NAME: ANNIBAN, EKKLESIA FAYE; BINWAG, ANGELIKA; BARCELA, HANNAH; CAJA, RENZO GABRIEL; GALINATO, ALORA MAE DATE:
DATE: _____________
BSN LEVEL II, Sec-1, Group D
ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
PROBLEM
Subjective: A postpartum mother STO: Dx: STO:
was admitted to the
The mother OB ward. The mother Within 30 minutes-1 Assess mother’s To assess the correlation (Goal Partially
verbalized “Wala has a difficulty in hour of effective knowledge about of the mother’s Met)
pong lumalabas na breast feeding the nursing interventions, breastfeeding and knowledge to
gatas kaya po siya the patient will be able extent of instruction that breastfeeding Within 30
baby and she
iyak ng iyak” to: has been provided. techniques. minutes-1 hour
verbalized “wala pong
of effective
lumalabas na gatas'
“Nahihirapan po a) Identify the Identify cultural Culture can determine nursing
'nahihirapan po na
dumede si baby". problems related to expectations and the practice and interventions,
dumede si baby (There
the inadequate supply conflicts about acceptance of the patient has
Objective: is no milk coming out;
of breast milk. breastfeeding and practices related to been identified
baby is having a hard
beliefs or practices breastfeeding. Cultural to have a
Breast time breastfeeding”. In b) Interventions create
regarding lactation, let- sensitivity may affect perceived
condition the acute setting after a developing state of
down techniques, and the mother’s opinion on outlook of
(soft, firm, delivery, little time will breast milk production
maternal food breast feeding. breast milk
engorged) have elapsed for the
preferences. inadequacy.
Nipples (sore, nurse to conclude that c) Breast milk
Nursing
dense nipple there is no problem in production for at least
Perform physical interventions
tissue is a breastfeeding, unless one to 2 feedings Physical examinations
examination, noting were carried
barrier to the mother is can determine diseases
appearance of breasts out and only a
feeding) experienced. For and disorders related to
and nipples, marked trickle of breast
No breast many mother–infant inability to breastfeed.
asymmetry of breasts, milk was
milk expelled dyads (NANDA).
obvious inverted or flat produced,
observed in 1
Breastfeeding nipples, minimal or no enough for at
hour.
management issues breast enlargement least 1 feeding
Ineffective LTO:
that can interfere with during pregnancy. only.
sucking
The following regular milk drainage Within 24-48 hours of
from the breast effective nursing Review lifestyle for Lifestyle choices can
was
include poor latch, interventions, the common causes of affect breast milk
observed
after inability unnecessary use of patient will: secondary lactation production. LTO:
to supplemental formula,
breastfeed timed or scheduled a) Have an increase in Evaluate signs of Inadequate infant (Goal Met)
due to lack feedings (as opposed breast milk inadequate infant intake may indicate
problems in both Within 24-48
of breast to on-demand intake.
b) neutralization of mother and infant. hours of
milk. feedings), and overuse
situation and normal effective nursing
of pacifiers. Medical
breastfeeding occurs. A feeding schedule interventions,
conditions in the infant Review feeding
Nursing Diagnosis: could keep track of the the patient
that result in weak or c) Normalization of schedule—frequency,
infants intake and reported
unco-ordinated breast milk production length of feeding,
INEFFECTIVE frequency of breast improved breast
sucking can cause low in accordance to the taking one or both
BREASTFEEDING as milk. milk production
milk supply by mother’s diet, etc. breasts at each
perceived by where
inhibiting the transfer feeding.
inadequate milk production
of milk to the baby.
supply Tx: supply has
Carpenito, L. J. normalized and
This would clear any
(2013). Nursing Instruct on how to has created
misconceptions and
diagnosis: application differentiate between adequate
entertain sense of relief
to clinical practice. perceived and actual supply of breast
to the mother.
Philadelphia, PA: insufficient milk supply. milk. Infant has
Wolters Kluwer. (Independent nursing continued
function) breastfeeding
Herdman, T. H., & Better learning within intervals
Kamitsuru, S. Use one-to-one of 2 hours.
experience for the
(2014). Nanda instruction with each
mother to correct and
International, Inc. feeding during hospital
learn techniques.
nursing diagnoses: stay and clinic or home
definitions & visits. (Independent
classification 2015- nursing function)
2017. Chichester: Wiley
Demonstrate breast Breast massages
Blackwell.
massage technique to increase blood flow to
increase milk supply breasts stimulating the
naturally (Independent flow and production of
nursing function) milk.
This could give an
Monitor increased filling
of breasts in response to estimate of milk
nursing and/ or production
pumping (Independent
nursing function)
Arrange a dietary Dietary consultations
consult to review could increase more
nutritional needs and chances of better
vitamin/mineral health and milk
supplements, such as production.
vitamin C, as indicated
(Collaboration)
Edx:
Encourage frequent rest Rest is essential in
periods, sharing breastfeeding mothers.
household and
childcare tasks.
A support system
Discuss with spouse/SO
could boost mother’s
mother’s requirement
self-perception and
for rest, relaxation, and
perception on
time together with
breastfeeding.
family members.
Weigh infant every This can give a
three days, or as correlation to the
directed by primary intake and output of
provider/lactation the infant in
consultant, and record. connection to
breastfeeding.
Refer to support groups
(e.g., La Leche League, Support groups are
parenting support opportunities to learn
groups, stress reduction, and share many
or other community
resources), as
indicated.
Doenges, M. E., Moorhouse, M.
F., & Geissler-Murr, A.
(2013). Nurses pocket guide:
diagnoses, prioritized
interventions, and rationales.
Philadelphia: F.A. Davis
Company.
