Last updated on February 11th, 2023 at 08:47 pm
Jaundice Nursing Care Plans Diagnosis and Interventions
Jaundice NCLEX Review and Nursing Care Plans
The hepatobiliary system is composed of the liver, gall bladder and the corresponding bile ducts. The primary function of this system is the production of bile, a type of digestive enzyme utilized in the digestion of fat.
Jaundice is a medical condition where there is an excess of bile in the circulatory system, producing unwanted effects such as yellowing of the eyes or icteric sclera. Patients of all ages can develop jaundice and causes will depend on various factors.
Signs and Symptoms of Jaundice
Adult Jaundice
The clinical manifestations of jaundice in Adults are as follows:
- Fever, chills, flu-like symptoms – if it is caused by an infection
- Abdominal pain – when usually caused by cancers
- Changes in skin color and sclera, i.e. yellowish in color
- Dark-colored urine and/or clay-colored stool
- Skin itchiness
Infant Jaundice
In infants, the clinical manifestations are as follows:
- Physiological jaundice – yellowing of the skin and the sclera – usually appears between the 2nd and 4th day after birth. This is usually due to the infant’s immature liver.
- Pathologic jaundice – yellowing of the skin that occurs within 24 hours from birth. Other signs of pathologic jaundice are:
- Skin turns more yellow
- Difficult to awaken, changes in sensorium
- Poor feeding
Causes and Risk factors of Jaundice
Adult Jaundice
In adults, the causes and risk factors of jaundice depend on which phase of bilirubin production and are as follows:
- Before bilirubin production (Unconjugated jaundice)
- Reabsorption of a large hematoma or a clotted blood under the skin
- Hemolytic anemia
- During bilirubin production
- Viruses – such as Hepatitis B infection
- Alcohol abuse
- Autoimmune disorders
- Rare genetic metabolic defects
- Medications – such as acetaminophen toxicity
- After bilirubin production (usually due to blockage)
- Gallstones
- Swelling of the gallbladder
- Gallbladder cancer
- Pancreatic tumor
Infant Jaundice
The causes of infant jaundice are the following:
- Physiology. Newborns produce bilirubin faster compared to adults. The breakdown of red blood cells is also quicker in newborns. Because of the immaturity of their liver, excess bilirubin spills into the bloodstream, causing the classic signs of jaundice.
- Pathology. Jaundice observed within 24 hours from birth signifies a pathologic origin and may be due to:
- Hemorrhage
- Infant sepsis
- ABO or Rh incompatibility between the mother and infant
- Liver abnormalities or malfunction, such as biliary atresia
- Enzyme deficiency
- Abnormalities in the infants red blood cells
The risk factors of neonatal jaundice are:
- Prematurity
- Significant bruising during birth
- Difference in the blood type# of the neonate and the mother
- Difficulties of the neonate to breastfeed
- East Asian ancestry
Complications of Jaundice
The complications of jaundice can be due to the following:
- Adult Jaundice
- Constipation and/or diarrhea
- Stomach pain
- Vomiting
- Bloatedness or feeling of fullness
- Infant Jaundice
- Acute bilirubin encephalopathy – bilirubin is toxic to the brain. When it crosses the blood-brain barrier, it will cause acute bilirubin encephalopathy as manifested by:
- Difficulty waking
- High-pitched crying
- Fever
- Poor feeding
- Acute bilirubin encephalopathy – bilirubin is toxic to the brain. When it crosses the blood-brain barrier, it will cause acute bilirubin encephalopathy as manifested by:
- Kernicterus – a syndrome indicating permanent damage to the brain. This is characterized by:
- Athetoid cerebral palsy – characterized by involuntary and uncoordinated movements
- Permanent upward gaze
- Hearing loss
- Poor tooth enamel development
Diagnosis of Jaundice
Diagnosing jaundice involves the following:
- Physical exam – this involves assessing for unusual bruising, abnormal collection of blood vessels under the skin (spider angiomas), red discoloration of the palms (palmar erythema) and palpation of the liver for signs of tenderness.
- Laboratory studies
- Urinalysis – testing urine samples will allow for the assessment of conjugated jaundice.
- Complete blood count (CBC) – to assess for signs of infections that may cause jaundice.
- Serum bilirubin levels – to assess for the baseline levels of bilirubin in the blood.
- Imaging studies
- Ultrasonography – to assess for the size of the liver and its surrounding structures
- CT scan – to assess for the presence of mass in the liver, gallbladder, and bile ducts.
- Liver biopsy – to confirm any suspicion of liver cancer.
- Transcutaneous bilirubinometer – includes a skin test that utilizes this device that measures the reflection of a special light through the skin.
Treatment for Jaundice
Adult Jaundice
The treatment for jaundice for adults will depend on the cause of the jaundice.
- Surgery. If the cause of jaundice is blockage due to stones in the gallbladder (cholelithiasis), surgical removal of the stones or gallbladder will be done
- Antibiotics and peritoneal dialysis. In instances where infection is the cause of jaundice (such as leptospirosis), antibiotics will be prescribed, and peritoneal dialysis will be done to correct the condition.
Infant Jaundice
The treatment plan for neonatal jaundice includes the following:
- Monitoring. For mild jaundice, the condition may subside within two to three weeks.
- Admission. For moderate to severe jaundice, a longer hospitalization stay will be warranted. The treatment options include:
- Enhanced nutrition – to supplement the nutritional needs of the infant.
- Light therapy – also known as phototherapy, light therapy helps by changing the structure of the excess bilirubin in the patient’s skin to allow for its excretion through the urine and stool.
- Intravenous immunoglobulin (IV Ig) – in instances of ABO and Rh incompatibility, administration of IV Ig is beneficial to reduce the serum levels of the antibodies in the blood of the infant.
- Exchange transfusion – in rare cases wherein the above procedures are unsuccessful, the infant’s blood is withdrawn repeatedly and replaced with a donor’s blood to remove the excess bilirubin.
Nursing Diagnosis for Jaundice
Jaundice Nursing Care Plan 1
Nursing Diagnosis: Hyperthermia related to infection and excessive bile in the blood secondary to adult jaundice as evidenced by temperature of 39 degrees Celsius, rapid and shallow breathing, flushed skin, profuse sweating, and weak pulse.
Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range.
| Nursing Interventions for Jaundice | Rationales |
| Assess the patient’s vital signs at least every 4 hours. | To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs administered. |
| Remove excessive clothing, blankets, and linens. Adjust the room temperature. | To regulate the temperature of the environment and make it more comfortable for the patient. |
| Administer the prescribed antibiotic and anti-pyretic medications. | Use the antibiotic to treat bacterial infection, which is the underlying cause of the patient’s jaundice and hyperthermia. Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature. |
| Offer a tepid sponge bath. | To facilitate the body in cooling down and to provide comfort. |
| Elevate the head of the bed. | Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively. |
Jaundice Nursing Care Plan 2
Nursing Diagnosis: Fatigue related to elevated serum bilirubin levels resulting to adult jaundice, as evidenced by overwhelming lack of energy, verbalization of tiredness, generalized weakness, and shortness of breath upon exertion
Desired Outcome: The adult patient will demonstrate active participation in necessary and desired activities and demonstrate increase in activity levels.
| Nursing Interventions for Jaundice | Rationales |
| Assess the patient’s degree of fatigability by asking to rate his/her fatigue level (mild, moderate, or severe). Explore activities of daily living, as well as actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try. | To create a baseline of activity levels, degree of fatigability, and mental status related to fatigue and activity intolerance. |
| Encourage progressive activity through self-care and exercise as tolerated. Explain the need to reduce sedentary activities such as watching television and using social media in long periods. Alternate periods of physical activity with rest and sleep. | To gradually increase the patient’s tolerance to physical activity. |
| Teach deep breathing exercises and relaxation techniques. Provide adequate ventilation in the room. | To allow the patient to relax while at rest. To allow enough oxygenation in the room. |
| Refer the patient to physiotherapy / occupational therapy team as required. | To provide a more specialized care for the patient in terms of helping him/her build confidence in increasing daily physical activity. |
Jaundice Nursing Care Plan 3
Nursing Diagnosis: Deficient Knowledge related to infant jaundice as evidenced by patient’s mother’s verbalization of “I want to know more about how I can take care of my baby.”
Desired Outcome: At the end of the health teaching session, the patient’s mother will be able to demonstrate sufficient knowledge of infant jaundice and its management.
| Nursing Interventions for Jaundice | Rationales |
| Assess the patient’s readiness to learn, misconceptions and blocks to learning. | To address the patient’s cognition and mental status towards the new diagnosis and to help the patient overcome blocks to learning. |
| Explain what jaundice is, the two main types/ causes of infant jaundice (physiologic and pathologic) and how it affects the vital organs such as the liver. Avoid using medical jargons and explain in layman’s terms. | To provide information on infant jaundice and its pathophysiology in the simplest way possible. |
| Inform the caregiver the details about the prescribed medications (e.g. drug class, use, benefits, side effects, and risks) to treat jaundice. | To inform the patient of each prescribed drug and to ensure that the patient fully understands the purpose, possible side effects, adverse events, and administration details. |
| Explain to the newborn’s mother what phototherapy is. | Phototherapy is a treatment wherein a baby is placed under a special blue spectrum light to reduce the bilirubin levels, while keeping the eyes protected. The nursing team may use a fiber optic blanket and place it under the baby if advised by the physician. |
| Educate the mother about the need for exchange transfusion for the baby before getting her consent. | Exchange transfusion may also be prescribed in babies with extremely high bilirubin levels. |
| Explain the reason behind the need for IV Ig administration if this is prescribed. | In instances of ABO and Rh incompatibility, administration of IV Ig is beneficial to reduce the serum levels of the antibodies in the blood of the infant. |
Other possible nursing diagnoses:
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
Disclaimer:
Please follow your facilities guidelines and policies and procedures.
The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.
This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.
Information is helpful