CHILD HEALTH NURSING I 2021 SCHEME UNIT III NURSING CARE OF A NEONATE by Mrs.Rani.G.S, Msc (N), Child Health Nursing

1. HYPERBILIRUBINEMIA

2. DEFINITION
• An excessive level of accumulated bilirubin in
the blood and is characterized by jaundice or
icterus , yellowish discolouration of the skin,
sclerae & nails.

3. INCIDENCE
• 25- 50% of all term neonates
• 60-80% of preterm

4. RBC destruction
Hemoglobin Globin used by body
Heme
Unconjugated bilirubin (insoluble substance bound to albumin)
In liver
Detached from albumin molecule
Glucorynyl transferase
Conjugated with glucuronic acid
Conjugated bilirubin (highly soluble substance)
Excreted into bile
BILIRUBIN METABOLISM

5. • In intestine bacterial action reduces the
conjugated bilirubin to urobilinogen
• Most of the reduced bilirubin is excreted through
feces , a small amount eliminated through urine.

6. CAUSES
• Physiologic factors – developmental
prematurity
• Inadequate breast feeding
• Excess production of bilirubin – hemolytic
disease, biochemical defects, bruises
• Disturbed capacity of the liver to secrete
conjugate bilirubin – enzyme deficiency,
bile duct obstruction

7. • Combined overproduction & undersecretion
– sepsis
• Some disease states – hypothyroidism, galactosemia,
infant of a diabetic mother
• Genetic predisposition to increased production – native
Americans, Asians

8. TYPES
Physiologic jaundice
• Occurs after 24hrs of birth
• Not associated with any pathologic disease
• 60% term, 70% preterm
• In term subside by 4-7 days
• Preterm 6-14 days

9. Pathologic jaundice
• Clinical jaundice
• Occurs with in 24 hrs
• 5% of new borns
• Hemolysis due to ABO/Rh incompatibility,
intrauterine infections
• Total bilirubin >15mg/dl

10. Breast feeding associated jaundice
Inadequate breastfeeding
Decreased caloric & fluid intake
Decreased hepatic clearance of bilirubin
Jaundice
• Early onset jaundice – begins at 2 to 4 days of
age

11. Breast milk jaundice
• Late onset jaundice – begins at 5 to 7 days of
age
• Factors in breast milk – pregnanodiol, fatty
acids, beta glucuronidase etc either inhibit
conjugation or decrease excretion of bilirubin

12. CLINICAL FEATURES
• Yellowish discoluration of skin, sclera or nails
• Lethargy
• Refusal to feed
• Dark colour urine & stool

13. Diagnostic evaluation
• Clinical estimation
 Skin blanching with digital pressure
 Dermal zone of jaundice

15. • Serum bilirubin level
 Total bilirubin - >5mg/dl (physiologic), > 15 mg/dl
(pathologic)
 Direct/conjugated – 1.5 to 2mg/dl
• Non invasive methods
 Ingram icterometer
 Transcutaneous bilirubinometer

16. MANAGEMENT
PHARMACOLOGIC MGT
 Phenobarbitone : promotes hepatic glucoronyl
transferase which increase bilirubin conjugation
 Metalloporphyrins : group of drugs inhibit heme
oxygenase activity , thus reducing breakdown of
heme to biliverdin

17. Phototherapy
• Application of fluorescent light for conversion of
unconjugated bilirubin into conjugated bilirubin

18. Principles of phototherapy
1. Photoisomerization :conversion of natural
isomer of unconjugated bilirubin to less toxic polar
isomer that diffuses into blood & is excreted into
bile without conjugation

19. 2. Structural isomerization:
• Conversion in the molecular structure
• Bilirubin lumirubin
• Lumirubin is rapidly excreted in bile & urine
without conjugation

20. 3. Photo oxidation:
• Converts bilirubin into small polar products that
are excreted in the urine

21. Indications of phototherapy
• Bilirubin level > 5 mg/dl
• As prophylactic phototherapy in ELBW
• Hemolytic disease of the newborn

22. Types
• Special blue lamps with 420 to 460nm
• white light lamps (550-600nm)
• Double light systems

23. Procedure
• Remove clothes of baby & kept under light
source
• Keep a distance of about 45cm from light source
• Cover eyes & genital areas as there is chance to
cause retinal damage and gonadal damage
• Change position frequently to expose all body
surfaces

24. Complications of phototherapy
• Insensible water loss
• Retinal damage
• Bronze baby syndrome
• Mutations of DNA

25. Care of baby under phototherapy
• Keep naked except for eye patches & diaper
• Ensure maximum exposure to greatest skin area
• Change position every 2 hours
• Ensure eye patches do not occlude the nares
• Monitor body temperature regularly
• Weigh the baby daily

26. • Provide extra fluids along with usual
requirements to compensate for increased
insensible loss & stooling
• Ensure breast feeding adequately
• Change diaper as & when required to avoid skin
excoriation
• Ensure parental contacts