NURSING CARE PLAN

(NCP)
NURSING CARE PLAN Document QF-CN-25 Revision 1
Code Number
(NCP)
Effectivity August 17, 2018

NAME/ INITIALS OF PATIENT:________________________________________________ AGE:____________ SEX: ___________ STATUS: ______________

ADDRESS: ________________________________________________________________ HOSPITAL: ______________________ WARD: _______________
PRINCIPAL MEDICAL DIAGNOSIS: ___________________________________________________________________________________________________
NURSING CARE PLAN DEVSED BY:_______________________________________________ YEAR AND SECTION:______________ GROUP______________
SCORING IMPLEMENTATION
CRITERIA VL L H VH
SOAPIE chart FOCUS chart
Content Feb. 5 2021
S> “Wala ako masyadong idea paano itong pagiging magulang. Hindi ko alam paano. Nagawa F> Ineffective infant feeding pattern related to maternal knowledge deficit of
Complete
ko kanina sa recovery room pero pagod pa ako magpadede noon. Yung nurse nalang breastfeeding as evidenced by mother’s verbalization on lack of experience
Assessment
umalalay sa baby ko.” As verbalized by the mother. Poor positioning was noted. knowledge towards child care, poor breastfeeding positioning and poor latch.
Parameters
O> Infant is unable to latch onto maternal breast correctly 7:00 AM D> Infant is unable to latch onto maternal breast correctly and poor positioning
Nursing
Diagnosis A> Ineffective infant feeding pattern related to maternal knowledge deficit of was noted. Mother verbalized that “Wala ako masyadong idea paano itong
Short-term breastfeeding as evidenced by mother’s verbalization on lack of experience and pagiging magulang. Hindi ko alam paano. Nagawa ko kanina sa recovery room
Outcome knowledge towards child care, poor breastfeeding positioning and poor latching. pero pagod pa ako magpadede noon. Yung nurse umalalay sa baby ko.”
P> After 2 hours of nursing intervention the mother will verbalize and demonstrate techniques 7:15 AM A> Established rapport.
Long-term
Outcome to manage breastfeeding problems and infant manifests signs of adequate intake at the breast. Assessed for presence/absence of related factors or conditions that
Nursing I> Independent: Establish rapport. Assessed related factors or conditions that would preclude breastfeeding.
Orders would preclude breastfeeding. Assessed breast and nipple structure. Evaluated and Assessed breast and nipple structure
Rationales Recorded the mother's ability to position, give cues and help the infant latch on. Evaluated and Recorded the mother's ability to position, give cues and help
Actual Evaluated and record the infant's ability to properly grasp and compress the areola the infant latch on.
outcome with lips, tongue, and jaw. Evaluated the infant's suckling and swallowing pattern at Evaluated and record the infant's ability to properly grasp and compress the
TOTAL SCORE the breast. Evaluated and recorded infant's state at the time of feeding. Assessed areola with lips, tongue, and jaw.
knowledge regarding psychophysiology of lactation and specific treatment measures Evaluated the infant's suckling and swallowing pattern at the breast.
for underlying problems. Promoted comfort and relaxation to reduce pain and anxiety. Evaluated and recorded infant's state at the time of feeding.
VH – Very High Provided support by actively helping the mother to correctly position the baby to Provided support by actively helping the mother to correctly position the
H – High attain a good latch on the nipple and encouraging her to continue trying. Explained the baby to attain a good latch on the nipple and encouraging her to keep trying.
L – Low mother and child's proper positioning during breastfeeding by showing the necessary Explained the mother and child's proper positioning during breastfeeding.
VL – Very Low technique. Provided health teachings about proper attachment and assisted mother Provided health teachings about proper attachment and assisted mother.
on doing them. Discouraged supplemental bottle feedings and encouraged exclusive, Discouraged supplemental bottle feedings and encouraged exclusive,
effective breastfeeding. Encouraged client to verbalize feelings and concerns. effective breastfeeding.
Rated by:
Re-assessed feeding pattern of infant and effectiveness of breastfeeding. Encouraged client to verbalize feelings and concerns.
E> After 2 hours of nursing intervention the mother verbalized and demonstrated techniques
Date: __________________ to manage breastfeeding problems and infant manifested signs of adequate intake at the breast.

ACTUAL OUTCOME DATE AND TIME RESOLVED

Conforme:
NURSING CARE Document QF-CN-25 Revision 1
Date:__________________
PLAN Code Number
Effectivity August 17, 2018
 (NCP)

DATE AND TIME NURSING DIAGNOSIS SHORT – TERM AND LONG – TERM OUTCOMES
Ineffective infant feeding pattern related to maternal knowledge deficit of
breastfeeding as evidenced by mother’s verbalization on lack of experience and
knowledge towards child care, poor breastfeeding positioning and poor latching.

ASSESSMET PARAMETERS
IMPLEMENTATION
NURSING ORDERS / APPROACHES RATIONALE

ACTUAL OUTCOME DATE AND TIME RESOLVED