00230 Risk Of Neonatal Hyperbilirubinemia (Jaundice)

Domain 2: nutrition
Class 4: Metabolism
Diagnostic Code: 00230
Nanda label: risk of hyperbilirubinemia neonatal
Diagnostic focus: hyperbilirubinemia
Approved 2010 • Revised 2013, 2017 • Evidence level 2.1

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « risk of hyperbilirubinemia neonatal is defined as: susceptible to accumulation of bilirubin not conjugated in circulation (less than 15 ml/dl) that appears after the first 24 hours of life and that can compromise health.

Risk factors

  • Delay in the expulsion of the meconium
  • Maternal behavior of inadequate nutrition
  • Malnourite infants

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

Suggestions of use

Skin color surveillance and observe the presence of jaundice, is a routine procedure for all neonates. Therefore, this diagnosis should only be used with children who present one or more of the previous risk factors. It should not be used routinely with all neonates.

NOC Results

  • Noc results have not yet been associated with this diagnosis, although the next one could be useful:
  • Adaptation of the newborn: adaptive response to the extrauterine environment by a physiologically mature newborn, during the first 28 days

Evaluation objectives and criteria

  • The neonate does not present neonatal jaundice, as evidenced by the adaptation of the newborn
  • Also see the examples with the use of Noc terms for the diagnosis of neonatal jaundice
  • Other examples

    • Parents or caregivers state that they understand the causes, possible results and the treatment of hyperbilirubinemia

    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
    • Newborn control: measurement and interpretation of the physiological state of the neonate during the first 24 hours after childbirth
    • Newborn care: neonate management during transition to extrauterine life and the subsequent stabilization period

    Nursing Activities

    • Nursing activities focus on the identification and surveillance of the risk factors of neonatal jaundice and monitor the symptoms of jaundice in the neonate (for example, skin coloration).
    • Abnormal loss of weight (> 7% -8% in the newborn, 15% in term neonate)

    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 skin with natural light to see signs of jaundice. Also observe the sclera and the oral mucosa
    • Determine the gestational age of the neonate
    • Review the laboratory results (bilirubin and albumin total serum, hemoglobin and hematocrit, as well as reticulocyte count)
    • 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

    Collaboration activities

    • Manage a formula as a substitute for breast milk for 24 to 48 hours, if it is indicated or prescribed
    • Notify the primary health care provider the risk factors or the presence of jaundice.

    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