Elevation of serum bilirubin levels is related to hemolysis of RBCs and subsequent re-absorption of unconjugated bilirubin from the small intestines. The condition may be benign or may place the neonate at risk for multiple complications/untoward effects.
NEONATAL ASSESSMENT DATA BASE
Activity/Rest
Lethargy, listlessness
Circulation
May be pale, indicating anemia
Residing at altitudes above 5000 ft
Cardiomegaly; increased bleeding tendencies (hydrops fetalis)
Residing at altitudes above 5000 ft
Cardiomegaly; increased bleeding tendencies (hydrops fetalis)
Elimination
Bowel sounds hypoactive.
Meconium passage may be delayed.
Stools may be loose/greenish brown during bilirubin excretion.
Urine dark, concentrated; brownish black (bronze baby syndrome).
Food/Fluid
History of delayed/poor oral feeding, poor sucking reflex.
More likely to be breastfed than bottle-fed.
Abdominal palpation may reveal enlarged spleen, liver.
Generalized edema, ascites (hydrops fetalis).
More likely to be breastfed than bottle-fed.
Abdominal palpation may reveal enlarged spleen, liver.
Generalized edema, ascites (hydrops fetalis).
Neurosensory
Large cephalhematoma may be noted over one or both parietal bones related to birth trauma/vacuum extraction delivery.
Loss of Moro reflex may be noted.
Opisthotonos with rigid arching of back, bulging fontanels, shrill cry, seizure activity (crisis stage).
Loss of Moro reflex may be noted.
Opisthotonos with rigid arching of back, bulging fontanels, shrill cry, seizure activity (crisis stage).
Respiration
History of asphyxia
Crackles, pink-tinged mucus (pleural edema, pulmonary hemorrhages)
Crackles, pink-tinged mucus (pleural edema, pulmonary hemorrhages)
Safety
History may be positive for infection/neonatal sepsis.
May have excessive ecchymosis, petechiae, intracranial bleeding.
May appear jaundiced initially on the face with progression to distal parts of the body; skin brownish black in color (bronze baby syndrome) as a side effect of phototherapy.
May have excessive ecchymosis, petechiae, intracranial bleeding.
May appear jaundiced initially on the face with progression to distal parts of the body; skin brownish black in color (bronze baby syndrome) as a side effect of phototherapy.
Sexuality
May be preterm, SGA infant, infant with IUGR, or LGA infant, such as IDM.
Birth trauma may have occurred associated with cold stress, asphyxia, hypoxia, acidosis, hypoglycemia, hypoproteinemia.
Occurs more often in male than female infants.
Teaching/Learning
May have congenital hypothyroidism, biliary atresia, cystic fibrosis (inspissated bile)
Family factors; e.g., ethnic descent (Asian, Greek, or Korean), history of hyperbilirubinemia in previous pregnancies/siblings, liver disease, cystic fibrosis, inborn errors of metabolism (galactosemia), blood dyscrasias (spherocytosis, glucose-6-phosphate dehydrogenase [G-6-PD] deficiency)
Maternal factors, such as maternal diabetes; ingestion of medications (e.g., salicylates, oral sulfonamides late in pregnancy or nitrofurantoin [Furadantin]; Rh/ABO incompatibility; infectious illness (e.g., rubella, CMV, syphilis, toxoplasmosis)
Intrapartal contributing factors, such as preterm labor, delivery by vacuum extraction, oxytocin induction, delayed clamping of umbilical cord, or traumatic delivery
Family factors; e.g., ethnic descent (Asian, Greek, or Korean), history of hyperbilirubinemia in previous pregnancies/siblings, liver disease, cystic fibrosis, inborn errors of metabolism (galactosemia), blood dyscrasias (spherocytosis, glucose-6-phosphate dehydrogenase [G-6-PD] deficiency)
Maternal factors, such as maternal diabetes; ingestion of medications (e.g., salicylates, oral sulfonamides late in pregnancy or nitrofurantoin [Furadantin]; Rh/ABO incompatibility; infectious illness (e.g., rubella, CMV, syphilis, toxoplasmosis)
Intrapartal contributing factors, such as preterm labor, delivery by vacuum extraction, oxytocin induction, delayed clamping of umbilical cord, or traumatic delivery
DIAGNOSTIC STUDIES
Coombs’ Test on Newborn Cord Blood: Positive result of indirect Coombs’ test indicates the presence of Rh-positive, anti-A, or anti-B antibodies in mother’s blood. Positive result of direct Coombs’ test indicates presence of sensitized (Rh-positive, anti-A, or anti-B) RBCs in neonate.
Infant and Maternal Blood Type: Identifies ABO incompatibilities.
Total Bilirubin: Direct (conjugated) levels are significant if they exceed 1.0–1.5 mg/dl, which may be associated with sepsis. Indirect (unconjugated) levels should not exceed an increase of 5 mg/dl in 24 hr, or should not be >20 mg/dl in a full-term infant or 15 mg/dl in a preterm infant (dependent on weight). Cord blood bilirubin 5 mg/dl indicates severe hemolysis.
Total Serum Protein: Levels <3.0>
Infant and Maternal Blood Type: Identifies ABO incompatibilities.
Total Bilirubin: Direct (conjugated) levels are significant if they exceed 1.0–1.5 mg/dl, which may be associated with sepsis. Indirect (unconjugated) levels should not exceed an increase of 5 mg/dl in 24 hr, or should not be >20 mg/dl in a full-term infant or 15 mg/dl in a preterm infant (dependent on weight). Cord blood bilirubin 5 mg/dl indicates severe hemolysis.
Total Serum Protein: Levels <3.0>
NURSING PRIORITIES
1. Prevent injury/progression of condition.
2. Provide support/appropriate information to family.
2. Provide support/appropriate information to family.
DISCHARGE CRITERIA:
1. Maintaining physiological homeostasis with bilirubin levels declining.
2. Complications prevented/resolving.
3. Parent(s) understand condition/prognosis and therapeutic regimen.
4. Plan in place to meet needs after discharge.
2. Complications prevented/resolving.
3. Parent(s) understand condition/prognosis and therapeutic regimen.
4. Plan in place to meet needs after discharge.
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