00194 Neonatal Hyperbilirubinemia (Jaundice)

Domain 2: nutrition
Class 4: metabolism
Diagnostic Code: 00194
Nanda label: neonatal hyperbilirubinemia
Diagnostic focus: hyperbilirubinemia
Approved 2008 • Revised 2010, 2017 • Evidence level 2.1

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « hyperbilirubinemia neonatal is defined as: accumulation of bilirubin not conjugated in circulation (less than 15 ml/dl) that appears after the first 24 hours of life. < /p>

Definite characteristics

  • Analytical results of abnormal liver function
  • Boarded skin
  • Yellow mucous membranes
  • Yellow sclerotic
  • Yellow-orange skin

Related factors

  • Delay in the expulsion of the meconium
  • Maternal behavior of inadequate nutrition
  • Malnourite infants
  • Child’s difficulty to make the transition to extrauterine life
  • Lack of well -established feeding pattern
  • Neonate between 1 and 7 days of age
  • Abnormal weight loss (> 7% -8% in the neonate, 15% in term neonate
  • Delay in expulsion of feces (meconium)

Risk population

  • Neonates of the East Asian
  • Infants with low birth weight
  • Neonates of native-American ethnicity
  • Neonates <7 days of age
  • Neonates with breastfeeding
  • Neonates with blood groups incompatible with maternal
  • Neonates whose mothers suffered gestational diabetes
  • Neonates with brothers with a history of jaundice
  • Neonates with significant bruises during childbirth
  • Populations living at great altitudes
  • Premature neonates

Associated problems

  • Bacterial infection
  • Enzymatic deficiency
  • Metabolism deterioration
  • Internal hemorrhage
  • Hepatic malfunction
  • Prenatal infection
  • sepsis
  • Viral infection

NOC Results

  • Noc results have not yet been associated with this diagnosis, although the following could be useful:
  • Adaptation of the newborn: adaptive response to the extrauterine environment by a physiologically mature newborn, during the first 28 days
  • Knowledge: Therapeutic procedure: degree of understanding demonstrated on a necessary procedure for a treatment regime

Evaluation objectives and criteria

  • The neonate does not present neonatal jaundice, as evidenced by the adaptation of the newborn and the knowledge of the parents: therapeutic procedure
  • Demonstrates adaptation of the newborn, which is manifested by the following indicators (specify from 1 to 5: severely diverted, substantially, moderately, slightly or without any deviation from normal limits):
    • Bilirubin levels
    • Intestinal elimination
    • skin color
    • Suction reflection
    • Weight
  • Other examples

    • Parents or caregivers state that they understand the causes, possible results and the treatment of hyperbilirubinemia
    • Jaundice disappears and bilirubin levels are reduced with phototherapy

    NIC Interventions

    • NIC interventions have not yet been associated with this diagnosis, although the following could be useful:
    • Breastfeeding assistance to maternal breast: preparation of a mother to breastfeed her baby
    • Phototherapy: Neonate: Use of light therapy to reduce bilirubin levels in the newborn

    Nursing Activities

    • Nursing activities focus on identification and surveillance for the improvement of factors that cause and/or contribute; monitor the symptoms of jaundice in the neonate; intervene independently and in collaboration to correct hyperbilirubinemia, as well as assess and prevent the collateral effects of phototherapy.

    Valuations

    • Review the medical history of childbirth to detect risk factors (premature birth, sepsis, low birth weight, birth trauma, need for birth resuscitation)
    • Evaluate the mother’s prenatal nutritional level, especially with respect to protein intake
    • Detect hypoglycemia signs (such as irritability, agitation, lethargy); obtain heel glucose levels, as indicated
    • Evaluate the success of breastfeeding to the maternal breast
    • Observe the presence of paleness and edema
    • Observe the skin with natural light to see signs of jaundice. Also observe the sclera and the oral mucosa
    • Record the age of the neonate when jaundice appears
    • Review the laboratory results (bilirubin and albumin total serum, hemoglobin and hematocrit, as well as reticulocyte count)
    • Observe the changes in the behavior that could indicate the toxicity of bilirubin (lethargy, inappropriateness, decrease or absence of reflexes, acute screams, torsions, fever, seizures)
    • Evaluate intake and expense; Observe physical dehydration signals
    • Monitor the central temperature
    • Monitor weight loss

    Patient and family education

    • Motivate feeding 4 to 6 hours after birth
    • Motivate the mother to breastfeed the neonate between 8 and 12 times a day
    • Indicate parents or caregivers that they should not apply lotion or oil on the skin of the neonate that receives phototherapy

    Collaboration activities

    • Start and manage phototherapy according to the protocol or prescription of the primary health care provider
    • Place protections in the eyes during phototherapy to avoid retinal lesions. Withdraw them for food and other activities
    • Manage a formula as a substitute for breast milk for 24 to 48 hours, if it is indicated or prescribed
    • Prepare and help with exangransfusion, if necessary
    • Organize phototherapy at home, if necessary
    • Make arrangements to perform serum bilirubin monitoring, if necessary

    Others

    • Keep the warm and dry neonate
    • Provide parents or care for a name and contact number in case the jaundice worsens or if other symptoms appear