Neonatal jaundice is a common condition in newborns characterized by yellowing of the skin and eyes due to elevated bilirubin levels. This nursing diagnosis focuses on identifying risk factors, monitoring bilirubin levels, preventing complications, and providing appropriate interventions for affected newborns.
Causes (Related to)
Neonatal jaundice can occur due to various physiological and pathological factors:
- Physiological factors:
- Normal newborn liver immaturity
- Increased red blood cell breakdown
- Delayed bilirubin conjugation
- Decreased bilirubin excretion
- Pathological factors:
- Blood type incompatibility (ABO, Rh)
- Breast milk jaundice
- Infection
- Genetic disorders
- Metabolic disorders
- Risk factors:
- Prematurity
- Birth trauma
- Poor feeding
- Maternal diabetes
- Family history
Signs and Symptoms (As evidenced by)
Subjective: (Parent/caregiver reports)
- Poor feeding
- Lethargy
- Irritability
- Changes in sleep patterns
- Decreased wet diapers
Objective: (Nurse assesses)
- Yellow discoloration of skin and sclera
- Elevated serum bilirubin levels
- Decreased muscle tone
- Changes in vital signs
- Altered feeding patterns
- Abnormal neurological signs
Expected Outcomes
- Bilirubin levels will decrease to the normal range
- Newborn will maintain adequate hydration
- Newborn will demonstrate normal feeding patterns
- No signs of kernicterus will develop
- Parents will demonstrate an understanding of the condition and treatment
- Normal growth and development will continue
Nursing Assessment
Monitor Bilirubin Levels
- Check total and direct bilirubin levels
- Assess skin color progression
- Document Kramer’s scale findings
- Monitor for signs of kernicterus
- Track treatment response
Assess Feeding Patterns
- Monitor frequency and duration
- Evaluate latch and sucking
- Track input and output
- Document weight changes
- Assess hydration status
Evaluate Neurological Status
- Monitor alertness
- Assess muscle tone
- Check reflexes
- Document sleep patterns
- Observe cry characteristics
Monitor Vital Signs
- Track temperature
- Monitor heart rate
- Assess respiratory rate
- Document blood pressure
- Check oxygen saturation
Assess Family Understanding
- Evaluate knowledge level
- Document concerns
- Check support systems
- Monitor coping mechanisms
- Assess compliance with care
Nursing Care Plans
Nursing Care Plan 1: Hyperbilirubinemia
Nursing Diagnosis Statement:
Hyperbilirubinemia related to physiologic immaturity of the liver as evidenced by elevated serum bilirubin levels and yellow skin discoloration.
Related Factors:
- Hepatic immaturity
- Increased red blood cell breakdown
- Delayed bilirubin conjugation
- Poor feeding patterns
Nursing Interventions and Rationales:
- Monitor bilirubin levels q8h
Rationale: Tracks progression and treatment effectiveness - Implement phototherapy as ordered
Rationale: Promotes bilirubin breakdown - Ensure proper eye protection
Rationale: Prevents retinal damage during phototherapy
Desired Outcomes:
- Bilirubin levels will decrease to the normal range
- Skin color will improve
- No signs of kernicterus will develop
Nursing Care Plan 2: Risk for Impaired Skin Integrity
Nursing Diagnosis Statement:
Risk for Impaired Skin Integrity related to phototherapy treatment and prolonged immobility.
Related Factors:
- Extended phototherapy exposure
- Limited position changes
- Increased skin sensitivity
- Temperature fluctuations
Nursing Interventions and Rationales:
- Perform skin assessment q4h
Rationale: Early detection of skin breakdown - Implement position changes q2h
Rationale: Prevents pressure areas - Monitor skin temperature
Rationale: Prevents overheating
Desired Outcomes:
- Skin will remain intact
- There is no evidence of a breakdown
- Normal skin temperature maintained
Nursing Care Plan 3: Risk for Ineffective Breastfeeding
Nursing Diagnosis Statement:
Risk for Ineffective Breastfeeding related to interrupted feeding schedule during phototherapy.
Related Factors:
- Treatment interruptions
- Maternal anxiety
- Newborn lethargy
- Positioning challenges
Nursing Interventions and Rationales:
- Assist with breastfeeding positioning
Rationale: Promotes effective latch - Monitor feeding frequency
Rationale: Ensures adequate nutrition - Provide lactation support
Rationale: Improves feeding success
Desired Outcomes:
- Effective breastfeeding established
- Adequate weight gain demonstrated
- Parent confidence improved
Nursing Care Plan 4: Anxiety (Parents)
Nursing Diagnosis Statement:
Anxiety related to the infant’s condition and treatment process as evidenced by verbalized concerns and increased questioning.
Related Factors:
- Limited knowledge
- Fear of complications
- Treatment concerns
- Separation anxiety
Nursing Interventions and Rationales:
- Provide education about jaundice
Rationale: Increases understanding - Demonstrate care techniques
Rationale: Builds confidence - Allow expression of concerns
Rationale: Reduces anxiety
Desired Outcomes:
- Parents will verbalize understanding
- Decreased anxiety levels
- Improved coping skills
Nursing Care Plan 5: Risk for Altered Body Temperature
Nursing Diagnosis Statement:
Risk for Altered Body Temperature related to phototherapy exposure and environmental factors.
Related Factors:
- The heat from phototherapy lights
- Minimal clothing requirements
- Environmental variations
- Immature thermoregulation
Nursing Interventions and Rationales:
- Monitor temperature q4h
Rationale: Ensures normothermia - Adjust environmental temperature
Rationale: Maintains comfort - Check skin temperature
Rationale: Prevents overheating
Desired Outcomes:
- Normal temperature maintained
- No signs of heat stress
- Stable vital signs
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2004 Jul;114(1):297-316. doi: 10.1542/peds.114.1.297. Erratum in: Pediatrics. 2004 Oct;114(4):1138. PMID: 15231951.
- Donkor DR, Ziblim SD, Dzantor EK, Asumah MN, Abdul-Mumin A. Neonatal Jaundice Management: Knowledge, Attitude, and Practice Among Nurses and Midwives in the Northern Region, Ghana. SAGE Open Nurs. 2023 Jul 13;9:23779608231187236. doi: 10.1177/23779608231187236. PMID: 37528906; PMCID: PMC10387689.
- Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
- Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
- Kemper AR, Newman TB, Slaughter JL, Maisels MJ, Watchko JF, Downs SM, Grout RW, Bundy DG, Stark AR, Bogen DL, Holmes AV, Feldman-Winter LB, Bhutani VK, Brown SR, Maradiaga Panayotti GM, Okechukwu K, Rappo PD, Russell TL. Clinical Practice Guideline Revision: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Pediatrics. 2022 Sep 1;150(3):e2022058859. doi: 10.1542/peds.2022-058859. PMID: 35927462.
- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
