Nursing Care Plans for Jaundice – Best Nursing Care Plans(2022)

This article discusses Nursing Care Plans for Jaundice plus its causes, symptoms, preventions, treatments, and interventions.

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Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

Introduction

Jaundice is a term used to describe a yellowish tinge to the skin and the whites of the eye. Body fluids may also be yellow. It is also known as icterus.

The color of the skin and whites of the eyes will vary depending on bilirubin levels. Bilirubin is a waste material found in the blood. Moderate levels lead to a yellow color, while very high levels will appear brown.

Jaundice can happen to people of all ages and is normally the result of an underlying condition. Jaundice normally indicates a problem with the liver or bile duct.

Nursing Care Plans for Jaundice – Causes of Jaundice

A problem in the liver may cause jaundice.

Jaundice is a yellowing of the skin and the whites of the eyes that happens when the body does not process bilirubin properly. This may be due to a problem in the liver.

Bilirubin is a yellow-colored waste material that remains in the bloodstream after iron is removed from the blood.

The liver filters waste out from the blood. When bilirubin reaches the liver, other chemicals attach to it. A substance called conjugated bilirubin results.

The liver produces bile, a digestive juice. Conjugated bilirubin enters the bile, then it leaves the body. It is this type of bilirubin that gives feces its brown color.

Too much bilirubin can leak into the surrounding tissues. This is known as hyperbilirubinemia, and it causes a yellow color in the skin and eyes.

Nursing Care Plans for Jaundice – Risk Factors of Jaundice

Jaundice most often happens due to an underlying disorder that either causes the production of too much bilirubin or prevents the liver from getting rid of it. Both of these result in bilirubin being deposited in tissues.

Underlying conditions that may cause jaundice include:

Acute inflammation of the liver: This may impair the ability of the liver to conjugate and secrete bilirubin, resulting in a buildup.

Inflammation of the bile duct: This can prevent bile secretion and removal of bilirubin, causing jaundice.

Obstruction of the bile duct: This prevents the liver from disposing of bilirubin.

Hemolytic anemia: Bilirubin production increases when large quantities of red blood cells are broken down.

Gilbert’s syndrome: This is an inherited condition that impairs the ability of enzymes to process the excretion of bile.

Cholestasis: This interrupts the flow of bile from the liver. The bile containing conjugated bilirubin remains in the liver instead of being excreted.

Rarer conditions that may cause jaundice include:

Crigler-Najjar syndrome: This inherited condition impairs the specific enzyme responsible for processing bilirubin.

Dubin-Johnson syndrome: This is an inherited form of chronic jaundice that prevents conjugated bilirubin from being secreted from the liver cells.

Pseudojaundice: This is a harmless form of jaundice. The yellowing of the skin results from an excess of beta-carotene, not from an excess of bilirubin. Pseudojaundice usually arises from eating large quantities of carrot, pumpkin, or melon.

Nursing Care Plans for Jaundice – Symptoms of Jaundice

An excess of bilirubin can cause a yellow tinge in the eyes and skin.

Common symptoms of jaundice include:

1. A yellow tinge to the skin and the whites of the eyes, normally starting at the head and spreading down the body
2. Pale stools
3. Dark urine
4. Itchiness

Accompanying symptoms of jaundice resulting from low bilirubin levels include:

1. Fatigue
2. Abdominal pain
3. Weight loss
4. Vomiting
5. Fever
6. Pale stools
7. Dark urine

Nursing Care Plans for Jaundice – Treatment of Jaundice

Medication or supplements can help jaundice depending on the cause.

Treatment will depend on the underlying cause. Jaundice treatment targets the cause rather than the jaundice symptoms.

The following treatments are used:

1. Anemia-induced jaundice may be treated by boosting the amount of iron in the blood by either taking iron supplements or eating more iron-rich foods. Iron supplements are available for purchase online.
2. Hepatitis-induced jaundice requires antiviral or steroid medications.
3. Doctors can treat obstruction-induced jaundice by surgically removing the obstruction.
4. If using medication has caused jaundice, treatment  involves changing to an alternative medication.

Nursing Care Plans for Jaundice – Prevention of Jaundice

Jaundice is related to liver function. People must maintain the health of this vital organ by eating a balanced diet, exercising regularly, and not consuming more than the recommended amounts of alcohol.

Nursing Care Plans for Jaundice – Complications of Jaundice

The itching that accompanies jaundice can sometimes be so intense that patients have been known to scratch their skin raw, experience insomnia, or, in extreme cases, even have thoughts of suicide.

When complications happen, this is usually because of the underlying problem, not jaundice itself.

For example, uncontrolled bleeding may result if an obstructed bile duct leads to jaundice. This is because the blockage leads to a shortage of vitamins needed for clotting.

Nursing Care Plans for Jaundice – Types of Jaundice

There are three main types of jaundice:

Hepatocellular jaundice occurs as a result of liver disease or injury.

Hemolytic jaundice occurs due to hemolysis, or an accelerated breakdown of red blood cells, leading to an increase in the production of bilirubin.

Obstructive jaundice occurs as a result of an obstruction in the bile duct. This prevents bilirubin from leaving the liver.

Nursing Care Plans for Jaundice – Diagnosis of Jaundice

Doctors will most likely use the history of the patient and a physical exam to diagnose jaundice and confirm bilirubin levels. They will pay close attention to the abdomen, feel for tumors, and check the firmness of the liver.

A firm liver indicates cirrhosis or scarring of the liver. A rock-hard liver suggests cancer.

Several tests can confirm jaundice. The first is a liver function test to determine whether the liver is functioning properly.

If a doctor cannot find the cause, a doctor may request blood tests to check bilirubin levels and blood composition. These include:

Bilirubin tests: A high level of unconjugated bilirubin compared to levels of conjugated bilirubin suggest hemolytic jaundice.

Full blood count (FBC) or complete blood count (CBC): This measures levels of red blood cells, white blood cells, and platelets.

Hepatitis A, B, and C tests: This tests for a range of liver infections.

The doctor will examine the structure of the liver if they suspect an obstruction. They will use imaging tests in these cases, including MRI, CT, and ultrasound scans.

They may also carry out an endoscopic retrograde cholangiopancreatography (ERCP). This is a procedure combining endoscopy and X-ray imaging.

A liver biopsy can check for inflammation, cirrhosis, cancer, and fatty liver. This test involves inserting a needle into the liver to obtain a tissue sample. The sample is then examined under a microscope.

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Nursing Care Plans for Jaundice Based on Diagnosis

Nursing Care Plans for Jaundice: Care Plan 1- Diagnosis: Hyperthermia related to infection and excessive bile in the blood secondary to adult jaundice

Evidenced by a temperature of 39 degrees Celsius, rapid and shallow breathing, flushed skin, profuse sweating, and weak pulse.

Desired Outcome

Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range.

Interventions	Rationales
Assess the patient’s vital signs at least every 4 hours.	To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs administered.
Remove excessive clothing, blankets, and linens. Adjust the room temperature.	To regulate the environment’s temperature and make it more comfortable for the patient.
Administer the prescribed antibiotic and anti-pyretic medications.	Use the antibiotic to treat a bacterial infection, which is the underlying cause of the patient’s jaundice and hyperthermia. Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature.
Offer a tepid sponge bath.	To facilitate the body in cooling down and to provide comfort.
Elevate the head of the bed.	Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively.

Nursing Care Plans for Jaundice: Care Plan 2 – Diagnosis: Fatigue related to elevated serum bilirubin levels resulting in adult jaundice

Evidenced by overwhelming lack of energy, verbalization of tiredness, generalized weakness, and shortness of breath upon exertion

Desired Outcome

The adult patient will demonstrate active participation in necessary and desired activities and demonstrate an increase in activity levels.

Interventions	Rationales
Assess the patient’s degree of fatigability by asking to rate his/her fatigue level (mild, moderate, or severe). Explore activities of daily living and actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try.	To create a baseline of activity levels, degree of fatigability, and mental status related to fatigue and activity intolerance.
Encourage progressive activity through self-care and exercise as tolerated. Explain the need to reduce sedentary activities such as watching television and using social media for long periods. Alternate periods of physical activity with rest and sleep.	To gradually increase the patient’s tolerance to physical activity.
Teach deep breathing exercises and relaxation techniques.   Provide adequate ventilation in the room.	To allow the patient to relax while at rest. To allow enough oxygenation in the room.
Refer the patient to the physiotherapy / occupational therapy team as required.	To provide more specialized care for the patient in terms of helping him/her build confidence in increasing daily physical activity.

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Nursing Care Plans for Jaundice: Care Plans 3 – Diagnosis: Deficient Knowledge related to infant jaundice

Evidenced by the patient’s mother’s verbalization of “I want to know more about how I can take care of my baby.”

Desired Outcome

At the end of the health teaching session, the patient’s mother will be able to demonstrate sufficient knowledge of infant jaundice and its management.

Interventions	Rationales
Assess the patient’s readiness to learn, misconceptions, and blocks to learning.	To address the patient’s cognition and mental status towards the new diagnosis and to help the patient overcome blocks to learning.
Explain what jaundice is, the two main types/ causes of infant jaundice (physiologic and pathologic), and how it affects the vital organs such as the liver. Avoid using medical jargon and explain in layman’s terms.	To provide information on infant jaundice and its pathophysiology in the simplest way possible.
Inform the caregiver of the details about the prescribed medications (e.g., drug class, use, benefits, side effects, and risks) to treat jaundice.	To inform the patient of each prescribed drug and to ensure that the patient fully understands the purpose, possible side effects, adverse events, and administration details.
Explain to the newborn’s mother what phototherapy is.	Phototherapy is a treatment wherein a baby is placed under a special blue spectrum light to reduce the bilirubin levels while keeping the eyes protected. The nursing team may use a fiber-optic blanket and place it under the baby if advised by the physician.
Educate the mother about the need for exchange transfusion for the baby before getting her consent.	Exchange transfusion may also be prescribed in babies with extremely high bilirubin levels.
Explain the reason behind the need for IV Ig administration if this is prescribed.	In instances of ABO and Rh incompatibility, administration of IV Ig is beneficial to reduce the serum levels of the antibodies in the infant’s blood.

Nursing Care Plans for Jaundice: Care Plan 4 – Risk for Injury (Infant)

Risk factors

• Complications of exchange transfusions
• An invasive procedure, abnormal blood profile, chemical imbalances.

Desired Outcomes

Neonate will complete exchange transfusion without complications.

Neonate will display decreasing serum bilirubin levels.

Interventions	Rationale
Note the condition of the infant’s cord prior to transfusion if the umbilical vein is to be used. If the cord is dry, administer saline soaks for 30–60 min prior to the procedure.	Soaks may be necessary to soften the cord and umbilical vein prior to transfusion for IV access and ease the umbilical catheter’s passage.
Verify infant’s and mother’s blood type and Rh factor. Note blood type and Rh factor of blood to be exchanged. (Exchanged blood will be the same type as the baby’s but will be Rh-negative or type O–negative blood that has been cross-matched with mother’s blood beforehand.)	Exchange transfusions are most often associated with Rh incompatibility problems. Using Rho(D)-positive blood would only increase hemolysis and bilirubin levels because antibodies in infants’ circulation would destroy new RBCs.
Assess the infant for weight changes.	Weight change reveals weight gain related to fluid overload. Fluid overload can cause respiratory and cardiac complications.
Assess the infant for neurologic changes.	Irritability, twitching, convulsions, or seizures are a sign of hyperkalemia, hypocalcemia, or neurotoxicity as a result of jaundice.
Maintain infant’s temperature prior to, during, and after the procedure. Place infant under radiant warmer with servomechanism. Warmblood prior to infusion by placing in an incubator, warm basin of water, or blood warmer.	Helps prevent hypothermia and vasospasm, reduces the risk of ventricular fibrillation, and decreases blood viscosity.
Ensure freshness of blood (not more than 2 days old), with heparinized blood preferred.	Older blood is more likely to hemolyze, thereby increasing bilirubin levels. Heparinized blood is always fresh but must be discarded if not used within 24 hr.
Avoid overheating of blood prior to transfusion.	Too much heat on the blood promotes hemolysis and release of potassium, causing hyperkalemia.
Ensure availability of resuscitative equipment.	To provide immediate support if necessary.
Maintain NPO status for 4 hr prior to the procedure, or aspirate gastric contents.	Reduces risk of possible regurgitation and aspiration during procedure.
Assess infant for excessive bleeding from IV site following the transfusion.	Infusion of heparinized blood (or citrated blood without calcium replacement) alters coagulation for 4–6 hr following the exchange transfusion and may result in bleeding.
Monitor venous pressure, pulse, color, and respiratory rate/ease before, during, and after transfusion. Suction as needed.	Establishes baseline values, identifies potentially unstable conditions (e.g., apnea or cardiac dysrhythmia/arrest), and maintains airway. Note: Bradycardia may occur if calcium is injected too rapidly.
Monitor for signs of electrolyte imbalance (e.g., lethargy, seizure activity, and apnea;  hyperreflexia, bradycardia, or diarrhea).	Hypocalcemia and hyperkalemia may develop during and following exchange transfusion.
Carefully document events during transfusion, recording the amount of blood withdrawn and injected (usually 7–20 ml at a time).	Helps prevent errors in fluid replacement. The amount of blood exchanged is approximately 170 ml/kg of body weight. A double-volume exchange transfusion ensures that between 75% and 90% of circulating RBCs are replaced.
Monitor laboratory studies, as indicated:
Hb/Hct levels prior to and the following transfusion	If Hct is 40% prior to transfusion, a partial exchange with packed RBCs may precede full exchange. Dropping levels following the transfusion suggest the need for a second transfusion.
Serum bilirubin levels immediately following the procedure, then every 4–8 hr.	Bilirubin levels may decrease by half immediately following the procedure but may rise shortly thereafter, necessitating a repeat transfusion. Multiplying level by 3.7 determines the degree of elevation of bilirubin necessitating exchange transfusion.
Serum calcium and potassium	Donor blood containing citrate as an anticoagulant binds calcium, thereby decreasing serum calcium levels. In addition, if blood is more than 2 days old, RBC destruction releases potassium, creating a risk of hyperkalemia and cardiac arrest.
Glucose	Low glucose levels may be associated with continued anaerobic glycolysis within donor RBCs. Prompt treatment is necessary to prevent untoward effects/CNS damage.
Serum pH levels.	The serum pH of donor blood is typically 6.8 or less. Acidosis may result when fresh blood is not used, and the infant’s liver cannot metabolize citrate used as an anticoagulant, or when donor blood continues anaerobic glycolysis, with the production of acid metabolites.
Administer albumin prior to transfusion if indicated.	Although somewhat controversial, administration of albumin may increase the albumin available for binding of bilirubin, thereby reducing levels of freely circulating serum bilirubin. Synthetic albumin is not thought to increase available binding sites.
Administer medications, as indicated:
5% calcium gluconate	From 2–4 ml of calcium, gluconate may be administered after every 100 ml of blood infusion to correct hypocalcemia and minimize possible cardiac irritability. Note: Some controversy exists as to the purpose and effectiveness of this practice.
Sodium bicarbonate	Corrects acidosis.
Protamine sulfate	Counteracts anticoagulant effects of heparinized blood.
Administer antibiotics as indicated.	Antibiotics prevent and/or treat infections.

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Related FAQs

1. What is a nursing diagnosis for hyperbilirubinemia?

Nursing Diagnosis: Hyperthermia related to elevated serum bilirubin levels as evidenced by temperature of 38.5 degrees Celsius, rapid and shallow breathing, flushed skin, profuse sweating, and weak pulse.

2. Can neonatal jaundice be a nursing diagnosis?

A nursing diagnosis of neonatal jaundice (00194) was included in the 2008 NANDA-I taxonomy and revised in 2010 and 2013.

3. What are the nursing intervention for neonatal jaundice?

Treatments to lower the level of bilirubin in your baby’s blood may include: Enhanced nutrition. To prevent weight loss, your doctor may recommend more-frequent feeding or supplementation to ensure that your baby receives adequate nutrition. Light therapy (phototherapy).

4. What are the nursing intervention for neonatal jaundice?

What nursing interventions are required during phototherapy?During phototherapy neonates require ongoing monitoring of:

• adequacy of hydration (urine output) and nutrition(weight gain)
• temperature.
• clinical improvement in jaundice.
• TSB or SBR levels.
• potential signs of bilirubin encephalopathy.

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