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 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 and nursing diagnosis for Hyperbilirubinemia (Neonatal Jaundice):
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.|
Risk For Injury (CNS Involvement)
- Prematurity, hemolytic disease, asphyxia, acidosis hypoproteinemia, and hypoglycemia.
Possibly evidenced by
- [Not applicable]
- Neonate will display indirect bilirubin levels below 12 mg/dl in term infant at 3 days of age.
- Neonate will show resolution of jaundice by end of the 1st wk of life.
- Neonate will be free of CNS involvement.
|Assess infant/maternal blood group and blood type.||ABO affect 20% of all pregnancies and most commonly occur 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 increases the risk for jaundice. Maternal antibodies cross the placenta in Rh- negative women who had been previously sensitized due to Rh-positive infant. Antibodies attach to fetal Rbc’s and increase the risk of hemolysis.|
|Assess the infant in daylight.||This prevents distortion of actual skin color through the use of artificial lightning.|
|Review infant’s condition at birth, noting need for resuscitation or evidence of excessive ecchymosis or petechiae, cold stress, asphyxia, or acidosis.||Asphyxia and acidosis reduce affinity of bilirubin to albumin.|
|Review intrapartal record 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 level of the cell membrane or within the cell itself, increasing the risk of CNS involvement.|
|Note use of vacuum extractor for delivery. Assess infant for presence of cephalhematoma and excessive ecchymosis or petechiae.||Resorption of blood trapped in fetal scalp tissue and excessive hemolysis may increase the amount of bilirubin being released and cause jaundice.|
|Observe infant on the sclera and oral mucosa, yellowing of skin immediately after blanching, and specific body parts involved. Assess oral mucosa, posterior portion of hard palate, and conjunctival sacs in dark-skinned newborns.||Detects evidence/degree of jaundice. Clinical appearance of jaundice is evident at bilirubin levels >7–8 mg/dl in full-term infant. Estimated degree of jaundice is as follows, with jaundice progressing from head to toe:
Note: Yellow underlying pigment may be normal in dark-skinned infants.
|Evaluate maternal and prenatal nutritional levels; note possible neonatal hypoproteinemia, especially in preterm infant.||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.|
|Note infant’s age at onset of jaundice; differentiate type of jaundice (i.e., physiological, breast milk–induced, or pathological). Establishes proper intestinal flora necessary for||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. The breast milk of some women is thought to contain an enzyme (pregnanediol) that inhibits glucuronyl transferase (the liver enzyme that conjugates bilirubin), or to contain several times the normal breast milk concentration of certain free 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|
|Initiate early oral feedings within 4–6 hr following birth, especially if infant is to be breastfed. Assess infant for signs of hypoglycemia. Obtain Dextrostix levels, as indicated.||Establishes proper intestinal flora necessary for reduction of bilirubin to urobilinogen; decreases enterohepatic circulation of bilirubin (bypassing liver with persistence of ductus venosus); and decreases reabsorption of bilirubin from bowel by promoting passage of meconium. Hypoglycemia necessitates use of fat stores for energy-releasing fatty acids, which compete with bilirubin for binding sites on albumin.|
|Keep infant warm and dry; monitor skin and core temperature frequently.||Cold stress potentiates release of fatty acids, which compete for binding sites on albumin, thereby increasing the level of freely circulating (unbound) bilirubin.|
|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 prior to 36 hr of life.|
|Evaluate infant for pallor, edema, or hepatosplenomegaly||These signs may be associated with hydrops fetalis, Rh incompatibility, and in utero hemolysis of fetal RBCs.|
|Apply transcutaneous jaundice meter.||Provides noninvasive screening of jaundice, quantifying skin color in relation to total serum bilirubin.|
|Discontinue breastfeeding for 24–48 hr, as indicated. Assist mother as needed with 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 do begin to fall within 48 hr after discontinuation of breastfeeding.|
|Monitor laboratory studies, as indicated:|
||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. The infant’s potential for kernicterus is best predicted by elevated levels of indirect bilirubin. Elevated indirect bilirubin levels of 18–20 mg/dl in full-term infant, or13–15 mg/dl in preterm or sick infant, are significant. Note: Stressed or preterm infant is susceptible to deposition of bile pigments within brain tissue at far lower levels than non stressed full-term infant.|
||Positive results of indirect Coombs’ test indicate presence of antibodies (Rh-positive or anti-A, anti-B) in mother’s and newborn’s blood; positive results of direct Coombs’ test indicate presence of sensitized (Rh-positive, anti-A, or anti-B) RBCs in neonate.|
||A decrease is consistent with hemolysis Excessive hemolysis causes reticulocyte count to increase. Smear identifies abnormal or immature RBCs.|
||Elevated Hb/Hct levels (Hb 22 g/dl; Hct 65%) indicate polycythemia, possibly caused by delayed cord clamping, maternal-fetal transfusion, twin-totwin transfusion, maternal diabetes, or chronic intrauterine stress and hypoxia, as seen in LBW infant or infant with compromised placental circulation. Hemolysis of excess RBCs causes elevated levels of bilirubin with 1 g of Hb yielding 35 mg of bilirubin. Low Hb levels (14 mg/dl) may be associated with hydrops fetalis or with Rh incompatibility occurring in utero and causing hemolysis, edema, and pallor.|
||Low levels of serum protein (3.0 g/dl) indicate reduced binding capacity for bilirubin.|
|Calculate plasma bilirubin-albumin binding capacity.||Aids in determining risk of kernicterus and treatment needs. When 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 degree of prematurity, presence of hypoxia or acidosis, and drug regimen (e.g., sulfonamides, chloramphenicol).|
|Initiate phototherapy per protocol, using fluorescent bulbs placed above the infant or bile blanket (except for newborn with Rh disease).||Causes photo-oxidation of bilirubin in subcutaneous tissue, thereby increasing water solubility of bilirubin, which allows rapid excretion of bilirubin in stool and urine. Rate of bilirubin reduction related to phototherapy, so that an exchange transfusion is the only appropriate treatment.|
|Administer enzyme induction agent (phenobarbital, ethanol), as appropriate.||Stimulates hepatic enzymes to enhance clearance of bilirubin.|
|Assist with preparation and administration of exchange transfusion. Use same type of blood as infant’s, but Rh-negative or type O-negative blood, if results of direct Coombs’ test on cord serum are >3.5 mg/dl in the 1st wk of life, serum unconjugated bilirubin levels are 20 mg/dl in the first 48 hr of life, or Hb is 12 g/dl at birth in infants with hydrops fetalis.||Exchange transfusions are necessary in cases of severe hemolytic anemia, which are usually associated with Rh incompatibility, to remove sensitized RBCs that would soon lyse; to remove serum bilirubin; to provide bilirubin-free albumin to increase binding sites for bilirubin; and to treat anemia by providing RBCs that are not susceptible to maternal antibodies.|
Risk For Injury
- Risk for Injury
- Complications of exchange transfusions
- Invasive procedure, abnormal blood profile, chemical imbalances.
Possibly evidenced by
- [not applicable].
- Neonate will complete exchange transfusion without complications.
- Neonate will display decreasing serum bilirubin levels.
|Note condition of infant’s cord prior to transfusion, if umbilical vein is to be used. If cord is dry, administer saline soaks for 30–60 min prior to procedure.||Soaks may be necessary to soften cord and umbilical vein prior to transfusion for IV access and to ease passage of umbilical catheter.|
|Verify infant’s and mother’s blood type and Rh factor. Note blood type and Rh factor of blood to be exchanged. (Exchanged blood will be the same type as the baby’s but will be Rh-negative or type O–negative blood that has been cross-matched with mother’s blood beforehand.)||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 infants circulation would destroy new RBCs.|
|Assess the infant for weight changes.||Weight change reveals weight gain related to fluid overload. Fluid overload can cause respiratory and cardiac complications.|
|Assess the infant for neurologic changes.||Irritabilty, twitching, covulsions or seizures are sign of hyperkalemia, hypocalcemia or neurotoxicity as a result from jaundice.|
|Maintain infant’s temperature prior to, during, and after procedure. Place infant under radiant warmer with servomechanism. Warm blood prior to infusion by placing in incubator, warm basin of water, or blood warmer.||Helps prevent hypothermia and vasospasm, reduces risk of ventricular fibrillation, and decreases blood viscosity.|
|Ensure freshness of blood (not more than 2 days old), with heparinized blood preferred.||Older blood is more likely to hemolyze, thereby increasing bilirubin levels. Heparinized blood is always fresh, but must be discarded if not used within 24 hr.|
|Avoid overheating of blood prior to transfusion.||Too much heat on the blood promotes hemolysis and release of potassium causing hyperkalemia.|
|Ensure availability of resuscitative equipment.||To provide immediate support if necessary.|
|Maintain NPO status for 4 hr prior to procedure, or aspirate gastric contents.||Reduces risk of possible regurgitation andaspiration during procedure.|
|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.|
|Monitor venous pressure, pulse, color, and respiratory rate/ease before, during, and aftertransfusion. Suction as needed.||Establishes baseline values, identifies potentially unstable conditions (e.g., apnea or cardiacdysrhythmia/arrest), and maintains airway. Note: 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.|
|Carefully document events during transfusion, recording amount of blood withdrawn and injected (usually 7–20 ml at a time).||Helps prevent errors in fluid replacement. 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.|
|Monitor laboratory studies, as indicated:|
||If Hct is 40% prior to transfusion, a partial exchange with packed RBCs may precede full exchange. Dropping levels following the transfusion suggest the need for a second transfusion.|
||Bilirubin levels may decrease by half immediately following procedure but may rise shortly thereafter, necessitating a repeat transfusion.Multiplying level by 3.7 determines the degree of elevation of bilirubin necessitating exchange transfusion|
||Donor blood containing citrate as an anticoagulant binds calcium, thereby decreasing serum calcium levels. In addition, if blood is more than 2 days old, RBC destruction releases potassium, creating a risk of hyperkalemia and cardiac arrest|
|Low glucose levels may be associated with continued anaerobic glycolysis within donor RBCs. Prompt treatment is necessary to prevent untoward effects/CNS damage|
||Serum pH of donor blood is typically 6.8 or less. Acidosis may result when fresh blood is not used and infant’s liver cannot metabolize citrate used as an anticoagulant, or when donor blood continues anaerobic glycolysis, with production of acid metabolites.|
|Administer albumin prior to transfusion if indicated.||Although somewhat controversial, administration of albumin may increase the albumin available for binding of bilirubin, thereby reducing levels of freely circulating serum bilirubin. Synthetic albumin is not thought to increase available binding sites.|
|Administer medications, as indicated:|
||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. Note: Some controversy exists as to the purpose and effectiveness of this practice.|
||Counteracts anticoagulant effects of heparinized blood.|
|Administer antibiotics as indicated.||Antibiotics prevent and/or treat infections.|
Risk For Injury
- Risk for Injury
- Physical properties of therapeutic intervention and effects on body regulatory mechanisms
- Phototherapy side effects
Possibly evidenced by
- [not applicable].
- Neonate will maintain body temperature and fluid balance WNL.
- Neonate will be free of skin/tissue injury.
- Neonate will demonstrate expected interaction patterns.
- Neonate will display decreasing serum bilirubin levels.
|Note presence/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|
|Document type of fluorescent lamp, total number of hours since bulb replacement, and the measured distance between lamp surface and infant.||Light emission may decay over time. Infant should be placed approximately 18–20 in (45 cm) from light source for maximal benefit. Note: Use of fiberoptic blanket connected to an illuminator (light source) allows infant to be “wrapped” in therapeutic light without risk to corneas. In addition, infant can be held and fed without interrupting therapy.|
|Measure quantity of photoenergy of fluorescent bulbs (white or blue light) using photometer.||The intensity of light striking skin surface from blue spectrum (blue lights) determines how close to the light source the infant should be placed. Photometer should register between 8 and 9 µW/cm2/nm of light when placed flush with 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|
|Cover testes and penis of male infant.||Prevents possible testicular damage from heat.|
|Place Plexiglas shield between baby and light.||Filters out ultraviolet radiation (wavelengths less than 380 nm) and protects infant if bulb breaks.|
|Apply patches to closed eyes; inspect eyes every 2 hr when patches are removed for feedings. Monitor placement frequently.||Prevents possible damage to the retina and conjunctiva from high-intensity light. Improper application or slipping of patches can cause irritation, corneal abrasions, and conjunctivitis, and compromise breathing by obstructing nasal passages.|
|Cleanse the infant’s eyes using sterile water.||To remove debris and prevents the growth of bacteria.|
|Monitor neonate’s skin and core temperature every 2 hr or more frequently until stable (e.g., axillary temperature of 97.8°F (36.5°C), rectal temperature of 98.8°F (37.4°C). Regulate incubator/ Isolette temperature, as appropriate.||Fluctuations in body temperature can occur in response to light exposure, radiation, and convection.|
|Reposition infant every 2 hr.||Allows equal exposure of skin surfaces to fluorescent light, prevents excessive exposure of individual body parts, and limits pressure areas.|
|Note color and frequency of stools and urine.||Frequent, greenish, loose stools and greenish urine indicate effectiveness of phototherapy with breakdown and excretion of bilirubin.|
|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). Increase oral fluid intake by at least 25%||Increased water losses through stools and evaporation can cause dehydration. Note: Infant may sleep for longer periods in conjunction with phototherapy, increasing risk of dehydration if frequent feeding schedule is not maintained.|
|Evaluate appearance of skin and urine, noting brownish black color.||An uncommon side effect of phototherapyinvolves exaggerated pigment changes (bronze baby syndrome), which may occur if conjugated bilirubin levels rise. The changes in skin color may last for 2–4 mo but are not associated with harmful sequelae.|
|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.|
|Carefully wash perianal area after each passageof stool; inspect skin for possible irritation or breakdown.||Early intervention helps prevent irritation and excoriation from frequent or loose stools.|
|Bring infant to parents for feedings. Encourage stroking, cuddling, eye contact, and talking to infant during feedings. Encourage parents to interact with infant in nursery between feedings.||Fosters attachment process, which may be delayedif separation required by phototherapy. Visual,tactile, and auditory stimulation helps infant overcome sensory deprivation. Intermittent phototherapy does not negatively affect photooxidation process. Note: Dependent on infant condition and policies/capabilities of hospital, phototherapy may be provided in conjunction with rooming-in.|
|Monitor laboratory studies, as indicated:|
||Decreases in bilirubin levels indicate effectiveness of phototherapy; continued increases suggest continued hemolysis and may indicate the need for exchange transfusion. Note: Blood sample drawn for bilirubin determination should be protected from light to prevent continued photo-oxidation.|
||Continued hemolysis is manifested by progressive decreases in Hb level.|
||Thrombocytopenia during phototherapy has been reported in some infants. Decrease in WBCs suggests a possible effect on peripheral lymphocytes.|
|Administer enteral or parenteral fluid as indicated.||Fluids compensate for insensible and intestinal fluid losses and supplies nutrients if feedings are withheld during phototherapy for infants with severe hyperbilirubinemia.|
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