Assesment Ncp

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  • Topic: Bilirubin, Breastfeeding, Neonatal jaundice
  • Pages : 3 (766 words )
  • Download(s) : 26
  • Published : April 9, 2013
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ASSESSMENT|
NURSING DIAGNOSIS|
NURSING INTERFERENCE|
NURSING GOAL|
NURSING INTERVENTION|
NURSING EVALUATION|
SUBJECTIVE:The mother of the patient verbalized “nabara toy anak ko ken sangit nga sangit”OBJECTIVE: v/s taken as follows:RR: 42 BPMPR: 144 BPMTemp: 38.6°CWBC: 8.81^10>skin warm to touch>loud cry| Hyperthermia related to inflammatory process or hypermetabolic state as evidenced by increase in body temperature of 38.6 °C, elevated WBC of 8.81^ 10 ,mild jaundice ,crying and verbalization of her mother “nabara toy anak ko ken sangit nga sangit”| Due to the presence of an infectious agents, stimulation of the monocytes triggers the release of the pyrogenic cytokines that stimulate anterior hypothalamic which results in elevated thermoregulatory set point that deals to an increased heat conservation (vasoconstriction) and increased heat production which results to fever | Ater 30 minutes of effective nursing intervention that patients hyperthermia shall maintain normal core temperature as evidenced by a normal temperature of 36°C, normal WBC of _____ stops crying | INDEPENDENT: 1. Monitor neonates conditionRationale: to determine the need for intervention and the effectiveness of therapy. 2. Monitor v/s Rationale: to have a baseline data 3. Provide TSBRationale: helps in lowering down the temperatureINTERDEPENDENT: 4. Ensure that all equipment used for infant is sterile, scrupulously clean. Do not share equipment with other infants Rationale: this would prevent the spread of pathogens to the infant from equipment.DEPENDENT: 5. Administer anti pyretics as orderedRationale: aids in lowering the temperature.| After 30 minutes of effective nursing intervention the patients hyperthermia will maintain normal core temperature as evidenced by a normal temperature of 36°, normal WBC of ____ and ek ek|

ASSESSMENT|
NURSING DIAGNOSIS|
NURSING INFERENCE|
NURSING GOAL|
NURSING INTERVENTION|...
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