NURSING CARE PLAN

NAME OF PATIENT: ALEXIS P. RAMOS NAME OF STUDENT: CRISTYL SHINE G. BARIAO _

AGE & GENDER OF PATIENT: 3 DAYS OLD/MALE WARD: NURSERY WARD _
DATE: MARCH 14, 2022 _

NURSING SCIENTIFIC NURSING NURSING

CUES RATIONALE EVALUATION
DIAGNOSIS BACKGROUND OBJECTIVES INTERVENTIONS
Subjective/s: Neonatal Jaundice Neonatal Jaundice is a Short Term Independent Goal Met:
related to yellow discoloration of
His mother stated
sclera and body skin of After 8 hours of  Encourage and  Frequent and After 8 hours of
that after 1 day of hyperbilirubinemia nursing interventions assist the effective nursing interventions
evidenced by serum the newborn caused by breastfeeding
birth she noticed the patient will be mother to the patient was able to
hyperbilirubinemia or helps the infant
yellowish discoloration bilirubin level of able to: frequently display decreased
excessive amount of excrete and
of the whole body and 26.46 mg/dl, bilirubin — which is
breastfed the
level of bilirubin,
sclera. She also  Display infant. decrease
yellowish responsible for the gained some energy
mentioned that on the decrease level amount of
discoloration of the yellow color of the body bilirubin. and obtain proper
3rd day after birth her whole body and and a pigment or of bilirubin.  Monitor the
baby experienced 1 intake and
 To determine therapy, treatment and
sclera, lethargy. substance that form  Gain some any progress and
episode of dark energy. output of the management as
when a red blood cells distinguish
colored urine and also  Obtain proper infant. whether the child
evidenced by serum
break down. It happens
the baby is lethargic
during the first few days therapy, is well hydrated bilirubin level of 19.5
that she need to wake or dehydrated. mg/dl and have an
of a newborn and it may treatment and
him up during feeds.  Assess the  To determine active movement and
be harmless or harmful management skin, eyes and whether the wakes up to feed.
Objective/s: to neonates depends on to elevate
high level of bilirubin. mucous treatment or
Severely jaundice bilirubin membranes. response should
Moreover, the most
excretion. be increase
Serum bilirubin level common symptoms of Dependent
hyperbilirubinemia are  To determine
– 26.46 mg/dl poor feeding or lethargy
 Monitor
bilirubin level whether the
and yellow discoloration amount of
through
of skin. bilirubin is
laboratory
increase or
based on
decrease.
(Dysart, K.,MD., 2021. doctor’s order.
“Neonatal
Hyperbilirubinemia.”  Begin
 Use to treat
Retrieved from phototherapy neonatal jaundice,
https://www.msdmanuals.com/
professional/pediatrics/metabo
ordered by the exposing the
lic,-electrolyte,-and-toxic- doctor. infant’s skin to
disorders-in-neonates/ light, which causes
neonatal-hyperbilirubinemia) the infant’s liver to
easily break down
and eliminate
bilirubin.
 NURSING CARE PLAN
NAME OF PATIENT: ALEXIS P. RAMOS NAME OF STUDENT: CRISTYL SHINE G. BARIAO _
AGE & GENDER OF PATIENT: 3 DAYS OLD/MALE WARD: NURSERY WARD _
DATE: MARCH 14, 2022 _

NURSING SCIENTIFIC NURSING NURSING

CUES RATIONALE EVALUATION
DIAGNOSIS BACKGROUND OBJECTIVES INTERVENTIONS
Subjective/s: Risk for Deficient Phototherapy is a Long Term Independent Goal Met:
His mother stated Fluid Volume treatment with special After 2 weeks of  Make a distance  To prevent too After 2 weeks of
that after 1 day of related to use of type of light used to nursing interventions: or space between much heat and to
nursing interventions
birth she noticed Phototherapy. excrete or remove the lamp and the ensure effective
that patient was able
 The patient infant. irradiance delivery.
yellowish discoloration bilirubin through  To maximize skin to maintain adequate
will not  Repositioned the
of the whole body and urine or stool. This infant frequently exposure. fluid intake and
sclera. She also may result in liquid exhibit to expose every
mentioned that on the deficient fluid output as evidenced
stools and increased part of the body.
by not experienced
3rd day after birth her insensible water loss, volume nor  Establish  To enhances
baby experienced 1 dehydration. frequently excretion of
dehydration and
with loose stool deficient fluid
episode of dark breastfeeding bilirubin and
indicating fluid loss and maintain increase fluid volume.
colored urine and also
the baby is lethargic and potentially adequate fluid intake to prevent
potential
that she need to wake leading to fluid intake.
dehydration.
volume deficit.  Monitor fluid
him up during feeds. intake and  To determine if
there’s any sign of
Objective/s: output. dehydration and
Ncp Risk for Fluid Volume fluid volume
Severely jaundice Deficit Phototherapy, 2012. deficit.
Serum bilirubin level
Retrieved from  Assess poor skin  To indicate level of
https://www.studymode.com/e turgor and
ssays/Ncp-Risk-For-Fluid-
dehydration.
– 26.46 mg/dl Volume-Deficit-1056542.html sunken eyes

Started Triple Kellerman, R.,MD., 2021. Dependent

“Infant Hyperbilirubinemia.”
Phototherapy Retrieved from  Monitor the
https://www.sciencedirect.com
amount of  To determine
/topics/medicine-and-
whether
dentistry/phototherapy bilirubin every
phototherapy is
4-12 hours working to the
based on infant or not.
doctor’s order.
 Monitor daily  Provide baseline
weigh based on data to determine
doctor’s order. fluid intake and
fluid loss cause
by phototherapy.