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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
Neonatal Jaundice
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.
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.
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.