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Neonatal Jaundice
The yellow-orange tint of the neonate’s skin and mucous membranes that occurs after 24 hours of life as a result of unconjugated bilirubin in the circulation
Defining Characteristics
Abnormal blood profile (e.g., hemolysis; total serum bilirubin greater than 2 mg/dL; total serum bilirubin in the high-risk range on age in hour-specific nomogram); abnormal skin bruising; yellow mucous membranes; yellow-orange skin; yellow sclera
Related Factors (r/t)
Abnormal weight loss (greater than 7% to 8% in breastfeeding newborn; 15% in term infant); feeding pattern not well established; infant experiences difficulty making transition to extrauterine life; neonate age 1 to 7 days; stool (meconium) passage delayed
Client Outcomes
Client (Infant) Will (Specify Time Frame)
• Establish effective feeding pattern (breast or bottle)
• Receive bilirubin assessment and screening within the first week of life to identify potentially harmful levels of serum bilirubin
• Receive appropriate therapy to enhance indirect bilirubin excretion
• Receive nursing assessments to determine risk for severity of jaundice
• Maintain hydration: moist buccal membranes, 4 to 6 wet diapers in 24 hour period, weight loss no greater than 8% of birth weight
• Evacuate stool within 48 hours of birth, and pass 3 or 4 stools per 24 hours by day 4 of life
Client (Parent[s]) Will (Specify Time Frame)
• Receive information on neonatal jaundice prior to discharge from birth hospital
• Verbalize understanding of physical signs of jaundice prior to discharge
• Verbalize signs requiring immediate health practitioner notification: sleepy infant who does not awaken easily for feedings, fewer than 4 to 6 wet diapers in 24-hour period by day 4, fewer than 3 to 4 stools in 24 hours by day 4, breastfeeds fewer than 8 times per day
• Demonstrate ability to operate home phototherapy unit if prescribed
Nursing Interventions
• Evaluate maternal and delivery history for risk factors for neonatal jaundice (RhD, ABO, G6PD deficiency, direct Coombs).
• Perform neonatal gestational age assessment once the newborn has had an initial period of interaction with mother and father.
• Encourage breastfeeding within the first hour of the neonate’s life.
• Encourage skin-to-skin mother-newborn contact shortly after delivery.
• Assess infant’s skin color at birth and every 8 hours thereafter until birth hospital discharge for the appearance of jaundice.
• Encourage and assist mother with frequent breastfeeding (at least 8 to 12 times per day in the first week of life).
• Assist parents with bottle-feeding neonate.
• Avoid feeding supplements such as water, dextrose water, or any other milk substitutes in breastfeeding neonate.
• Assess neonate’s stooling pattern in first 48 hours of life.
Collect and evaluate laboratory blood specimens as prescribed or per unit protocol.
Monitor transcutaneous bilirubin level in jaundiced neonate per unit protocol or at least once every 8 hours.
• Perform hour-specific total serum bilirubin risk assessment before newborn’s birth center discharge and document the results.
• Monitor newborn for signs of inadequate breast milk or formula intake: dry oral mucous membranes, fewer than 4 to 6 wet diapers per 24 hours, no stool in 24 hours, body weight loss greater than 7% to 8% in breastfeeding infant.
• Assess late preterm infant (born between 34 weeks and 366⁄7 weeks’ gestation) for ability to breastfeed successfully and adequate intake of breast milk.
• Assist mother with breastfeeding and assess latch-on.
• Encourage alternate methods for providing expressed breast milk if maternal health status is compromised (use of expressed breast milk) and assist mother with collection of breast milk via use of breast pump or hand expression.
• Encourage father’s participation in newborn care by changing diapers, helping position newborn for breastfeeding, and holding newborn while mother rests. Weigh newborn daily.
When phototherapy is ordered, place seminude infant (diaper only) under prescribed amount of phototherapy lights.
• Protect infant’s eyes from phototherapy light source with eye shields. Remove eye shields periodically when infant is removed from light source for feeding and parent-infant interaction.
• Monitor infant’s hydration status, fluid intake, skin status, and body temperature while undergoing phototherapy.
Collect and evaluate laboratory blood specimens (total serum bilirubin) while infant is undergoing phototherapy.
• Encourage continuation of breastfeeding and brief infant care activities such as changing diapers while infant is being treated with phototherapy; phototherapy may be interrupted for breastfeeding.
• Provide emotional support for parent(s) of infant undergoing phototherapy.
• Assess infants of Chinese ethnicity for early rising bilirubin levels, especially when breastfeeding.
• Encourage early and exclusive breastfeeding among Chinese and other Asian newborns.
• Assess Chinese and other Asian newborns suspected of being jaundiced with a serum bilirubin level or transcutaneous monitor.
Client/Family Teaching and Discharge Planning
• Teach the breastfeeding mother and support persons about the appearance of jaundice (yellow or orange color of skin) after birth center discharge, and provide health care resource telephone number for parents to call for concerns related to newborn’s care.
• Teach parents regarding the signs of inadequate milk intake: fewer than 3 to 4 stools by day 4, fewer than 4 to 6 wet diapers in 24 hours, and dry oral mucous membranes; additional danger signs include a sleepy baby that does not awaken for breastfeeding or appears lethargic (decreased activity level from usual newborn pattern).
• Teach parents to avoid placing infant in sunlight at home to treat jaundice.
Teach the parent(s) about the importance of medical follow-up in the first several days of life for the evaluation of jaundice.
• Teach parents about the use of phototherapy (hospital or home, as prescribed), the proper use of the phototherapy equipment, feedings, and assessment of hydration, body temperature, skin status, and urine and stool output.
• Patient Safety: Minimizes risk of harm to patient
• Knowledge: Nurses continually assess newborns for risk factors associated with the development of jaundice
• Skills: Nurses use transcutaneous and serum bilirubin measurements to determine the newborn’s bilirubin risk according to the hour-specific nomogram
• Attitudes: Nurses appreciate their role as one of promoting safety for the newborn at risk for developing jaundice
• Knowledge: Nurses implement patient-focused strategies to promote serum bilirubin reduction; these include but are not limited to placing the newborn to mother’s breast in first hours of life and encouraging frequent (every 2 hours) breastfeeding
• Skills: Nurses identify individual clinical risk factors in the neonate that place him/her at risk for jaundice
• Attitudes: Nurses value their role as a health care team member to promote the safe care of the newborn at discharge from the birth center and beyond
• Knowledge: Nurses understand use of phototherapy to reduce levels of indirect bilirubin
• Skills: Nurses use phototherapy lights appropriately
• Skills: Nurses assess infant for untoward effects of phototherapy
• Attitudes: Nurses appreciate the role of phototherapy as a treatment
• Attitudes: Nurses value their role in the promotion of safety with the use of phototherapy
• Quality and Safety Education for Nurses: http://www.qsen.org/ksas_graduate.php#safety and http://www.qsen.org/about_qsen.php
Risk for neonatal Jaundice
At risk for the yellow-orange tint of the neonate’s skin and mucous membranes that occurs after 24 hours of life as a result of unconjugated bilirubin in the circulation
Risk Factors
• Abnormal weight loss (greater than 7% to 8% in breastfeeding newborn; 15% in term infant)
• Feeding pattern not well established
• Infant experiences difficulty making transition to extrauterine life
Nursing Interventions
• Evaluate maternal and delivery history for risk factors for neonatal jaundice (RhD, ABO, G6PD deficiency, direct Coombs).
• Perform neonatal gestational age assessment once the newborn has had an initial period of interaction with mother and father.
• Encourage breastfeeding within the first hour of the neonate’s life.
• Encourage skin-to-skin mother-newborn contact shortly after delivery.
• Assess infant’s skin color at birth and every 8 hours thereafter until birth hospital discharge for the appearance of jaundice.
• Encourage and assist mother with frequent breastfeeding (at least 8 to 12 times per day in the first week of life).
• Assist parents with bottle feeding neonate.
• Avoid feeding supplements such as water, dextrose water, or any other milk substitutes in breastfeeding neonate.
• Assess neonate’s stooling pattern in first 48 hours of life.
• Identify clinical risk factors that place the infant at greater risk of developing neonatal jaundice: exclusive breastfeeding, preterm birth (less than 37 weeks’ gestation), previous sibling with jaundice, East Asian ethnicity, and significant bruising.
Collect and evaluate laboratory blood specimens as determined by presence of clinical risk factors or as prescribed.
Monitor transcutaneous bilirubin level in jaundiced neonate per unit protocol or at least once every 8 hours. The transcutaneous bilirubin levels are a screening tool and not used as a diagnostic measure.
Perform hour-specific total serum bilirubin risk assessment prior to newborn’s birth center discharge and document the results.
• Monitor newborn for signs of inadequate breast milk or formula intake: dry oral mucous membranes, fewer than 4 to 6 wet diapers per 24 hours, no stool in 24 hours, body weight loss greater than 7% to 8% in breastfeeding infant.
• Assist mother with breastfeeding and assess latch-on.
• Encourage alternate methods for providing expressed breast milk if maternal health status is compromised (use of expressed breast milk) and assist mother with collection of breast milk via use of breast pump or hand expression.
• Encourage father’s participation in newborn care by changing diapers, helping position newborn for breastfeeding, and holding newborn while mother rests.
• Weigh late preterm infant and the term newborn daily who is at high risk for inadequate caloric intake daily for the first week of life.
Assess infants of Chinese ethnicity for early rising bilirubin levels, especially when breastfeeding.
• Encourage early and exclusive breastfeeding among Chinese and other Asian newborns.
Assess Chinese and other Asian newborns suspected of being jaundiced with a serum bilirubin level or transcutaneous monitor.
Client/Family Teaching and Discharge Planning
• Teach the breastfeeding mother and support persons about the appearance of jaundice (yellow or orange color of skin) after birth center discharge, and provide health care resource telephone number for parents to call for concerns related to newborn’s care.
• Teach parents regarding the signs of inadequate milk intake: fewer than 3 to 4 stools by day 4, fewer than 4 to 6 wet diapers in 24 hours, and dry oral mucous membranes; additional danger signs include a sleepy baby who does not awaken for breastfeeding, or appears lethargic (decreased activity level from usual newborn pattern).
• Teach parents to avoid placing infant in sunlight at home to treat jaundice.
Teach the parent(s) about the importance of medical follow-up in the first several days of life for the evaluation of jaundice, especially in the late preterm infant.
• Client Safety: Minimizes risk of harm to client
• Knowledge: Nurses continually assess newborns for risk factors associated with the development of jaundice
• Skills: Nurses use transcutaneous and serum bilirubin measurements to determine the newborn’s bilirubin risk according to the hour-specific nomogram
• Attitudes: Nurses appreciate their role as one of promoting safety for the newborn at risk for developing jaundice
• Knowledge: Nurses implement client-focused strategies to promote serum bilirubin reduction; these include but are not limited to placing the newborn to mother’s breast in first hours of life and encouraging frequent (every 2 hours) breastfeeding
• Skills: Nurses identify individual clinical risk factors in the neonate that place him/her at risk for jaundice
• Attitudes: Nurses value their role as a health care team member to promote the safe care of the newborn at discharge from the birth center and beyond
• Quality and Safety Education for Nurses: http://www.qsen.org/ksas_graduate.php#safety and http://www.qsen.org/about_qsen.php