Jaundice Nursing Diagnosis Care Plan: Comprehensive Guide for Neonatal Care

Hyperbilirubinemia: Understanding Jaundice in Newborns

Hyperbilirubinemia, commonly known as jaundice, is a condition characterized by elevated levels of bilirubin in the blood. This condition is frequently observed in newborns due to the breakdown of red blood cells and the immaturity of their livers, which are not yet fully capable of processing bilirubin. While physiological jaundice is a normal and transient condition in many newborns, pathological jaundice can pose significant risks and lead to severe complications if not properly managed. Understanding the nuances of jaundice, along with appropriate nursing diagnoses and care plans, is crucial for healthcare professionals.

The newborn’s liver plays a vital role in bilirubin metabolism. After birth, red blood cells are naturally broken down, releasing bilirubin. An immature liver may struggle to efficiently remove this bilirubin, leading to its accumulation in the blood and tissues, resulting in the yellowish discoloration characteristic of jaundice. The severity of jaundice and the associated risks of neurological damage are directly related to the level of bilirubin in the blood. Physiological jaundice, a benign condition, typically appears after 24 hours of birth. In contrast, pathological jaundice, which occurs within the first 24 hours, is indicative of an underlying medical issue such as ABO or Rh incompatibility. Premature infants are particularly susceptible to hyperbilirubinemia due to their even more underdeveloped liver function and slower bilirubin processing. Breast milk jaundice is another variation, occurring in breastfed infants, typically appearing later than physiological jaundice.

Hemolytic disease of the newborn, historically often due to Rh incompatibility, is now more commonly caused by ABO incompatibility, thanks to advancements in Rh antibody prevention. In both scenarios, blood type differences between mother and fetus can trigger the mother’s immune system to produce antibodies against fetal red blood cells. This leads to hemolysis, causing anemia and hyperbilirubinemia in the newborn.

Nursing Care Plans and Management for Neonatal Jaundice

Effective nursing care is essential in managing hyperbilirubinemia in newborns. The primary goals of a nursing care plan are to prevent the condition from worsening, support the family, maintain physiological stability as bilirubin levels decrease, and avert potential complications.

Nursing Problem Priorities

The critical nursing priorities for managing hyperbilirubinemia (jaundice) in newborns include:

Continuous Bilirubin Level Monitoring: Regular assessment of bilirubin levels is paramount to determine the severity of jaundice and guide interventions.
Identify the Underlying Cause of Jaundice: Determining the etiology of hyperbilirubinemia is essential for targeted treatment and management.
Administer and Manage Phototherapy: Phototherapy is a key intervention used to break down bilirubin and lower serum levels.
Prepare for and Assist with Blood Transfusion: In severe cases, blood transfusions may be necessary to rapidly reduce bilirubin levels and replace red blood cells.
Comprehensive Neonatal Assessment: A thorough assessment helps evaluate the newborn’s overall condition and identify any additional health concerns related to hyperbilirubinemia.
Parent Education and Support: Educating parents about jaundice, its management, and the importance of follow-up care is crucial for home care and early intervention.
Liver Function Evaluation: Assessing liver function helps identify any underlying liver disorders contributing to hyperbilirubinemia.
Collaboration with Pediatric Specialists: Working with pediatricians and specialists ensures holistic and expert management of the condition.
Promote and Support Breastfeeding: Supporting breastfeeding mothers with proper feeding techniques can aid in bilirubin elimination through increased bowel movements.
Long-Term Follow-up Planning: Ensuring a plan for long-term monitoring is essential to track the resolution of hyperbilirubinemia and detect any potential long-term effects.

Nursing Assessment for Jaundice

Nurses should meticulously assess for the following subjective and objective data in newborns with or at risk of hyperbilirubinemia:

Detailed assessment parameters would be listed here if provided in the original article. (The original article moves directly to Nursing Diagnosis without listing specific assessment data points here. However, assessment is implied in the interventions and monitoring sections.)

Jaundice Nursing Diagnosis

Based on a comprehensive assessment, a nursing diagnosis is formulated to address the specific needs of the newborn with hyperbilirubinemia (jaundice). This diagnosis is crucial for guiding individualized care. While standardized nursing diagnoses provide a framework, the nurse’s clinical expertise is paramount in tailoring the care plan to meet each newborn’s unique needs and health status.

Nursing Goals for Jaundice Management

The overarching goals and expected outcomes in the nursing care plan for neonatal jaundice include:

The parents will articulate a clear understanding of the causes, treatment modalities, and potential outcomes of hyperbilirubinemia.
Parents will be able to recognize and report signs and symptoms in the infant that necessitate prompt medical attention.
Parents will confidently demonstrate appropriate care techniques for their infant at home.
The neonate will achieve and maintain indirect bilirubin levels within the normal range (below 12 mg/dL in term infants by day three).
The neonate will exhibit a visible resolution of jaundice by the end of the first week of life.
The neonate will remain free from central nervous system (CNS) involvement or neurological complications.
The neonate will undergo any necessary exchange transfusion procedures without experiencing complications.
The neonate’s serum bilirubin levels will show a consistent downward trend.
The neonate will maintain stable body temperature and fluid balance within normal physiological limits.
The neonate will remain free from skin or tissue injury, particularly related to treatment interventions.
The neonate will demonstrate expected age-appropriate interaction patterns and neurological responses.

Nursing Interventions and Actions for Jaundice

Therapeutic nursing interventions and actions for newborns with hyperbilirubinemia (jaundice) are focused on reducing bilirubin levels, preventing complications, and supporting the family.

1. Patient Education and Health Teachings for Jaundice

Neonatal jaundice is a frequent cause for hospital readmission. Often, infants discharged as healthy are readmitted around day five with severe hyperbilirubinemia or bilirubin encephalopathy. Since bilirubin levels typically peak when newborns are at home, parents and community health services play a critical role in early detection and effective breastfeeding management (Kaplan et al., 2019).

Assess family dynamics and support systems. Providing support to parents throughout hospitalization is crucial as they adjust to caring for a newborn, especially one requiring treatment. Mothers often feel anxious about their ability to care for a fragile infant. Involving mothers in basic care activities like diapering, bathing, and feeding can build confidence. However, the mother is sometimes discharged before the infant, which can strain family bonding and attachment.

Evaluate the parents’ understanding of jaundice. Assessing the parents’ current knowledge is vital to tailor education effectively. It helps identify specific information gaps and clarify any misconceptions about the diagnosis and prolonged recovery.

Provide detailed written instructions on home phototherapy. Clear, written guidelines are essential for parents managing home phototherapy. Kaplan et al. (2019) found that inadequate explanations about hyperbilirubinemia’s risks contributed to poor follow-up attendance. Comprehensive instructions should cover the technique, potential issues, and critical safety measures.

Educate on monitoring home therapy. Instruct parents on how to monitor the infant’s condition at home, including recording daily weight, feeding patterns, intake/output, stool frequency and consistency, and temperature. Emphasize the importance of reporting any changes in the infant’s status promptly. Home phototherapy is generally suitable for full-term infants older than 48 hours, with bilirubin levels between 14 and 18 mg/dL and no direct bilirubin elevation (Morrison, 2021). It is increasingly favored for maintaining the mother-infant bond and ensuring continuity of care.

Explain jaundice types, causes, and implications. Providing information on physiological, pathological, and breast milk jaundice helps parents understand the condition. Encourage questions and address concerns to reduce guilt and fear. Explain the rationale behind phototherapy and its function. Reassure parents about the generally low risks associated with phototherapy, provided eye protection is maintained and dehydration is prevented.

Discuss home management of mild jaundice. Advise on strategies for managing mild physiological jaundice at home, such as increasing feeding frequency, providing indirect sunlight exposure (with careful monitoring), and scheduling follow-up bilirubin tests. Note: Direct sunlight exposure is contraindicated due to the risk of infant skin injury. While long-term skin cancer risks from phototherapy are not confirmed, sun protection is advisable for all infants (and especially those who have undergone phototherapy).

Guide mothers on maintaining milk supply. Advise mothers on using a breast pump to maintain milk supply if breastfeeding is temporarily interrupted. This ensures continued milk production for when breastfeeding can be resumed. For infants over 1500 g, bottle feeding with a soft nipple may be possible to minimize energy expenditure during feeding. Expressed breast milk can be given via bottle to preterm infants.

Demonstrate bilirubin level assessment at home. Teach parents how to check for increasing jaundice by blanching the skin to observe the underlying color, monitoring weight, and noting behavioral changes. Observing skin, sclera, and mucous membranes for jaundice progression (face to abdomen to feet) is important, as it can indicate rising bilirubin levels.

Provide 24/7 emergency contact information. Give parents a 24-hour emergency phone number and contact person’s name. Emphasize the importance of immediate medical evaluation if jaundice worsens. Increased parental awareness and prompt hospital referral are crucial in reducing jaundice complications (Sardari et al., 2019).

Explain hospital procedures and bilirubin level changes. Keep parents informed about all hospital treatments (phototherapy, exchange transfusions) and changes in bilirubin levels, especially if the mother is discharged while the infant remains hospitalized. This helps them understand the necessity of treatment and promotes informed decision-making. Some hospitals offer rooms for parents to stay with their infants. Intensive phototherapy, combined with hydration and bilirubin monitoring, has significantly decreased the need for exchange transfusions.

Discuss potential long-term effects of hyperbilirubinemia. Explain the risk of kernicterus, which can cause long-term neurological damage, including cerebral palsy, developmental delays, hearing and vision problems, and learning disabilities.

Explain Rh immune globulin (RhIg) administration. For Rh-negative mothers with Rh-positive infants, discuss the need for RhIg within 72 hours post-delivery to prevent maternal sensitization and subsequent Rh incompatibility issues in future pregnancies.

Arrange follow-up bilirubin testing. Schedule follow-up bilirubin tests at the same lab facility to monitor levels after discharge. Treatment typically stops when bilirubin levels fall below 14 mg/dL, but rebound hyperbilirubinemia monitoring is crucial within 12-24 hours.

Refer to home phototherapy programs when appropriate. If indicated, refer parents to home phototherapy services, especially for mild to moderate physiological jaundice. Visiting nurses may be necessary if support systems are lacking.

Educate about home phototherapy specifics. Instruct parents on using home phototherapy equipment like blankets or fiberoptic pads. Provide written instructions and emphasize daily record-keeping of temperature, weight, intake/output, stools, and feedings. Stress the importance of eye and gonad protection during phototherapy.

2. Safety Promotion and Complication Prevention in Jaundice

Promoting safety and preventing complications are paramount in managing newborns with hyperbilirubinemia. This involves meticulous attention to phototherapy protocols, vigilant monitoring, and prompt intervention.

Assess infant and maternal blood types. ABO incompatibility affects a significant portion of pregnancies, especially in type O mothers. ABO and Rh incompatibilities increase jaundice risk due to maternal antibodies crossing the placenta and causing fetal RBC hemolysis.

Evaluate infant jaundice in daylight. Daylight assessment prevents misinterpretation of skin color under artificial lighting. Jaundice often becomes noticeable within the first 24 hours, indicating hemolysis in Rh and ABO incompatibility.

Review birth conditions and risk factors. Note any resuscitation needs at birth, ecchymosis, petechiae, cold stress, asphyxia, or acidosis. Asphyxia and acidosis can decrease bilirubin’s binding to albumin, increasing CNS risk. Review intrapartum records for risks like low birth weight, prematurity, metabolic disorders, vascular injuries, sepsis, or polycythemia, which elevate hyperbilirubinemia risk and CNS complications.

Observe for jaundice progression. Assess sclera, oral mucosa, and skin blanching for yellowing. Jaundice typically appears first on the face and forehead (Hansen & Aslam, 2017). Clinical jaundice is usually visible at bilirubin levels above 7-8 mg/dL in term infants.

Assess maternal and prenatal nutrition. Evaluate for neonatal hypoproteinemia, especially in preterm infants. Albumin binds to bilirubin, and low albumin levels increase unbound bilirubin and CNS risk.

Determine jaundice onset and type. Differentiate between physiological, breast milk, and pathological jaundice based on onset. Physiological jaundice appears on days 2-3; breast milk jaundice on days 4-6; pathological jaundice within 24 hours, carrying higher kernicterus risk.

Monitor for signs of kernicterus. Assess for behavioral changes like lethargy, poor feeding, high-pitched cry, or arching of the back. Kernicterus symptoms usually appear between days 3 and 10.

Check for pallor, edema, or hepatosplenomegaly. These signs may indicate hydrops fetalis or Rh incompatibility and in utero hemolysis.

Regularly monitor bilirubin blood levels. Phototherapy effectiveness is tracked by frequent bilirubin measurements. Significant jaundice levels vary by gestational and postnatal age (Hansen & Aslam, 2017).

Assess for hypoglycemia. Hypoglycemia can increase bilirubin levels as fatty acids released for energy compete with bilirubin for albumin binding sites (Salman et al., 2021).

Initiate early feedings. Start oral feedings within 4-6 hours after birth, especially for breastfed infants, to promote intestinal flora, reduce bilirubin reabsorption, and encourage meconium passage (Aynalem et al., 2020).

Maintain infant warmth. Keep the infant warm and dry to prevent cold stress, which can release fatty acids and increase unbound bilirubin.

Use a transcutaneous jaundice meter. Screen all newborns at 35 weeks gestation and beyond for hyperbilirubinemia using transcutaneous bilirubin (TcB) measurement or serum bilirubin (SB) testing (Maya-Enero et al., 2021).

Consider temporary breastfeeding cessation. In some cases, temporary breastfeeding cessation for 24-48 hours may be recommended to reduce bilirubin levels, while maintaining milk supply through pumping.

Monitor laboratory studies. Regularly review bilirubin levels and other relevant lab results as ordered.

Calculate bilirubin-albumin binding capacity. This helps assess kernicterus risk and guide treatment decisions.

Initiate phototherapy. Start phototherapy according to protocol, using overhead fluorescent lights or a bile blanket, except in Rh disease cases. Continue until bilirubin levels decline to 14 mg/dL.

Administer enzyme induction agents. In rare cases, phenobarbital may be used to enhance bilirubin metabolism (Hansen & Aslam, 2017).

Prepare for exchange transfusion. Assist with preparation and administration for severe cases, especially in blood incompatibility.

Check umbilical cord condition. If using the umbilical vein for transfusion, ensure the cord is soft and prepared for catheter insertion.

Verify blood types for transfusion. Confirm infant and mother’s blood types and Rh factor. Use O Rh-negative blood for exchange transfusions.

Monitor infant weight changes. Track weight before and after transfusion to detect fluid overload.

Assess for neurological changes. Monitor for irritability, twitching, or seizures, which may indicate neurotoxicity.

Observe for bleeding. Monitor for bleeding at IV sites post-transfusion due to altered coagulation.

Monitor vital signs. Continuously monitor venous pressure, pulse, color, and respiratory rate during and after transfusion.

Monitor for electrolyte imbalance. Watch for signs of hypocalcemia and hyperkalemia, which can occur during exchange transfusion.

Assess for congenital diseases. Evaluate for other hemolytic diseases or cardiac failure, which might necessitate immediate exchange transfusion.

Maintain infant temperature. Use a radiant warmer to maintain temperature during exchange transfusion.

Warm blood before infusion. Use a blood warmer to prevent hypothermia, avoiding overheating.

Ensure blood freshness. Use fresh blood (less than two days old) for transfusion.

Avoid overheating blood. Prevent hemolysis and hyperkalemia by not overheating blood.

Ensure resuscitation equipment availability. Have resuscitative equipment readily available for potential complications during transfusion.

Maintain NPO status. Keep the infant NPO for 4 hours before exchange transfusion to prevent aspiration.

Document transfusion details. Accurately document blood volume withdrawn and infused during transfusion.

Administer albumin before transfusion. Albumin administration may be considered to increase bilirubin binding capacity, although its efficacy is debated.

Administer medications. Give prescribed medications as indicated.

Administer antibiotics. Administer antibiotics to prevent or treat infections, especially post-transfusion.

Assist with IVIG administration. Intravenous immunoglobulin (IVIG) may reduce the need for exchange transfusion in hemolytic disease.

Monitor for biliary or intestinal obstruction. Phototherapy is contraindicated in these conditions. Monitor for signs of intestinal obstruction post-phototherapy.

Monitor temperature regularly. Check skin and core temperature every two hours during phototherapy to regulate incubator temperature.

Note stool and urine characteristics. Monitor stool color and frequency and urine color to assess phototherapy effectiveness.

Monitor fluid intake and output. Track fluid balance and weigh the infant twice daily to detect dehydration.

Evaluate skin and urine color. Assess for brownish-black urine, indicating bronze baby syndrome.

Note behavioral changes. Monitor for lethargy, hypotonia, or hypertonicity, which may indicate kernicterus.

Assess for rash and petechiae. Check for skin rashes or petechiae related to phototherapy.

Note fussiness or crying. Document increased crying episodes, possibly related to phototherapy.

Document phototherapy lamp details. Record lamp type, hours of use, and distance from infant.

Measure photon energy. Use a photometer to measure fluorescent bulb intensity.

Cover testes and penis. Protect male genitalia during phototherapy.

Apply eye patches. Use eye patches, check eyes every two hours, and clean eyes regularly.

Reposition infant frequently. Reposition every two hours for even light exposure.

Cleanse perianal area. Clean perianal area after each stool to prevent skin irritation.

Encourage increased fluid intake. Ensure adequate fluid intake to prevent dehydration.

Bring infant to parents for feeding. Encourage parent-infant interaction during feedings to promote bonding.

Shield chest during phototherapy. Shield the chest during phototherapy, especially in preterm infants, to reduce patent ductus arteriosus risk.

3. Pharmacologic Support for Jaundice

Pharmacologic interventions in neonatal jaundice are generally limited but can be crucial in specific situations.

Sodium Bicarbonate: Administered to correct acidosis, which can improve bilirubin binding to albumin.
Intravenous Fluids: Enteral or parenteral fluids compensate for fluid losses and provide nutrition, especially when oral feedings are interrupted.

4. Diagnostic and Laboratory Procedure Monitoring for Jaundice

Monitoring laboratory results is crucial for assessing jaundice severity, identifying causes, and guiding treatment.

Direct and Indirect Bilirubin Levels: Elevated indirect bilirubin is a key indicator of kernicterus risk. Significant levels are 18-20 mg/dL in term infants and 13-15 mg/dL in preterm or sick infants (Hansen & Aslam, 2017).
Total Serum Bilirubin Level: Often the primary test for jaundice, especially in routine cases without pathological signs (Hansen & Aslam, 2017).
Direct/Indirect Coombs’ Test: Detects antibodies in mother and infant’s blood (indirect Coombs’) and sensitized RBCs in the neonate (direct Coombs’), indicating hemolytic disease.
CO2-combining power, Reticulocyte Count, and Peripheral Smear: Decreased CO2 and increased reticulocytes suggest hemolysis. Smear identifies abnormal RBCs.
Total Serum Protein or Albumin Levels: Low protein levels reduce bilirubin binding capacity.
Glucose Levels: Monitor glucose post-exchange transfusion due to dextrose in donor blood, watching for rebound hypoglycemia (Wani et al., 2018).
Platelet and WBC Counts: Monitor for thrombocytopenia during phototherapy and potential WBC changes (Sarkar et al., 2021).

Recommended Resources for Jaundice Care

Links to recommended nursing diagnosis and care plan books and resources would be placed here as in the original article.

References and Resources

References and resources used in the article, formatted as in the original article.

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

Newborn jaundice under phototherapy light

Alt text: Visual guide demonstrating how to assess jaundice progression in a newborn infant by observing skin discoloration from head to toe, indicating bilirubin level changes.

Alt text: Diagram illustrating the bilirubin metabolism pathway in newborns, from red blood cell breakdown to liver conjugation and excretion, highlighting potential points of hyperbilirubinemia.