1. Disorders affecting fluid-gas transport: hemolytic disease of the newborn
    1. Rh incompatibility
      1. Pathophysiology
      2. Etiology
      3. Assessment:
        1. Prenatal-maternal Rh titers, amniocentesis.
        2. Intrapartal-amniotic fluid color:
          1. Straw-colored: mild disease.
          2. Golden: severe fetal disease.
        3. Direct Coombs’ blood; positive test demonstrates Rh antibodies in fetal blood.
      4. Nursing care plan/implementation-exchange transfusion:
        1. Goal: health teaching.
          1. Explain purpose and process to parents.
          2. Removes anti-Rh antibodies and fetal cells that are coated with antibodies.
          3. Reduces bilirubin levels-indicated when 20 mg/dl in term neonate and 15 mg/dl in preterm.
          4. Corrects anemia-supplies RBCs that will not be destroyed by maternal antibodies.
          5. Rh-negative type O blood elicits no reaction; maximum exchange is 500 mL; duration of exchange: 45-60 minutes.
        2. Goal: minimize transfusion hazards.
          1. Warm blood to room temperature, since cold blood may precipitate cardiac arrest.
          2. Use only fresh blood-to reduce possibility of hypocalcemia, tetany, convulsions.
          3. Give calcium gluconate, as ordered, after each 100 mL of transfusion.
        3. Goal: prepare for transfusion procedure. Ready necessary equipment-monitor, resuscitation equipment, radiant heater, light.
        4. Goal: assist with exchange transfusion.
          1. Continuous monitoring of vital signs; record baseline, and every 15 minutes during procedure.
          2. Record: time, amount of blood withdrawn; time and amount injected; medications given.
          3. Observe for dyspnea, listlessness, bleeding from transfusion site, cyanosis, cardiovascular irregularity or arrest; coolness of lower extremities.
        5. Goal: posttransfusion care.
          1. Assessment:
            1. Observe for dyspnea, cyanosis, cardiac arrest or irregularities, jaundice, hypoglycemia; frequent vital signs.
            2. Signs of sepsis-fever, tachycardia, dyspnea, chills, tremors.
          2. Nursing care plan/implementation:
            1. Maintain thermal stability-to reduce physiological stress, possibility of metabolic acidosis.
            2. Give oxygen-to relieve cyanosis.
            3. Keep cord moist-to facilitate repeat transfusion, if necessary.
            4. Maintain nutrition/hydration- feed per schedule.
      5. Evaluation/outcome criteria:
        1. Infant’s hemolytic process ceases; bilirubin level drops.
        2. Infant makes successful transition to extrauterine life.
        3. Infant experiences no complications of therapeutic regimen.
        4. Infant shows evidence of bonding.
  1. ABO incompatibility
    1. Pathophysiology-fetal blood carrying antigens A/B enters maternal type O bloodstream-antibody formation-antibodies cross placenta-hemolyze fetal RBCs. Note: less severe than Rh reaction.
    2. Etiology:
      1. Type O mother carries anti-A and anti-B antibodies.
      2. Even first pregnancy is jeopardized if fetal blood enters maternal system.
      3. Reaction possible if fetus is type A, type B, or type AB and mother is type O.
    3. Assessment:
      1. Jaundice within first 24 hours.
      2. Rising bilirubin levels.
      3. Enlarged liver and spleen.
    4. Nursing care plan/implementation: Goal: reduce hazard to newborn.
      1. Prepare for exchange transfusion with O negative blood.
      2. Phototherapy may be ordered if bilirubin is 10 mg/dl, and anemia is mild or absent.
      3. Close monitoring of status.
      4. Supportive care.
    5. Evaluation/outcome criteria:
      1. Infant responds to medical/nursing regimen.
      2. Infant’s assessment findings within normal limits.
  2. Hyperbilirubinemia
    1. Pathophysiology-bilirubin, a breakdawn product of hemolyzed RBCs, appears at increased levels; exceeds 13-15 mg/dl. Bilirubin is safe when bound with albumin and conjugated by user for body excretion; danger is when unconjugated and deposits in CNS.
      1. WARNING: There is no “safe” serumbilirubin level; kernicterus is a function of the bilirubin level and neonatal age and condition; poor fluid-and-caloric balance subjects the infant (especially the preterm infant) to kernicterus at low serumbilirubin levels.
      2. Kernicterus-high bilirubin levels result in deposition of yellow pigment in basal ganglia of brain-irreversible retardation.
    2. Etiology:
      1. Rh or ABO incompatibility, during first 48 hours.
      2. Resolution of an enclosed hemorrhage (cephalhematoma).
      3. Infection.
      4. Drug induced-vitamin K injection, maternal ingestion of sulfisoxazole (Gantrisin).
      5. Bile duct blockage.
      6. Albumin-binding capacity is exceeded.
      7. “Breastfeeding jaundice” (pregnandiol in milk). Breastfeeding is not dangerous and not a cause of physiologic jaundice.
      8. Dehydration.
      9. Immature liver (interferes with conjugation).
    3. Assessment:
      1. Jaundice noted after blanching skin to suppress hemoglobin color; noted in sclera or mucosa in dark-skinned neonates; make sure light is adequate; spreads from head down, with increasing severity.
      2. Pallor.
      3. Concentrated, dark urine.
      4. Blood level determination-hemoglobin or indirect bilirubin (unconjugated, unbound bilirubin deposits in CNS).
      5. Kernicterus-similar to intracranial hemorrhage.
        1. Poor feeding or sucking.
        2. Regurgitation, vomiting.
        3. High-pitched cry.
        4. Temperature instability.
        5. Hypertonicity/hypotonicity.
        6. Progressive lethargy; diminished Moro reflex.
        7. Respiratory distress.
        8. Cerebral palsy, mental retardation.
        9. Death.
    4. Analysis/nursing diagnosis:
      1. Fluid volume (RBC) deficit related to hemolysis secondary to blood incompatibility.
      2. High risk for injury (brain damage) related to kernicterus.
      3. Altered thought processes (mental retardation) related to brain damage secondary to kernicterus.
      4. Knowledge deficit (parental) related to infant condition.
    5. Nursing care plan/implementation:
      1. Medical management:
        1. Prenatal-amniocentesis.
        2. Postnatal-exchange transfusion, phototherapy.
      2. Goal: assist bilirubin conjugation through phototherapy.
        1. Cover closed eyelids while under light; remove eyepads when not under light (feeding, cuddling, during parental visits)-to protect eyes.
        2. Expose as much skin as possible-to maximize exposure of circulating blood to light. Remove for only brief periods.
        3. Change position qlh-to maximize exposure of circulating blood to light.
        4. Note: any loose green stools as bile is cleared through gut; watch for skin breakdown on buttocks.
        5. Monitor temperature-to identify hyperthermia.
        6. Push fluids (to 25% more than average) between feedings-to counteract dehydration. Breast milk has natural laxative effects that help clear bile.
      3. Goal: health teaching. Explain, discuss phototherapy, bilirubin levels, implications.
      4. Goal: emotional support.
        1. Encourage verbalization of anxiety, fears, concerns.
        2. Encourage contact with infant.
        3. Reassure, as possible.
    6. Evaluation/outcome criteria:
      1. Infant’s hemolytic process ceases; bilirubin level drops.
      2. Infant makes successful transition to extrauterine life.
      3. Infant experiences no complications of therapeutic regimen.
      4. Infant shows evidence of effective bonding.