Jaundice is yellowing of the skin, the whites of the eyes, and the mucous membranes caused by too much bilirubin in the blood. It is a sign, not a disease: the cause is either too much red blood cell breakdown, a liver that cannot process bilirubin, or a blocked bile duct. The nursing diagnoses used most often are Impaired Comfort, Acute Pain, Risk for Bleeding, and Risk for Infection. Nursing care centers on finding the pattern, relieving itching and pain, watching clotting and mental status, catching cholangitis early, and preparing the patient for tests such as ERCP.
At a glance
- What it is
- A yellow color from bilirubin building up in the blood and tissues. Also called icterus. It is usually seen first in the sclera.
- Main causes
- Hemolysis (before the liver), hepatitis, cirrhosis, alcohol or drug injury (in the liver), and gallstones in the common bile duct, strictures, or tumors of the pancreas or bile ducts (after the liver).
- Key signs
- Yellow sclera and skin, dark tea-colored urine, pale or clay-colored stools, itching, right upper quadrant pain, fatigue, and poor appetite. Bruising points to poor clotting.
- Nursing focus
- Assess color in natural light, track bilirubin, liver tests, and INR, relieve itching and protect the skin, use bleeding precautions, watch mental status, and prepare for imaging and ERCP.
- Act now
- Fever or chills with right upper quadrant pain and jaundice can be acute cholangitis. Report it at once, especially with low blood pressure or confusion. Report new confusion or drowsiness, vomiting blood, black stools, or a sudden rise in INR.
Pathophysiology of jaundice
When old red blood cells break down, heme is turned into unconjugated (indirect) bilirubin. It does not dissolve in water, so it travels in the blood bound to albumin and cannot pass into urine. The liver takes it up and joins it to glucuronic acid, making conjugated (direct) bilirubin, which dissolves in water and leaves the liver in bile. In the gut, bacteria turn it into urobilinogen and stercobilin, which give stool its brown color.
Jaundice appears when this chain is overloaded or broken. Too much hemolysis floods the liver with unconjugated bilirubin. Liver cell injury slows both uptake and conjugation, so both types can rise. A blocked bile duct (cholestasis) backs conjugated bilirubin up into the blood. Because conjugated bilirubin dissolves in water, it spills into the urine and turns it dark, while stools turn pale because no bile reaches the gut. Bile salts that build up in the skin are one cause of the intense itching of cholestasis. Bile is also needed to absorb fat and vitamins A, D, E, and K, so long-standing obstruction can lower vitamin K and raise the INR.
Jaundice is usually visible once total bilirubin is above about 2.5 to 3 mg/dL. The upper limit of normal is about 1.2 mg/dL in many labs, so always read the reference range on your own lab report.
The three patterns
| Type | Common causes | Typical pattern |
|---|---|---|
| Prehepatic (hemolytic) | Hemolytic anemia, sickle cell crisis, G6PD deficiency, transfusion reaction, malaria | Mostly unconjugated bilirubin. Urine not darkened by bilirubin, stool color normal. Anemia, high LDH, low haptoglobin. |
| Hepatic (hepatocellular) | Viral or alcoholic hepatitis, cirrhosis, drug injury such as acetaminophen overdose, Gilbert syndrome | Mixed bilirubin. ALT and AST high out of proportion to alkaline phosphatase. INR and albumin show how well the liver is making proteins. |
| Posthepatic (obstructive) | Gallstones in the common bile duct, strictures, pancreatic or bile duct cancer, primary sclerosing cholangitis | Mostly conjugated bilirubin. Dark urine, pale stools, itching. Alkaline phosphatase and GGT high. Dilated ducts on ultrasound. |
These are typical patterns, not rules. Many patients have more than one process, and the provider uses the full history, labs, and imaging to decide the cause.
Nursing assessment
Subjective data
- When the yellow color, dark urine, or pale stools started
- Itching: where, how severe, worse at night, and effect on sleep
- Abdominal pain: location, timing with meals, radiation to the back or right shoulder
- Fever, chills, nausea, vomiting, appetite, and weight loss
- Alcohol use, all medicines including acetaminophen, herbal and dietary supplements
- Hepatitis risk: travel, injection drug use, transfusions, sexual exposures, vaccination history
- History of gallstones, liver disease, sickle cell disease, or recent surgery on the bile ducts
- Easy bruising, nosebleeds, bleeding gums, or black stools
- Changes in memory, sleep, or mood noticed by the patient or family
Objective data
- Color of sclera, skin, palate, and mucous membranes in natural light; on darker skin, check the sclera, palms, soles, and under the tongue
- Scratch marks, broken skin, and signs of skin infection
- Temperature, heart rate, blood pressure, and respiratory rate, with trends
- Abdominal tenderness, liver size, ascites, and abdominal girth if ordered
- Urine and stool color; stool test for blood if ordered
- Bruising, petechiae, and bleeding at IV and puncture sites
- Level of consciousness, orientation, and asterixis (flapping tremor)
- Labs as ordered: total and direct bilirubin, ALT, AST, alkaline phosphatase, GGT, albumin, INR, CBC, lipase, and blood cultures if febrile
- Imaging results: ultrasound, CT, MRCP, or ERCP findings
Nursing diagnoses used with jaundice
- Impaired Comfort — itching from cholestasis, poor sleep
- Acute Pain — biliary colic, liver capsule stretch, or pain after ERCP
- Risk for Bleeding — impaired liver function, vitamin K malabsorption, a high INR, and procedures such as sphincterotomy
- Risk for Infection — stasis of bile behind a blockage, invasive procedures
- Risk for Impaired Skin Integrity — scratching and dry skin
- Inadequate Nutritional Intake — nausea, poor appetite, fat malabsorption
- Fatigue — liver disease and anemia
- Acute Confusion — hepatic encephalopathy in advanced liver failure
- Anxiety — uncertainty about the cause, especially while cancer is being ruled out
Worked care plans
Four plans in the same ADPIE shape. The scenario is a 54-year-old woman with known gallstones. For 3 days she has had right upper quadrant pain after meals. Yesterday her daughter noticed her eyes were yellow, and she reports dark urine, pale stools, and itching that kept her awake. Temperature is 37.4 C (99.3 F), heart rate 96, blood pressure 132/80, respiratory rate 18, and oxygen saturation 97% on room air. She is alert and oriented. Labs show total bilirubin 6.2 mg/dL (direct 4.8 mg/dL), alkaline phosphatase 390 U/L, ALT 160 U/L, lipase within the lab’s normal range, WBC 10.4 x 109/L, and INR 1.5. Ultrasound shows gallstones and a dilated common bile duct. The provider diagnoses suspected choledocholithiasis (a stone in the common bile duct) and plans ERCP with stone removal. Vitamin K has been ordered.
1. Impaired Comfort
Problem-focusedSubjective: “The itching is driving me crazy, especially at night.” “I only slept about two hours.”
Objective: Yellow sclera and skin, linear scratch marks on forearms and shins with no open areas, dry skin, frequent scratching during the interview. Itch rated 8 out of 10. Direct bilirubin 4.8 mg/dL.
Impaired Comfort related to buildup of bile salts in the skin from bile duct obstruction, as evidenced by reports of severe itching, scratching, inability to relax, and disturbed sleep.
- Patient reports itching at a level she finds tolerable
- Patient uses at least two non-drug measures to reduce itching
- Skin stays intact without new breaks or infection
- Patient sleeps for longer stretches
- Rate itching with a 0–10 scale each shift and ask how it affects sleep
- Keep the room cool, use light cotton clothing and bedding, and offer lukewarm (not hot) baths
- Apply fragrance-free emollients after bathing; avoid alcohol-based lotions and harsh soaps
- Keep nails short and clean; teach her to press, pat, or apply a cool cloth instead of scratching
- Give anti-itch medicines as ordered, such as cholestyramine; give other oral medicines at a different time as directed by the pharmacist, because cholestyramine binds them in the gut
- Use sedating antihistamines only as ordered and with caution in liver disease, because they can cause drowsiness and falls and can mask early confusion
- Explain that itching usually improves once bile flow is restored
After cool baths, emollient, and the ordered medicine, she rated itching 4 out of 10 and slept for 5 hours. No new skin breaks. Two days after ERCP she said the itching was “almost gone.” Goal met.
2. Acute Pain
Problem-focusedSubjective: “It’s a deep ache under my right ribs that gets worse after I eat.” Pain rated 6 out of 10, sometimes into the right shoulder.
Objective: Guarding of the right upper quadrant, tenderness on palpation, lying still with knees flexed, heart rate 96. Dilated common bile duct on ultrasound.
Acute Pain related to biological injury from obstruction of the common bile duct by a stone, as evidenced by reported pain 6 out of 10, guarding, protective positioning, and tenderness of the right upper quadrant.
- Patient reports pain at or below the comfort goal she sets
- Patient can rest, move, and take part in care
- Any change in the pain pattern is recognized and reported
- Assess pain location, severity, character, and radiation before and after each intervention
- Give analgesics as ordered; check with the provider about acetaminophen limits, which may be lower for patients with liver injury
- Keep NPO or offer the diet ordered; low-fat foods cause less gallbladder stimulation when eating is allowed
- Offer position of comfort, often semi-Fowler’s with knees flexed, and quiet rest
- Report pain that becomes severe and steady, spreads to the back, or comes with fever, vomiting, or low blood pressure; these may mean pancreatitis, cholangitis, or perforation
- After ERCP, monitor for new or worse abdominal pain, nausea, and vomiting, and check lipase if ordered, because post-ERCP pancreatitis is the most common complication
Before ERCP she rated pain 3 out of 10 after the ordered analgesic and positioning. ERCP with sphincterotomy removed the stone. After the procedure she had mild soreness only, rated 2 out of 10, with no back pain or vomiting. Goal met.
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3. Risk for Bleeding
RiskSubjective: “I’ve noticed some bruises on my legs, but I don’t remember bumping them.”
Objective: INR 1.5, two small bruises on the shins, no active bleeding, stools pale and negative for blood. Bile duct obstruction for several days. ERCP with possible sphincterotomy planned.
Risk for Bleeding with risk factors of inadequate knowledge of bleeding precautions; associated conditions: impaired liver function, reduced vitamin K absorption from bile duct obstruction, coagulopathy, and a planned invasive procedure.
Risk diagnosis: risk factors only, because bleeding has not occurred.
- INR moves toward the target set by the provider before the procedure
- No signs of bleeding during the stay; any bleeding is found and reported early
- Patient states three bleeding precautions
- Give vitamin K by the route ordered and recheck the INR as ordered before ERCP
- Check for bruising, petechiae, gum or nose bleeding, blood in urine, and black or bloody stools each shift
- Use a soft toothbrush and electric razor, avoid unneeded needle sticks, and hold pressure longer at puncture sites
- Review the medicine list with the provider for anticoagulants, antiplatelets, and NSAIDs
- After sphincterotomy, monitor for vomiting blood, black stools, falling blood pressure, and rising heart rate, and check hemoglobin as ordered
- Report any active bleeding, a drop in hemoglobin, or a rising INR to the provider immediately
After vitamin K, her INR came within the range the provider required for ERCP. No bleeding before or after sphincterotomy, and hemoglobin stayed stable. She named soft toothbrush, no NSAIDs, and reporting black stools as precautions. Goal met.
4. Risk for Infection
RiskSubjective: Denies chills. “I just feel tired and achy.”
Objective: Temperature 37.4 C (99.3 F), WBC 10.4 x 109/L, blood pressure 132/80, alert and oriented. Stone blocking the common bile duct with a dilated duct. Peripheral IV in place. ERCP planned.
Risk for Infection with risk factor of stasis of body fluid (bile held behind the obstruction); associated conditions: choledocholithiasis and a planned invasive procedure (ERCP).
Risk diagnosis: risk factors only, because infection has not occurred.
- Patient stays free of signs of cholangitis and sepsis
- Early signs of infection are recognized and reported at once
- Patient states the warning signs to report after discharge
- Monitor temperature, heart rate, blood pressure, respiratory rate, and mental status at the frequency ordered and with any change
- Watch for fever, chills, rising pain, deepening jaundice, low blood pressure, or confusion, and report them immediately
- If infection is suspected, follow the sepsis protocol: draw blood cultures and lactate as ordered, then start antibiotics and IV fluids as prescribed without delay
- Give prophylactic antibiotics around ERCP only if ordered
- Use aseptic technique for IV care and assess the IV site each shift
- Prepare her for ERCP: confirm consent, NPO status, allergies, and labs as ordered
She stayed afebrile with stable vital signs and normal mental status before and after ERCP. Bilirubin was trending down at discharge. She named fever, chills, and returning yellow color as reasons to call. Goal met.
Interventions and rationales
Jaundice in newborns
Newborn jaundice is common and is usually unconjugated bilirubin from a short red cell life span and an immature liver. Jaundice in the first 24 hours of life is never treated as normal and needs a bilirubin level. Treatment thresholds for phototherapy and exchange transfusion depend on gestational age, the baby’s age in hours, and risk factors for brain injury, and are taken from the current American Academy of Pediatrics guideline, not from one fixed number. Signs such as poor feeding, lethargy, a high-pitched cry, or arching need urgent attention. For the full newborn plan, see our neonatal jaundice care plan.
Client and family teaching
- Jaundice is a sign that something is affecting how your body clears bilirubin; the team is treating the cause
- The yellow color fades over days to weeks after the cause is fixed; itching often improves sooner
- Call your provider or go to the emergency department for fever or chills, worse belly pain, yellow color returning or getting deeper, vomiting, or confusion
- Get emergency care for vomiting blood, black or bloody stools, or fainting
- Avoid alcohol while your liver is recovering, and ask before taking acetaminophen, herbal products, or supplements
- Use a soft toothbrush and an electric razor if your clotting is affected, and avoid ibuprofen and other NSAIDs unless your provider says they are safe
- For itching: lukewarm showers, fragrance-free moisturizer, loose cotton clothing, and short nails
- If cholestyramine is prescribed, take your other medicines at the times the pharmacist gives you
- If your gallbladder is still in place, ask about surgery to remove it, because more stones can form
- If hepatitis is the cause, ask about vaccines for household contacts and how to prevent spread
NurseStudyPrep.com
You’ve read the care plan. Now answer one.
A priority item in the NCLEX format. On Prep, every option gets a written rationale — including the three that are wrong.
A client with jaundice from a stone in the common bile duct is waiting for ERCP. Which finding should the nurse report to the provider immediately?
Why C. Fever and chills with low blood pressure in a patient with a blocked bile duct suggest acute cholangitis progressing to septic shock, which needs cultures, antibiotics, fluids, and urgent drainage. Options A, B, and D are expected findings with obstructive jaundice. They need nursing care and documentation, but they do not signal a threat to life. Prep also explains why each wrong option looks reasonable.
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Frequently asked questions
Is jaundice a nursing diagnosis?
No. Jaundice is a clinical sign of a medical problem. Nurses choose NANDA-I diagnoses for the patient’s response, such as Impaired Comfort, Acute Pain, Risk for Bleeding, Risk for Infection, Risk for Impaired Skin Integrity, and Inadequate Nutritional Intake.
What is the priority nursing diagnosis for a patient with jaundice?
It depends on the cause and the findings. Threats to life come first: infection and sepsis from cholangitis, bleeding from a high INR, and confusion from hepatic encephalopathy. When those are not present, comfort and pain are often the main problems.
At what bilirubin level does jaundice appear?
In adults, yellowing is usually visible once total bilirubin is above about 2.5 to 3 mg/dL. Many labs list about 1.2 mg/dL as the upper limit of normal. Use the reference range on your own lab report.
Why does jaundice cause dark urine and pale stools?
When bile cannot drain, water-soluble conjugated bilirubin backs up into the blood and is passed in the urine, making it dark. Without bile reaching the intestine, stool loses its brown color.
Why do patients with jaundice itch?
Itching is common in cholestasis, when bile flow is blocked. Bile acids and other substances that build up are thought to trigger it. Bilirubin itself is not the main cause, so itching can be severe even when the yellow color is mild.
What is Charcot’s triad?
Fever, right upper quadrant pain, and jaundice. Together they suggest acute cholangitis. Adding low blood pressure and confusion (Reynolds’ pentad) suggests septic shock. Both need immediate reporting.
References
- Fargo, M. V., Grogan, S. P., & Saguil, A. Evaluation of jaundice in adults. American Family Physician, 2017;95(3):164–168.
- Kwo, P. Y., Cohen, S. M., & Lim, J. K. ACG Clinical Guideline: Evaluation of abnormal liver chemistries. American Journal of Gastroenterology, 2017;112(1):18–35.
- Buxbaum, J. L., Abbas Fehmi, S. M., Sultan, S., et al. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointestinal Endoscopy, 2019;89(6):1075–1105.
- Kiriyama, S., Kozaka, K., Takada, T., et al. Tokyo Guidelines 2018: Diagnostic criteria and severity grading of acute cholangitis. Journal of Hepato-Biliary-Pancreatic Sciences, 2018;25(1):17–30.
- Kemper, A. R., Newman, T. B., Slaughter, J. L., et al. Clinical practice guideline revision: Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics, 2022;150(3):e2022058859.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). NANDA International Nursing Diagnoses: Definitions and Classification, 2024–2026. Thieme.
- Ackley, B. J., Ladwig, G. B., Makic, M. B. F., Martinez-Kratz, M. R., & Zanotti, M. Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (13th ed.). Elsevier, 2023.
- Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C. Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.
- Silvestri, L. A. Saunders Comprehensive Review for the NCLEX-RN Examination. Elsevier, 2023.
- American Liver Foundation. Jaundice. liverfoundation.org.
Normal bilirubin ranges, liver test reference ranges, INR targets, vital sign parameters, medicines and their doses, antibiotic choices, and timing of ERCP vary by patient, by provider, by laboratory, and by facility. Follow the provider’s written orders, current guidelines, and your own institution’s policies. This page supports study and does not replace course instruction or clinical judgment.
