A STUDY TO ASSESS THE EFFECTIVENESS OF

STRUCTURED TEACHING PROGRAMME ON THE KNOWLEDGE AND PRACTICE OF

3RD YEAR Bsc NURSING STUDENTS REGARDING THE MANAGEMENT OF DIFFERENT

TYPES OF NEONATAL JAUNDICE IN SELECTED

COLLEGES OF TUMKUR.

PROFORMA FOR REGISTRATION OF

SUBJECT FOR DISSERTATION

Miss.KEERTHI D’COSTA

AKSHAYA COLLEGE OF NURSING S.I.T. MAIN ROAD ,TUMKUR. DECEMBER 2008

1

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION.

1. Name of the Candidate

and address

: Ms. KEERTHI D’COSTAMsc Nursing I yearAkshaya College of NursingAshoknagar, 2nd CrossTumkur-572102Karnataka.

2. Name of the Institution : Akshaya College of Nursing.

3. Course of Study and Subject : Msc Nursing 1st yearPaediatric Nursing.

4. Date of Admission to Course :

5. Title of the Topic : “A study to assess the effectiveness of structured teaching programme on knowledge and practice of 3rd year Bsc nursing students regarding the management of different types of Neonatal jaundice in selected nursing colleges of Tumkur”.

.

2

6. BRIEF RESUME OF THE INTENDED WORK.

INTRODUCTION

‘So I triumphed my passion sweeping through me, left me dry, left me with a

palsied heart and left me with a jaundiced eye’

- Lord Alfred Tennyson.

Jaundice also known as icterus, comes from the French word jaune, meaning

yellow. Jaundice is the yellowish discoloration of the skin, sclera (whites of the eyes)

and mucous membranes caused by hyperbilirubinemia.1

Hyperbilirubenemia subsequently causes increased levels of bilirubin in the

extra cellular fluids. Typically, the concentration of bilirubin in plasma must exceed

1.5 mg/ dl three times the usual value of approximately 0.5 mg/dl for the coloration to

be easily visible.1

It was believed that persons suffering from the medical condition jaundice

saw everything as yellow. By extension the jaundiced eye came to mean a prejudiced

view usually rather negative or critical.1

Neonatal jaundice is usually harmless, this condition is often seen in neonates

around 2nd day after birth, lasting until 8 days in normal birth and to around day 14 in

preterm births. Newborns frequently go through a brief period of jaundice right after

their birth. This is termed as PHYSIOLOGICAL JAUNDICE of newborn and is due

to immaturity of infants liver, if carefully monitored these newborns generally

improve within 48-72 hrs.2

Jaundice appearing within 24 hrs of birth persisting for more than 1 week in a

term infant or more than 2 weeks in preterm infant where there will be excessive red

cell haemolysis is called as PATHOLOGICAL JAUNDICE.2

3

In neonates benign jaundice tends to develop because of two factors-the

breakdown of fetal hemoglobin which is replaced with adult hemoglobin and

secondly the relatively immature hepatic metabolic pathways, which are unable to

conjugate and so excrete bilirubin as quickly as an adult. This causes accumulation

of bilirubin in blood leading to symptoms of jaundice. Prolonged neonatal jaundice is

serious and should be followed promptly.1

6.1 NEED FOR THE STUDY

Jaundice is presumably a consequence of metabolic and physiological

adjustments after birth. The raised serum bilirubin normally drops to a low level

without any interventions in some cases whereas other requires prompt management.

Neonatal jaundice is the risk factor for many complications. Normal bilirubin value

should be more than 2mg/dl. A value of more than 5mg/dl is considered high.

Jaundice appears on 2nd and third day and disappears by 7th-10th day, a rise of 12mg/dl

in term neonates is seen in physiological range and jaundice appearing within 24hours

of birth with a rise of 15mg/dl in preterm and 12mg/dl in term neonates is seen in

pathological jaundice.2

A study conducted to estimate the causes of neonatal death where

data was collected from 44 countries reported that the causes for neonatal death

varied substantially and the major cause detected where: infections such as sepsis,

pneumonia, tetanus, diarrhea in 52% preterm birth, with deficiency diseases in 28%

and birth asphyxia in 23%. 3

A study was conducted to evaluate the etiology of indirect

hyperbilirubenemia and prevalence of glucose-6 phosphate dehydrogenace deficiency

in newborns. Out of 159(42.3%) boys and 217 (57.7%) girls, the prevalence of

glucose-6 phosphate dehydrogenace deficiency was in 59(15.7%) neonates, ABO

incompatibility in 14(3.7%) neonates, Rh incompatibility in 2(0.5%) neonates.4

4

A Study was conducted to overview the prevalence of neonatal jaundice in

neonatal intensive care unit of Koirala institute of health sciences in India. Among

293 neonates including 201 males and 92 females admitted: increased prevalence of

the disease was seen in 30% premature neonates, 29% of birth asphyxiated babies,

23% in respiratory distress babies.5

Apart from the above-mentioned studies neonatal jaundice can also result in

many complications. Prolonged hyperbilirubinemia can result into chronic bilirubin

encephalopathy, a brain damaging condition called KERNICTERUS. An effect of

kernicterus is fever. A study conducted on a male full term neonate with

hyperbilirubinemia at the age of 4 days displayed symptoms of increased lethargy,

refusal to eat and had fever.6

Another effect of kernicterus is seizures. The neonatal unit at allied hospital

Faisalabad studied 200 neonates of either gender who presented seizure during the

hospital stay from April 2003 to June 2004. The cause of seizure was evaluated and

one cause of seizure was kernicterus.4.5percentage or nine neonates displayed

seizures caused by kernicterus.7

High-pitched crying is also an effect of kernicterus. Scientists used a

computer to record and measured cranial nerves 8, 9 and 12. 50 infants were divided

into two groups equally depending upon bilirubin concentrations. Of the 50 infants,

43 had tracings of high-pitched crying. Neonatal jaundice is also risk factor for

hearing loss.8

From the above data the potentially correctable causes are:

Underestimating the severity of jaundice by clinical (i.e. visual) assessment.

Lack of concern regarding presence of jaundice.

Failure to recognize the presence of risk factors for hyperbilirubenimia.

Early discharge with no follow-up.9

5

From the above studies and if the above mentioned potential correctable

causes are seriously considered the incidence of Neonatal jaundice can be reduced.

Student nurses during their clinical training if develops concern and proper

knowledge about the causes, severity of jaundice and implements proper measures the

newborn will be protected from the risk of complications. Today’s student nurses are

tomorrow’s staff nurses and their knowledge will help in the prevention of

complications of jaundice. As 3rd year Bsc nursing student’s study child health

nursing, it is the base to construct their knowledge, so the investigator felt the need to

take up the study.

6.2 REVIEW OF LITERATURE.

The reviews of literature are presented under the following headings.

Risk factors and prevalence of hyperbilirubenemia.

Incidence and causes of Neonatal jaundice.

Awareness of neonatal jaundice.

Knowledge, practice of Neonatal jaundice.

Prevention of neonatal jaundice.

Management of Neonatal Jaundice.

Complications of neonatal jaundice.

RISK FACTORS AND PREVALANCE OF NEONATAL JAUNDICE.

RISK FACTORS

A study was conducted on “prevalence and risk factor of

hyperbilirubenemia” and the identified risk factors included Rh and ABO

incompatibility, glucose-6-phosphate dehydrogenase (G-6PD) deficiency and

elevated transcutaneous bilirubin level. G-6-PD deficiency occurrence was seen in

11-13% of blacks and was more common in immigrants from the Mediterranean

countries and Southeast Asia. These causes were associated with kernicterus in

United States also.10

6

EFFECT OF EARLY HOSPITAL DISCHARGE

A study was conducted on “early newborn hospital discharge and

readmission for mild and severe hyperbilirubenimia” in Washington. The result

showed that 750 infants readmissions to the hospital for jaundice in first 2 weeks of

life and revealed infants discharged from the hospital early were at increased risk for

jaundice. 11

Another study conducted on “early discharge of newborns: what problems

to anticipate” among 913 neonates, 42 presented the complications and among them

four required urgent neonatal care. The most common complication was

hyperbilirubinemia and 23 newborns were treated with phototherapy.12

INCIDENCE AND CAUSES OF NEONATAL JAUNDICE.

In Full Term Neonates.

A study was conducted in Canada on “Incidence and causes of severe

Neonatal hyperbilirubenemia” and out of 367 cases reported, 258 were confirmed to

be severe neonatal hyperbilirubenemia for an estimated incidence of one in 2480 live

births. Causes identified in 93 cases included ABO incompatibility, glucose 6-

Phosphate dehydrogenase deficiency, antibody incompatibility and hereditary

spherocytosis. The mean peak bilirubin level reported was 471 mol/l. Fifty-seven

infants underwent an exchange transfusion. 185 infants were readmitted to hospital

121 of them were within 5 days of age. 13

In Low Birth Weight Infants

A study was conducted on 94 preterm very low birth weight infants and

determined that the mean daily bilirubin values peaking on 4th day of life at

188.1 mol/l. 28 infants developed hyperbilirubenemia and they were exposed to

phototherapy. When individual peak bilirubin values were evaluated the overall peak

values was 213.9 mol/l occurring at 4.81 days. All the infants remained well and

progressed satisfactorily ‘Healthy’. Thus very low birth weight infant experience a

7

much greater incidence and severity of neonatal jaundice than mature with the same

clinical status.14

Incidence in Nether land.

A study was conducted on “ glucose- 6- phosphate dehydrogenase

deficiency: clinical presentation and eliciting factors” showed that glucose- 6-

phosphate dehydrogenase deficiency is most common enzymatic disorder of red

blood cells in humans which increased the incidence of neonatal jaundice. It also

showed its increased prevalence in Netherlands due to immigrants from the Middle

East and Africa.15

Causes

A study was conducted in panama to detect the case of Kernicterus in

glucose- 6- phosphate dehydrogenase deficient newborn clothed in naphthalene-

impregnated garments which showed a reduced psychomotor development, neuro

sensory hypoacousia, absence of speech and poor reflex of the pupils to light. The

study tells, as the use of naphthalene in stored clothes is a common practice, glucose-

6- phosphate dehydrogenase testing in neonatal screening could prevent severe

neonatal consequences.16

General

A Study was conducted on “jaundice in newborns” which showed that

hyperbilirubenemia is the commonest morbidity in neonatal period and 5-10% of all

newborns require interventions for pathological jaundice it also showed neonates on

exclusive breast feeding had a different pattern and degree of jaundice as compared to

artificially fed babies the study advised to provide separate guidelines for the

management of jaundice in sick term babies, preterm and low birth weight babies. 17

8

AWARENESS OF NEONATAL JAUNDICE.

o In Mediterranean region.

A study was conducted on “Awareness of Neonatal jaundice in

Mediterranean region” which observed adequate knowledge of the participants in

many aspects of Neonatal jaundice but also revealed some misconceptions of the

respondents in the use of medications and management of Neonatal jaundice. The

study called for a well-structured health education programmes stressing on such

misconceptions.18

o In family health care professionals.

A study conducted on yellow alerts showed the increased incidence for

neonatal jaundice is because the families have been falsely reassured that their baby’s

jaundice is normal, as the family health care professionals are unaware to identify

neonatal jaundice. It reviews the importance of awareness of family health care

professionals to identify the infants with liver diseases.19

KNOWLEDGE AND PRACTICE OF NEONATAL JAUNDICE

Knowledge and Practice by the Mothers.

A study was conducted on Iranian mothers with icteric newborn to assess their

knowledge and practice. About 77% of the mothers had moderate to high-level

knowledge of Neonatal jaundice. Approximately 1/3rd of the mothers consulted

physician within 24hrs of appearance of jaundice and 13.8% mothers declared that

they waited and managed their children with traditional remedies until they sought

medical advices. 32.2% of mothers discontinued feeding their icteric offspring with

colored foods and colostrums. The study determined poor knowledge of Iranian

mothers with incomparable level of related practice.20

9

Knowledge and practice by the nurses.

A study was conducted on ‘Neonatal jaundice and its management:

Knowledge, attitude and practice of community health workers in Nigeria’. 66 of 71

health workers participated in survey 34 respondents defined neonatal jaundice

correctly, 26 responses were either partially correct or incorrect while six people did

not respond. Thus the researcher concluded that knowledge gaps exists among

primary health workers concerning neonatal jaundice and its management and they

recommended that regular training, workshops or seminars should be conducted to

bridge these gaps.21

Pediatricians’ practices.

A study was conducted to evaluate “Pediatricians practices and believes

regarding management of neonatal hyperbilirubenemia” and identified that

pediatricians utilized very low laboratory diagnosis for quantification of jaundice and

they also underestimated the risk factors that contribute to the development of severe

hyperbilirubenemia. They also initiated phototherapy at lower parameters than the

recommended treatment parameters.22

PREVENTION OF NEONATAL JAUNDICE.

A study was conducted on “a practical approach to neonatal jaundice” showed

that kernicterus and neurologic sequence caused by severe hyperbilirubenemia are

preventable conditions. Primary prevention includes ensuring adequate feeding.

Secondary prevention is achieved by vigilant monitoring of neonatal jaundice. Thus,

the study showed if a structured and practical approach is applied to the identification

and care of infants with jaundice could facilitate its prevention.23

MANAGEMENT OF NEONATAL JAUNDICE.

10

Phototherapy.

A study was conducted for the specific recommendations on the

initiation of phototherapy and guided that the thresholds at which phototherapy is

used should be adjusted according to gestational age, birth weight and age of

jaundiced babies. They also suggested that phototherapy could be taken off when the

serum bilirubin drops below 185 micro mol/L on two consecutive readings for a

minimum duration of 24 hours.24

Effect of phototherapy

A study was conducted on neonates with hyperbilirubenemia to find out

the possible relation between phototherapy and DNA damage. The study included 33

full term newborns with non-physiologic jaundice and 14 healthy newborns with

physiological jaundice as controls. Phototherapy was performed with an array of six

fluorescent lamps producing radiation with wavelengths of 480-520nm. DNA damage

in lymphocytes was determined by use of alkaline comet assay. It showed increased

incidence of DNA damage with the increased duration of phototherapy.25

Pharmacotherapy.

A study was conducted on “An old traditional herbal remedy for Neonatal

jaundice with a newly identified risk” in Hong Kong. Result indicated that Yen-Chen

(Artemisia Scoparia) is very popular intravenous herbal preparation that displaces

bilirubin from its protein binding free bilirubin liberated in this process increases the

risk of brain damage in jaundiced infants. Therefore, the use of traditional herbal

therapies should be strongly discouraged in neonates. They suggested the use of

medical preparations such as Phenobarbital therapy that induces hepatic microsomal

enzymes and increases bilirubin conjugation and excretion. 26

Exchange transfusion.

Guidelines for exchange transfusion

11

A study was conducted on “Guidelines for exchange transfusion in infants

35 or more weeks of gestation” and suggested if total serum bilirubin (TSB) raises

above levels despite phototherapy in readmitted infants exchange transfusion may be

indicated. The blood should be sent for immediate type and only trained personnel in

a neonatal intensive care unit with full monitoring and resuscitation capabilities

should perform cross matching and exchange transfusion. 27

Exchange transfusion using Peripheral vessels

A study was conducted on “exchange transfusion using peripheral vessels”

out of 123 newborns that underwent exchange transfusion, 24 were performed via

umbilical vein and 99 via peripheral vessel method. It showed that severe adverse

effects occurred in umbilical vein group than peripheral vessels group. Thus, the

study revealed peripheral veins and arteries are safe and effective for exchange

transfusion in newborn infants.28

COMPLICATIONS OF NEONATAL JAUNDICE

A Study was conducted on “unbound bilirubin concentration is associated

with abnormal automated auditory brainstem response for jaundiced newborns” out of

44 infants with proximate total bilirubin concentration, 4 of them showed

neurotoxicity, 5 showed the possibility of deafness and remaining exhibited abnormal

automated auditory brainstem responses.29

6.3 STATEMENT OF THE PROBLEM.

12

6.4 OBJECTIVES OF THE STUDY

To assess the knowledge of the students regarding management of

different types of Neonatal jaundice.

To identify the practices of the students regarding management of

different types of Neonatal jaundice.

To evaluate the effectiveness of structured teaching programme on

knowledge and practice regarding management of different types of

Neonatal jaundice.

To find the correlation between knowledge and practice of students

regarding the management of different types of neonatal jaundice.

To associate the selected demographic data of students with their

knowledge and practice.

6.5 OPERATIONAL DEFINITONS.

ASSESS

It refers to the statistical measurement of knowledge of the students on

questionnaire regarding management of different types of Neonatal jaundice.

EFFECTIVENESS

It is the significant improvement in knowledge and practice among the

students after the implementation of structured teaching programme as evidenced by

the differences in the pretest and post test scores.

STRUCTURED TEACHING PROGRAMME.

It refers to systematically developed instructions designed for a group of

students to provide information regarding management of different types of Neonatal

jaundice.

13

KNOWLEDGE

It refers to the responses of the respondent to the knowledge regarding

management of different types of Neonatal jaundice.

PRACTICE

It refers to the action of the students in relation to management of different

types of Neonatal jaundice.

STUDENTS.

III year Bsc nursing students those who have not appeared for the final exams.

MANAGEMENT

Continue to function, to progress or succeed, usually despite difficulty. In this study

it is refers to the effective use or application of,

Phototherapy

Pharmacotherapy

Exchange blood transfusion

.

NEONATAL JAUNDICE

Yellowish discoloration of the skin and mucosa caused by excessive

accumulation of bilirubin is neonatal jaundice. Different types are;

Physiological jaundice: usually harmless noticed

during 3-5 days of life.

Pathological jaundice: here bilirubin will be seen

in the blood which affects babies brain cells

leading to complications..

Not enough breast milk jaundice: seen in poorly

breastfed babies where inadequate breast milk

increases bilirubin in blood

14

Inadequate liver function: Jaundice which

occurs due to infections of the liver

Jaundice of prematurity: seen in preterm babies

Breast milk jaundice: seen in inadequately

breastfed babies.

6.6 ASSUMPTIONS:

It is assumed that 3rd year Bsc nursing students have some knowledge

about management of different types of neonatal jaundice.

Structured teaching programme will enhance the knowledge and practice

of 3rd year Bsc nursing students regarding the management of different

types of neonatal jaundice.

6.6 HYPOTHESIS

H1: there will be significant relationship between knowledge and practice

regarding management of different types of neonatal jaundice

among 3rd year Bsc nursing students.

H2: there will be significant relationship between structured teaching

programme and the changes in knowledge and practice among

3rd year students regarding management of different types of

neonatal Jaundice.

H3: there will be significant association of selected demographic variables

with knowledge and practice of 3rd year Bsc students regarding the

management of different types of neonatal jaundice.

15

7 MATERIALS AND METHODS

7.1 SOURCES OF DATA

Research Design : Quasi-experimental. One group pretest and

. post test designs.

Setting of the Study : Akshaya college of nursing and

Anirudh college of nursing

Population : students of 3rd year Bsc nursing in selected

Nursing colleges of Tumkur.

Sample size :60 subjects

Sampling Technique : Simple random sampling

Selected variables.

Demographic variable – age, sex, education etc

Dependent variable – knowledge & practice

Independent variable – structured teaching programme

Sampling criteria

Inclusion Criteria

Students studying in III year Bsc Nursing in selected

nursing colleges.

Students who can understand either English or

Kannada.

Students who are willing to participate in the study.

Exclusion criteria

Students who are not willing to participate

Students who do not understand either English

or Kannada.

Students who are not available at the time of

data collection

16

7.2 METHODS OF DATA COLLECTION

Tools of data collection:

After obtaining the permission from concerned authorities, the investigator

will introduce herself to the study subjects and explains the purpose of the

study. Informed consent will be obtained from the study samples and the

data will be collected by interview method using structured questionnaire

Descripition of the tool

Part A : Proforma for collecting demographic data

Part B : Structured questionnaire to assess the knowledge and

Practice regarding the management of different types of

Neonatal Jaundice.

7.2.1 Methods of data analysis and interpretation

Data will be analyzed according to the objectives of the study using

descriptive and inferential statistics and will be presented in the form of tables, graphs

and diagrams

7.2.2 Duration of the Study : 6 weeks

7.3 Does the study require any investigation or intervention to be conducted

on the patients or other human being or animals if so please describe

briefly.

NO

7.4 Has ethical clearance been obtained from your institution in case of the

above?

NA.

17

8. REFERENCES

1. Annama Jacob, “comprehensive textbook of midwifery” jaypee

publications, Page no: 551-555

2. Dutta D C, “Text book of obstetrics” Hilular konnar publications 6 th

edition 2004 page no: 477-480.

3. Joy E Lawn, Katarzyna, Wilczynska “Estimating the cause of neonatal

death” newyork, 22 feb 2006.

4. Kooshat , Rafizadehview B, “ Evaluation of indirect hyperbilirubenemia

and prevalence of glouse-6- phosphate dehydrogenace deficiency” 2005

5. Koirala institute of health sciences “Overview of cases and prevalence of

neonatal jaundice in neonatal intensive care units” Nepal june 8th 2006

133-35.

6. www. Wilkipedia.com

7. www.who.com

8. Poland Ronald “Journal of acute bilirubin encephalopathy” American

academy of paediatrics

9. Shashank and V.Parulekas “textbook for midwifery” Vora medical

publications 2nd edition, Page no: 483-488.

10. Friedman L “Prevalance and risk factors of hyperbilirubenemia” May

2004

11. Jacqueline grupp, Phelan, James.A, Taylor.M.D, “Early newborn hospital

discharge and readmission for mild and severe jaundice” 1994

12. Straizek H, Vieux R, Hubert C, Miton A, “Early discharge of newborns

what problems to anticipate” June 2008.

13. Michael saro, Douglas Campbell “Incidence and causes of neonatal

hyperbilirubinemia” Canada 2006.

14. Tan K L, “Incidence of neonatal hyperbilirubinemia in low birth weight

babies” 2006.

18

15. .Dors.N, Rodriguez Pereira.R, Yan Zwieten R, Fijnvandraat.K, Peters.M,

“glucose- 6- phosphate dehydrogenase deficiency: Clinical presentation

and eliciting factors”, May 2008.

16. . De Gurrola G C, Arauz J J, Duran E, Aguilar Medina M, Ramos Payan ,

“Kernictures by glucose- 6- phosphate dehydrogenase deficiency” Panama

May 2008.

17. Mishra.S, Agarwal.R, “jaundice in newborns” pub med, Feb.: 2008.

18. Friedman L “ Prevalance and risk factors of hyperbilirubenemia” 2003

19. Tizzard.S, Yiannouzis.K, “Yellow Alert: how to identify neonatal

jaundice” pediatric liver center, London, April 2008

20. Amirshaghaghi.A, Ghabili.k, “Neonatal jaundice: knowledge, practice of

Iranian mother with icteric newborn” 2004

21. Ogunfowora, “neonatal jaundice and its management: knowledge,

attitude and practice of community health workers in Nigeria” Biomed

central journal’2006

22. Anna petrova, Rajeev Mehta, Gillian Birchwood, Barbara ostfeld,

“management of neonatal hyperbilirubinemia: pediatricians practices”

2006

23. Moerschel. S.K, Cianciaruso.L.B, Tracy.L.R, “A Practical approach to

neonatal jaundice” department of family medicine, Virginia; USA, May

2008.

24.. Lee at A,”phototherapy in management of neonatal management”2001

25. Tatli.M.M, Minnet.C, Kocyigit.A, Karadag.A, “Phototherapy increases

DNA damage in lymphocytes of hyperbilirubinemia neonates” June

2008.

26. Yung.c.y, “old traditional herbal remedy for neonatal jaundice with a

newly identified risk” 1993

27. American academy of pediatrics, subcommittee on hyperbilirubinemia

“management of hyperbilirubinemia in the newborn infant 35 or more

weeks of gestation” 2004

19

28. Chen.H.N, Lee.M.C, Tsao. L.Y, “Exchange transfusion using peripheral

Vessels is safe and effective in newborn infants” Department of

pediatrics, Taiwan: Dec 2007

29. Ahlfors C E, Parker A E “ Unbound bilirubin concentration and

automated brainstem response for jaundiced neonates” May 2008

20

9. Signature of the candidate :

10. Remarks of the guide :

11. Name and designation of : [in block letters]

11.1. Guide : 11.2. Signature :

11.3. Co-Guide [if any] :

11.4. Signature :

11.5. Head of the department :

11.6. Signature : 12 12.1. Remarks of the chairman

and principal :

12.2. Signature :

21