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Nursing Care Plan for Hyperbilirubinemia in Infants


Hyperbilirubinemia is a condition where excessive concentration of bilirubin in the blood, causing joundice in neonates (Dorothy R. Marlon, 1998)



1. Impaired Skin Integrity related to jaundice or radiation.

Goal: good skin integrity / normal.

Expected outcomes:
  • Good skin integrity could be maintained.
  • No injuries / lesions on the skin.
  • Good tissue perfusion.
  • Protect the skin and retain moisture and natural treatments.
Intervention:
  • Avoid wrinkles in the bed.
  • Keep your skin to stay clean and dry.
  • Mobilization of the patient every 2 hours.
  • Monitor the existence of skin redness.
  • Wash with soap and warm water.

2. Hyperthermia related to exposure to a hot environment.

Goal: temperature in the normal range.

Expected outcomes:
  • Body temperature within normal range.
  • Pulse and respiration within normal limits.
  • There is no change in skin color.
Intervention:
  • Monitor the temperature as much as possible.
  • Monitor skin color.
  • Monitor blood pressure, pulse, and respiration.
  • Monitor intake and output.

3. Fluid volume deficit related to inadequate fluid intake, phototherapy, and diarrhea.

Goal: adequate body fluids.

Expected outcomes:
  • Adequate fluid.

Intervention:
  • Record the number and quality of feces.
  • Monitor the skin turgor.
  • Monitor intake output.
  • Give water between breastfeeding or giving a bottle.

4. Knowledge Deficit related to the limitations of exposure.

Goal: family got knowledge about the disease that affects children.

Expected outcomes:
  • The family said the understanding of the disease, condition, prognosis and treatment programs.
  • Families are able to carry out the procedure described correctly.
  • The family was able to explain again what is described nurse / other health team.
Iintervention:
  • Describe the pathophysiology of the disease.
  • Describe the signs and symptoms of the disease that usually appears in the right way.
  • Describe the disease process in a proper way.
  • Provide information on the patient's family about the conditions in an appropriate manner.