Jaundice: Nursing

Jaundice, also called icterus, is characterized by yellowish discoloration of the skin, mucous membranes, and the sclera, due to the deposition of bilirubin.Now, let’s go over some physiology.

Bilirubin is a yellowish pigment that’s normally found in bile, and is produced in the liver by breaking down hemoglobin from red blood cells.

Normally, red blood cells have an average lifespan of 120 days. When red blood cells get old or damaged, they travel to the spleen, where they are broken down to release hemoglobin.

The hemoglobin is degraded into unconjugated or indirect bilirubin, which is then released into the bloodstream. Unconjugated bilirubin then travels to the liver, where it gets taken up by hepatocytes.

These cells bind a molecule called glucuronic acid to the unconjugated bilirubin, forming conjugated or direct bilirubin.

Then, the hepatocytes use this conjugated bilirubin, as well as cholesterol and phospholipids, to produce bile. Then, bile is secreted by the liver through the hepatic bile ducts towards the gallbladder, where it’s stored.

Now, when food reaches the stomach, the gallbladder secretes bile through the cystic and common bile duct into the duodenum.

The bile then mixes with the food to help digestion while traveling along the intestines. Ultimately, upon reaching the colon, the colonizing bacteria convert bile’s conjugated bilirubin into urobilinogen.

Most of that urobilinogen gets reabsorbed into the blood and travels to the kidneys, where it gets excreted into the urine, giving it its distinct yellow color.

The urobilinogen that remains in the colon gets further converted by colonizing bacteria to stercobilinogen, which is excreted into the feces, giving the distinct brown color.

Alright, now the causes of jaundice can be classified as hemolytic or prehepatic, hepatocellular or intrahepatic, and obstructive or posthepatic.

Hemolytic jaundice is caused by hemolysis or breakdown of red blood cells; which occurs in conditions like hemolytic anemia, sickle cell disease, spherocytosis, thalassemia, G6PD deficiency, or blood transfusion reactions, as well as with reabsorption of large hematomas.

On the other hand, hepatocellular jaundice can be caused by conditions that damage the liver, such as hepatitis, cirrhosis, liver failure, or liver cancer, and certain medications that may cause hepatotoxicity, such as acetaminophen or rifampin; as well as inherited disorders that affect the liver function, such as Gilbert syndrome, Crigler Najjar syndrome, or Dubin Johnson syndrome.

Lastly, obstructive jaundice is caused by conditions that block the bile ducts, causing cholestasis or obstructed bile flow.

These conditions include gallstones, pancreatitis, and pancreatic cancer, as well as congenital defects, and pregnancy.Now, risk factors for jaundice include newborn and elderly clients, in addition to hepatic disease, alcohol use, certain medications, and pregnancy.

Now, let’s discuss the pathology of each type of jaundice. First is hemolytic jaundice, in which there’s excessive breakdown of red blood cells, releasing all their hemoglobin into the blood.

The excess hemoglobin is then degraded into unconjugated bilirubin, but the high amount of this bilirubin exceeds the liver’s ability to conjugate it.

As a result, the excess unconjugated bilirubin will start to build up in blood. Similarly, in hepatocellular jaundice, the liver damage decreases its ability to conjugate the unconjugated bilirubin, causing unconjugated bilirubin to build up in blood.

In addition, the liver damage also impairs its ability to secrete the little conjugated bile that’s produced into bile, thus also causing a build up of conjugated bilirubin in blood.

Finally, obstructive jaundice results from cholestasis, which causes bile to build up in the gallbladder, and ultimately, the conjugated bilirubin in it leaks into the blood.

Now, regardless of the underlying cause, the excess bilirubin in blood can’t be processed and removed from the body, so it ends up depositing in tissues like the skin, mucous membranes, and sclera.

The first clinical manifestation of jaundice is the yellowish discoloration of the sclera, followed by yellowish discoloration of the skin and mucous membranes.

This discoloration can often be accompanied by pruritus. Additional signs and symptoms can vary depending on the underlying cause of jaundice.

For example, clients with hemolytic anemia may present with fatigue and hepatosplenomegaly. Another example is hepatitis, which can be associated with fever, muscle and joint pain, and hepatomegaly.

Cirrhosis and liver failure may also cause gynecomastia or breast tissue enlargement in clients assigned male at birth; as well as ascites or abnormal accumulation of fluid in the abdomen; and caput medusae or engorged veins in the abdomen, radiating from the umbilicus.

Finally, cholestasis is typically associated with right upper quadrant tenderness. In addition, clients may present with dark urine or pale stools.

The diagnosis of jaundice starts with the client’s history and physical assessment. These are followed by blood tests revealing hyperbilirubinemia.

Additional diagnostic tests can help find the underlying cause. These include blood tests to detect if bilirubin is unconjugated or conjugated.

Additionally, a complete blood count, or CBC for short, shows decreased red blood cell count in clients with hemolytic causes, and a blood smear can reveal the appearance of the red blood cells.

Clients may also get liver function tests, albumin, PT, and PTT, which can be abnormal in clients with liver damage. In addition, urinalysis can reveal the presence of bilirubin in urine.

Also, imaging tests may aid in the diagnosis, including CT scan, MRI, and endoscopic retrograde cholangiopancreatography, or ERCP for short, which may reveal conditions like gallstones or cancer.

Lastly, some clients may require liver biopsy to confirm hepatocellular causes.Finally, the treatment of jaundice focuses on addressing the underlying cause.

In addition, antihistamines can be prescribed to relieve the pruritus. Alright, now let’s look at the nursing care you’ll be providing for a client with jaundice.

The goals of care center on treating the underlying condition and providing supportive care. Begin by collaborating with the healthcare provider to identify the underlying cause.

Then assess your client’s baseline vital signs and review their current laboratory test results, including CBC, liver enzymes, serum and urine bilirubin.

If your client is diagnosed with hemolytic jaundice, report to the healthcare provider a rising reticulocyte count, a critically low hemoglobin level, and symptoms of hypoxemia.

Then, administer the prescribed medications and blood products as indicated. For clients with hepatocellular and obstructive jaundice, assess their abdomen for ascites, hepatic or splenic enlargement, as well as abdominal tenderness or pain.

Administer IV fluids, analgesics, and medications to treat the underlying condition, as ordered. Continue to assess your client for resolution of their jaundice, keeping in mind that the degree of jaundice you can observe will vary depending on your client’s natural skin color.

In clients of color, be sure to assess for jaundice in areas with the least pigmentation, such as the sclera near the iris, as well as the buccal mucosa, and the hard palate.

Next, provide supportive care as indicated by the underlying condition. If your client is experiencing pruritus, provide therapies to offer relief, such as lotions and antihistamines, as prescribed.

Okay, now let's move on to client and family teaching. First, teach your client how they can manage symptoms of pruritus.

Encourage the use of soft linens while they sleep in order to decrease irritation of the skin. Teach them to maintain their home at an ambient temperature that is not too hot, because pruritus tends to increase in warmer conditions.

Then, let them know that they can relieve itching by avoiding irritants to the skin, such as strong soaps and detergents, and by using therapies such as moisturizing baths, cool compresses, and calamine lotions; and instruct them how to take the prescribed antihistamine, as directed.

Lastly, remind your client to prevent breaks in their skin by rubbing the affected area with their knuckles instead of scratching with their fingernails.

Next, teach your client that a healthy lifestyle is essential to manage the underlying disorder causing their jaundice. Advise them to avoid alcohol and smoking, and review with them the prescribed diet specific to their underlying disorder.

Review each of the medications they are taking, including herbal supplements and over the counter medications like acetaminophen, to ensure they are not taking medications that could make their condition worse.

Lastly, emphasize the importance of taking medications as prescribed for their underlying condition, and to keep all of their scheduled appointments with their healthcare provider for ongoing monitoring and treatment.Alright, as a quick recap… Jaundice is characterized by yellowish discoloration of the skin, mucous membranes, and the sclera, that happens when excess bilirubin in blood can’t be processed and removed from the body, so it ends up depositing in tissues.

Jaundice can be classified as hemolytic, hepatocellular, or obstructive. Depending on the cause, jaundice can often be accompanied by pruritus, dark urine, or pale stools.

Diagnosis starts with a history and physical assessment, followed by blood tests, as well as imaging tests, such as CT scan, MRI; and endoscopic retrograde cholangiopancreatography, or ERCP for short, in order to identify the underlying cause.

Treatment is focused on addressing the underlying cause, as well as treating symptoms like pruritus. Nursing management of care centers on treating the underlying condition