Class 10: Jaundice Flashcards
jaundice is the clinical manifestation of…
- elevated serum unconjugated bilirubin lvls
jaundice is the clinical manifestation of…
- elevated serum unconjugated bilirubin lvls = hyperbilirubinemia
how is jaundice seen as?
- yellow coloring in the sclera, skin, and mucosal membranes
jaundice is characterized as..
- physiologic vs pathologic
__% of full term newborns and __% of preterm newborns experience physiological jaundice
- 60% of full term newborns
- 80% of preterm
what is the best method to prevent jaundice
- early & freq breastfeeding
what also helps clear bilirubin
- freq passage of stools
what are risks for jaundice in the NB (13)
- prematurity (35-38 weeks)
- exclusive breast feeding that is not well-established breastfeeding (less milk = less stool) & excessive weight loss
- sibling who had neonatal jaundice
- visible bruising
- cephalohematoma
- DAT+ or other hemolytic disease (G6PD)
- ethnic background (East Asian)
- asphyxia
- acidosis (pH <7)
- albumin <30 g/L
- sepsis
- temp instability
- lethargy/poor feeding
what are signs of asphyxia in the NB that contributes to the risk of jaundice (2)
- APGAR 0-3 beyond 5 min
- cord pH <7
what impact can hyperbilirubinemia have on the neuro system>
neurotoxicity:
- acute bilirubin encephalopathy
- chronic bilirubin encephalopathy (Kernicterus)
what are signs of acute encephalopathy (2)
- poor sucking
- poor muscle tone
what occurs w chronic encephalopathy
- irreversible brain damage
what is pathologic jaundice
- jaundice that presents in the first 24 hrs after birth is always considered abnormal (pathologic) and needs to be investigated
what total serum bilirubin (TSB) indicated pathologic jaundice (2)
- if TSB increases more than 100 mcmol/L in 24 hrs
- if TSB >256 mcmol/L at any time (any age of infant)
- high lvl for gestational age/weight
what else indicates pathologic jaundice
- if caused by pathological condition (ex. HDN)
if jaundice is present in first 24 hrs after birth, what is it typically due to?
- hemolytic disease of the newborn (HDN)
what therapy can be used to treat pathologic jaundice (2)
- phototherapy
- if severe, exchange transfusion
describe treatment for physiologic jaundice
- treatment not required if serum bilirubin not overly high & not rising rapidly
what is considered physiologic jaundice
- jaundice that occurs after that 1st 24 hrs and usually within the 1st week
what are 2 types of jaundice related to breastfeeding
- breastfeeding-associated jaundice = “early”
- breastmilk jaundice = “late”
when does breastfeeding-associated jaundice occur?
- usually occurs during days 2-5
breastfeeding-associated jaundice is mainly related to? (2)
- insufficient feeding
- insufficient stooling
how can we correct breastfeeding-associated jaundice r/t insufficient feeding & stooling (3)
- increase feed freq
- assess for position, latch, engorgement
- may require BF support +/- supplemental feeding device while continuing BF
when does breast milk jaundice usually occur?
- between days 5-10
with breast milk jaundice, infants are usually…
- feeding well
- gaining weight
breast milk jaundice is uncommon to be…
- uncommon to be pathological
breast milk jaundice is thought to occur due to
- a compound in the breastmilk that competitively inhibits glucuronyl transferase
if at any time the serum bilirubin falls in higher than acceptable range with jaundice r/t breastfeeding, they may require?? (2)
- phototherapy
- alone w measures to ensure adequate feeding and stooling
if the infant looks jaundiced at ______ days/weeks, the parents should follow up & have serum bilirubin measured
- at 2-3 weeks
define: hemolytic disease of the newborn (HDN)
- an abnormally rapid rate of RBC destruction
HDN usually occurs due.. (2), which is more common? which has less severe effects?
- Rh isoimmunization
- ABO incompatibility –> more common, and less severe effects
why has Rh isoimmunization become reduced?
- reduced due to prenatal screening and prophylactic admin of WinRho
what is isoimmunization
- occurs with Rh- mom and Rh+ fetus
- mom can develop antibodies against the fetal RBCs, which attac and cause lysis of the fetal RBCs –> usually in subsequent pregnancy
describe ABO incompatability in NB
- when mother has blood type “O” and baby has “A”, “B”, or “AB”
- no prior exposure to fetal blood required to develop
- all individuals naturally have antibodies against other blood types (except those w AB)
what other conditions can also cause HDN? (5)
- G6PD
- hereditary spherocytosis
- galactosemia
- Crigler-najjar disease
- hypothyroidism
what occurs with HDN
- something causes lysis of fetal RBCs = overproduction of bilirubin that newborn cannot efficiently excrete = jaundice
when does HDN usually occur
- early in the first 24-48 hrs
HDN with more significant lvls of bilirubin require treatment w? (2)
- phototherapy
- and/or exchange transfusion
if Rh isoimmunization is determined during pregnancy (maternal antibody screen is positive) what treatment options can be offered? (2)
- IVIG
- intrauterine transfusion
describe use of IVIG as treatment for isoimmunization (2)
- may be given to mother (decreases severity of HDN)
- may be given to neonate to block maternal antibody effect of attacking newborn RBCs, decreasing hemolysis, and jaundice
describe intrauterine transfusion (IUT)
- infusion of donor blood into the umbilical vein of the fetus
what is used w intrauterine transfusion to determine the degree of fetal anemia & need for IUT
- serial US measuring the peak systolic velocity of the fetal middle cerebral artery
severe forms of HDN are referred to as…
- erythroblastosis fetalis
what is the nurse’s role in assessing for jaundice (9)
- visually assess for jaundice during every interaction
- universal screening for jaundice
- assess infant weight, feeding, stools, urine output
- provide support & education for breastfeeding, consider referral for lactation consult
- provide community resources
- advise mother when to be concerned about jaundice, where to seek help
- encourage to keep breastfeeding
- support & encourage continued feeding even when phototherpy required
- facilitate skin to skin & bonding
who is included in universal screening for jaundice
screen all NB of any gestation age who, have not received phototherapy or an exchange transfusion, for the development of hyperbilirubinemia using the TcB monitor
what is a TcB monitor
- handheld transcutaneous bilirubin monitor that provides an estimate of circulating bilirubin
when is universal screening for jaundice completed?
- initially between 24-30 hrs and every am thereafter until discharged from hospital
describe universal screening for jaundice in NB admitted to a neonatal intensive care unit
- continue for the first 7 days unless otherwise ordered by infant’s prescribing practitioner
what is the primary site for TcB reading?
- infant’s forehead
when shouldn’t the infant forehead by used as primary site for TcB
- if extensively bruised or discolored
what is the 2ndary site for TcB monitoring
- sternum
when is the sternum used for TcB monitoring (2)
- if cannot use forehead
- or infant has been discharged and exposed to ambient sunlight
what is the measurement range for TcB
- measurement range is 0-340 umol/L
what does a reading of “ _ _ _” on the TcB monitor indciate?
> 340
what is total serum bilirubin (TSB)
- blood sample sent to lab to determine serum bilirubin
if clinically you suspect high lvl than TcB reading, what should you do?
- advocate for TSB lvl (handheld model isn’t always reliable)
what should be done if the baby appears jaundiced <24 hrs of age (4)
- screen using TcB
- plot TcB on nomogram
- notify infant’s care provider of result
- obtain order for TSB and DAT
what does a nomogram show?
- graph where plot bilirubin lvl in terms of age (hr)
- shows 4 different zones: high, high intermediate, low intermediate, low zone
what zone do we want the infants in on a nomogram?
- low zone
what assessments cause concern for jaundice? (5)
- infant weight loss >7%
- decreased mill intake (decreased freq & length of feeds)
- decrease in stools
- decrease in urine output
- check bilirubin lvls
what stool output causes causes concern for jaundice
<3 stools/day by day 4
what urine output causes concern for jaundice
<4-6 voids/day by day 4
what is recommended during phototherapy for jaundice (2)
- professional breastfeeding support
- exclusive breastfeeding support
what is the nurses role during phototherapy (7)
- expose as much skin as possible –> aim for 80% exposed to light
- cover infant’s eyes and genitals
- no creams on skin, except diaper area prn
- documentation & graph
- assist BF at least 8x/day or formula feeding
- monitor urine & stools, and amt of feeding
- once initiated, continuous until TSB decreasing, the only interrupt for brief time
describe assessment of temp, RR, and HR in well infants during phototherapy
- temp q2h
- q4h RR and HR
phototherapy may use.. (3)
- fibreoptic blanket
- overhead light
- or both
