Steps

Rationale/Points of Emphasis

1 Gather the necessary supplies. Perform hand hygiene.

Promotes efficient time management and provides an organized approach to the procedure. Reduces transmission of microorganisms.

2 Determine whether the infant will be able to maintain his or her temperature and can be cared for in an open bassinet. If so, set up bassinet. If not, set up an isolette following the manufacturer’s instructions.

Neonates have limited ability to regulate or maintain body temperature and must be protected against hypothermia and hyperthermia. Relatively healthy term neonates should be able to maintain their temperature; preterm or sick neonates often cannot maintain adequate temperature and thus must be placed in an environment where temperature can be regulated for them.

3 Set up the phototherapy lights, following the manufacturer’s recommendations, as close to the infant as possible: in an open bassinet, about 4 inches (10 cm) from the infant; in an isolette, about 15-18 inches (38-46 cm) from the infant.

Bilirubin absorbs visible light in the range of 400-500 nm. The distance of the light source from the infant affects how well the light penetrates skin and is absorbed by bilirubin (this effect is most significant when special blue tubes are used).

Halogen lamps emit more heat than fluorescent bulbs and therefore increase the risk of a burn; do not position close to the infant. Follow manufacturer’s instructions for distance when using halogen lights.

4 Turn the light unit on. Using a light meter, verify that the level of irradiance is appropriate to the manufacturer’s recommendations for the system in use, approximately 12-15 µW/cm²/nm for low intensity (conventional or single phototherapy) or 30-35 µW/cm²/nm for high intensity (intensive or double phototherapy) (Figure 85-1).

Figure 85-1 A light meter is used to verify the light of irradiance, ensuring the minimum of 10 to 12 µW/cm²/nm.

Intensity of lights may decrease over time. Lights of less intensity may be ineffective or may require longer lengths of exposure to the infant to achieve the desired therapeutic effect.

5 Perform hand hygiene.

Reduces transmission of microorganisms.

6 Undress the infant, leaving a diaper in place to cover the genitals. Use a surgical mask for a diaper if it covers too much skin area of a small infant.

Undressing the infant increases the amount of skin surface area exposed. The diaper protects the gonads against chromatic radiant damage from the phototherapy light exposure.

7 Ensuring that the infant’s eyelids are closed, carefully cover the eyes completely with protective shields, making sure not to obstruct the nares. Remove eye patches a minimum of every 4 hours.

The eyes are closed to prevent corneal excoriation. The eyes are covered by protective eye shields at all times during use of overhead phototherapy to protect them against retinal damage.

Figure 85-2 Properly positioned patches do not put pressure over the bridge of the nose, which could cause airway compromise.

caREminder

Check the position of the eye patches every hour. Infants often wiggle enough to push the eye patches either above or below the eyes, leaving them exposed. If the eye shields have slipped during treatment, damage can be done to the eyes. Also, the edges of the patches can dig into the eyes or compress the nose and can therefore interfere with the infant’s breathing (Figure 85-2). If adhesive is used to fasten the eye patches, check for skin irritation. Remove the eye shields and inspect for purulent drainage and abrasion each time the lights are turned off for feedings, family contact, or diaper-area care. If eye discharge is present, cleanse with wet warm gauze or cotton ball from the inner to the outer eye.

8 Place the infant in the bassinet or isolette. Ensure that the position of the lights is maintained about 4 inches (10 cm) from the infant in a bassinet or about 15-18 inches (38-46 cm) from the infant in an isolette.

For the overhead lights to be safe and effective, an exact distance from the lights must be maintained throughout the treatment.

9 Turn the infant every 2 hours, assessing skin integrity, hydration, temperature, and neurologic status.

Ongoing skin surveillance can detect problems early and prevent dehydration or damage to the infant’s skin integrity.

caREminder

Turn the lights off when changing the infant’s diapers or when collecting blood specimens for bilirubin levels.

10 Monitor the infant’s temperature in an open bassinet every 30 minutes for the first hour and then every 2 hours and as needed after that. If in an isolette, monitor the infant’s temperature every 2-3 hours.

Verifies that the naked infant in an open bassinet can maintain his or her temperature in a safe range and to detect alterations promptly. Although the isolette has a servocontrol, the thermal homeostasis of the infant can be compromised. A neutral thermal environment needs to be maintained.

11 Remain vigilant in keeping the diaper area as clean as possible.

Excretion of bilirubin and exposure to phototherapy cause the infant’s skin to be at greater risk for compromise.

12 Provide both breast-fed and formula-fed infants with nutrition every 2-3 hours. Water supplements are not recommended. Unless the infant’s condition is critical phototherapy can be interrupted during feedings.

Provides the caloric support for hepatic processing of bilirubin and stimulates peristalsis, which allows the bilirubin-rich meconium stool to be excreted.

caREminder

Because of increased insensible stool water losses, encourage increased fluid intake. Bilirubin binds with protein; because there is no protein in water, it allows for limited flushing of the bilirubin. Water also supplies no nutrients, but it will fill the newborn’s stomach, and the infant will then feed less frequently.

13 Ensure that bilirubin blood monitoring is completed as ordered by the healthcare prescriber.

Evaluation of bilirubin levels provides data needed to determine when phototherapy can be discontinued.

14 Discontinue the therapy when ordered by the healthcare prescriber.

Therapy can be discontinued when bilirubin levels fall into normal range for the infant.