ASSLSSMLn1 ulACnCSlS

lnlL8LnCL LAnnlnC ln1L8vLn1lCn 8A1lCnALL LvALuA1lCn

Sub[ect|ve
nanlnllaw ang
maLa aL balaL ng
baby ko" as
verba||zed by the
mother

Cb[ect|ve
Skln
appearlng llghL
Lo brlghL
yellow

Sclerae
Appearlng
yellow

uark amber
urlne

v/S Laken as
follows
1 363
1113
8 33
8lsk for
ln[ury
relaLed Lo
premaLurlLy
Pyperblllrublnemla
([aundlce) ln Lhe
neonaLe ls an
accumulaLlon of
serum blllrubln
above normal
levels CnseL of
cllnlcal [aundlce ls
seen when serum
blllrubln levels are
3 Lo 7 mg/100 dL
hyslologlc
[aundlce occurs 3
Lo 3 days afLer blrLh
and ls an lncrease
ln uncon[ugaLed
blllrubln levels LhaL
do noL exceed 3
mg/100 dL/ day
AfLer 7
days of
nurslng
lnLervenLlo
ns Lhe
paLlenL
skln color
wlll be
normal
lndependenL
noLe Lhe
lnfanL's age
AsslsL wlLh
phoLoLherapy
LreaLmenL
Pave Lhe lnfanL
compleLely
undressed
keep Lhe eyes
and gonads
covered
uevelop a
sysLemaLlc
schedule of
Lurnlng Lhe
lnfanL

CollaboraLlve
CbLaln blllrubln
level as
dlrecLed
AdmlnlsLer
flulds as
dlrecLed
May alds ln
dlagnoslng
underlylng
cause ln
connecLlon wlLh
Lhe appearance
of [aundlce
1o allow for
uLlllzaLlon of
alLernaLe
paLhways for
blllrubln
excreLlon
1o expose Lhe
enLlre skln ln
phoLoLherapy
1o proLecL Lhem
from Lhe
consLanL
exposure Lo
hlgh lnLenslLy
llghL
ldeally every 2
hours so LhaL all
Lhe surfaces are
exposed

1o have a
basellne daLa lf
Lhe LherapeuLlc
reglmen ls
AfLer 7 days
of nurslng
lnLervenLlon
s Lhe
paLlenL skln
color was
normal
effecLlve
1o ensure
adequaLe
hydraLlon


















ASSLSSMLn1

ulACnCSlS lnlL8LnCL LAnnlnC ln1L8vLn1lCn 8A1lCnALL LvALuA1lCn
Sub[ecLlve
Plndl gumagallng
ang sugaL ko" (My
wounds are noL
heallng) as
verballzed by Lhe
paLlenL
Cb[ecLlve
llushed
appearance
Wound
dralnage
v/S Laken as
follows
1374
87
819
8 120/9
8lsk for
lnfecLlon
relaLed Lo hlgh
glucose levels
decreased
leukocyLe
funcLlon
1ype 2 dlabeLes
melllLus occurs
when Lhe
pancreas
produces
lnsufflclenL
amounLs of Lhe
hormone lnsulln
and/or Lhe bodys
Llssues become
reslsLanL Lo normal
or even hlgh
levels of lnsulln
1hls causes hlgh
blood glucose
(sugar) levels
whlch can lead Lo
a number of
compllcaLlons lf
unLreaLed
AfLer 8 hours
of nurslng
lnLervenLlons
Lhe paLlenL
wlll ldenLlfy
lnLervenLlons
Lo prevenL or
reduce rlsk
of lnfecLlon
lndependenL
Cbserve for slgns
of lnfecLlon and
lnflammaLlon
romoLe good
handwashlng by
nurse and paLlenL
MalnLaln asepLlc
Lechnlque for lv
lnserLlon
procedure
admlnlsLraLlon of
medlcaLlons and
provldlng
malnLenance and
slLe care 8oLaLe
lv slLes as
lndlcaLed
rovlde caLheLer
or perlneal care
1each Lhe female
paLlenL Lo clean
from fronL Lo back
afLer ellmlnaLlon
rovlde
consclenLlous
skln care genLly massage
bony areas keep Lhe
skln dry llnens
dry and wrlnkle
free

aLlenL may be
admlLLed wlLh
lnfecLlon whlch
could have
preclplLaLed Lhe
keLoacldoLlc
sLaLe or may
develop a
nosocomlal
lnfecLlon
8educes Lhe
rlsk of
crossconLamlnaLlon
Plgh glucose ln
Lhe blood
creaLes an
excellenL
medlum for
bacLerlal
growLh
Mlnlmlzes Lhe
rlsk for
lnfecLlon
erlpheral
clrculaLlon may
be lmpalred placlng
paLlenL
aL lncreased
rlsk for skln
lrrlLaLlon or
breakdown and
lnfecLlon
AfLer 8
hours of
nurslng
lnLervenLlon
s Lhe
paLlenL was
able Lo
ldenLlfy
lnLervenLlon
s Lo prevenL
or reduce
rlsk of
lnfecLlon
lace ln seml
fowler's poslLlon
Lncourage
adequaLe dleLary
and fluld lnLake of
3000 ml per day
CollaboraLlve
CbLaln speclmen
for culLure and
senslLlvlLles as
lndlcaLed
laclllLaLes lung
expanslon and
reduces rlsk of
asplraLlon
uecrease
suscepLlblllLy Lo
lnfecLlon
ldenLlfles
organlsms so
LhaL mosL
approprlaLe
drug Lherapy
can be
lnsLlLuLed











ASSLSSMLn1


ulACnCSlS lnlL8LnCL LAnnlnC ln1L8vLn1lCn 8A1lCnALL LvALuA1lCn
Sub[ecLlve daLa

nung naklLa ko yung
anak ko pagkapanganak
na pagkapanganak ko sa
kanya parang lba yung
kulay nya maasul" Lhe
moLher verballzed

1he moLher also
explalned hlndl ko
gaanong umllyak yung
anak ko Lapos parang
hlrap slyang humlnga"


ag humlhlnga yung
baby ko parang may
halak akong narlrlnlg"
Lhe moLher sald

Cb[ecLlve daLa

34weekold baby boy

vlLal slgns
1 362C
8 109 bpm
88 63 cpm

Seen havlng dlfflculLy
lmpalred Cas Lxchange
relaLed Lo lmmaLurlLy of
newborn's lungs and lack
of surfacLanL
A membrane prevenLs
exchange of oxygen and
carbon dloxlde aL Lhe
alveolarcaplllary
membrane 1he cause ls
a lowlevel or absence of
surfacLanL Lhe
phosphollpld LhaL
normally llnes Lhe alveoll
and reduces surface
Lenslon on explraLlon Lo
keep Lhe alveoll from
collapslng on explraLlon
(MaLernal Chlld PealLh
nurslng vol 1 pg 777 by
llllLerrl)

WlLh deflclenL
surfacLanL areas
hypolnflaLlon begln Lo
occur and pulmonary
reslsLance lncreases 1he
lungs are poorly
perfused affecLlng gas
exchange (MaLernal
Chlld PealLh nurslng vol
1 pg 777 by llllLerrl)

8ecause surfacLanL does
noL form unLll Lhe 34Lh
week of gesLaLlon as
AfLer 8 hours of nurslng
lnLervenLlons Lhe cllenL
wlll be able Lo
demonsLraLe lmproved
venLllaLlon
ulscuss Lhe meanlng of
8uS


Lxplaln Lhe lmporLance
of proper venLllaLlon on
an lnfanL



Lxplaln and enumeraLe 3
facLors affecLlng 8uS


MalnLaln L1 Lube
mechanlcal venLllaLlon
and supplemenLal warm
humldlfled oxygen



AdmlnlsLer surfacLanL vla
L1 Lube as per proLocol
8efraln from sucLlonlng
for 1 hour






ulscusslon of Lhe maln
problem decreases Lhe
anxleLy of Lhe moLher

ulscusslng Lhe
lmporLance of normal
alrways wlll make Lhe
moLher cooperaLe Lo Lhe
LreaLmenL reglmen

knowledge of such wlll
enable Lhe cllenL know
how Lo ellmlnaLe or
reduce Lhelr effecLs
when posslble






1he L1 Lube proLecLs a
paLenL alrway
Mechanlcal venLllaLlon
asslsLs wlLh dellverlng
necessary alr Lo Lhe
lungs uslng warm
humldlfled oxygen
prevenLs cold sLress and
drylng of mucous
membranes
- AfLer 8
hours of
nurslng
lnLervenLlon
s Lhe
paLlenL was
able Lo demonsLraLe
lmproved venLllaLlon and
demonsLraLe adequaLe
oxygenaLlon of Llssues
wlLhln hls/her l
esLabllshlng resplraLlons
aL blrLh

upon ausculLaLlon flne
rales heard

LxplraLory grunLlng
heard and seen nasal
flarlng

Skln pale and somewhaL
cyanoLlc

LaboraLory
ChesL xray hazy
appearance
A8C resplraLory
acldosls
many as 30 of low
blrLhwelghL lnfanLs and
as many as 30 of very
lowblrLhwelghL lnfanLs
are suscepLlbe
(MaLernal Chlld PealLh
nurslng vol 1 pg 777 by
llllLerrl)

AdmlnlsLer nuLrlLlon vla
enLeral feedlngs breasL
mllk supplemenLed wlLh
hlghcalorle formula
AnLlclpaLe Lhe need for
LoLal parenLeral nuLrlLlon
lf welghL galn ls noL
sufflclenL


8eporL hypoglycemla
(blood glucose level
below 40 mg/dL)

MonlLor vS and cardlac
rhyLhm

rovlde oxygen aL lowesL
concenLraLlon lndlcaLed
by laboraLory resulLs and
cllenL
sympLoms/slLuaLlon

romoLe a calm and
resLful envlronmenL


AusculLaLe breaLh
sounds noLe areas
decreased rales or
grunLlng sounds

noLe resplraLory raLe and

SurfacLanL resLores Lhe
naLurally occurrlng lung
surfacLanL Lo lmprove
lung compllance
SucLlonlng would remove
Lhe drug from lLs
lnLended slLe

AddlLlonal nuLrlenLs are
necessary because sLress
of 8uS requlres
lncreased calorlc
expendlLure 1n may be
necessary Lo meeL Lhese
addlLlonal needs

MonlLorlng glucose
levels helps Lo deLermlne
lf sufflclenL energy ls
avallable Lo meeL Lhe
newborn's meLabollc
needs

Lnsures progress of
LreaLmenL

SLablllzes oxygenaLlon



Pelps llmlL oxygen needs
and consumpLlon

assess areas of pallor or
cyanosls



CbLaln evaluaLlon of Lhe
moLher ln regards wlLh
Lhe LreaLmenL her chlld
recelved

Lnsures progress of
LreaLmenL


Lnsures progress of
LreaLmenL



1aklng noLe of Lhe
cllenL's response wlll
enable Lhe nurse Lo
know Lhe progress of Lhe
lnLervenLlons