NURSING CARE PROCESS

Cues Nursing Analysis Goals and Implementation Rationale Evaluation

Diagnosis Objective
Subjective Risk for SCIENTIFIC Long-term Goal: Dependent- Skin discomfort is Goal: MET.
Cues: impaired skin ANALYSIS The patient will be able to Facilitative common in the
integrity related The skin is the maintain skin integrity The nurse will teach the perineal setting
o Premature to ongoing human body's and discolored skin and ways of preventing skin due to changes in 1. Does the mother
Aog phototherapy largest organ which eyes. The patient will be integrity and promoting the skin barrier. be able to site 5
o Using of secondary to serves as a able to bave adequate healthy diet. Skin breakdown ways to prevent
Isolette increased defensive shield. It nutritional intake and will can be impaired siin
o Undergoes bilirubin levels . protects the body have a normal bilirubin exacerbated by integrity and 2-3
Phototherapy from harmful level. Independent- increased diet tips?
elements such as Supplemental moisture, __ MET
sun, light, injury, The nurse will just prolonged contact __ NOT MET
and infection. Skin Objectives: guide the mother on with irritants, and
health is linked to what to do and what to an alkaline skin
skin honesty. A 1. Cognitive make. surface. 2. Does the mother
problem with skin After the health (Kennedy, 2020) be able to
integrity may mean teaching demonstrate the
that the skin is discussion, the Collaborative- ways to prevent
impaired, injured, or mother would Developmental and ways to make
unable to heal and be able to site 5 The nurse will explain the diet food?
recover normally. ways prevent to the patient the __ MET
Hyperbilirubinemia impaired skin importance of the ways __ NOT MET
is an increase in integrity and 2-3 to prevent impaired
serum bilirubin diet tips to have skin integrity and
levels caused by adequate having a healthy diet 3. Does the mother
RBC hemolysis and nutrional intake for the baby. be able to
subsequent for the baby. verbalize her
unconjugated feelings, thoughts
bilirubin 2. Psychomotor or concerns
reabsorption from After health regarding the
the small intestine. teaching ways to prevent
The condition may discussion, the and food diet?
be harmless or put mother would __ MET
the newborn at risk be able to __ NOT MET
for a variety of demonstrate
complications and how to prevent
side effects. having impaired
skin integrity
(Nurseslabs, 2021) and how to

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make or prepare
the diet food for
SITUATIONAL the baby.
ANALYSIS:
The patient is a 3. Affective
premature baby and After the health
is at risk to have teaching
impaired skin discussion, the
integrity related to mother should
his ongoing be able to
phototherapy verbalize her
secondary to feelings,
increased bilirubin thoughts or
level. The patient is concerns
premature that is regarding the
why he is placed in ways to prevent
an isolette and and food diet.
under phototherapy.

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