4 Hyperbilirubinemia (Jaundice) Nursing Care Plans

Deficient Knowledge

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).

Nursing Diagnosis

• Deficient Knowledge

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

Desired Outcomes

• 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.

Nursing Assessment and Rationales

1. 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.

2. 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.

Nursing Interventions and Rationales

1. 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).

2. 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).

3. 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.

4. 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.

5. 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.

6. 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.

7. 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).

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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.