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ncp

ncp

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Published by Dhan Mark Trinidad

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Published by: Dhan Mark Trinidad on Sep 20, 2010
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07/22/2013

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JOSE RIZAL UNIVERSITY
COLLEGE OF NURSING
NURSING CARE PLAN
ASSESSMENTNURSINGDIAGNOSISINFERENCE GOALS andOBJECTIVESINTERVENTIONSRATIONALE EVALUATION
S: none, asthis is apotentialdiagnosis.O: skinappears brightyellowRisk forinjuryrelated toeffects of physicalproperties of phototherapyHyperbilirubinemia JaundicePhototherapyEffects of PhototherapyRisk for injuryWithin the shift,the client will befree from injuryand modifyenvironment asindicated toenhance safety.*Reviewprenatal andlabor deliverysummary forinfant riskfactors forhyperbilirubinemia.*Monitor serumbilirubin level asobtained.Monitor otherlab work asobtained.*Observe infant*Reviewprovidesinformationabout infants athigh risk forpathologichyperbilirubinemia.*Monitoringprovidesinformationabout factorscontributing tohyperbilirubinemia.*ChangesWithin theshift theclient , theclient is freefrom injuryandmodifiedtheenvironment thatenhancessafety.
 
for subtle signsof neurologicinjury: changesin behavior,lethargy,irritability,rigidity, orseizure activity.Note caregiver.*Explain theetiology andsignificance of hyperbilirubinemia to family. Teach themabout theprocess andgoals of phototherapy.*Administerprescribedphototherapy. If infant is to beunder bili lights,cover infant’sclosed eyeswithappropriateshield appliedto preventslipping. Placeshield overmaybe subtle. There is nospecific bloodlevel thatsignalsbeginning riskfor kernicterus. Term infantsare moresusceptiblethan preterminfants.*Explanationsassist thefamily tounderstand thetherapy.*Eye shieldsprotect theretina frominjury fromultraviolet light.Covering testesmay protectthem frominjury. Turningnude infantfrequentlyallows greater
 
testes perprotocol. Placenude infant ondiaper underlight source andturn every 2hours.*Monitorinfant’stemperature.*Assess skinevery 2 hours.*Removeinfants fromlights forfeeding andparent-infantinteraction.Removepatches andassess eyes forinjury ordrainage.skin exposureto light.*Exposing theinfant mayresult inhypothermia.Heat fromphototherapylights maycausehyperthermia.*Monitoringprevents injury.*Isolationduringphototherapymay interferewith parent-infant bonding.Frequent eyeassessmentshelp detectinjury from

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