1. When nurse assessed the baby, her pain score based on N-PASS tool was 5 and a score which is more than +3 indicates pain in N-PASS tool (Hillman, Tabrizi, Gauda, Carson, & Aucott, 2015). Nurse also noticed a yellow tint to her face that spreads to her bilateral nipple line which was unnatural as opposed to normal baby’s skin. When nurse enquired the mother about the baby she complained that the baby is always sleepy, does not want to breastfeed and when she latched after multiple attempts, baby used to get frustrated and begin to cry.

• Report of pertinent findings

• As per Bhutani Nomogram, Maria falls into low intermediate risk zone of hyperbilirubinemia (O’Reilly, Walsh, Allen, & Corcoran, 2015).  

Monogram for Maria

Major risk factors for hyperbilirubinemia include pre-discharge TSB in the high-risk zone, jaundice detected in the first 24 hours, incompatible blood group with positive direct antiglobulin test, other known hemolytic disease, raised ETCOc, gestational age 35 between 36 week, previous brother or sister were given phototherapy, cephalohematoma or substantial bruising, exclusive breastfeeding, specifically when nursing is not going well and there is excessive weight loss and lastly East Asian ethnicity.

Minor risk factors for hyperbilirubinemia include pre-discharge TSB in the high intermediate-risk zone, gestational age between 37 and 38 week, jaundice detected prior to discharge, previous brother or sister with jaundice, macrosomic infant of a mother who has diabetes, age of the mother less than 25 years and gender of the baby being male.

• It is suspected that Maria most likely has pathological unconjugated hyperbilirubinemia. It is suspected as the mother indicated that Maria is lethargic and has been exhibiting poor feeding. The peak total serum bilirubin is less than 15 mg/dL in the case of a full-term, breastfed infant and for Maria it is 13 mg/dL. All these report findings and observations indicate that Maria has pathological unconjugated hyperbilirubinemia.

• The expected treatment plan for Maria will include phototherapy. Phototherapy is the key treatment option in newborn who are diagnosed with unconjugated hyperbilirubinemia (ULLAH, RAHMAN, & HEDAYATI, 2016). In phototherapy, Maria will be exposed to blue light which has wavelength between 420 and 480 nm. It will convert unconjugated bilirubin in skin which is hydrophobic in nature to a form which is water-soluble. Then the water soluble form will get excreted in urine and/or bile. Phototherapy will be performed until total bilirubin levels is less than 15 mg/dL. Adequate fluid will be supplemented to Maria for prevention of dehydration. Furthermore, her eyes will be protected against UV light. In case Maria does not respond to phototherapy adequately or there is a rapid increase in TSB level, that is more than 6 mg/dL within 6 hours, exchange transfusion will be done.

If Maria is left untreated, she may develop severe hyperbilirubinemia and will be at risk of developing bilirubin-induced neurologic dysfunction (BIND) if the bilirubin crosses the blood-brain barrier. The condition neurotoxicity which is manifested as acute bilirubin encephalopathy (ABE) distinguished by reversible lethargy, hypotonia, and reduced suck (Karadag, et al., 2013). And if ABE advances, kernicterus may occur which is a permanent condition. Kernicterus exhibits as cerebral palsy, seizures, arching, posturing, and sensorineural hearing loss.

• Plan for implementation based on family centered interventions and education
• Nurse will make Maria’s parents aware about the types of jaundice, the type which has affected Maria, pathophysiological factors and complications of hyperbilirubinemia. It will improve their understanding of Maria’s condition, correct any false impression and prevent the feelings of guilt and fear particularly her in her mother.
• Nurse will also have a discussion regarding possible long-term impacts of hyperbilirubinemia and why is it essential to continue the assessment and intervention.
• Nurse will explain the home management of mild or moderate physiological jaundice which will consist of more number of feedings, diffused sunlight exposure, and follow-up serum testing program. Gaining parents’ understanding is vital as it nurtures their cooperation post-discharge. In addition, the knowledge given by nurse will help Maria’s parents to perform home management in a safe and suitable manner and to appreciate the significance of every aspect of management intervention.
• Nurse will also give a demonstration of means of examining Maria for increasing bilirubin levels by techniques of skin blanching with digital pressure to identify the skin colour, weight supervision, or behavioral modification, especially if infant is to be discharged early. It will help the parents in detecting the signs and symptoms of elevated bilirubin levels.
• While giving information to Maria’s parents about her daughter’s condition, Nurse will encourage them to ask questions and gain clarity of Maria’s condition.
• Nurse will give a 24-hr emergency telephone number and name of contact person to Maria’s parents and emphasise on the significance of informing about worsening of jaundice.
• Nurse will also make an assessment of Maria’s family situation and support systems. 
• Nurse will provide an easy to understand and comprehensive written explanation of home phototherapy to Maria’s parents which will include explanation of procedure, potential issues and safety precautions (Lynn & Linda, 2007).

• Bowlby’s attachment theory proposed that children are born with an inherent must form attachments. These attachments will assist the child to survive by making sure that the child will receive care and protection. In this theory, attachment is seen as a product of evolutionary processes. Maria is born with an innate drive to form attachments with caregivers. However, currently she is in pre-attachment stage which ranges between birth and three months, infants do not show any particular attachment to a specific caregiver. But in the next stage which is indiscriminate infant prefers her primary and secondary caregivers. So if Maria’s hospitalization is extended then her primary and secondary caregivers will become nurse and her other healthcare professional instead of what should have been parents and other family member. In this phase, Maria will build a feeling of trust that the caregiver will respond to her needs. It has been found that when children fail to build secure attachments in early life can may show a negative effect on behavior in later childhood or may be their whole life (Young, Simpson, Griskevicius, Huelsnitz, & Fleck, 2019). Children who are diagnosed with certain psychological issues often exhibit attachment issues.

• Diagnosis- The diagnosis for Maria is advancing pathological unconjugated hyperbilirubinemia.

Goal-The goal is to control the jaundice for progressing further and reversing the child back to non-jaundice state.

Intervention- Intervention is assessment of Maria for signs of progression of hyperbilirubinemia or behavioural changes. Nurse must be aware of the different stages of CNS involvement which are neuro-depression, neuro hyperreflexia, lack of manifestations and lastly cerebral palsy (Lauer & Spector, 2011).

Expected outcome- The expected outcome is by ensuring that Maria indicates indirect bilirubin levels less than 12 mg/dl, resolve jaundice by completion of the 1st week of her life and CNS does not get involved.

Plan of implementation and evaluation- If hyperbilirubinemia persists for more than two weeks in Maria then the nurse will evaluate further. Further laboratory tests would be warranted such as a fractionated bilirubin level, thyroid profiles, assessment for metabolic or hemolytic ailments, and an examination to check for intestinal obstruction.

References

Hillman, B., Tabrizi, M., Gauda, E., Carson, K., & Aucott, S. (2015). The Neonatal Pain, Agitation and Sedation Scale and the bedside nurse’s assessment of neonates. J Perinatol., 35(2), 128-31. doi:10.1038/jp.2014.154

Karadag, Zenciroglu, Eminoglu, Dilli, Karagol, Kundak, . . . Okumus. (2013). Literature review and outcome of classic galactosemia diagnosed in the neonatal period. Clin. Lab, 59(9-10), 1139-46.

Lauer, B. J., & Spector, N. D. (2011). Hyperbilirubinemia in the Newborn. Pediatrics in Review, 32(8).

Lynn, C., & Linda. (2007). Mosby’s Pediatric Nursing Reference (6 ed.). Mosby.

O’Reilly, Walsh, Allen, & Corcoran. (2015). The Bhutani Nomogram Reduces Incidence of Severe Hyperbilirubinaemia in Term and Near Term Infants. Ir Med J., 108(6), 181-2.

ULLAH, S., RAHMAN, K., & HEDAYATI, M. (2016). Hyperbilirubinemia in Neonates: Types, Causes, Clinical Examinations, Preventive Measures and Treatments: A Narrative Review Article. Iran J Public Health, 45(5), 558–568.

Young, E. S., Simpson, J. A., Griskevicius, V., Huelsnitz, C. O., & Fleck, C. (2019). Childhood attachment and adult personality: A life history perspective. Self and Identity, 22-38. doi:10.1080/15298868.2017.1353540