JOSE RIZAL UNIVERSITY

COLLEGE OF NURSING NURSING CARE PLAN

ASSESSMEN T
S: none, as this is a potential diagnosis.

NURSING DIAGNOSI S
Risk for injury related to effects of physical properties of phototherap y

INFERENCE
Hyperbilirubine mia Jaundice Phototherapy Effects of Phototherapy Risk for injury

GOALS and OBJECTIVES
Within the shift, the client will be free from injury and modify environment as indicated to enhance safety.

INTERVENTIO NS

RATIONALE

EVALUATI ON
Within the shift the client , the client is free from injury and modified the environmen t that enhances safety.

O: skin appears bright yellow

*Review prenatal and labor delivery summary for infant risk factors for hyperbilirubine mia. *Monitor serum bilirubin level as obtained. Monitor other lab work as obtained. *Observe infant

*Review provides information about infants at high risk for pathologic hyperbilirubine mia. *Monitoring provides information about factors contributing to hyperbilirubine mia. *Changes

for subtle signs of neurologic injury: changes in behavior, lethargy, irritability, rigidity, or seizure activity. Note caregiver. *Explain the etiology and significance of hyperbilirubine mia to family. Teach them about the process and goals of phototherapy. *Administer prescribed phototherapy. If infant is to be under bili lights, cover infant’s closed eyes with appropriate shield applied to prevent slipping. Place shield over

maybe subtle. There is no specific blood level that signals beginning risk for kernicterus. Term infants are more susceptible than preterm infants. *Explanations assist the family to understand the therapy.

*Eye shields protect the retina from injury from ultraviolet light. Covering testes may protect them from injury. Turning nude infant frequently allows greater

testes per protocol. Place nude infant on diaper under light source and turn every 2 hours.

skin exposure to light.

*Monitor infant’s temperature.

*Exposing the infant may result in hypothermia. Heat from phototherapy lights may cause hyperthermia. *Monitoring prevents injury.

*Assess skin every 2 hours. *Remove infants from lights for feeding and parent-infant interaction. Remove patches and assess eyes for injury or drainage.

*Isolation during phototherapy may interfere with parentinfant bonding. Frequent eye assessments help detect injury from

light or incorrect eye shield application.

JOSE RIZAL UNIVERSITY
COLLEGE OF NURSING NURSING CARE PLAN

ASSESSMEN T
S: none, as this is a potential diagnosis

NURSING DIAGNOSIS
Risk for deficient fluid volume related to increased losses from evaporation.

INFERENCE
Hyperbilirubine mia Jaundice Phototherapy

GOALS and OBJECTIVES
Within the shift, the client will maintain adequate fluid balance during phototherapy.

INTERVENTIO NS

RATIONALE

EVALUATI ON
Within the shift, the client maintained adequate fluid balance during phototherap y.

O: none, as this is a potential diagnosis

Fluid losses Deficient fluid volume and electrolyte imbalance

*Monitor weight.

*Monitoring weight provides information about excessive fluid losses. *Assessment of intake and output provides information about fluid balance. Infant should have output of 12cc/kg/hour.

*Assess infant’s hourly intake and output

*Monitor number, color, and consistency of bowel movement.

*Assess urine specific gravity.

*Phototherapy may result in fluid loss from frequent loose stools. Monitoring proved information about losses. *Specific gravity provides information about fluid balance. High specific gravity (>1.030) indicates dehydration, low (>1.010) indicates fluid overload. *Assessment provides information about dehydration of tissues: skin turgor, dry mucous membranes,

*Assess skin turgor, mucous membranes, and anterior fontanel every 2 hours.

*Notify caregiver of signs of dehydration.

and sunken anterior fontanel. *Provide additional fluids during phototherapy. *Caregiver may initiate IV fluids of p.o. intake is insufficient to meet fluid needs. *Additional fluids are necessary to balance the losses from therapy. Phototherapy may result in increased fluid losses through the skin, urine and loose bowel movement. *Explanations and teaching assist parents to care for their infant after discharge and seek medical treatment for

*Show parents how to assess skin turgor, membranes and fontanel for signs of dehydration. Teach them that infant should have 6 – 8 wet diapers daily. *Monitor lab values as obtained.

dehydration. *Lab values indicate fluid and electrolyte balance or imbalance.

JOSE RIZAL UNIVERSITY
COLLEGE OF NURSING NURSING CARE PLAN

ASSESSME NT
S: O: - warm to touch if in phototherapy - reduction in body temperature if phototherapy has been turned off and because of the aircondition. - chills

NURSING DIAGNOSIS
Ineffective thermoregula tion related to fluctuating environmenta l temperature as manifested by chills, cold skin if not in phototherapy and warm skin if in phototherapy .

INFERENCE
Phototherapy Increased body temperature Ineffective thermoregulati on Airconditioner (Phototherapy off) Decreased body temperature Chills

GOALS and OBJECTIVES
After 2 hours of nursing intervention, the infant will have effective thermoregulation.

INTERVENTI ONS

RATIONALE

EVALUATI ON
After 2 hours of nursing intervention , the infant have effective thermoregul ation.

*Identify underlying condition (environment) *Assess axillary temperature.

*Influences choice of intervention. *Axillary temperature is preferred to avoid risk of rectal perforation. Assessment provides information about neonate's temperature regulation. *Tests may indicate infections, organ damage

*Monitor lab studies. Ineffective thermoregulati *Dry newborn

on

thoroughly and quickly and discard wet blanket. Place infant on a warm blanket. *Position the warmer's temperature probe over non-bony area on infant's abdomen. Set controls to maintain skin temperature of 36.5 – 37 degree Celsius. *Avoid placing infant on cool surfaces or using cold instruments in assessment (stethoscope, thermometer etc.)

or drug screens. *Drying quickly and placing is on a warm, dry surface prevents heat loss by evaporation. *Placing the probe over a bony area will give a false high skin temperature.

*Placing the infant on a cool surface or using cool instruments increases heat loss by conduction.

*Maintain room temperature at 72 degrees Fahrenheit. Teach family to adjust infant's coverings after discharge to the room temperature based on how they are feeling.

*Teaching assists parents to care for their infant. The infant may suffer from hyperthermia if overdressed.