Cues/Needs

Nursing Diagnosis

Rationale

Goals and Objective

Intervention

Rationale

Evaluation

Subjective: Inuubo ang anak ko as verbalize by the patients mother.

Ineffective airway clearance related to secretions as manifested by crackles

Crackles produced when air is passing throught fluid or mucus in any passage of air in the respiratory tract

After 30 mins of nursing intervention patien will be able to : -demonstrate behaviors to improve or maintain clear airway

Independent: - Place the child in a Semi Fowlers position -Placing the child in comfortable position helps to promote easier ventilation

After 30 mins of nursing intervention the goal was fully met by the patient as manifested by: -decreased pain evidence by the patients decrease in pain scale from 6/10 to 2/10 -absence of facial grimace

Objective: (+) sore thoat (+) nasal flaring (+)crackles

Dependent: -Administer pain medication as prescribed by the physician

Cues/Needs

Nursing Diagnosis

Rationale

Goals and Objective

Intervention

Rationale

Evaluation

Subjective: Hindi ko alam kung paano magpasuso sa anak ko as verbalize by the patient

Ineffective breastfeeding related to maternal anxiety as manifested by insufficient milk production

Ineffective breastfeeding defines a difficulty of a mother & infant experiences with breastfeeding process

After 15 mins of nursing intervention: -patient and infant will demonstrate effective breastfeeding

Independent: -Provide for privacy and a calm relaxed atmosphere. Reassure client that breastfeeding is a natural activity in which her body is prepared to engage -Teach patient that relaxation is necessary for effective breastfeeding. Describe how the infants behavior and the let down reflex are affected by her emotions -Anxiety and embarassment interfere with learning. Reassurance helps patient to believe in the wisdom of her body

After 15 mins of nursing Intervention patient the goal was fully met as manifested by : -demonstrating a effective breastfeeding to her infant

Objective: (+) anxiety

-Teaching helps patient understand that infants respond to their mothers emotional state and tension level. Maternal tension & emotional upset inhibit the let down reflex causing frustation for the infant

-Instruct patient about comfortable positions for breastfeeding. Suggest she keeps a glass of water close by a used pillows for support.

-Comfort promotes relaxation. Nursing stimulates thirst and the patient shouldnt interrupt feeding to go get a drink. Pillows may help to support patients arm to avoid discomfort or fatigue -Patient may benefit from suggestions about infant and self positioning to avoid fatigue and promote correct latching on

-Assist Patient to get herself & infant into a comfortable position for nursing with infants body flat against hers: tummy to tummy -Encourage patient to stimulate infants rooting reflex & help

-Encouragement & assistance help the client to develop needed skills for

infant to latch on while his/her mouth is open -Show patient how to hold her fingers in C position around the breast while nursing to ensure the infants nose is not covered

initiating nursing her infant

-Praise patient for skill development & nurturing behaviors. Reinforce that breastfeeding is an natural process -Instruct patient in breast care. Wash hands before nursing: wash nipples with warm water & no soap allow to air dry: may

-Demonstration facilitates maternal understanding. Newborns are obligate nosebreathers and will detach form the breast if unable to breathe -Praise increases selfworth & promotes confidence in abilities

-Instruction promotes selfcare. Handwashing prevents the

rub some colostrum or milk into nipples after feeding

spread of pathogens. Soap may dry the nipples causing cracks; colostrum & milk have healing properties

-Teach patient that the infant will empty a breast within 1015 mins. The patient may choose to alternate breasts once or more often during each feeding. The hind milk or last milk in the breast contains increase fat content to promote growth

-Understanding the physiology of breastfeeding promotes selfconfidence & decision making about method for breastfeeding

Cues/Needs

Nursing Diagnosis Readiness for enhanced family coping related to adaptation of family to new family member as manifested by resilience of family

Rationale

Goals & Objectives After 15 mins of nursing intervention patient will be able to: -express feelings freely and appropriately -verbalize understanding of desire for enhanced family dynamics

Intervention

Rationale

Evaluation

Subjective: Tanggap ng pamilya ko ang pagbubuntis ko at lagi sila nandyan para sa akin

A pattern of family functioning that is sufficient to support the well being of family members and can be strengthened

Independent: -Identify family structure and encourage members participation in home visit -Assess family members verbal & nonverbal responses to the new baby -Assess the infants sleeping & eating patterns and how this affect family members -Praise effective coping mechanisms used by the Family -Family may include grandparents or friends in addition to nuclear family -Birth of a new family member alters each members role in the family -Frequent infant feeding and lack of sleep are stressors for new families

After 15 mins of nursing intervention the goal was fully met by the patient as manifested by ; -able to express feelings freely and appropriately - understanding of desire for enhanced family dynamic

Objective: (+) family members are involved in care of the mother and newborn

-Praise reinforce the familys effective coping with the stress of a new baby

-Discuss infant growth and development with the family. Point out infant reflexes & attachment behaviors

-Discussion provides anticipatory guidance for family to facilitate infant growth and development

Cues/Needs

Nursing Diagnosis Disturbed Sleep pattern related to fatigue as manifested by lack hours of sleep

Rationale

Goals and Objective After 30 mins of nursing interventionn patient will be able to ; -attain a adequate hours of sleep -decrease fatigue

Intervention

Rationale

Evaluation

Subjective: Kulang ang tulog ko as verbalize by the patient

Objective: (+) fatigue

Sleep is required to provide energy for physical and mental activities. Disruption in the individuals usual diurnal pattern of sleep and wakefulness may be temporary or chronic. Such disruptions may result in both subjective distress and apparent impairment in functional abilities.

Independent: -Instruct patient to follow as consistent a daily schedule for retiring and arising as possible. - This promotes regulation of the circadian rhythm, and reduces the energy required for adaptation to changes. - Though hunger can also keep one awake, gastric digestion and stimulation from caffeine and nicotine can disturb sleep. - This helps patients who otherwise may need to void during the night.

After 30 mins of nursing intervention the goal was fully met as manifested by: -attaining a adequate hours of sleep -decrease fatigue

- Instruct to avoid heavy meals, alcohol, caffeine, or smoking before retiring

- Instruct to avoid large fluid intake before bedtime

- Increase daytime physical activities as indicated - Instruct to avoid strenuous activity before bedtime

- This reduces stress and promotes sleep.

- Overfatigue may cause insomnia

- Discourage pattern of daytime naps unless deemed necessary to meet sleep requirements or if part of ones usual pattern.

-Napping can disrupt normal sleep patterns; however, elderly patients do better with frequent naps during the day to counter their shorter nighttime sleep schedules. -Obviously, this will interfere with inducing a restful state. Planning a designated time during the next day to address

- Explain the need to avoid concentrating on the next days activities or on ones problems at bedtime.

these concerns may provide permission to "let go" of the worries at bedtime.

- If unable to fall asleep after about 30 to 45 minutes, suggest getting out of bed and engaging in a relaxing activity.

- The bed should not be associated with wakefulness