jaundice

1.  PRESENTED BY
 SAKSHI-KANWER
 MSC(N)1ST YEAR
 MEDICAL SURGICAL
NURSING

2.  It’s a disease that turns your skin and the whites of
your eyes yellow.
 Jaundice is often a sign of a problem with the liver,
gallbladder, or pancreas

4. INTRODUCTION:
 (Greek hepar: liver)
 It is the largest gland of the body.
 Occupying much of the right upper part of
the abdominal cavity.
 It consists of both exocrine and endocrine parts.
 The liver performs a wide range of metabolic
activities necessary for homeostasis, nutrition,
and immune response.

6.  Shape : The liver is wedge shaped and resembles
a four-sided pyramid laid on one side with its
base directed towards the right and apex directed
towards the left.
 Colour : It is red-brown in colour.
 Weight:
 In males: 1.4 to 1.8kg.
 In females: 1.2 to 1.4kg.
 In newborn: 1/18th of the body weight.
 At birth: 150 g.
 Proportional weight: In adult /40th of the body
weight

7.  Bile production and excretion
 Excretion of bilirubin, cholesterol, hormones, and
drugs
 Metabolism of fats, proteins, and carbohydrates
 Enzyme activation
 Storage of glycogen, vitamins, and minerals
 Synthesis of plasma proteins, such as albumin, and
clotting factors
 Blood detoxification and purification

8.  Gall bladder is a gastrointestinal organ located
within the right hypochondria region of the
abdomen. This Intraperitoneal, pear-shaped sac
lies with a fossa formed between the inferior
aspects of the right and quadrate lobes of the
liver.

9.  The gall bladder is 7 to 10 cm long,
 3 cm broad
 30 to 50 ml in capacity.

10.  The main function of the gallbladder is to store and
concentrate bile (which is produced in the liver) as
well as to release bile into the digestive system.

11.  Bile is a bitter-tasting, dark green to yellowish
brown fluid, produced by the liver.
 Bile aids the process of digestion of lipids in the
small intestine.
 Bile is stored in the gallbladder and upon eating is
discharged into the duodenum

12.  Daily secretion: 500 – 1000 ml
 Transparent alkaline fluid, light yellow in colour.
 pH : 7.8 – 8.6
 Water
 Bile Salts : These are sodium & potassium salts of
bile acid

15. Secretion occurs in three stages :-
A) Formation & Secretion of constituents of bile by
the liver:
• Bile salts are synthesized in hepatocytes and
transferred into bile canaliculi .
• Bile salts along with glucose, amino acids and bile
pigments are actively secreted into canaliculi.

16. B) Filling of gall bladder:-
• Bile then passes through the biliary tree and
ultimately to the hepatic duct
• And then it reaches the gall bladder where it is
concentrated and stored temporarily.

17. C) Discharge of bile in intestine :-
When there is chyme in the intestine sphincter of Oddi
and sphincter of Boyden are relaxed and bile flows
into the intestine.

18.  Bile passes out of the liver through the bile ducts
and is stored in the gallbladder. After a meal, it is
released into the small intestine. When the bile ducts
become blocked, bile builds up in the liver,
and jaundice (yellow color of the skin) develops
due to the increasing level of bilirubin in the blood.

21.  Jaundice is a yellowish discoloration of the skin and
sclera that is an important symptom of elevated
serum bilirubin, which is caused by an abnormality
of bilirubin metabolism or excretion.

 Bilirubin is a brownish yellow substance found in
bile. It is produced when the liver breaks down old
red blood cells. Bilirubin is then removed from the
body through the stool (feces) and gives stool its
normal color.

22.  The bilirubin can be either unconjugated or
conjugated.
 Unconjugated bilirubin is a waste product of
hemoglobin breakdown that is taken up by the liver,
where it is converted by the enzyme uridine
diphosphoglucuronate glucuronosyltransferase
(UGT) into conjugated bilirubin. Conjugated
bilirubin is water-soluble and is excreted into the
bile to be cleared from the body.

23.  Normal serum bilirubin level - 0.3-1.0
mg/DL
 Conjugated - 0.1-0.3 mg/DL
 Unconjugated - 0.2-0.7 mg/d

24.  Jaundice, also known as icterus
 Jaundice is yellowish discoloration of the skin, sclera
and mucous membranes due to hyperbilirubinemia
and deposition of bile pigments.
 Jaundice is the yellowish discoloration of the tissues
due to deposition of bilirubin which occurs in
presence of hyperbilirubinemia.

25.  Jaundice is yellow discoloration of the sclera , skin ,
and mucus membrane resulting from an increased
bilirubin concentration in the blood ( more than
3mg/dl )
 The word Jaundice is actually a derivative of French
word ‘Jaune’ which means ‘yellow’.
 A medical condition with yellowing of the skin or
whites of the eyes, arising from excess of the
pigment bilirubin and typically caused by
obstruction of the bile duct, by liver disease, or by
excessive breakdown of red blood cells.

27.  Pre-Hepatic
 Hepatocellular ( intrahepatic)
 Post-Hepatic (obstruction of biliary drainage)

29.  In pre-hepatic jaundice, there is excessive red cell
breakdown which overwhelms the liver’s ability to
conjugate bilirubin. This causes an unconjugated
hyperbilirubinemia.
 Any bilirubin that manages to become conjugated
will be excreted normally, yet it is
the unconjugated bilirubin that remains in the
blood stream to cause the jaundice.

30.  In Hepatocellular (or intrahepatic) jaundice, there
is dysfunction of the hepatic cells. The liver loses
the ability to conjugate bilirubin, but in some cases
where it also may become cirrhotic, it compresses
the intra-hepatic portions of the biliary tree to cause
a degree of obstruction.
 This leads to both unconjugated and
conjugated bilirubin in the blood, termed a ‘mixed
picture’

31.  Post-hepatic jaundice refers to obstruction of
biliary drainage. The bilirubin that is not excreted
will have been conjugated by the liver; hence the
result is a conjugated hyperbilirubinemia.


32.  PATHOLOGIC JAUNDICE: Severe type of
jaundice usually appears within 24 hours of birth
which is characterized by a rapid rise in serum
bilirubin level by more than 5mg/dl/24 hours,
yellow discoloration of the skin, mucous membrane
and sclera for prolonged time which is called
pathological jaundice.

33.  Pathologic jaundice can occurs in children and
adults and is diagnosed when jaundice presents a
health risk. Several forms of hepatitis, cirrhosis of
the liver and other liver diseases, bile duct blockage,
along with infections and medications, can also
cause pathological jaundice.

35.  Gilbert Syndrome: Gilbert's syndrome is a
common, harmless liver condition in which the liver
doesn't properly process bilirubin. Bilirubin is
produced by the breakdown of red blood cells.

36.  Gilbert's syndrome produces an elevated level of
unconjugated bilirubin in the bloodstream, but
normally has no serious consequences. Mild
jaundice may appear under conditions of exertion,
stress, fasting, and infections, but the condition is
otherwise usually asymptomatic.

37.  Jaundice is clinically detectable in the newborn
when the serum bilirubin levels are greater than
85µmol/L. This occurs in approximately 60%of
term infants and 80% of preterm infants.
 Neonatal jaundice is a yellowish discoloration of the
white part of the eyes and skin in a newborn baby
due to high bilirubin levels.

38.  Yellow discoloration of the skin and the mucosa due
to accumulation of excess of bilirubin in the tissue
and plasma in neonates (more than 7mg/dl).

39. 1. Pathologic jaundice: Pathologic jaundice is the
most serious type of jaundice. It occurs within 24
hours after birth, and is characterized by a rapid rise
in a baby’s bilirubin level. The most likely cause is
blood incompatibility or liver disease. Prompt
medical attention is necessary, and blood
transfusions may be required. Breastfeeding can
continue during treatment.

40. 2. Physiologic (neonatal) jaundice: Physiologic
jaundice usually appears at day 2-5 and lasts about
10–12 days. The best treatment for physiologic
jaundice is frequent and effective breastfeeding—at
least 8-12 or more times in each 24-hour period.

42. 3. Breast milk jaundice: Breast milk jaundice is a type
of jaundice associated with breast-feeding. It typically
occurs one week after birth. The condition can
sometimes last up to 12 weeks, but it rarely causes
complications in healthy, breast-fed infants. The
Exact cause of breast milk jaundice isn’t known.

43.  However, it may be linked to a substance in the
breast milk that prevents certain proteins in the
infant’s liver from breaking down bilirubin. The
condition may also run in families. Breast milk
jaundice is rare, affecting less than 3 percent of
infants. When it does occur, it usually doesn’t cause
any problems and eventually goes away on its own.
It’s safe to continue breast-feeding your baby.

44. 4. Suboptimal intake jaundice: Suboptimal intake
jaundice, also called breastfeeding jaundice, most
often occurs in the first week of life when
breastfeeding is being established. Newborns may
not receive optimal milk intake, which leads to
elevated bilirubin levels due to increased
reabsorption of bilirubin in the intestines.

45.  Inadequate milk intake also delays the passage of
meconium, which contains large amounts of
bilirubin that is then transferred into the infant’s
circulation. In most cases breastfeeding can, and
should, continue. More feedings can reduce the risk
of jaundice

47.  Haemolytic anemia
 Gilbert’s syndrome
 Crigler- Najjar syndrome

48.  Alcoholic liver disease
 Viral hepatitis
 Iatrogenic,eg medication
 Hereditary haemochromatosis
 Autoimmune hepatitis
 Primary biliary cirrhosis
 Hepatocellular carcinoma

49.  Intra- luminal causes, such as gall stones
 Mural causes ,such as cholangiocarcinoma,
strictures, or drug-induced cholestasis
 Extra-mural causes, such as pancreatic cancer or
abdominal masses(e.g. lymphomas)

50.  Hepatitis: Most of the time, this infection is caused by a
virus. It may be short-lived (acute) or chronic, which
means it lasts for at least 6 months. Drugs or autoimmune
disorders can cause hepatitis. Over time, it can damage
the liver and lead to jaundice.
 Alcohol-related liver disease: If you drink too much
over a long period of time -- typically 8 to 10 years -- you
could seriously damage your liver. Two diseases in
particular, alcoholic hepatitis and alcoholic cirrhosis,
harm the liver.

51.  Blocked bile ducts: These are thin tubes that carry a
fluid called bile from the liver and gallbladder to the
small intestine. Sometimes, they get blocked
by gallstones, cancer, or rare liver diseases. If they
do, you could get jaundice.
 Pancreatic cancer: This is the 10th most
common cancer in men and the ninth in women. It
can block the bile duct, causing jaundice.
 Certain medicines: Drugs
like acetaminophen, penicillin, birth control pills,
and steroids have been linked to liver disease.

53. When RBC completed their life span or
damage, Hemolytic anemia
Hemoglobin phagocyte by
macrophages
Heme+ Globin
Biliverdin (Biliverdin reducatse)
(Heme
oxygenase)

54. Bilirubin
Bilirubin transported from
plasma to liver for conjugation
Unconjugated bilirubin remain
in blood stream
Causes jaundice

55. Bilirubin released as unconjugated
form
Transport to hepatocytes bound to
albumin
Albumin- bilirubin bond is broken
Alone bilirubin take by hepatocytes
through carrier membrane transport and
bound protein in cytosol

56. Unconjugated bilirubin proceed
to endoplasmic reticulum
Unconjugated bilirubin
conjugation to glucuronic acid
Formation of conjugated
bilirubin which soluble in bile

57. Dysfunction in pre-hepatic phase
Elevated serum levels of unconjugated
bilirubin
Elevated conjugated bilirubin
Hepatic phase elevate both unconjugated
and conjugated bilirubin
Conjugated hyper bilirubin anemia

58.  Yellow discoloration of:
 The skin
 Mucous membrane
 The white of the eyes
 Light colored stools
 Dark –coloured urine
 Itching of the skin

59.  Nausea and vomiting
 Abdominal pain
 Fever
 Weakness
 Loss of appetite
 Headache

60.  Confusion
 Swelling of the legs and abdomen
 Fatigue
 Weight loss

63. Health History:
 Duration of Jaundice
 Tattoos, sexual activity, and alcohol history
 Loss of weight or appetite
 Abdominal pain
 Fever

64. The health care provider will perform a physical
examination.
SKIN INSPECTION:
 Pallor, Jaundice: skin, mucosa and sclera
 Muscle atrophy, edema, skin excoriation from
scratching.

65. ABDOMINAL ASSESSMENT:
 Dilated abdominal wall veins, ascites, and
abdominal dullness.
 Palpation for liver tenderness.
 Acute hepatitis: soft edges and easily moves.

66.  A bilirubin blood test
 Hepatitis virus panel to look for infection of the
liver
 Complete blood count to check for low blood count
or anemia
 Abdominal ultrasound
 Abdominal CT Scan
 ERCP( Endoscopic retrograde
cholangiopancreatography)

67.  PTCA( Percutaneous transhepatic cholangiogram)
 Liver biopsy
 Cholesterol level
 Prothrombin time
 Urinalysis
 bilirubinometer is used to check for jaundice in
babies

69.  To prevent the recurrence of the
disease.
 Symptomatic relief

70.  Drink 6-8 glasses of water a day
 Eat lots of ray fruits and vegetable(especially green
leafy vegetables)
 Provide plenty of fluids, juice
 Provide high protein diet
 Do not eat processed foods white sugar, white flour,
etc
 Use stress relief like going to walk

71.  Brown rice and millet are good
 Avoid red meat and animal fat
 Reduce dairy products cheese, milk
 Exercise light to moderate amount. E.g. yoga
and stretching are good
 Do not smoke and avoid second hand
smoking.

72.  G6PD deficiency: mostly people recover on their
own if progresses to hemolytic anemia, oxygen
therapy or blood transfusion may be required.

73.  Spherocytosis:
 These infants should be treated with phototherapy
and/ or exchange transfusion as clinically indicated.
 Folic acid is required to sustain erythropoiesis.
 Patients with HS( Hidradenitis suppurativa) are
instructed to take supplementary folic acid for life in
order to prevent a megaloblastic crisis.
 Splenectomy is the definitive treatment for HS.

74.  Sickle cell anemia: Treatments may include
medications to reduce pain and prevent
complication, blood transfusion and supplemental
oxygen, as well as bone marrow transplant.
 Antibiotics: children with sickle cell anemia may
begin taking the antibiotic penicillin when they’re
about 2 month of age and continue taking it until
they’re at least 5 year old

75.  Immune related hemolysis: corticosteroids, folic
acid is main line of treatment.
 Parasitic infections: like malaria are treated with
anti malarial drugs, like chloroquine, artesunate,
lumefantrine, amodiaquine.
 Ineffective erythropoiesis: iron and folic acid
supplementation, vitB12 , tablets given and repeated
blood transfusions.

76.  VIRAL HEPATITIS:
 Hepatitis A is mostly self limiting no treatment is
required, but in some cases 0.02ml/kg administration
of anti-HAV Ig can be given.
 Hepatitis B treated with combination of HBIG and
hep B vaccines.
 Recombivax and Engerix- B are 2 vaccines for
Hepatitis B
 Hepatitis C is treated with interferons.
 Other viral infection like EBV, CMV, HSV, are treated
with antiviral medications like acyclovir, ganciclovir
and foscarnet.

77.  Discriminant function - determines the prognosis
of the person suffering from alcoholic liver disease.
Given by Maddrey.
 It is calculated by a simple formula:
 (4.6 x (PT test - control))+ S.Bilirubin in mg/dl A
value more than 32 implies poor outcome.

78.  MELD – model for end stage liver disease
 Scoring system for assessing the severity of chronic
liver disease.
 MELD uses the patient's values for serum bilirubin,
serum creatinine, and the international normalized
ratio for prothrombin time (INR) to predict survival.
 Wilson’s disease- pharmacologic treatment with:
chelating agents such as D-penicillamine and other
agents include sodium dimercaptosuccinate,
dimercaptosuccinic acid.

79.  Preoperative biliary decompression (ERCP or PTC)
 Intravenous admistration of 5% dextrose saline
followed by 10%mannitol or loop diuretics to
prevent hepatorenal syndrome/ renal failure(12 to
24 hours prior to surgery)
 catheterization to monitor output
 Broad spectrum antibiotic prophylaxis with 3rd
generation cephalosporins

80.  Parenteral vitamin K +/- fresh frozen plasma
 Need careful fluid balance to correct dehydration
 Correction of hypokalemia and other electrolyte
imbalance.
 Cholestyramine and antihistamine for symptomatic
relief of pruritis

81.  Carcinoma of head of pancreas- whipple resection
done
 Ca gall bladder- whipple resection done but if
unoperable radiological stenting is done.
 Choledochal cyst- excision of the cyst with
reconstruction of extrahepatic biliary tree.
 Stricture- endoscopic stenting. Standard care is
surgery by roux-en-y choledocojejunostomy.

83.  Age of the patient
 Fever
 Yellow colour of skin, mucous and eye
 Assess for liver disease

84.  ADULT PATIENTS:
 Yellow skin and the white part of the eyes(sclera)
 Yellow color inside the mouth
 Dark or brown-colored urine
 Pale or clay colored stool
 In newborns- Jaundice is detected by blanching the
skin with pressure applied by a finger so that it
reveals underlying skin and subcutaneous tissue.

86.  Hyperthermia related to infection and elevated
serum bilirubin level as evidence by
temperature of 38.5 ℃, rapid and shallow
breathing, flushed skin, profuse sweating and
weak pulse.
 Fatigue related to elevated serum bilirubin
levels as evidence by overwhelming lack of
energy, verbalization of tiredness, generalized
weakness and shortness of breath upon
exertion.

87.  NURSING DIAGNOSIS: Hyperthermia related to
infection and elevated serum bilirubin level as
evidence by temperature of 38.5 ℃, rapid and
shallow breathing, flushed skin, profuse sweating
and weak pulse.
 Desired outcome: within 4 hours of nursing
interventions, the patient will have a stabilized
temperature within the normal range.

88. 1.Assess the patient vital sign at least every 4
hours
2.Remove excessive clothing, blankets and
linens. Adjust the room temperature.
3.Offer a tepid sponge bath.
4.Administer the prescribed anti-pyretic
medications.

90.  Avoid heavy alcohol use (alcoholic hepatitis,
cirrhosis, and pancreatitis).
 Vaccines for hepatitis (hepatitis A, hepatitis B)
 Avoid medications and toxins which can cause
hemolysis or directly damage the liver.

91.  Radish: Radish juice and radish leaves are told to
be excellent in making your body free from
bilirubin.
 Gooseberry: Indian gooseberry is known for its
abundance of vitamin C. When combined with
lemon it becomes a magical cocktail of health for
anyone suffering from jaundice.
 Sugarcane: Sugarcane juice has some excellent
properties that can help patients suffering from
jaundice.

92.  Papaya Leaves: Papaya leaves have some excellent
natural qualities that can aid in the recovery of the
liver and also helps in the detoxification of the
bloodstream.
 Barley:
 Barley is well-known around the world for its
excellent medicinal qualities. Consuming well-
boiled barley can act as a powerful diuretic that can
help in the efficient detoxification of the
bloodstream and the liver.

94. Effects of infant massage on jaundiced neonates
undergoing phototherapy
Background: Infant massage is a natural way for
caregivers to improve health, sleep patterns, and
reduce colic. We aimed to investigate the effects of
infant massage on neonates with jaundice who are
also receiving phototherapy.

95.  Methods: Full-term neonates with jaundice,
admitted for phototherapy at a regional teaching
hospital, were randomly allocated to either a control
group or a massage group. The medical information
for each neonate, including total feeding amount,
body weight, defecation frequency, and bilirubin
level, was collected and compared between two
groups.

96. Results: A total of 56 patients were enrolled in the
study. This included 29 neonates in the control
group and 27 in the experimental group. On the
third day, the massage group showed significantly
higher defecation frequency (p = 0.045) and
significantly lower bilirubin levels (p = 0.03)
compared with the control group. No significant
differences related to feeding amount or body
weight were observed between the two groups.

97. Conclusion: Infant massage could help to reduce
bilirubin levels and increase defecation frequency in
neonates receiving phototherapy for jaundice.

100.  Basavanthappa BT, Textbook of Medical Surgical
Nursing, Edition 2, Page Number 464- 465
 Hinkle JancieL, Cheever Kerry H. Brunner and
Suddarth’s ,Textbook of Medical Surgical Nursing
,Volume-2
 Lippincott Manual”A text book of Medical Surgical
nursing” 10th edition, published by Wolters Kluwer
 Pee Vee A text book of Medical Surgical Nursing 5th
edition, Page Number -474- 478
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