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JOSE RIZAL UNIVERSITY

COLLEGE OF NURSING

NURSING CARE PLAN

ASSESSMEN NURSING INFERENCE GOALS and INTERVENTIO RATIONALE EVALUATI


T DIAGNOSI OBJECTIVES NS ON
S
S: none, as Risk for Hyperbilirubine Within the shift, Within the
this is a injury mia the client will be shift the
potential related to free from injury client , the
diagnosis. effects of and modify client is free
physical Jaundice environment as from injury
properties of indicated to and
phototherap enhance safety. modified
y Phototherapy the
environmen
*Review *Review t that
Effects of prenatal and provides enhances
O: skin Phototherapy labor delivery information safety.
appears bright summary for about infants at
yellow infant risk high risk for
Risk for injury factors for pathologic
hyperbilirubine hyperbilirubine
mia. mia.

*Monitor serum *Monitoring


bilirubin level as provides
obtained. information
Monitor other about factors
lab work as contributing to
obtained. hyperbilirubine
mia.

*Observe infant *Changes


for subtle signs maybe subtle.
of neurologic There is no
injury: changes specific blood
in behavior, level that
lethargy, signals
irritability, beginning risk
rigidity, or for kernicterus.
seizure activity. Term infants
Note caregiver. are more
susceptible
than preterm
*Explain the infants.
etiology and
significance of *Explanations
hyperbilirubine assist the
mia to family. family to
Teach them understand the
about the therapy.
process and
goals of
phototherapy.

*Administer
prescribed *Eye shields
phototherapy. If protect the
infant is to be retina from
under bili lights, injury from
cover infant’s ultraviolet light.
closed eyes Covering testes
with may protect
appropriate them from
shield applied injury. Turning
to prevent nude infant
slipping. Place frequently
shield over allows greater
testes per skin exposure
protocol. Place to light.
nude infant on
diaper under
light source and
turn every 2
hours.

*Monitor *Exposing the


infant’s infant may
temperature. result in
hypothermia.
Heat from
phototherapy
lights may
cause
hyperthermia.
*Assess skin
every 2 hours.
*Monitoring
prevents injury.
*Remove
infants from
lights for *Isolation
feeding and during
parent-infant phototherapy
interaction. may interfere
Remove with parent-
patches and infant bonding.
assess eyes for Frequent eye
injury or assessments
drainage. help detect
injury from
light or
incorrect eye
shield
application.
JOSE RIZAL UNIVERSITY

COLLEGE OF NURSING

NURSING CARE PLAN

ASSESSMEN NURSING INFERENCE GOALS and INTERVENTIO RATIONALE EVALUATI


T DIAGNOSIS OBJECTIVES NS ON
S: none, as this Risk for Hyperbilirubine Within the Within the
is a potential deficient fluid mia shift, the client shift, the
diagnosis volume will maintain client
related to adequate fluid maintained
increased Jaundice balance during adequate
losses from phototherapy. fluid
evaporation. balance
Phototherapy during
phototherap
O: none, as *Monitor *Monitoring y.
this is a Fluid losses weight. weight
potential provides
diagnosis information
Deficient fluid about
volume and excessive fluid
electrolyte losses.
imbalance
*Assess infant’s
hourly intake *Assessment
and output of intake and
output
provides
information
about fluid
balance. Infant
should have
output of 1-
2cc/kg/hour.
*Monitor
number, color,
and consistency
of bowel *Phototherapy
movement. may result in
fluid loss from
frequent loose
stools.
Monitoring
proved
*Assess urine information
specific gravity. about losses.

*Specific
gravity
provides
information
about fluid
balance. High
specific gravity
*Assess skin (>1.030)
turgor, mucous indicates
membranes, dehydration,
and anterior low (>1.010)
fontanel every 2 indicates fluid
hours. overload.

*Assessment
provides
information
about
dehydration of
*Notify tissues: skin
caregiver of turgor, dry
signs of mucous
dehydration. membranes,
and sunken
anterior
fontanel.
*Provide
additional fluids *Caregiver
during may initiate IV
phototherapy. fluids of p.o.
intake is
insufficient to
meet fluid
needs.

*Additional
fluids are
necessary to
*Show parents balance the
how to assess losses from
skin turgor, therapy.
membranes and Phototherapy
fontanel for may result in
signs of increased fluid
dehydration. losses through
Teach them the skin, urine
that infant and loose
should have 6 – bowel
8 wet diapers movement.
daily.
*Explanations
*Monitor lab and teaching
values as assist parents
obtained. to care for
their infant
after discharge
and seek
medical
treatment for
dehydration.

*Lab values
indicate fluid
and electrolyte
balance or
imbalance.
JOSE RIZAL UNIVERSITY

COLLEGE OF NURSING

NURSING CARE PLAN

ASSESSME NURSING INFERENCE GOALS and INTERVENTI RATIONALE EVALUATI


NT DIAGNOSIS OBJECTIVES ONS ON
S: Ineffective Phototherapy After 2 hours of After 2
thermoregula nursing hours of
O: tion related intervention, the nursing
- warm to to fluctuating Increased body infant will have intervention
touch if in environmenta temperature effective , the infant
phototherapy l temperature thermoregulation. *Identify *Influences have
as underlying choice of effective
- reduction in manifested Ineffective condition intervention. thermoregul
body by chills, cold thermoregulati (environment) ation.
temperature skin if not in on
if phototherapy *Assess axillary *Axillary
phototherapy and warm temperature. temperature is
has been skin if in Airconditioner preferred to
turned off phototherapy (Phototherapy avoid risk of
and because . off) rectal
of the perforation.
aircondition. Assessment
Decreased provides
- chills body information
temperature about
neonate's
temperature
Chills regulation.
*Monitor lab
studies. *Tests may
indicate
Ineffective infections,
thermoregulati *Dry newborn organ damage
on thoroughly and or drug
quickly and screens.
discard wet *Drying
blanket. Place quickly and
infant on a placing is on a
warm blanket. warm, dry
surface
prevents heat
*Position the loss by
warmer's evaporation.
temperature
probe over
non-bony area *Placing the
on infant's probe over a
abdomen. Set bony area will
controls to give a false
maintain skin high skin
temperature of temperature.
36.5 – 37
degree Celsius.

*Avoid placing
infant on cool
surfaces or
using cold
instruments in *Placing the
assessment infant on a
(stethoscope, cool surface or
thermometer using cool
etc.) instruments
increases heat
loss by
conduction.
*Maintain room
temperature at
72 degrees
Fahrenheit. *Teaching
Teach family to assists
adjust infant's parents to
coverings after care for their
discharge to infant. The
the room infant may
temperature suffer from
based on how hyperthermia
they are if
feeling. overdressed.