Assessment

  1. Obtain a detailed medical history, including the duration and progression of hyperbilirubinemia, any known underlying causes, and previous treatments.
  2. Assess the patient’s vital signs, including temperature, heart rate, and blood pressure.
  3. Monitor the level of bilirubin in the blood using laboratory tests.
  4. Observe the patient’s skin and sclera for jaundice and note the severity and progression.
  5. Assess the patient’s mental status and level of consciousness.

Nursing Diagnosis

  1. Hyperbilirubinemia related to impaired liver function.
  2. Risk for complications related to increased bilirubin levels.

Planning

  1. The patient will maintain optimal liver function.
  2. The patient will achieve normal bilirubin levels.
  3. The patient will receive appropriate education and support regarding their condition.
  4. The patient will be monitored for complications related to hyperbilirubinemia.

Implementation

  1. Collaborate with the healthcare team to identify and treat the underlying cause of hyperbilirubinemia.
  2. Encourage the patient to adhere to any prescribed medications and treatments.
  3. Monitor the patient’s bilirubin levels regularly and document trends and changes.
  4. Implement measures to prevent complications such as dehydration, hypoglycemia, and kernicterus.
  5. Promote adequate hydration by encouraging the patient to drink fluids and providing intravenous fluids if necessary.
  6. Ensure proper nutrition by coordinating with a dietitian to provide a balanced diet.
  7. Encourage and assist the patient with frequent position changes and ambulation to prevent complications like deep vein thrombosis.
  8. Provide emotional support and education to the patient and their family regarding the condition, its management, and signs of complications.
  9. Collaborate with the healthcare team to determine the need for phototherapy or other interventions to reduce bilirubin levels.
  10. Monitor and manage any side effects or adverse reactions to medications or treatments.
  11. Collaborate with social services or community resources to provide additional support for the patient and their family.

Evaluation

  1. Monitor bilirubin levels and note any reduction within the expected time frame.
  2. Assess the patient for signs of complications such as dehydration, hypoglycemia, or neurological changes.
  3. Evaluate the patient’s understanding of their condition and their ability to adhere to the prescribed treatment plan.
  4. Modify the care plan as needed based on the patient’s response to interventions and ongoing assessment.

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