Hyperbilirubinemia is a condition where excessive concentration of bilirubin in the blood, causing joundice in neonates (Dorothy R. Marlon, 1998)
1. Impaired Skin Integrity related to jaundice or radiation.
Goal: good skin integrity / normal.
Expected outcomes:
- Good skin integrity could be maintained.
- No injuries / lesions on the skin.
- Good tissue perfusion.
- Protect the skin and retain moisture and natural treatments.
- Avoid wrinkles in the bed.
- Keep your skin to stay clean and dry.
- Mobilization of the patient every 2 hours.
- Monitor the existence of skin redness.
- Wash with soap and warm water.
2. Hyperthermia related to exposure to a hot environment.
Goal: temperature in the normal range.
Expected outcomes:
- Body temperature within normal range.
- Pulse and respiration within normal limits.
- There is no change in skin color.
- Monitor the temperature as much as possible.
- Monitor skin color.
- Monitor blood pressure, pulse, and respiration.
- Monitor intake and output.
3. Fluid volume deficit related to inadequate fluid intake, phototherapy, and diarrhea.
Goal: adequate body fluids.
Expected outcomes:
- Adequate fluid.
Intervention:
- Record the number and quality of feces.
- Monitor the skin turgor.
- Monitor intake output.
- Give water between breastfeeding or giving a bottle.
4. Knowledge Deficit related to the limitations of exposure.
Goal: family got knowledge about the disease that affects children.
Expected outcomes:
- The family said the understanding of the disease, condition, prognosis and treatment programs.
- Families are able to carry out the procedure described correctly.
- The family was able to explain again what is described nurse / other health team.
- Describe the pathophysiology of the disease.
- Describe the signs and symptoms of the disease that usually appears in the right way.
- Describe the disease process in a proper way.
- Provide information on the patient's family about the conditions in an appropriate manner.