Ncp Risk for Fluid Volume Deficit Phototherapy
Nursing Care Plan Assessment | Nursing Diagnosis | Rationale | Objective/s | Nursing Interventions | Rationale | Evaluation | OBJECTIVE:Clinical jaundice evident within 24 hour of birth | Risk for fluid volume deficit related to phototherapy | Phototherapy enhances the excretion of unconjugated bilirubin through the bowel. | The infant will exhibit no signs of dehydration, clear amber urine output of 1-3 mL/kg/hr, and will display appropriate weight gain. | 6. Initiate early feedings and offer feedings ever 2-3 hours.2. Monitor urine specific gravity.3. Administer fluid intake that is 25% above normal requirements. 4. Assess for signs of dehydrations such as poor skin turgor, depressed fontanelles, sunken eyes, decreased urine output, weight loss, and changes in electrolytes.5. Monitor daily weights.6. Assess quantity and characteristics of each stool. | 6. To increase increase intestinal motility and promote the excretion of unconjugated bilirubin through the clearance of stools and to decrease the potential for dehydration. 2. Urine specific gravity can be an indicator of dehydration. Dehydration and fluid volume deficit will show an elevation in the urine specific gravity3. Additional fluids will help compensate for the increased water that is lost through the skin and in the stools.4. Phototherapy treatment may cause liquid stools and increased insensible water loss, which increases risk of dehydration.5. Increased fluid excretion in the stools and a decrease in fluid intake may put the newborn at risk for weight loss. Daily weights can provide accurate dertermination fluid intake and insensible water loss that is caused by phototherapy.6. Loose stools indicate fluid loss which may lead to a fluid volume deficit. With an increase in stools per day, dehydration is possible. |