Nursing Care of Neonatal Hyperbilirubinemia PDF

Nursing care of neonatal Hyperbilirubinemia Under supervision : Dr Naglaa Fathy Dr Nehal Shehta  Presented by:- NO Student Name Student ID 1 Ahmed Mohamed Ibrahim Elfeshawy 2022011266 2 Ahme...

Nursing care of neonatal Hyperbilirubinemia Under supervision : Dr Naglaa Fathy Dr Nehal Shehta  Presented by:- NO Student Name Student ID 1 Ahmed Mohamed Ibrahim Elfeshawy 2022011266 2 Ahmed Fekry Mostafa Abdel Hamid 2021008893 3 Hassan Khaled Fathe Ibrahim 2022012837 4 Ahmed Abdel Fattah Elsayed 2021010366 5 Ahmed Saeed Mohamed Mohamed 2023004074 6 Hossam Rabie Muhammad 2022014328 7 Hassan Abdel Hamid Ibrahim 2022014280 8 Ahmed Ayman Youssef 202020268 9 Alhassan Ali 2021010212 10 Ahmed Mohamed Hussein 20228532 At the end of this presentation the student will able to :- Define Hyperbilirubinemia and jaundice Discuss pathophysiology of Hyperbilirubinemia List causes and clinical manifestation of Hyperbilirubinemia. Explain Complication of Hyperbilirubinemia. Apply the management for the newborn baby. Illustrate prevention to Hyperbilirubinemia. Outline Introduction Definition of Hyperbilirubinemia and jaundice Types of bilirubin Pathophysiology of Hyperbilirubinemia Causes of Hyperbilirubinemia Types of Jaundice Clinical manifestion of Hyperbilirubinemia Complication of Hyperbilirubinemia Management of Hyperbilirubinemia Prevention of Hyperbilirubinemia Discharge plan  Introduction Hyperbilirubinemia refers to an excessive level of accumulated bilirubin in the blood and is characterized by jaundice, or icterus, a yellowish discoloration of the skin, sclerae , and nails. Hyperbilirubinemia is a common finding in newborns and in most instances is relatively benign. However, in extreme cases, it can indicate a pathologic state. Hyperbilirubinemia may result from increased unconjugated or conjugated bilirubin. The unconjugated form or indirect hyperbilirubinemia  Definition Hyperbilirubinemia refers to an excessive level of accumulated bilirubin in the blood Hyperbilirubinemia is a common finding in newborns and in most instances is relatively benign. However, in extreme cases, it can indicate a pathologic state Jaundice is yellowish discoloration of the skin, sclerae, and mucous membranes resulting from deposition of the bile pigment bilirubin.  Normal range of bilirubin :- The presence of jaundice on clinical examination indicates hyperbilirubinemia, which is defined as a total serum bilirubin greater than 1.5 mg/dL. In general, jaundice becomes evident at serum bilirubin concentrations greater than 3 mg/dL in older children and greater than 5 mg/dL in newborns. Normal values of unconjugated bilirubin are 0.2 to 1.4 mg/dl Hyperbilirubinemia is typically characterized by the fraction of bilirubin that is increased, unconjugated (indirect), or conjugated (direct).  Function of the liver Glucose, protein, fat metabolism Ammonia conversion Vitamins (A, B, D); iron and copper storage Drug/Hormone metabolism Bile formation Bilirubin excretion Immunity Bilirubin Metabolism Pathophysiology : Causes Early Intermediate Late Hemolytic causes:- Physiological jaundice:- Conjugated (Dark urine, pale Rh isoimmunization Breast milk jaundice stools):- ABO incompatibility (In adequate intake) Bile duct obstruction G6PD Deficiency Sepsis Biliary atresia Polycythemia ,bruising. Neonatal hepatitis Congenital infection. Hemolysis. Cephalhematoma. Un conjugated: Physiological Breast milk jaundice Infection Hypothyroidism Risk factors for jaundice  Types of jaundice:- Physiologic Jaundice Pathologic Jaundice Cause ▪ Immature hepatic function ▪ Hemolytic diseases (ABO & ▪ Increase bilirubin load from RBC hemolysis Rh)Incompatibility,G6PD) ▪ Inability of liver to excrete excess of bilirubin Onset After 24 h ((preterm infants, prolonged) During first 24h (levels increase >5 mg/dl/day) Peak 3nd to 4th day variable Duration Declines on 5th to 7th day Depends on severity and treatment Therapy ▪ Increase frequency of feeding ▪ Monitor TSB(Total serum bilirubin) ▪ Evaluate stool pattern ▪ Phototherapy ▪ Monitor bilirubin level ▪ Intravenous immunoglobulin ▪ Use phototherapy if bilirubin levels increase ▪ Exchange Transfusion significantly or significant hemolysis is ▪ If mother is breastfeeding, assist with present. maintenance and storage of milk; may bottle feed expressed milk as appropriate to therapy  Types of jaundice cont :- Breast feeding associated jaundice(Early Breast milk jaundice onset) (late onset) Cause ▪ Decreased milk intake related to fewer ▪ Possible factors in breast milk that calories consumed by infant before mother's prevent bilirubin conjugation milk is well established; enterohepatic ▪ Less frequent stooling shunting Onset 2nd to 4th day 4th to 8th day Peak 3rd to 5th day 10th to 15th day Duration Variable May remain jaundice for 3-12 week or more Therapy ▪ Evaluate stooling pattern; stimulate as needed ▪ phototherapy with a temporary (10 to 12 ▪ Increase frequency of breast feeding (10 to 12 hours) discontinuation of breastfeeding; times/day) a subsequent TSB may be drawn to ▪ Use phototherapy if bilirubin levels increase evaluate a drop in serum levels. significantly or significant hemolysis is present  Diagnosis of Jaundice:- General Clinical examination manifestations  General examination Kaiser Fleisher ring 1. Growth pattern and developmental milestones. 2. Eye: Chronic liver ❖ Color of the sclera, skin , mucous membranes disease ❖ Corneal examination for Wilson Disease 3. Evidence of vitamin deficiency (ADEK ex: bleeding tendency) 4. Evidence of chronic liver disease (ex: Palmar erythema)  Radiology: It is not a routine but depends on the history, examination and initial labs: 1. Abdominal U/S: The most useful initial imaging investigation for assessment of intra and extrahepatic biliary systems. 2. MRCP: Magnetic resonance cholangiopancreatography (MRCP) May be useful in diagnosing obstruction of the biliary system. 3. Liver biopsy: Indications: 1 Hepatitis of unknown etiology 2 Tumor 3 Cysts 4 Parasites 5 Differentiate between hepatic and biliary problem when other methods failed Hazards: 6 Hemorraghe 7 Missed lesion 3 – Liver parenchymal damage  Investigations Laboratory 1. B:ilirubin total and direct. 2. Blood group, CBC, Retics count 3. Liver Panel tests: Serum ALT, AST, GGT, Alk ph, albumin 4. Coagulopathy profile: PT, PTT 5. Other lab tests: according to history and initial lab tests. I. HB electrophoresis II. G6PD III. Osmotic fragility tests, etc. IV. Hepatitis markers and TORCH V. Blood culture VI. Ceruloplasmin/ Enzyme essay for storage ds VII. Auto immune markers oAbdominal swelling. Local examination oHepatomegaly. oSplenomegaly. oDivarication of recti. oAbdominal wall vascular pattern. oAscites.  Lab investigation ▪ Persistent jaundice over 2 weeks in a full-term formula-fed infant ▪ Total serum bilirubin levels over 12.9 mg/dl (term infant) or over 15 mg/dl (preterm infant); the upper limit for breastfed infant is 15 mg/dl ▪ Increase in serum bilirubin by 5 mg/dl/day ▪ Direct bilirubin exceeding 1.5 to 2 mg/dl ▪ Total serum bilirubin level over the 95th percentile for age (in hours) on an hour-specific nomogram  Clinical Manifestations ❑Yellow discoloration of the skin ❑ mucous membranes and sclera of the eyes ❑excessive sleepiness ❑Light-colored stool ❑Lethargy ❑Changes in muscle tone ❑High-pitched crying ❑Fever ❑Vomiting Complication ❑Kernicterus (Bilirubin Encephalopathy) : Is a neurological disorder occurs when the unconjugated serum bilirubin level exceeds than 20 mg/dl. In small, sick preterm infants, even a bilirubin level in a low range may cause Kernicterus. ❑Acute Bilirubin Encephalopathy Definition :- Is a syndrome of disturbed neurologic function in the earliest days of life in an infant born at or beyond 35 weeks of gestation.  Management for Neonatal Jaundice:- Medical Management:-  Nonpharmacological:- Phototherapy Exchange Transfusion Pharmacological:- Intravenous Immunoglobulin (IVIG) phenobarbital Nursing Management  Non Pharmacological Phototherapy consists of the application of a special source of light (irradiance) to the infant's exposed skin. Light promotes bilirubin excretion by photoisomerization, which alters the structure of bilirubin to a soluble form (lumirubin) for easier excretion.  Types of Phototherapy LED Phototherapy : Light-emitting diode (LED) phototherapy uses light-emitting diodes to emit specific wavelengths of light. LED lights are cooler and consume less energy compared to conventional fluorescent lights. They are available in various colors, including blue and green, and can be used for both mild and severe cases of hyperbilirubinemia. Double Phototherapy : Double phototherapy involves using two light-emitting devices simultaneously, either two overhead lights or a combination of overhead lights and a fiber-optic blanket. This method increases the surface area exposed to light, allowing for more effective treatment.  Types of Phototherapy:- Conventional phototherapy:- more effective at lowering serum bilirubin values than fiberoptic lights alone Fiber optic phototherapy :- Bili blankets are another popular means of Administering phototherapy to infants with jaundice. Combination phototherapy (fiberoptic mattress and conventional overhead lights) was found to be more effective than conventional therapy alone  Side effect of Phototherapy : Hyperthermia. dehydration. Loose bowel movements. Electrolyte imbalance. Retinal damage. Skin rash Bronze baby syndrome (if used with direct Hyperbilirubinemia). Potential genetic mutations.  Nursing care for phototherapy : ❑ Perform hand wash. ❑Place baby naked in incubator. ❑place the infant about 45 to 50 cm bellow the phototherapy light. ❑Position phototherapy lamps or mattresses to provide the most complete skin exposure possible. ❑Provide Eye Protection: Opaque eye shields must be used during phototherapy to protect the infant's eyes from retinal damage. Each shift, eyes are checked for evidence of discharge or excessive pressure on the lids. Provide eye care using warm water, then apply eye drops or ointment ❑Provide gonad protection : ✓phototherapy can produce DNA strand breakage Cover the infant’s eye and genital organs. ❑Assess Skin Exposure. ❑Proper Positioning : ✓The infant repositioned frequently (every 2 h). ✓monitor vital signs every 2-4 hours. ✓Maintain a neutral thermal environment ❑Promoting elimination and Skin Integrity : ✓Assess the infant's urine output is an important measure not only of hydration but also of elimination of bilirubin. ✓Protective skin care is necessary to prevent perianal skin breakdown from watery stools. ✓Do not apply any cream or oil to the exposed area of skin because they can cause skin burns during therapy. ✓Examine the newborn's skin regularly for signs of developing pressure areas, bronzing, rash.  Exchange Transfusion : is a more invasive procedure used in severe cases of hyperbilirubinemia. It involves removing a small amount of the baby's blood and replacing it with donor blood or a blood substitute. Exchange transfusion rapidly lowers bilirubin levels by directly replacing the baby's blood, but it carries some risks and is reserved for critical situations. The exchange transfusion usually is performed through an umbilical venous catheter placed in the inferior vena cava or at confluence of the umbilical vein and the portal system.  Complications o exchange transfusion : o Air embolism o Volume imbalance o Arrhythmias o Acidosis o Respiratory distress o Unexpected collapse o Hyperkalemia o Anemia/Polycythemia o Hypocalcaemia o Hypoglycemia o Thrombocytopenia  Nursing management:- Observations should be repeated at 15 minute intervals Temperature Heart rate Respiratory rate Blood pressure Oxygen saturations Every 30 minutes check the glucose level Monitored intake and output Maintain adequate fluid intake Monitoring Bilirubin Levels Provide family support  pharmacology Therapy:- Intravenous Immunoglobulin (IVIG): is effective in reducing bilirubin levels in infants with Rh isoimmunization and ABO incompatibility. Studies have shown a decrease in hospital stay and duration of phototherapy when IVIG is administered either as single-dose or two-dose regimens in neonates with hemolytic disease. Healthy late-preterm and full-term infants with jaundice may also benefit from early initiation of feedings and frequent breastfeeding. These preventive measures are aimed at promoting increased intestinal motility, decreased enterohepatic shunting, and normal bacterial flora in the bowel to effectively enhance the excretion of unconjugated bilirubin  Pharmacology(cont.):- phenobarbital :-has centered primarily on the infant with hemolytic disease and is most effective when given to the mother several days before delivery. Action:- Phenobarbital promotes hepatic glucuronyl transferase synthesis which increases bilirubin conjugation and hepatic clearance of the pigment in bile and protein synthesis which may increase albumin for more bilirubin binding sites. The use of phenobarbital in either the antenatal or the postnatal period has not proved to be as effective as other treatments in reducing bilirubin.  Nursing care plan Nursing diagnosis Objective Nursing Intervention Evaluation Interrupted breastfeeding Short term: Assessment : after 24 hrs from nursing related to increased after 24 hours of nursing: 1. Assess the baby feeding intervention : bilirubin levels in the blood intervention the bilirubin level pattern 1. the Baby bilirubin level as evidenced by will decrease to 1.9 mg/dl. 2. Assess bilirubin level in the decreased to 1.9mg /dl After 3 Subjective data : 1: Long term: blood regularly days from nursing intervention : Verbal report of mother that After 3 days of nursing 3. Assess the signs of 2. (1.5)The bilirubin level : intervention The bilirubin level dehydration reterned to normal level 1. Baby not feed well will return to normal range. 4. Assess the baby weight dialy 2.yellowish coloration of (1.5)The baby will regain normal Intervention : 3. The baby regained the normal face breastfeeding. 1. Weight baby dialy breast feeding Objective data : 2. pattern: As evidenced by No 2. Monitor breastfeeding pattern As evidenced by : 1.Baby has signs of jaundice. verbal report of yellowish 3. Encourage mother to 1. No verbal report of yellowish 2. Poor weight gain (15 mg coloration of the.1of the skin No breastfeeding frequently to coloration of the skin dialy sings of jaundice.2Normal promot bilirubin excretion 2. No signs of jaundice 3.increase bilirubin level in weight gain (30mg/ dialy) 4. Observe sings of dehydration 3. Normal weight gain (30 mg the blood to 6 mg /dl 3.Normal level of bilirubin 4.No 5. Provide appropriate skin care dialy) 4.signs of dehydration sings of dehydration in needed 4. Normal bilirubin level in the 5. Decreased urine output 5.Normal urine output 6.Normal 6. Collaborate with dietitian to blood urine output describe appropriate formula if 5. No signs of dehydration needed 6. Normal urine output Nursing diagnosis Objective Nursing Intervention Evaluation 7. Adminster phototherapy as prescribed and monitor for any side effect as (skin rash, dehydration and loose bowel movement) Health Education : 1. Instruct the mother about the importance of breast feeding 2. Instruct the mother about the importance of hydration and diet to support breast feeding 3.. Educate the mother about how to perform nipple care 4. Instruct the mother about how to express breast milk and use of breast pump in available Nursing diagnosis Objective Nursing Intervention Evaluation Risk for Neonatal Jaundice - The newborn will maintain Assessment:- - Assess daily bilirubin levels related to Immaturity of the bilirubin levels within the Monitor bilirubin levels, showing a downward trend. Liver normal range. including total and direct - Note improvement in skin and as evidenced by - - The newborn will show no bilirubin. scleral color Subjective data : signs of jaundice by - Assess skin and sclera for.- Confirm adequate feeding and Verbal report of mother that discharge. jaundice hydration status : - - The newborn will have - Evaluate feeding patterns.- Verify parental understanding 1. Baby not feed well adequate hydration and (breastfeeding or formula) of jaundice and care instructions 2.yellowish coloration of face nutrition. - Monitor weight and As evidenced by : hydration status 1. No verbal report of yellowish Objective data : - Observe urine and stool coloration of the skin 1. Elevated bilirubin levels on color. 2. No signs of jaundice laboratory tests Interventions:- 3. Normal weight gain (30 mg 2. Abnormal movements, Assess and Monitor: dialy) such as arching of the back or - Measure and document 4. Normal bilirubin level in the muscle stiffness bilirubin levels daily as per blood 3. Light-colored stools protocol. 5. No signs of dehydration 4. Dark yellow urine - Perform frequent assessments 6. Normal urine output of skin and scleral color. - Encourage early and frequent feeding Nursing diagnosis Objective Nursing Intervention Evaluation Ensure the newborn is well-hydrated to support liver function and bilirubin excretion. Health Education - Educate Parents: - Inform about signs of jaundice to monitor after discharge. - Provide guidance on the importance of follow-up appointments for bilirubin checks. - Educate parents on proper breastfeeding techniques or formula feeding, if necessary.  Prevention Promote and support successful breastfeeding Perform a systematic assessment before discharge for the risk of severe hyperbilirubinemia. Provide early and focused follow-up based on the risk assessment; and when indicated, treat newborns with phototherapy. Interpret all bilirubin levels according to the infant’s age in hours Recognize that infants at less than 38 weeks’ gestation, particularly those who are breastfed, are at higher risk of developing hyperbilirubinemia and require closer surveillance and monitoring. Recognize that visual estimation of the degree of jaundice can lead to errors, particularly in darkly pigmented infants.  Breast feeding:- -Should be encourage for most women.-8- 12times /day for 1st several days. -Avoid supplements in non dehydrate infant. Parent education Discharge Planning and Home Care.