jaundice , kernictrus

1. Nursing care of newborn with Hyperbilirubinemia
Hyperbilirubinemia is a condition in which the blirubin level in
the blood is increased. It is characterized by a yellow discoloration of the
skin, mucous membrane, sclera, and various organs. The yellow
discoloration is caused primarily by accumulation in the skin of
unconjugated blirubin, a breakdown product of hemoglobin forming after
its release from hemolysed RBCs.
Bilirubin metabolism:
Bilirubin is one of the breakdown products of hemoglobin. When RBCs
are destroyed, the breakdown products are released into the circulation,
where the hemoglobin spits into heme and globin. The body uses the
globin (protein) and heme is converted to unconjugated blirubin. In the
liver the bilirubin is conjugated with the glucuronyl transferase .This,
conjugated bilirubin is excreted into the bile. In the intestine, bacterial
action reduces the conjugated bilirubin into urobilinogen and
stercobilinogen.
Normally the body is able to maintain a balance between the destruction
of RBCs and the use or excretion by the body. When this balance is
upset, bilirubin accumulates in the body causing jaundice.
Causes of hyperbilirubinemia in a newborn
• Prematurity
• Breast milk
• Excess production of bilirubin(hemolytic disease, bruises)
• Enzyme deficiency, bile duct obstruction
• Sepsis
• Diseases like hypothyroidism, IDM

2. • Genetic predisposition
Types of hyperbilirubinemia:
Physiological jaundice Pathological jaundice
-3 Not appear before the 2
nd
or
3
rd
day in term baby. In
premature baby, it appears after
3
rd
or 4
th
day.
-4 Appears within the 1
st
day (24
hours after birth).
-5 I term newborn, it
disappears by the end of 7
th
days while in premature lasts
for 9 to 10 days.
-3 Needs longer time.
-6 The level of total serum
bilirubin never exceeds 12
mg/dl in fullterm newborn and
15 mg/dl in preterm newborn
and the direct bilirubin does not
exceed 1 mg/dl of the total
bilirubin.
-4 Serum bilirubin exceeds that
level.
-7 Daily raise of s. Bilirubin
never exceed 5 mg/dl.
-8 Serum bilirubin exceeds the
daily raise of physiological
jaundice.
-9 No kernicterus. -10 Cause kernicterus in
indirect

3. Hyperbilruibinemia.
-11 Requires no treatment Treatment is important as soon
as possible
-12 The newborn is good
sucker, no anemia, not sick,
normal stool, and urine color.
-13 The newborn looks sick,
poor sucking, pale, abnormal
stool and urine color.
Kernicterus:
It is also called the bilirubin encephalopathy and is caused by the
deposition of the unconjugated bilirubin in the brain. It results in the
yellowish staining of the brain tissue and the necrosis of neurons and
occurs if the concentration of the unconjugated bilirubin reaches toxic
level.
Stages of kernicterus:
1. Stage 1: poor Moro reflex, poor feeding, vomiting, high-pitched
cry, decreased tone and lethargy.
2. Stage 2: opisthotonus, seizures, fever, occulogyric crises, and
paralysis of upward gaze. Many newborns die in this phase.
3. Stage 3: spasticity is decreased at about one week of age. (a
symptomatic).
4. Stage 4: progressive spasticity, deafness, and mental
retardation.
Management of hyperbilirubinaemia:
1. Increase feeds in volume and calories. Early feeding lowers serum
bilirubin lever by stimulating the peristalsis.
2. Stop drugs interfering with bilirubin metabolism.

4. 3. Correct hypoxia, infection, and acidosis.
4. Phototherapy.
-3 Prophylactic: in LBW or bruised neonate.
-4 Therapeutic.
5. Exchange transfusion.
Phototherapy:
It consists of the application of fluorescent light (blue or white)
to the newborns naked skin. Light causes break down of bilirubin by the
process of photo oxidation. It alters the structure of bilirubin to a
soluble form for easier excretion.
Indications of phototherapy:
It is used when bilirubin level is:
-3 5-9 mg/dl at the 1
st
day of life.
-4 9-15 mg/dl at the 2
nd
day of life.
-5 15-20 mg/dl at the 3
rd
day of life.
Side effects of phototherapy:
1. Dehydration due to increased insensible water loss.
2. Watery diarrhea.
3. Hypocalcemia.
4. Retinal damage.
5. Erythema and skin rashs.
6. Bronze baby syndrome.
7. maternal newborn interaction is affected.
8. Dark yellow urine.
Nurse’s responsibility in phototherapy:
1. The lamp should be 5-8 cm over the incubator.

5. 2. Continue the feeding.
3. Shield the newborn’s eyes.
4. Keep newborn naked except for the diaper area and change
position frequently.
5. Cleanse skin frequently to prevent irritation.
6. Maintain adequate fluid intake to prevent dehydration and
calculate intake and output.
7. Check newborn’s body temperature every four hours.
8. Weight newborn daily.
9. Observe skin, mucous membranes, and stool.
10.Bilirubin levels should be followed for at least 24 hours after
discontinuing phototherapy.
Exchange transfusion:
It is an ideal dilution of s. Bilirubin and antibodies. A catheter is
introduced into the umbilical vein after cutting the cord. Through a
special valve, the umbilical catheter is connected with the donor blood.
Exchange is carried out over 45-60 min period by alternating aspiration
of 20 ml of newborn’s blood and infusions of 20 ml of the donor blood. .
Complications:
1. Embolism, thrombosis, infarction.
2. Arrhythmias, heart failure, arrest.
3. Electrolyte disturbances.
4. Thromobocytopenia.
5. Infections
6. Hypo and hyperthermia.
Nursing responsibilities:
1. Keep the newborn npo for 2-4 hours before exchange to prevent
aspiration.

6. 2. Check donor blood carts compatibility.
3. Keep resuscitation equipment at bedside: oxygen, ambo bag,
endotracheal tubes, and laryngoscope.
4. Assist physician with exchange transfusion procedure.
5. Track amount of blood withdrawn and transfused to maintain
balanced blood volume.
6. Maintain body temperature to avoid hypothermia and cold stress.
7. Monitor vital signs and observe for rash.
8. After transfusion, continue to monitor vital signs and check
umbilical cord for bleeding or signs of infection.
NURSING CARE PLAN
The Newborn with Hyperbilirubinemia
NURSING DIAGNOSIS: Risk for injury from breakdown products of red
blood cells in greater numbers than normal and functional immaturity of
liver
Patient Goal 1: Will receive appropriate therapy if needed to accelerate
bilirubin excretion
• Nursing Interventions/Rationales
Initiate early feedings to enhance excretion of bilirubin in the stool
Assess skin for evidence of jaundice, which indicates rising bilirubin
levels
Check bilirubin levels with transcutaneous bilirubinometry to determine
rising levels

7. Note time of initial jaundice to distinguish physiologic jaundice (appears
after 24 hours) from jaundice due to hemolytic disease or other causes
(appears before 24 hours)
Assess infant's overall status, especially factors (e.g., hypoxia,
hypothermia, hypoglycemia, and metabolic acidosis) that increase the
risk of brain damage from hyperbilirubinemia
Initiate phototherapy as prescribed
• Expected Outcomes
Newborn begins feeding soon after birth
Newborn is exposed to prescribed light source
Patient Goal 2: Will experience no complications from phototherapy
• Nursing Interventions/Rationales
Shield infant's eyes
Make certain that lids are closed before applying shield to prevent
corneal irritation
Check eyes each shift for drainage or irritation
Place infant nude under light for maximum skin exposure
Change position frequently, especially during the first several hours of
treatment, to increase body surface exposure
Monitor body temperature to detect hypothermia or hyperthermia
Check axillary temperature
Chart duration of therapy, type of lights, distance of lights from infant,
use of open or closed bassinet, and shielding of infant's eyes to
document correct use of phototherapy
With increased stooling, cleanse skin frequently to prevent perianal
irritation
Avoid use of oily applications on skin to prevent tanning and burning

8. Ensure adequate fluid intake to prevent dehydration
• Expected Outcome
Infant displays no evidence of eye irritation, dehydration, temperature
instability, or skin breakdown
Patient Goal 3: Will experience no complications from exchange
transfusion (if therapy required)
• Nursing Interventions/Rationales
Give infant nothing by mouth before procedure (usually for 2 to 4 hours)
to prevent aspiration
Check donor blood for correct blood group and Rh type to prevent
transfusion reaction
Assist practitioner during procedure; ensure asepsis to prevent infection
Keep accurate records of amounts of blood infused and withdrawn to
maintain proper blood volume
Maintain optimum body temperature of infant during procedure to
prevent hypothermia and cold stress or hyperthermia
Observe for signs of exchange transfusion reaction (tachycardia or
bradycardia, respiratory distress, dramatic change in blood pressure,
temperature instability, and rash) to initiate therapy promptly
Have resuscitation equipment (supplemental oxygen, airway, manual
resuscitation bag, endotracheal tube, and laryngoscope) at bedside to be
prepared for an emergency
Check umbilical site for bleeding or infection
Monitor vital signs during and following transfusions to detect
complications such as cardiac dysrhythmias

9. • Expected Outcomes
Infant exhibits no signs of adverse effects from exchange transfusion
Vital signs remain within normal limits (see inside back cover for
normal variations)
There is no evidence of infection or bleeding at infusion site
NURSING CARE PLAN
The Newborn with Hyperbilirubinemia
NURSING DIAGNOSIS: Altered family processes related to maturational
crisis, birth of term infant, change in family unit
Patient (Family) Goal 1: Will exhibit parent-infant attachment behaviors
• Nursing Interventions/Rationales
As soon after delivery as possible, encourage parents to see and hold
infant; place newborn close to face of parents to establish visual contact
Ideally, perform eye care after initial meeting of infant and parents,
within 1 hour after birth when infant is alert and most likely to visually
relate to parent
Identify for parents specific behaviors manifested by infant (e.g.,
alertness, ability to see, vigorous suck, rooting behavior, and attention to
human voice)
Discuss with parents their expectations of fantasy child vs real child if
indicated
Identify behavioral steps in attachment process, and evaluate those
aspects that could be considered positive and those that may represent
inadequate or delayed parenting

10. Encourage family to room-in or to call for infant frequently if not
rooming-in
Observe and assess reciprocity of cues between infant and parent to
identify behaviors that may need strengthening
Assist parents in recognizing attention-nonattention cycles and in
understanding their significance
Assess variables affecting development of attachment through observing
infant and parent and interviewing each parent or other significant
caregiver
• Expected Outcomes
Parents establish contact with infant immediately or soon after birth
Parents demonstrate attachment behaviors, such as touch, eye contact,
naming and calling infant by name, talking to infant, participating in
caregiving activities
Parents recognize attention-nonattention cycles
Patient (sibling) Goal 2: Will demonstrate adjustment/attachment
behaviors toward newborn
• Nursing Interventions/Rationales
Allow to visit and touch newborn when feasible
Explain physical differences in newborn, such as bald head, umbilical
stump and clamp, circumcision, to lessen any fear siblings might have
Explain to siblings realistic expectations regarding newborn's abilities
and needs
Requires complete care
Is not a playmate
Encourage siblings to participate in care at home to make them feel part
of the experience

11. Encourage parents to spend individual time with other children at home
to reduce feelings of jealousy toward new sibling
• Expected Outcome
Siblings express interest in newborn and realistic expectations for their
age
Patient (family) Goal 3: Will be prepared for discharge and home care
• Nursing Interventions/Rationales
Discuss with parents correct preparation of formula
Stress that proportions must not be altered to dilute or concentrate the
formula
Discourage microwaving of bottles to avoid burns
Encourage use of support persons for assistance with breast-feeding
Instruct in other aspects of newborn care
Bathing
Umbilical cord and circumcision care
Recognize states of activity for optimum interaction
Encourage participation in parenting classes, if offered
Discuss importance and proper use of federally approved car seat
restraints
If infant is small, advise parents to use rolled blankets and towels in
crotch area to prevent slouch and along sides to minimize lateral
movement, but never use padding underneath or behind infant, since it
creates slackness in harness, leading to possible ejection from seat in a
crash
parent-infant attachment is at risk, refer to appropriate agencies (social
services, family and child services, at-risk programs)

12. • Expected Outcomes
Family demonstrates ability to provide care for infant
Family keeps appointments for follow-up care
Family members avail themselves of needed services