Nursing Care Plan (NCP) for Hyperbilirubinemia of the Newborn / Infant Jaundice / Neonatal Hyperbilirubinemia

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Outline

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.

 

Writing a Nursing Care Plan (NCP) for Hyperbilirubinemia of the Newborn / Infant Jaundice / Neonatal Hyperbilirubinemia

A Nursing Care Plan (NCP) for Hyperbilirubinemia of the Newborn / Infant Jaundice / Neonatal Hyperbilirubinemia starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.


References

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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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