NURSING CARE PLAN

Assessment
Subjective:

Objective:
Loose stools
High
Bilirubin
level
Under
intermittent
phototherap
y

Nursing
Diagnosis
Risk for fluid
volume
deficit
related to
prolonged
use of
phototherap
y
Scientific
reason:
Phototherap
y enhances
the excretion
of
unconjugate
d bilirubin
through the
bowel.

Outcome
Short term
goal:
After 8 hrs of
nursing
intervention
the infant will
exhibit no
signs of
dehydration
Long term
goal:
After several
days of
nursing
intervention
fluid volume
deficit will be
prevented.

Nursing Interventions
1. Assess quantity and
characteristics of each
stool.
Phototheraphy may result
in fluid loss from frequent
loose stools.
2. Assess for signs of
dehydrations such as poor
skin turgor, depressed
fontanelles, sunken eyes,
weight loss, and changes
in electrolytes.
Phototherapy treatment
may cause liquid stools
and increased insensible
water loss, which
increases risk of
dehydration.
3. Assess infant hourly intake
and output.
Infant should have output
of 1-3 mL/kg/hr.

Evaluation
Standard
Criteria
After 8 hrs of
nursing
intervention
the infant will
exhibit no signs
of dehydration
as evidenced
by good skin
turgor,
clear amber
urine output of
1-3 mL/kg/hr,
and will display
appropriate
weight gain.

After 8 hrs of
nursing
intervention
the client risk
for fluid volume
deficit has
prevented

4. Monitor weight.
Increased fluid excretion in
the stools and a decrease
in fluid intake may put the
newborn at risk for weight
loss. Daily weights can
provide accurate
dertermination of fluid
intake and insensible water
loss that is caused by
phototherapy
5. Monitor urine specific
gravity.
Urine specific gravity can
be an indicator of
dehydration. Dehydration
and fluid volume deficit will
show an elevation in the
urine specific gravity
6. Provide additional fluid
during phototherapy.
Additional fluids will help
compensate for the
increased water that is lost
through the skin and in the
stools.