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  Genetic predisposition

Types of hyperbilirubinemia: Physiological jaundice Pathological jaundice -3 Not appear before the 2nd or 3rd -4 Appears within the 1st day (24 day in term baby. In premature hours after birth). baby, it appears after 3rd or 4th day. -5 I term newborn, it disappears -3 Needs longer time. by the end of 7th days while in premature lasts for 9 to 10 days. -6 The level of total serum -4 Serum bilirubin exceeds that bilirubin never exceeds 12 mg/dl level. in fullterm newborn and 15 mg/dl in preterm newborn and the direct bilirubin does not exceed 1 mg/dl of the total bilirubin. -7 Daily raise of s. Bilirubin -8 Serum bilirubin exceeds the never exceed 5 mg/dl. daily raise of physiological jaundice.

-9 No kernicterus. -10 Cause kernicterus in indirect Hyperbilruibinemia.

-11 Requires no treatment Treatment is important as soon as possible -12 The newborn is good -13 The newborn looks sick, sucker, no anemia, not sick, poor sucking, pale, abnormal stool normal stool, and urine color. 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. 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 1st day of life. -4 9-15 mg/dl at the 2nd day of life. -5 15-20 mg/dl at the 3rd 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. 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. 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 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 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 • 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 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 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)

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