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Neonatal Jaundice By Dr. Nahed Al-Nagger. Neonatal Jaundice. Learning Objectives: Define hyperbilirubinemia. Differentiate between physiological and pathological jaundice. State causes of hyperbilirubinemia. Discuss the pathophysiology of hyperbilirubinemia.

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Neonatal jaundice by dr nahed al nagger
Neonatal JaundiceBy Dr. Nahed Al-Nagger


Neonatal jaundice
Neonatal Jaundice

  • Learning Objectives:

  • Define hyperbilirubinemia.

  • Differentiate between physiological and pathological jaundice.

  • State causes of hyperbilirubinemia.

  • Discuss the pathophysiology of hyperbilirubinemia.

  • Describe the most dangerous complication of hyperbilirubinemia.

  • List the three elements of therapeutic management.

  • Design plan of care for baby has hyperbilirubinemia.


Neonatal jaundice hyperbilirubinemia
Neonatal Jaundice(Hyperbilirubinemia)

  • Definition: Hyperbilirubinemia refers to an excessive level of accumulated bilirubin in the blood and is characterized by jaundice, a yellowish discoloration of the skin, sclerae, mucous membranes and nails.

  • Unconjugated bilirubin = Indirect bilirubin.

  • Conjugated bilirubin = Direct bilirubin.


Neonatal jaundice1
Neonatal Jaundice

  • Visible form of bilirubinemia

    • Newborn skin >5 mg / dl

  • Occurs in 60% of term and 80% of preterm neonates

  • However, significant jaundice occurs in 6 % of term babies


Bilirubin metabolism
Bilirubin metabolism

Hb → globin + haem

1g Hb = 34mg bilirubin

Non – heme source

1 mg / kg

Bilirubin

Ligandin

(Y - acceptor)

Intestine

Bilirubin glucuronidase

Bil glucuronide

Bil glucuronide

β glucuronidase

bacteria

Bilirubin

Stercobilin



Clinical assessment of jaundice
Clinical assessment of jaundice

Area of body Bilirubin levels mg/dl(*17=umol)

Face 4-8

Upper trunk 5-12

Lower trunk & thighs 8-16

Arms and lower legs 11-18

Palms & soles > 15


Physiological jaundice
Physiological jaundice

Characteristics

  • Appears after 24 hours

  • Maximum intensity by 4th-5th day in term & 7th day in preterm

  • Serum level less than 15 mg / dl

  • Clinically not detectable after 14 days

  • Disappears without any treatment

    Note: Baby should, however, be watched for worsening jaundice.


Why does physiological jaundice develop
Why does physiological jaundice develop?

  • Increased bilirubin load.

  • Defective uptake from plasma.

  • Defective conjugation.

  • Decreased excretion.

  • Increased entero-hepatic circulation.


15

10

5

Bilirubin level

mg/dl

Term

Preterm

1 2 3 4 5 6 10 11 12 13 14

Age in Days

Course of physiological jaundice


Pathological jaundice
Pathological jaundice

  • Appears within 24 hours of age

  • Increase of bilirubin > 5 mg / dl / day

  • Serum bilirubin > 15 mg / dl

  • Jaundice persisting after 14 days

  • Stool clay / white colored and urine staining clothes yellow

  • Direct bilirubin> 2 mg / dl


Causes of jaundice
Causes of jaundice

Appearing within 24 hours of age

  • Hemolytic disease of NB : Rh, ABO

  • Infections: TORCH, malaria, bacterial

  • G6PD deficiency


Causes of jaundice1
Causes of jaundice

Appearing between 24-72 hours of life

  • Physiological

  • Sepsis

  • Polycythemia

  • Intraventricular hemorrhage

  • Increased entero-hepatic circulation


Causes of jaundice2
Causes of jaundice

After 72 hours of age

  • Sepsis

  • Cephalhaematoma

  • Neonatal hepatitis

  • Extra-hepatic biliary atresia

  • Breast milk jaundice

  • Metabolic disorders (G6PD).


Risk factors for jaundice
Risk factors for jaundice

JAUNDICE

  • J - jaundice within first 24 hrs of life

  • A - a sibling who was jaundiced as neonate

  • U - unrecognized hemolysis

  • N – non-optimal sucking/nursing

  • D - deficiency of G6PD

  • I - infection

  • C – cephalhematoma /bruising

  • E - East Asian/North Indian


Diagnostic evaluation
Diagnostic evaluation:

  • Normal values of unconjugated B. are 0.2 to 1.4 mg/dL.

  • Investigate the cause of jaundice.


Therapeutic management
Therapeutic Management

  • Purposes: reduce level of serum bilirubin and prevent bilirubin toxicity

  • Prevention of hyperbilirubinemia: early feeds, adequate hydration

  • Reduction of bilirubin levels: phototherapy, exchange transfusion,

  • Drugs Use of Phenobarbital promote liver enzymes and protein synthesis.


Babies under phototherapy
Babies under phototherapy

Baby under conventional phototherapy

Baby under triple unit intense phototherapy


Prognosis
Prognosis

  • Early recognition and treatment of hyperbilirubinemia prevents severe brain damage.


Nursing considerations of hyperbilirubinemia
Nursing considerations of Hyperbilirubinemia

  • Assessment:

  • observing for evidence of

    jaundice at regular intervals.

  • Jaundice is common in

    the first week of life and

    may be missed in dark skinned

    babies

Blanching the tip

of the nose


Approach to jaundiced baby
Approach to jaundiced baby

  • Ascertain birth weight, gestation and postnatal age

  • Ask when jaundice was first noticed

  • Assess clinical condition (well or ill)

  • Decide whether jaundice is physiological or pathological

  • Look for evidence of kernicterus* in deeply jaundiced NB

    *Lethargy and poor feeding, poor or absent Moro's, or convulsions


Nursing diagnosis
Nursing diagnosis

  • See the high risk infant plan of care. Plus:

  • Body T., risk for imbalanced T. related to use of phototherapy.

  • Fluid volume, risk for deficient related to phototherapy.

  • Interrupted family process related to situational crisis, re hospitalization for the therapy.


The goals of planning
The goals of planning

  • Infant will receive appropriate therapy if needed to reduce serum bilirubin levels.

  • Infant will experience no complications from therapy.

  • Family will receive emotional support.

  • Family will be prepared for home phototherapy (if prescribed).



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