Newborn Hyperbilirubinemia - Nursing Case Study
Pathophysiology
• Primary mechanism: Newborns produce more bilirubin due to the breakdown of fetal red blood cells. However, their immature liver cannot effectively process and excrete this excess bilirubin, leading to its accumulation in the blood.
• Secondary mechanism: An inadequate intake of milk can further enhance bilirubin levels. This is because breastfeeding stimulates bowel movements, which helps to eliminate bilirubin from the body. If the baby is not feeding well, less bilirubin is excreted through stool, increasing its levels in the blood.
• Key complication: Prolonged hyperbilirubinemia may cause bilirubin to cross the blood-brain barrier, a condition called kernicterus. This could lead to permanent brain damage and associated neurological and developmental issues.
Patient Profile
Demographics:
1 day old, Male, N/A
History:
• Key past medical history: None, newborn
• Current medications: None
• Allergies: None
Current Presentation:
• Chief complaint: Yellow discoloration of skin and eyes
• Key symptoms: Jaundice, mild lethargy
• Vital signs: Temperature 98.6°F, Pulse 140 bpm, Respirations 40 breaths per minute, Oxygen saturation 98% on room air.
Section 1
Initial Assessment Findings:
Upon physical examination, the newborn male appears generally healthy except the noted yellowish tint to his skin and sclera. His anterior fontanelle is flat, eyes are reactive to light, and his Moro reflex is normal. His lungs are clear to auscultation and his heart rhythm is regular without any murmurs. Abdominal assessment reveals a soft, non-distended abdomen with bowel sounds present in all four quadrants. He is alert, moving all his extremities, and his pulses are strong and equal bilaterally. He latched and fed well during the assessment.
New Diagnostic Results:
The pediatrician ordered a bilirubin level test to confirm the diagnosis of hyperbilirubinemia. The total serum bilirubin (TSB) level came back at 15 mg/dL, confirming the diagnosis. A complete blood count (CBC) was also ordered. The hemoglobin was 18.5 g/dL, hematocrit 55%, and reticulocyte count was slightly elevated at 6%. The slight elevation in reticulocyte count suggests increased breakdown of red blood cells, contributing to the elevated bilirubin level. The newborn's glucose level was within the normal range at 90 mg/dL, indicating that he is feeding adequately. The pediatrician decided to monitor the newborn closely and encouraged frequent breastfeeding to promote excretion of bilirubin.
Section 2
Change in Patient Status:
Over the next 24 hours, the newborn's skin and sclera gradually become more yellow. He appears slightly lethargic but is still feeding well, producing an adequate number of wet and dirty diapers. His heart rate is regular at 140 beats per minute, respiratory rate is 40 breaths per minute, and his temperature is stable at 98.6°F (37°C). However, his total serum bilirubin (TSB) levels continue to rise and are now at 17 mg/dL.
Response to Interventions:
In response to the rising levels of bilirubin, the pediatrician decides to start the newborn on phototherapy. After 12 hours under the special blue light, the newborn's skin color starts to look less yellow and he becomes more alert. A repeat bilirubin test shows a decrease in TSB level to 14 mg/dL. The pediatrician explains that the light therapy helps to break down the excess bilirubin in the newborn's skin, which can then be excreted in the urine and stools. The parents are encouraged to continue frequent feedings to help further promote the excretion of bilirubin.
Section 3
New Diagnostic Results:
After 48 hours of phototherapy, the pediatrician orders a repeat bilirubin test. The results show that the newborn's TSB levels have further reduced to 11 mg/dL. The pediatrician also orders a complete blood count (CBC) to rule out any underlying conditions that might cause an elevated bilirubin level. The CBC results return normal, with a hemoglobin level of 16 g/dL, white blood cell count of 10,000/mm3, and a platelet count of 250,000/mm3.
Change in Patient Status:
The newborn's skin color continues to improve and he becomes more active. His heart rate is steady at 140 beats per minute, respiratory rate is 40 breaths per minute, and his temperature remains stable at 98.6°F (37°C). He continues to feed well, and his diaper count remains adequate. The parents report that he seems to be more comfortable and alert when awake. The pediatrician and nursing staff continue to monitor the newborn's status closely, ensuring that the TSB levels continue to decrease and that the newborn remains stable. The parents are educated about the signs of worsening jaundice, such as increasing lethargy, poor feeding, or a change in skin color, and are advised to seek immediate medical attention if these occur.
Section 4
New Diagnostic Results:
After two more days of phototherapy, the pediatrician orders another bilirubin test to monitor the newborn's progress. The test results show that the TSB levels have further reduced to 9 mg/dL, indicating that the phototherapy is effective. The pediatrician also orders a repeat CBC to ensure no underlying conditions have developed. The results of the CBC are still within normal ranges: a hemoglobin level of 15.8 g/dL, white blood cell count of 9,000/mm3, and a platelet count of 245,000/mm3.
Change in Patient Status:
The newborn's skin color continues to normalize, and he becomes even more active. He maintains a heart rate of 130 beats per minute, a respiratory rate of 35 breaths per minute, and his temperature remains stable at 98.4°F (36.9°C). His feeding habits remain consistent and his diaper count is still adequate. The parents report he is more responsive during his wakeful periods. They also note he has begun to display a regular sleep-wake cycle. The nursing staff continues to monitor the newborn's status closely, with particular attention to his skin color, activity level, and feeding habits. The parents are reassured by the improvement in their baby's condition but are reminded to stay vigilant for any signs of worsening jaundice.
Section 5
New Diagnostic Results:
After another two days, the pediatrician decides to conduct another bilirubin test. This time the TSB levels have reduced to 7 mg/dL, indicating the baby is responding positively to the phototherapy treatment. The pediatrician also orders a metabolic panel to monitor the baby's electrolyte balance and kidney function. The results return within normal ranges: Sodium at 140 mmol/L, Potassium at 4.5 mmol/L, Chloride at 105 mmol/L, and Creatinine at 0.5 mg/dL, suggesting good renal function.
Change in Patient Status:
The baby's skin color further normalizes, and he is more active than before. His heart rate remains consistent at 130 beats per minute, his respiratory rate is steady at 35 breaths per minute, and his temperature is stable at 98.4°F (36.9°C). He continues to feed well, and his diaper count remains sufficient. The parents report he is even more responsive during his wakeful periods and observe a more definite sleep-wake cycle. The nursing staff continues to closely monitor his skin color, activity level, and feeding habits. The parents are becoming more confident in managing their baby's condition, but they are still reminded to be watchful for any sudden changes in his behavior or appearance.