation of

unconjugated bilirubin in serum. According to a study, Kernicterous causes at least 10%

of mortality and 70% of morbidity. However, correct use of phototherapy and blood

exchange to control serum bilirubin level, can prevent complications.14

Nowadays, because of early discharge of mothers and neonates from hospitals,

responsibility of mothers about recognising jaundice has increased. Parents, therefore,

play an important role in the final results of neonatal jaundice . On the other hand, there

is a close association between neonatal bilirubin level and incidence of neurological

complications. An exposure to levels higher than 20mg/dl even in less than 6 hours,

results in neurological disorders in 2.3% cases. In 6-12 hours interval and for exposure

more than 12 hours, the risk will be 18.7% and 26%, respectively14

A study was conducted by Kedar PS, Warang P, Colah RB, Mohanty D on Red

cell pyruvate kinase deficiency in neonatal jaundice cases in India.The results shows that

the prevalence of PK deficiency in Indian neonatal jaundice cases is 3.21%, which is

5

relatively high. This emphasizes the need for screening neonatal hyperbilirubinemia cases

in India for PK deficiency.15

A study was conducted by Basu K, Das PK, Bhattacharya R, Bhowmik PK on a

new look on neonatal jaundice Out of 6586 live born babies, 736 babies with jaundice

were studied from 1st July 1996 to 30th June, 1997, in a city based medical college

nursery. Physiological jaundice was present in 8.92% of all live born babies and

accounted for 79.89% of babies with jaundice. Breast milk jaundice and prematurity were

next common causes responsible for 5.29% each of all cases with neonatal jaundice.

Septicaemia caused jaundice in 4.75% cases. Among the babies with jaundice appearing

between day 4 and day 7 of life, breast milk jaundice was the commonest cause occurring

in 49.25% cases. The last entity surfaced probably due to exclusive breastfeeding recently

initiated in the baby friendly hospital nursery.16

t It is very important to reduce neonatal jaundice as it contribute for high mortality

rate and the nurses can play a vital role in reduction of mortality rate due to neonatal

jaundice. So the researcher got an interest to carry out this study.

6.2 REVIEW OF LITERATURE

Review of literature is a key step in research process. It provides you with the

current theoretical and scientific knowledge about a particular problem, and resulting in

synthesis of what is known or not known.

The literature reviewed under following headings.-

Part 1: Reviews related to incidence rate on neonatal jaundice.

Part 2: Reviews related to management of neonatal jaundice.

Part 3: Reviews related to knowledge on neonatal jaundice

Part 4: Reviews related to educational programmes on neonatal jaundice..

6

Part 1: Reviews related to incidence and prevalence of neonatal jaundice.

A study was conducted to determine noenatal jaudice in very low birth weight

babies.There were 12193 live births during the study period. . The result shows that 867

(7.1%) babies were VLBW and 668 (77%) amongthem survived for more than 2 days

and were includedin the analysis. A total of 512 (76.6%) babies developed clinical

jaundice.17

A study was conducted to evaluate the prevalence of neonatal jaundice in

newborns with G6PD deficiency. During this two-year period, 2505 neonatal cord blood

samples from 1278 boys and 1227 girls were screened for G6PD. There were 50 positive

results for G6PD deficiency (39 boys and 11girls), and the prevalence was estimated to

be around 2%. The sex-specific prevalence for boys was3.05%, and for girls 0.9%. Male

to female ratio was 3:1. Neonatal jaundice developed in six (12%)babies, five male and

one female. All were treated with phototherapy and discharged within one weekof birth.18

A stuuy was conducted on incidence and causes of severe neonatal

hyperbilirubinemia in Canada . The resultsshows that of 367 cases reported, 258 were

confirmed to be severe neonatal hyperbilirubinemia, for an estimated incidence of 1 in

2480 live births. Causes were identified in 93 cases and included ABO incompatibility (n

= 48), glucose-6-phosphate dehydrogenase deficiency (n = 20), other antibody

incompatibility (n = 12) and hereditary spherocytosis (n = 7). The mean peak bilirubin

level reported was 471 µmol/L (standard deviation [SD] 76 µmol/L, range 156–841

µmol/L). Fifty-seven infants (22.1%) underwent an exchange transfusion. A total of 185

infants (71.7%) were readmitted to hospital, 121 (65.4%) of them within 5 days of age.19

PART 2: Reviews related to management of neonatal jaundice.

A study was conducted on management of neonatal hyperbilirubinemia: The

setting was a local government area i.e. an administrative district within the south-

western part of Nigeria. Results of the study shows that Primary health care workers may

have inadequate knowledge and misconceptions on NNJ which must be addressed

concertedly before the impact of the condition on child health and well-being can be

significantly reduced. We recommend regular training workshops and seminars for this

purpose.20

7

A study was conducted on early detection and treatment of neonatal

hyperbilirubinemia is important in the prevention of bilirubin-induced encephalopathy..

Study conclude that the pediatricians' practices regarding the low utilization of laboratory

diagnosis for the quantification of jaundice after discharge and underestimation of risk

factors that contribute to the development of severe hyperbilirubinemia are associated

with initiation of phototherapy at lower than AAP recommended treatment parameters

and recognition of neonatal hyperbilirubinemia as an important public health concern.21

A study was conducted by Department of Pediatrics, Kasturba Medical College,

Manipal University, Manipal, Udupi district,Karnataka to assess the utility of 24 and 48

hours transcutaneous bilirubin index for predicting subsequent significant

hyperbilirubinaemia in health term neonates. Result shows that the mean birth weight

was 2949 (+/- 390) gm and mean gestation of 38.6 (+/- 1.1) weeks. Eight one (17.6%)

had significant hyperbilirubinemia. Of 461, 135 (29.3%) had TcB index.22

A clinical controlled study was performed in two groups of healthy full term

neonates. Thirty neonates were treated with a single oral dose of clofibrate 100 mg/kg

plus phototherapy clofibrate-treated group while another 30 neonates (control group)

received only phototherapy. Results shows that the mean plasma total bilirubin levels of

12th, 24th and 48th hours were significantly lower in the clofibrate-treated group as

compared with the control group .. No side effects were observed.23

A study conducted on phototherapy for jaundice is a common treatment in

neonatal medicine and is used to prevent the neurotoxic effects of bilirubin.. Outcome

measures have been duration of need for phototherapy or rate of reduction of serum

bilirubin over a given time.. This work reviews the evidence concerning the speed of

photoisomer formation, as well as the evidence regarding the relative neurotoxicity of

bilirubin isomers.24

PART 3: Reviews related to knowledge on neonatal jaundice.

A study was conducted to determine knowledge, attitude, and behaviour of

mothers about neonatal jaundice. In this cross-sectional study, 400 cases who delivered at

8

Ali-Ebne Abitaleb Hospital in Zahedan-Iran during April and May 2006 were

interviewed to complete 21-point questionnaires.. Results showed a direct correlation

between knowledge, attitude and behaviour P<0.001.14

An explorative study was conducted in University and community hospitals by

using grounded theory methods to explore whether mothers currently express concerns

about neonatal jaundice and perceive it as a serious condition; Result shows Mothers

continued to voice concerns about jaundice and perceive it as serious.25

A descriptive study as conducted to investigate nursery practices regarding

outpatient recognition of neonatal jaundice. Results shows head nurses from 204 nurseries

and 200 pediatricians were surveyed, with 62% of head nurses and 55% of pediatricians

responding. Almost half of the head nurses (45%) reported lack of a written neonatal

jaundice protocol. Twenty-seven percent of head nurses and pediatricians reported that no

system is in place to track jaundiced newborns after discharge. Forty percent of head

nurses and 26% of pediatricians reported from higher-risk nurseries, defined as nurseries

where more than 25% of mothers did not have a high school diploma or more than 50% of

infants were born to single-parent families26.

PART 4: Reviews related to educational programmes on neonatal jaundice

A historic cohort was conducted on the prevention of bilirubin-induced brain

injury is based on the detection of infants at risk for developing severe

hyperbilirubinemia. Results shows that the study involved 101272 neonates: 48789 in

period 1 and 52483 in period 2. Before the program, 1 in every 77 neonates born at an

IHC hospital had 1 or more serum bilirubin levels >20 mg/dL. After initiating the

program, the incidence fell to 1 in 142 and the number of neonates with a level >25

mg/dL fell from 1 in 1522 before to 1 in 4037 after. The rate of hospital readmission with

a primary diagnosis of jaundice fell from 0.55% in period 1 to 0.43% in period 2.27

A study was conducted by Gagnon AJ, Waghorn K, Jones MA, Yang H to identify

the indicators nurses employ in deciding to test healthy full-term newborns for total

serum bilirubin in the absence of a written protocol. The result shows that Newborns are

9

over tested for bilirubin. Indicators used by nurses in deciding to test a healthy newborn

for total serum bilirubin are the presence of jaundice and feeding frequency. Nurses who

assess feeding frequency are less likely to order bilirubin testing.28

A study was conducted to evaluate the sensitivity and specificity of total serum

bilirubin concentration (TSB) and free (unbound) bilirubin concentration as predictors of

risk for bilirubin toxicity and kernicterus and to examine consistency between these

findings and proposed mechanisms of bilirubin transport and brain uptake. Results shows

that there are insufficient published data to precisely define sensitivity and specificity of

either TSB or Bf in determining risk for acute bilirubin neurotoxicity or chronic sequelae

(kernicterus)..29

STATEMENT OF THE PROBLEM

A STUDY TO ASSESS THE KNOWLEDGE AND KNOWLEDGE ON

PRACTICE OF STAFF NURSES REGARDING MANAGEMENT OF

NEONATAL JAUNDICE IN SELECTED PEADIATRIC HOSPITALS AT

HASSAN WITH A VIEW TO DEVELOP AN INFORMATION BOOKLET.

6.3 OBJECTIVES

To assess the level of knowledge regarding management of neonatal jaundice

among staff nurses working in peadiatric hospitals.

To assess the knowledge on practice regarding management of neonatal jaundice

among staff nurses working in peadiatric hospitals.

To correlate the level knowledge with knowledge on practice regarding

management of neonatal jaundice among staff nurses working in peadiatric

hospitals.

To associate the knowledge score with the selected sociodemographic variables

of staff nurse.

6.3.1 HYPOTHESIS

10

H1: There will be a significant relationship between the knowledge and knowledge on

practice neonatal jaundice among nursing staffs.

H2: There will be a significant association between level of the knowledge and with

selected socio demographic variables

6.3.2 ASSUMPTIONS

Staff Nurses may have some knowledge on neonatal jaundice.

Self instructional module may improve the knowledge and hence it helps the staff

nurses to detect and prevent early of neonatal jaundice.

6.3.3 OPERATIONAL DEFINITIONS.

Assess

To judge or decide the amount, value, quality or importance of something.

Knowledge

Knowledge refers to the respondent verbal response regarding first aid and

prevention of road traffic accidents.

Knowledge on practice

Knowledge on practice refers to awareness of staff nurses on skills and

management of babies with neonatal jaundice.

Staff nurses

Nurses those who are working in peadiatric hospital settings,providing nursing

care to children with illness

Neonatal jaundice

Neonatal jaundice refers to the yellow discoloration of the skin and sclera of

newborn babies that results from hyperbilirubinaemia. Most infants develop visible

11

jaundice due to elevation of unconjugated bilirubin concentration during their first week.

This common condition is called physiological jaundice.

Peadiatric hospitalPeadiatric hospital is the health care institution where children with illness will be treated.

Nursing staff.

One who provide services essential to or helpful in the promotion, maintenance, and

restoration of health and well-being.

Information booklet

In this study, it refers to a formal and specific teaching materials which includes

all information regarding management of neonatal jaundice.

6.3.4 DELIMITATIONS

The study is limited to,

Staff nurses working in pediatric wards of selected hospitals at Hassan

Sample size is limited to 60 staff nurses.

Period of data collection is limited to 4 - 6 weeks.

6.3.5 CONCEPTUAL FRAMEWORK

This study is based on general system theory.

6.3.6 SIGNIFICANCE OF THE STUDY.

Study implies the effectiveness of self instructional module regarding the

knowledge on management of neonatal jaundice among staff nurses.

7. MATERIAL AND METHODS.

7.1.1 SOURCES OF DATA

The data will be collected from staff nurses at selected hospital at Hassan.

7.1.2 RESEARCH DESIGN

12

Descriptive design

SAMPLE OBSERVATION

ONE GROUP 01

01-Administration of structured interview schedule to assess the knowledge of staff

nurses.

7.2 METHODS OF DATA COLLECTION

Data is intended to collect by using structured questionnaires on management of neonatal

jaundice.

The tool will be categorized into two sections,

Part 1: Sociodemographic variables.

Part 2: Structured knowledge questionnaires on management on neonatal jaundice.

Part3. Structured questionnaires on knowledge on pratice regarding management of

neonatal jaundice

7.2.1 SAMPLING PROCESS

7.2.2. CRITERIA FOR SAMPLE SELECTION.

INCLUSION CRITERIA

Staff nurses of selected hospitals at Hassan

Staff nurses who are present at the time of data collection.

Staff nurses who are willing to participate.

7.2.3 POPULATION

Staff nurses of selected hospitals at Hassan.

13

7.2.4 SAMPLES

Staff nurses that fulfill the inclusion criteria.

7.2.5 SAMPLE SIZE

Sample size is 60

7.2.6 SAMPLE TECHNIQUE

Non probability sampling by using convenient method.

7.2.7 SETTING

The present study will be conducted at selected hospitals at Hassan.

7.2.8 PILOT STUDY

Pilot study is planned with 10% of samples.

7.2.9 VARIABLES

Independent variable

Self instructional module regarding management of neonatal jaundice.

Dependent variable

Knowledge regarding management of neonatal jaundice.

7.2.10 PLAN FOR DATA ANALYSIS

The plan for data analysis includes descriptive and inferential statistics.

Descriptive statistics

Mean, median, percentage and frequency, will be used to describe the knowledge aspect.

Inferential statistics

Pre and post test difference will be analyzed using, paired t’- test within the group.

Association between demographic variables and post test level of awareness will be

analyzed using Chi- square test.

14

Correlation co-efficient will be used to find out the relationship between knowledge ad

knowledge practice.

7.3.1. DOES THE STUDY REQUIRE ANY INVESTIGATION OR

INTERVENTION TO BE CONDUCTED ON HUMANS ?

Yes ,the study requires investigation. In my study I will be collecting data from staff

nurses regarding knowledge on managemant of neonatal jaundice..

7.3.2. HAS ETHICAL CLEARANCE BEING OBTAINED FROM YOUR INSTITUTION?

Yes, ethical clearance has been obtained from the ethical committee of Rathna

College of Nursing. Permission has been obtained from the authority of Peadiatric

hospital. Informed consent will be obtained from each study participants.

8. LIST OF REFERENCE.

1. Herbert Hoover, 31st U.S. President.Children are our most valuable natural resource.

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2. Thor W R Hasen.2010,March-24 http//emedicine.medscape.com/article/974786..

3. Neil k.Kaneshiro,MD<MHA. David Zieve,MD, MHA .Doctor-reviewed article from

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4. Anonymous.Neonatal jaundice.2009-March-19 URL: http://en.wikipedia.org/wiki/

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7. Wikipedia, the free encyclopedia

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18. Mohammed AhmedMuzaffer. The prevalence of neonatal jaundice in newborns

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25. Hannon PR, Willis SK, Scrimshaw SC. Persistence of maternal concerns surrounding

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26. Catherine C. Wiley, MD; Naline Lai, MD; Christopher Hill; Georgine Burke,

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1998;152:972-975. URL:http://archpedia.ama-assn.org

27. Larry D. Eggert, MD, Susan E. Wiedmeier, MDa,b, Janie Wilson, RN, MSa,

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