EDAPT HYPERBILIRUBINEMIA – Maternal-Child Nursing

EDAPT HYPERBILIRUBINEMIA – Maternal-Child Nursing
Hyperbilirubinemia is the elevation of serum bilirubin levels that is related to the hemolysis of red blood cells
(RBCs) and subsequent reabsorption of unconjugated bilirubin from the small intestines. Jaundice is
considered abnormal or nonphysiologic when the total serum bilirubin (TSB) rises quickly and to a higher level
and extends longer than what is considered normal.
A nurse is managing a high-risk bilirubin level in a newborn who is receiving phototherapy. Which
interventions should be part of the plan of care? Select all that apply.
Feeding the newborn at a regular frequency is key and formula may be used as a supplement if there is not
adequate breast milk production. Breastfeeding does not need to be stopped because of phototherapy, but
the nurse may need to offer extra support to ensure the newborn is receiving adequate nutrition. Eye
protection is always needed when the newborn is under phototherapy lights. In order to expose as much skin
as possible to the phototherapy light, newborns should be placed under the lights wearing only a diaper. The
temperature must be checked every 2-4 hours or per agency policy, because temperature instability increases
with phototherapy.
The nurse is discussing jaundice with a concerned mother of a newborn. The nurse knows that with high
levels of bilirubin, the primary concern is KERNICTERUS.
When high bilirubin levels go untreated for too long, it can cause a condition called kernicterus. Kernicterus is a
type of brain damage that can result from high levels of bilirubin in a newborn’s blood. The newborn may
become more lethargic and difficult to awaken and thus has a lower respiratory rate rather than tachypnea.
A nurse is assessing a newborn for the presence of jaundice. Which of the following assessments may be
used? Select all that apply.
Blanching the skin over a bony prominence and looking at the color before blood returns will reveal yellowing
of the skin. In newborns with dark skin, assessing the color of the palate or mucus membranes of the mouth
can also be used to assess for jaundice. Transcutaneous bilirubinometers are non-invasive devices that will
record bilirubin levels when placed against the newborn’s skin.
CBC does not include a bilirubin level. Checking the level of irradiance is related to ensuring the phototherapy
machine is functioning properly, and not an assessment of jaundice.