As a home care nurse,you are visiting a 5-day-old male infant for a scheduled follow-up appointment to ensure that he is responding to home phototherapy for treatment of jaundice.Based on the diagnosis of hyperbilirubinemia,you are aware that the development of acute bilirubin encephalopathy is a risk for this infant.This disease process occurs after the bilirubin level has peaked.After completing a thorough assessment and obtaining a history from the parents,you recognize that this infant is in the first phase of encephalopathy when he exhibits:

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The early and most subtle symptoms of bilirubin encephalopathy include hypotonia,lethargy,poor suck,and depressed or absent Moro reflex.Should the infant display symptoms such as a high-pitched cry,severe muscle spasms,hyperreflexia,or arching of the back,the nurse should be aware that the baby has progressed beyond the more subtle signs of the first phase.Medical attention is necessary immediately.Should the infant display symptoms such as a high-pitched cry,severe muscle spasms,hyperreflexia,or arching of the back,the nurse should be aware that the baby has progressed beyond the more subtle signs of the first phase.Medical attention is necessary immediately.Symptoms may progress from the subtle indications of the first phase to fever and seizures in as little as 24 hours.Only about half of these infants survive and will have permanent sequelae including auditory deficiencies,intellectual deficits,and movement abnormalities.

As a Home Care Nurse,you Are Visiting a 5-Day-Old Male