Patient Code Name: Omamalin, Princess Kaye Age: 15 Sex: Female Date of Assessment: 10-12-23

Chief Complaint/s: Lack of Breastmilk production

NANDA Nursing Diagnosis ( PES ): Ineffective breastfeeding related to limited knowledge and age as manifested by difficulty in breastfeeding.

NANDA Definition: Difficulty feeding milk from the breasts, which may compromise nutritional status of the infant/child.

PLANNING
ASSESSMENT/ CUES INTERVENTIONS RATIONALE EVALUATION
(Goals & Objectives)
It allows for personalized
SUBJECTIVE DATA: Short term: Independent: education and support Short term:
“wala pa ka inom si baby After 8 hours of nursing - Assess the patient's current based on the patient's The planned care was met as
kay walay mugawas interventions The patient knowledge and concerns individual needs and level of evidenced by demonstrating
will successfully breastfeed about breastfeeding. understanding.
gatas” as verbalized by effective latching,
patient her baby, demonstrating positioning, and
effective latching, - Provide one-on-one Teaching techniques for
understanding of infant cues.
positioning, and infant cues education on the benefits of effective latching and
OBJECTIVE DATA: positioning is crucial as it
breastfeeding and the
Experiencing difficulty understanding. ensures a comfortable and Long Term:
techniques for effective
breastfeeding latching and positioning. successful breastfeeding After 2 days of nursing
experience, interventions, the patients
Baby showing signs of Long Term: - Offer demonstrations and will maintain successful
distress After 2 days of nursing allows for real-time breastfeeding, continuing
observe the patient's practice
interventions, the patients corrections and adjustments, for the entire
to ensure proper technique.
Vital signs are taken as will maintain successful enhancing the patient's recommended duration of
follows: breastfeeding, continuing - Address any questions and confidence and skills. at least six months."
T-37.1 for the entire concerns related to
HR- 60 bpm recommended duration of breastfeeding. encouraging the patient to
RR- 20 cpm at least six months." ask questions and express
- Requesting milk from concerns fosters open
BP-110/70mmhg
other mothers in the ward communication and trust.
O2- 97%
(when necessary).
to ensure the infant's
Ordered labs, results not immediate nutritional
availbale needs are met.
Dependent:
Administering medications,
such as galactagogues (to To promoting successful
increase milk supply) or and comfortable
antibiotics (to treat breastfeeding while
mastitis), as prescribed by
 the healthcare provider.
Collaborative:
- Discuss available support
resources for teen mothers,
such as local parenting
support groups and
counseling services.
REFERENCE/S:
ensuring the well-being of
both the mother and the
infant.
ensures that the patient is
aware of the various types of
support available to her,
including emotional,
educational, and practical
assistance.
Patient Code Name: Omamalin, Princess Kaye Age: 15 Sex: Female Date of Assessment: 10-12-23
Chief Complaint/s: Pain at incision site
NANDA Nursing Diagnosis ( PES ): Acute pain related to surgical incision (episiotomy) as manifested by pain scale of 5/10.

NANDA Definition: Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage
(International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end, and with a
duration of less than 3 months.

PLANNING
ASSESSMENT/ CUES INTERVENTIONS RATIONALE EVALUATION
(Goals & Objectives)

SUBJECTIVE DATA: Short term: Independent: Short term:

“Lisod e tindog kay sakit After 8 hours of nursing 1. To promote patient After 8 hours of nursing
sa may tahi dapit” as interventions the patients  Assessment cooperation. interventions the patients
pain will be decrease from 2. To establish baseline
verbalized by patient  Therapeutic pain will be decreased to
5/10 to 2/10. data
 Educative 3/10
3. Monitor progress of
OBJECTIVE DATA: 1. Establish trust and treatment
Presence of episiotomy rapport 4. To relieve pressure on Long Term:
wound Long Term: episiotomy site. Within 2 days of nursing
2. Obtain patients vital
Within 2 days of nursing 5. To promote relaxation interventions the patient did
signs
Difficulty moving interventions the patient and pain reduction not manifest any signs or
3. Routinely assess
will not manifest any 6. Helps with pain symptoms of pain.
signs or symptoms of patients level of pain . management by
Vital signs are taken as
pain. Note changes in degree redirecting attention
follows:
(Use scale of 0-10) and
T-36.5
HR- 54 bpm site.
RR- 18 cpm 4. Place patient in side
lying position with 1. Provides alleviation of
BP-120/80 mmhg discomfort when other
O2- 98% available pillows as
support. methods have been
ineffective.
Laboratory Results: 5. educate and assist
Hematology: patient of breathing
Hematocrit- 34.3% and relaxation 1. to ensure the best
Hemoglobin- 11.9% technique. possible care and
WBC- 9,580 6. Assist with or provide outcomes for the
Platelets- 430,000/L diversional techniques patient.
2. To identify the
Blood Type: indications, the progress
O RH + Dependent: or the storage of the
 Assessment expected results
Serology:  Therapeutic
(-) HBsAg  Educative

Administer prescribed pain

medication as ordered by the
healthcare provider to relieve
pain.
 Cefalexin 500mg cap
#18
Sig: Take 1 capsule
3x a day after meals
for 6 days
 Mefenamic Acid 3x
tab #30
Sig: Take 1 tablet 3x a
day after meals for 3
days

Collaborative:
 Assessment
 Therapeutic
 Educative

-Refer to the head nurse on

duty if the pain is still sever
after nesting intervention is
done.

-Monitor lab results

REFERENCE/S:
Patient Code Name: Omamalin, Princess Kaye Age: 15 Sex: Female Date of Assessment: 10-12-23
Chief Complaint/s: Anxiety
NANDA Nursing Diagnosis ( PES ): Anxiety related to deficient knowledge and experience regarding maternal care as manifested by verbalization of
concern.

NANDA Definition: Vague, uneasy feeling of discomfort or dread accompanied by an autonomic response (the source is often nonspecific or unknown to the
individual); a feeling of apprehension caused by anticipation of danger. It is an alerting sign that warns of impending danger and enables the individual to
take measures to deal with that threat

PLANNING
ASSESSMENT/ CUES INTERVENTIONS RATIONALE EVALUATION
(Goals & Objectives)
It allows for personalized
SUBJECTIVE DATA: Short term: Independent: education and support based Short term:
“kay mama rako mag salig After 8 hours of nursing - Establish rapport on the patient's individual The planned care was met as
kay di ko kabalo unsa interventions The patient needs and level of evidenced by verbalize
understanding.
buhaton” as verbalized by will verbalize reduced reduced anxiety about her
- Assess the patient's current
patient anxiety about her pregnancy and
knowledge and concerns Teaching techniques for
pregnancy and about maternal care. effective latching and
demonstrate improved
OBJECTIVE DATA: demonstrate improved positioning is crucial as it knowledge and self-
poor eye contact, knowledge and self- - Provide one-on-one ensures a comfortable and confidence regarding
confidence regarding education on the benefits of successful breastfeeding pregnancy care.
nervousness, pregnancy care. breastfeeding and the experience,
techniques for effective Long Term:
uncertainty latching and positioning. allows for real-time The planned care was met as
corrections and adjustments, evidenced by successful
Experiencing difficulty - Offer demonstrations and enhancing the patient's breastfeeding, continuing
breastfeeding Long Term: observe the patient's practice confidence and skills. for the entire
After 2 days of nursing to ensure proper technique. recommended duration of
encouraging the patient to
Baby showing signs of interventions, the patients at least six months."
- Address any questions and ask questions and express
distress will maintain successful
concerns related to maternal concerns fosters open
breastfeeding, continuing communication and trust.
care and after childbirth.
Vital signs are taken as for the entire
follows: recommended duration of
Dependent:
T-37.1 at least six months." ensures a comprehensive
Refer the patient to a
HR- 60 bpm mental health specialist or and tailored approach to
RR- 20 cpm counselor for more in- her mental well-being
BP-110/70mmhg depth assessment and
O2- 97% treatment of anxiety,
especially if it is beyond the ensures that the patient is
Ordered labs, results not scope of general maternity aware of the various types of
support available to her,
availbale care.
including emotional,
educational, and practical
assistance.
Collaborative:
- Discuss available support
resources for teen mothers,
such as local parenting
support groups and
counseling services.

REFERENCE/S: