Cues/Needs Nursing Diagnosis Rationale Goals and Intervention Rationale Evaluation

Objective

Subjective: Ineffective Crackles After 30 mins of Independent: After 30 mins of

airway clearance produced when nursing nursing
“Inuubo ang anak related to air is passing intervention - Place the child -Placing the child intervention the
ko” as verbalize secretions as throught fluid or patien will be in a Semi in comfortable goal was fully
by the patient’s manifested by mucus in any able to : Fowler’s position position helps to met by the patient
mother. crackles passage of air in promote easier as manifested by:
the respiratory -demonstrate ventilation
tract behaviors to -decreased pain
improve or - evidence by the
maintain clear patient’s decrease
airway in pain scale from
Objective: 6/10 to 2/10

(+) sore thoat -absence of facial

(+) nasal flaring Dependent: grimace
(+)crackles
-Administer pain
medication as
prescribed by the
physician
 Cues/Needs Nursing Diagnosis Rationale Goals and Intervention Rationale Evaluation
Objective

Subjective: Ineffective Ineffective After 15 mins of Independent: After 15 mins of

breastfeeding breastfeeding nursing nursing
“Hindi ko alam related to defines a intervention: -Provide for -Anxiety and Intervention
kung paano maternal anxiety difficulty of a privacy and a embarassment patient the goal
magpasuso sa as manifested by mother & infant -patient and calm relaxed interfere with was fully met as
anak ko” as insufficient milk experiences with infant will atmosphere. learning. manifested by :
verbalize by the production breastfeeding demonstrate Reassure client Reassurance
patient process effective that helps patient to -demonstrating a
breastfeeding breastfeeding is believe in the effective
a natural activity wisdom of her breastfeeding to
Objective: in which her body her infant
body is prepared
(+) anxiety to engage

-Teach patient -Teaching helps

that relaxation is patient
necessary for understand that
effective infants respond
breastfeeding. to their mother’s
Describe how emotional state
the infant’s and tension
behavior and the level. Maternal
“let down reflex” tension &
are affected by emotional upset
her emotions inhibit the “let
down” reflex
causing
frustation for the
infant
-Instruct patient -Comfort
about promotes
comfortable relaxation.
positions for Nursing
breastfeeding. stimulates thirst
Suggest she and the patient
keeps a glass of should’nt
water close by a interrupt feeding
used pillows for to go get a
support. drink. Pillows
may help to
support patient’s
arm to avoid
discomfort or
fatigue
-Assist Patient to
get herself & -Patient may
infant into a benefit from
comfortable suggestions
position for about infant and
nursing with self positioning
infant’s body flat to avoid fatigue
against hers: and promote
“tummy to correct latching
tummy” on

-Encourage
patient to -Encouragement
stimulate & assistance
infant’s rooting help the client to
reflex & help develop needed
infant to latch on skills for
while his/her initiating
mouth is open nursing her
infant
-Show patient
how to hold her
fingers in “C” -Demonstration
position around facilitates
the breast while maternal
nursing to ensure understanding.
the infant’s nose Newborns are
is not covered obligate nose-
breathers and
will detach form
the breast if
-Praise patient unable to
for skill breathe
development &
nurturing -Praise
behaviors. increases self-
Reinforce that worth &
breastfeeding is promotes
an natural confidence in
process abilities

-Instruct patient
in breast care.
Wash hands
before nursing:
wash nipples -Instruction
with warm water promotes self-
& no soap allow care.
to air dry: may Handwashing
rub some prevents the
colostrum or spread of
milk into nipples pathogens. Soap
after feeding may dry the
nipples causing
cracks;
colostrum &
milk have
healing
properties

-Teach patient
that the infant -Understanding
will empty a the physiology of
breast within 10- breastfeeding
15 mins. The promotes self-
patient may confidence &
choose to decision making
alternate breasts about method
once or more for
often during breastfeeding
each feeding.
The “hind milk”
or last milk in
the breast
contains increase
fat content to
promote growth
 Cues/Needs Nursing Rationale Goals & Intervention Rationale Evaluation
Diagnosis Objectives

Subjective: Readiness for A pattern of After 15 mins of Independent: After 15 mins of

enhanced family family nursing nursing
“Tanggap ng coping related to functioning that intervention -Identify family -Family may intervention the
pamilya ko ang adaptation of is sufficient to patient will be structure and include goal was fully
pagbubuntis ko family to new support the well able to: encourage grandparents or met by the
at lagi sila family member being of family members friends in patient as
nandyan para sa as manifested by members and -express feelings participation in addition to manifested by ;
akin” resilience of can be freely and home visit nuclear family
family strengthened appropriately -able to express
-Assess family -Birth of a new feelings freely
Objective: -verbalize members verbal family member and
understanding of & nonverbal alters each appropriately
(+) family desire for responses to the member’s role in
members are enhanced family new baby the family - understanding
involved in care dynamics of desire for
of the mother -Assess the -Frequent infant enhanced family
and newborn infant’s sleeping feeding and lack dynamic
& eating patterns of sleep are
and how this stressors for new
affect family families
members

-Praise effective -Praise

coping reinforce the
mechanisms family’s effective
used by the coping with the
Family stress of a new
 baby

-Discuss infant
growth and -Discussion
development provides
with the family. anticipatory
Point out infant guidance for
reflexes & family to
attachment facilitate infant
behaviors growth and
development

Cues/Needs Nursing Rationale Goals and Intervention Rationale Evaluation

Diagnosis Objective
Subjective: Disturbed Sleep Sleep is required After 30 mins of Independent: After 30 mins of
pattern related to to provide nursing nursing
“ Kulang ang fatigue as energy for interventionn -Instruct patient - This promotes intervention the
tulog ko” as manifested by physical and patient will be to follow as regulation of the goal was fully
verbalize by the lack hours of mental activities. able to ; consistent a daily circadian met as
patient sleep Disruption in the schedule for rhythm, and manifested by:
individual’s -attain a retiring and reduces the
usual diurnal adequate hours arising as energy required -attaining a
pattern of sleep of sleep possible. for adaptation to adequate hours
Objective: and wakefulness changes. of sleep
may be -decrease fatigue
(+) fatigue temporary or - Instruct to - Though hunger -decrease fatigue
chronic. Such avoid heavy can also keep
disruptions may meals, alcohol, one awake,
result in both caffeine, or gastric digestion
subjective smoking before and stimulation
distress and retiring from caffeine
apparent and nicotine can
impairment in disturb sleep.
functional
abilities. - Instruct to - This helps
avoid large fluid patients who
intake before otherwise may
bedtime need to void
during the night.
- Increase
daytime physical - This reduces
activities as stress and
indicated promotes sleep.

- Instruct to
avoid strenuous - Overfatigue
activity before may cause
bedtime insomnia

- Discourage
pattern of -Napping can
daytime naps disrupt normal
unless deemed sleep patterns;
necessary to however, elderly
meet sleep patients do
requirements or better with
if part of one’s frequent naps
usual pattern. during the day
to counter their
shorter
nighttime sleep
- Explain the schedules.
need to avoid
concentrating on -Obviously, this
the next day’s will interfere
activities or on with inducing a
one’s problems restful state.
at bedtime. Planning a
designated time
during the next
day to address
 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 - The bed should
getting out of not be
bed and associated with
engaging in a wakefulness
relaxing activity.