NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Independent:
Subjective: • Risk for • Hyperbilirubinemia • After 7 • Note the • May aids in • After 7 days
injury days of infant’s age. diagnosing of nursing
“Naninilaw ang (jaundice) in the
related to nursing underlying intervention
mata at balat ng prematurity neonate is an interventio cause in s, the
baby ko” as . accumulation of ns, the connection with patient skin
verbalized by the serum bilirubin patient the appearance color was
mother. above normal skin color of jaundice. normal.
levels. Onset of
will be • Assist with • To allow for
Objective: normal. phototherapy utilization of
clinical jaundice is treatment. alternate
• Skin seen when serum pathways for
appearing light bilirubin levels are bilirubin
to bright 5 to 7 mg/100 dL. excretion
yellow. Physiologic • Have the infant • To expose the
completely entire skin in
jaundice occurs 3
• Sclerae undressed. phototherapy.
appearing to 5 days after birth • Keep the eyes • To protect them
yellow. and is an increase and gonads from the
in unconjugated covered. constant
• Dark amber bilirubin levels that exposure to
urine. do not exceed 5 high intensity
light.
mg/100 dL/ day.
• V/S taken as • Develop a • Ideally every 2
follows: systematic hours so that all
schedule of the surfaces are
T: 36.3 turning the exposed.
P: 110 infant.
R: 30 .
Collaborative: • To have a
• Obtain bilirubin baseline data if
level as the therapeutic
directed. regimen is
effective.
• To ensure
adequate
• Administer hydration.
fluids as
directed.