Hyperbilirubinemia Care Plan : Assessment, Nursing Diagnosis and Interventions (NIC NOC)
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Assessment
1. Parental history
The imbalance of blood type, mother, and children such as Rh, ABO, polycythemia, infection, hematoma, gastrointestinal obstruction, and breast milk.
2. Physical examination
Yellow, pallor convulsions, lethargy, hypotonic, shrill cry, weak suckle reflex, irritability.
3. Psychosocial assessment
The impact of pain on the relationship with the child's parents.
4. Knowledge of the family, include:
The cause of the disease and treatment, further treatment, whether familiar with other families who have the same disease, level of education, ability to learn hyperbilirubinemia.
Nursing Diagnosis for Hyperbilirubinemia
1. Fluid volume deficit r / t inadequate fluid intake, fototherapy, and diarrhea.
2. Increased body temperature r / t effects of phototherapy3. Impaired skin integrity r / t hyperbilirubinemia and diarrhea.
4. Impaired parenting r / t separation.
5. Anxiety: parents r / t therapy given to infants.
6. Risk for injury r / t effects of phototherapy.
Intervention
1. Fluid volume deficit r / t inadequate fluid intake, fototherapy, and diarrhea.
NOC: Body fluids of neonates adequate
NIC:
- Record the number and quality of stool
- Monitor skin turgor
- Monitor intake output
- Give water between breastfeeding or bottle-feed.
2 . Increased body temperature r / t effects of phototherapy .
NOC : The stability of a baby 's body temperature can be maintained
NIC :
- Give a neutral ambient temperature
- Keep the temperature between 35.5 - 37 ° C
- Check vital signs every 2 hours.
3 . Impaired skin integrity r / t hyperbilirubinemia and diarrhea .
NOC : Integrity of the baby's skin can be maintained
NIC :
- Assess skin color every 2 hours
- Monitor direct and indirect bilirubin
- Change positions every 2 hours
- Massage prominent area
- Keep your skin clean and moisture.
NOC : parent and infant behavior shows " Attachment " , parents can express ignorance of the bounding
NIC :
- Bring the baby to the mother for breastfeeding
- Encourage parents to talk to their children
- Involve parents in care when possible
- Encourage parents to express feelings.
NOC : Parents know about treatments , can identify gejala2 to be submitted to the health care team .
NIC :
- Assess the client's knowledge of family
- Give health education causes of yellow
- The process of therapy and treatment
- Give health education on how to care of the baby at home.
6 . Risk for injury r / t effects of phototherapy .
NOC : neonates will evolve without interference due forotherapy tanda2
NIC :
- Place the neonate at a distance of 45 cm from the light source , let the baby naked except for the eyes and genital area and buttocks covered with a fabric that reflects light , keep the eye patch does not cover the nose and mouth , turn off the lights , open your eyes to assess the presence of conjunctivitis every 8 hours , will open the eyes of every feeding, and give a touch of talking to each provide care .