NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

- skin appearing Risk for injury After series of Remove clothing and Aids in diagnosing Goal met.
light yellow related to nursing exposed to underlying cause in After series of
- sclera abnormal blood interventions, the phototherapy. connection with the nursing
appearing light profile as bilirubin level will appearance of intervention the
yellow evidenced by be decreased. jaundice bilirubin level was
- afebrile increase decreased to 0.20
- with thin and bilirubin level of Covered eyes and To prevent eyes from mg/dl.
dry skin 1.59mg/dl genitalia direct exposure to
- under intensive light and prevent
and sterility of the baby
phototherapy
-with eye and Repositioned the baby To prevent burns
genital shield every 2 hours.

Kept warm and dry. To prevent further

complications.

Vital signs taken and To obtain the baseline

recorded every 1 hour. data

Instructed on Strict To prevent aspiration

Aspiration Precaution pneumonia and to
(SAP) and advised the prevent colic.
mother to burp the
baby every after
feeding

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NURSING CARE PLAN

Monitored input and To prevent

output. dehydration and
replace fluid and
electrolyte lost

Provided quiet and To promote comfort

warm environment and prevent irritability

Instructed the mother To promote sense of

to use stimulation warmth, security and
technique such as attachment
touching.

Health teachings given To detect early the

to the mother such as possible diseases of
personal hygiene, the patient
importance of
breastfeeding, and
newborn screening.

40
NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

- with slightly Risk for fluid After series of Monitored input and To prevent Goal met.
yellowish skin imbalance nursing output. dehydration and After series of
color and sclera related to interventions, the replace fluid and nursing
- fairly active prolonged risk for fluid electrolyte lost interventions, the
- with good exposure to imbalance will be risk for fluid
sucking reflex phototherapy as prevented. Vital signs taken and To obtain the baseline imbalance is
- afebrile evidenced by recorded data prevented as
- negative (-) dry skin evidenced by good
adventitious Bedside care done To promote comfort skin turgor.
breath sounds including stretching of and good hygiene
upon linens and organizing
auscultation on bedsides
both bilateral
lung fields Instructed Strict To prevent aspiration
Aspiration Precaution pneumonia
(SAP)

Kept back dry To prevent further

complications

Health teachings given To promote healthy

to the mother such as lifestyle
the importance of
breastfeeding, hand
washing, and proper
hygiene

41
NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

- skin appearing Risk for skin After series of Maintained and To protect retina from Goal met.
light yellow breakdown nursing monitored babys eye damage due to high After 8 hours of
- sclera related to interventions, the patches while under intensity of light nursing
appearing light prolonged use patients risk of phototherapy interventions, the
yellow of phototherapy skin breakdown patient was free
- afebrile will be avoided. Removed baby under To provide visual from skin
- with thin and phototherapy and stimulation and breakdown.
dry skin removed eye patches facilitates attachment
-with during feeding behaviors
desquamation of
the skin Inspected eyes every To reduce
- under intensive after phototherapy for complications and
and single conjunctivitis, drainage monitor the
phototherapy and corneal abrasions effectiveness of the
due to irritation from management
eye patches

Provided minimal To provide maximal

coverage of the body exposure and
except for genitals shielded the sensitive
parts such as the
eyes and genitals

Repositioned the baby To promote equal

every 2 hours distribution of
phototherapy
exposure

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