1. In-room Phototherapy Implementation
A. Smirnova, RN BSN
Mother & Baby Care Unit
Fountain Valley Regional Hospital
Hello everybody! As we all know our postpartum unit has experienced changes as we all work toward being a Baby Friendly Hospital. In order to implement the Baby Friendly Hospital initiative, one of our unit’s goals is to minimize mother and baby separation time. Some newborns need phototherapy during their stay in the hospital during their mothers’ postpartum period. Those newborns are put into isolettes in the nursery and are observed by nursery nurses while they are getting their phototherapy. In order to minimize mother and baby separation time and decrease parental anxiety, phototherapy can be done in the patients’ rooms.

2. OBJECTIVES Phototherapy in a couplet care settings Safety concerns
Equipment
Documentation
Patients’ education

3. PHOTOTHERAPY Assessment newborns for jaundice
Goal of phototherapy treatments
Methods of phototherapy treatment
Conventional
Fiberoptic
Combined
Neonatal hyperbilirubinaemia or jaundice is a relatively common condition in newborn babies presenting with changes to RBC metabolism (Turnbul, 2012). We assess newborns for jaundice by using nursing clinical judgement, doing transcutaneous monitoring on the day of discharge, and doing a serum bilirubin test, if indicated. The goal of phototherapy is to convert unconjugated bilirubin to a conjugated bilirubin, which can be excreted by a newborn. There are several methods for delivering phototherapy: conventional, fiberoptic, and combined. In conventional method LED, halogen, or fluorescent lamps are used above or below the neonate. The intensity of the lights depends on the distance between the lights and skin. In the fiberoptic method, the light from a quartz halogen bulb is delivered to a bili blanket by optic fibers. In that method, the bili blanket can be in contact with neonate’s skin. In combined method, conventional lights are used in addition to a bili blanket.

4. Couplet care and phototherapy
Round every hour, answer call lights promptly
Help patients to move baby from an isolette for breastfeeding and placing baby back to isolette
Room for an isolette in OB room (use private rooms, moving second bed to make a room for an isolette)
Involvement parents in baby care (education, handouts)

5. SAFETY CONCERNS Risk of eye and skin damage Risk of falls
Effect of phototherapy on newborns’ retina
Eye and skin protection
Equipment check every 12 hours
Risk of falls
Use windows for baby care
Patients’ education
Hyperthermia and hypothermia
Vital signs check every 4 hours
A study revealed that, one of the complications of the phototherapy is that it causes degeneration of the retina through exposure to light (Silva, 2008). Therefore, it is very important to provide eye and skin protection. The lights intensity has to be checked every twelve hours using a bili meter at the level of baby’s skin to prevent skin damage. Another risk for newborns’ safety is a risk of falls. Mothers have to be educated regarding isolette safety. All the equipment has to be checked every shift. Isolettes’ temperature settings have to be monitored and baby’s temperature checked every four hours to prevent hyper- and hypothermia in newborns in isolettes.

6. SAFETY: eye and skin protection
Eyes should be protected by eye mask and genitals should be protected by diaper at all times when baby is under lights.

7. SAFETY: risk of falls
Educate patients about the risk of falls. Teach them to care for the baby using isolette windows and to open isolette door only if in the case of an emergency. Provide handouts with pictures. Demonstrate how to use isolette and ask patients to teach back.

8. SAFETY: hypo- or hyperthermia
Check the baby’s temperature every 4 hours
Adjust isolette temperature settings according to baby’s temperature

9. Equipment: bili blancket
Large pad: (D+E+F)/3 ≥ 48.5 µW/cm²/nm
Small pad: (C+D)/2 ≥ 70 µW/cm²/nm

10. Equipment: bili blancket (cont.)
Phototherapy can be provided in a crib. Ensure that the covered light emitting section of the pad remains in direct contact with the skin.

11. Equipment: overheads
To regulate the intensity of the lights, the distance between patient’s skin and the light can be adjusted.

12. Equipment: overheads (cont.)
High intensity: µW/cm²/nm
Low intensity: µW/cm²/nm

13. PATIENT EDUCATION Purpose of phototherapy Isolettes safety
Bili lights safety
Newborn fall prevention
Importance of eye protection
Importance of adequate feedings
Importance of continuance phototherapy
with minimal interruption
Tests for bilirubin levels
Handouts

14. DOCUMENTATION Phototherapy bond Type of phototherapy
Eye and skin protection
Safety checks
Bili meter every 12 hours
In addition to routine documentation, phototherapy has to be documented every 4 hours. To document phototherapy, open phototherapy bond. Safety checks have to be done every 12 hours and documented accordingly.

16. DOCUMENTATION (continued)
Plan of care update
Risk of falls
Risk for impaired bonding
Education update
Fall risk education
Phototherapy and tests education
Assessment every 4 hours
The nursing plan of care has to be updated to include risk of falls and risk for impaired bonding between mother and baby. Education regarding risk of falls, phototherapy, and tests for bilirubin levels have to be provided to parents and documented accordingly. The neonate under phototherapy is at risk for hyper and hypothermia. Body temperature has to be checked every 4 hours and documented. Isolette settings can be adjusted according to neonate body temperature. Neonate position in isolette has to be documented. Eyes and genitals have to be covered during phototherapy to avoid damage. The type of protection provided has to be documented.

17. Conclusion In-room phototherapy benefits
Safety issues related to phototherapy
Phototherapy implementation and documentation
Patient education
To implement Baby Friendly Hospital Initiative, we can provide phototherapy in-room. The risks include risk of falls, risk of eye and skin damage, and risk for hypo- and hyperthermia. Phototherapy has to be documented. Patient education should be provided and assessed by asking parents to teach back and demonstrate.

18. References
Goulet, L., Fall, A., D'Amour, D., & Pineault, R. (2007). Preparation for discharge, maternal satisfaction, and newborn readmission for jaundice: comparing postpartum models of care. Birth: Issues In Perinatal Care, 34(2), Galuska, L. (2011). Prevention of In-Hospital Newborn Falls. Nursing For Women's Health, 15(1), doi: /j X x Kaur, S., Chawla, D., Pathak, U., & Jain, S. (2012). Pre-discharge non-invasive risk assessment for prediction of significant hyperbilirubinemia in term and late preterm neonates. Journal Of Perinatology, 32(9), doi: /jp Silva, L., da Silva, F., Turiani, M., Juliani, C., & Spiri, W. (2008). Development of an eye protector for phototherapy on newborns: a technology. Revista Latino-Americana De Enfermagem (RLAE), 16(1), doi: /S