nursing diagnoses!

  1. Hi all. At work we write PAR notes (Problem, assessment, response)
    Anyway, the P is a nursing diagnosis, or should be. I am having a terrible time finding a nursing diagnosis for jaundice. Specifically, asymptomatic jaundice of the newborn. Some people write risk for impaired skin integrity, which I know is wrong. Others just write hyperbilirubinemia or just plain jaundice (what I've done til now) But I want to get it right. Help! If the bilimeter is high, and I do a blood draw for bili, would it be okay to write risk for jaundice r/t increased bilirubin as evidenced by facial yellowing? I can't believe this wasn't covered in school. I've been thru all my notes and simply can't find the right diagnosis. At work we don't use the 'r/t' part anyway, but I want to get them right. Thanks!
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  2. 14 Comments

  3. by   SmilingBluEyes
    hmmm working on this one...
  4. by   Nurse_Diane
    How about:
    Impaired Comfort: pruritis r/t toxic metabolites excreted in the skin

    For specific neonatal jaundice:
    Readiness for enhanced Knowledge of information on assessing jaundice when infant is discharged from the hospital, when to call the physician and possible preventative measures such as frequent breastfeeding.

    Under Hyperbilirubinemia:
    Disturbed Senory perception: visual (infant) r/t use of eye patches for protection of eyes during phototherapy.

    Parental role Conflict r/t interruption of family life because of care regimen.

    Risk for disproportionate Growth: infant r/t disinterest in feeding because of jaundice-related lethargy.
  5. by   MIA-RN1
    diane those are great but I am looking for a nursing diagnosis specific to the newborn w. asymptomatic jaundice. I think the readiness for enhanced knowledge is a great one tho, for later when I am teaching parents.
    Maybe I should get out of the box. Instead of jaundice could it be something more broad and blood-related? Imbalanced something or another?
    How frustrating!
  6. by   BittyBabyGrower
    We have gotten away from nursing diagnosis. Why can't you just write Hyperbili as your problem? We PIP note (problem, impression, plan). Our problems would be
    1. Hyperbili
    2. Parent teaching
    3. Nutrition

    I: Infant jaundiced, last bili as XXX, under single phototherapy per protocol. Eyes covered, no irritation. Skin intact. Parents in today, updated on bili levels, reinforced that infant to stay under lites unless out feeds and they stated understanding. Infant not eating well, ng placed to supplement. Lost weight last night. P: Follow q8hr bili, follow protocol. Keep parents updated. Follow tolerance of feeds, offer bottle/breast as tolerated, ng remainder. Keep at 140ml/kg/day. Weight qd.
  7. by   Mommy TeleRN
    I'd have to relook up patho on jaundice.. but two sort of encompassing ones are risk for injury and ineffective protection.. would either of those work?
  8. by   IslandtrainedRN
    I got this great book to help me make care plans in nursing school. It's called Nursing Diagnosis Handbook: A Guide to Planning Care (6th Ed.). It's not really a handbook, it's pretty big. You look up the "Problem" that you have - in this case, Jaundice - and it gives you a list of potential nursing diagnoses that may apply. Then you can look up those nursing diagnoses in the planning care section, and it makes a general care plan that you can individualize for your patient.

    That book has helped me to make many a care-plan. It's by Mosby. Maybe your unit manager might be interested in buying one for nurses to have access to?

    Oh, and for jaundice, it suggests:

    1) Disturbed thought processes related to toxic blood metabolites.
    2) Impaired comfort: pruritis related to toxix metabolites excreted in the skin.
    3) Risk for impaired skin integrity related to pruritis, itching.

    Hope that helps! Good luck!
  9. by   Daytonite
    jaundice can be benign or malignant. for benign jaundice nursing intervention focuses on preventing injury or the further progression of the condition. actually, your colleagues are not wrong in using risk for impaired skin integrity. you need to consider all the side effects of the treatment for asymptomatic jaundice. injury to the skin is a real threat and something that the infant must be protected from.

    risk for injury r/t side effects of phototherapy, or just phototherapy

    the assessment that you chart should include your assessment, monitoring, evaluation and/or observation of the condition of the infant's skin. you should also be charting the specific care you perform or give to the infant to prevent any damage to his/her skin. specific things you should be addressing in your documentation include information about the lamp, hours under the lamp, distance from the lamp, inspection of the patient's eyes, that the male's genitalia are protected, skin temperature, that patient was repositioned to equalize expose to skin surfaces to the light. and, of course, if there are any questions or teaching done with the parents in regard to any of these treatments being rendered for the treatment of the patients jaundice you should also chart them as well since this pertains to this nursing diagnosis.

    although most of this information i've put together is from what i know about nanda diagnosing and care planning, i got a tad of help from maternal/newborn plans of care: guildelines for individualized care, third edition, by marilynn e. doenges and mary frances moorhouse. hyperbilirubinemia in the newborn is specifically addressed on pages 538-547 of this care plan book.
  10. by   MIA-RN1
    everyone here has been so helpful! Daytonite that book sounds great I am going to look for it.
    Again, this note is for before the lights are indicated, for just when yellowing to the umbilicus is noted or when any jaundice is noted before 24h of age.
    So how does this sound (I made up the numbers)
    P: Risk for impaired skin integrity, risk for injury.
    A: At 1700, infant noted have jaundice to umbilicus. Transcutaneous bilimeter reading of 9.7. Serum bilirubin obtained via heelstick @ 1730. Direct bilirubin was 10.4, indirect was 1. Pediatrician notified of these results.
    R: Will continue to monitor per newborn pathway.
    Last edit by MIA-RN1 on Nov 7, '06
  11. by   SmilingBluEyes
    Never forget the need for education. In any case, whether symptomatic or not, the knowledge or lack of it, should be addressed in your care planning for the parents. You can never go wrong there.
  12. by   Jolie
    I like Daytonite's suggestion of Risk for Injury, but I would word it a little differently, since you are seeking a nursing diagnosis for babies who are not yet being treated with phototherapy.

    Risk for Injury d/t elevated bilirubin as evidenced by...... Remember that untreated hyperbilirubinemia in the newborn can lead to kernicterus, so there is definitely a risk for injury unrelated to the phototherapy itself.
  13. by   Daytonite
    ok, i understand your dilemma here. a nursing diagnosis represents a problem or potential problem that the patient is having or might have. so, with an elevated bilirubin or the appearance of jaundice, what is going on in your mind? what is the concern for the baby? that is where you look to formulate a nursing diagnosis. i think that where you need to start is to do a little investigation of the medical diagnosis and pathophysiology of jaundice in newborns. with that in mind, i found a ce article for physicians on emedicine about it. http://www.emedicine.com/ped/topic1061.htm i did read through it and it is rather involved. but, i can see why there is concern for this. there seem to be a number of serious pre-existing conditions that could be the potential reasons and worst case scenarios for which jaundice is one of the first indications. now, most of the time things don't turn into those worst case scenarios, but in the interest of good standards of care, that is really what the physicians are wanting to monitor for because the worst case scenarios have a really bad outcome for the babies. the symptoms of those diseases, then, need to be monitored for. that monitoring would be nursing interventions. your nursing diagnosis, then, would be a "risk for" problem(s) caused by some of these diseases whose appearance or nonappearance of symptoms you are going to be addressing in your charting when the first evidence of jaundice is noted. does that make a lot more sense to you?
  14. by   mitchsmom
    Have you tried searching this one? It seems like a student asked this same question on the site before (I'm pretty sure- but I don't know which forum).

    My dx book (Nursing Dx Handbook: A Guide to Planning Care - Ackley and Ladwig) lists:
    Disturbed thought process r/t toxic blood metabolites
    Impaired comfort: pruritis r/t toxic metabolites excreted in the skin
    Risk for impaired skin integrity r/t pruritis, itching

    also Readiness for enhanced knowledge

    you could also use nutrition ones, especially if breastfeeding has been interrupted.

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