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4 Hyperbilirubinemia (Jaundice) Nursing Care Plans

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By Paul Martin, BSN, R.N.
Jaundice Nursing Care Plans and Nursing Diagnosis

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 place the neonate at risk for multiple complications/untoward effects.

The newborn‘s liver is immature, which contributes to icterus, or jaundice. The liver cannot clear the blood of bile pigments that result from the normal postnatal destruction of red blood cells. The higher the blood bilirubin level is, the deeper jaundice and the greater risk for neurological damage. Physiological jaundice is normal, while pathological jaundice is more serious, which occurs within 24 hours of birth, and is secondary to an abnormal condition, such ABO-Rh incompatibility. The normal rise in bilirubin levels in preterm infants is slower than in full-term infants. It lasts longer, which predisposes the infant to hyperbilirubinemia or excessive bilirubin levels in the blood.

Physiological jaundice is the most common type of newborn hyperbilirubinemia. This unconjugated hyperbilirubinemia presents in newborns after 24 hours of life and can last up to the first week. Pathological jaundice is defined as the appearance of jaundice in the first 24 hours of life due to an increase in serum bilirubin levels greater than 5 mg/dl/day, conjugated bilirubin levels ≥ 20% of total serum bilirubin, peak levels higher than the normal range, and the presence of clinical jaundice greater than two weeks. Breast milk jaundice occurs in breastfed newborns between the first and third day of life but peaks by day 5 to 15, with a decline occurring by the third week of life (Morrison, 2021).

In the past, hemolytic disease of the newborn was most often caused by an Rh blood type incompatibility. Because the prevention of Rh antibody formation has been available for almost 50 years, the disorder is now most often caused by an ABO incompatibility. In both instances, because the fetus has a different blood type than the mother, the mother builds antibodies against the fetal red blood cells, leading to hemolysis of the cells, severe anemia, and hyperbilirubinemia.

Table of Contents

Nursing Care Plans and Management

The nursing care plan for clients with hyperbilirubinemia involves preventing injury/progression of the condition, providing support/appropriate information to family, maintaining physiological homeostasis with bilirubin levels declining, and preventing complications.

Nursing Problem Priorities

The following are the nursing priorities for patients with hyperbilirubinemia (jaundice):

  • Bilirubin level monitoring. Regularly monitoring the bilirubin levels in the patient’s blood to assess the severity of hyperbilirubinemia.
  • Identification of underlying cause. Investigating and identifying the underlying cause of hyperbilirubinemia to guide treatment decisions.
  • Phototherapy. Initiating and managing phototherapy to help break down bilirubin and reduce its levels in the blood.
  • Blood transfusion. Considering blood transfusion in severe cases of hyperbilirubinemia to remove excess bilirubin and provide additional red blood cells.
  • Neonatal assessment. Conducting a thorough neonatal assessment to evaluate the overall health and identify any additional concerns associated with hyperbilirubinemia.
  • Parent education. Educating parents about the causes, management, and signs of worsening hyperbilirubinemia, as well as the importance of follow-up care.
  • Liver function evaluation. Assessing liver function to determine if there are any underlying liver disorders contributing to hyperbilirubinemia.
  • Coordinating with pediatric specialists. Collaborating with pediatricians and specialists to ensure comprehensive care and appropriate management of hyperbilirubinemia.
  • Support for breastfeeding. Providing guidance and support to breastfeeding mothers to optimize feeding practices, which can help with bilirubin elimination.
  • Long-term follow-up. Planning for long-term follow-up to monitor the resolution of hyperbilirubinemia and identify any potential long-term effects or complications.

Nursing Assessment

Assess for the following subjective and objective data:

  • See nursing assessment cues under Nursing Interventions and Actions.

Nursing Diagnosis

Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with hyperbilirubinemia (jaundice) based on the nurse’s clinical judgment and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.

Nursing Goals

Goals and expected outcomes may include:

  • The mother will verbalize understanding of the cause, treatment, and possible outcomes of hyperbilirubinemia.
  • The mother will identify signs/symptoms requiring prompt notification of the healthcare provider.
  • The mother will demonstrate appropriate care for the infant.
  • The neonate will display indirect bilirubin levels below 12 mg/dl in term infants at three days of age.
  • The neonate will show resolution of jaundice by the end of the 1st wk of life.
  • The neonate will be free of CNS involvement.
  • The neonate will complete the exchange transfusion without complications.
  • The neonate will display decreasing serum bilirubin levels.
  • The neonate will maintain body temperature and fluid balance within the normal limits.
  • The neonate will be free of skin/tissue injury.
  • The neonate will demonstrate expected interaction patterns.
  • The neonate will display decreasing serum bilirubin levels.

Nursing Interventions and Actions

Therapeutic interventions and nursing actions for patients with hyperbilirubinemia (jaundice) may include:

1. Initiating Patient Education and Health Teachings

Neonatal jaundice is the main reason for admission from home to a neonatal unit. Many neonates are readmitted with extreme hyperbilirubinemia or bilirubin encephalopathy at or around day five and had been discharged as healthy from birth hospitalization. As the newborn is usually at home at the time of the bilirubin peaking, much of the onus for detecting the development of severe hyperbilirubinemia and evaluating the success of breastfeeding falls on the parents and community medical services (Kaplan et al., 2019).

Assess the family situation and support systems.
Parents need guidance throughout the infant’s hospitalization to help to prepare them for this new experience. The mother is usually concerned with her ability to care for such a small and helpless creature. When she feels ready, she may assist the nurse in diapering, bathing, feeding, and other activities. Often the mother is discharged without her infant. This is difficult for the entire family and complicates attachment and bonding.

Assess the client’s and family members’ knowledge and level of understanding.
This helps in determining specific needs and clarifying previous information. The client and her family are assessed for their understanding of the diagnosis and their ability to cope during the unexpected extended period of recovery.

Provide parents with an appropriate written explanation of home phototherapy, listing technique and potential problems, and safety precautions.
Non-specific written instructions are most likely a key factor contributing to the low attendance rate for early community follow-up for jaundice, as studied by Kaplan et al.. Some mothers provided reasons contributing to poor attendance. Poor understanding and insufficient explanation of the potential dangers of hyperbilirubinemia were leading factors. It is possible that the medical/nursing team, at the time of discharge, did not fully expound to parents the full reasons necessitating early follow-up (Kaplan et al., 2019).

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. Nowadays, home phototherapy is very popular due to the importance of preventing mother-infant separation and continuity of care at home (Morrison, 2021).

Provide information about the types of jaundice, pathophysiological factors, and future implications of hyperbilirubinemia. Encourage to ask questions; reinforce or clarify information as needed.
This promotes understanding 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. Parents need an explanation of the rationale for phototherapy and why their infant needs it. Although phototherapy has not been used long enough that long-term effects can be studied, there appears to be minimal risk to an infant from the procedure, provided the infant’s eyes remain covered, and dehydration from increased insensitive water loss does not occur.

Discuss home management of mild or moderate physiological jaundice, including increased feedings, diffused exposure to sunlight (checking infant frequently), and a follow-up serum testing program.
Parents’ understanding helps foster their cooperation once the infant is discharged. The information helps parents carry out home management safely and appropriately and recognize the importance of all aspects of the management program. Note: Exposure to direct sunlight is contraindicated as an infant’s tender skin is highly susceptible to thermal injury. Even though there is no evidence so far that infants who received phototherapy are at greater risk for developing skin cancer, all infants who receive phototherapy should (as should all infants) have sunscreen applied when they are in the sun and follow-up assessments in the coming years to detect skin cancer that possibly could occur from the therapy.

Provide information about maintaining milk supply through a breast pump and reinstating breastfeeding when jaundice necessitates interruption of breastfeeding.
This helps mothers maintain adequate milk supply to meet the infant’s needs when breastfeeding is resumed. Infants weighing more than 1500 g (3.3 lb) may be able to bottle feed if a small, soft nipple with a large hole is used to minimize the energy and effort required for sucking. Breast milk may be manually expressed by the mother and placed in a bottle for her preterm infant.

Demonstrate means of assessing the 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 the infant is to be discharged early.
To aid the parents in recognizing signs and symptoms of increasing bilirubin levels. Observing the infant’s skin, sclera, and mucous membranes for jaundice is included in the nursing care. Blanching of the skin over bony prominences enhances the evaluation for jaundice. Observing and reporting the progression of jaundice from the face to the abdomen and feet is important because the progression may indicate increasing bilirubin levels.

Provide parents with a 24-hr emergency telephone number and the name of the contact person, stressing the importance of reporting increased jaundice
This decreases anxiety and prepares an immediate seek timely medical evaluation/intervention. Increased awareness of the importance of jaundice and early referring to hospitals among families can help reduce the complications of jaundice (Sardari et al., 2019).

Review rationale for specific hospital procedures/therapeutic interventions (e.g., phototherapy, exchange transfusions) and changes in bilirubin levels, especially if the neonate must remain in the hospital for treatment while the mother is discharged.
This assists parents in understanding the importance of therapy, keep parents informed about the infant’s status and promotes informed decision-making. Note: Some hospitals have overnight rooms that allow the mother/father to remain with the infant. The use of intensive phototherapy in conjunction with hydration and close monitoring of serum bilirubin levels has greatly reduced the need for exchange transfusions. Exchange transfusion reduces the serum concentration of indirect bilirubin and can prevent heart failure in infants with severe anemia or polycythemia.

Discuss possible long-term effects of hyperbilirubinemia and the need for continued assessment and early intervention.
Kernicterus is caused by a high bilirubin level 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, and enamel hypoplasia or yellowish-green staining of teeth, and even death.

Discuss the need for Rh immune globulin (RhIg) within 72 hours following delivery for an Rh-negative mother with an Rh-positive infant who has not been previously sensitized.
Rh-Ig may minimize the incidence of maternal isoimmunization in non-sensitized mothers and may help to prevent erythroblastosis fetalis in subsequent pregnancies. Rh incompatibility is not commonly seen today because if Rh-negative women receive Rho immune globulin (RHIG or RhoGAM) within 72 hours after the birth of an Rh-positive newborn, the process of antibody formation will be halted, and sensitization will not occur.

Make appropriate arrangements for follow-up serum bilirubin testing at the 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. Although phototherapy may prevent an increase in bilirubin levels, it does not affect the underlying cause of jaundice. If phototherapy fails to keep the total serum bilirubin at acceptable levels to prevent kernicterus, an exchange transfusion may be indicated.

Provide appropriate referral for a home phototherapy program, if necessary.
The lack of available support systems and education may necessitate visiting nurses to monitor the home phototherapy program. /Home phototherapy programs are being used for newborns with mild to moderate physiological jaundice. The infant’s pediatrician makes a referral for home care based on the newborn’s health, bilirubin levels (generally between 10 to 14 mg/dL), evidence of jaundice, and the family’s suitability for complying with the home program.

Educate the parents regarding home phototherapy.
The parents can use a phototherapy blanket in a bassinet or a fiberoptic pad for home phototherapy. These allow the infant to be held, reducing the risk of eye damage. Written instructions are given to parents. Parents keep a daily record of their infant’s temperature, weight, intake and output, stools, and feedings. The parents must ensure that the infant’s eyes are covered under the lights to prevent injury to the infant’s retina and place a small diaper over the infant’s gonad area to protect their ovaries or testes.

2. Promoting Safety and Preventing Injuries and Complications

Promoting safety and preventing injuries and complications in patients with hyperbilirubinemia (jaundice) involves implementing measures to mitigate the risks associated with elevated bilirubin levels. This includes strict adherence to phototherapy protocols, ensuring proper eye protection during phototherapy sessions, monitoring vital signs and hydration status, closely observing for signs of neurotoxicity or kernicterus, promptly addressing any concerning symptoms, providing education to parents on safe handling and care practices, and maintaining a collaborative approach among healthcare professionals to promptly identify and manage any complications that may arise.

Assess infant/maternal blood group and blood type.
ABO incompatibility affects 20% of all pregnancies and most commonly occurs in mothers with type O blood, whose anti-A and anti-B antibodies pass into fetal circulation, causing RBC agglutination and hemolysis. ABO and Rh incompatibilities increase the risk for jaundice. Maternal antibodies cross the placenta in Rh-negative women who had previously been sensitized due to Rh-positive infants. Antibodies attach to fetal RBCs and increase the risk of hemolysis.

Assess the infant in daylight.
This prevents distortion of actual skin color through the use of artificial lighting. Most infants do not appear jaundiced at birth because the maternal circulation has evacuated the rising indirect bilirubin level. With birth, progressive jaundice, usually occurring within the first 24 hours of life, will begin, indicating that a hemolytic process is occurring in both Rh and ABO incompatibility.

Review infant’s condition at birth, noting the need for resuscitation or evidence of excessive ecchymosis or petechiae, cold stress, asphyxia, or acidosis.
Asphyxia and acidosis reduce the affinity of bilirubin to albumin. A study found that perinatal asphyxia was negatively associated with neonatal hyperbilirubinemia. This might be explained by acidosis in asphyxia is generally corrected soon after birth before significant hyperbilirubinemia develops in preterm infants. Although one study from Pakistan showed birth asphyxia was a risk factor for severe jaundice (Aynalem et al., 2020).

Review intrapartal records for specific risk factors, such as low birth weight (LBW) or intrauterine growth restriction (IUGR), prematurity, abnormal metabolic processes, vascular injuries, abnormal circulation, sepsis, or polycythemia.
Certain clinical conditions may cause a reversal of the blood-brain barrier, allowing bound bilirubin to separate either at the cell membrane level or within the cell itself, increasing the risk of CNS involvement. The higher the blood bilirubin level is, the deeper jaundice and the greater the risk for neurological damage.

Observe the infant on the sclera and oral mucosa, yellowing of skin immediately after blanching, and specific body parts. Assess oral mucosa, posterior portion of the hard palate, and conjunctival sacs in dark-skinned newborns.
The yellow discoloration of the skin and sclera in neonates diagnosed with jaundice results from the accumulation of unconjugated bilirubin. Neonatal jaundice first becomes visible on the face and forehead (Hansen & Aslam, 2017). Clinical appearance of jaundice is evident at bilirubin levels >7–8 mg/dl in full-term infants. Note: Yellow underlying pigment may be normal in dark-skinned infants.

Evaluate maternal and prenatal nutritional levels; note possible neonatal hypoproteinemia, especially in preterm infants.
Hypoproteinemia in the newborn may result in jaundice. One gram of albumin carries 16 mg of unconjugated bilirubin. Lack of sufficient albumin increases the amount of unbound circulating (indirect) bilirubin, which may cross the blood-brain barrier. The binding of compounds to albumin may reduce their toxicity, such as in the case of unconjugated bilirubin in the neonate. Albumin is also involved in maintaining acid-base balance as it acts as a plasma buffer (Gounden et al., 2021).

Note infant’s age at onset of jaundice; differentiate the type of jaundice (i.e., physiological, breast milk–induced, or pathological).
Physiological jaundice usually appears between the 2nd and 3rd days of life, as excess RBCs needed to maintain adequate oxygenation for the fetus are no longer required in the newborn and are hemolyzed, thereby releasing bilirubin, the final breakdown product of heme. Breast milk jaundice usually appears between the 4th and 6th days of life, affecting only 1%–2% of breastfed infants. Some women’s breast milk is thought to contain an enzyme (pregnanediol) that inhibits glucuronyl transferase (the liver enzyme that conjugates bilirubin) or contain several times the normal breast milk concentration of certain free freezer fatty acids, which are also thought to inhibit the conjugation of bilirubin. Pathological jaundice appears within the first 24 hr of life and is more likely to lead to the development of kernicterus/bilirubin encephalopathy.

Assess infant for progression of signs and behavioral changes.
Excessive unconjugated bilirubin (associated with pathologic jaundice) has an affinity for extravascular tissue, including the basal ganglia of brain tissue. Behavior changes associated with kernicterus usually occur between the 3rd and 10th days of life and rarely occur before 36 hours of life. The characteristic clinical manifestations of kernicterus that are routinely described and are consistent with neuropathological findings include athetoid cerebral palsy, paralysis of upward gaze, and hearing disorders. However, these may represent only “the tip of the iceberg” (Amin et al., 2018).

Evaluate infant for pallor, edema, or hepatosplenomegaly
These signs may be associated with hydrops fetalis, Rh incompatibility, and in utero hemolysis of fetal RBCs. With Rh incompatibility, an infant may not appear pale at birth despite the red cell destruction that occurred in utero because the accelerated production of red cells during the last few months in utero compensates to some degree for the destruction. The liver and spleen may be enlarged from attempts to destroy damaged blood cells. Suppose the number of red cells has significantly decreased. In that case, the blood in the vascular circulation may be hypotonic to interstitial fluid, causing fluid to shift from the lower to higher isotonic pressure by osmosis, resulting in extreme edema. Hydrops fetalis is a Greek term that refers to a pathologic accumulation of at least two or more cavities with a fluid collection in the fetus.

Assess the neonate’s bilirubin blood levels regularly.
Phototherapy success is determined by frequently measuring serum bilirubin levels. Neonatal hyperbilirubinemia is extremely common because almost every newborn develops an unconjugated serum bilirubin level of more than 1.8 mg/dL during the first week of life. Significant jaundice was defined according to gestational and postnatal age and leveled off at 14 mg/dL at four days in preterm infants and 17 mg/dL in the term infants (Hansen & Aslam, 2017).

Assess infant for signs of hypoglycemia.
Hypoglycemia necessitates fat stores for energy-releasing fatty acids, which compete with bilirubin for binding sites on albumin. A study reported that 70.8% of late preterm neonates and 29.1% of term neonates has at least one neonatal morbidity like neonatal jaundice, hypoglycemia, respiratory morbidities, and sepsis. They observed jaundice in 55.1% of late preterm neonates who required phototherapy, and hypoglycemia was found in 8.8% of late preterm neonates (Salman et al., 2021).

Initiate early oral feedings within 4–6 hours following birth, especially if the infant is breastfed.
This establishes proper intestinal flora necessary for reducing bilirubin to urobilinogen; decreases the enterohepatic circulation of bilirubin (bypassing the liver with the persistence of ductus venosus), and decreases reabsorption of bilirubin from the bowel by promoting passage of meconium. A delay in enteral feeding may limit intestinal motility and bacterial colonization, resulting in decreased bilirubin clearance (Aynalem et al., 2020).

Keep infant warm and dry; frequently monitor skin and core temperature.
Cold stress potentiates the release of fatty acids, which compete for binding sites on albumin, thereby increasing freely circulating (unbound) bilirubin. A neutral thermal environment permits the infant to maintain a normal core temperature with minimum oxygen consumption and caloric expenditure. Preterm infants have little or no muscular activity; they remain in an extended posture because of a lack of muscle tone; they cannot shiver.

Apply transcutaneous jaundice meter.
Since visual assessment of jaundice is not accurate, both the American Academy of Pediatrics and the Spanish Association of Pediatrics recommend that all newborns as of 35 weeks of gestation undergo screening for hyperbilirubinemia by measuring either total serum bilirubin (SB) or transcutaneous bilirubin (TcB). Transcutaneous bilirubinometry measures the bilirubin subcutaneously, and therefore, TcB is not the same value as SB. although current jaundice meters have been designed to agree as closely as possible with SB (Maya-Enero et al., 2021).

Discontinue breastfeeding for 24–48 hr, as indicated. Assist mother as needed with the pumping of breasts and reestablishment of breastfeeding.
Opinions vary as to whether interrupting breastfeeding is necessary when jaundice occurs. However, formula ingestion increases GI motility and excretion of stool and bile pigment, and serum bilirubin levels begin to fall within 48 hours after discontinuation of breastfeeding. Certain factors present in the breast milk of some mothers may also contribute to the increased enterohepatic circulation of bilirubin (breast milk jaundice). Beta-glucuronidase may play a role by uncoupling bilirubin from its binding to glucuronic acid, thus making it available for reabsorption (Hansen & Aslam, 2017).

Monitor laboratory studies, as indicated.
See Diagnostic and Laboratory Procedures

Calculate plasma bilirubin-albumin binding capacity.
This aids in determining the risk of kernicterus and treatment needs. When the total bilirubin value divided by total serum protein level is <3.7, the danger of kernicterus is very low. However, the risk of injury is dependent on the degree of prematurity, presence of hypoxia or acidosis, and drug regimen (e.g., sulfonamides, chloramphenicol) (Hansen & Aslam, 2017).

Initiate phototherapy per protocol, using fluorescent bulbs above the infant or bile blanket (except for newborns with Rh disease).
Phototherapy causes photooxidation of bilirubin in subcutaneous tissue, thereby increasing the water solubility of bilirubin, which allows rapid excretion of bilirubin in stool and urine. The rate of bilirubin reduction is related to phototherapy, so an exchange transfusion is the only appropriate treatment. Phototherapy is discontinued when the bilirubin level steadily declines to 14 mg/dL.

Administer enzyme induction agent  (phenobarbital, ethanol) as appropriate.
Medications are not usually administered in infants diagnosed with physiologic neonatal jaundice. However, in certain instances, phenobarbital, an inducer of hepatic bilirubin metabolism, has been used to enhance bilirubin metabolism. Several studies have shown that phenobarbital effectively reduces mean serum bilirubin values during the first week of life (Hansen & Aslam, 2017).

Assist with preparation and administration of exchange transfusion.
Exchange transfusion can be used as therapy for blood incompatibility, wherein it removes approximately 85% of sensitized red cells. It reduces the serum concentration of indirect bilirubin and can prevent heart failure in infants with severe anemia or polycythemia. The type of blood used for transfusion is O Rh-negative blood, even if an infant’s blood type is positive; if Rh-positive or type A or B blood was given, the maternal antibodies that entered the infant’s circulation would destroy this blood also, and the transfusion would be ineffective.

Note the condition of the infant’s cord before transfusion if the umbilical vein is to be used. If the cord is dry, administer saline soaks for 30–60 min before the procedure.
Soaks may be necessary to soften the cord and umbilical vein before transfusion for IV access and ease the umbilical catheter’s passage. In general, access via the umbilical vein is the recommended exchange transfusion method for treating severe hyperbilirubinemia in neonates. However, some reports have shown that exchange transfusion via the umbilical vessels is a relatively high-risk procedure (Chen et al., 2008).

Verify infant’s and mother’s blood type and Rh factor. Note blood type and Rh factor of blood to be exchanged.
Exchange transfusions are most often associated with Rh incompatibility problems. Using Rho(D)-positive blood would only increase hemolysis and bilirubin levels because antibodies in an infant’s circulation would destroy new RBCs. The type of blood used for transfusion is O Rh-negative blood, even if an infant’s blood type is positive.

Assess the infant’s weight prior to transfusion and for consequent weight changes.
Adverse events are more frequent in infants of lower gestation and birth weights and those who were sicker. These results are similar to other studies because sicker and smaller infants have multiple comorbidities and are at risk of more complications (Chacham et al., 2019). Additionally, weight change reveals weight gain related to fluid overload. Fluid overload can cause respiratory and cardiac complications.

Assess the infant for neurologic changes.
Irritability, twitching, convulsions, or seizures are signs of neurotoxicity resulting from jaundice. An increasing bilirubin level becomes dangerous if the level rises above 20 mg/dL in a term infant and perhaps as low as 12 mg/dL in a preterm infant because brain damage from bilirubin-induced neurologic dysfunction (BIND), a wide spectrum of disorders caused by increasingly severe hyperbilirubinemia ranging from mild dysfunction to acute bilirubin encephalopathy (ABE) (invasion of bilirubin into brain cells), can occur.

Assess infant for excessive bleeding from IV site following the transfusion.
Infusion of heparinized blood (or citrated blood without calcium replacement) alters coagulation for 4–6 hr following the exchange transfusion and may result in bleeding. Thrombocytopenia was seen in 57.4% of neonates undergoing exchange transfusion. It was observed that there was a decrease in the platelet count following the transfusion with a nadir at 24 hours and full recovery at or after 72 hours (Chacham et al., 2019).

Monitor venous pressure, pulse, color, and respiratory rate/ease before, during, and after transfusion. Suction as needed.
This establishes baseline values, identifies potentially unstable conditions (e.g., apnea or cardiac dysrhythmia/arrest), and maintains the airway. Exchange transfusion is not free of risk, with the estimated morbidity rate at 5% and the mortality rate as high as 0.5%. The most common adverse events are apnea, bradycardia, cyanosis, vasospasm, and hypothermia with metabolic abnormalities (Wagle & Aslam, 2017). Bradycardia may occur if calcium is injected too rapidly. 

Monitor for signs of electrolyte imbalance (e.g., lethargy, seizure activity, and apnea;  hyperreflexia, bradycardia, or diarrhea).
Hypocalcemia and hyperkalemia may develop during and following exchange transfusion. Hypocalcemia is one of the most frequent adverse events, with the incidence ranging from 22.5% to 98%. Hypocalcemia following exchange transfusion is due to certain chelating properties of citrate, which is present in a very high concentration in the donor blood as a component of the anticoagulant (Chacham et al., 2019).

Assess the infant for any congenital diseases such as other hemolytic diseases and cardiac failure.
An infant born with cardiac failure and edema resulting from hemolytic disease is a candidate for immediate exchange transfusion with fresh whole blood. When red cells have significantly decreased due to a hemolytic disease, the blood in the vascular circulation may be hypotonic to interstitial fluid, causing fluid to shift from lower to higher isotonic pressure by osmosis in extreme edema.

Maintain the infant’s temperature prior to, during, and after the procedure. Place infant under radiant warmer with servomechanism.
A transfusion should be done under a radiant heat warmer to keep the infant warm during what can be a lengthy procedure to prevent energy expenditure from having to maintain body temperature. This also helps prevent vasospasm, reduces the risk of ventricular fibrillation, and decreases blood viscosity.

Warm the blood prior to infusion by placing it in blood warmer.
Donor blood must be maintained at room temperature, or hypothermia from the cold insult could result. Use only commercial blood warmers to warm the blood, not hot towels or a radiant heat warmer, to avoid destroying red cells.

Ensure freshness of blood (not more than two days old), with heparinized blood preferred.
Older blood is more likely to hemolyze, thereby increasing bilirubin levels. Moreover, old stored blood has high levels of leucocyte-secreted cytokines that significantly raise the risk of non-hemolytic febrile transfusion reactions. Heparinized blood is always fresh but must be discarded if not used within 24 hr. Blood transfusion using heparinized blood can be employed to avoid citrate toxicity in neonates undergoing exchange transfusion. Moreover, repetitive small top-up transfusions can also be carried out with fresh heparinized blood collected as and when needed from a dedicated safe walking donor (Ahmed & Ibrahim, 2018).

Avoid overheating of blood prior to transfusion.
Too much heat in the blood promotes hemolysis and the release of potassium, causing hyperkalemia. The risk of hemolysis with heated blood requires the choice of heating temperature to be considered. In their study, Van der Walt and Russel (Van der Walt & Russel, 1978) argue that the blood should ideally be heated to a human body temperature of 37°C (98.6℉), but that any temperature between 32°C (89.6℉) and 37°C (98.6℉) is acceptable (Poder et al., 2015).

Ensure availability of resuscitative equipment.
Access to resuscitative equipment provides immediate support if necessary. Exchange transfusions can lead to complications such as life-threatening bleeding, sepsis, cardiac arrhythmias, and even death, apart from transient hypocalcemia, hyperkalemia, bradycardia, and thrombocytopenia (Chacham et al., 2019).

Maintain NPO status for 4 hr prior to the procedure, or aspirate gastric contents.
The infant should be nil orally as soon as the decision is made to perform an exchange transfusion. Pass an oro-nasogastric tube and aspirate stomach contents. Leave the tube in situ and on free drainage for the duration of the procedure (The Royal Children’s Hospital, 2004). This reduces the risk of possible regurgitation and aspiration during the procedure.

Carefully document events during transfusion, recording the amount of blood withdrawn and injected (usually 7–20 ml at a time).
Documentation helps prevent errors in fluid replacement. The amount of blood exchanged is approximately 170 ml/kg of body weight. A double-volume exchange transfusion ensures that between 75% and 90% of circulating RBCs are replaced. The process is time-consuming and labor-intensive but remains the ultimate treatment to prevent kernicterus (Wagle & Aslam, 2017).

Administer albumin prior to transfusion if indicated.
Although somewhat controversial, administration of albumin may increase the albumin available for bilirubin binding, thereby reducing levels of freely circulating serum bilirubin. Synthetic albumin is not thought to increase available binding sites. Due to the elicited increase in plasma bilirubin, albumin administration to reduce bilirubin-induced neurological damage invalidates the use of plasma total bilirubin as an indicator of the overall risk of bilirubin neurotoxicity (Vodret et al., 2015).

Administer medications, as indicated.
See Pharmacologic Management

Administer antibiotics as indicated.
Antibiotics prevent and/or treat infections. After a transfusion, the infant is closely observed to be certain that there is no umbilical vessel inflammation of the cord if this was the transfusion site, which would suggest infection.

Assist with administration of intravenous immunoglobulin (IVIG) as indicated.
IVIG has been shown to reduce the need for exchange transfusion in hemolytic disease of the newborn due to Rh or ABO incompatibility. The number needed to treat to prevent one exchange transfusion was noted to be 2.7 and was estimated to be ten if all the infants with strongly positive direct Coombs test were to receive the medication. Although IVIG has been proven safe, a retrospective review reported an almost 30-times increased risk of necrotizing enterocolitis in late preterm and term infants (Wagle & Aslam, 2017).

Note the presence or development of biliary or intestinal obstruction.
Phototherapy is contraindicated in these conditions because the photoisomers of bilirubin produced in the skin and subcutaneous tissues by exposure to light therapy cannot be readily excreted. The risk of secondary intestinal obstruction may increase after phototherapy. The velocity of blood flow in the upper mesenteric artery at the end of the diastolic period is accelerated post-phototherapy, indicating that the mesenteric vascular smooth muscle may undergo diastolic changes during phototherapy, leading to mesenteric ischemia, which may be one of the causes of intestinal obstruction in premature infants (Wang et al., 2021).

Monitor the neonate’s skin and core temperature every two hours or more frequently until stable. Regulate incubator/ Isolette temperature as appropriate.
Fluctuations in body temperature can occur in response to light exposure, radiation, and convection. When the jaundiced newborn is treated with blue phototherapy, apart from the areas protected by the black blindfold and the diaper, all other areas are exposed to illumination. As a result, neonates diagnosed with jaundice treated with blue light often experience alterations in body temperature (Wang et al., 2021).

Note color and frequency of stools and urine.
Frequent, greenish, loose stools and greenish urine indicate the effectiveness of phototherapy with the breakdown and excretion of bilirubin. The nurse must determine loose, greenish stools caused by photodegradation products from true diarrhea.

Monitor fluid intake and output; weigh infant twice a day. Note signs of dehydration (e.g., reduced urine output, depressed fontanels, dry or warm skin with poor turgor, and sunken eyes).
Dehydration may occur during phototherapy, particularly in premature infants. By measuring the skin moisture content of premature infants before and after phototherapy, Maayan-Metzger et al. found that the mean skin moisture loss increased by 26.4% during phototherapy, with the most significant loss observed in the elbow socket, groin, and back (Wang et al., 2021). Note: Infant may sleep for longer periods in conjunction with phototherapy, increasing the risk of dehydration if a frequent feeding schedule is not maintained.

Evaluate the appearance of skin and urine, noting brownish-black color.
An uncommon side effect of phototherapy involves exaggerated pigment changes (bronze baby syndrome), which may occur if conjugated bilirubin levels rise. The changes in skin color may last for 2–4 months but are not associated with harmful sequelae. The bronze baby syndrome is an irregular pigmentation resulting from phototherapy in newborn infants diagnosed with neonatal jaundice that is mainly noticeable in the skin, mucous membranes, and urine and generally occurs in neonates with elevated serum conjugated bilirubin levels (Wang et al., 2021).

Note behavioral changes or signs of deteriorating condition (e.g., lethargy, hypotonia, hypertonicity, or extrapyramidal signs).
Such changes may indicate the deposition of bile pigment in the basal ganglia and developing kernicterus. Following neonatal phototherapy, the serum level of total free calcium is often diminished, leading to hypocalcemia, which is higher among premature infants than that among full-term infants (Wang et al., 2021).

Assess for the presence of rash and petechiae.
Certain newborns develop petechiae and skin rashes from phototherapy, which gradually fade when phototherapy is discontinued. Petechiae may be associated with light-induced thrombocytopenia; thus, the platelet count should be closely monitored during phototherapy. A small number of infants diagnosed with cholestatic jaundice develop a purpuric rash and bullous eruptions after phototherapy, which may increase the total circulating porphyrin levels (Wang et al., 2021).

Note fussiness or increased crying episodes and irritability.
It has been reported that newborns receiving phototherapy have more frequent crying episodes than those receiving no therapy for clinical jaundice, which may be associated with changes in the circadian rhythm during neonatal phototherapy.

Document the type of fluorescent lamp, the total number of hours since bulb replacement, and the measured distance between lamp surface and infant.
Light emission may decay over time. The infant should be approximately 18–20 in (45 cm) from the light source for maximal benefit. Note: A fiberoptic blanket connected to an illuminator (light source) allows the infant to be “wrapped” in therapeutic light without risk to corneas. In addition, infants can be held and fed without interrupting therapy.

Measure the quantity of photon energy of fluorescent bulbs (white or blue light) using a photometer.
The intensity of light striking the skin surface from the blue spectrum (blue lights) determines how close to the light source the infant should be placed. The photometer should register between 8 and 10 mW/cm2/nm of light when placed flush with the infant’s abdomen. Blue and special blue lights are considered more effective than white light in promoting bilirubin breakdown, but they create difficulty in evaluating the newborn for cyanosis. The American Academy of Pediatrics defines standard phototherapy as 8-10 mW/cm2 per nm and intensive phototherapy as more than 30 mW/cm2 per nm in the 430-490 nm band (Sawyer & Nimavat, 2018).

Cover the testes and penis of a male infant. The infant is undressed except for a diaper to protect the ovaries or testes, and so as much skin surface as possible is exposed to light. Some phototherapy lights may affect reproduction. Potential and embryonic development because of the combined effects of light penetration in the tissues. The light had probably stimulated some neuroendocrine structures in the skin. Koc et al. reported the seminiferous tubule diameters were thinner than the control group after phototherapy in rats. Similar histological changes were obtained in cryptorchid testis in humans (Cetinkursun et al., 2006).

Apply patches to closed eyes; inspect eyes every two hours when patches are removed for feedings. Monitor placement frequently.
Retinal damage represents another challenge associated with phototherapy for neonatal jaundice. The light-sensitive retinas absorb photons more readily when exposed to blue light, most effective at degrading bilirubin. Following continuous or stronger blue light irradiation, the retinal function degenerates due to a significantly increased retinal cell death rate (Wang et al., 2021). In addition to eye shields, many centers also prescribe lubricating eye drops for an infant receiving phototherapy (Sawyer & Nimavat, 2018).

Cleanse the infant’s eyes using sterile or normal saline water.
As the incidence of conjunctivitis is increased among children receiving phototherapy who wear eye masks over prolonged periods, thorough eye care, such as cleaning eye secretions and surrounding skin with normal saline cotton balls, must be applied (Wang et al., 2021). 

Reposition the infant every two hours.
This allows equal exposure of skin surfaces to fluorescent light, prevents excessive exposure of individual body parts, and limits pressure areas.

Carefully wash the perianal area after each passage of stool; inspect the skin for possible irritation or breakdown.
Early intervention helps prevent irritation and excoriation from frequent or loose stools. An infant’s stools under bilirubin lights are often bright green because of the excessive bilirubin being excreted as a result of the therapy. They are also frequently loose and may be irritating to the skin.

Encourage an increased oral fluid intake.
To prevent the loss of water and electrolytes caused by phototherapy, water and electrolytes must be replenished when necessary. The warming effect of conventional phototherapy increases water loss from the body surface, while light-emitting diode (LED) phototherapy, which is currently widely used, causes less water loss (Wang et al., 2021).

Bring infant to parents for feedings. Encourage stroking, cuddling, eye contact, and talking to the infant during feedings. Encourage parents to interact with the infant in the nursery between feedings.
This fosters the attachment process, which may be delayed if phototherapy requires separation. Visual, tactile, and auditory stimulation helps the infant overcome sensory deprivation. Intermittent phototherapy does not negatively affect the photooxidation process. Note: Dependent on infant condition and policies/capabilities of the hospital, phototherapy may be provided in conjunction with rooming-in.

Ensure that the infant’s chest is properly shielded during phototherapy.
50% of premature infants receiving phototherapy were diagnosed with patent ductus arteriosus, the re-opening of the ductus arteriosus may be evoked by blue light penetrating the chest wall of the premature infant and causing relaxation of the smooth muscle of the cardiovascular system by activating the Ca2+ dependent K+ channel. It has been reported that appropriate shielding of the chest during phototherapy may reduce the incidence of patent ductus arteriosus (Wang et al., 2021).

3. Administer Medications and Provide Pharmacologic Support

Administering medications and providing pharmacologic support in patients with hyperbilirubinemia (jaundice) involves careful consideration of the specific medications used, their dosages, and their potential effects on bilirubin metabolism and liver function.

  • 10% calcium gluconate.
    From 2–4 ml of calcium, gluconate may be administered after every 100 ml of blood infusion to correct hypocalcemia and minimize possible cardiac irritability (Wani et al., 2018). The general approach is to give IV calcium during exchange transfusion, but this issue is still controversial. There is not enough literature data about calcium requirements during exchange transfusion. Complications such as tetany convulsions and death have been reported when blood products containing adenine-citrate dextrose (ACD) were used for exchange transfusion despite IV calcium infusion (Aydin et al., 2021).
  • Sodium bicarbonate.
    Sodium bicarbonate corrects acidosis. Relatively higher serum pH may be attributed to higher serum bicarbonate concentration in freshly CPDA-treated blood. The serum bicarbonate concentration in CPDA-treated blood usually starts decreasing after three days of storage.
  • Protamine sulfate.
    Protamin sulfate counteracts anticoagulant effects of heparinized blood. Some clinicians remain skeptical about the safety of heparinized blood transfusion due to the possible risk of heparin-induced bleeding. This skepticism may be valid for hemostatically unstable neonates due to comorbid hemorrhagic conditions such as hemophilia, thrombocytopenia, DIC, or vitamin K deficiency. If overheparinization is clinically suspected during or after the transfusion, protamine sulfate can be used to neutralize it (Ahmed & Ibrahim, 2018).
  • Administer enteral or parenteral fluid as indicated.
    Fluids compensate for insensible and intestinal fluid losses and supply nutrients if feedings are withheld during phototherapy for infants with severe hyperbilirubinemia. Due to this increase in insensible water loss, recommendations have been made to increase maintenance fluid by 10 ml/kg/day in premature infants exposed to conventional phototherapy (Sawyer & Nimavat, 2018).

4. Monitoring Results of Diagnostic and Laboratory Procedures

Monitoring the results of diagnostic and laboratory procedures is crucial in the management of hyperbilirubinemia (jaundice) to assess the severity of the condition, identify the underlying cause, and guide appropriate treatment decisions. Various diagnostic tests and laboratory procedures are employed to evaluate liver function, bilirubin levels, and other relevant parameters.

  • Direct and indirect bilirubin.
    Bilirubin appears in two forms: direct bilirubin, which is conjugated by the liver enzyme glucuronyl transferase, and indirect bilirubin, which is unconjugated and appears in a free form in the blood or bound to albumin. Elevated levels of indirect bilirubin best predict the infant’s potential for kernicterus. Elevated indirect bilirubin levels of 18–20 mg/dl in the full-term infant or13–15 mg/dl in preterm or sick infants are significant (Hansen & Aslam, 2017).
  • Total serum bilirubin level.
    Usually, a total serum bilirubin level test is the only one required in an infant with moderate jaundice who presents on the typical second or third day of life without a history or physical findings suggestive of a pathologic process (Hansen & Aslam, 2017).
  • Direct/indirect Coombs’ test on cord blood.
    Positive results of the indirect Coombs test indicate the presence of antibodies (Rh-positive or anti-A, anti-B) in the mother’s and newborn’s blood; positive results of the direct Coombs test indicate the presence of sensitized (Rh-positive, anti-A, or anti-B) RBCs in the neonate.
  • CO2-combining power; Reticulocyte count and peripheral smear.
    A decrease is consistent with hemolysis. Excessive hemolysis causes reticulocyte count to increase. Smear identifies abnormal or immature RBCs. The reticulocyte count provides an indirect insight into the bone marrow condition by distinguishing if the anemia is related to inadequate RBC production or accelerated loss/destruction (Szigeti & Staros, 2014).
  • Hemoglobin/hematocrit (Hb/Hct).
    Elevated Hb/Hct levels (Hb 22 g/dl; Hct 65%) indicate polycythemia, possibly caused by delayed cord clamping, maternal-fetal transfusion, twin-to-twin transfusion, maternal diabetes, or chronic intrauterine stress and hypoxia, as seen in low birth weight (LBW) infant or infant with compromised placental circulation. Hemolysis of excess RBCs causes elevated bilirubin levels with 1 g of Hb yielding 35 mg of bilirubin. Low Hb levels (14 mg/dl) may be associated with hydrops fetalis or Rh incompatibility occurring in utero and causing hemolysis, edema, and pallor.
  • Total serum protein or serum albumin levels.
    Low serum protein levels (3.0 g/dl) indicate a reduced binding capacity for bilirubin. Serum albumin levels appear to be a useful adjunct in evaluating the risk of toxicity levels because albumin binds bilirubin in a ratio of 1:1 at the primary high-affinity binding site (Hansen & Aslam, 2017).
  • Serum calcium and potassium.
    Measure urea and electrolytes regularly until the infant is stable, as indicated. Donor blood containing citrate as an anticoagulant binds calcium, decreasing serum calcium levels. In addition, if blood is more than two days old, RBC destruction releases potassium, creating a risk of hyperkalemia and cardiac arrest (The Royal Children’s Hospital, 2004).
  • Glucose.
    Perform blood glucose levels immediately post-procedure and then hourly until the infant is stable (The Royal Children’s Hospital, 2004). There is a significant rise in post-exchange serum glucose, attributed to high dextrose content in the donor blood and anticoagulants for preservation. Although normal mean blood sugar was observed at 12 hours post-exchange, one needs to be cautious as rebound hypoglycemia may occur during the initial hours (Wani et al., 2018).
  • Serum pH levels.
    The serum pH of donor blood is typically 6.8 or less. Acidosis may result when fresh blood is not used, and the infant’s liver cannot metabolize citrate used as an anticoagulant, or when donor blood continues anaerobic glycolysis with the production of acid metabolites. Low serum potassium after exchange transfusion coincided with higher serum pH, which is known to cause a shift of serum potassium into the intracellular compartment (Wani et al., 2018).
  • Platelets and WBCs.
    Thrombocytopenia during phototherapy has been reported in some infants. A decrease in WBCs suggests a possible effect on peripheral lymphocytes. There is a significant association between the decrease in platelet count with the duration of phototherapy and lower gestational age in the neonate (Sarkar et al., 2021).
  • Riboflavin levels.
    Since the wavelength of absorption of blue light by riboflavin is similar to that of bilirubin, both riboflavin and bilirubin will decompose at the same time when a newborn with jaundice receives blue light therapy, leading to the loss of riboflavin in the body. The riboflavin deficiency will reduce the synthesis of active riboflavin adenine dinucleotide, impair hydrogen delivery of erythrocytes, reduce glutathione reductase, and weaken the activity of erythrocyte glutathione reductase, thus aggravating hemolysis (Wang et al., 2021).

Recommended nursing diagnosis and nursing care plan books and resources.

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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care 
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health 
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.

See Also

Other recommended site resources for this nursing care plan:

Other care plans related to the care of the pregnant mother and her baby:

References and Resources

Resources and journals you can use to further your reading about Hyperbilirubinemia (Jaundice).

Reviewed and updated by M. Belleza, R.N.

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Paul Martin, BSN, R.N.
Paul Martin R.N. brings his wealth of experience from five years as a medical-surgical nurse to his role as a nursing instructor and writer for Nurseslabs, where he shares his expertise in nursing management, emergency care, critical care, infection control, and public health to help students and nurses become the best version of themselves and elevate the nursing profession.

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