Mangilit, Ayessa Laine B.
BSN2A
Patient: X
Assessment
Subjective:
“Parang wala naman
nakukuha si baby ko na
gatas sakin...Paano ba ‘to?
Hindi na ako nakakatulog
kasi iyak siya ng iyak lagi
kapag papadedehin ko” as
verbalized by the mother.
Objective Data (Mother):
● G1P0T1A0L1
● Facial expression
appears worried, in
pain, and disappointed.
●
●
Sunken eyes
Normal skin turgor
● Left breast is larger
than the right breast
● Minimal breast
engorgement
● Dark brown areola, with
suck marks, light
Date of Admission: Oct 1,2021
Sex: F
Nursing Scientific Planning Nursing Interventions Rationale Evaluation
Diagnosis Explanation
Insufficient breast Primary Lactation After 48 hours of nursing Independent After 48 hours of nursing
milk production Failure interventions the mother will: interventions the mother:
related to ↓ ● Establish rapport with ● To promote trusting
Ineffective ● Demonstrate proper the mother therapeutic nurse- ● Demonstrated proper
Ineffective sucking
latching on the latching in patient relationship latching in
reflex of the infant
breast, sucking breastfeeding breastfeeding
reflex
↓ ● Express satisfaction and ● To know on what extent ● Expressed satisfaction
Failure to stimulate comfort in ● Assess the knowledge of of health education and comfort in
the release of breastfeeding the mother about breastfeeding breastfeeding
Prolactin hormone you will provide
● ●
↓ Verbalize at least three
ways on how to
Verbalized at least
three ways on how to
Deterioration of
improve breast milk ● Prolactin deficiency improve breast milk
Prolactin hormone ● Assess other causes that
production may not be the sole production
level may contribute to cause of insufficient
↓ primary lactation failure. milk production. Other
Putting mother at Recommend making factors and conditions
increased risk of lifestyle changes if may contribute such as
blocked milk ducts applicable and necessary anemia, stress, The infant :
↓ The infant will be able to : medications etc.
● Executed competent
Insufficient Breast ● Execute competent sucking reflex
Milk Production sucking reflex
● Breastfed comfortably
● Breastfeed comfortably and successfully
and successfully without crying
without crying ● To not be able to reach
 bruising and cracks
● Everted nipples
● Inadequate milk
production upon nipple
stimulation via breast
pump (15 oz/day)
Objective Data (Infant):
● Ineffective sucking
reflex
● 5 wet diapers within 24
hours ); Yellowish urine
● 3 times to eliminate
(stool) in a day
● Frequently cries upon
breastfeeding
V/S of the Mother:
Temp: 36. 7 ° C
BP: 120/80 mmHg
PR: 78 bpm
RR: 16cpm
O2Sat: 95%
V/S of the Infant:
Temp: 36.5 ° C
BP: 90/45 mmHg
PR: 105 bpm
RR: 40 cpm
O2Sat: 97%
● Provide a support system the nutritional ● Prevented from
● Prevent from further for the mother; it could be requirements needed further dehydration
dehydration having 4-6 the nurse or significant by your baby, may be having 4-6 wet
wet diapers each day others. frustrating, especially diapers each day
for a first time mother.
Emotional support is
very crucial to prevent
the mother from any
stress because this may
just worsen the
mother’s condition.
● To further stimulate the
● Encourage unbounded breast tissue which will
frequency and duration of enhance the milk
breastfeeding supply
● Breastfeeding
● Promote exclusive and promotes mother-child
effective breastfeeding relationships as well as
for 6 months and skin-to-skin contact.
discourage infant formula Nutrition brought by
bottle-feeding breast milk cannot be
replaced by infant
formula.
● Improper latching leads
● Demonstrate proper to blockage of the milk
position and latching ducts and therefore
(Demonstrate an prevent milk supply to
asymmetric latch aiming the mother’s breast
at the infant’s lower lip as
 far from the base of the
nipples, then bringing the
infant's chin and lower
jaw in contact with the
breast while the mouth is
widely open and before
the upper lip touches the
breast. This promote
effective breastfeeding )

● This technique will

● Teach the mother on how naturally enhance milk
to massage the breast supply on the mother’s
breast

● Continued breast
● Educate about the stimulation triggers the
necessity of using breast body that more milk
pump 8-12 times a day secretion is needed,
thus will improved milk
production.

● There were herbals that

● Discuss about the effects
of using herbals
scientifically approved
to be use to improve
milk production
however there are
herbs like oregano,
parsley, sage,
peppermint, and
jasmine that has milk
decreasing properties.
 ● There were noted
● Educate about the foods meals such as those
that may enhance milk protein-rich foods like
production after tofu, eggs, chicken, etc.
collaborating with a that may contribute to
dietician increased milk
production.

Dependent:
● These medications are
● Physician may prescribe approved by American
Domperidone or Academy of Pediatrics
Metoclopramide that was proven to
improve milk
production

Interdependent:
● Nutritionists or
● Consult a Dietician dieticians have more
regarding the proper expertise on how to
dietary regimen to individualize a good
improve milk production dietary for a specific
of the patient patient with a certain
condition.