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Henry Kinuthia Date: September 29, 2014

Fresno City College


Health Sciences Division
Associate Degree Nursing Program

Pathophysiology: The client is a two-day old neonate male, born on September 28th, 2014 at 36th week and 4 days of gestation through a
Cesarean section secondly to placenta previa and abruptio placenta. The clients birth weight was 6 pounds 3 ounces. The mother is G4 T3 P1
A0 L4. Lab results for clients blood drawn at the 23rd hour of life shows a total serum bilirubin level of 8.3 mg/dL.
Serum total bilirubin level greater than 2 mg/dL is an indicator for Jaundice. The clients jaundice is considered pathological since it
appeared within the first 24 hours of life. The cause of the jaundice in this client is attributed to prematurity since he was born at the 36th week
of gestation. Pathological jaundice in preterm neonates is results from the inability of the premature liver to conjugate bilirubin. Bilirubin is a
waste produced when red blood cells are destroyed. In neonates, bilirubin becomes elevated as fetal red blood cells are destroyed in order to
make room for new postnatal red blood cells. It is the unconjugated bilirubin that causes the yellow skin color.
Since conjugated bilirubin is eliminated through the GI system, slow or delayed stooling in neonates can aggravate the level of serum
total bilirubin. Hence, ineffective neonate feeding (or breastfeeding) can contribute to elevation of total serum bilirubin since there is a direct
correlation between neonate feeding and stooling. The client is scheduled to receive phototherapy today, September 29, 2014.
Fill out two nursing diagnosis on your patient.
Nursing Diagnosis R/T AEB
Nursing Interventions

Rationales

Outcomes

Remember this must match what is


written in your assessment.

This is measureable. How often will


you do this intervention?

Ask yourself why are you doing this


intervention?

This is measurable in longer term.


Usually Q 24-48 hours or by
discharge.

Neonatal Jaundice

Evaluate the neonate clients total


and direct serum bilirubin values
every 12-24 hours.

Visual skin color assessment is not a


sufficient indicator in determining
the levels of serum bilirubin.
Measurements of bilirubin is
important in evaluating the risk of
pathology The purpose in
monitoring and evaluating neonatal
hyperbilirubinemia is to prevent
neonatal encephalopathy (Ackley &
Ladwig, 2014).

Short term goal: Neonate client lab


values for bilirubin will be less than
2 mg/dL by discharge.

Henry Kinuthia Date: September 29, 2014


Related to: premature birth

Assess the 36 weeker neonate client


for ability to breastfeed successfully
and teach the clients primary care
giver (mother) to how to collect
breast milk via hand expression and
feed the neonate client in order to
promote adequate hydration,
feeding, and stooling within the one
hour of client contact.

Late preterm infants are at higher


risk for breastfeeding and
inadequate milk intake and they are
at a much higher risk for severe
jaundice than term counterparts, and
therefore it is important to promote
and educated mothers about
alternate feeding methods that
would also promote stooling and
enhance bilirubin excretion, during
phototherapy (Ackley & Ladwig,
2014).

Short term goal: The clients


primary care giver (mother) will
demonstrate back by collecting
breast milk via hand expression
within one hour of client contact
and the neonate client will feed at
least once very two to three hours
on the third day of life.

As Evidence By: total serum


bilirubin level of 8.3 mg/dL for
blood drawn at 23 hours of life;
yellow mucous membranes; and
yellow skin.

Educate the neonate clients primary


care giver (mother) how to care for
a client undergoing phototherapy for
the treatment of hyperbilirubinemia
within three hours. Such care
includes covering clients genitals
and eyes, and turning and feeding
the client.

Short term goal: The clients


primary caregiver (mother) will
perform a return demonstration by
covering the client genitals with
diaper and eyes with eye shields and
feeding the client with the collected
breast milk within three hours.

Nursing Diagnosis R/T AEB


Ineffective Breastfeeding

Nursing Interventions
Educate the neonate clients primary
care giver (mother) about breastfeeding position that promotes
neonate latching such as football,
cradle, across-the-lap, and side lying
hold within 2 hours.

The client undergoes phototherapy


while naked, but the genitals and the
eyes should be covered to minimize
risk of damaging the retinal.
Neonates undergoing phototherapy
are at risk of dehydration and they
should be fed regularly to replace
any insensible water loss (Ricci,
2012).
Rationales
Positioning a neonate in a breast
feeding position promotes latching
(Ricci, 2012).

Related to: newborn prematurity

Educate the neonate clients primary


caregiver (mother) about clients
cue for readiness to feed such
opening mouth turning head from
side to side, rooting, starring,
stretching, agitation and putting
hands in mouth as cues for readiness
to feed within one hours.

The mother and the baby should be


able to communicate through babys
cues and mothers response to such
cues. This promotes feeding the
baby on demand (Ricci, 2012).

Long term goal: The clients


primary caregiver (mother) will
verbalize neonate cues for readiness
to feed such as opening mouth
turning head from side to side,
rooting, starring, stretching,
agitation and putting hands in mouth
within one hour.

Outcomes
Long term goal: The clients
primary caregiver (mother) will
perform a return demonstration by
positioning the neonate client
football, cradle, across-the-lap, and
side lying hold within 2 hours.

Henry Kinuthia Date: September 29, 2014


As Evidence By: neonate inability
to latch on to maternal breast
correctly; and clients primary care
giver (mother) stating, by baby is
not able to emptying the breasts;
and non-sustained suckling at the
breast.

Educate the neonate clients primary


caregiver (mother) to have the
areola into clients mouth instead of
just having the nipple in the mouth,
as a technique for initiating and
promoting latch-on within 2 hour.

Breastfeeding mothers should be


educated and assisted with
breastfeeding. (Ricci, 2012).

T Short term goal: the clients


primary caregiver (mother) will
perform a return demonstration by
having the newborn clients mouth
covering the areola within 2 hours.

Reference
Ackley, B. J. & Ladwig, G. B. (2014). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (10th Ed.). St. Louis, MO:
Mosby Elsevier.
Ricci, S. S. (2012). Essentials of Maternity, Newborn, and Women's Health Nursing (3rd Ed.). Lippincott Williams & Wilkins. Philadelphia.