3 April 2015

Hyperbilirubinemia or Neonatal Jaundice Nursing Diagnosis and Intervetions

Neonatal Hyperbilirubinemia or Neonatal Jaundice in newborn is one of the most common problems encountered in term newborns. Although up to 60 percent of the term new borns have clinical jaundice in the first week of life. Hyperbilirubinemia is a conditionin which there is too much bilirubin in blood. When red blood cells breakdown, a substance called bilirubin is formed. Babies are not easily able to get rid of the bilirubinand it can build up in the blood and other tissues and fluids of the baby’s body. This is called Hyperbilirubinemia. Because of bilirubin has a pigment or coloring, it causes a yellowing of the baby’s skin and tissues. This is called jaundice. Depending on the cause of the hyperbilirubinemia, jaundice may appear at birth or at any time afterward. Generalsigns and symptoms are yellow eyes, skin, tiredness, fatigue, light colored stools, anddark urine.

Nursing Diagnosis
1.Risk for Injury related to abnormal blood profile as evidenced by increase bilirubin level of 1.59mg/dl.

Nursing Interventions

  • Remove clothing and exposed to photo therapy.Rational:Aids in diagnosing underlying cause in connection with the appearance of jaundice.
  • Covered eyes and genitalia.Rational:To prevent eyes from direct exposure to light and prevent sterility of the baby.
  • Re positioned the baby every 2 hours.Rational:To prevent burns.
  • Kept warm and dry.Rational:To prevent further complications.
  • Vital signs taken and recorded every 1 hour.Rational:To obtain the baseline data.
  • Instructed on Strict Aspiration Precaution(SAP) and advised the mother to burp the baby every after feeding.Rational:To prevent aspiration pneumonia and to prevent colic.
  • Monitored input andoutput; IVF regulatedat 14 uggts/ min.Rational:To prevent dehydration and replace fluid and electrolyte lost .
  • Provided quiet and warm environment .Rational:To promote comfortand prevent irritability.
  • Instructed the mother to use stimulation technique such as touching.Rational:To promote sense of warmth, 
  • Security and attachment.Health teachings given to the mother such as personal hygiene,importance of breastfeeding, and newborn screening.Rational:To detect early the possible diseases of the patient.

Nursing Diagnosis
2.Risk for fluid imbalance related to prolonged exposure to photo therapy as evidenced by dry skin

Nursing Interventions

  • Monitored input andoutput; IVF regulatedat 14 uggts/ min.Rational:attended To prevent dehydration andreplace fluid and electrolyte lost
  • Vital signs taken and recorded.Rational:To obtain the baselinedata
  • Bedside care done including stretching of linens and organizing bedsides.Rational:To promote comfort and good hygiene
  • Instructed Strict Aspiration Precaution(SAP) Rational:To prevent aspiration pneumonia
  • Kept back dry Rational:To prevent further complications.
  • Health teachings given to the mother such asthe importance of breastfeeding, handwashing, and proper hygiene Rational:To promote healthy lifestyleursing
  • Needs attended

Nursing Diagosis:
Risk for skin breakdown related to prolonged use of photo therapy.

Nursing Interventions

  • Maintained and monitored baby’s eye patches while under phototherapy.Rational:To protect retina from damage due to high intensity of light.
  • Removed baby under phototherapy and removed eye patches during feeding.Rational:To provide visual stimulation and facilitates attachment behaviors.
  • Inspected eyes everyafter phototherapy for conjunctivitis, drainage and corneal abrasions due to irritation from eye patches .Rational:To reduce complications and monitor the effectiveness of the management.
  • Provided minimal coverage of the body except for genitals.Rational:To provide maximal exposure and shielded the sensitive parts such as the eyes and genitals.
  • Repositioned the babyevery 2 hours.Rational:To promote equal distribution of phototherapy exposure