UBC Undergraduate Research

Jaundice guidelines MacAulay, Chelsea; Rama, Sarika; Tharmaratnam, Thayanthi 2014

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+Jaundice Guidelines N344 ? Synthesis Project Group #21 Team Members: Chelsea MacAulay, Sarika Rama & Thayanthi Tharmaratnam +Introduction  ??Our nursing synthesis project focused on: ??Partnering with the BC Perinatal Services to revise their provincial guidelines about jaundice ??Researching and utilizing updated literature regarding jaundice assessment, risk factors, strategies, treatment etc. for the guideline     +This presentation?  ?? Provides an overview of what we have worked on and touch upon in the guideline that we put together based on updated literature: ?? Significance ?? Risk Factors ?? Strategies for Decreasing Incidence ?? Assessments ?? Issues with Management of Jaundice ?? Clinical Evaluation +Significance ?? Occurs in 60% of term infants and nearly all preterm infants ??  Potential devastating effects such as progression to kernicterus (accumulation of bilirubin in the tray matter of CNS causing neurological damage) ?? Nursing implications:  ?? being able to recognize risk factors, identifying newborns at risk, implementing assessments and being aware of screening protocols +Risk Factors  ?? This is what nurses working in maternity should keep in mind when caring for newborns: ?? GA 35-36 weeks ABO incompatibility (Rh factors) ??  Previous sibling with jaundice ?? Exclusive and insufficient breast milk transfer ??  Heavy bruising resulting from delivery (vacuum extraction ??  Visible jaundice in first 24 hrs of life  +Strategies for Decreasing Incidence  ?? Parental Education: ?? Teach parents how to recognize signs and symptoms, risk factors and what to do if jaundice is suspected ?? Discharge/follow up: ?? Postpartum follow up in community ?? Referral to Lactation Consultant ?? Assessments: ?? Visual inspection includes checking naked baby in bright and natural light (not accurate and may lead to errors) ?? Visual assessment should be done whenever vital signs are taken +Strategies Continued? ??Screening: ??Measure TSB or TCB if jaundice occurs in the first 24 hoursInterpret bilirubin levels according to infant age in hours ??Breastfeeding:  ??Provide early assistance education and support for breastfeeding. ??Encourage mothers to breastfeed 8-12 times a day ?? Assess adequate intake of newborn +Assessing for Jaundice: Color ?? Assess skin after blanching by pressure from the thumb. Perform assessment in a well-lit room, or in natural light if performed in the home. Prolonged exposure to direct or indirect sunlight can bleach a newborn?s skin, making it more difficult to assess for jaundice (Lease & Whalen, 2010). ? ?? Kramer?s 5-point Scale is commonly used by nurses to describe the extent of infant jaundice (Keren, Tremont, & Luan, 2009). ?The scale?s score is based on cephalocaudal progression of an infant?s jaundice, with facial jaundice being a score of 1 and increasing numerically as jaundice extends toward the feet. ? ?? The Kramer Scale should not be the used as primary assessment for jaundice, as research shows poor correlation between assessments based on the Kramer Scale and measured bilirubin values.  ?? Extra caution should be taken with the examination of late preterm infants, as the Kramer Scale is particularly limited with this population (Keren et al., 2009). ? +Assessing for Jaundice: Age ??Physiological jaundice is a  common and normally self-limiting condition seen in infants that occurs after 24 hours of age.  It can last as long as two weeks (Lease & Whalen, 2010). ?? Pathological Jaundice (eg, caused by a pathological abnormality or issue) occurs before 24 hours or after 10 days of life is always, and the cause should be investigated prior to initiating any treatment (Lease & Whalen, 2010). ??Jaundice that occurs between 24 hours to 10 days of life is determined to be pathological or physiological by plotting the age of the infant against their total bilirubin levels on the Bhutani Risk Graph. ?Knowing an infant?s risk zone can be beneficial when deciding to initiate treatment (Lease & Whalen, 2010). +Assessing for Jaundice: Feeding & Intake ??Feeding helps newborns to pass bilirubin in their stool.  After the first 1-2 days of life, newborns should be breastfed 8 or more times in a 24 hour period.  If bilirubin levels increase, the newborn may become more lethargic. If the newborn is sleepy during feeds, utilize stimulation techniques to keep them active (eg, removing a layer of clothes, tickling feet, talking to baby) (Perinatal Services BC, 2013). Day 1 Day 2 Day 3 Day 4  Day 5 # of stools/day At least 1 meconium At least 1 meconium or 1 transitional stool 3-4 transitional stools 3-4 transitional stools  3-6 yellow, seedy stools  # of wet diapers/day At least 1 1-2 2-3 3-5 4-6 (Perinal Services, 2013) ??Adequate intake during feeds can be determined by assessing the following (Perinatal Services BC, 2013): ??Signs and symptoms of dehydration (eg: skin turgor, moistness of mouth/mucous membranes). ??Newborn?s weight. ?Weight loss ??Energy levels. ??Feeding pattern/behaviors. ??Elimination (see guide below, based on breastfed infant). +Issues With Management of Jaundice ?? Breastfeeding & Phototherapy ?? Family centred care is encouraged where little interuption of breastfeeding is recommend  ?? Adequate intake of milk minimzes bilirubin levels to increase ?? Breastfeeding should only be interupted when bilirubin levels are high and there is a risk of exchange transfusion  ?? Daylight treatment is NOT recommended as this disguises and often misleads parents into believing their infant has jaundice +Issues Continued? ?? Fibroptic Treatment ?? Use of ?bili blankets? as ?double? phototherapy treatment  ?? Bili blankets should not be used alone as primary treatment due to efficacy ?? The device does not interfere with parent-child bonding ?? Home Phototherapy ?? There is very little research done in North America ?? Cochrane review suggests home treatment increases parent-infant bonding but duration of treatment will be longer compare to hospital treatment +Clinical Evaluation ??Based on three criteria: ?? Serum bilirubin levels at which phototherapy is initiated ?? Bilirubin levels at which the infant is readmitted ?? Numbers of readmissions for jaundice +References ??American Academy of Pediatrics (2004). Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. PEDIATRICS, 114(1), 297-316. Retrieved from http://pediatrics.aappublications.org/content/114/1/297.full.pdf ??Bhutani, V. K., Vilms, R. J., & Hamerman-Johnson, L. (2010). Universal bilirubin screening for severe neonatal hyperbilirubinemia. Journal of perinatology, 30, S6-S15. ??Canadian Paediatric Society. (2007). Guidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm infants (35 or more weeks? gestation). Paediatrics and Child Health, 12(5),1B-12B. Malwade, U. S., & Jardine, L. A. (2012). Home versus hospital?based phototherapy for the treatment of non?haemolytic jaundice in infants more than 37 weeks gestation. The Cochrane Library. doi: 10.1002/14651858.CD010212 ??Okwundu, C. I., Okoromah, C. A., & Shah, P. S. (2013). Cochrane review: Prophylactic phototherapy for preventing jaundice in preterm or low birth weight infants. Evidence?Based Child Health: A Cochrane Review Journal, 8(1), 204-249. doi: 10.1002/ebch.1898 ??Perinatal Services BC. (2013). Newborn nursing care pathway. Newborn Guideline 13, Retrieved from Http://www.perinatalservicesbc.ca/NR/rdonlyres/757B1BCE-E87C-4F79-8401-57156ED829B2/0/PSBC_Guideline_13_NewbornNursingCarePathway.pdf Szucs, K. A., & Rosenman, M. B. (2013). Family-Centered, Evidence-Based Phototherapy Delivery. Pediatrics, 131(6), e1982-e1985. Retrieved from http://pediatrics.aappublications.org.ezproxy.library.ubc.ca/content/131/6/e1982 The End! 

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