Risk jaundice care plan help

[kristimarieSC]

I am developing 3 priority nursing problem statements for both mother and baby in postpartum (baby 24 hours old). baby's transcutaneous bili was 6.7 at 24 hours, which places him at high intermediate risk on the bilitool, and prompting a serum bilirubin test. My shift ended before results of serum were available, leaving me in an awkward position for a care plan. am I right to be treating this as a "risk" for jaundice? I would also like insight for other NANDAs for this patient, if you have it!

20 y/o G1P1 (now), with 24 hour old baby boy w/ TCB of 6.7

breastfeeding exclusively with no difficulties with latch and visit from the lactation consultant. no neonatal bruising, capitus, or injury. No familial hx jaundice, Caucasian descent. stooling meconium/voiding regularly. unremarkable vitals. otherwise healthy mother and baby without usual jaundice risk factors.

Mother:

1) Anxiety r/t baby health status AMB patient states I'm very worriesd about the test results”

2) Deficient knowledge: jaundice r/t inexperience AMB what is jaundice? Is it dangerous for my baby?”

3) ?

Baby:

1) Risk for injury r/t elevated bilirubin levels AWBMB bilirubin encephalopathy

2) ?

3)?

I feel a bit stumped because the baby is feeding and voiding/stooling well, eliminating fluid and electrolyte imbalance and ineffective breastfeeding, isn't being treated for jaundice yet, so all that goes along with phototherapy doesn't apply. baby also received vitamin K, so that eliminates any risk for bleeding, right? any thoughts or words of advice?

[kristimarieSC]

Edit:

add- Risk for neonatal jaundice r/t neonatal age 1-7 days AWBMB serum bilirubin greater than 4mg/dL

[fsnurselaur9]

Do you have any more information on the the mother and the delivery? Was it lady partsl? Was it a C-section? Did the mother need an episiotomy? Does the mother have HTN? Was she pre-eclampsia? How old is the mother? Was the baby term? How much did the baby weigh? Does the mom have diabetes? Was the mother having any pain? Any hemorrhoids? Has she been able to urinate or have a bowel movement? How about something related to sleep deprivation for the mother? Maternal bleeding and infection are always risks with any kind of delivery.

[nurseprnRN, BSN, RN]

There is no such thing as "a NANDA." NANDA-I is the international nursing organization that researches, validates, and disseminates information on nursing diagnoses. Its current resource (updated q2years) is 2015-2017, which you must use. Other "care plan handbooks" are based on outdated editions, as they usually take at least two years to produce. You wouldn't want your physician to rely on an outdated microbiology text to make a diagnosis, would you? Nope. Same here.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. As physicians make medical diagnoses based on evidence, so do nurses make nursing diagnoses based on evidence.

You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

You don't "pick" or "choose" a nursing diagnosis. You MAKE a nursing diagnosis the same way a physician makes a medical diagnosis, from evaluating evidence and observable/measurable data.

This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

A nursing diagnosis statement translated into regular English goes something like this: "I'm making the nursing diagnosis of/I think my patient has ____(diagnosis)_____________ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics)________________."

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological." You can thumb through your NANDA-I 2015-2017 and find lots and lots of medical diagnoses as related factors. They are not the origins of nursing diagnoses, however.

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic." Defining characteristics for all approved nursing diagnoses are found in the NANDA-I 2015-2017 (current edition). $39 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. This edition also includes an EXCELLENT FAQs section aimed at students.

NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

If you do not have the NANDA-I 2015-2017, you are cheating yourself out of the best reference for this you could have. I don't care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. CONGRATULATIONS! You made a nursing diagnosis! :anpom: If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

About Risk for” diagnoses:

First: "Risk for" nursing diagnoses are very often properly placed first, as safety ranks above all of the physiological needs in Maslow's hierarchy. This poster is asking specifically for a ranking in Maslow's hierarchy. What are nurses for if not to protect a patient's safety?

Second: It is a fallacy that "risk for..." nursing diagnosis is somehow lesser or not "real." If you look in your NANDA-I 2015-2017, there is a whole section on Safety, and almost all of the nursing diagnoses in that section are "risk for..." diagnoses. However, because NANDA-I has learned that nursing faculty is often responsible for this fallacy, the language on these has recently been revisited and was changed to include "Vulnerable to ..." in the defining characteristics the current edition.

Now, as to your particular situation: There is a nursing diagnosis called "neonatal jaundice." (p. 172) Its definition is, "The yellow-orange tint of the neonates skin and mucous membranes that occurs after 24 hours of life as a result of unconjugated bilirubin in the circulation."

Defining characteristics include:

* Abnormal blood profile

* bruised skin

* yellow mucous membranes

* yellow sclera

* yellow-orange skin color

Related factors:

* age less than 7 days

* deficient feeding pattern

* delay in meconium passage

* infant experiences difficulty making transition to extra-uterine life

* unintentional weight loss

Does this describe your baby? If not, go to the next page, page 173, and look at "risk for neonatal jaundice."

Definition: Vulnerable to the yellow-orange tent of the neonatal skin and mucous membranes that occur after 24 hours of life as a result of unconjugated bilirubin in circulation, which may compromise health.

Risk factors:

* abnormal weight loss (greater than 7 to 8% in breast-feeding newborn, 15% in non-breast-feeding newborn)

* age less than 7 days

* delay in meconium passage

* feeding pattern not well established

* infant experiences difficulty making transition to extra-uterine life

* prematurely

Does this baby meet criteria for making this diagnosis?

I have no idea what "AWBMB" and "AMB" mean.

I am looking at the "risk for injury" (page 386), defined as, "Vulnerable to physical damage due to environmental conditions interacting with the individual's adaptive and defensive resources, which may compromise health." I leave it to you to look up the risk factors, both external and internal, and see if you could justify making this diagnosis based on them.

Two more books to you that will save your bacon all the way through nursing school, starting now. The first is NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions. This is a wonderful synopsis of major nursing interventions, suggested interventions, and optional interventions related to nursing diagnoses. For example, on pages 113-115 you will find Confusion, Chronic. You will find a host of potential outcomes, the possibility of achieving of which you can determine based on your personal assessment of this patient. Major, suggested, and optional interventions are listed, too; you get to choose which you think you can realistically do, and how you will evaluate how they work if you do choose them.It is important to realize that you cannot just copy all of them down; you have to pick the ones that apply to your individual patient. Also available at Amazon. Check the publication date-- the 2006 edition does not include many current NANDA-I 2015-2017 nursing diagnoses and includes several that have been withdrawn for lack of evidence.

The 2nd book is Nursing Interventions Classification (NIC) is in its 6th edition, 2013, edited by Bulechek, Butcher, Dochterman, and Wagner. Mine came from Amazon. It gives a really good explanation of why the interventions are based on evidence, and every intervention is clearly defined and includes references if you would like to know (or if you need to give) the basis for the nursing (as opposed to medical) interventions you may prescribe. Another beauty of a reference. Don't think you have to think it all up yourself-- stand on the shoulders of giants.

[nurseprnRN, BSN, RN]

OP? What happened c your plan of care?