COLLEGE OF NURSING

Silliman University Dumaguete City

Nursing Care Plan

CUES/EVIDENCES SUBJECTIVE: -Patient verbalized that the pregnancy was unwanted. Stated as: Dili man ko ganahan mamabdos. -Patient verbalized: Bali nakong ampo nga unta di ko mamabdos. Kay dili ganahan akong papa nga maburos ko. -Patient verbalized fatigue in taking care of the neonate, stated as: Lisoda pod aning magbaton og bata. -Patient verbalized lack of support system from the significant others. Stated: Namatay naman akong mama. Ako rang pares ang nidu.aw nako ug

NURSING DIAGNOSIS

Risk for altered parentinfant attachment r/t immaturity and lack of support from significant others.

OBJECTIVES Within our 4-hour care, the client will be able to manifest change of parenting behavior as evidenced by: 1. Demonstrating appropriate bonding behavior. 2. Identify 3 out of at least 5 purposes for parent-infant attachment. 3. Identifying concerns related to parentig at least 3 out of 5. 4. Discussing parenting role in a realistic manner. 5. Making spouse more involved in taking care of the neonate. 6. Building rapport with family members.

INTERVENTIONS INDEPENDENT: -Assess patients/couples strengths and weaknesses, maturity level, reaction to conception and preparation for parenting. -Assess clients interaction with the infant. Document verbal and nonverbal responses and presence of positive or negative behaviors.

RATIONALE -Assessed data will directly give an impact to the ability or desire to gain comfort or skill in parenting. -In Filipino culture, attachment is considered positive if the parent makes an eye to eye contact with the infant, calls the infants name and holds the neonate upclose. Lack of culturally acceptable or appropriate attachment behaviors puts the infant at risk for abuse.

EVALUATION After the 4-hour nursing care, the objectives were:

-Determine -Clients with unrealistic clients/couples perception perception of infant of infant behavior. behavior or who voices displeasure with specific caretaking tasks(e.g. providing

1. Goal Met. Patient showed appropriate behavior. 2. Goal Unmet. Client failed to identify 3 purposes for parent infant attachment. 3. Goal Unmet. Patient failed to identify concerns. 4. Goal Met. Client participated in discussing role in realistic manner. 5. Partner wasnt enthusiastic about infant care. 6. Goal Unmet. Rapport had not been met due to

akong igsuon. Wala jud ko gi.duaw sa akong amahan. -Patient also verbalized: Sige rag gawas-gawas akong pares. OBJECTIVE: -Patient scrambles to find the reason why the neonate was crying. -Patients age is 15 y.o. -Has reduced eye contact with neonate when giving breastmilk. -No visitation other than her partner. -Partner was always away leaving the client alone on bed with the neonate. -No visual account of partner handling the neonate.

7. Let the mother breastfeed the infant with ease and less discomfort.

diaper/feeding)will need closer monitoring and more extensive support. -Give the mother a comprehensive health teaching on the importance of breastfeeding. -Do health teaching on the importance of parent-infant bonding and the effects of such for the infant. -Breastfeeding is essential in parent-infant bonding. This determines what future the child may have. -Explaining the importance of parentinfant attachment will help develop positive attitudes and skills that will help the mother in raising her infant. -This provides support and reduces possible negative outcome for family/infant volunteer support programs also may provide ongoing follow-up and may serve as role models for parenting skills.

having no opportunity. 7. Goal Met. Recent breastfeeding was less awkward which manifested ease and less discomfort.

COLLABORATIVE: -Refer family to social services, home healthcare agency, volunteer support program(DSWD, Barangay Health Centre).