DATE AND TIME
After 8 hours of nursing intervention After 3 days of nursing intervention
December 2, 2016 Ineffective Breastfeeding r/t to inadequate milk supply secondary to inverted nipple
ASSESSMENT PARAMETERS
S > “Hindi makadede si babay ng
maayos lasi maliit lang ang gatas na
lumalabas”
> Perceived inadequate milk supply
> Client verbalized insufficient
intake of fluids
> Verbalized not knowing how to
properly hold the baby when
breastfeeding.
O > infant inability to latch onto
maternal breast correctly
> Noted maternal breast anomaly
such as inverted nipple
> Insufficient opportunity for
suckling at the breast
NURSING DIAGNOSIS SHORT-TERM AND LONG-TERM GOAL
the client will verbalize understanding the client will achieve adequate and
of breastfeeding techniques. effective breastfeeding.
IMPLEMENTATION
NURSING ORDERS/APPROACHES RATIONALE
DX
 Assess client knowledge about breastfeeding and extent of - To know the level of client’s knowledge on breastfeeding
instruction that has been given
 Assess position during breastfeeding - To evaluate if the patient has knowledge on other breastfeeding
positions
 Perform physical assessment noting appearance of breast and - To check for any abnormalities preventing effective breastfeeding
nipples - To determine causative factors of lactation failure
 Evaluate patient’s fluid and lactogenic food intake
TX - To increase production of milk
 Increase fluid and lactogenic food intake like malunggay and papaya - To maintain or increase the milk supply
 Demonstrate the use of hand expression, hand pump, and breast
massage - For comfort and adequate breastfeeding
 Demonstrate proper holding and position when breastfeeding such
as football hold, cradle hold, cross cradle hold, and side-lying - To stimulate the flow of breastmilk
position - To invert inverted nipple
 Perform breast massage - To enhance milk production
 Use breast pump - To promote equal production of milk on each breast
 Have mother pump breast after feeding
 Inform mother to switch breast every 5-10 minutes - To limit fatigue and facilitate relaxation at feeding time
EX - To help increase lactation
 Encourage frequent rest periods
 Discuss the importance of adequate nutrition and fluid intake on - For hygienic purposes
breastfeeding
 Reiterated to clean breast with warm water
ACTUAL OUTCOME DATE AND TIME RESOLVED
The short-term goal was met as evidenced by the client demonstrating proper breastfeeding
techniques, client does not show signs of ineffective breastfeeding. December 2, 2016
NAME/INITIALS OF PATIENT: X AGE: 18 y/o SEX: F STATUS: Single____
ADDRESS: Baguio City, Philippines 2600___________________________________________________________________________________
PRINCIPAL MEDICAL DIAGNOSIS: 𝐺1 𝑃1 (1-0-0-1) Pregnancy Uterine delivered cephalic term (38-39 weeks) live baby girl (3.24 kg) appropriate for gestational age by normal spontaneous delivery
NURSING CARE PLAN DEVISED BY: _ ____ GROUP A: ANTIOLA, APOLONIO, ATAS, BACOLING, BAKIL, BANGILI, BASILIO, BUGTONG__________ YEAR and SECTION: BSN2A_ GROUP: _A__