Neonatal Jaundice Nursing Diagnosis and Care Plan

Last updated on February 18th, 2023 at 07:24 am

Neonatal Jaundice Nursing Care Plans Diagnosis and Interventions

Neonatal jaundice, also known as neonatal hyperbilirubinemia, results from an increase in total serum bilirubin, and its clinical characteristics are yellowish discoloration of the skin, sclera, and mucous membranes.

Neonatal jaundice is common in around two-thirds of all healthy babies. It may, however, be a symptom of a problem with the baby’s nutrition, hydration, or red blood cell length of life.

Signs and Symptoms of Neonatal Jaundice

• Yellow discoloration. The yellow appearance of the skin and eyes is one of the early signs of newborn jaundice. The baby’s skin may turn yellow as early as the first or second day of life. The appearance may look more yellow at 3 to 4 days old before gradually improving. Jaundice is termed “physiologic or normal” newborn jaundice. No testing is required.
• Dark yellow urine. A newborn baby’s urine should be colorless
• Pale color feces. It should be yellow or orange.

Causes of Neonatal Jaundice

• Hyperbilirubinemia. Newborns produce more bilirubin than adults because of the increased production and rapid breakdown of red blood cells during the first few days of life.   The liver filters typically bilirubin from the bloodstream and delivers it into the intestine. A newborn’s underdeveloped liver frequently cannot quickly eliminate bilirubin, resulting in excess bilirubin. Jaundice caused by these normal neonatal conditions is known as physiologic jaundice, and it usually occurs on the second or third day of life.
• Breastfeeding. Breastfeeding can raise the newborn’s likelihood of acquiring jaundice. However, if the baby has jaundice, it is not necessary to discontinue breastfeeding because the symptoms usually resolve in a few weeks. Some breastfed newborns can have jaundice for up to 12 weeks. However, it requires the assessment of a healthcare professional or Doctor to rule out other more severe causes of jaundice.
• Congenital hypothyroidism. This is a common cause of newborn jaundice.
• Rhesus disease. Rhesus disease is when antibodies in a pregnant woman’s blood attack the fetal blood cells. Referred to as hemolytic disease of the fetus and newborn (HDFN). Rhesus disease is not harmful to the mother but may cause anemia and neonatal jaundice.
• Crigler-Najjar syndrome. Crigler-Najjar syndrome type I symptoms appear shortly after birth. Characteristics include increased unconjugated bilirubin levels in the blood (unconjugated hyperbilirubinemia). Affected newborns have significant, persistent yellowing of their skin, mucous membranes, and sclera (jaundice).

Risk Factors to Neonatal Jaundice

• Race. The prevalence is lower among Africans and African Americans and higher for East Asians and American Indians.
• Geographic. The rate is higher in communities living at high altitudes.
• Genetics and familial risk. The risk is greater in newborns with siblings with significant neonatal jaundice, especially in infants whose older siblings with a history of neonatal jaundice treatment.
• Mother-related factors. Newborns with moms who have diabetes have a higher incidence of neonatal jaundice. Some medications may raise the occurrence, while others may reduce it. Some herbal medicines a nursing mother uses appear to worsen the infant’s jaundice.
• Birthweight and gestational age. Premature newborns and infants with low birth weight have a higher incidence. Premature babies may consume less and have fewer bowel movements, resulting in less bilirubin excreted in the stool. A newborn born before 38 weeks of pregnancy may be unable to metabolize bilirubin as promptly as a full-term baby.
• Infection. It can happen if the newborn has an infection in the urine, blood, liver, or other organs. Infections may not metabolize bilirubin normally, resulting in elevated blood levels.
• Galactosemia. ​​In rare cases, the baby’s liver is unable to digest galactose. This condition is known as galactosemia. Galactosemia can cause jaundice in newborns and is associated with other severe symptoms.
• Birth trauma. A considerable bruise across the scalp or skull may occur using vacuum extractors or forceps during birth. The body will re-absorb this massive bruise. The old blood from the bruise will break down and produce more bilirubin, which the liver must eliminate. It can also be transported into the bloodstream.

Complications of Neonatal Jaundice

When severe jaundice is left untreated for an extended period, it can result in complications, including:

• Bilirubin encephalopathy. A rare neurological disease that affects some newborns who have severe jaundice. It commonly occurs in the first week of life but can appear as late as the third week after birth. Some neonates with Rh hemolytic disease are prone to severe jaundice, which can lead to this illness.
• Neonatal Cholestasis. Most commonly observed in the first two weeks of life. The fundamental failure in cholestasis is bilirubin excretion, which causes too much-conjugated bilirubin in the bloodstream and reduced bile salts in the digestive (GI) tract.
• Kernicterus. A rare but severe complication of unresolved neonatal jaundice. Excess bilirubin damages the brain and central nervous system. Bilirubin can pass the thin layer of tissue that separates the brain and blood (the blood-brain barrier) in newborn babies with very high bilirubin levels in the blood (hyperbilirubinemia). Bilirubin can cause brain and spinal cord damage, which can be fatal.

Diagnosis of Neonatal Jaundice

The doctor will most likely diagnose infant jaundice based on the baby’s appearance.  However, the amount of bilirubin in the infant’s blood must still be determined. The following tests are used to diagnose jaundice and measure bilirubin:

• Physical Examination. To determine the existence of jaundice, examine the newborn in a well-lit room and blanch the skin with digital pressure to show the appearance of the skin’s color and subcutaneous tissue.

• Blood tests, such as:
  • Unconjugated or indirect bilirubin. This pigment is commonly elevated in newborns with neonatal jaundice. A baby’s urine is pale yellow, while the stool is mustard yellow. Bilirubin is linked to the breakdown of aging red blood cells.
  • Conjugated or direct bilirubin. The preceding pigment (indirect or unconjugated bilirubin) is packaged in the liver into a form suitable for evacuation into the bile and gallbladder. This pigment is known as conjugated (packed) bilirubin or direct bilirubin. Since the liver cannot eliminate it for various reasons, direct bilirubin flows back into the circulation and accumulates on the skin. The baby’s urine can be dark as coca-cola in color, and his feces can sometimes be pale beige.
  • CBC and reticulocyte count. A reticulocyte level greater than 6% signifies hemolysis.

• Blood type and Rh determination in mother and infant.
  • Serum albumin level. Because albumin binds bilirubin in a 1:1 ratio at the major high-affinity binding site, this is a valuable adjunct in monitoring and evaluating toxicity levels.

• Coomb’s test. Coomb tests a newborn’s blood specimen, commonly in the case of a newborn with jaundice. The procedure tests for “foreign” antibodies that have already attached themselves to the newborn’s red blood cells (RBCs), which could be the cause of hemolysis. Antibody-mediated hemolysis is the term for this.
• Urinalysis. To assess the levels of substances in the urine associated with liver function.

• Nomogram for hour-specific bilirubin values. Nomogram is a useful tool for forecasting which newborns are likely to have high blood bilirubin levels, either before or at the time of hospital release. Infants diagnosed in this manner require intensive supervision and frequent bilirubin testing.
• Measurement of end-tidal carbon monoxide in the breath. End-tidal carbon monoxide in breath (ETCO) can be utilized as an indicator of bilirubin generation. ETCO measurement may help identify patients with more excellent bilirubin production and, as a result, a higher risk of having excessive bilirubin levels.
• Ultrasonography. The healthcare provider recommends liver and bile duct sonography in newborns with cholestatic illness symptoms and laboratory findings.

Treatment for Neonatal Jaundice

• Phototherapy. The primary therapy for infants with unconjugated hyperbilirubinemia is phototherapy. Place the baby under special lighting that produces blue-green light. The light alters the structure and form of bilirubin molecules and allows elimination in both urine and stool. During treatment, the baby will only wear a diaper and eye patches. The use of a light-emitting pad or mattress enhances light therapy.
• Intravenous Immunoglobulin (IVIg). Differences in the blood type of the mother and the newborn could be a factor in jaundice. As a result of this disorder, the baby inherits antibodies from their mother, which contributes to the rapid breakdown of the newborn’s red blood cells. Although the results are inconclusive, intravenous immunoglobulin — a blood protein that can lower antibody levels — may alleviate jaundice and reduce the need for an exchange transfusion.
• Exchange transfusion. When alternative treatments fail to relieve acute jaundice, a baby may require a blood exchange transfusion. Treatment includes extracting small volumes of blood and replacing it with donor blood, diluting the bilirubin and maternal antibodies – a process is done in a newborn critical care unit.

Prevention of Neonatal Jaundice

• Blood test. The baby’s blood type will be tested after birth if necessary to rule out the risk of blood type incompatibility, which can cause neonatal jaundice.
• Frequent feedings. Feeding the infant more frequently will result in more milk and bowel movements, increasing the quantity of bilirubin excreted in the baby’s feces. Breast-fed newborns should receive eight to twelve daily feedings for the first few days of life. For the first week, formula-fed newborns should consume 1 to 2 ounces (approximately 30 to 60 milliliters) of formula every two to three hours.
• Supplemental feeding. Consult the doctor about the best feeding alternatives for the baby. If the newborn has difficulty breastfeeding, is losing weight, or is dehydrated, the doctor may advise supplementing breastfeeding with formula or expressed milk. In rare circumstances, the doctor may recommend taking formula only for a few days before returning to breastfeeding.

Neonatal Jaundice Nursing Diagnosis

Nursing Care Plan for Neonatal Jaundice 1

Deficient Knowledge

Nursing Diagnosis: Deficient Knowledge related to unfamiliarity with information resources secondary to Neonatal jaundice as evidenced by incorrect execution of instructions.

Desired Outcomes:

• The mother will express her awareness of hyperbilirubinemia’s causes, treatment, and possible outcomes.
• The mother will recognize signs/symptoms that necessitate immediate reporting to the healthcare practitioner.
• The mother will provide adequate care for the newborn.

Nursing Interventions for Neonatal Jaundice

Give parents a detailed description of home phototherapy, including method, possible issues, and safety considerations.  Non-specific written instructions are most likely a significant contributor to the low attendance rate for early community follow-up for jaundice. Some mothers explained why their children were absent. The first reason is the lack of understanding and inadequate presentation of the possible consequences of hyperbilirubinemia. The medical/nursing team may not correctly explain to parents the reasons for the early follow-up at the time of discharge.

Explain to the parents the client’s care monitoring, which includes the weight, feedings, intake/output, feces, temperature, and status report.  During the first 48 hours of birth, home phototherapy suggests for full-term infants with serum bilirubin levels between 14 and 18 mg/dl without an increase in direct responding bilirubin concentration.

Provide information to the parents about the different types of jaundice, its pathophysiology, and its long-term complications. Encourage them to ask questions and reinforce or clarify information as needed.  It assists the parents in understanding the disease condition, corrects misconceptions, and reduces feelings of shame and anxiety.

Give parents 24-hour emergency contact information and the contact person’s name, emphasizing the importance of reporting any indications of worsening jaundice.  To reduce anxiety and prepare parents to seek quick medical evaluation/intervention. Increased family understanding of the significance of jaundice and timely referral to hospitals can help decrease jaundice complications.

Inform the parents about home phototherapy.  For home phototherapy, parents can use a phototherapy blanket in a bassinet or a fiberoptic pad. These let the newborn be held, lowering the danger of eye damage. Give parents written instructions and tell them to record their infant’s temperature, weight, intake and output, stools, and feedings daily. To safeguard the infant’s ovaries or testes, the parents must guarantee to cover beneath the lights and place a little diaper over the infant’s perineal area.

Nursing Care Plan for Neonatal Jaundice 2

Risk for Injury

Nursing Diagnosis: Risk for Injury related to hemolytic disease secondary to neonatal jaundice.

Desired Outcomes:

• The newborn will have indirect bilirubin levels of less than 12 mg/dl after three days of intervention.
• The neonate’s jaundice will disappear by the end of the first week of life.
• The neonate will be clear of CNS impairment.

Nursing Interventions for Neonatal Jaundice

Start early oral feedings within the first 4-6 hours after delivery, mainly for the breastfeeding infant.  To enhance the passage of meconium, which promotes the establishment of proper intestinal flora necessary to reduce bilirubin to urobilinogen, decrease the enterohepatic circulation of bilirubin (bypassing the liver with the persistence of ductus venosus), and decrease the reabsorption of bilirubin from the bowel. A delay in enteral feeding may reduce intestinal motility and bacterial colonization, causing lower bilirubin clearance.

Keep the newborn warm and dry, and regularly monitor their skin and core temperature.  Cold stress increases the production of fatty acids, which compete for binding sites on albumin, increasing circulating (unbound) bilirubin. A neutral thermal environment allows the newborn to keep a normal core temperature while using the least amount of oxygen and calories. Premature newborns have minimal or no muscular activity; they maintain an extended posture due to a lack of muscle tone; and cannot shiver.

Use a transcutaneous jaundice meter.  Visual assessment of jaundice is not enough to measure assessing jaundice. Pediatric associations suggest hyperbilirubinemia screening of all babies at 35 weeks of gestation. By measuring total serum bilirubin (SB) or transcutaneous bilirubin (TB) (TcB). Because the transcutaneous bilirubinmeter measures bilirubin subcutaneously, TcB is not the same as SB.

Determine the bilirubin-albumin binding capability of plasma.  Aids in identifying the risk of kernicterus and the necessity for treatment. The kernicterus risk is minimized by dividing the total bilirubin value by the total serum protein level of 3.7. The risk of harm, however, is determined by the degree of immaturity, hypoxia, or acidosis and the treatment regimen.

Nursing Care Plan for Neonatal Jaundice 3

Risk for Injury (Exchange Transfusion)

Nursing Diagnosis: Risk for Injury related to exchange transfusion secondary to neonatal jaundice

Desired Outcomes:

• The neonate will complete the exchange transfusion.
• The serum bilirubin levels in the newborn will decrease.

Nursing Interventions for Neonatal Jaundice

Keep the infant’s temperature before, during, and after the procedure. Put the newborn in a radiant warmer with servomechanism.  To avoid energy costs from needing to maintain body temperature. Also, it helps to prevent vasospasm, lowers the risk of ventricular fibrillation, and reduces blood viscosity.

Place the blood in a blood warmer before infusion.  Keep the blood at room temperature to avoid hypothermia caused by cold exposure. To prevent harming red cells, only use listed commercial warmers to warm the blood rather than hot towels or a radiant heat warmer.

Make sure the blood is fresh (no more than two days old).  Older blood is more prone to hemolyze, resulting in higher bilirubin levels. Furthermore, old stored blood contains high quantities of leucocyte-secreted cytokines, which increase the likelihood of non-hemolytic febrile transfusion responses considerably.

Avoid overheating the blood.  Excess heat in the blood stimulates hemolysis and the production of potassium, resulting in hyperkalemia.

Ensure that resuscitation equipment is readily available.  If necessary, access to resuscitation equipment gives prompt assistance. Exchange transfusions can cause life-threatening complications such as bleeding, infection, cardiac arrhythmias, transitory hypocalcemia, hyperkalemia, bradycardia, and thrombocytopenia.

Keep NPO state for at least 4 hours before the surgery, or aspirate gastrointestinal contents.  When the decision to do an exchange transfusion is made, the newborn should be nil orally. Aspirate stomach contents using an oro-nasogastric tube.

Document every step of the transfusion process, including the volume of blood removed and infused (usually 7–20 ml at a time).  Documentation aids in the prevention of fluid replacement errors.

Nursing Care Plan for Neonatal Jaundice 4

Risk for Injury

Nursing Diagnosis: Risk for Injury related to side effects of phototherapy secondary to neonatal jaundice.

Desired Outcomes:

• The newborn will maintain appropriate body temperature and fluid balance.
• The neonate will be safe from skin or tissue damage.
• The neonate will exhibit standard interaction patterns.
• The neonate’s serum bilirubin levels will decrease.

Nursing Interventions for Neonatal Jaundice

Take note of the presence or progression of biliary or intestinal blockage.  Phototherapy is not recommended in these cases because the photo isomers of bilirubin generated in the skin and subcutaneous tissues by light therapy cannot be eliminated easily. Following phototherapy, it may increase the risk of secondary intestinal blockage.

Check the neonate’s skin and core temperature every two hours or more often until it is stable. Adjust the temperature of the incubator/isolette as needed.  Body temperature fluctuations can occur as a result of exposure to light exposure, radiation, and convection.

Take note of the color and frequency of feces and urine.  Frequent, greenish, loose stools and greenish urine suggest that phototherapy is helping with bilirubin breakdown and elimination.

Keep track of the fluid intake and output; weigh the infant twice daily. Take note of any indications of dehydration.  Phototherapy can cause dehydration, especially in premature infants. Measure the skin moisture content of the premature baby before and after phototherapy.

Examine the skin’s and urine’s appearance, and pay attention to the brownish-black color.  Excessive pigment changes (bronze baby syndrome) are an uncommon side effect of phototherapy that can occur if conjugated bilirubin levels increase. There is no relation between skin color changes lasting for 2-4 months to negative consequences.

Take note of any behavioral changes or symptoms of deterioration (e.g., lethargy, hypotonia, hypertonicity, or extrapyramidal signs).  Those alterations may represent bile pigment accumulation in the basal ganglia and the development of kernicterus. Following newborn phototherapy, there is a frequent decrease in serum total free calcium levels, resulting in hypocalcemia.

Nursing Care Plan for Neonatal Jaundice 5

Constipation

Nursing Diagnosis: Constipation related to dehydration secondary to neonatal jaundice as evidenced by passing fewer than three stools a week and having lumpy stools.

Desired Outcomes:

• Within 1 to 2 days of nurse intervention and therapy, the patient will pass a soft, formed stool regularly.
• The patient will be free from discomfort while passing stools.

Nursing Interventions for Neonatal Jaundice

Keep a balanced diet and fluid consumption.  Feed the infant slowly and carefully in a peaceful atmosphere; the child may need to be snugly hugged and softly rocked during feeding; initially, feeding the child every 2 to 3 hours may be essential.

Provide post-feeding Instructions.  Burp the infant repeatedly during and after each feeding, then place them on the side with the head slightly elevated or held chest-to-chest.

Keep track of every consumption.   Document food intake carefully using calorie intake and rigorous intake and output data.

Examine elimination patterns.   Bowel activity and urine production return to normal as food and fluid intake are kept increasing, and the child becomes hydrated.

Providing family education.  While providing care for the child, make the family member aware of the child’s growth and responsiveness while applauding any effective parenting techniques they use.

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. (2020). 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

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