Gabrielle C.

Gatela
BSN23

Ineffective Breastfeeding
Assessment Data Nursing Diagnosis Desired Outcomes

Nursing Assessment Ineffective -Mother will report

Jhoana Perez is a 17 year old mother Breastfeeding related confidence in
who gave birth to her first baby girl. to lack of knowledge establishing satisfying,
She stopped going to school and effective breastfeeding
stayed at home during her independently.
pregnancy. Doing light household -will have a relaxed,
chores serves as her daily activity. feeding infant.
She is engaged to her boyfriend who
is working at Dubai. Her boyfriend
supports their baby. She says that
she is going to continue her studies
and that she is also excited of
becoming a mother. She reported of
having a smooth delivery although
her stitch still hurts and her upper
outer arm is swelling because of the
injection she received.

Physical Examination
T=36.2
PR=98 bpm
RR= 22, regular
BP= 110/60

Nursing Intervention Rationale

Explain the benefits of breast feeding;
the mechanisms involve in lactation,
the proper breast care and most
especially the proper breast feeding
position.
Encourage mother to exclusively
breastfeed up to 6 months
To promote breast feeding because breast
milk contains all the necessary nutrients a baby
needs for the first 6 months of life
To promote bonding between mother and child.
Breastfeeding helps stop bleeding after delivery
and provides protection against infection.
Breastfed babies have less diarrheas,
gastrointestinal and respiratory infections.

Discuss the importance of adequate obtaining adequate nutrition during lactation is

nutrition during lactation made more difficult because nursing itself
consumes time that could be spent in food
gathering, and because lactating women are
 accompanied by a vulnerable infant whose
presence may interfere with food gathering.

Demonstrate proper positioning of Proper positioning of baby will ensure that baby
baby is sucking effectively.
Evaluation
Outcomes partially met. Patient verbalizes to continue breastfeeding, provided with
knowledge on proper breastfeeding and positiong. Patient was not able to demonstrate
because baby was still not hungry and is still sleeping during the shift.

Acute Pain
Assessment Data Nursing Desired Outcomes
Diagnosis
Nursing Assessment Acute Pain Pain control as
Jhoana Perez is a 17 year old mother related to evidenced by often
who gave birth to her first baby girl. perineum during demonstrating ability
She stopped going to school and labor and delivery to
stayed at home during her  Use
pregnancy. Doing light household analgesics
chores serves as her daily activity. appropriately
She is engaged to her boyfriend who  Use
is working at Dubai. Her boyfriend nonanalgesic
supports their baby. She says that pain relief
she is going to continue her studies measures
and that she is also excited of
becoming a mother. She reported of
having a smooth delivery although
her perineum still hurts and her upper
outer arm is swelling because of the
injection she received.

Physical Examination
T=36.2
PR=98 bpm
RR= 22, regular
BP= 110/60
Skin warm to touch. (+) swelling of
deltoid region.

Anticipate need for pain relief.
Eliminate additional stressors or
sources of discomfort whenever
One can most effectively deal with pain
by preventing it. Early intervention may
decrease the total amount of analgesic
required.
atients may experience an exaggeration
in pain or a decreased ability to tolerate
possible.
Provide rest periods to facilitate
comfort, sleep, and relaxation.
Determine the appropriate pain relief
method.: Cognitive-behavioral
strategies as follows:
 Distraction
techniques(Biofeedback,
breathing exercises, music
therapy)
 Relaxation exercises
Evaluation
Goal Partially Met. Pain alleviated through pain relief measures and intake of
prescribed analgesic by the physician.
Sedentary Lifestyle
Assessment Data
Nursing Assessment
Jhoana Perez is a 17 year old mother
who gave birth to her first baby girl.
She stopped going to school and
stayed at home during her
pregnancy. Doing light household
chores serves as her daily activity.
She is engaged to her boyfriend who
is working at Dubai. Her boyfriend
supports their baby. She says that
she is going to continue her studies
and that she is also excited of
becoming a mother. She reported of
having a smooth delivery although
painful stimuli if environmental,
intrapersonal, or intrapsychic factors are
further stressing them.
The patient’s experiences of pain may
become exaggerated as the result of
fatigue. In a cyclic fashion, pain may
result in fatigue, which may result in
exaggerated pain and exhaustion. A
quiet environment, a darkened room,
and a disconnected phone are all
measures geared toward facilitating rest.
Heighten one’s concentration upon
nonpainful stimuli to decrease one’s
awareness and experience of pain.
Some methods are breathing
modifications and nerve stimulation.
Techniques are used to bring about a
state of physical and mental awareness
and tranquility. The goal of these
techniques is to reduce tension,
subsequently reducing pain.
Nursing Desired Outcomes
Diagnosis
Sedentary -Patient will
Lifestyle related verbalize intent to or
to inadequate engage in increased
knowledge of physical activity.
exercise routines.
her stitch still hurts and her upper
outer arm is swelling because of the
injection she received.

Physical Examination
T=36.2
PR=98 bpm
RR= 22, regular
BP= 110/60

Discuss benefits of Exercise Informing the patient of the benefits will

motivate them to engage in physical
activities.
Assist client to increase interest and Increasing patient’s interest will help
motivation in physical activities them enjoy the performed activities and
with more motivation they will perform it
more often.
Evaluation
Goals not met. Patient was not educated with promoting her lifestyle because
patient does not bother about it much. However, patient will have an increase in
activities since she will continue her studies.