Jaundice: Hyperbilirubinemia is an elevation of serum bilirubin levels resulting in jaundice.

. Jaundice normally appears in the head (especially the sclera and mucous membranes), and then progresses down the thorax, abdomen, and extremities. Jaundice can be either physiologic or pathologic Physiologic jaundice is considered benign (resulting from normal newborn physiology of increased bilirubin production due to the shortened lifespan and breakdown of fetal RBCs and liver immaturity). The infant with physiological jaundice has no other symptoms and shows signs of jaundice after 24 hr of age. Pathologic jaundice is a result of an underlying disease. Pathologic jaundice appears before 24 hr of age or is persistent after day 7. In the term infant, bilirubin levels increase more than 0.5 mg/dL/hr, peaks at greater than 13 mg/dL, or is associated with anemia and hepatosplenomegaly. Pathologic jaundice is usually caused by a blood group incompatibility or an infection, but may be the result of RBC disorders. Kernicterus (bilirubin encephalopathy) can result from untreated hyperbilirubinemia with bilirubin levels at or higher than 25 mg/dL. It is a neurological syndrome caused by bilirubin depositing in brain cells. Survivors may develop cerebral palsy, epilepsy, or mental retardation. They may have minor effects such as learning disorders or perceptual-motor disabilities. Risk Factors Increased RBC production or breakdown Rh- or ABO-incompatibility Decreased liver function Ineffective breastfeeding Sibling with diagnosed jaundice Certain medications (maternal ingestion of aspirin, tranquilizers, and sulfonamides) Hypoglycemia Hypothermia Anoxia Prematurity

Physical assessment findings Note yellowish tint to skin, sclera, and mucous membranes. To verify jaundice, press the infants skin on the cheek or abdomen lightly with one finger. Then, release pressure and observe the infants skin color for yellowish tint as the skin is blanched. Note the time of jaundice onset to distinguish between physiologic and pathologic jaundice. Assess the underlying cause by reviewing the maternal prenatal, family, and newborn history. Signs of hypoxia, hypothermia, hypoglycemia, and metabolic acidosis can occur as a

result of hyperbilirubinemia and may increase the risk of brain damage. Signs and symptoms of kernicterus: Very yellowish or orange skin Lethargy Hypotonic Poor suck reflex Increased sleepiness If untreated, the infant will become hypertonic with backward arching of the neck and trunk High-pitched cry Fever

Laboratory Tests : An elevated serum bilirubin level may occur (direct and indirect bilirubin). Monitor the infants bilirubin levels every 4 hr until the level returns to normal. Assess maternal and newborn blood type to determine if there is a presence of ABO-incapability. This occurs if the newborn has blood type A, B or AB, and the mother is type O. Review Hgb and Hct. A direct Coombs test reveals the presence of antibody-coated (sensitized) Rhpositive RBCs in the newborn. Check electrolyte levels for dehydration from phototherapy.

Treatment Phototherapy is the primary treatment for hyperbilirubinemia. It is prescribed if an infants serum bilirubin is greater than 15 mg/dL prior to 48 hr of age, greater 18 mg/dL prior to 72 hr of age, and greater 20 mg/dL at anytime. Nursing Care: Observe the infants skin and mucous membranes for signs of jaundice. Monitor the infants vital signs. Set up phototherapy if prescribed. Maintain an eye mask over the newborns eyes for protection of corneas and retinas. Keep the newborn undressed with the exception of a male newborn. A surgical mask should be placed (make like a bikini) over the genitalia to prevent possible testicular damage from heat and light waves. Be sure to remove the metal strip from the mask to prevent burning. Avoid applying lotions or ointments to the infant because they absorb heat and can cause burns. Remove the newborn from phototherapy every 4 hr and unmask the newborns eyes, checking for signs of inflammation or injury. Reposition the newborn every 2 hr to expose all of the body surfaces to the phototherapy lights and prevent pressure sores. Check the lamp energy with a photometer per unit protocol.

 Turn off the phototherapy lights before drawing blood for testing. Observe the newborn for side effects of phototherapy. Bronze discoloration not a serious complication Maculopapular skin rash not a serious complication Development of pressure areas Dehydration (poor skin turgor, dry mucous membranes, decreased urinary output) Elevated temperature Monitor elimination and daily weights, watching for signs of dehydration. Check the newborns axillary temperature every 4 hr during phototherapy, because temperature may become elevated. Feed the newborn early and frequently every 3 to 4 hr. This will promote bilirubin excretion in the stools. Continue to breastfeed the newborn. Supplementing with formula may be prescribed. Maintain adequate fluid intake to prevent dehydration.

Reassure the parents that most newborns experience some degree of jaundice. Explain hyperbilirubinemia, its causes, diagnostic tests, and treatment to parents. Explain that the newborns stool contains some bile that will be loose and green. Nursing Diagnoses: Risk for Fluid Volume Deficit related to phototherapy, increased insensible water loss, and frequent loose stools Potential for Injury related to use of phototherapy Sensory-Perceptual Alterations related to neurologic damage secondary to kernicterus Risk for Altered Parenting related to deficient knowledge of infant care and prolonged separation of infant and parents secondary to illness