Nursing Care Plan: Hyperbilirubinemia

Asessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Risk for injury Long term goal: Independent: After 7 days of
related to nursing
“Naninilaw ang mata interventions, the
prematurty
at balat ng baby ko” After 7 days of -Note the infant’s -May aids in patient skin color
minute.
as claim by the Nursing age. diagnosing is normal.
mother. Intervention, the underlying cause
patient skin color in connection with
will be normal. the appearance of
Objective:
jaundice.
-Skin appearing -To allow for
light to bright utilization of
yellow. -Assist with alternate
phototheraphy pathways for
-Sclera appearing
treatment. bilirubin
yellow.
excretion.
-Dark amber urine.
-To expose the
-V/S taken as
entire skin in
follows:
phototheraphy.
-Febrile: 36.3 -Have the infant
-Keep the eye and
completely
-PR: 110 bpm. gonads covered.
undressed.
-RR: 56/min. -Ideally every 2
-Keep the eye and
hrs.
gonads covered.

-Develop a
systematic
scheduleof turning
the infant.

Myrnalyn V. Ortiz

BSN 1-9