- Develop a clear understanding of the pathophysiology of hyperbilirubinemia in newborns, including the normal physiological jaundice and potential complications.
- Identify and recognize the risk factors associated with neonatal hyperbilirubinemia, such as prematurity, ABO/Rh incompatibility, breastfeeding issues, and maternal diabetes, to facilitate early detection and intervention.
- Acquire skills in assessing jaundice in newborns through systematic clinical evaluation, including visual inspection, transcutaneous bilirubin measurement, and laboratory tests.
- Learn evidence-based nursing interventions for managing hyperbilirubinemia, including phototherapy administration, monitoring bilirubin levels, and providing support for breastfeeding mothers.
- Develop effective communication skills to educate parents about the causes, signs, and management of neonatal hyperbilirubinemia. Provide support and guidance for parents in caring for their jaundiced newborns at home.
Pathophysiology for Neonatal Jaundice | Hyperbilirubinemia in Newborns
- Bilirubin Production:
- Bilirubin is a yellow pigment produced from the breakdown of heme, a component of hemoglobin. In newborns, there is an increased breakdown of fetal hemoglobin, contributing to elevated bilirubin levels.
- The newborn liver has limited capacity to conjugate and excrete bilirubin. The enzyme glucuronyl transferase, responsible for conjugating bilirubin for elimination, is not fully functional, leading to a slower clearance of bilirubin.
- Bilirubin can be reabsorbed from the intestines into the bloodstream, a process known as enterohepatic circulation. This recycling of bilirubin prolongs its exposure in the body, contributing to jaundice.
- Breast milk contains substances that inhibit bilirubin conjugation, contributing to a condition known as breast milk jaundice. This can lead to prolonged jaundice in breastfed infants.
- Conditions such as ABO or Rh incompatibility between the mother and baby can result in increased breakdown of red blood cells, leading to higher bilirubin levels. Hemolysis contributes to the severity of jaundice in these cases.
Etiology for Neonatal Jaundice | Hyperbilirubinemia in Newborns
- Physiological Jaundice:
- Most newborns experience a normal and temporary increase in bilirubin levels during the first few days of life. This physiological jaundice is typically benign and resolves without intervention.
- Breast milk jaundice is associated with the composition of breast milk, which contains substances that can interfere with bilirubin metabolism. It tends to occur after the first week of life and may persist for several weeks.
- Conditions such as ABO or Rh incompatibility can lead to increased breakdown of red blood cells, resulting in elevated bilirubin levels. Hemolysis contributes to jaundice in these cases.
- Delayed passage of meconium, the infant’s first stool, can contribute to elevated bilirubin levels. Meconium helps eliminate excess bilirubin, and a delay in its passage can lead to increased reabsorption.
- Glucose-6-phosphate dehydrogenase (G6PD) deficiency, an inherited enzyme deficiency, can result in hemolysis and an increased risk of jaundice in newborns. Exposure to certain triggers, such as certain medications or infections, can exacerbate jaundice in infants with G6PD deficiency.
Desired Outcome for Neonatal Jaundice | Hyperbilirubinemia in Newborns
- Bilirubin Levels within Normal Range:
- The primary goal is to reduce and maintain bilirubin levels within the normal range for the infant’s age, minimizing the risk of bilirubin-induced neurotoxicity.
- Achieve the resolution of jaundice, ensuring that the yellow discoloration of the skin and sclera diminishes as bilirubin levels decrease.
- Regular monitoring for potential complications, such as kernicterus or acute bilirubin encephalopathy, and promptly addressing any signs or symptoms to prevent long-term neurological damage.
- Provide thorough education to parents or caregivers regarding the importance of monitoring feeding, promoting adequate hydration, and recognizing signs of worsening jaundice. This empowers parents to actively participate in the care of their newborn.
- Establish effective communication and collaboration between healthcare providers, including pediatricians, neonatologists, and nursing staff, to ensure a coordinated approach to monitoring and managing hyperbilirubinemia in the newborn.
Hyperbilirubinemia of the Newborn / Neonatal Jaundice / Neonatal Hyperbilirubinemia Nursing Care Plan
Subjective Data:
Patient’s mother/caregiver reports:
- Difficulty with breastfeeding
- Loss of color in stools
- Fussiness
Objective Data:
- Yellowing of the skin and/or eyes (sclera)
- Greater than expected weight loss
- High-pitched cries
- Infant is difficult to awaken
- Serum indirect bilirubin >5mg/dL
Nursing Assessment for Neonatal Jaundice | Hyperbilirubinemia in Newborns
- Bilirubin Levels:
- Monitor and document serum bilirubin levels regularly, paying close attention to trends and changes over time.
- Perform a thorough clinical assessment, including a physical examination to evaluate the extent and progression of jaundice. Note the presence of yellow discoloration in the skin and sclera.
- Identify and assess potential risk factors for hyperbilirubinemia, such as prematurity, ABO or Rh incompatibility, exclusive breastfeeding, and a family history of jaundice.
- Evaluate the infant’s feeding patterns, ensuring adequate intake and addressing any issues related to breastfeeding or formula feeding that may contribute to dehydration or insufficient caloric intake.
- Monitor the frequency and characteristics of the infant’s bowel movements and urination to assess the elimination of bilirubin.
- Perform a focused neurological assessment to identify any signs of acute bilirubin encephalopathy or kernicterus, such as changes in muscle tone, irritability, poor feeding, or abnormal reflexes.
- Assess the newborn’s skin color and tone, particularly in areas where jaundice may be less apparent, such as the palms and soles.
- Actively engage with parents to gather information about any concerns they may have, address misconceptions, and provide education on the importance of monitoring and reporting changes in the infant’s condition.
Implementation for Neonatal Jaundice | Hyperbilirubinemia in Newborns
- Phototherapy:
- Initiate phototherapy as prescribed, ensuring the newborn is exposed to the therapeutic light source for the prescribed duration. Monitor the effectiveness of phototherapy by regularly assessing bilirubin levels.
- Encourage and support breastfeeding, ensuring that the newborn is adequately fed. If necessary, supplement with formula to promote effective calorie intake and reduce the risk of dehydration.
- Implement a systematic monitoring plan for bilirubin levels, feeding patterns, and elimination. Document changes in clinical status, response to interventions, and any concerns raised by parents.
- Educate parents about the importance of phototherapy, feeding, and the significance of regular follow-up appointments. Provide clear instructions on recognizing signs of worsening jaundice or other concerning symptoms.
- Collaborate with pediatricians, neonatologists, and other healthcare team members to ensure a coordinated approach to care. Participate in regular team discussions to review the infant’s progress and adjust the care plan as needed.
Nursing Interventions and Rationales for Neonatal Jaundice | Hyperbilirubinemia in Newborns
- Assess infant for skin abnormalities; note color (yellowing) of skin or eyes
Yellowing of the skin can be determined by lightly pressing on the skin of a baby’s forehead. This is the most common indicator of neonatal jaundice.
- Assess infant for neurological involvement
- Infant will likely be very fussy when awake, and difficult to awaken from sleep. Many mothers inadvertently delay waking the baby to feed.
- More advanced stages include hyperreflexia (twitching, over-excitability, sensitive reflexes, and convulsions)
- Obtain history of pregnancy and delivery
- A stressful delivery, including the use of assistive devices such as forceps or vacuum, can increase the risk of neonatal jaundice.
- Also, determine if there is any family medical history that could affect the infant like spleen and liver disease or hypothyroidism.
- Obtain serum or transcutaneous bilirubin level
- Transcutaneous method is preferred due to non-invasive nature of test. Levels greater than 12 mg/dL usually require treatment;
- Serum bilirubin may be required and is obtained by heel stick per facility protocol.
- Observe breastfeeding and offer assistance to improve latch and encourage frequent feedings every 2 hours; supplement with formula as appropriate
- Jaundice may be present in infants if they are having difficulty breastfeeding.
- Frequent feedings promote good hydration of the infant and increase milk supply in the mother.
- Breast milk may be insufficient; infant may require additional nutrients from formula
- Begin phototherapy per facility protocol
Baby will be placed under bili lights or blanket. Phototherapy helps improve the solubility of bilirubin for faster excretion through the stool and urine. This is non-invasive treatment.
- Monitor infants skin and eyes every 2 hours during phototherapy
- To prevent damage to skin, cover infant’s genitalia and eyes during phototherapy
- Assess skin and eyes every two hours when patient is removed from lights for feedings.
- Monitor for increased temperature / fever
Patient may experience higher temperature with bili lights; note signs of fever that may indicate infection or sepsis
- Administer medication or blood transfusion as appropriate
- Hyperbilirubinemia that is related to Rh incompatibility or severe anemia may require blood transfusions
- Medications (phenobarbital) may be given to stimulate liver enzymes to metabolize bilirubin.
- Provide education for patient’s parents/caregivers regarding care for infant with jaundice
- Discuss home management, return visits for evaluation and treatment, and possible long-term effects.
- Provide information for resources and referral for home therapy as needed.
Evaluation for Neonatal Jaundice | Hyperbilirubinemia in Newborns
- Bilirubin Levels:
- Regularly assess and compare bilirubin levels to determine if they are decreasing within the expected range. Evaluate the effectiveness of phototherapy and other interventions in reducing bilirubin levels.
- Monitor the newborn for clinical signs of improvement, such as a decrease in jaundice, improved feeding patterns, and increased activity. Evaluate whether the infant’s overall condition is progressing positively.
- Assess the adequacy of feeding by monitoring weight gain, diaper output, and the infant’s overall nutritional status. Ensure that the newborn is receiving sufficient nutrition to support recovery.
- Evaluate parents’ understanding of the care plan, including the importance of phototherapy, feeding practices, and signs of worsening jaundice. Address any misconceptions and provide additional education if needed.
- Convene with the healthcare team to review the overall progress of the newborn. Discuss any challenges encountered during the implementation phase, make adjustments to the care plan as necessary, and ensure continued collaboration among team members.
References
- https://emedicine.medscape.com/article/974786-clinical#showall
- https://www.mayoclinic.org/diseases-conditions/infant-jaundice/diagnosis-treatment/drc-20373870
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Example Nursing Diagnosis for Neonatal Jaundice | Hyperbilirubinemia
- Impaired Liver Function: Jaundice results from impaired liver function, making this diagnosis appropriate as it addresses the root cause of the condition.
- Risk for Altered Skin Integrity: Jaundice can cause pruritus and skin changes, putting the patient at risk for skin problems. This diagnosis focuses on skin integrity.
- Imbalanced Nutrition: Less than Body Requirements: Jaundiced patients may have poor intake due to nausea or anorexia, making this diagnosis relevant to address nutritional deficits.
Transcript
Hey guys, in this care plan, we are going to be discussing hyperbole group anemia, or as it's sometimes called infant jaundice. What we're going to cover here is a description of the diagnosis, your subjective and objective data and your nursing interventions and rationales.
Infant Jaundice is actually the medical diagnosis for when newborns have an excessive amount of bilirubin in the blood or in the body and that is where you get that diagnosis of hyperbilirubinemia. Bilirubin is the yellow pigment that is left over when red blood cells break down. Normally, this by-product or bilirubin is going to be absorbed and processed in the liver, but newborns sometimes lack or don't have enough of the enzyme that's needed to help metabolize that now, as the bilirubin builds up in the body and you get increased levels, you're going to see that in the skin and the eyes of the newborn. So, the eyes and skin become yellow tinted and it's really important to know that if we don't detect it, and if it's left untreated, really high levels of this can cause brain damage. Now, there are some risk factors that are associated with this that can make newborns more likely to develop jaundice. So, we've written about a few of those here. Definitely take a second to read about those.
The most important outcome for these patients is that they will have a bilirubin level that is within normal range and when we start to reach that, we're going to see the eyes decrease in yellowness and the skin as well. Another really important outcome is that we maintain adequate nutritional intake and adequate hydration as well.
Okay, let's get started with our care plan. The subjective data that you're going to see with this diagnosis, probably the first thing that parents may report is that they're going to have difficulty with breastfeeding. Now, sometimes this is given to us as information that they have poor feeding, but it also may come out as information that they have a decreased amount of urine output or that they're having fewer wet diapers. Parents may also notice that there's a loss of color in the stool and they may describe the stool as being pale. Mom and Dad may also notice that the baby's a bit fussier or even a bit more tired than usual.
Let's look at the objective data for this diagnosis. Some of the most important information that we're going to get in our assessment is the serum indirect bilirubin, and the number that we would get that would cause us to diagnose hyperbilirubinemia is five. So, anything greater than five is hyperbilirubinemia. Then, you're also likely going to be seeing that yellowing of the skin and the eyes and sometimes, you'll see a greater than expected weight loss. Now, what I mean by that is that the baby has lost more than 10% of their body weight. 10% is what we expect newborns to lose. Um, so if it's more than that, we would be concerned and we might see that with infant jaundice. Now, these last two things that you might observe here, these last two symptoms are associated with a change in neurological status. Remember, high levels of bilirubin can cause brain damage and two signs of that in your newborn might be the high-pitched cries and an infant that is difficult to awaken.
Your first intervention here is you're going to assess the infant skin for abnormalities and really by that, we're looking for yellowing of the skin. The best way to do this is to lightly press on the center of the forehead and then just see what the color of the skin is when you do that. It's also really important that you take a second to check their eyes. Continuing on with your assessment, you always want to be on the lookout for signs that this is causing any brain damage to the patient, so this is really all about a neuro assessment. Now, again, remember the two symptoms that we mentioned are the high-pitched cry and increased lethargy, but in more advanced stages of brain damage, you could also see hyperreflexia and seizures occur.
Okay. Now, thinking back to those risk factors that I mentioned before, you want to get a history from the parents and find out what the pregnancy and the delivery were like. You want to ask about trauma and stress in the delivery, as well as family history. Then, we want to pay attention to if mom and baby had different blood types. Once we've determined that an infant does in fact appear jaundiced, it's super important that we find out what their actual bilirubin level is. We're going to do that by obtaining either a serum or a transcutaneous bilirubin level. Now, the serum blood test is usually done with something called a heel stick, but the transcutaneous is actually the preferred method. Now, when we're looking at our values here, there are two numbers that are important. If the level is greater than five, that would indicate that they have hyperbilirubinemia, but we don't actually treat it until it's greater than 12.
The next couple of interventions here are going to be focused on treatment and getting that bilirubin level to come down. One of the most important things for this is hydration. The more hydrated a patient is, the easier it will be for them to excrete it. What we really need to do, is make sure that we're observing breastfeeding, we're providing encouragement, and that we are making sure that those babies are being offered a feeding at least every two hours. If parents are struggling with breastfeeding, then we want to encourage them to supplement with formula. If needed next, and sort of the major part of treatment for this is, we're going to start the patient on phototherapy. There are a couple of different ways that you can do this and we'll talk about some of the process of that and the next intervention, but you want to make sure that you look at your facility's protocol and you follow that. Basically, what happens is the phototherapy helps the body to excrete that bilirubin more quickly. When a baby Is receiving phototherapy, that's usually going to be done through what's called a billy blanket or billy lights. The best way for this to work, is that the baby actually has to have as much skin exposed as possible. This means that they're only going to have their diaper on, and then we're going to make sure that their eyes are covered as well. So, a really huge important part of our nursing intervention here is to monitor that infant's skin and their eyes to make sure they're protected and not becoming irritated by the light. Now, most of the time, this needs to be done at least every two hours, but again, follow your hospital protocol there, but keep in mind that this two hour check falls in line nicely with our encouragement to feed every two hours, so you can cluster some of your care there. In addition to assessing the skin, you're going to want to monitor their temperature really closely. Because they're under those lights, there's actually a risk that they can have an increase in temperature, so we wanna keep an eye on that. Then, if they do have a really high temperature, don't forget that it could be a sign of infection, so we want to look for that as well.
Now sometimes, if our phototherapy or the increasing hydration isn't working, we may need to give medications or even a blood transfusion. Usually, the blood transfusion is when we've got blood and compatibility between mom and baby, and that's when we may need to do that. Then for medication, what we sometimes could give is phenobarbital, which actually stimulates the liver to metabolize the bilirubin more quickly. Our last intervention here is to provide patient education. Sometimes, this treatment that we talked about can actually be done at home, especially if they're using a billy blanket. So, it's really important that our parents know about monitoring skin, monitoring temperature, and encouraging those feeds every two hours. It's also really important to highlight that they must attend appointments, and this is because we need to be checking those bilirubin levels really closely and frequently.
That is it for our care plan on infant jaundice. Remember, we love you guys. Now, please go out and be your very best self today and as always, happy nursing!
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