Hyperbilirubinemia SKINNY Reasoning-CERTIFIED

Hyperbilirubinemia SKINNY Reasoning Sarah Daniels, newborn infant Primary Concept Elimination Interrelated Concepts (In order of emphasis) • Clinical Judgment • Patient Education NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment • Management of Care 17-23%  • Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12%  Psychosocial Integrity 6-12%  Physiological Integrity • Basic Care and Comfort 6-12%  • Pharmacological and Parenteral Therapies 12-18%  • Reduction of Risk Potential 9-15%  • Physiological Adaptation 11-17%  SKINNY Reasoning Part I: Recognizing RELEVANT Clinical Data History of Present Problem: Sarah Daniels was born six hours ago by vaginal delivery after 22 hours of labor at 36 weeks gestation because of premature rupture of membranes. She weighed 9 lbs 0 ounces. (4090 g). Her Apgar was 8 at one minute and 9 at 5 minutes. Her newborn assessment revealed a cephalohematoma on the right-posterior aspect of her head. All other assessment data is within normal limits. Sarah has breastfed once since birth for seven minutes. She is noted to be sleepy when at the breast and not an aggressive feeder, consistent with her gestational age. She has voided once since birth, but has not yet stooled. Sarah’s mom Morgan was a diet-controlled gestational diabetic. Morgan’s prenatal labs are as follows: Blood type is O +, GBS is negative, Hepatitis B is negative. Her prenatal course was unremarkable other than the premature rupture of membranes. Sarah’s blood type is A+. Blood sugars were obtained per protocol starting at two hours after birth and have been consistently > 50 mg/dL. Her hematocrit was tested per protocol of a baby of a diabetic mother born before 37 weeks and was 48% four hours after birth. Twelve hours after birth, her transcutaneous bilirubin level is 6.1 mg/dL. Personal/Social History: Morgan Daniels is a 22-year-old single mom who attends a local community college. The father of the baby is not involved. Morgan lives with her parents, who are supportive and available. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: premature chephlohematoma A+ blood type, mother o+ Billiruben 6.1 Hct 48 (low) breast fed for 7 mins 9.0 pounds premature babies risk the chance of having premature liver, the lab values may indicate signs of liver issues and the low Hct may indicate sign of insufficient RBC, the mother has gestational diabetes causing the high birth weight RELEVANT Data from Social History: Clinical Significance: mother is student, age of mother, support system from mothers parents, father not involved this mother is a first time mother at a young age, absence of father can cause additional stress as well as school, has a good support system through mothers parents Patient Care Begins: Current VS: NIPS Pain Assessment: T: 98.3 F/36.8 C (axillary) Facial Expression: Relaxed P: 138 (regular) Cry: No cry R: 54 (regular) Breathing Pattern: Relaxed Legs: Relaxed State of Arousal: Sleeping NIPS Score: 0 What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: VS are WNL, NIPS score-0 No sign of pain or distress Current Assessment: GENERAL APPEARANCE: Calm, body flexed, no grimacing, appears to be resting comfortably RESP: Breath sounds clear, nonlabored respiratory effort. No grunting, retracting or nasal flaring noted CARDIAC: Heart sounds regular with no abnormal beats, S1S2, brisk cap refill, no edema. Moderate systolic murmur present over apex. NEURO: Sleepy; difficult to wake for feedings, does not stay awake at breast. All reflexes intact INTEG: Facial jaundice noted, skin color pink with acrocyanosis. Cephalohematoma to right-posterior aspect of head. Swelling does not cross sutures lines. RELEVANT Assessment Data: Clinical Significance: neuro assessment, Integ. assesmet all of these symptoms are consistent with jaundice, biliruben is rising which is why the symptoms are presenting Lab Results: Current: High/Low/WNL? Bilirubin (<5 mg/dL) 6.4 high Hgb (15-24 g/dL) 18 low Hct (45-65%) 60 WNL Glucose (40-60 mg/dL) 55 WNL What lab results are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: biliruben, HBG high biliruben is causing jaundice, HBG may be related to lack of feeding since the baby is nit staying awake for feedings biliruben is rising, HCT has stablized and Hbg is low Part II: Put it All Together to THINK Like a Nurse! 1. After interpreting relevant clinical data, what is the primary problem? (Management of Care/Physiologic Adaptation) Problem: Pathophysiology in OWN Words: hyperbiliruben emia excessive amount of billiruben is in the babys blood, when RBCs break down biliruben is formed from the differnt blood type in the mother the baby creates antibodies to destroy the RBC and the baby is unable to break down the biliruben due to a premature liver Collaborative Care: Medical Management 2. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies) Medical Management: Rationale: Expected Outcome: Obtain parental consent. Check body temp hourly. Place eye mask over Sarah’s eyes. Remove all clothing except for her diaper. Place Sarah on the Bilibed and under the bili lights. Accurate and strict I and O Repeat serum bilirubin level in 6 hours after phototherapy is initiated. these are all interventions for photo therapy to help lower the level of biliruben in the baby. Consent is needed because the baby is not old enough to make decisions, temp is needed to ensure the baby is WNL mask is needed to protect the eyes from the light, all the clothes are removed so the bili light can reach the most amount of surface area,serum is repeated to measure if the photo therapy is working, I&Os are measured because during photo therapy biliruben is excreated through stool and urine the babys biliruben will begin to decrease and the signs of jaundice will improve Collaborative Care: Nursing 3. What nursing priority (ies) will guide your plan of care? (Management of Care) Nursing PRIORITY: hyperbilirubenemia PRIORITY Nursing Interventions: Rationale: Expected Outcome: educate mother on promotes understanding of the disease the parent hyperbilirubenemia process, prevents knowledge deficit on the understands the condition condition and knows what to expect, the parent feels comfortable asking questions 4. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial Integrity/Basic Care and Comfort) Psychosocial PRIORITIES: physical, physological, and mental staability PRIORITY Nursing Interventions: Rationale: Expected Outcome: CARE/COMFORT: being present, assisting the mother with infant management and communication skills creating a comfortable environment for the new mother to settle into her role Physical comfort measures EMOTIONAL (How to develop a therapeutic relationship): being engaged, building trust and using therapeutic communication to be empathic The mother is able to create the needed bond with the baby and maintain mental stability. SPIRITUAL: Asses spiritual beliefs and try to incorporate this will effect the in patient care well being of the mother making the overall experience better. 5. What educational/discharge priorities need to be addressed to promote health and wellness for this patient and/or family? (Health Promotion and Maintenance)