Jaundice Nursing Care Plan: 5 Key Nursing Diagnoses and Interventions

Hyperbilirubinemia, commonly known as jaundice, is a frequent condition in newborns characterized by elevated serum bilirubin levels. This elevation arises from the breakdown of red blood cells (RBCs) and the subsequent reabsorption of unconjugated bilirubin from the small intestines. While often benign, jaundice can pose significant risks to neonates, potentially leading to various complications if not properly managed.

A newborn’s liver, still in its developmental stage, is a primary factor contributing to neonatal jaundice. This organ’s immaturity hinders its ability to effectively clear bile pigments from the blood, pigments that are a natural byproduct of postnatal RBC destruction. The severity of jaundice, indicated by the depth of yellowing of the skin and eyes, correlates directly with the level of bilirubin in the blood and, consequently, the risk of neurological damage. Physiologic jaundice is considered normal and transient, whereas pathological jaundice is a more serious concern. Pathological jaundice occurs within the first 24 hours after birth and is often linked to underlying conditions such as ABO-Rh incompatibility. It’s also important to note that preterm infants typically experience a slower rise in bilirubin levels compared to their full-term counterparts, but this elevation lasts longer, making them more susceptible to hyperbilirubinemia.

Physiological jaundice represents the most prevalent form of newborn hyperbilirubinemia. This unconjugated hyperbilirubinemia typically manifests after the first day of life and can persist for up to a week. Pathological jaundice, in contrast, is identified by jaundice appearing within the first 24 hours of life. It is marked by a rapid increase in serum bilirubin levels exceeding 5 mg/dL per day, conjugated bilirubin levels making up 20% or more of the total serum bilirubin, peak bilirubin levels surpassing the normal range, and clinical jaundice lasting beyond two weeks. Breast milk jaundice is another specific type, affecting breastfed newborns typically between days one and three, peaking around days 5 to 15, and gradually declining by the third week of life (Morrison, 2021).

Historically, Rh blood type incompatibility was a leading cause of hemolytic disease in newborns. However, due to advancements in prevention strategies for Rh antibody formation over the past half-century, ABO incompatibility has become a more common cause. In both scenarios, the underlying issue is the same: the mother develops antibodies against the fetal red blood cells because of blood type differences. This antibody reaction leads to hemolysis of fetal red blood cells, potentially resulting in severe anemia and hyperbilirubinemia in the newborn.

Nursing Care Plans and Management

The nursing care plan for newborns with hyperbilirubinemia is comprehensive, aiming to prevent the condition from worsening and to minimize risks. It focuses on providing crucial support and information to the family, maintaining the newborn’s physiological balance by reducing bilirubin levels, and preventing any potential complications.

Nursing Problem Priorities

Key nursing priorities for managing hyperbilirubinemia (jaundice) include:

Consistent Bilirubin Level Monitoring: Regular assessment of bilirubin levels in the newborn’s blood is crucial for determining the severity of hyperbilirubinemia and guiding treatment adjustments.
Identifying the Root Cause: Determining the underlying cause of hyperbilirubinemia is essential for effective treatment strategies and addressing the specific needs of the newborn.
Effective Phototherapy Administration: Initiating and carefully managing phototherapy is vital to help break down bilirubin in the skin and reduce blood levels, thereby mitigating jaundice.
Considering Blood Transfusion: In severe cases of hyperbilirubinemia, especially when other treatments are insufficient, blood transfusion may be necessary to remove excess bilirubin directly from the bloodstream and replenish red blood cells.
Thorough Neonatal Assessment: Comprehensive neonatal assessments are essential to evaluate the newborn’s overall health status and identify any additional health issues related to hyperbilirubinemia or its treatment.
Comprehensive Parent Education: Educating parents about hyperbilirubinemia, its causes, management, and warning signs is critical. Parents need to understand the importance of follow-up care and how to support their newborn at home.
Liver Function Evaluation: Assessing liver function helps to determine if any underlying liver disorders are contributing to hyperbilirubinemia, which can influence the overall management approach.
Collaboration with Specialists: Coordinating care with pediatric specialists ensures a multidisciplinary approach to managing hyperbilirubinemia, especially in complex cases.
Breastfeeding Support: Providing support and guidance to breastfeeding mothers is important to optimize breastfeeding practices. Effective breastfeeding can aid in bilirubin elimination through frequent stools.
Long-Term Follow-Up Planning: Establishing a plan for long-term follow-up is crucial to monitor the resolution of hyperbilirubinemia and detect any potential long-term effects or complications that may arise as the newborn develops.

Nursing Assessment

A detailed nursing assessment is crucial for identifying and managing hyperbilirubinemia in newborns. This assessment involves gathering both subjective and objective data to understand the newborn’s condition comprehensively.

Subjective Data: While newborns cannot directly communicate symptoms, relevant subjective data often comes from the mother’s report and medical history. This includes:

Maternal history: Information about the mother’s pregnancy, labor, and delivery, including any complications, medications used, and health conditions like diabetes or Rh-negative blood type.
Family history: Any family history of jaundice, anemia, liver disease, or related conditions can provide insights into potential risk factors.
Feeding patterns: Details about how well the newborn is feeding, whether breastfeeding or formula feeding, frequency and volume of feeds, and any difficulties encountered.
Activity level and behavior: Changes in the newborn’s usual activity patterns, such as increased lethargy, irritability, or changes in muscle tone.
Stool and urine output: Reports on the frequency, color, and consistency of stools and urine, as these can indicate bilirubin excretion and hydration status.

Objective Data: This is gathered through direct observation and physical examination of the newborn. Key objective findings in hyperbilirubinemia include:

Visual assessment of jaundice: Observing the skin, sclera (whites of the eyes), and mucous membranes for yellowish discoloration. Jaundice typically appears first in the face and progresses downwards to the chest, abdomen, and extremities as bilirubin levels rise. Blanching the skin by applying gentle pressure can help in assessing the degree of jaundice by revealing the underlying skin color.
Vital signs: Monitoring temperature, heart rate, respiratory rate, and blood pressure. Temperature instability, especially hypothermia, can exacerbate jaundice.
Weight: Daily weight measurement is important to assess for fluid balance, especially if phototherapy is being used, as it can lead to insensible water loss.
Hydration status: Assessing for signs of dehydration such as dry mucous membranes, decreased urine output, sunken fontanels, and poor skin turgor.
Neurological assessment: Observing for signs of bilirubin encephalopathy (kernicterus), which include lethargy, poor feeding, high-pitched cry, hypotonia or hypertonia, seizures, and in severe cases, apnea and coma.
Abdominal examination: Palpating for liver and spleen enlargement (hepatosplenomegaly), which can be associated with hemolytic jaundice.
Umbilical cord and skin: Checking the umbilical cord site for any signs of infection or bleeding, and the skin for bruising (ecchymosis) or petechiae, which might indicate blood incompatibilities or bleeding disorders.
Laboratory results: Reviewing bilirubin levels (total, direct, and indirect), blood type and Rh factor of mother and newborn, Coombs’ test results, hemoglobin and hematocrit levels, reticulocyte count, and other relevant blood chemistry values.
Transcutaneous bilirubin (TcB) measurement: Using a non-invasive bilirubinometer to estimate bilirubin levels through the skin, often used for screening and monitoring jaundice.

By systematically collecting and analyzing both subjective and objective data, nurses can accurately assess the severity of hyperbilirubinemia, identify potential underlying causes, and tailor appropriate nursing interventions and care plans to meet the individual needs of each newborn.

Nursing Diagnosis

Based on a comprehensive assessment, a nursing diagnosis is formulated to specifically address the health challenges associated with hyperbilirubinemia in newborns. This diagnosis reflects the nurse’s clinical judgment and understanding of the patient’s unique condition. While nursing diagnoses provide a structured approach to care planning, their direct application in clinical settings can vary. The expertise and clinical judgment of the nurse are paramount in shaping the care plan to effectively meet each newborn’s specific health needs and priorities.

Common Nursing Diagnoses for Neonatal Jaundice:

Risk for Injury related to hyperbilirubinemia as evidenced by elevated serum bilirubin levels and immature liver function.
Risk for Deficient Fluid Volume related to phototherapy as evidenced by increased insensible water loss and potential for inadequate fluid intake.
Risk for Impaired Skin Integrity related to phototherapy as evidenced by exposure to phototherapy lights and potential for skin irritation.
Interrupted Breastfeeding related to medical therapy (phototherapy) as evidenced by temporary separation of mother and infant and recommendations to interrupt breastfeeding.
Anxiety (Parental) related to newborn’s condition and treatment as evidenced by expressed concerns about newborn’s health status and treatment procedures.

These nursing diagnoses help guide the development of individualized care plans to address the specific needs of newborns with jaundice and their families.

Nursing Goals

The goals for nursing care in cases of neonatal hyperbilirubinemia are focused on improving the newborn’s condition, supporting the family, and preventing complications. These goals are measurable and patient-centered, guiding the nursing interventions and expected outcomes.

Goals and Expected Outcomes:

Maternal Understanding: The mother will clearly articulate an understanding of the causes, treatment options, and potential outcomes of hyperbilirubinemia. This ensures informed participation in the care process and reduces parental anxiety.
Symptom Recognition: The mother will be able to identify and verbalize the signs and symptoms in the infant that require prompt medical attention. This empowers parents to monitor their infant effectively at home and seek timely help if needed.
Competent Infant Care: The mother will demonstrate the ability to provide appropriate care for her infant, including feeding, monitoring, and recognizing signs of worsening jaundice. This ensures effective home management and promotes infant well-being.
Bilirubin Level Reduction: The neonate will achieve and maintain indirect bilirubin levels below 12 mg/dL in term infants by the third day of life. This objective laboratory value indicates successful management of hyperbilirubinemia within a critical timeframe.
Jaundice Resolution: The neonate will show visible resolution of jaundice by the end of the first week of life. This clinical sign marks the improvement and eventual recovery from hyperbilirubinemia.
Neurological Integrity: The neonate will remain free from central nervous system (CNS) involvement, particularly kernicterus, throughout the treatment and recovery period. This prevents severe neurological damage associated with high bilirubin levels.
Exchange Transfusion Success: If an exchange transfusion is necessary, the neonate will complete the procedure without complications. This ensures the safe and effective execution of a critical intervention for severe cases.
Decreasing Bilirubin Trend: The neonate will exhibit a consistent decrease in serum bilirubin levels following the initiation of treatment. This trend confirms the effectiveness of the interventions and the newborn’s positive response to therapy.
Stable Physiological Parameters: The neonate will maintain body temperature and fluid balance within normal limits. This physiological stability is crucial, especially during treatments like phototherapy, which can impact these parameters.
Skin and Tissue Integrity: The neonate will be free from skin or tissue injury throughout the course of treatment, particularly related to phototherapy or invasive procedures. This protects the newborn from iatrogenic harm.
Normal Interaction Patterns: The neonate will demonstrate expected interaction patterns and developmental behaviors appropriate for their age. This indicates overall well-being and neurological health.

These goals provide a framework for nursing care, ensuring that interventions are targeted, effective, and focused on achieving the best possible outcomes for newborns with hyperbilirubinemia and their families.

Nursing Interventions and Actions

Therapeutic interventions and nursing actions for newborns with hyperbilirubinemia (jaundice) are multifaceted, aiming to reduce bilirubin levels, prevent complications, and support the newborn and family.

1. Initiating Patient Education and Health Teachings

Neonatal jaundice is a primary cause for hospital readmission from home to neonatal units. Many newborns are readmitted with severe hyperbilirubinemia or bilirubin encephalopathy around day five, often after being discharged as healthy from their birth hospitalization. Given that bilirubin levels typically peak when newborns are at home, the responsibility for detecting severe jaundice and assessing breastfeeding success largely falls on parents and community health services (Kaplan et al., 2019).

Nursing Interventions:

Assess family situation and support systems.
- Rationale: Parents need guidance throughout the infant’s hospitalization to help them adapt to this new experience. Understanding the family’s dynamics and support systems helps tailor education and emotional support effectively. Often, mothers are concerned about their ability to care for a small and vulnerable infant. Engaging them in basic care activities like diapering, bathing, and feeding can boost their confidence and readiness. The separation of mother and infant due to hospitalization can be emotionally challenging and complicate bonding; thus, addressing these emotional aspects is crucial.
Assess client’s and family members’ knowledge and level of understanding.
- Rationale: This assessment is crucial for identifying specific educational needs and clarifying any existing misunderstandings about jaundice. Evaluating their comprehension of the diagnosis and their coping mechanisms during an extended recovery period allows for personalized support and education.
Provide parents with a detailed written explanation of home phototherapy, including technique, potential problems, and safety precautions.
- Rationale: Clear, written instructions are vital for effective home phototherapy. Studies indicate that non-specific instructions contribute to poor follow-up for jaundice (Kaplan et al., 2019). Mothers have reported that a lack of understanding about hyperbilirubinemia’s dangers was a major factor in poor adherence to follow-up appointments. It’s essential that healthcare teams thoroughly explain the necessity of early follow-up to parents before discharge.
Discuss appropriate monitoring at home, such as recording infant’s weight, feedings, intake/output, stools, temperature, and proper reporting of infant status.
- Rationale: Home phototherapy is typically recommended for full-term infants after the first 48 hours of life with bilirubin levels between 14 and 18 mg/dL, and without elevated direct bilirubin. Home therapy is increasingly favored because it prevents mother-infant separation and promotes continuous care in a familiar environment (Morrison, 2021). Educating parents on monitoring these parameters ensures they can effectively manage and report any changes in the infant’s condition.
Provide information about the types of jaundice, pathophysiological factors, and potential future implications of hyperbilirubinemia. Encourage questions and clarify information as needed.
- Rationale: Understanding the etiology of neonatal jaundice—whether physiological, pathological, or breast milk-induced—is crucial for parents. Explaining the rationale behind phototherapy and why it’s necessary helps alleviate guilt and fear. While long-term effects of phototherapy are still under study, it is generally considered safe with proper eye protection and hydration management to prevent dehydration from insensible water loss.
Discuss home management of mild to moderate physiological jaundice, including increased feedings, indirect exposure to sunlight (with frequent checks), and scheduled follow-up serum bilirubin testing.
- Rationale: Educating parents about home management strategies fosters their cooperation and competence after discharge. This information enables them to safely and appropriately manage mild jaundice and recognize the importance of each aspect of the management plan. Important Note: Direct sunlight exposure is contraindicated due to the risk of thermal injury to the infant’s sensitive skin. While current evidence suggests minimal long-term skin cancer risk from phototherapy, it is prudent for all infants, especially those who have undergone phototherapy, to use sunscreen and undergo future skin assessments to monitor for potential long-term effects.
Provide guidance on maintaining milk supply using a breast pump and re-establishing breastfeeding if jaundice necessitates interruption.
- Rationale: This support is essential for mothers who need to temporarily halt breastfeeding due to jaundice. Maintaining an adequate milk supply ensures that breastfeeding can resume smoothly once it is safe for the infant. For infants over 1500 g (3.3 lb), bottle feeding with a soft nipple and large hole may be feasible to reduce sucking effort. Mothers can also manually express breast milk for bottle feeding to ensure the preterm infant receives breast milk.
Demonstrate how to assess the infant for increasing bilirubin levels, such as blanching the skin, monitoring weight, and observing behavioral changes, especially if discharged early.
- Rationale: Equipping parents with the skills to recognize signs of worsening jaundice is crucial for early intervention. Observing skin, sclera, and mucous membranes for jaundice progression is a key nursing responsibility. Blanching the skin over bony prominences aids in better jaundice evaluation. Progression of jaundice from the face to the abdomen and feet indicates increasing bilirubin levels and should be reported.
Provide parents with a 24-hour emergency telephone number and contact person, emphasizing the importance of reporting increased jaundice.
- Rationale: This measure reduces parental anxiety and ensures they can promptly seek medical evaluation and intervention if needed. Increased awareness and quick access to medical advice can significantly decrease jaundice complications (Sardari et al., 2019).
Review the rationale for specific hospital procedures/therapeutic interventions (e.g., phototherapy, exchange transfusions) and changes in bilirubin levels, especially if the neonate remains hospitalized after the mother is discharged.
- Rationale: Keeping parents informed about the infant’s status and treatment rationale promotes informed decision-making and helps them understand the importance of the therapy. Some hospitals offer overnight rooms for parents to stay with their infants, facilitating continuous involvement. Intensive phototherapy, combined with hydration and close bilirubin monitoring, has significantly reduced the need for exchange transfusions, which are reserved for severe cases to lower indirect bilirubin and prevent heart failure in infants with severe anemia or polycythemia.
Discuss potential long-term effects of hyperbilirubinemia and the necessity for continued assessment and early intervention.
- Rationale: Kernicterus, caused by high bilirubin levels, can lead to severe, long-term neurological damage if untreated. Educating parents about these risks, including cerebral palsy, intellectual disabilities, sensory issues, speech delays, motor coordination problems, learning difficulties, dental enamel hypoplasia, and even death, underscores the importance of adherence to treatment and follow-up care.
Discuss the need for Rh immune globulin (RhIg) within 72 hours post-delivery for Rh-negative mothers with Rh-positive infants who are not previously sensitized.
- Rationale: Rh-Ig prevents maternal isoimmunization in Rh-negative mothers, thereby helping to prevent erythroblastosis fetalis in future pregnancies. Rh incompatibility is less common today because of routine RhIg administration, which halts antibody formation and prevents sensitization when given within 72 hours after delivering an Rh-positive newborn.
Arrange for follow-up serum bilirubin testing at the same laboratory facility.
- Rationale: Continuous monitoring is essential to detect rebound hyperbilirubinemia after treatment cessation. Treatment is typically stopped when bilirubin levels fall below 14 mg/dL, but levels must be rechecked within 12-24 hours to monitor for any rebound. While phototherapy effectively manages bilirubin levels, it does not address the underlying cause of jaundice, necessitating ongoing monitoring and potential further interventions like exchange transfusion if phototherapy fails.
Provide a referral for a home phototherapy program, if necessary.
- Rationale: Home phototherapy programs are suitable for newborns with mild to moderate physiological jaundice. Referral depends on the newborn’s health, bilirubin levels (usually 10-14 mg/dL), presence of jaundice, and the family’s ability to comply with the home program. Lack of support systems and education may require visiting nurses to oversee home phototherapy.
Educate parents about home phototherapy procedures.
- Rationale: Parents should be trained on using phototherapy blankets or fiberoptic pads at home. These devices allow the infant to be held, reducing eye damage risks. Provide written instructions and emphasize the importance of keeping a daily record of the infant’s temperature, weight, intake/output, stools, and feedings. Parents must also be instructed to ensure eye protection for the infant under lights and to protect the gonad area with a small diaper.

By providing comprehensive education and health teachings, nurses empower parents to actively participate in their newborn’s care, improve adherence to treatment plans, and ensure timely recognition and management of jaundice at home.

2. Promoting Safety and Preventing Injuries and Complications

Ensuring safety and preventing injuries and complications in newborns with hyperbilirubinemia is crucial. This involves meticulous implementation of safety protocols during treatments like phototherapy and exchange transfusions, as well as vigilant monitoring for potential adverse effects of elevated bilirubin levels.

Nursing Interventions:

Assess infant/maternal blood group and blood type.
- Rationale: ABO incompatibility affects a significant portion of pregnancies and is most common in mothers with type O blood. Their anti-A and anti-B antibodies can cross into fetal circulation, causing RBC agglutination and hemolysis, thereby increasing jaundice risk. Rh incompatibility also elevates this risk. Maternal antibodies cross the placenta in Rh-negative women previously sensitized by Rh-positive infants, attaching to fetal RBCs and promoting hemolysis.
Assess the infant in daylight.
- Rationale: Daylight assessment prevents distortion of the infant’s actual skin color that can occur under artificial lighting. Jaundice may not be immediately apparent at birth because maternal circulation clears rising indirect bilirubin. Post-birth, progressive jaundice within the first 24 hours indicates a hemolytic process, common 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.
- Rationale: Conditions like asphyxia and acidosis reduce bilirubin’s affinity for albumin. While some studies suggest perinatal asphyxia is negatively associated with neonatal hyperbilirubinemia due to early correction of acidosis, other research indicates birth asphyxia as a risk factor for severe jaundice (Aynalem et al., 2020). These conditions complicate bilirubin management and increase the risk of neurological damage.
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.
- Rationale: These conditions can compromise the blood-brain barrier, allowing bilirubin to dissociate from albumin and enter brain tissue, thus increasing CNS involvement risk. Higher bilirubin levels increase jaundice severity and neurological damage risk.
Observe the infant’s sclera and oral mucosa, yellowing of skin immediately after blanching, and specific body parts. Assess oral mucosa, posterior hard palate, and conjunctival sacs in dark-skinned newborns.
- Rationale: Yellow discoloration in jaundice results from unconjugated bilirubin accumulation. Jaundice typically appears first on the face and forehead (Hansen & Aslam, 2017) and is clinically evident at bilirubin levels >7–8 mg/dL in full-term infants. Note that a yellow undertone can be normal in dark-skinned infants, requiring careful differentiation.
Evaluate maternal and prenatal nutritional levels; note possible neonatal hypoproteinemia, especially in preterm infants.
- Rationale: Hypoproteinemia reduces bilirubin-binding capacity. Albumin binds with unconjugated bilirubin, and insufficient albumin increases unbound bilirubin, which can cross the blood-brain barrier. Albumin’s role in binding reduces toxicity and helps maintain acid-base balance as a plasma buffer (Gounden et al., 2021).
Note infant’s age at jaundice onset; differentiate jaundice type (physiological, breast milk–induced, or pathological).
- Rationale: Physiological jaundice usually appears on the 2nd or 3rd day of life due to the hemolysis of excess RBCs no longer needed post-birth. Breast milk jaundice appears later, between the 4th and 6th days, affecting a small percentage of breastfed infants, possibly due to breast milk components that inhibit bilirubin conjugation. Pathological jaundice appears within the first 24 hours and poses a higher risk for kernicterus.
Assess infant for progression of signs and behavioral changes.
- Rationale: Unconjugated bilirubin has an affinity for brain tissue, particularly basal ganglia. Kernicterus-related behavioral changes typically occur between the 3rd and 10th days but rarely before 36 hours. Classic signs include athetoid cerebral palsy, upward gaze paralysis, and hearing disorders, although these may represent only the most obvious symptoms (Amin et al., 2018).
Evaluate infant for pallor, edema, or hepatosplenomegaly.
- Rationale: These signs can indicate hydrops fetalis, Rh incompatibility, and in utero hemolysis. In Rh incompatibility, infants might not appear pale at birth despite RBC destruction due to compensatory red cell production in utero. Liver and spleen enlargement result from attempts to manage damaged blood cells. Severe red cell reduction can cause hypotonic blood relative to interstitial fluid, leading to fluid shift and edema. Hydrops fetalis is characterized by fluid accumulation in at least two fetal cavities.
Assess the neonate’s bilirubin blood levels regularly.
- Rationale: Frequent bilirubin measurements determine phototherapy effectiveness. Neonatal hyperbilirubinemia is common, with most newborns developing unconjugated bilirubin levels >1.8 mg/dL in the first week. Significant jaundice is defined by gestational and postnatal age, leveling at 14 mg/dL at four days in preterm and 17 mg/dL in term infants (Hansen & Aslam, 2017).
Assess infant for signs of hypoglycemia.
- Rationale: Hypoglycemia necessitates fat metabolism for energy, releasing fatty acids that compete with bilirubin for albumin binding sites. Studies show a high incidence of morbidities like jaundice and hypoglycemia in late preterm and term neonates (Salman et al., 2021). Jaundice requiring phototherapy and hypoglycemia are significant concerns in these groups.
Initiate early oral feedings within 4–6 hours post-birth, especially if breastfeeding.
- Rationale: Early feeding establishes gut flora for bilirubin reduction to urobilinogen, reduces enterohepatic bilirubin circulation, and promotes meconium passage, decreasing bilirubin reabsorption. Delayed feeding can impair intestinal motility and bacterial colonization, reducing bilirubin clearance (Aynalem et al., 2020).
Keep infant warm and dry; frequently monitor skin and core temperature.
- Rationale: Cold stress releases fatty acids, competing for albumin binding sites and increasing unbound bilirubin. A neutral thermal environment minimizes oxygen and calorie consumption to maintain normal core temperature. Preterm infants lack muscular activity and cannot shiver, making temperature regulation critical.
Apply transcutaneous jaundice meter.
- Rationale: Visual jaundice assessment is inaccurate. Guidelines recommend hyperbilirubinemia screening for newborns ≥35 weeks gestation using serum bilirubin (SB) or transcutaneous bilirubin (TcB) measurement. TcB measures subcutaneous bilirubin and correlates closely with SB, aiding in non-invasive monitoring (Maya-Enero et al., 2021).
Discontinue breastfeeding for 24–48 hours, as indicated. Assist mother with breast pumping and breastfeeding re-establishment.
- Rationale: While opinions vary, temporary breastfeeding interruption can reduce bilirubin levels. Formula feeding increases GI motility and bile pigment excretion, lowering serum bilirubin within 48 hours. Breast milk jaundice may be due to factors in some mothers’ milk that enhance bilirubin enterohepatic circulation. Beta-glucuronidase in breast milk may deconjugate bilirubin, increasing reabsorption (Hansen & Aslam, 2017).
Monitor laboratory studies as indicated.
- Rationale: Refer to Diagnostic and Laboratory Procedures section. Regular monitoring of bilirubin levels, blood counts, and other lab values is essential to assess the severity of jaundice and guide treatment.
Calculate plasma bilirubin-albumin binding capacity.
- Rationale: This calculation helps assess kernicterus risk and guide treatment, especially in preterm infants or those with hypoxia or acidosis. The ratio of total bilirubin to serum protein helps determine risk levels (Hansen & Aslam, 2017).
Initiate phototherapy per protocol, using fluorescent bulbs or a bile blanket (except for newborns with Rh disease).
- Rationale: Phototherapy photooxidizes bilirubin in subcutaneous tissue, making it water-soluble for excretion in stool and urine. Bilirubin reduction rate is therapy-dependent; exchange transfusion is for rapid reduction. Phototherapy is typically discontinued when bilirubin levels steadily decline to 14 mg/dL.
Administer enzyme induction agents (phenobarbital, ethanol) as appropriate.
- Rationale: While not routine for physiological jaundice, phenobarbital can enhance hepatic bilirubin metabolism. Studies show it effectively reduces mean serum bilirubin levels in the first week of life (Hansen & Aslam, 2017) in specific cases.
Assist with preparation and administration of exchange transfusion.
- Rationale: Exchange transfusion treats blood incompatibility by removing sensitized red cells and reducing indirect bilirubin, preventing heart failure in severe anemia or polycythemia. Type O Rh-negative blood is used to avoid maternal antibody reaction.
Note infant’s cord condition before transfusion if the umbilical vein is used. If dry, apply saline soaks for 30–60 minutes pre-procedure.
- Rationale: Soaks soften the cord and umbilical vein for easier IV access and catheter passage. Umbilical vein access is common for exchange transfusion in severe hyperbilirubinemia. However, it carries risks (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.
- Rationale: Exchange transfusions are common for Rh incompatibility. Rho(D)-positive blood increases hemolysis due to maternal antibodies. Type O Rh-negative blood is used even if the infant is Rh-positive to prevent antibody reactions.
Assess the infant’s weight before transfusion and for subsequent weight changes.
- Rationale: Lower gestation and birth weight infants are at higher risk for adverse events during transfusion (Chacham et al., 2019). Weight changes indicate fluid balance issues; weight gain may suggest fluid overload, leading to respiratory and cardiac complications.
Assess the infant for neurologic changes.
- Rationale: Irritability, twitching, convulsions, or seizures indicate neurotoxicity from jaundice. Bilirubin levels >20 mg/dL in term infants and >12 mg/dL in preterm infants pose brain damage risks from bilirubin-induced neurologic dysfunction (BIND), ranging from mild dysfunction to acute bilirubin encephalopathy (ABE).
Assess infant for excessive bleeding from the IV site post-transfusion.
- Rationale: Heparinized or citrated blood used in transfusion alters coagulation for 4–6 hours, increasing bleeding risk. Thrombocytopenia is common post-transfusion, with platelet count nadir at 24 hours and recovery by 72 hours (Chacham et al., 2019).
Monitor venous pressure, pulse, color, and respiratory rate/ease pre-, during, and post-transfusion. Suction as needed.
- Rationale: Establishes baselines, identifies instability (apnea, dysrhythmia), and maintains airway. Exchange transfusion has morbidity and mortality risks. Common adverse events include apnea, bradycardia, cyanosis, vasospasm, and hypothermia with metabolic abnormalities (Wagle & Aslam, 2017). Bradycardia can occur if calcium is infused too rapidly.
Monitor for electrolyte imbalance signs (lethargy, seizure activity, apnea, hyperreflexia, bradycardia, or diarrhea).
- Rationale: Hypocalcemia and hyperkalemia can occur during and after exchange transfusion. Hypocalcemia is a frequent adverse event due to citrate in donor blood, an anticoagulant (Chacham et al., 2019).
Assess the infant for congenital diseases like other hemolytic diseases and cardiac failure.
- Rationale: Infants with cardiac failure and edema from hemolytic disease may need immediate exchange transfusion with fresh whole blood. Hemolytic diseases can cause hypotonic blood and fluid shifts, leading to severe edema.
Maintain infant temperature pre-, during, and post-procedure. Use radiant warmer with servomechanism.
- Rationale: Radiant warmers maintain infant warmth during lengthy procedures, preventing energy expenditure for temperature regulation. This prevents vasospasm, reduces ventricular fibrillation risk, and decreases blood viscosity.
Warm blood pre-infusion using a blood warmer.
- Rationale: Donor blood should be at room temperature to prevent hypothermia. Use commercial blood warmers, not hot towels, to avoid RBC damage.
Ensure blood freshness (not more than two days old), with heparinized blood preferred.
- Rationale: Older blood is more likely to hemolyze, increasing bilirubin. Old stored blood has cytokines that increase non-hemolytic febrile transfusion reaction risk. Heparinized blood is fresh and preferred but must be used within 24 hours. It avoids citrate toxicity and allows for repeated small top-up transfusions (Ahmed & Ibrahim, 2018).
Avoid overheating blood pre-transfusion.
- Rationale: Overheating causes hemolysis and potassium release, leading to hyperkalemia. Blood should ideally be warmed to 37°C (98.6℉), but 32°C–37°C (89.6℉–98.6℉) is acceptable (Poder et al., 2015).
Ensure resuscitative equipment availability.
- Rationale: Immediate support is crucial due to potential life-threatening complications like bleeding, sepsis, arrhythmias, death, hypocalcemia, hyperkalemia, bradycardia, and thrombocytopenia (Chacham et al., 2019).
Maintain NPO status for 4 hours pre-procedure, or aspirate gastric contents.
- Rationale: NPO status and gastric aspiration reduce regurgitation and aspiration risk during the procedure (The Royal Children’s Hospital, 2004).
Document transfusion events, recording withdrawn and injected blood amounts (7–20 ml at a time).
- Rationale: Accurate documentation prevents fluid replacement errors. Exchange volume is about 170 ml/kg body weight. Double-volume exchange replaces 75%–90% of RBCs. It is labor-intensive but prevents kernicterus (Wagle & Aslam, 2017).
Administer albumin pre-transfusion if indicated.
- Rationale: Albumin administration may increase bilirubin binding capacity, reducing free serum bilirubin. However, it may invalidate plasma total bilirubin as a neurotoxicity risk indicator (Vodret et al., 2015).
Administer medications as indicated.
- Rationale: Refer to Pharmacologic Management section. Medications like sodium bicarbonate may be used to manage metabolic acidosis.
Administer antibiotics as indicated.
- Rationale: Antibiotics prevent or treat infections, especially post-transfusion at the umbilical site, indicating potential infection.
Assist with intravenous immunoglobulin (IVIG) administration as indicated.
- Rationale: IVIG reduces exchange transfusion need in hemolytic disease due to Rh or ABO incompatibility. It prevents one exchange transfusion in about 2.7 infants treated. However, it may increase necrotizing enterocolitis risk in preterm and term infants (Wagle & Aslam, 2017).
Note biliary or intestinal obstruction presence or development.
- Rationale: Phototherapy is contraindicated in these conditions because photoisomers produced cannot be excreted. Phototherapy may increase secondary intestinal obstruction risk due to mesenteric ischemia (Wang et al., 2021).
Monitor neonate’s skin and core temperature every two hours or more until stable. Regulate incubator/Isolette temperature.
- Rationale: Temperature fluctuations can occur due to light exposure. Blue phototherapy can cause body temperature alterations (Wang et al., 2021).
Note stool and urine color and frequency.
- Rationale: Frequent, greenish, loose stools and greenish urine indicate effective bilirubin breakdown and excretion from phototherapy. Differentiate photodegradation-related stools from true diarrhea.
Monitor fluid intake and output; weigh infant twice daily. Note dehydration signs (reduced urine, sunken fontanels, poor turgor, sunken eyes).
- Rationale: Dehydration can occur during phototherapy, especially in preterm infants, increasing skin moisture loss (Wang et al., 2021). Infants may sleep more during phototherapy, increasing dehydration risk if feeding schedules aren’t maintained.
Evaluate skin and urine appearance, noting brownish-black color.
- Rationale: Bronze baby syndrome, a rare side effect, may occur with conjugated bilirubin level increases, causing skin pigment changes lasting 2–4 months (Wang et al., 2021).
Note behavioral changes or deteriorating condition signs (lethargy, hypotonia, hypertonicity, extrapyramidal signs).
- Rationale: These signs may indicate bilirubin deposition in basal ganglia and kernicterus. Hypocalcemia, indicated by these changes, may occur post-phototherapy, especially in premature infants (Wang et al., 2021).
Assess for rash and petechiae.
- Rationale: Phototherapy can cause petechiae and skin rashes, usually fading post-treatment. Petechiae may be linked to light-induced thrombocytopenia, requiring platelet count monitoring. Purpuric rash and bullous eruptions may occur in cholestatic jaundice, increasing porphyrin levels (Wang et al., 2021).
Note fussiness or increased crying and irritability.
- Rationale: Phototherapy may increase crying episodes due to circadian rhythm changes.
Document fluorescent lamp type, hours since bulb replacement, and lamp-infant distance.
- Rationale: Light emission decays over time. Optimal distance is 18–20 inches (45 cm). Fiberoptic blankets allow infant wrapping in therapeutic light without corneal risk and enable holding and feeding during therapy.
Measure photon energy of bulbs (white or blue light) using a photometer.
- Rationale: Light intensity determines infant placement distance. Photometer should read 8–10 mW/cm2/nm. Blue and special blue lights are more effective but hinder cyanosis assessment. Standard phototherapy is 8–10 mW/cm2 per nm, intensive is >30 mW/cm2 per nm (Sawyer & Nimavat, 2018).
Cover male infant’s testes and penis.
- Rationale: Protect gonads from potential phototherapy light effects on reproduction and embryonic development. Studies suggest seminiferous tubule diameter thinning in rats post-phototherapy (Cetinkursun et al., 2006).
Apply patches to closed eyes; inspect eyes every two hours during feedings. Monitor placement frequently.
- Rationale: Protect retinas from light damage. Retinas absorb blue light, most effective for bilirubin degradation, but can cause retinal cell death (Wang et al., 2021). Eye shields and lubricating eye drops are recommended (Sawyer & Nimavat, 2018).
Cleanse infant’s eyes with sterile or normal saline water.
- Rationale: Prevents conjunctivitis. Clean eye secretions and surrounding skin with saline cotton balls to maintain hygiene (Wang et al., 2021).
Reposition infant every two hours.
- Rationale: Ensures even skin exposure, prevents overexposure of body parts, and minimizes pressure areas.
Wash perianal area after each stool; inspect skin for irritation or breakdown.
- Rationale: Prevents irritation from frequent, loose stools, which are often bright green due to bilirubin excretion and can irritate skin.
Encourage increased oral fluid intake.
- Rationale: Replenishes water and electrolytes lost due to phototherapy, especially with conventional phototherapy, which increases insensible water loss. LED phototherapy causes less water loss (Wang et al., 2021).
Bring infant to parents for feedings; encourage interaction during feedings and nursery visits.
- Rationale: Fosters attachment, which separation for phototherapy can delay. Sensory stimulation aids infant development. Intermittent phototherapy is effective and allows for parental interaction. Rooming-in may be possible depending on hospital policies.
Ensure chest shielding during phototherapy.
- Rationale: Chest shielding may reduce patent ductus arteriosus incidence, potentially caused by blue light penetrating the chest wall and affecting cardiovascular smooth muscle (Wang et al., 2021).

By diligently implementing these safety measures and preventive actions, nurses play a crucial role in minimizing risks and complications associated with hyperbilirubinemia and its treatment, ensuring the best possible outcomes for newborns.

3. Administer Medications and Provide Pharmacologic Support

Pharmacologic support in neonatal hyperbilirubinemia is generally limited but can be crucial in specific situations to manage underlying conditions or complications.

Medications:

Sodium Bicarbonate:
- Rationale: Sodium bicarbonate is used to correct metabolic acidosis, which can exacerbate hyperbilirubinemia by reducing bilirubin binding to albumin. It helps to maintain an optimal serum pH. Fresh CPDA-treated blood typically has a higher serum bicarbonate concentration, which gradually decreases after three days of storage.
Intravenous Fluids (Enteral or Parenteral):
- Rationale: Fluids are essential to compensate for insensible and intestinal fluid losses, especially during phototherapy. Phototherapy increases insensible water loss, particularly in premature infants, necessitating increased fluid intake. Recommendations suggest increasing maintenance fluid by 10 ml/kg/day in premature infants under conventional phototherapy (Sawyer & Nimavat, 2018). Fluids also provide necessary nutrients if oral feedings are temporarily withheld in cases of severe hyperbilirubinemia.

These pharmacologic interventions are adjunctive and used based on the specific clinical needs of the newborn, alongside primary treatments like phototherapy and exchange transfusions.

4. Monitoring Results of Diagnostic and Laboratory Procedures

Continuous monitoring of diagnostic and laboratory results is vital in managing neonatal hyperbilirubinemia. These tests help assess the severity of jaundice, identify its cause, and guide treatment decisions.

Diagnostic and Laboratory Procedures:

Direct and Indirect Bilirubin Levels:
- Rationale: Bilirubin exists in two forms: direct (conjugated) and indirect (unconjugated). Indirect bilirubin, which is either free in the blood or bound to albumin, is the form that poses a risk for kernicterus. Elevated indirect bilirubin levels are a key indicator of this risk. Significant levels are generally considered to be 18–20 mg/dL in full-term infants and 13–15 mg/dL in preterm or sick infants (Hansen & Aslam, 2017).
Total Serum Bilirubin (TSB) Level:
- Rationale: For most infants with jaundice appearing on the typical second or third day of life, without any history or physical signs of a pathological process, a TSB test is often sufficient. It provides an overall measure of bilirubin levels to assess the need for and response to treatment (Hansen & Aslam, 2017).
Direct and Indirect Coombs’ Test on Cord Blood:
- Rationale: These tests detect antibodies in the mother’s and newborn’s blood. A positive indirect Coombs test in the mother indicates antibodies (Rh-positive or anti-A, anti-B). A positive direct Coombs test in the newborn indicates sensitized RBCs (Rh-positive, anti-A, or anti-B), suggesting hemolytic disease of the newborn due to blood group incompatibility.
CO2-combining power, Reticulocyte Count, and Peripheral Smear:
- Rationale: A decreased CO2-combining power is consistent with hemolysis. Reticulocyte count increases in response to excessive hemolysis as the bone marrow produces more RBCs. A peripheral smear helps identify abnormal or immature RBCs, indicating the nature of hemolysis. Reticulocyte count helps differentiate between anemia due to inadequate RBC production versus accelerated loss or destruction (Szigeti & Staros, 2014).
Total Serum Protein or Serum Albumin Levels:
- Rationale: Low serum protein levels (below 3.0 g/dL) indicate reduced bilirubin-binding capacity, increasing the risk of kernicterus. Albumin binds bilirubin, and low albumin levels increase the amount of unbound, dangerous bilirubin. Serum albumin levels are useful in assessing toxicity risk as albumin’s primary binding site has a 1:1 ratio with bilirubin (Hansen & Aslam, 2017).
Glucose Levels:
- Rationale: Blood glucose levels should be monitored immediately post-exchange transfusion and hourly until stable (The Royal Children’s Hospital, 2004). Exchange transfusion can cause a significant rise in serum glucose due to the dextrose content in donor blood and anticoagulants. Rebound hypoglycemia may occur in the initial hours post-exchange (Wani et al., 2018), necessitating careful glucose monitoring.
Platelet and White Blood Cell (WBC) Counts:
- Rationale: Thrombocytopenia has been associated with phototherapy in some infants. A decrease in WBCs might indicate effects on peripheral lymphocytes. Studies suggest a correlation between decreased platelet count, phototherapy duration, and lower gestational age (Sarkar et al., 2021). Monitoring platelet and WBC counts helps detect potential hematologic side effects of phototherapy.

Regular monitoring of these diagnostic and laboratory parameters allows for timely adjustments in the nursing care plan, ensuring optimal management of hyperbilirubinemia and prevention of severe complications.