Jaundice Nursing Diagnosis and Nursing Care Plans

Jaundice is a condition characterized by yellowing of the skin and whites of the eyes due to elevated bilirubin levels in the blood.

This nursing diagnosis is crucial for identifying and managing patients with jaundice, which can be a symptom of various underlying conditions affecting the liver, gallbladder, or blood cells.

Causes (Related to)

Jaundice can result from various conditions that affect bilirubin metabolism or excretion. The following are common causes of jaundice:

• Liver disease
• Hepatitis
• Cirrhosis
• Liver cancer
• Biliary tract obstruction
• Gallstones
• Pancreatic cancer
• Cholangitis
• Blood disorders:
• Hemolytic anemia
• Sickle cell disease
• Neonatal jaundice

Signs and Symptoms (As evidenced by)

Jaundice manifests with various signs and symptoms. During a physical assessment, a patient with jaundice may present with one or more of the following:

Subjective: (Patient reports)

• Fatigue
• Abdominal pain or discomfort
• Itching (pruritus)
• Dark urine
• Clay-colored stools
• Loss of appetite
• Nausea

Objective: (Nurse assesses)

• Yellow discoloration of skin and sclera
• Enlarged liver (hepatomegaly)
• Enlarged spleen (splenomegaly)
• Ascites (fluid accumulation in the abdomen)
• Fever
• Weight loss
• Lab values:
• Elevated serum bilirubin levels (total and direct)
• Abnormal liver function tests (elevated ALT, AST, ALP)
• Imaging findings:
• Ultrasound or CT scan showing liver abnormalities or biliary obstruction

Expected Outcomes

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

• The patient will demonstrate a reduction in yellow discoloration of skin and sclera.
• The patient will report relief from pruritus and other associated symptoms.
• The patient will maintain adequate nutrition and hydration.

Nursing Assessment

The nursing assessment is crucial in gathering comprehensive data about the patient’s condition. The following section covers subjective and objective data related to jaundice.

1. Assess the patient’s skin and sclera color.
   Examine the patient’s skin and eyes for yellow discoloration. The intensity of jaundice can indicate the severity of the underlying condition.
2. Monitor vital signs.
   Check temperature, blood pressure, heart rate, and respiratory rate. Fever may indicate infection, while changes in other vital signs can suggest complications.
3. Perform a comprehensive abdominal assessment.
   Palpate the abdomen for liver enlargement, tenderness, or ascites. These findings can provide clues about the underlying cause of jaundice.
4. Assess for pruritus.
   Ask the patient about itching and observe for signs of scratching. Pruritus is a common symptom in cholestatic jaundice.
5. Evaluate nutritional status.
   Assess the patient’s appetite, recent weight changes, and ability to eat. Jaundice can affect nutritional intake and metabolism.
6. Review medication history.
   Identify any medications that could potentially cause or exacerbate jaundice.
7. Assess for signs of bleeding.
   Check for easy bruising, petechiae, or bleeding gums, as liver dysfunction can affect blood clotting factors.
8. Monitor urine and stool characteristics.
   Dark urine and clay-colored stools can indicate obstructive jaundice.
9. Evaluate mental status.
   Assess for confusion, disorientation, or changes in consciousness, which could indicate hepatic encephalopathy.

Nursing Interventions

Nursing interventions are essential for managing jaundice and its underlying causes. The following section outlines possible nursing interventions for a patient with jaundice.

Promote skin care and comfort.

• Apply moisturizers to relieve dry skin and reduce itching.
• Encourage the use of soft, cotton clothing to minimize skin irritation.
• Keep the patient’s nails short to prevent skin damage from scratching.

Maintain adequate nutrition and hydration.

• Collaborate with a dietitian to develop an appropriate meal plan.
• Encourage small, frequent meals if the patient experiences nausea.
• Monitor fluid intake and output to ensure adequate hydration.

Administer medications as prescribed.

• Give antipruritic medications to relieve itching.
• Administer antibiotics if infection is present.
• Provide vitamins and supplements as ordered to support liver function.

Implement infection control measures.

• Use standard precautions to prevent the spread of infectious causes of jaundice.
• Educate the patient and family about proper hand hygiene.

Monitor for complications.

• Assess for signs of hepatic encephalopathy, such as confusion or asterixis.
• Watch for symptoms of gastrointestinal bleeding, such as hematemesis or melena.

Nursing Care Plans

The following nursing care plans provide detailed interventions and rationales for managing patients with jaundice. Each plan addresses a specific aspect of care related to jaundice.

Care Plan #1

Nursing Diagnosis: Impaired Skin Integrity related to pruritus secondary to elevated serum bilirubin levels as evidenced by scratching and excoriations on the skin.

Related factors/causes:

• Elevated bilirubin levels cause skin irritation and itching
• Excessive scratching due to intense pruritus
• Dry skin associated with jaundice

Nursing Interventions and Rationales:

1. Assess skin integrity daily, paying attention to areas prone to scratching.
   Rationale: Regular assessment allows for early detection of skin breakdown and prompt intervention.
2. Apply moisturizers or emollients to the skin, especially after bathing.
   Rationale: Moisturizers help maintain skin hydration and reduce itching.
3. Encourage the use of cool compresses or lukewarm baths with colloidal oatmeal.
   Rationale: Cool temperatures and oatmeal can provide temporary relief from itching.
4. Administer antihistamines or other antipruritic medications as prescribed.
   Rationale: These medications can help reduce the intensity of itching.
5. Teach the patient relaxation techniques or distraction methods to cope with itching.
   Rationale: Alternative coping strategies can help reduce the urge to scratch.
6. Keep the patient’s nails short and smooth, and provide cotton gloves for nighttime use if necessary.
   Rationale: This prevents skin damage from scratching, especially during sleep.
7. Educate the patient about the importance of avoiding scratching and alternative methods to relieve itching.
   Rationale: Patient education promotes self-management and reduces the risk of skin breakdown.

Desired Outcomes:

• The patient will demonstrate improved skin integrity with no new areas of breakdown within three days.
• The patient will report a decrease in itching intensity within 24 hours of interventions.
• The patient will utilize alternative methods to relieve itching without resorting to scratching by the end of the shift.

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Care Plan #2

Nursing Diagnosis: Imbalanced Nutrition: Less than Body Requirements related to decreased appetite and altered metabolism secondary to liver dysfunction as evidenced by weight loss and reduced oral intake.

Related factors/causes:

• Nausea and loss of appetite associated with jaundice
• Altered taste perception due to liver dysfunction
• Increased metabolic demands related to the underlying condition

Nursing Interventions and Rationales:

1. Assess the patient’s nutritional status, including weight, dietary intake, and laboratory values.
   Rationale: Comprehensive assessment guides nutritional interventions and monitors progress.
2. Collaborate with a dietitian to develop an appropriate meal plan tailored to the patient’s needs and preferences.
   Rationale: A personalized diet plan ensures adequate nutrition while considering the patient’s condition and preferences.
3. Offer small, frequent meals throughout the day instead of three large meals.
   Rationale: Smaller meals are often better tolerated and can help increase overall intake.
4. Provide oral care before meals to improve taste perception and appetite.
   Rationale: Good oral hygiene can enhance food taste and stimulate appetite.
5. Administer antiemetic medications as prescribed before meals if nausea is present.
   Rationale: Controlling nausea can improve food intake and nutritional status.

Desired Outcomes:

• The patient will demonstrate weight stabilization or gain within one week.
• The patient will report improved appetite and increased oral intake within 3 days.
• The patient will maintain serum albumin and pre-albumin levels within normal range.

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Care Plan #3

Nursing Diagnosis: Deficient Knowledge related to lack of information about jaundice and its management as evidenced by verbalization of misconceptions and questions about the condition.

Related factors/causes:

• Lack of exposure to information about jaundice
• Misinterpretation of health information
• Complexity of the disease process and treatment regimen

Nursing Interventions and Rationales:

1. Assess the patient’s knowledge of jaundice, its causes, and management.
   Rationale: Identifying knowledge gaps allows for targeted education.
2. Provide concise information about jaundice, its causes, and treatment options.
   Rationale: Accurate information promotes understanding and informed decision-making.
3. Use visual aids, such as diagrams or models, to explain the anatomy and physiology involved in jaundice.
   Rationale: Visual representations can enhance comprehension of complex concepts.
4. Teach the patient about prescribed medications, including their purpose, dosage, and potential side effects.
   Rationale: Understanding medication regimens promotes adherence and safety.
5. Discuss dietary modifications and lifestyle changes that may be necessary to manage jaundice.
   Rationale: Lifestyle adjustments are often crucial in managing jaundice and supporting liver health.

Desired Outcomes:

• The patient will verbalize an accurate understanding of jaundice, its causes, and its management within 24 hours.
• The patient will demonstrate the correct technique for self-monitoring and medication administration by discharge.
• The patient will express confidence in managing their condition and knowing when to seek medical attention.

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Care Plan #4

Nursing Diagnosis: Risk for Impaired Liver Function related to underlying hepatic disease as evidenced by elevated liver enzymes and bilirubin levels.

Related factors/causes:

• Presence of liver disease (e.g., hepatitis, cirrhosis)
• Exposure to hepatotoxic substances
• Biliary tract obstruction

Nursing Interventions and Rationales:

1. Monitor liver function tests (ALT, AST, ALP, bilirubin) and report significant changes to the healthcare provider.
   Rationale: Regular monitoring allows for early detection of worsening liver function and prompt intervention.
2. Assess for signs of hepatic encephalopathy, such as confusion, asterixis, or changes in consciousness.
   Rationale: Early recognition of hepatic encephalopathy is crucial for timely treatment.
3. Administer medications as prescribed, paying careful attention to dosages of hepatically metabolized drugs.
   Rationale: Proper medication management prevents further liver damage and ensures therapeutic efficacy.
4. Educate the patient about avoiding alcohol and other hepatotoxic substances.
   Rationale: Abstinence from harmful substances is essential for liver protection and recovery.
5. Encourage a balanced diet that supports liver health in consultation with a dietitian.
   Rationale: Proper nutrition is crucial in maintaining liver function and promoting healing.

Desired Outcomes:

• The patient will maintain stable liver function tests or show improvement within the expected timeframe.
• The patient will demonstrate adherence to the prescribed treatment regimen and lifestyle modifications.
• The patient will verbalize understanding of signs and symptoms that require immediate medical attention.

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Care Plan #5

Nursing Diagnosis: Anxiety related to uncertainty about prognosis and impact of jaundice on daily life, as evidenced by expressed worries and increased tension.

Related factors/causes:

• Lack of information about the disease process and treatment outcomes
• Fear of potential complications or lifestyle changes
• Concern about the impact of jaundice on personal and professional life

Nursing Interventions and Rationales:

1. Assess the patient’s level of anxiety and identify specific concerns or fears.
   Rationale: Understanding the source of anxiety allows for targeted interventions.
2. Provide a calm and supportive environment, allowing the patient to express feelings and concerns.
   Rationale: A non-judgmental atmosphere promotes open communication and trust.
3. Offer clear and honest information about the patient’s condition, treatment plan, and prognosis.
   Rationale: Accurate information can help alleviate fears stemming from uncertainty.
4. Teach relaxation techniques such as deep breathing, progressive muscle relaxation, or guided imagery.
   Rationale: These techniques can help reduce anxiety and promote a sense of control.
5. Encourage the patient to engage in activities that promote relaxation and distraction, such as listening to music or reading.
   Rationale: Positive distractions can help shift focus away from anxiety-provoking thoughts.

Desired Outcomes:

• The patient will report decreased anxiety levels within 24 hours of interventions.
• The patient will demonstrate effective use of at least one relaxation technique by the end of the shift.
• The patient will verbalize a positive outlook on their condition and treatment plan within three days.

Conclusion

Jaundice is a complex condition that requires comprehensive nursing care to manage symptoms, prevent complications, and support the patient’s overall well-being.

By implementing these nursing care plans, healthcare providers can address patients’ physical, emotional, and educational needs with jaundice, promoting better outcomes and quality of life.

References

1. American Liver Foundation. (2021). Jaundice. Retrieved from https://liverfoundation.org/for-patients/about-the-liver/diseases-of-the-liver/jaundice/
2. Fargo, M. V., Grogan, S. P., & Saguil, A. (2017). Evaluation of Jaundice in Adults. American Family Physician, 95(3), 164-168.
3. Gulanick, M., & Myers, J. L. (2017). Nursing Care Plans: Diagnoses, Interventions, and Outcomes (9th ed.). Elsevier.
4. Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). NANDA International Nursing Diagnoses: Definitions and Classification 2018-2020 (11th ed.). Thieme.
5. National Institute of Diabetes and Digestive and Kidney Diseases. (2020). Jaundice. Retrieved from https://www.niddk.nih.gov/health-information/liver-disease/jaundice
6. Roy-Chowdhury, N., & Roy-Chowdhury, J. (2021). Classification and causes of jaundice or asymptomatic hyperbilirubinemia. In T. W. Post (Ed.), UpToDate. Waltham, MA: UpToDate Inc.
7. Toney-Butler, T. J., & Thayer, W. M. (2021). Nursing Process. In StatPearls. Treasure Island (FL): StatPearls Publishing.
8. World Health Organization. (2021). Jaundice. In International Classification of Diseases, 11th Revision (ICD-11). Retrieved from https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1744576348