Help with my clinical scenario

cursenurse · May 11, 2008

Mom's labor was induced due to gestational diabetes mellitus, diet controlled. A healthy baby was delivered lady partslly without complications, Apgar score 9,9.
4234 grams, 9 pounds 5 ounces
24 Hours of Life
The nurse assesses the newborn and finds a cephalhematoma to the left occipital region. Current weight is 4185 grams, 9 pounds 4 ounces.
Dextrostik result is 52. T 37 (98.6) P 140 R 40.
Breast feeding; LATCH of L=1, A=0, T=2, C=2, H=1. (Total 6)
Baby has had 1 void and 1 stool.
Day 2,
Dextrostik result is 60, jaundice noted to nipple line, total bilirubin is 12.
T 98.2 (36.8), 150, RR 50.
Day 2, Weight and Feeding
Current weight is 3984 grams (8#12.5oz) LATCH score is 9, 1 off for audible sucking. There have been 2 wet diapers and 1 stool in the last 24 hours.
Question @ Day 2 of Life
The mother says the baby is being good, the baby sleeps most of the time. The mother asks the nurse, "Is it okay for the baby to be discharged this morning? I am eager to go home."
Here are my nsg diagnosis:
#1 Risk for newborn injury (neurological), related to elevated serum bilirubin levels secondary to hemolysis of RBCs occurs in cephalohematoma as manifested by bilirubin level of 12 mg/dl.
#2 Risk for newborn injury related to hypoglycemia secondary to trauma from lady partsl delivery from large for gestational age infant.
#3 and i need one more.
My plan is to discharge mom, and reschedule her for a follow-up care.
please check to see if im doing correctly. thanks for the help.

Okay, now i am not an L&D nurse(I'm ER) and i am not a mom- but only 2 wet diapers in a 24 hour period seems odd. I know that if i had an adult who had only voided twice in a 24 hour period that would be very much a reason for concern. So you would know better than I, should a newborn baby be voiding more than twice per day? If so, your 3rd dx should focus on that.

core0 · May 11, 2008

Mom's labor was induced due to gestational diabetes mellitus, diet controlled. A healthy baby was delivered lady partslly without complications, Apgar score 9,9.
4234 grams, 9 pounds 5 ounces
24 Hours of Life
The nurse assesses the newborn and finds a cephalhematoma to the left occipital region. Current weight is 4185 grams, 9 pounds 4 ounces.
Dextrostik result is 52. T 37 (98.6) P 140 R 40.
Breast feeding; LATCH of L=1, A=0, T=2, C=2, H=1. (Total 6)
Baby has had 1 void and 1 stool.
Day 2,
Dextrostik result is 60, jaundice noted to nipple line, total bilirubin is 12.
T 98.2 (36.8), 150, RR 50.
Day 2, Weight and Feeding
Current weight is 3984 grams (8#12.5oz) LATCH score is 9, 1 off for audible sucking. There have been 2 wet diapers and 1 stool in the last 24 hours.
Question @ Day 2 of Life
The mother says the baby is being good, the baby sleeps most of the time. The mother asks the nurse, "Is it okay for the baby to be discharged this morning? I am eager to go home."
Here are my nsg diagnosis:
#1 Risk for newborn injury (neurological), related to elevated serum bilirubin levels secondary to hemolysis of RBCs occurs in cephalohematoma as manifested by bilirubin level of 12 mg/dl.
#2 Risk for newborn injury related to hypoglycemia secondary to trauma from lady partsl delivery from large for gestational age infant.
#3 and i need one more.
My plan is to discharge mom, and reschedule her for a follow-up care.
please check to see if im doing correctly. thanks for the help.

you could do:

Risk for altered parent/child interaction secondary to jaundice and cephalohematoma.

Knowledge deficit related to neonatal jaundice as evidenced by ....

You could also split number one into two different diagnoses. The cephalohematoma really doesn't have anything to do with the jaundice.

Of course with any infant there is always: risk for altered body temperature.

David Carpenter, PA-C

OzMW · May 11, 2008

Okay, now i am not an L&D nurse(I'm ER) and i am not a mom- but only 2 wet diapers in a 24 hour period seems odd. I know that if i had an adult who had only voided twice in a 24 hour period that would be very much a reason for concern. So you would know better than I, should a newborn baby be voiding more than twice per day? If so, your 3rd dx should focus on that.

This is normal output for a newborn.

cursenurse · May 11, 2008

This is normal output for a newborn.

Really, Wow. Well you learn something new every day.

LizzyL&DRN · May 11, 2008

You could also split number one into two different diagnoses. The cephalohematoma really doesn't have anything to do with the jaundice.
Of course with any infant there is always: risk for altered body temperature.
David Carpenter, PA-C

The cephalohematoma absolutely does have something to do with the jaundice. Bilirubin is a produced by the breakdown of hemoglobin. As the baby's body breaks down the hematoma, excess bilirubin in the blood is a risk if the baby is not eating well to excrete the bilirubin in the stool . Any infant with a birth injury (i.e. brusing, cephalohematoma, etc) is at risk for jaundice.

shortstuff31117 · May 11, 2008

yep, one wet diaper per day of life...well until the milk comes in or is it day

QTBabyNurse, BSN, RN · May 11, 2008

well...there are a couple of things that concern me in this post and replies....first of all you mentioned the baby had 2 wet and 1 soiled diaper in 24 hours...usually 6-8 wet/soiled diapers in 24 hours is more normal. secondly, another poster stated that the cephalohematoma really had nothing to do with the jaundice...i'd like to respectfully disagree with that comment...it most certainly can have something to do with the jaundice. i would add a knowledge deficit diagnosis for the parents r/t hyperbilirubinemia and/or a diagnosis r/t sufficient intake of fluids to help lower the bilirubin. the blood sugars you got were normal. if you are discharging the newborn that day, make sure that baby has another bili done in the morning after discharge because the initial result of 12 that you got in the first 24 hours was rather high. i'd ask the pediatrician to order another one prior to writing a discharge order for that infant.

cubeo · May 11, 2008

Thank you all for the information, so the baby can be discharge right? and i will schedule the baby to come back within 4 days to evaluate the bilirubin level since it can increase from hemolysis of RBCs which place newborn at risk for kernicterus; i would teach mom how to access for jaundice.

any suggestion? Thank you

cubeo · May 11, 2008

well...there are a couple of things that concern me in this post and replies....first of all you mentioned the baby had 2 wet and 1 soiled diaper in 24 hours...usually 6-8 wet/soiled diapers in 24 hours is more normal. secondly, another poster stated that the cephalohematoma really had nothing to do with the jaundice...i'd like to respectfully disagree with that comment...it most certainly can have something to do with the jaundice. i would add a knowledge deficit diagnosis for the parents r/t hyperbilirubinemia and/or a diagnosis r/t sufficient intake of fluids to help lower the bilirubin. the blood sugars you got were normal. if you are discharging the newborn that day, make sure that baby has another bili done in the morning after discharge because the initial result of 12 that you got in the first 24 hours was rather high. i'd ask the pediatrician to order another one prior to writing a discharge order for that infant.

thank you all for the information, so the baby can be discharge right? the rationales you gave me are very nice. i will schedule the baby to come back within 4 days to evaluate the bilirubin level since it can increase from hemolysis of rbcs which place newborn at risk for kernicterus; i would teach mom how to access for jaundice.

p.s what do you think about this nsg diagnosis:

deficient knowledge related to neonatal jaundice and cephalhematoma as evidence by lack of concern from mother.

rn students

thanks

QTBabyNurse, BSN, RN · May 11, 2008

thank you all for the information, so the baby can be discharge right? the rationales you gave me are very nice. i will schedule the baby to come back within 4 days to evaluate the bilirubin level since it can increase from hemolysis of rbcs which place newborn at risk for kernicterus; i would teach mom how to access for jaundice.
thank you

i would ask the pediatrician for an order to run a bili prior to discharge. if the level is still high, the physician might want to keep the baby in the hospital for phototherapy. if he does discharge the baby home, i would not wait 4 days to bring that baby back for another bili, that baby needs to be re-evaluated by the physician with 48 hours of discharge. most of our peds would have the bilirubin re-checked the following morning after discharge home.

CEG · May 12, 2008

Thank you all for the information, so the baby can be discharge right? the rationales you gave me are very nice. i will schedule the baby to come back within 4 days to evaluate the bilirubin level since it can increase from hemolysis of RBCs which place newborn at risk for kernicterus; i would teach mom how to access for jaundice.
p.s what do you think about this nsg diagnosis:
Deficient knowledge related to neonatal jaundice and cephalhematoma as evidence by lack of concern from mother.
RN students
Thanks

I would have the bili checked again prior to discharge and depending on the level discharge home to go to the clinic the next day for bili again or d/c home with bili blanket and clinic the next day for bili. Kernicterus doesn't occur until much higher levels of bili (>20) but in four days it could be 20 if no improvement/ followup. I would avoid holding the baby if at all possible to allow better bonding/breastfeeding. Even if mom is taken in as a boarder I think the stress level goes up. 12 isn't super high, just keep an eye on high, particularly with the cephalohematoma.

To another poster, 6-8 wet diapers a day is much later like day 6 or 7. We teach our moms to look for one wet diaper per day of life and one poo per day until about day 6. Before the mature milk comes in baby is not taking in a lot of fluids so we would not expect a lot of output.