Anda di halaman 1dari 3

ASSESSMENT

NURSING DIAGNOSIS (RATIONALE) OBJECTIVE DATA Deficient >Age = 17 knowledge >G1P0 related to lack >High school of exposure as graduate manifested by request for SUBJECTIVE information DATA >Patient verbalized (Patient does concerns regarding not know many her condition and common what are the measures of possible things that care that would happen next multipara prior to delivery women has learned from experience)

PLAN >OBJECTIVES Within the 8 hours of nursing intervention and implementation, the patient will verbalized understanding of condition and will cooperate necessary action regarding procedure that will be done.

INTERVENTION

RATIONALE

IMPLEMENTATION

EVALUATION

1. Assess readiness to learn and individual learning needs 2. Determine factor pertinent to the learning process 3.Assess the clients motivation 4. Establish priorities in conjunction with client

1. Individual may not be physically, emotionally or mentally capable at this time. 2. To note for personal factors that greatly influence learning 3. Motivation can be negative stimulus or positive

1. Monitor characteristics of contraction. 2. Informed patient and SO that she was in the active phase of delivery and that the frequency and duration of each contraction felt by the patient was normal for this stage.

Within the 8 hours of nursing intervention and implementation, the patient has able to verbalized understanding to condition and has able to cooperate necessary action regarding procedure that has been done.

>to participate in learning process >to identify interference of learning and specific 5. To develop learners objective actions to deal with them. 6. To facilitate learning >to exhibit increased in interest >to verbalized understanding of the condition

3. Done Leopolds maneuver to determine fetal heart tone and the 4. To know urgent need fetal lie and that the babys from both client and position is still changing. nurses viewpoint 4. Informed the client and 5. To meet learners SO that the bloody needs discharge that the patient is having at that moment was 6. Allow client to not a ruptured amniotic proceed at own pace. membrane. 5. Informed client and SO that duration for labor for a primipara patient will be 14 hours but not more than 20 hours.

ASSESSMENT

NURSING PLAN DIAGNOSIS >OBJECTIVES (RATIONALE)


Readiness for enhanced family processes as manifested by express willingness to enhance family dynamics (To assess whether the future family is using stageappropriate health promotion activities) Within 8 hours, the patient would be able to explain importance of familys developmental stage specifically early childbearing stage. >to express feelings freely and appropriately >to verbalized understanding of desire for enhanced family dynamics >to demonstrate individual involvement in problem solving to improve family communication >to be not stagnant to the specific developmental stage.

INTERVENTION

RATIONALE

IMPLEMENTATION

EVALUATION

>Verbalized that family members and relatives are supportive to them >Relationship with the spouse is generally positive >They have strong family ties >Family resilience is evident

1. Determine family composition 2. Identify participating members of family and how they define family. 3. Determine cultural and/or religious factors influencing family interactions 4. Determine economic and social role changes 5. Discuss and encourage use and participation in stress management techniques.

1. Many family forms exist in society. 2. Establishes members of family who need to be directly involved/taken into consideration when developing plan of care to improve family functioning. 3. Expectations related to socioeconomic beliefs may be different in various cultures. 4. Birth of the first baby is usually both exciting and a stressful event 5. Relaxation exercises, visualization, and similar skills can be useful for promoting reduction of anxiety and ability to manage stress that occurs in their lives.

1. Encouraged SO to share personal experiences to the newly parents. 2. Encouraged to identify personal needs as such activity in daily living 3.Encouraged to seek guidance about health education about well-child care and how to integrate a new member into the family 4. Provided information about sharing problems between the patient and spouse as a form of stressreduction technique 5. Provided brief information about family developmental stage and at what stage are they now.

Within 8 hours, the patient was cooperative and has be able to explain importance of familys developmental stage specifically early childbearing stage.

ASSESSMENT

>G1P1 >Skin is a bit pale but lips is pinkish already >Patient verbalized that she still does not have milk in her breast >Patient also verbalized that her grandmother said that it will be until 3 days before breast milk comes out from her breast

NURSING PLAN DIAGNOSIS >OBJECTIVES (RATIONALE) Ineffective Within 8 hours of breastfeeding nursing intervention related to along with the knowledge implementation, the deficit patient will be able to verbalize understanding (The patient is about breastfeeding and having difficulty can perform techniques in the to stimulate let-down breastfeeding reflex.
process or stimulating the let down reflex for she lacks experience about it)

INTERVENTION

RATIONALE

IMPLEMENTATION

EVALUATION

1. Assess knowledge about breastfeeding. 2.Identify cultural expectations and conflicts about breastfeeding and beliefs and practices regarding lactation, letdown techniques and maternal food preferences 3.Perform physical assessment on the breast (Note for appearance, symmetry, inverted or flat nipples, minimal or no enlargement of breast during pregnancy.) 4Determine maternal feelings 5. Assist mother to develop skills of adequate breastfeeding

1. To correct incorrect myths/misunderstandings especially in teenage mother. 2. To correct incorrect myths/misunderstandings especially in teenage mother. 3. To determine certain abnormalities

1. Encouraged SO to share personal experiences to the patient regarding breastfeeding 2. Encouraged mother to eat food that are fresh, juicy and soupy (avoid dry feeding) 3.Encouraged the mother to massage her breast

Within 8 hours, the patient has able to verbalize and communicate understanding about breastfeeding and has been performing techniques to stimulate let-down reflex.

>to verbalize understanding of contributing factor about the dx >to demonstrate techniques to enhance breastfeeding experience >to achieve mutually satisfactory breastfeeding regimen with infant content after feedings and gaining wt. appropriately.

4. Emotion can affect milk 4. Encouraged mother to production 5. To provide more milk to the infant

let her spouse suck her nipple to stimulate letdown reflex effectively.

5. Provided information the importance of breastfeeding and mentioned about colostrum and its .