1. Physiological jaundice
FACTUALLY OF NURSING
MIDWIFARY DEPARTMENT
Physiological jaundice
SUBMITTED TO:
KHOLOD AL- AZAB

2. Presented by: Ghadeer Moqaied Maram al ghusein Aseel abu Jeri
Wala Hassona
Raeda Sbieh
Abeer Dawwas
Eman abu Msalem
Rawan abu Swerich
Samah Dababish

9. High levels of unconjugated bilirubin can potentially be a serious
problem becouse
It can cross the blood _brain barrier .this can cause a bilirubin encephalopathy
And in longer term can result in cerebral palsy and learning
difficulties
Kernicterus is a pathological finding of bilirubin in the brain

11. BILIRUBIN PHYSIOLOGY
bilirubin is produced as one of the breakdown products of haemoglobin ageing , immature or malformed red cells are
removed from the cirulation and broken down the reticuloethellial system .(liver, spleen,and macrophages)

13. Haemoglobin from these cells is broken down into the products of haem , globin and iron . haem is converted to biliverdin and thin to unconjugated bilirubin . globin is broken down into amino acids, which are used by the body to make proteins . iron is stored in the body or used for new red blood cells , the unconjugated bilirubin is then transported to the liver.
once in the liver, uncojugated bilirubin is detached from albumin , combined with glucose and glucuronic acid and conjuagtion occurs using the enzyme uridine diphos –phoglucuronyl transferase . the conjugated bilirubin is now water –soluble and available for excretion .

14. Conjugated bilirubin is excreted via the biliary system into the small intestine where normal bacteria change the conjugated bilirubin into urobilinogen . this is then oxidized into orange – coloured urobilin . most is excreted in the faeces , with a small amount excreted in urine .

15. Physiological jaundice
All newborn babies have a rise in unconjugated bilirbin during the first few days after birth .
Reasons :
The turnover of haemoglobin in high in the fetus and newborn،
But before birth the bilirubin from the fetus is removed via placenta .
 At birth :
The more efficient lungs increase oxgen level
he newborn liver enzymes system may be immature and not as effective.
* Most babies will look yellow by 3-4 days
* Serum albumin become saturated.

16. *Babies on the first few days after birth will not appear
jaundiced
*But most babies will look yellow by day 3_4 .

17. * Causes of concern in physiological jaundice
Jaundice in the first 24 hours after birth.
History of antibodies.
Any baby who is visibly jaundiced.
Any baby who remain jaundiced beyond 14 days of age.

18. * Early Physiological Jaundice (Within First 5 days after birth )
Causes include:
Physiological jaundice
Haemolysis (Rhesus isoimmunisation , ABO incompatibility , other blood group antigen problems )
Infection
Bruising
Polycythaemia
Dehydration (unlikely in the first 48 hours but must be considered in babies presenting between 2-7 days after birth , particularly those who are breast fed )

19. Assessment and diagnosis of physiological jaundice :
The initial important question are :
Is the jaundice physiological due to the normal process of breakdown of bilirubin or the presence of another pathological process ?
Is the baby at risk of bilirubin encephalopathy ?
Before assessment should identify risk factor..

20. RISK FACTOR :
Birth trauma or evident bruising (Increased production of unconjugated bilirubin )
Family history of significant haemolytic disease or jaundice sibling
Maternal antibodies at booking
Evidence of infection
Prematurity
Timing of jaundice (within the first 24 hours (suggesting haemolysis) or jaundice at 3-6 days of age could be related to dehydration )

21. Physical assessment :
Observation of extent of changes in skin and scleral colour , skin bruising ,or cephalhaematoma
Lethargy
Decreased eagerness
Dark urine , light stools which could indicate intrahepatic or extrahepatic obstructive disease

22. Haemoglobin concentration to assess anaemia _ polycythaemia
Laboratory Investigation :
Investigation will always include SBR . If the bilirubin level is high then following investigation should also be carried out :
Direct coombs test (DCT) to detect presence of maternal antibodies on baby’s red blood cell
Blood groups (baby and mother ) and Rh type for possible incompatibility
Haemoglobin concentration to assess anaemia _ polycythaemia
Conjugated bilirubin if there are any factor to suggest conjugated hyperbilirubinemia

23. Pathological jaundice
in new bornJaundice is considered pathologic if it presents within the first 24 hours after birth.
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.

24. Causes of jaundice Hemolytic disease of NB: Rh, ABO
Infections: TORCH, malaria, bacterial
G6PD deficiency.
T – Toxoplasmosis / Toxoplasma gondii
O – Other infections
R – Rubella
C – Cytomegalovirus
H – Herpes simplex virus or neonatal herpes simplex

25. After 72 hours of age
Sepsis
Cephalhaematoma
Neonatal hepatitis
Extra-hepatic biliary atresia
Breast milk jaundice
Metabolic disorders (G6PD).

26. Normal values of unconjugated Biliruben are 0.2 to 1.4 mg/dL.
Investigation to know the cause of jaundice.
Mother blood Rh.

27. Mangament of pathological jaundice
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.

28. of physiological jaundice
Management
of physiological jaundice

30. The goal of jaundice treatment is to quickly and safely
reduce the level of bilirubin. Infants with mild jaundice may need no treatment.
Infants with higher bilirubin levels or hyperbilirubinemia
will require treatment, which is described below

31. Jaundice
is common in premature infants (those born before 38 weeks of gestation).
Premature infants are at greater risk for hyperbilirubinemia because brain toxicity occurs at lower levels of bilirubin than in term infants. As a result, premature infants are treated at lower levels of bilirubin, but with the same treatments discussed here.ai

33.  Phototherapy ("light" therapy) is the most common medical treatment for jaundice in newborns. In most cases, phototherapy is the only treatment required. It consists of exposing an infant's skin to blue light, which breaks bilirubin down into parts that are easier to eliminate in the stool and urine.
Treatment with phototherapy using special blue lights, is successful
for almost all infants.
Phototherapy is usually done in the hospital, but in select cases, it can be
done in the home if the baby is healthy and at low risk for complications.
Infants undergoing phototherapy should have as much skin exposed to the light as possible. Infants are usually naked (or wearing only a diaper) in an open bassinet or warmer, but wear eye patches to protect the eyes. It is important to ensure that the lamps do not generate excessive heat, which could burn an infant's skin. In some institutions, phototherapy blankets are used
Phototherapy should be continuous, with breaks only for feeding.

34. Phototherapy is stopped when bilirubin levels decline to a safe level
Phototherapy is stopped when bilirubin levels decline to a safe level. It is not unusual for infants to still appear jaundiced after phototherapy is completed. Bilirubin levels may rebound 18 to 24 hours after stopping phototherapy, although this rarely requires further treatment

35. Side effect of photograpy
Phototherapy is very safe, but it can have temporary side effects, including
1- a skin rash and loose bowel movements.
2- Overheating
3-dehydration can occur if the infant does not get enough breast milk or formula. Therefore, the infant's skin color, body temperature, and number of wet diapers are closely monitored.
4-Rarely, some infants will develop "bronze baby" syndrome, a dark, grayish-brown discoloration of the skin and urine. Bronze baby syndrome is not harmful and gradually resolves without treatment after several weeks.

36. 5-hydration– It is important for infants receiving phototherapy to drink adequate fluids (breast milk or a supplement) since bilirubin is excreted in urine and bowel movements. Breast- or bottle-feeding should continue during phototherapy. Use of oral glucose water is not necessary. In some babies with severe dehydration, intravenous fluids
may be necessary.
6-Breastfeeding – Breastfed infants who are not able to consume enough breast milk, whose weight loss is excessive, or who are dehydrated may need extra expressed breast milk or other milk supplements. Mothers who supplement should continue to breastfeed and/or pump to maintain their

37.  Exchange transfusion
 Exchange transfusion is a procedure that is done urgently to prevent or minimize bilirubin-related brain damage. The transfusion replaces an infant's blood with donated blood in an attempt to quickly lower bilirubin levels. Exchange transfusion may be performed in infants who have not responded to other treatments and who have signs of or are at significant neurologic risk
of bilirubin toxicity

39. Nursing dignosis
Body Temp., risk for imbalanced Temp. related to use of phototherapy.
Fluid volume, risk for deficient related to phototherapy.

40.  deficent fluid volume related to inadequate fluid intake, photo-therapy, and diarrhea. Goal: Adequate neonatal body fluids Intervention:
Record the number and quality of stools,
Monitor skin turgor,
Monitor intake output,
Give water between breast-feeding or give bottle.

41. Hyperthermia related to the effects of phototherapy Goal: The stability of the baby's body temperature can be maintained Intervention:
Give a neutral ambient temperature,
Keep the temperature between 35.5 ° - 37 ° C,
Check vital signs every 2 hours.

42. Impaired skin integrity related to hyperbilirubinemia and diarrhea Goal: The integrity of the baby's skin can be maintained Intervention:
Assess skin color every 8 hours,
Monitor direct and indirect bilirubin,
Change position every two hours,
Massage the area that stands out,
Keep skin clean and moisture.

43. anxiety related to medical therapy given to the baby
anxiety related to medical therapy given to the baby. Goal:  Parents know about treatment, symptoms can be identified to deliver the health care team. Intervention:
Review knowledge of the client's family,
Give the cause of yellow health education, therapy and treatment process.
Give health education on infant care to home.