VI Nursing Care Plan

Assessment Subjective: Naninilaw yung mata at balat ng anak ko as verbalized by the mother Objective: Skin appearing to light and yellow Sclerae appearing yellow Diagnosis Risk for injury related to abnormal blood profile Planning After 7 days of nursing intervention , the patient skin color will be normal Nursing Intervention Independent Initiate breastfeeding within 1st hour of life in delivery Assess skin for jaundice every 4 hour. Monitor intake and output with each occurrence Maintain accurate record of urine and stool output and assist parents in same. Monitor vital signs every 2 hour. Report signs of transition to extra uterine life. Instruct parents regarding newborn care, including jaundice appearance, significance, importance within 2-3days of discharge, feeding Rationale To promote breast milk intake and stooling To detect evidence of clinical jaundice and rising bilirubin levels To evaluate effectiveness of breast-feeding or formula intake be measuring urinary and stool output To provide accurate record of output to evaluate effectiveness of feedings. To evaluate transitional events and ensure infants is making an effective transition without cardiorepiratory, metabolic, thermoregulatory, or other physiologic problems Evaluation After 7 days of nursing interventions, the patient skin color was normal

methods and noting stooling and voiding patterns. Assist with Phototherapy treatment Have the infant complete undressed Keep the eyes and gonads covered

To promote physical care of newborn and decrease parents anxiety related to home care To enhance parentinfant interaction and acquaintances with newborn To allow for utilization or alternate pathways for bilirubin excretions To expose the entire skin in phototherapy To protect them from the constant exposure to high intensity light

Collaborative Monitor transcutaneous bilirubin levels per institution protocol or at least every 6 8 hours Administer fluid as ordered

To detect rising levels of bilirubin for institutions of appropriate therapy To ensure adequate hydration

Assessment Subjective: Objective: Impact of child illness on relationship with parents Separation from children

Diagnosis Anxiety related to therapy given to infants

Planning Parents of newborn assume responsibility for emotional and physical care and wellbeing of the new family member

Nursing Intervention Initiate skin-to-skin contact between mother and newborn and father. Encouraged early breast-feeding in 1st hour of birth Perform physical assessment with parents presents and show typical newborn characteristics. Encouraged parents participation in care behaviors such as diapering, formula feeding and bathing Encouraged siblings visitation and participation in care and holding of newborn as age appropriate

Rationale To enhance breastfeeding and parentinfant interaction and to promote early stooling and bilirubin clearance To promote parents knowledge of infant physical characteristics and behavior To promote familiarity with the behaviors and decrease parental anxiety To enhance parental feeding of contribution as newborns primary caretakers To promote siblings participation in care acceptance of new family member

Evaluation Parents of newborn will take the responsibility for emotional and physical care and wellbeing of the new family member