A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy

Hyperbilirubinemia is the elevation of serum bilirubin levels that is related to the hemolysis of RBCs and subsequent reabsorption of unconjugated bilirubin from the small intestines. The condition may be benign or place the neonate at risk for multiple complications/untoward effects.

The newborn‘s liver is immature, which contributes to icterus, or jaundice. The liver cannot clear the blood of bile pigments that result from the normal postnatal destruction of red blood cells. The higher the blood bilirubin level is, the deeper jaundice and the greater risk for neurological damage. Physiological jaundice is normal, while pathological jaundice is more serious, which occurs within 24 hours of birth, and is secondary to an abnormal condition, such ABO-Rh incompatibility. The normal rise in bilirubin levels in preterm infants is slower than in full-term infants. It lasts longer, which predisposes the infant to hyperbilirubinemia or excessive bilirubin levels in the blood.

Physiological jaundice is the most common type of newborn hyperbilirubinemia. This unconjugated hyperbilirubinemia presents in newborns after 24 hours of life and can last up to the first week. Pathological jaundice is defined as the appearance of jaundice in the first 24 hours of life due to an increase in serum bilirubin levels greater than 5 mg/dl/day, conjugated bilirubin levels ≥ 20% of total serum bilirubin, peak levels higher than the normal range, and the presence of clinical jaundice greater than two weeks. Breast milk jaundice occurs in breastfed newborns between the first and third day of life but peaks by day 5 to 15, with a decline occurring by the third week of life (Morrison, 2021).

In the past, hemolytic disease of the newborn was most often caused by an Rh blood type incompatibility. Because the prevention of Rh antibody formation has been available for almost 50 years, the disorder is now most often caused by an ABO incompatibility. In both instances, because the fetus has a different blood type than the mother, the mother builds antibodies against the fetal red blood cells, leading to hemolysis of the cells, severe anemia, and hyperbilirubinemia.

Nursing Care Plans

The nursing care plan for clients with hyperbilirubinemia involves preventing injury/progression of the condition, providing support/appropriate information to family, maintaining physiological homeostasis with bilirubin levels declining, and preventing complications.

Here are four (4) nursing care plans and nursing diagnoses for Hyperbilirubinemia (Neonatal Jaundice): 

Phototherapy is universally recognized as the first option for treating neonatal jaundice due to its unparalleled efficiency and safety in reducing the high serum-free bilirubin levels and limiting its neurotoxic effects. However, several studies have suggested that phototherapy may elicit short- and long-term adverse reactions associated with pediatric diseases, including hemolysis, allergic diseases, DNA damage, or even cancer (Wang et al., 2021).

Nursing Diagnosis

• Risk for Injury related to phototherapy

Risk factors

• Physical properties of therapeutic intervention and effects on body regulatory mechanisms
• Phototherapy side effects

Possibly evidenced by

Desired Outcomes

• The neonate will maintain body temperature and fluid balance within the normal limits.
• The neonate will be free of skin/tissue injury.
• The neonate will demonstrate expected interaction patterns.
• The neonate will display decreasing serum bilirubin levels.

Nursing Assessments and Rationales

1. Note the presence or development of biliary or intestinal obstruction.
Phototherapy is contraindicated in these conditions because the photoisomers of bilirubin produced in the skin and subcutaneous tissues by exposure to light therapy cannot be readily excreted. The risk of secondary intestinal obstruction may increase after phototherapy. The velocity of blood flow in the upper mesenteric artery at the end of the diastolic period is accelerated post-phototherapy, indicating that the mesenteric vascular smooth muscle may undergo diastolic changes during phototherapy, leading to mesenteric ischemia, which may be one of the causes of intestinal obstruction in premature infants (Wang et al., 2021).

2. Monitor the neonate’s skin and core temperature every two hours or more frequently until stable. Regulate incubator/ Isolette temperature as appropriate.
Fluctuations in body temperature can occur in response to light exposure, radiation, and convection. When the jaundiced newborn is treated with blue phototherapy, apart from the areas protected by the black blindfold and the diaper, all other areas are exposed to illumination. As a result, neonates diagnosed with jaundice treated with blue light often experience alterations in body temperature (Wang et al., 2021).

3. Note color and frequency of stools and urine.
Frequent, greenish, loose stools and greenish urine indicate the effectiveness of phototherapy with the breakdown and excretion of bilirubin. The nurse must determine loose, greenish stools caused by photodegradation products from true diarrhea.

4. Monitor fluid intake and output; weigh infant twice a day. Note signs of dehydration (e.g., reduced urine output, depressed fontanels, dry or warm skin with poor turgor, and sunken eyes). 
Dehydration may occur during phototherapy, particularly in premature infants. By measuring the skin moisture content of premature infants before and after phototherapy, Maayan-Metzger et al. found that the mean skin moisture loss increased by 26.4% during phototherapy, with the most significant loss observed in the elbow socket, groin, and back (Wang et al., 2021). Note: Infant may sleep for longer periods in conjunction with phototherapy, increasing the risk of dehydration if a frequent feeding schedule is not maintained.

5. Evaluate the appearance of skin and urine, noting brownish-black color.
An uncommon side effect of phototherapy involves exaggerated pigment changes (bronze baby syndrome), which may occur if conjugated bilirubin levels rise. The changes in skin color may last for 2–4 months but are not associated with harmful sequelae. The bronze baby syndrome is an irregular pigmentation resulting from phototherapy in newborn infants diagnosed with neonatal jaundice that is mainly noticeable in the skin, mucous membranes, and urine and generally occurs in neonates with elevated serum conjugated bilirubin levels (Wang et al., 2021).

6. Note behavioral changes or signs of deteriorating condition (e.g., lethargy, hypotonia, hypertonicity, or extrapyramidal signs).
Such changes may indicate the deposition of bile pigment in the basal ganglia and developing kernicterus. Following neonatal phototherapy, the serum level of total free calcium is often diminished, leading to hypocalcemia, which is higher among premature infants than that among full-term infants (Wang et al., 2021).

7. Assess for the presence of rash and petechiae.
Certain newborns develop petechiae and skin rashes from phototherapy, which gradually fade when phototherapy is discontinued. Petechiae may be associated with light-induced thrombocytopenia; thus, the platelet count should be closely monitored during phototherapy. A small number of infants diagnosed with cholestatic jaundice develop a purpuric rash and bullous eruptions after phototherapy, which may increase the total circulating porphyrin levels (Wang et al., 2021).

8. Note fussiness or increased crying episodes and irritability.
It has been reported that newborns receiving phototherapy have more frequent crying episodes than those receiving no therapy for clinical jaundice, which may be associated with changes in the circadian rhythm during neonatal phototherapy.

Nursing Interventions and Rationales

1. Document the type of fluorescent lamp, the total number of hours since bulb replacement, and the measured distance between lamp surface and infant.
Light emission may decay over time. The infant should be approximately 18–20 in (45 cm) from the light source for maximal benefit. Note: A fiberoptic blanket connected to an illuminator (light source) allows the infant to be “wrapped” in therapeutic light without risk to corneas. In addition, infants can be held and fed without interrupting therapy.

2. Measure the quantity of photon energy of fluorescent bulbs (white or blue light) using a photometer.
The intensity of light striking the skin surface from the blue spectrum (blue lights) determines how close to the light source the infant should be placed. The photometer should register between 8 and 10 mW/cm2/nm of light when placed flush with the infant’s abdomen. Blue and special blue lights are considered more effective than white light in promoting bilirubin breakdown, but they create difficulty in evaluating the newborn for cyanosis. The American Academy of Pediatrics defines standard phototherapy as 8-10 mW/cm2 per nm and intensive phototherapy as more than 30 mW/cm2 per nm in the 430-490 nm band (Sawyer & Nimavat, 2018).

3. Cover the testes and penis of a male infant. The infant is undressed except for a diaper to protect the ovaries or testes, and so as much skin surface as possible is exposed to light. Some phototherapy lights may affect reproduction. Potential and embryonic development because of the combined effects of light penetration in the tissues. The light had probably stimulated some neuroendocrine structures in the skin. Koc et al. reported the seminiferous tubule diameters were thinner than the control group after phototherapy in rats. Similar histological changes were obtained in cryptorchid testis in humans (Cetinkursun et al., 2006).

4. Apply patches to closed eyes; inspect eyes every two hours when patches are removed for feedings. Monitor placement frequently.
Retinal damage represents another challenge associated with phototherapy for neonatal jaundice. The light-sensitive retinas absorb photons more readily when exposed to blue light, most effective at degrading bilirubin. Following continuous or stronger blue light irradiation, the retinal function degenerates due to a significantly increased retinal cell death rate (Wang et al., 2021). In addition to eye shields, many centers also prescribe lubricating eye drops for an infant receiving phototherapy (Sawyer & Nimavat, 2018).

5. Cleanse the infant’s eyes using sterile or normal saline water.
As the incidence of conjunctivitis is increased among children receiving phototherapy who wear eye masks over prolonged periods, thorough eye care, such as cleaning eye secretions and surrounding skin with normal saline cotton balls, must be applied (Wang et al., 2021). 

6. Reposition the infant every two hours.
This allows equal exposure of skin surfaces to fluorescent light, prevents excessive exposure of individual body parts, and limits pressure areas.

7. Carefully wash the perianal area after each passage of stool; inspect the skin for possible irritation or breakdown.
Early intervention helps prevent irritation and excoriation from frequent or loose stools. An infant’s stools under bilirubin lights are often bright green because of the excessive bilirubin being excreted as a result of the therapy. They are also frequently loose and may be irritating to the skin.

8. Encourage an increased oral fluid intake.
To prevent the loss of water and electrolytes caused by phototherapy, water and electrolytes must be replenished when necessary. The warming effect of conventional phototherapy increases water loss from the body surface, while light-emitting diode (LED) phototherapy, which is currently widely used, causes less water loss (Wang et al., 2021).

9. Bring infant to parents for feedings. Encourage stroking, cuddling, eye contact, and talking to the infant during feedings. Encourage parents to interact with the infant in the nursery between feedings.
This fosters the attachment process, which may be delayed if phototherapy requires separation. Visual, tactile, and auditory stimulation helps the infant overcome sensory deprivation. Intermittent phototherapy does not negatively affect the photooxidation process. Note: Dependent on infant condition and policies/capabilities of the hospital, phototherapy may be provided in conjunction with rooming-in.

10. Ensure that the infant’s chest is properly shielded during phototherapy.
50% of premature infants receiving phototherapy were diagnosed with patent ductus arteriosus, the re-opening of the ductus arteriosus may be evoked by blue light penetrating the chest wall of the premature infant and causing relaxation of the smooth muscle of the cardiovascular system by activating the Ca2+ dependent K+ channel. It has been reported that appropriate shielding of the chest during phototherapy may reduce the incidence of patent ductus arteriosus (Wang et al., 2021).

11. Monitor laboratory studies, as indicated: 

• Bilirubin levels every 12 hours.
  Decreases in bilirubin levels indicate the effectiveness of phototherapy; continued increases suggest continued hemolysis and may indicate the need for exchange transfusion. Note: A blood sample drawn for bilirubin determination should be protected from light to prevent continued photooxidation.

• Platelets and WBCs.
  Thrombocytopenia during phototherapy has been reported in some infants. A decrease in WBCs suggests a possible effect on peripheral lymphocytes. There is a significant association between the decrease in platelet count with the duration of phototherapy and lower gestational age in the neonate (Sarkar et al., 2021).

• Riboflavin levels.
  Since the wavelength of absorption of blue light by riboflavin is similar to that of bilirubin, both riboflavin and bilirubin will decompose at the same time when a newborn with jaundice receives blue light therapy, leading to the loss of riboflavin in the body. The riboflavin deficiency will reduce the synthesis of active riboflavin adenine dinucleotide, impair hydrogen delivery of erythrocytes, reduce glutathione reductase and weaken the activity of erythrocyte glutathione reductase, thus aggravating hemolysis (Wang et al., 2021).

12. Administer enteral or parenteral fluid as indicated.
Fluids compensate for insensible and intestinal fluid losses and supply nutrients if feedings are withheld during phototherapy for infants with severe hyperbilirubinemia. Due to this increase in insensible water loss, recommendations have been made to increase maintenance fluid by 10 ml/kg/day in premature infants exposed to conventional phototherapy (Sawyer & Nimavat, 2018).

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy.

• Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
  An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
• Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
  A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
• NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
  The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
• Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
  Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
• Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
  Useful for creating nursing care plans related to mental health and psychiatric nursing.
• Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
  Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
• Maternal Newborn Nursing Care Plans (3rd Edition)
  If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
• Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
  An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
• All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
  Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.

See Also

Other recommended site resources for this nursing care plan:

Other care plans related to the care of the pregnant mother and her baby:

References and Resources

Resources and journals you can use to further your reading about Hyperbilirubinemia (Jaundice).

• Ahmed, S.G., & Ibrahim, U.A. (2018, April). Donor Blood Selection Criteria For Neonatal Red Cell Transfusion: General And Tropical Perspectives. The Tropical Journal of Health Sciences, 25(2).
• Amin, S. B., Smith, T., & Timler, G. (2018, October 23). Developmental influence of unconjugated hyperbilirubinemia and neurobehavioral disorders. Pediatric Research, 85, 191-197.
• Aydin, B., Yilmaz, H. C., Botan, E., Aktepe, A. O., & Dilli, D. (2021, December). Is it necessary to give calcium infusion during the exchange transfusion in newborns? Transfusion and Apheresis Science, 30(6), 103236.
• Aynalem, S., Abayneh, M., Metaferia, G., Demissie, A. G., Gidi, N. W., Demtse, A. G., Berta, H., Worku, B., Nigussie, A. K., Mekasha, A., Bonger, Z. T., McClure, E. M., Goldenberg, R. L., & Muhe, L. M. (2020). Hyperbilirubinemia in Preterm Infants Admitted to Neonatal Intensive Care Units in Ethiopia. Global Pediatric Health, 7, 1-8.
• Cetinkursun, S., Demirbag, S., Cincik, M., Baykal, B., & Gunal, A. (2006, January-February). Effects of Phototherapy on Newborn Rat Testicles. Archives of Andrology, 52(1), 61-70.
• Chacham, S., Kumar, J., Dutta, S., & Kumar, P. (2019, April-June). Adverse Events Following Blood Exchange Transfusion for Neonatal Hyperbilirubinemia: A Prospective Study. Journal of Clinical Neonatology, 8(2), 79-84.
• Chen, H.-N., Lee, M.-L., & Tsao, L.-Y. (2008, October). Exchange Transfusion Using Peripheral Vessels Is Safe and Effective in Newborn Infants. Pediatrics, 122(4).
• Gounden, V., Vashisht, R., & Jialal, I. (2021, September 28). Hypoalbuminemia – StatPearls. NCBI. Retrieved May 15, 2022.
• Hansen, T. W., & Aslam, M. (2017, December 27). Neonatal Jaundice: Background, Pathophysiology, Etiology. Medscape Reference. Retrieved May 15, 2022.
• Kaplan, M., Zimmerman, D., Shoob, H., & Stein-Zamir, C. (2019, November 19). Post-discharge neonatal hyperbilirubinemia surveillance. Acta Pediatrica, 109(5), 923-929.
• Kim, M.-S., Chung, Y., Kim, H., Ko, D.-H., Jung, E., Lee, B. S., Hwang, S.-H., Oh, H.-B., Kim, E. A.-R., & Kim, K.-S. (2020). Neonatal exchange transfusion: Experience in Korea. Transfusion and Apheresis Science, 59.
• Koc, H., Altunhan, H., Dilsiz, A., Kaymakci, A., Duman, S., Oran, B., & Erkul, I. (1999, July). Testicular Changes in Newborn Rats Exposed to Phototherapy. Pediatric and Developmental Pathology, 2(4), 333-336.
• Leifer, G. (2018). Introduction to Maternity and Pediatric Nursing. Elsevier.
• Maayan-Metzger, A., Yosipovitch, G., Hadad, E., & Sirota, L. (2001). Transepidermal Water Loss and Skin Hydration in Preterm Infants During Phototherapy. American Journal of Perinatology, 18(7), 393-396.
• Maya-Enero, S., Candel-Pau, J., Garcia-Garcia, J., Duran-Jorda, X., & Lopez-Vilchez, M. A. (2021, January 6). Reliability of transcutaneous bilirubin determination based on skin color determined by a neonatal skin color scale of our own. European Journal of Pediatrics, 180, 607-616.
• Morrison, K. L. (2021). Improving the Identification of Newborns at Risk for Hyperbilirubinemia. ProQuest.
• Poder, T. G., Nonkani, W. G., & Leponkouo, T. (2015, July). Blood Warming and Hemolysis: A Systematic Review With Meta-Analysis. Transfusion Medicine Reviews, 29(3), 172-180.
• The Royal Children’s Hospital. (2004). Exchange Transfusion: Neonatal. The Royal Children’s Hospital. Retrieved May 19, 2022.
• Salman, M., Rathore, H., Arif, S., Ali, R., Khan, A. A., & Nasir, M. (2021, January 5). Frequency of Immediate Neonatal Complications (Hypoglycemia and Neonatal Jaundice) in Late Preterm and Term Neonates. Cureus. Retrieved May 15, 2022.
• Sardari, S., Mohammadizadeh, M., & Namnabati, M. (2019, January 19). Efficacy of Home Phototherapy in Neonatal Jaundice. Journal of Comprehensive Pediatrics, 10(1).
• Sarkar, S. K., Biswas, B., Laha, S., Sarkar, N., Mondal, M., Angel, J., Dr, V., Abhisek, K., Kumar, V., Acharya, A., Biswas, P., Mal, S., Ghosh, D., & Mukherjee, T. (2021). A study on the effect of phototherapy on platelet count in neonates with unconjugated hyperbilirubinemia: a hospital-based prospective observational study. Asian Journal of Medical Sciences, 12(5).
• Sawyer, T. L., & Nimavat, D. J. (2018, May 1). Phototherapy for Jaundice: Background, Indications, Contraindications. Medscape Reference. Retrieved May 20, 2022.
• Silbert-Flagg, J., & Pillitteri, A. (2018). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. Wolters Kluwer.
• Szigeti, R. G., & Staros, E. B. (2014, September 5). Reticulocyte Count and Reticulocyte Hemoglobin Content: Reference Range, Interpretation, Collection, and Panels. Medscape Reference. Retrieved May 15, 2022.
• Van der Walt, J.H., & Russel, W.J. (1978, August). Effect of Heating on the Osmotic Fragility of Stored Blood. British Journal of Anaesthesia, 50(8), 815-820.
• Vodret, S., Bortolussi, G., Schreuder, A. B., Jasprova, J., Vitek, L., Verkade, H. J., & Muro, A. F. (2015). Albumin administration prevents neurological damage and death in a mouse model of severe neonatal hyperbilirubinemia. “ – Wiktionary. Retrieved May 19, 2022.
• Wagle, S., & Aslam, M. (2017, December 28). Hemolytic Disease of the Newborn Treatment & Management: Approach Considerations, Medical Care, Complications. Medscape Reference. Retrieved May 19, 2022.
• Wang, J., Guo, G., Cai, W.-Q., & Wang, X. (2021, March). Challenges of phototherapy for neonatal hyperbilirubinemia. Experimental and Therapeutic Medicine, 21(3).
• Wani, M. I., Nazir, M., Lone, R., Rafiq, M., Ali, S. W., & Charoo, B. A. (2018, October 5). Impact of Double Volume Exchange Transfusion on Biochemical Parameters in Neonatal Hyperbilirubinemia. International Journal of Pediatric Research, 4(2).

Reviewed and updated by M. Belleza, R.N.