NURSING CARE PLAN ASSESSMENT Subjective Data: Kakatapos lang niya maoperahan sa atay nia ng mga alas dos

kahapon. as stated by the mother. NURSING DIAGNOSES -Risk for infection r/t post-op surgery EXPLANATION Incision site Tissue damage impaired skin integrity risk for infection Objective Data: V/S: T-36..2C RR-35 CR-121 -Risk for bleeding r/t post op -yellowish discoloration of the surgery skin and sclera -irritable -visible operation site at the abdomen Goal: During hospitalization, the patient will not manifest any sign of infection, bleeding, impaired skin integrity and lessen the occurrence of pain. Objectives: Incision site Tissue damage Disruption of blood vessels Risk for bleeding - Assess for respiratory rate -During 8 hours of duty, the and auscultate for abnormal client will not manifest any breath sounds signs of infection and bleeding - Note location of surgical procedures. - During 8 hours of duty ,the client will able to maintain - Observe for localized signs good skin integrity of infection at insertion sites of invasive lines, sutures, - During 8 hours of duty, the surgical incisions, wounds. client will not manifest any sign of pain. - Note signs and symptoms of sepsis: fever, chills, -During 8 hours duty, the diaphoresis, altered level of parents will cope up with the consciousness, positive blood changes to their baby after the cultures. operation done. - Assess skin color and moisture, urinary output, level of consciousness. Changes in this signs may be indicative of blood loss affecting systemic circulation or local organ function such as kidney or PLANNING IMPLEMENTATION Diagnostic: - Assess the vital signs including the respiratory rate, cardiac rate and temperature -Assess the for cardiac rate and its rhythm

Incision site -Impaired skin integrity r/t changes in pigmentation Tissue damage Impaired Skin Integrity Tissue damage Incision site Tissue damage -Acute pain r/t post surgery as evidenced by expressive behavior (crying, restlessness) Wound healing Pain

brain. -Determine nutritional status and potential for delayed healing or tissue exacerbated by malnutrition. -Observe non verbal cues and pain behaviors. -Observe communication patters of the parents. Listen to the parents expression of hope and planning for the baby. Treatment: -Administer/ monitor medication regimen (antibiotics, pain relievers, vitamins, antipyretics) as indicated - Check for the proper IVF solutions and regulate accordingly as indicated. -Administer prophylactic antibiotics and immunizations as indicated. - Change surgical or other wound dressings, as indicated, using proper technique for changing/disposing of contaminated materials. -Provide comfort measures (eg., touch, repositioning,

Post op situation of the baby Family coping about the condition of the baby -Readiness for enhanced family coping r/t situational crisis

nurses presence) - Encourage adequate rest periods to prevent fatigue. -Maintain appropriate moisture environment for particular wound, as indicated. Educative: - Educate the parents about the drugs given to the client. - Educate the parents that Ampicillin is an antibacterial and this serves as an prophylactic antibiotic for the baby because the baby is at risk for infection due to the operation site. - Educate the parents that Paracetamol given q4 serves as pain reliever. - Inform the parents about the Vitamin K which is given OD that it is a clotting factor that helps to avoid bleeding. -Educate the parents that Fentanyl is a pain reliever to help the baby decrease the feeling of pain. -Educate the parents that Ranitidine is a medicine that decrease the production of

acid in the stomach to prevent ulcer because the baby is on NPO status. -Educate the parents about the importance of handwashing before handling the baby to prevent acquired infection.

Prepared by: Hidalgo, Louella C. BSN4-1C

PATHOPHYSIOLOGY

Risk Factors: Age: Infant Immaturity of the immune system Maternal nutrition

Etiology: Unknown

Viral Exposure

Immaturity of Infants Immune system

Immune Mediated Bile Duct Injury

Intrahepatic and Extrahepatic bile duct fibrosis

Ductal Obstruction

Block bile flow to the intestine

Lack of bilirubin metabolites in the intestine

Gray Colored Stool/ Acholic Stool

Exess amount of deposits to skin

Bile excessively accumulate in the blood (Conjugated bilirubin is elevated (12.1 uMol/L))

Excess amount through urine

Jaundice (yellow discoloration of the skin)

Tea-colored urine Icteric Sclera Hyperbilirubinemia