Jaundice neonatal

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  • 1. Neonatal jaundice
  • 2. Neonatal Jaundice• Learning Objectives:• Define hyperbilirubinemia.• Differentiate between physiological and pathological jaundice.• State causes of hyperbilirubinemia.• Discuss the pathophysiology of hyperbilirubinemia.• Describe the most dangerous complication of hyperbilirubinemia.• List the three elements of therapeutic management.• Design plan of care for baby has hyperbilirubinemia. NJ -
  • 3. Neonatal Jaundice (Hyperbilirubinemia)• Definition: Hyperbilirubinemia refers to an excessive level of accumulated bilirubin in the blood and is characterized by jaundice, a yellowish discoloration of the skin, sclerae, mucous membranes and nails.• Unconjugated bilirubin = Indirect bilirubin.• Conjugated bilirubin = Direct bilirubin. NJ -
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  • 5. Neonatal Jaundice• Visible form of bilirubinemia – Newborn skin >5 mg / dlOccurs in 60% of term and 80% of preterm neonatesHowever, significant jaundice occurs in 6 % of term babies NJ -
  • 6. Bilirubin Production & Metabolism NJ -
  • 7. Clinical assessment of jaundiceArea of body Bilirubin levels mg/dl (*17=umol)Face 4-8Upper trunk 5-12Lower trunk & thighs 8-16Arms and lower legs 11-18Palms & soles > 15 NJ -
  • 8. Physiological jaundiceCharacteristics• Appears after 24 hours• Maximum intensity by 4th-5th day in term & 7th day in preterm• Serum level less than 15 mg / dl• Clinically not detectable after 14 days• Disappears without any treatment Note: Baby should, however, be watched for worsening jaundice. NJ -
  • 9. Why does physiological jaundice develop?• Increased bilirubin load.• Defective uptake from plasma.• Defective conjugation.• Decreased excretion.• Increased entero-hepatic circulation. NJ -
  • 10. Course of physiological jaundice 15Bilirubin level mg/dl 10 5 Term Preterm 1 2 3 4 5 6 10 11 12 13 14 Age in Days NJ -
  • 11. Pathological jaundice• Appears within 24 hours of age• Increase of bilirubin > 5 mg / dl / day• Serum bilirubin > 15 mg / dl• Jaundice persisting after 14 days• Stool clay / white colored and urine staining clothes yellow• Direct bilirubin> 2 mg / dl NJ -
  • 12. Causes of jaundiceAppearing within 24 hours of age• Hemolytic disease of NB : Rh, ABO• Infections: TORCH, malaria, bacterial• G6PD deficiency NJ -
  • 13. Causes of jaundiceAppearing between 24-72 hours of life• Physiological• Sepsis• Polycythemia• Intraventricular hemorrhage• Increased entero-hepatic circulation NJ -
  • 14. Causes of jaundiceAfter 72 hours of age• Sepsis• Cephalhaematoma• Neonatal hepatitis• Extra-hepatic biliary atresia• Breast milk jaundice• Metabolic disorders (G6PD). NJ -
  • 15. Risk factors for jaundice JAUNDICE• J - jaundice within first 24 hrs of life• A - a sibling who was jaundiced as neonate• U - unrecognized hemolysis• N – non-optimal sucking/nursing• D - deficiency of G6PD• I - infection• C – cephalhematoma /bruising• E - East Asian/North Indian NJ -
  • 16. Diagnostic evaluation:• Normal values of unconjugated B. are 0.2 to 1.4 mg/dL.• Investigate the cause of jaundice. NJ -
  • 17. Therapeutic Management• Purposes: reduce level of serum bilirubin and prevent bilirubin toxicity• Prevention of hyperbilirubinemia: early feeds, adequate hydration• Reduction of bilirubin levels: phototherapy, exchange transfusion,• Drugs Use of Phenobarbital promote liver enzymes and protein synthesis. NJ -
  • 18. Babies under phototherapyBaby under conventional Baby under triple unit intense phototherapy phototherapy
  • 19. Maisel’s chart Age in hrs Sr BirthBilirubin weight (mg/dl) < 24 24 – 48 49 – 72 >72 <5 All Phototherapy 5-9 All if hemolysis < 2500g Phototherapy PHOTOTHERAPY 10-14 if hemolysis Investigate if bilirubin > 2500g > 12mg% < 2500g EXCHANGE 15-19 > 2500g Consider Exchange Phototherapy All
  • 20. Prognosis• Early recognition and treatment of hyperbilirubinemia prevents severe brain damage. NJ -
  • 21. phototherapy• In practice light is used in the white ,blue and green>• A dose response relationship exists . Amount of irradiation directly propotion to decrease serum bilirubin .• The energy delivered to infant skin decreased with increasing distance between infant and light source (50cm) NJ -
  • 22. phototherapy• Irradiating a large surface area is more efficient• Nature and character of the light sourcee.g (quartz halide spotlight )• Fibrostic light is also used in phototherapy unit > NJ -
  • 23. Key point in the practical execution of phototherapy1- The infant should be naked except for diaper , eye to be covered2- distance between the skin and light source .3-when used spotlight , the infant is placed in centre .4- routinely add 10-15% extra fluid .5- timing of follow -up S.B testing must be indevedualized. NJ -
  • 24. Adverse effect of photo therapy• Photo therapy is associated with loose stool .• Increase risk of retinopathy.• The combination of phototherapy & increased S.B can produce DNA strand breakage .• Skin blood flow is increased, redistribution of blood flow may occur – PDA is reported in premature. NJ -
  • 25. Adverse effect of phototherapy• Hypocalcemia appears to be more common in premature.• Concentration of certain aminoacid may change.• burn. NJ -
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  • 27. Nursing considerations of Hyperbilirubinemia• Assessment: observing for evidence of jaundice at regular intervals. Jaundice is common in the first week of life and may be missed in dark skinned Blanching the tip babies of the nose NJ -
  • 28. Approach to jaundiced baby• Ascertain birth weight, gestation and postnatal age• Ask when jaundice was first noticed• Assess clinical condition (well or ill)• Decide whether jaundice is physiological or pathological• Look for evidence of kernicterus* in deeply jaundiced NB*Lethargyand poor feeding, poor or absent Moros, or convulsions NJ -
  • 29. Nursing diagnosis• See the high risk infant plan of care. Plus: Body T., risk for imbalanced T. related to use of phototherapy. Fluid volume, risk for deficient related to phototherapy. Interrupted family process related to situational crisis, re hospitalization for the therapy. NJ -
  • 30. The goals of planning• Infant will receive appropriate therapy if needed to reduce serum bilirubin levels.o Infant will experience no complications from therapy.o Family will receive emotional support.o Family will be prepared for home phototherapy (if prescribed). NJ -
  • 31. QUESTIONS? NJ -
  • 32. Reference1- Dr. Nahed Al-Nagger2- manual of neonatal &pediatric intensive nursing course