Jaundice Nursing Diagnosis & Care Plan

Neonatal jaundice is a common occurrence due to the immaturity of an infant’s liver, which usually hinders its ability to clear bile pigments from the blood. Hyperbilirubinemia—an elevation in serum bilirubin levels that arises from red blood cell hemolysis and reabsorption of unconjugated bilirubin into the small intestines—can be benign or have serious implications for a newborn’s health if not closely monitored. If left unchecked, high concentrations of this pigment could lead to neurological damage during infancy.

Jaundice

Jaundice is a common affliction among newborns and can be worrisome for parents. When prompt action is not taken, severe hyperbilirubinemia or bilirubin encephalopathy may occur causing hospital readmission. As healthcare professionals, we must guide families to identify the signs of rising bilirubin levels in order to mitigate any possible long-term medical complications (Kaplan et al., 2019).

 

Hyperbilirubinemia is a condition that is characterized by an increase in the level of serum bilirubin which ultimately causes symptoms such as jaundice or icterus. This condition may be caused by the hemolysis of red blood cells and their reabsorption back into the intestine, or it could also be caused by an immature liver in a newborn baby. The symptoms of this condition can range from being completely harmless to have potentially adverse effects on the newborn, so it is important that careful monitoring is undertaken so that other symptoms, such as anemia and increased heart rate, can be noted and treated appropriately if needed. Nurses must remain vigilant for these symptoms of health conditions, as symptoms outside of jaundice may not always be apparent.

 

The normal postnatal breakdown of red blood cells produces bile pigments, which cannot be removed from the blood by the liver because they are a product of this process. The severity of jaundice and the likelihood of suffering neurological impairment increases in proportion to the amount of bilirubin in the blood. Jaundice that is physiological is perfectly normal, but jaundice that is pathological is much more harmful. 

 

Pathological jaundice is jaundice that develops in the first 24 hours after birth and is caused by an aberrant condition such as ABO-Rh incompatibility. In preterm infants, the usual rise in bilirubin levels occurs at a more gradual pace than it does in full-term infants. Because it lasts for a longer period of time, the infant is more likely to develop hyperbilirubinemia, also known as high levels of bilirubin in the blood.

 

Nursing Diagnosis: Unsatisfactory Levels of Knowledge

 

Causes of Related Factors:

• Lack of exposure to information
• Misinterpretation or unfamiliarity with information resources

 

Possibly evidenced by the:

• Clarification of the Issues and Misconceptions
• Insufficient attention to detail in carrying out the instructions

Defining Characteristics

• Jaundice is a yellowing of the skin, eyes, and mucous membranes caused by high levels of bilirubin in the blood.
• Babies who are premature are even less equipped to eliminate bilirubin. They are susceptible to issues even at lower bilirubin levels than babies who were born later. They receive medical care sooner.
• Newborns may encounter a form of jaundice, aptly named breastfeeding jaundice, if they lack sufficient access to breast milk. With this in mind, it’s recommended that preterm infants requiring such nourishment be fed more often than usual while their mothers’ supply kicks into gear or as the baby learns how to nurse properly. Thankfully professional lactation consultants can provide considerable guidance should assistance become necessary.
• As nurses, it is our ability to recognize and identify genetic conditions such as Hereditary spherocytosis and G6PD deficiency early on that plays a vital role in ensuring the well-being of those affected. We must take initiative to be knowledgeable about these conditions and develop appropriate nursing care plans for their management. It is only by providing prompt, educated care to those with these issues that their health complications can be addressed in a timely and effective manner.

Nursing Assessment: Rationale

1. Take note of the presence of biliary or intestinal blockage, as well as its progression.

In certain medical circumstances, phototherapy is not recommended because the photoisomers of bilirubin that are formed in the skin and subcutaneous tissues as a result of exposure to light therapy are unable to be efficiently excreted. After phototherapy, there is a possibility of an increased risk of subsequent intestinal blockage. Post-phototherapy, there is an increase in the speed of blood flow in the upper mesenteric artery at the end of the diastolic period. This finding suggests that the mesenteric vascular smooth muscle may undergo diastolic changes during phototherapy, which can result in mesenteric ischemia, which is thought to be one of the causes of intestinal obstruction in preterm infants(Wang et al., 2021).

 

2. Check the skin temperature and the core temperature of the neonate every two hours or more frequently until the temperature is stable. Regulate incubator/ Isolette temperature as appropriate.

There are a number of factors, including light exposure, radiation, and convection, that can cause fluctuations in body temperature. When a jaundiced infant is treated with blue phototherapy, all regions of the baby are exposed to illumination. The only places that are shielded from the light are the ones protected by the black blindfold and the diaper. As a direct consequence of this, infants that have been diagnosed with jaundice and are being treated with blue light frequently experience changes in their body temperature (Wang et al., 2021).

 

3. Observe the consistency, color, and frequency of your urine and feces.

The presence of frequent, greenish, loose stools as well as greenish urine are both signs that the phototherapy being administered is efficient in the breakdown and elimination of bilirubin. The nurse needs to distinguish between real diarrhea and the loose, greenish feces that are caused by photodegradation products.

 

4. Make sure to keep track of the infant’s fluid intake and output, and weigh the baby twice a day. Keep an eye out for symptoms of dehydration (e.g., reduced urine output, depressed fontanels, dry or warm skin with poor turgor, and sunken eyes).

During phototherapy, patients, particularly preterm infants, run the risk of becoming dehydrated. Maayan-Metzger et al. found that the mean skin moisture loss increased by 26.4% during phototherapy by measuring the skin moisture content of premature infants before and after phototherapy. 

 

The areas of the body that experienced the most significant loss of skin moisture were the back, groin, and elbow sockets (Wang et al., 2021). Note: If your infant is receiving phototherapy, they may sleep for longer periods of time than usual. This can increase the risk of dehydration if you do not keep up with their regular feeding schedule.

 

5. Observe the color of the skin and urine, which is described as having a brownish-black hue.

While abnormal pigment changes, also known as a bronze baby syndrome, is an incredibly rare side effect of phototherapy, it remains a potential risk associated primarily with abnormal blood profiles. Those with conjugated bilirubin levels outside of the normal range can experience this abnormal pigmentation due to the phototherapy. It’s important to note that these abnormal pigment changes are not permanent and generally only last two to four months; furthermore, they are unrelated to any serious repercussions and affect the skin, mucous membranes, and urine (Wang et al., 2021). As such, when performing phototherapy on newborn infants with neonatal jaundice, it’s crucial for nurses to keep an eye out for signs of abnormal pigmentation and pigment changes.

 

6. Take note of any changes in behavior or indications of a worsening condition (e.g., lethargy, hypotonia, hypertonicity, or extrapyramidal signs).

Recent research indicates that the risk of developing hypocalcemia is significantly higher in preterm infants than in full-term infants. Changes in total free calcium levels often result from phototherapy and can be indicative of the development of kernicterus, as well as the accumulation of bile pigment in the basal ganglia (Wang et al., 2021). Nurses must ensure that they remain aware of risk factors associated with hypocalcemia and create nursing care plans accordingly. Through maintaining close monitoring of any fluctuations related to serum calcium levels, nurses can provide effective clinical management for this condition.

 

7. Determine whether or not a rash and/or petechiae are present.

Some babies may develop petechiae and skin rashes as a result of phototherapy; however, these side effects will eventually disappear after phototherapy is no longer administered. Petechiae have been linked to light-induced thrombocytopenia; as a result, it is imperative that the platelet count be continuously checked throughout the phototherapy process. After receiving phototherapy, a purpuric rash and bullous eruptions may appear on a small percentage of infants who have been diagnosed with cholestatic jaundice. This may lead to an increase in the total amount of porphyrin that is circulating in the body (Wang et al., 2021).

 

8. Take note of the baby’s irritation and fussiness, as well as any increasing bouts of weeping.

It has been reported that neonates undergoing phototherapy for clinical jaundice have more frequent episodes of crying than those undergoing no therapy for the condition. This may be connected with alterations in the circadian rhythm that occur during neonatal phototherapy.

 

Desired Goals/Outcomes:

• In order to guarantee optimal health, the neonate’s body temperature and fluid balance will remain within normal levels. 
• Additionally, their skin tissue is expected to go uninjured while also displaying appropriate interactions with others. 
• Moreover, we anticipate a decrease in serum bilirubin levels – signifying improved liver function over time.

 

Nursing Interventions: Rationale

• Examine the infant’s skin to look for any abnormalities and make a note of its color (yellowing).
• Newborn jaundice is commonplace, with yellow-orange skin color being the main indicator. As a nurse, it is important to look for this yellowing of the infant’s forehead to determine if they may have jaundice or not. While pressing very lightly on the skin of the baby’s forehead during a routine examination, any yellowing may be detected and brought to appropriate medical attention. This yellowing skin is an indication of newborn jaundice, which can generally be treated successfully if caught in its early stages.
• Examine the baby for signs of neurological involvement.
• The infant will most likely have a tough time waking up from sleep and will be highly fussy when awake. A lot of mothers accidentally put off waking their infants up to feed them.
• In more advanced phases, hyperreflexia may be present (twitching, over-excitability, sensitive reflexes, and convulsions)
• Traumatic deliveries utilizing tools such as forceps or suction can cause newborns to develop jaundice. After the baby is numerous days old, the cause of this is that the blood cells in their bodies are destroyed faster than they are being produced. Jaundice, if left untreated, can cause a variety of long-term health issues. It is important for nurses to be aware of the cause and recovery process for cases of jaundice so that immediate and appropriate treatment can begin for newborns upon diagnosis. In most instances, babies will be able to make a full recovery from the jaundice without any lasting problems if the cause and treatments are addressed quickly.
• Find out whether there is any history of illness in the family that could have an impact on the baby, such as conditions affecting the spleen, liver, or thyroid.
• Because the transcutaneous approach is non-invasive, it is the method of choice for the test. Treatment is typically necessary when levels are greater than 12 mg/dL; if serum bilirubin is required, it is acquired using a heel stick in accordance with the protocol of the facility.
• Maintain breastfeeding, provide support to increase the baby’s latch, and encourage frequent feedings at regular intervals of every 2 hours; supplement with formula as needed.
• Infants who are experiencing problems being breastfed are at an increased risk for developing jaundice.
• Frequent feedings are beneficial for the infant’s hydration as well as the mother’s ability to produce more milk for the baby.
• There is a possibility that an infant will require additional nutrients from formula due to insufficiency of breast milk.
• Start phototherapy as directed by the facility’s procedure.
• The baby will either be covered by a blanket or placed beneath bili lights. The solubility of bilirubin can be improved with phototherapy, resulting in more rapid elimination of the substance through feces and urine. This is a treatment that is not intrusive.
• During phototherapy, the skin and eyes of babies should be monitored every two hours.
• During phototherapy, it is important to protect the baby’s skin by covering its eyes and genitalia.
• When the patient is removed from the lights for feedings, check the patient’s skin and eyes every two hours.
• Keep an eye out for an increase in temperature and fever.
• The patient may experience an increase in temperature with bili lights; keep an eye out for indications of fever that could point to infection or sepsis.
• When necessary, medicines or blood transfusions should be administered.
• Transfusions of blood are an essential part of the medical treatment given to patients suffering from two primary conditions, hyperbilirubinemia caused by Rh incompatibility or severe anemia. One kind of exchange transfusion used to manage these conditions is particularly important for preterm infants where it is often a definitive manner in which the patient responds to medical treatment. As a nurse, I understand that when blood transfusions are administered correctly and promptly, they can be lifesaving treatments for these individuals.
• Phenobarbital is a medication used to help increase the level of liver enzymes, responsible for metabolizing bilirubin. Bilirubin is made up of both direct and indirect components, and boosts in its level can indicate something more serious going on with the body. Therefore, phenobarbital can be beneficial when it comes to limiting Bilirubin levels in your body, as well as for ensuring there isn’t any drastic decrease in the level of indirect bilirubin that could elude other tests or diagnoses. Thus, this medication is an effective way to look after your body’s well-being and monitor the level of bilirubin metabolism.
• It is important to educate the patient’s parents or other caregivers about how to care for an infant who has jaundice.
• Discuss the possibility of long-term consequences, as well as home management, repeat visits for evaluation and treatment, and follow-up appointments.
• If necessary, provide information regarding resources and referrals for patients to receive home treatment.

 

References:

https://emedicine.medscape.com/article/974786-clinical#showall

https://www.mayoclinic.org/diseases-conditions/infant-jaundice/diagnosis-treatment/drc-20373870

Kim, M.-S., Chung, Y., Kim, H., Ko, D.-H., Jung, E., Lee, B. S., Hwang, S.-H., Oh, H.-B., Kim, E. A.-R., & Kim, K.-S. (2020). Neonatal exchange transfusion: Experience in Korea. Transfusion and Apheresis Science, 59.

Wang, J., Guo, G., Cai, W.-Q., & Wang, X. (2021, March). Challenges of phototherapy for neonatal hyperbilirubinemia. Experimental and Therapeutic Medicine, 21(3).

Sarkar, S. K., Biswas, B., Laha, S., Sarkar, N., Mondal, M., Angel, J., Dr, V., Abhisek, K., Kumar, V., Acharya, A., Biswas, P., Mal, S., Ghosh, D., & Mukherjee, T. (2021). A study on the effect of phototherapy on platelet count in neonates with unconjugated hyperbilirubinemia: a hospital-based prospective observational study. Asian Journal of Medical Sciences, 12(5).

Kaplan, M., Zimmerman, D., Shoob, H., & Stein-Zamir, C. (2019, November 19). Post-discharge neonatal hyperbilirubinemia surveillance. Acta Pediatrica, 109(5), 923-929.