Need help with careplan

PLEASE HELP! I am doing a careplan on a newborn that is a 3 day old male infant with hyperbilirubemia. Can anyone help? I am trying to figure out what NRS DXs I can use.

Edited Feb 2, 2009 by algrewet
Forgot to include PLEASE HELP!

[Daytonite, BSN, RN]

risk for injury r/t phototherapy and risk for infection r/t break in skin integrity at umbilical cord site. useeffective breastfeeding if the baby is breastfeeding. sometimes more frequent breastfeeding is encouraged or formula supplementation is instituted because of the jaundice.

[Scrubmouse RN]

Imbalanced nutrition; less than body requirements r/t disinterest in feeding because of jaundice related lethargy

Anxiety: Parent r/t threat to infant, unknown future

I JUST started nursing school and looked this up in my nursing diagnosis handbook. I'm not sure if this is what you were looking for. Thought I'd give it a shot.

[Daytonite, BSN, RN]

Anxiety: Parent r/t threat to infant, unknown future

This is inappropriate for a newborn. Remember who the patient is and who the focus of the care plan is about--the baby.

[algrewet]

how does this look ...this is what i came up with...(little bit of feedback)

nrs. dx: risk for imbalanced fluid volume r/t inadequate oral intake to meet needs of increased insensible water loss and frequent loose stools

aeb:n/a

assessment data: delayed/poor oral breastfeeding and sucking reflex. tsb [color=#2d2d2d]13 mg/dl

treatments: phototherapy

medications:

medical hx: cesearan section 3rdday post-op

key problem patient response #3

nrs. dx: impaired skin integrity r/t frequent loose stools

aeb: diaper area slightly reddened and irritated from frequent loose/greenish brown stools during bilirubin excretion..

assessment data: diaper area slightly reddened and irritated from frequent stools. tsb [color=#2d2d2d]13 mg/dl

treatments: cleanse the diaper area with soap and water after each stool, exposure to air for short periods when phototherapy is not on, place diaper under infant to catch urine and stool, calmoseptine to buttocks, phototherapy

medications: n/a

medical hx: cesearan section 3rd day post-op

key problem patient response #3

nrs. dx: knowledge deficit r/t prognosis, condition

aeb: mother requested information on the cause and treatment.

assessment data:

subjective: mother states, “i would like some information on the cause and prognosis”.

objective: mother appeared worried and anxious, because she is unaware of the cause. tsb [color=#2d2d2d]13 mg/dl

treatments: phototherapy

medications: n/a

medical hx: cesearan section 3rd day post-op

key problem patient response #4

nrs. dx: risk for injury: infant r/t kernicterus, phototherapy lights

aeb: n/a

assessment data:

tsb [color=#2d2d2d]13 mg/dl

treatments: phototherapy eye protectors

medications: n/a

medical hx: cesearan section 3rd day post-op

[Daytonite, BSN, RN]

nrs. dx: risk for imbalanced fluid volume r/t inadequate oral intake to meet needs of increased insensible water loss and frequent loose stools

aeb:n/a

assessment data:delayed/poor oral breastfeeding and sucking reflex.tsb 13 mg/dl

treatments: phototherapy - how is this going to prevent a fluid volume imbalance?

medications:

medical hx: cesearan section 3rdday post-op

there are 3 kinds of nursing interventions for "risk for" diagnoses:

• strategies to prevent the problem from happening in the first place
  
  
• monitoring for the specific signs and symptoms of this problem
  
  
• reporting any symptoms that do occur to the doctor or other concerned professional
  
  

key problem patient response #3

nrs. dx: impaired skin integrity r/t frequent loose stools

the loose stools may be the reason the skin is becoming impaired, but the science behind this is that it is the chemical composition of the stools, the moisture and the repeated skin irritation of cleaning with soaps that is breaking the skin down.

impaired skin integrity r/t moisture and mechanical trauma secondary to loose stools

aeb: diaper area slightly reddened and irritated from frequent loose/greenish brown stools during bilirubin excretion..

assessment data: diaper area slightly reddened and irritated from frequent stools. tsb 13 mg/dl

treatments: cleanse the diaper area with soap and water after each stool, exposure to air for short periods when phototherapy is not on, place diaper under infant to catch urine and stool, calmoseptine to buttocks, phototherapy

medications: n/a

medical hx: cesearan section 3rd day post-op

key problem patient response #3

nrs. dx: knowledge deficit r/t prognosis, condition

i would mark this as inappropriate for the care plan of a newborn. a newborn is not capable of a

deficient knowledge, condition/prognosis r/t lack of information

and does not meet the criteria for this diagnosis. additionally, you did not title it correctly according to nanda standards and have an incorrect etiology. the related factor must indicate the cause (etiology) of the deficient knowledge (which is where this diagnosis fails) because the

patient

is unable to meet the deficiency or absence of cognitive information related to a specific toipic.

aeb: mother requested information on the cause and treatment.

assessment data:

subjective: mother states, "i would like some information on the cause and prognosis".

objective: mother appeared worried and anxious, because she is unaware of the cause. tsb 13 mg/dl

treatments: phototherapy

medications: n/a

medical hx: cesearan section 3rd day post-op

key problem patient response #4

nrs. dx: risk for injury: infant r/t kernicterus, phototherapy lights

kernicterus is a medical disease and cannot be used in a nursing diagnosis. the use of the lights can cause burns on the skin. that is why the patient is at risk for injury. you have some control over this treatment. you have no control over kernicterus. it is a medical condition. you need to remove it from this diagnostic statement.

aeb: n/a

assessment data:

tsb 13 mg/dl

treatments: phototherapy eye protectors

medications: n/a

there are 3 kinds of nursing interventions for "risk for" diagnoses:

• strategies to prevent the problem from happening in the first place
  
  
• monitoring for the specific signs and symptoms of this problem
  
  
• reporting any symptoms that do occur to the doctor or other concerned professional
  
  

medical hx: cesearan section 3rd day post-op

diagnoses need to be sequenced by priority:

• impaired skin integrity
  
• deficient knowledge, condition/prognosis
  
• risk for imbalanced fluid volume
  
• risk for injury