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Client (Infant) Will (Specify Time Frame)

Client (Parent[s]) Will (Specify Time Frame)

• Evaluate maternal and delivery history for risk factors for neonatal jaundice (RhD, ABO, G6PD deficiency, direct Coombs). Assessment of maternal and neonatal risk factors that may cause jaundice is important in the detection of neonatal jaundice (Perry et al, 2010).

• Perform neonatal gestational age assessment once the newborn has had an initial period of interaction with mother and father. EB: Gestational age assessment is important to determine potential risk factors in the neonatal population. Infants who are born late preterm (34 to 36 weeks at birth) are at significantly increased risk for problems related to hyperbilirubinemia, feeding problems, and hospital readmission (Blackburn, 2012; Souto & Hallas, 2011).

• Encourage breastfeeding within the first hour of the neonate’s life. EB: Early feedings increase neonatal intestinal activity, and infant begins establishing intestinal flora; in addition, early breastfeeding promotes enhanced maternal confidence in breastfeeding (Alex & Gallant, 2008; Blackburn, 2012).

• Encourage skin-to-skin mother-newborn contact shortly after delivery. Early skin-to-skin mother-baby contact helps promote maternal confidence in nurturing abilities (Alex & Gallant, 2008).

• Assess infant’s skin color at birth and every 8 hours thereafter until birth hospital discharge for the appearance of jaundice. Initial and ongoing neonatal skin assessment is important in the detection of jaundice (National Association of Neonatal Nurses, 2010). CEB: Jaundice is visible when bilirubin levels reach 5 to 6 mg/dL (Blackburn, 2012) and is reported to first appear on the face and head, then slowly advance to the trunk, arms, and lower extremities (Ambalavanan & Carlo, 2011). CEB: Skin color alone is not a reliable assessment for neonatal jaundice; therefore, it is important that such assessments be supported with empiric serum bilirubin measurements or transcutaneous bilirubin measurements when jaundice is suspected (American Academy of Pediatrics, 2004).

• Encourage and assist mother with frequent breastfeeding (at least 8 to 12 times per day in the first week of life). Frequent breastfeeding stimulates neonatal gut motility and enhances stooling, thus decreasing intestinal reabsorption of bilirubin; in addition, frequent breastfeeding stimulates breast milk production (Blackburn, 2012). Exclusive breastfeeding is recommended for neonatal feedings yet is associated with the development of hyperbilirubinemia, not directly as a result of the feeding substrate but perhaps due to decreased caloric intake in the first week of life and a substance in breast milk that may interfere with bilirubin excretion (Alex & Gallant, 2008; Blackburn, 2012).

• Assist parents with bottle-feeding neonate. Adequate caloric intake is essential for the promotion of stooling and the subsequent elimination of bilirubin from the intestine. Parents are assisted in feeding the neonate to ensure adequate growth and development (Blackburn, 2012; Hockenberry & Wilson, 2011).

• Avoid feeding supplements such as water, dextrose water, or any other milk substitutes in breastfeeding neonate. CEB: Supplements may act to decrease the effective establishment of breastfeeding (American Academy of Pediatrics, 2004; Blackburn, 2012).

• Assess neonate’s stooling pattern in first 48 hours of life. Delayed stooling may indicate inadequate breast milk intake and may further increase reabsorption of bilirubin from neonate’s intestine (Blackburn, 2012).

 Collect and evaluate laboratory blood specimens as prescribed or per unit protocol. Because visual assessments of skin color alone are inadequate to determine rising levels of bilirubin, serum bilirubin measurement may be gathered to evaluate risk for pathology (Ambalavanan & Carlo, 2011; National Association of Neonatal Nurses, 2010). The purpose in monitoring, evaluating, and implementing treatment in moderate to severe cases of neonatal hyperbilirubinemia is to prevent neonatal encephalopathy, an early acute central nervous system bilirubin toxicity that is related to the amount of unbound (indirect) bilirubin. Kernicterus describes the yellow staining of brain cells and subsequent necrosis that occurs secondary to exposure to high levels of unconjugated (indirect) bilirubin; kernicterus involves long-term, permanent central nervous system changes (American Academy of Pediatrics, 2004; Blackburn, 2012). Bilirubin-induced neurologic dysfunction (BIND) is a term used to describe the spectrum of symptoms associated with acute encephalopathy and kernicterus (Johnson & Bhutani, 2011).

 Monitor transcutaneous bilirubin level in jaundiced neonate per unit protocol or at least once every 8 hours. Noninvasive bilirubin monitoring is a safe and effective means for monitoring bilirubin levels and determining risk for increasing serum bilirubin levels (American Academy of Pediatrics, 2004; National Association of Neonatal Nurses, 2010).

• Perform hour-specific total serum bilirubin risk assessment before newborn’s birth center discharge and document the results. CEB: The use of an hour-specific nomogram for designation of risk in healthy, late preterm, and term infants, as well as clinical risk factors, may be used to determine the relative risk of rapidly increasing bilirubin levels requiring medical intervention such as phototherapy (American Academy of Pediatrics, 2004; Maisels et al, 2009). In addition to the hour-specific nomogram risk factors that have been identified as predicting an increased probability for severe jaundice include lower gestational age and exclusive breastfeeding (Maisels et al, 2009; National Association of Neonatal Nurses, 2010).

• 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. Inadequate intake of breast milk in the neonatal period has been identified as a risk factor for the development of hyperbilirubinemia (Alex & Gallant, 2008).

• Assess late preterm infant (born between 34 weeks and 36 weeks’ gestation) for ability to breastfeed successfully and adequate intake of breast milk. Late preterm infants are at higher risk for breastfeeding and inadequate milk intake due to physiological immaturity. Such infants are also at a much higher risk for severe jaundice than term counterparts (Radtke, 2011; Souto & Hallas, 2011).

• Assist mother with breastfeeding and assess latch-on. Successful breastfeeding in the first few weeks of life is associated with decreased levels of serum bilirubin (Blackburn, 2012).

• 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. Alternate feeding methods for the ingestion of breast milk may be used to enhance milk intake necessary to promote stooling and enhance bilirubin excretion (Alex & Gallant, 2008).

• Encourage father’s participation in newborn care by changing diapers, helping position newborn for breastfeeding, and holding newborn while mother rests. Weigh newborn daily. Daily weights assist in the detection of excess weight loss, which is often indicative of inadequate caloric intake (Alex & Gallant, 2008).

 When phototherapy is ordered, place seminude infant (diaper only) under prescribed amount of phototherapy lights. EB: Phototherapy is the primary therapy used to treat mild to moderate neonatal indirect (unconjugated) hyperbilirubinemia; phototherapy enhances indirect bilirubin excretion. In order for phototherapy to be effective, the infant must have a large skin surface area exposed to the light source (Blackburn, 2012; Stokowski, 2011). Turning the infant periodically has not been shown to reduce circulating bilirubin levels (Stokowski, 2011).

• 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. Retinal damage may occur from light exposure (Bhutani and American Academy of Pediatrics, 2011; Stokowski, 2011).

• Monitor infant’s hydration status, fluid intake, skin status, and body temperature while undergoing phototherapy. Transient side effects of phototherapy include increased body temperature, increased insensible water loss, increased gastrointestinal water loss (loose stools), lethargy, irritability, and poor feeding. There is no evidence that removing the infant for parent-infant interaction during feedings and for brief caregiving activities prevents the effectiveness of phototherapy when the infant has mild to moderate hyperbilirubinemia (Blackburn, 2012; Stokowski, 2011).

 Collect and evaluate laboratory blood specimens (total serum bilirubin) while infant is undergoing phototherapy. Transcutaneous bilirubin measurements do not provide an adequate estimate of serum bilirubin level and are not effective once phototherapy has been initiated (American Academy of Pediatrics, 2004).

• 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. EB: In most cases breastfeeding is not interrupted for phototherapy; the benefits of breastfeeding exceed any potential harm (American Academy of Pediatrics, 2004). If the infant’s oral intake with breastfeeding is inadequate, the American Academy of Pediatrics (2004) recommends supplementation with expressed breast milk or formula.

• Provide emotional support for parent(s) of infant undergoing phototherapy. Separation of the infant from the mother for phototherapy disrupts parent-infant interaction and may promote parental stress and decrease the effective establishment of breastfeeding (Stokowski, 2011).

• 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

• Prematurity

• Stool (meconium) passage delayed

• Neonatal total serum bilirubin will be monitored and there will be no undetected values in the high-risk or high-intermediate risk critical categories (as determined by hour-specific nomogram)

• Newborn will receive appropriate therapy to enhance bilirubin excretion

• Newborn will remain free of undetected signs of bilirubin neurotoxicity

• Establish effective feeding pattern (breast or bottle)

• Receive bilirubin assessment and screening within the first week of life to detect increasing levels of serum bilirubin

• Receive nursing assessments to determine risk for severity of jaundice prior to discharge

• 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 to 4 stools per 24 hours by day 4 of life

• Evaluate maternal and delivery history for risk factors for neonatal jaundice (RhD, ABO, G6PD deficiency, direct Coombs). CEB: Assessment of maternal and neonatal risk factors that may cause jaundice is important in the detection of neonatal jaundice (American Academy of Pediatrics, 2004).

• Perform neonatal gestational age assessment once the newborn has had an initial period of interaction with mother and father. EB: Gestational age assessment is important to determine potential risk factors in the neonatal population. Infants who are born late preterm (34 to 36 weeks at birth) are at significantly increased risk for problems related to hyperbilirubinemia, feeding problems, and hospital readmission (Maisels et al, 2009; Souto, Pudel, & Hallas, 2011; Watchko, 2009).

• Encourage breastfeeding within the first hour of the neonate’s life. EB: Early feedings increase neonatal intestinal activity, and infant begins establishing intestinal flora; in addition, early breastfeeding promotes enhanced maternal confidence in breastfeeding (Alex & Gallant, 2008; Blackburn, 2012; Lawrence & Lawrence, 2011).

• Encourage skin-to-skin mother-newborn contact shortly after delivery. Early skin-to-skin mother-baby contact helps promote maternal confidence in nurturing abilities (Alex & Gallant, 2008).

• Assess infant’s skin color at birth and every 8 hours thereafter until birth hospital discharge for the appearance of jaundice. Initial and ongoing neonatal skin assessment is important in the detection of jaundice (Hockenberry & Wilson, 2011). Jaundice is visible when bilirubin levels reach 5 to 6 mg/dL (Blackburn, 2012) and is reported to first appear on the face and head, then slowly advance to the trunk, arms, and lower extremities (Beachy, 2007). CEB: Skin color alone is not a reliable assessment for neonatal jaundice; therefore, it is important that such assessments be supported with empiric serum bilirubin measurements or transcutaneous bilirubin measurements when jaundice is suspected (American Academy of Pediatrics, 2004; Bhutani et al, 2008).

• Encourage and assist mother with frequent breastfeeding (at least 8 to 12 times per day in the first week of life). CEB: Frequent breastfeeding stimulates neonatal gut motility and enhances stooling, thus decreasing intestinal reabsorption of bilirubin; in addition, frequent breastfeeding stimulates breast milk production (Blackburn, 2012). Exclusive breastfeeding is recommended for neonatal feedings, yet is associated with the development of hyperbilirubinemia, not directly as a result of the feeding substrate but perhaps due to decreased caloric intake in the first week of life and a substance in breast milk that may interfere with bilirubin excretion (Alex & Gallant, 2008; Blackburn, 2012; Lawrence & Lawrence, 2011).

• Assist parents with bottle feeding neonate. Adequate caloric intake is essential for the promotion of stooling and the subsequent elimination of bilirubin from the intestine. Parents are assisted in feeding the neonate to ensure adequate growth and development (Blackburn, 2012; Hockenberry & Wilson, 2011).

• Avoid feeding supplements such as water, dextrose water, or any other milk substitutes in breastfeeding neonate. CEB: Supplements may act to decrease the effective establishment of breastfeeding (American Academy of Pediatrics, 2004; Blackburn, 2012).

• Assess neonate’s stooling pattern in first 48 hours of life. Delayed stooling may indicate inadequate breast milk intake and may further increase reabsorption of bilirubin from neonate’s intestine (Blackburn, 2012).

• 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. EB: Exclusive breastfeeding and preterm birth have been identified as being the most predictive of neonatal jaundice (Maisels et al, 2009; Watchko, 2009). The other risk factors listed may also play a significant role in the development of neonatal jaundice and should be considered in the overall assessment.

 Collect and evaluate laboratory blood specimens as determined by presence of clinical risk factors or as prescribed. Because visual assessments of skin color alone are inadequate to determine rising levels of bilirubin, serum bilirubin measurement may be gathered to evaluate risk for pathology (Bhutani et al, 2008). The purpose in monitoring, evaluating, and implementing treatment in moderate to severe cases of neonatal hyperbilirubinemia is to prevent bilirubin-induced neurological dysfunction (BIND), a spectrum of neurological manifestations that includes both acute and chronic neurological symptoms in vulnerable infants as a result of exposure to large amounts of unbound (indirect) bilirubin (Johnson & Bhutani, 2011). Kernicterus describes the yellow staining of brain cells and subsequent necrosis that occurs secondary to exposure to high levels of unconjugated (indirect) bilirubin; kernicterus involves long-term, permanent central nervous system changes (American Academy of Pediatrics, 2004; Blackburn, 2012).

 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. Noninvasive bilirubin monitoring is a safe and effective means for monitoring bilirubin levels and determining risk for increasing serum bilirubin levels (American Academy of Pediatrics, 2004; Maisels et al, 2009).

 Perform hour-specific total serum bilirubin risk assessment prior to newborn’s birth center discharge and document the results. EB: The use of an hour-specific nomogram for designation of risk in healthy, late preterm, and term infants, as well as clinical risk factors mentioned previously, may be used to determine the relative risk of rapidly increasing bilirubin levels requiring medical intervention such as phototherapy (American Academy of Pediatrics, 2004; Maisels et al, 2009; Watchko, 2009).

• 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. EB: Inadequate intake of breast milk in the neonatal period has been identified as a risk factor for the development of hyperbilirubinemia (Alex & Gallant, 2008; Watchko, 2009).

• Assist mother with breastfeeding and assess latch-on. Successful breastfeeding in the first few weeks of life is associated with decreased levels of serum bilirubin (Academy of Breastfeeding Medicine, 2010; Blackburn, 2012; Watchko, 2009).

• 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. Alternate feeding methods for the ingestion of breast milk may be used to enhance milk intake necessary to promote stooling and enhance bilirubin excretion (Academy of Breastfeeding Medicine, 2010; Alex & Gallant, 2008).

• Encourage father’s participation in newborn care by changing diapers, helping position newborn for breastfeeding, and holding newborn while mother rests. Paternal involvement in the care of the newborn helps solidify the father’s role as a parent and strengthens the paternal-infant attachment process; paternal participation also helps the mother to get some rest during the recovery from labor and delivery (Hockenberry & Wilson, 2011).

• 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. Daily weights assist in the detection of excess weight loss, which is often indicative of inadequate caloric intake (Alex & Gallant, 2008). Late preterm infants are at increased risk for inadequate caloric intake and hyperbilirubinemia; their body weight should be followed closely (Souto, Pudel, & Hallas, 2011).