Hyperbilirubinemia is the elevation of serum bilirubin levels that is related to the hemolysis of RBCs and subsequent reabsorption of unconjugated bilirubin from the small intestines. The condition may be benign or may place the neonate at risk for multiple complications/untoward effects.
Nursing Care Plans
Nursing care plan for patients with hyperbilirubinemia involves preventing injury/progression of condition, providing support/appropriate information to family, maintaining physiological homeostasis with bilirubin levels declining and preventing complications.
Here are four (4) nursing care plans for Hyperbilirubinemia (Neonatal Jaundice):
- Deficient Knowledge
- Risk For Injury (CNS Involvement)
- Risk For Injury (complications of exchange transfusions)
- Risk For Injury (side effects of phototherapy)
- See Also and Further Reading
Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.
May be related to
- Lack of exposure to information.
- Misinterpretation or unfamiliarity with information resources.
Possibly evidenced by
- Request for information.
- Statement of problem/misconceptions.
- Inaccurate follow-through of instructions.
- Mother will verbalize understanding of the cause, treatment, and possible outcomes of hyperbilirubinemia.
- Mother will identify signs/symptoms requiring prompt notification of healthcare provider.
- Mother will demonstrate appropriate care of infant.
|Provide information about the types of jaundice, pathophysiological factors and future implications of hyperbilirubinemia. Encourage to ask questions; reinforce or clarify information, as needed.||Promotes understanding of the disease condition, correction of misconceptions, and reducing feelings of guilt and fear. Neonatal jaundice may be pathological, physiological,or breast milk–induced in etiology.|
|Discuss home management of mild or moderate physiological jaundice, including increased feedings, diffused exposure to sunlight (checking infant frequently), and follow-up serum testing program.||Parents’ understanding helps foster their cooperation once infant is discharged. Information helps parents to carry out home management safely and appropriately and to recognize the importance of all aspects of management program. Note: Exposure to direct sunlight is contraindicated as infant’s tender skin is highly susceptible to thermal injury.|
|Provide information about maintaining milk supply through use of breast pump and about reinstating breastfeeding when jaundice necessitates interruption of breastfeeding.||Helps mother maintain adequate milk supply to meet infant’s needs when breastfeeding is resumed.|
|Demonstrate means of assessing infant for increasing bilirubin levels (e.g., blanching the skin with digital pressure to reveal the color of the skin, weight monitoring,or behavioral changes), especially if infant is to be discharged early.||To aid the parents to recognize signs and symptoms of increasing bilirubin levels.|
|Provide parents with 24-hr emergency telephone number and name of contact person, stressing importance of reporting increased jaundice||To decrease anxiety and to prepare an immediate seek timely medical evaluation/intervention.|
|Review rationale for specific hospital procedures/therapeutic interventions (e.g., phototherapy, exchange transfusions) and changes in bilirubin levels, especially in the event that neonate must remain in hospital for treatment while mother is discharged.||Assists parents in understanding importance of therapy. Keeps parents informed about infant’s status. Promotes informed decision making. Note: Some hospitals have overnight rooms that allow mother/father to remain with infant.|
|Discuss possible long-term effects of hyperbilirubinemia and the need for continued assessment and early intervention.||Kernicterus is caused by a high level of bilirubin in a baby’s blood. If left untreated, the bilirubin can then spread into the brain, where it causes long-term damage which includes cerebral palsy, mental retardation, sensory difficulties, delayed speech, poor muscle coordination, learning difficulties, enamel hypoplasia or yellowish green staining of teeth and even death.|
|Discuss need for Rh immune globulin (RhIg) within 72 hr following delivery for an Rh-negative mother who has an Rh-positive infant and who has not been previously sensitized.||In Rho(D)-negative client with no Rh antibodies, who has given birth to an Rho(Du)-positive infant. Rh-Ig may minimize the incidence of maternal isoimmunization in non sensitized mother and may help to prevent erythroblastosis fetalis in subsequent pregnancies.|
|Assess family situation and support systems. Provide parents with appropriate written explanation of home phototherapy, listing technique and potential problems, and safety precautions. Discuss appropriate monitoring of home therapy, e.g., periodic recording of infant’s weight, feedings, intake/output, stools, temperature, and proper reporting of infant status.||Home phototherapy is recommended only for full term infants after the first 48 hr of life, whose serum bilirubin levels are between 14 and 18 mg/dl with no increase in direct reacting bilirubin concentration.|
|Make appropriate arrangements for follow-up testing of serum bilirubin at same laboratory facility.||Treatment is discontinued once serum bilirubin concentrations fall below 14 mg/dl, but serum levels must be rechecked in 12–24 hr to detect possible rebound hyperbilirubinemia.|
|Provide appropriate referral for home phototherapy program, if necessary.||Lack of available support systems and education may necessitate use of visiting nurse to monitor home phototherapy program.|
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Maternal and Newborn Care Plans
Nursing care plans related to the care of the pregnant mother and her infant. See care plans for maternity and obstetric nursing:
- Abruptio Placenta| 3 Care Plan
- Cesarean Birth | 10 Care Plans
- Cleft Palate and Cleft Lip | 6 Care Plans
- Dysfunctional Labor (Dystocia) | 4 Care Plans
- Elective Termination | 6 Care Plans
- Gestational Diabetes Mellitus | 4 Care Plans
- Hyperbilirubinemia | 4 Care Plans
- Labor Stages, Induced and Augmented Labor | 36 Care Plans
- Neonatal Sepsis | 5 Care Plans
- Perinatal Loss | 5 Care Plans
- Placenta Previa | 3 Care Plans
- Postpartum Hemorrhage | 8 Care Plans
- Postpartum Thrombophlebitis | 4 Care Plans
- Prenatal Hemorrhage | 7 Care Plans
- Prenatal Substance Dependence/Abuse | 6 Care Plans
- Precipitous Labor | 3 Care Plans
- Pregnancy Induced Hypertension | 6 Care Plans
- Premature Dilation of the Cervix | 3 Care Plans
- Prenatal Infection | 3 Care Plans
- Preterm Labor | 6 Care Plans
- Puerperal Infection | 4 Care Plans
Recommended books and resources:
- Nursing Care Plans: Diagnoses, Interventions, and Outcomes
- Nurse's Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
- Nursing Diagnoses 2015-17: Definitions and Classification
- Diagnostic and Statistical Manual of Mental Disorders (DSM-V-TR)
- Manual of Psychiatric Nursing Care Planning
- Maternal Newborn Nursing Care Plans
- Delmar's Maternal-Infant Nursing Care Plans, 2nd Edition
- Maternal Newborn Nursing Care Plans