11.05 Hyperbilirubinemia (Jaundice)

Overview

  1. Definition: an elevated total bilirubin compared to the newborns age in hours
    1. Graphed: Bilirubin level compared to hours of age

Nursing Points

General

  1. Bilirubin explanation
    1. Formed in the liver when old RBC’s are broken down (a natural, normal process) → excreted into bile and urine
    2. When it’s needed, it is released from the gallbladder and goes to the small intestines to get to work, helping digest fats
    3. We then excrete it in our feces and it is what makes feces brown
  2. Why is this commonly seen in newborns?
    1. In utero, the placenta removes the bilirubin from the baby’s body because they don’t excrete it in their feces until  after they are birth
    2. Some newborn’s will have a liver that is immature or takes longer to work efficiently
  3. Pathological vs. physiological
    1. Physiological jaundice- starts 2nd or 3rd day of life can be expected as this normal transition from placenta doing the work to the baby’s liver.  
      1. Breastfeeding
      2. Broken down RBCs (bruising)
      3. Prematurity
    2. Pathological:Jaundice that appears within the first 24 hours of life indicates that there is a pathological process going on. Something else other than this normal process, and requires further investigation/assessment.
      1. Blood incompatibility
      2. Problem with liver
  4. Concern
    1. Kernicterus-brain damage that can occur If hyperbilirubinemia is sustained

Assessment

  1. Jaundice
    1. Definition: Accumulation of bilirubin, resulting in yellowing of skin, sclera
    2. Assess skin in natural light
    3. Assess skin head to extremities, usually starts in forehead or face
    4. Jaundice in first 24 hours is a red flag for PATHOLOGICAL issues – notify MD!
  2. Elevated bilirubin levels
    1. Plotted on graph as low risk, high-intermediate risk, or high risk
      1. High risk needs phototherapy
    2. Some variant but a total level  of 12 at day 2 to 3 is usually high risk with critical being greater than 15 mg/dl

Therapeutic Management

  1. Frequent feeding→ hydration and nutrition
  2. Phototherapy

Nursing Concepts

  1. Human Development
  2. Gastrointestinal/Liver Metabolism
  3. Nutrition

Patient Education

  1. Feeding frequently
  2. Keeping them under the light
  3. Goggles
  4. Importance of phototherapy

Reference Links

Instantly Unlock over 1000+ Nursing Lessons

Create Your Free Account

Get Started

Video Transcript

In this lesson I will talk about hyperbilirubinemia and your role in care of this patient.

So what is hyperbilirubinemia? It is high bilirubin. Ok what is bilirubin? Bilirubin is form in the liver from broken down red blood cells. The bilirubin is then excreted into the feces. Why is this a common problem in newborns? Well a few things, the newborns didn’t have to worry about doing this when they were in utero and now they sometimes have an immature liver that is trying to do its job. They might have bruising from delivery which means more broken down red blood cells. They might not be feeding great which means they aren’t stooling alot and excreting the bilirubin. There are two classifications, pathological and physiological jaundice to understand.

So our pathological versus physiological. Pathological jaundice appears within the first 24 hours of life and it indicates that there is a pathological process going on. This means something else other than this normal process. So this could be a blood incompatibility between mom and baby and blood mixture has occurred. If the baby has maternal blood that doesn’t match then he is going to work hard to break down those red blood cells which means there will be more broken down red blood cells. Another cause could be a diseased liver. It is working properly. So pathological jaundice will requires further investigation and assessment. Physiological jaundice starts the 2nd or 3rd day of life and can be expected as this normal transition from placenta doing the work to the baby’s liver. Causes of this are bruising from delivery. So bruising is broken down red blood cells so if we have extra of these it is adding to the work of the liver and the baby can not excrete it quick enough. Prematurity because the liver is just immature and not able to keep up. Breastfeeding is another cause because the baby isn’t getting enough to stool enough and get the bilirubin excreted. Our concern for anytime of jaundice is if it goes untreated and levels rise to dangerous levels then kernicterus could occur which is brain damage.

This newborn is going to be assessed like normal with the head to toe assessment but you will observe jaundice on a patient with hyperbilirubinemia. So yellowing of the skin and sclera. This starts at the head usually and as it builds the yellow color spreads from head to extremities. So they might be a touch yellow on face and then as you see it move down to the diaper area it is rising. You need to have good lighting and really assess the skin. If jaundice coloring happens in first 24 hours it is a red flag that we have pathological problems so notify the doctor to draw a bilirubin. Once you have your bilirubin level from the lab you can graph it. This is how you will assess if phototherapy is needed. So let me draw this graph for you. On one side we have the bilirubin level on the other it is the hours of life. And you plot your number and it will either fall in the low risk, ow intermediate, high-intermediate, or high risk. High risk levels needs phototherapy. You do need a physician order for phototherapy but at least you will know to expect that we need to light the kid up. There is some variant based on different labs or if it is a pathological issue but a total level of 12 mg/dl at day 2 to 3 is usually high risk with critical being greater than 15 mg/dl.

Management is going to be frequent feeding. We need the baby to stay hydrated and get enough volume so that the baby will stool more. The more they eat the more they excrete, right? We will initiate phototherapy treatment if levels are high enough. Education is important if the lights are started. The baby needs to wear protective goggles over their eyes and stay under the light. So you can see in this image the goggles on the eyes. I just wanted you to have an idea of what that was and have a visual. The googles protect their eyes from the light and it is funny because when you take them out from the light to assess them or draw labs you remove the goggles and can see a yellow ring around their eyes like a racoon. That is always a good sign that the bilirubin is coming down. The babies hate being under this light because they have no clothes on, they are un-swaddled and can’t be held. So it can be quite miserable for them and the parents. But if they don’t stay under this light it will get worse.

Human development is a concept because if this is pathological then it is related to development, liver metabolism because it is working to excrete the bilirubin and nutrition because we need the baby well fed and hydrated to excrete the bilirubin.
So on to the important facts. Remember these and you will have a good grasp of what this is. We have high bilirubin levels in the blood. The bilirubin comes from broken down red blood cells. It is secreted by the liver so if we have anything that causes a lot of broken down red blood cells like bruising or blood incompatibility and an immature liver then the bilirubin can’t be excreted fast enough. This will cause jaundice to occur and our treatment is phototherapy to reduce the bilirubin.

Make sure you check out the resources attached to this lesson and review the differences between physiological and pathological. Now, go out and be your best selves today. And, as always, happy nursing.

Read more

  • Question 1 of 10

A 3-day old infant requires phototherapy for elevated bilirubin levels. Which of the following is part of nursing care for an infant undergoing phototherapy? Select all that apply.

  • Question 2 of 10

You are working in a postpartum unit caring for 4 mothers and 5 babies. Which of the following newborn bilirubin levels are MOST concerning to you? Select all that apply.

  • Question 3 of 10

A nurse enters the room after receiving report that a newborn is on overhead phototherapy. Which finding would be most concerning?

  • Question 4 of 10

A nurse notes a high risk bilirubin level on a newborn. After notifying the provider, which provider order should be questioned?

  • Question 5 of 10

You are caring for a newborn on phototherapy due to hyperbilirubinemia. Which of the following interventions are nursing priorities with this diagnosis? Select all that apply.

  • Question 6 of 10

Which priority intervention should a nurse expect for an infant that is jaundice on the face and sclera at 22 hours of life?

  • Question 7 of 10

A nurse is educating a breastfeeding mother on how to help a newborn with a high bilirubin level. Which of the following should be included?

  • Question 8 of 10

A nurse is caring for a 2-day-old infant who requires phototherapy for treatment of jaundice. Which information would be included as part of the nurse’s subjective assessment?

  • Question 9 of 10

Which infants are most at risk for hyperbilirubinemia? Select all that apply

  • Question 10 of 10

A nurse is caring for a three day old, full-term infant who requires phototherapy for increased levels of bilirubin in the body. Which of the following nursing diagnoses is most appropriate for this infant? Select all that apply.

Module 0 – OB Course Introduction

Study Plans are available to NRSNG Users
Sign Up Now