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Outline
Overview
Pathophysiology
Bilirubin is the yellow pigment that is left over when red blood cells break down. The liver normally absorbs and processes bilirubin, but in the newborn there are not enough enzymes present yet for the liver to absorb and metabolize the bilirubin. Therefore, about the second to fourth day after birth, the skin and eyes become yellow-tinted. If the jaundice is not treated, high levels of bilirubin can lead to brain damage.
Etiology
In the newborn, the liver is not mature enough to have adequate levels of enzymes present to metabolize the bilirubin fast enough. Premature infants are at higher risk of jaundice as well as those who have had bruising during birth (as with forcep or vacuum assisted delivery), when there is a blood type difference between mother and baby, and in cases of neonatal sepsis. Breastfeeding infants will often develop jaundice as a result of dehydration or not enough calorie intake if they are having difficulty nursing.
Desired Outcome
Patient will have decreased yellowing of the skin and eyes; patient will have adequate nutritional intake; patient will have bilirubin level within normal range.
Hyperbilirubinemia of the Newborn / Infant 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 Interventions and Rationales
- 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.
References
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