Hyperbilirubinemia Nursing Diagnosis & Care Plan

Hyperbilirubinemia is a condition characterized by elevated levels of bilirubin in the blood. This nursing diagnosis is crucial for healthcare providers to understand as it can lead to serious complications, particularly in newborns, if not properly managed.

This lesson plan will provide a comprehensive overview of hyperbilirubinemia, including its causes, signs and symptoms, expected outcomes, nursing assessment, interventions, and detailed care plans.

Causes (Related to)

Hyperbilirubinemia can result from various conditions that affect the production, metabolism, or excretion of bilirubin. Common causes include:

• Increased bilirubin production
• Decreased bilirubin conjugation or excretion
• Impaired bilirubin elimination
• Physiological jaundice in newborns
• Breastfeeding jaundice or breast milk jaundice
• Blood type incompatibility between mother and baby (ABO or Rh factor)
• Certain medications affecting bilirubin metabolism
• Genetic disorders affecting bilirubin processing

Signs and Symptoms (As evidenced by)

Hyperbilirubinemia can manifest with various signs and symptoms. During a physical assessment, a patient with hyperbilirubinemia may present with one or more of the following:

Subjective: (Patient reports)

• Fatigue
• Itching (pruritus)
• Abdominal discomfort
• Dark urine

Objective: (Nurse assesses)

• Yellowing of the skin (jaundice)
• Yellowing of the sclera (icterus)
• Pale stools
• Enlarged liver (hepatomegaly)
• Elevated bilirubin levels in blood tests
• Altered liver function tests

In newborns, additional signs may include:

• Poor feeding
• Lethargy
• High-pitched crying
• Hypotonia (decreased muscle tone)

Expected Outcomes

The following are common nursing care planning goals and expected outcomes for hyperbilirubinemia:

• The patient will demonstrate decreasing bilirubin levels within the normal range.
• The patient will show improved skin color and reduced yellowing of the sclera.
• The patient (or caregiver) will verbalize understanding of the condition and its management.
• Newborn will demonstrate adequate feeding and hydration status.
• The patient will maintain neurological status within normal limits.
• The patient will report relief from pruritus (if present).
• The patient will have no signs of complications related to hyperbilirubinemia.

Nursing Assessment

The first step in nursing care is a thorough assessment. The following section covers subjective and objective data related to hyperbilirubinemia.

1. Obtain a detailed history:
   Gather information about risk factors, onset of symptoms, and any associated conditions. For newborns, include maternal history and delivery details.
2. Perform a physical examination:
   Assess for jaundice using Kramer’s rule (progression of jaundice from head to toe). Check the sclera, gums, and palms for yellowing in darker-skinned individuals.
3. Monitor vital signs:
   Pay particular attention to temperature, as hypothermia can exacerbate jaundice in newborns.
4. Assess neurological status:
   In severe cases, look for signs of kernicterus, including lethargy, poor feeding, a high-pitched cry, and abnormal muscle tone.
5. Evaluate feeding patterns:
   In newborns, assess the frequency and duration of feedings, urine output and stool characteristics.
6. Check skin integrity:
   Assess for signs of scratching in patients experiencing pruritus.
7. Review laboratory results:
   Monitor total and direct bilirubin levels, complete blood count, liver function tests, and blood type (for newborns and mothers).
8. Prepare for diagnostic tests:
   These may include transcutaneous bilirubinometry, liver ultrasound, or other imaging studies as ordered.

Nursing Interventions

Proper nursing interventions are crucial for managing hyperbilirubinemia effectively. Here are interventions:

1. Administer phototherapy as ordered:
   Ensure proper positioning, eye protection, and temperature regulation during phototherapy sessions.
2. Monitor bilirubin levels:
   Regularly check bilirubin levels as per facility protocol or physician’s orders.
3. Promote adequate hydration:
   Encourage frequent newborn feedings or fluid intake for older patients to help eliminate bilirubin through urine and stools.
4. Provide skin care:
   Apply emollients for patients experiencing pruritus and educate them about avoiding scratching.
5. Assist with exchange transfusion if needed:
   Prepare the patient and assist the physician during the procedure if severe hyperbilirubinemia requires an exchange transfusion.
6. Educate patients and caregivers:
   Provide information about the condition, treatment options, and signs of worsening symptoms.
7. Monitor for signs of kernicterus:
   In newborns with severe hyperbilirubinemia, closely observe for neurological changes indicating bilirubin encephalopathy.
8. Promote breastfeeding:
   Support and encourage breastfeeding mothers, as breast milk can help in bilirubin excretion.
9. Administer medications as prescribed:
   This may include phenobarbital or other medications to enhance bilirubin conjugation and excretion.
10. Ensure proper nutrition:
    Collaborate with a dietitian to ensure adequate nutrition, especially in cases of prolonged jaundice.

Nursing Care Plans

The following nursing care plans address various aspects of hyperbilirubinemia management:

Care Plan 1: Risk for Impaired Skin Integrity

Nursing Diagnosis: Risk for Impaired Skin Integrity related to elevated bilirubin levels and potential for pruritus.

Related factors/causes:

• Hyperbilirubinemia
• Pruritus associated with elevated bilirubin levels
• Potential for scratching due to itching

Nursing Interventions and Rationales:

1. Assess skin integrity daily.
   Rationale: Early detection of skin breakdown allows for prompt intervention.
2. Teach the patient/caregiver about gentle skin care techniques.
   Rationale: Proper skin care can prevent complications and relieve discomfort.
3. Apply emollients as prescribed.
   Rationale: Moisturizers can help relieve itching and protect skin integrity.
4. Educate about avoiding scratching and alternative methods for itch relief (e.g., cool compresses).
   Rationale: Reduces the risk of skin damage from scratching.
5. Monitor for signs of infection at any areas of skin breakdown.
   Rationale: Early detection of infection allows for prompt treatment.

Desired Outcomes:

• The patient will maintain intact skin without evidence of breakdown.
• The patient will demonstrate an understanding of skin care techniques.
• The patient will report a decreased itching sensation.

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Care Plan 2: Ineffective Feeding Pattern

Nursing Diagnosis: Ineffective Feeding Pattern related to lethargy and poor sucking reflex secondary to hyperbilirubinemia in newborns.

Related factors/causes:

• Neurological effects of elevated bilirubin levels
• Fatigue and lethargy associated with hyperbilirubinemia
• Interruptions in feeding due to phototherapy

Nursing Interventions and Rationales:

1. Assess feeding patterns, including frequency, duration, and effectiveness.
   Rationale: Identifies potential feeding issues early for intervention.
2. Encourage frequent, small feedings.
   Rationale: Promotes adequate nutrition and hydration, which aids in bilirubin excretion.
3. Teach proper positioning and latching techniques for breastfeeding.
   Rationale: Improves feeding effectiveness and reduces maternal nipple trauma.
4. Monitor weight and hydration status daily.
   Rationale: Helps evaluate the effectiveness of feeding interventions.
5. Collaborate with a lactation consultant if breastfeeding difficulties persist.
   Rationale: Provides specialized support to improve feeding outcomes.

Desired Outcomes:

• Newborn will demonstrate improved feeding patterns with adequate intake.
• Newborn will show steady weight gain.
• The mother will verbalize confidence in feeding techniques.

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Care Plan 3: Risk for Impaired Neurological Function

Nursing Diagnosis: Risk for Impaired Neurological Function related to potential bilirubin encephalopathy (kernicterus) in severe hyperbilirubinemia.

Related factors/causes:

• Extremely elevated bilirubin levels
• Delayed or inadequate treatment of hyperbilirubinemia
• Prematurity or other risk factors for kernicterus

Nursing Interventions and Rationales:

1. Monitor neurological status frequently, including level of consciousness, cry, and muscle tone.
   Rationale: Early detection of neurological changes allows for immediate intervention.
2. Ensure timely administration of phototherapy or preparation for exchange transfusion as ordered.
   Rationale: Prompt treatment reduces the risk of bilirubin encephalopathy.
3. Educate parents about signs of neurological deterioration to report immediately.
   Rationale: Empower parents to participate in monitoring and early detection of complications.
4. Maintain a quiet, low-stimulation environment.
   Rationale: Reduces stress and energy expenditure in the vulnerable newborn.
5. Document and report any signs of neurological changes promptly.
   Rationale: Facilitates rapid medical intervention if needed.

Desired Outcomes:

• The patient will maintain stable neurological status without signs of encephalopathy.
• Parents will demonstrate an understanding of signs to monitor and report.
• The patient will receive timely and appropriate treatment to prevent neurological complications.

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Care Plan 4: Deficient Knowledge

Nursing Diagnosis: Deficient Knowledge related to hyperbilirubinemia management and home care instructions.

Related factors/causes:

• Lack of exposure to information about hyperbilirubinemia
• Anxiety and stress related to the diagnosis
• Complexity of home care instructions, especially for phototherapy

Nursing Interventions and Rationales:

1. Assess the patient’s/caregiver’s current understanding of hyperbilirubinemia.
   Rationale: Identifies knowledge gaps to guide education.
2. Provide concise information about the condition, its causes, and treatment options.
   Rationale: Increases understanding and promotes informed decision-making.
3. Demonstrate proper techniques for home phototherapy if prescribed.
   Rationale: Ensures safe and effective treatment continuation at home.
4. Teach signs and symptoms that require immediate medical attention.
   Rationale: Promotes early recognition of complications and timely intervention.
5. Provide written materials and reliable resources for further information.
   Rationale: Reinforces verbal instructions and provides ongoing reference.

Desired Outcomes:

• The patient/caregiver will verbalize understanding of hyperbilirubinemia and its management.
• The patient/caregiver will demonstrate proper techniques for home care, if applicable.
• The patient/caregiver will identify signs and symptoms requiring medical attention.

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Care Plan 5: Anxiety

Nursing Diagnosis: Anxiety related to diagnosis of hyperbilirubinemia and concerns about potential complications.

Related factors/causes:

• Uncertainty about the prognosis
• Fear of potential long-term effects on the newborn
• Stress related to hospitalization and treatment procedures

Nursing Interventions and Rationales:

1. Assess the level of anxiety and specific concerns of the patient/family.
   Rationale: Identifies areas needing focused intervention and support.
2. Provide clear, honest information about the condition, treatment, and expected outcomes.
   Rationale: Reduces fear of the unknown and promotes realistic expectations.
3. Encourage expression of feelings and concerns.
   Rationale: Allows for emotional ventilation and helps in addressing specific anxieties.
4. Teach relaxation techniques to manage stress.
   Rationale: Provides coping mechanisms for anxiety reduction.
5. Facilitate bonding between parents and newborns within treatment constraints.
   Rationale: Promotes parental confidence and reduces anxiety related to separation.

Desired Outcomes:

• The patient/family will report decreased anxiety levels.
• The patient/family will demonstrate the use of effective coping strategies.
• The patient/family will verbalize a realistic understanding of the condition and its management.

Conclusion

Effective management of hyperbilirubinemia requires a comprehensive nursing approach that addresses not only the physiological aspects of the condition but also the educational and emotional needs of patients and their families.

References

1. American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. (2004). Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics, 114(1), 297-316.
2. Maisels, M. J., & McDonagh, A. F. (2008). Phototherapy for neonatal jaundice. New England Journal of Medicine, 358(9), 920-928.
3. Watchko, J. F., & Tiribelli, C. (2013). Bilirubin-induced neurologic damage—mechanisms and management approaches. New England Journal of Medicine, 369(21), 2021-2030.
4. Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). NANDA International Nursing Diagnoses: Definitions & Classification 2018-2020. Thieme.
5. Wong, D. L., Hockenberry, M. J., & Wilson, D. (2019). Wong’s Nursing Care of Infants and Children. Elsevier Health Sciences.
6. Lissauer, T., Fanaroff, A. A., Miall, L., & Fanaroff, J. (2015). Neonatology at a Glance. John Wiley & Sons.
7. Bhutani, V. K., & Johnson, L. (2009). Kernicterus in the 21st century: frequently asked questions. Journal of Perinatology, 29(1), S20-S24.
8. Ives, N. K. (2015). Management of neonatal jaundice. Paediatrics and Child Health, 25(6), 276-281.
9. Muchowski, K. E. (2014). Evaluation and treatment of neonatal hyperbilirubinemia. American Family Physician, 89(11), 873-878.
10. Kaplan, M., Bromiker, R., & Hammerman, C. (2014). Severe neonatal hyperbilirubinemia and kernicterus: are these still problems in the third millennium? Neonatology, 106(2), 131-141.