Nursing care of newborn with Hyperbilirubinemia
Hyperbilirubinemia is a condition in which the blirubin level
in the blood is increased. It is characterized by a yellow
discoloration of the skin, mucous membrane, sclera, and various
organs. The yellow discoloration is caused primarily by
accumulation in the skin of unconjugated blirubin, a breakdown
product of hemoglobin forming after its release from hemolysed
RBCs.
Bilirubin metabolism:
Bilirubin is one of the breakdown products of hemoglobin. When
RBCs are destroyed, the breakdown products are released into the
circulation, where the hemoglobin spits into heme and globin. The
body uses the globin (protein) and heme is converted to
unconjugated blirubin. In the liver the bilirubin is conjugated with
the glucuronyl transferase .This, conjugated bilirubin is excreted
into the bile. In the intestine, bacterial action reduces the
conjugated bilirubin into urobilinogen and stercobilinogen.
Normally the body is able to maintain a balance between the
destruction of RBCs and the use or excretion by the body. When
this balance is upset, bilirubin accumulates in the body causing
jaundice.
Causes of hyperbilirubinemia in a newborn
 Prematurity
 Breast milk
 Excess production of bilirubin(hemolytic disease, bruises)
 Enzyme deficiency, bile duct obstruction
 Sepsis
 Diseases like hypothyroidism, IDM
 Genetic predisposition
Types of hyperbilirubinemia:
Physiological jaundice
-
Pathological jaundice
Not appear before the 2nd
or 3rd day in term baby. In
premature baby, it appears
after 3rd or 4th day.
- I term newborn, it
disappears by the end of 7th
days while in premature
lasts for 9 to 10 days.
- The level of total serum
bilirubin never exceeds 12
mg/dl in fullterm newborn
and 15 mg/dl in preterm
newborn and the direct
bilirubin does not exceed 1
mg/dl of the total bilirubin.
- Daily raise of s. Bilirubin
never exceed 5 mg/dl.
-
-
No kernicterus.
-
-
Requires no treatment
Treatment is important as
soon as possible
-
The newborn is good
sucker, no anemia, not sick,
normal stool, and urine color.
Appears within the 1st day
(24 hours after birth).
-
-
Needs longer time.
Serum bilirubin
that level.
exceeds
-
Serum bilirubin exceeds the
daily raise of physiological
jaundice.
Cause
kernicterus
indirect
Hyperbilruibinemia.
-
in
The newborn looks sick,
poor sucking, pale, abnormal
stool and urine color.
Kernicterus:
It is also called the bilirubin encephalopathy and is caused
by the deposition of the unconjugated bilirubin in the brain. It
results in the yellowish staining of the brain tissue and the
necrosis of neurons and occurs if the concentration of the
unconjugated bilirubin reaches toxic level.
Stages of kernicterus:
1. Stage 1: poor Moro reflex, poor feeding, vomiting, highpitched cry, decreased tone and lethargy.
2. Stage 2: opisthotonus, seizures, fever, occulogyric crises, and
paralysis of upward gaze. Many newborns die in this phase.
3. Stage 3: spasticity is decreased at about one week of age. (a
symptomatic).
4. Stage 4:
progressive spasticity, deafness, and mental
retardation.
Management of hyperbilirubinaemia:
1. Increase feeds in volume and calories. Early feeding lowers
serum bilirubin lever by stimulating the peristalsis.
2. Stop drugs interfering with bilirubin metabolism.
3. Correct hypoxia, infection, and acidosis.
4. Phototherapy.
- Prophylactic: in LBW or bruised neonate.
- Therapeutic.
5. Exchange transfusion.
Phototherapy:
It consists of the application of fluorescent light (blue or
white) to the newborns naked skin. Light causes break down of
bilirubin by the process of photo oxidation. It alters the structure
of bilirubin to a soluble form for easier excretion.
Indications of phototherapy:
-
It is used when bilirubin level is:
5-9 mg/dl at the 1st day of life.
9-15 mg/dl at the 2nd day of life.
15-20 mg/dl at the 3rd day of life.
Side effects of phototherapy:
1.
2.
3.
4.
5.
6.
7.
8.
Dehydration due to increased insensible water loss.
Watery diarrhea.
Hypocalcemia.
Retinal damage.
Erythema and skin rashs.
Bronze baby syndrome.
maternal newborn interaction is affected.
Dark yellow urine.
Nurse’s responsibility in phototherapy:
1.
2.
3.
4.
The lamp should be 5-8 cm over the incubator.
Continue the feeding.
Shield the newborn’s eyes.
Keep newborn naked except for the diaper area and change
position frequently.
5. Cleanse skin frequently to prevent irritation.
6. Maintain adequate fluid intake to prevent dehydration and
calculate intake and output.
7. Check newborn’s body temperature every four hours.
8. Weight newborn daily.
9. Observe skin, mucous membranes, and stool.
10.
Bilirubin levels should be followed for at least 24 hours
after discontinuing phototherapy.
Exchange transfusion:
It is an ideal dilution of s. Bilirubin and antibodies. A
catheter is introduced into the umbilical vein after cutting the
cord. Through a special valve, the umbilical catheter is connected
with the donor blood. Exchange is carried out over 45-60 min
period by alternating aspiration of 20 ml of newborn’s blood and
infusions of 20 ml of the donor blood. .
Complications:
1.
2.
3.
4.
Embolism, thrombosis, infarction.
Arrhythmias, heart failure, arrest.
Electrolyte disturbances.
Thromobocytopenia.
5. Infections
6. Hypo and hyperthermia.
Nursing responsibilities:
1. Keep the newborn npo for 2-4 hours before exchange to
prevent aspiration.
2. Check donor blood carts compatibility.
3. Keep resuscitation equipment at bedside: oxygen, ambo bag,
endotracheal tubes, and laryngoscope.
4. Assist physician with exchange transfusion procedure.
5. Track amount of blood withdrawn and transfused to
maintain balanced blood volume.
6. Maintain body temperature to avoid hypothermia and cold
stress.
7. Monitor vital signs and observe for rash.
8. After transfusion, continue to monitor vital signs and check
umbilical cord for bleeding or signs of infection.
NURSING CARE PLAN
The Newborn with Hyperbilirubinemia
NURSING DIAGNOSIS: Risk for injury from breakdown products
of red blood cells in greater numbers than normal and functional
immaturity of liver
Patient Goal 1: Will receive appropriate therapy if needed to
accelerate bilirubin excretion
• Nursing Interventions/Rationales
Initiate early feedings to enhance excretion of bilirubin in the stool
Assess skin for evidence of jaundice, which indicates rising
bilirubin levels
Check bilirubin levels with transcutaneous bilirubinometry to
determine rising levels
Note time of initial jaundice to distinguish physiologic jaundice
(appears after 24 hours) from jaundice due to hemolytic disease or
other causes (appears before 24 hours)
Assess infant's overall status, especially factors (e.g., hypoxia,
hypothermia, hypoglycemia, and metabolic acidosis) that increase
the risk of brain damage from hyperbilirubinemia
Initiate phototherapy as prescribed
• Expected Outcomes
Newborn begins feeding soon after birth
Newborn is exposed to prescribed light source
Patient Goal
phototherapy
2:
Will
experience
no
complications
from
• Nursing Interventions/Rationales
Shield infant's eyes
Make certain that lids are closed before applying shield to prevent
corneal irritation
Check eyes each shift for drainage or irritation
Place infant nude under light for maximum skin exposure
Change position frequently, especially during the first several
hours of treatment, to increase body surface exposure
Monitor body temperature to detect hypothermia or hyperthermia
Check axillary temperature
Chart duration of therapy, type of lights, distance of lights from
infant, use of open or closed bassinet, and shielding of infant's
eyes to document correct use of phototherapy
With increased stooling, cleanse skin frequently to prevent
perianal irritation
Avoid use of oily applications on skin to prevent tanning and
burning
Ensure adequate fluid intake to prevent dehydration
• Expected Outcome
Infant displays no evidence of eye irritation, dehydration,
temperature instability, or skin breakdown
Patient Goal 3: Will experience no complications from exchange
transfusion (if therapy required)
• Nursing Interventions/Rationales
Give infant nothing by mouth before procedure (usually for 2 to 4
hours) to prevent aspiration
Check donor blood for correct blood group and Rh type to prevent
transfusion reaction
Assist practitioner during procedure; ensure asepsis to prevent
infection
Keep accurate records of amounts of blood infused and withdrawn
to maintain proper blood volume
Maintain optimum body temperature of infant during procedure to
prevent hypothermia and cold stress or hyperthermia
Observe for signs of exchange transfusion reaction (tachycardia or
bradycardia, respiratory distress, dramatic change in blood
pressure, temperature instability, and rash) to initiate therapy
promptly
Have resuscitation equipment (supplemental oxygen, airway,
manual resuscitation bag, endotracheal tube, and laryngoscope) at
bedside to be prepared for an emergency
Check umbilical site for bleeding or infection
Monitor vital signs during and following transfusions to detect
complications such as cardiac dysrhythmias
• Expected Outcomes
Infant exhibits no signs of adverse effects from exchange
transfusion
Vital signs remain within normal limits (see inside back cover for
normal variations)
There is no evidence of infection or bleeding at infusion site
NURSING CARE PLAN
The Newborn with Hyperbilirubinemia
NURSING DIAGNOSIS: Altered family processes related to
maturational crisis, birth of term infant, change in family unit
Patient (Family) Goal 1: Will exhibit parent-infant attachment
behaviors
• Nursing Interventions/Rationales
As soon after delivery as possible, encourage parents to see and
hold infant; place newborn close to face of parents to establish
visual contact
Ideally, perform eye care after initial meeting of infant and
parents, within 1 hour after birth when infant is alert and most
likely to visually relate to parent
Identify for parents specific behaviors manifested by infant (e.g.,
alertness, ability to see, vigorous suck, rooting behavior, and
attention to human voice)
Discuss with parents their expectations of fantasy child vs real
child if indicated
Identify behavioral steps in attachment process, and evaluate
those aspects that could be considered positive and those that may
represent inadequate or delayed parenting
Encourage family to room-in or to call for infant frequently if not
rooming-in
Observe and assess reciprocity of cues between infant and parent
to identify behaviors that may need strengthening
Assist parents in recognizing attention-nonattention cycles and in
understanding their significance
Assess variables affecting development of attachment through
observing infant and parent and interviewing each parent or other
significant caregiver
• Expected Outcomes
Parents establish contact with infant immediately or soon after
birth
Parents demonstrate attachment behaviors, such as touch, eye
contact, naming and calling infant by name, talking to infant,
participating in caregiving activities
Parents recognize attention-nonattention cycles
Patient (sibling) Goal 2: Will demonstrate adjustment/attachment
behaviors toward newborn
• Nursing Interventions/Rationales
Allow to visit and touch newborn when feasible
Explain physical differences in newborn, such as bald head,
umbilical stump and clamp, circumcision, to lessen any fear
siblings might have
Explain to siblings realistic expectations regarding newborn's
abilities and needs
Requires complete care
Is not a playmate
Encourage siblings to participate in care at home to make them
feel part of the experience
Encourage parents to spend individual time with other children at
home to reduce feelings of jealousy toward new sibling
• Expected Outcome
Siblings express interest in newborn and realistic expectations for
their age
Patient (family) Goal 3: Will be prepared for discharge and home
care
• Nursing Interventions/Rationales
Discuss with parents correct preparation of formula
Stress that proportions must not be altered to dilute or
concentrate the formula
Discourage microwaving of bottles to avoid burns
Encourage use of support persons for assistance with breastfeeding
Instruct in other aspects of newborn care
Bathing
Umbilical cord and circumcision care
Recognize states of activity for optimum interaction
Encourage participation in parenting classes, if offered
Discuss importance and proper use of federally approved car seat
restraints
If infant is small, advise parents to use rolled blankets and towels
in crotch area to prevent slouch and along sides to minimize
lateral movement, but never use padding underneath or behind
infant, since it creates slackness in harness, leading to possible
ejection from seat in a crash
parent-infant attachment is at risk, refer to appropriate agencies
(social services, family and child services, at-risk programs)
• Expected Outcomes
Family demonstrates ability to provide care for infant
Family keeps appointments for follow-up care
Family members avail themselves of needed services