NCP 1

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Sleep Short Term Goal: Independent: Short Term Goal:
“Maglisod kog deprivation After 3 hours of 1. Suggest an 1. Fewer distractions After 4 hours of nursing
tulog kay sakit related to nursing environment help many people interventions, goals were
jud akong tahi pain and interventions, the conducive to rest or sleep better. met. The patient
ma’am.” discomfort client will: sleep. verbalized increased
of the 1. Verbalize 2. Prevent the patient 2. This allows the patient feeling of comfort, had a
Objective: perineum feeling of from having to “let go” of their comfortable position,
• Maximum as comfort, (5 distracting thoughts worries before reported decreased
of 1 hr evidenced out of 10) before sleeping. bedtime. malaise and fatigue, and
and 30 by 2. Achieve a 3. Place patient in a 3. The nurses’ station is showed signs of
mins of laceration comfortable quiet room distant often the center of decreased yawning.
sleep per position from the nurses’ noise and activity.
day PTA 3. Report station. Long Term Goal:
• Pain: 8 decreased 4. Provide a “Do not 4. To avoid disruption of After 4 days of nursing
out of 10 malaise and disturb” sign on the sleep. interventions, goals were
• Frequent fatigue patient’s met.
yawning 4. Show signs room. The client:
during of 5. Give back rubs and 5. This facilitates • Showed signs
daytime decreased other relaxing relaxation and of improved
• Manifests yawning techniques before promote the physical
malaise bedtime. onset of sleep. activity
and Long Term Goal: 6. Position client in a 6. To alleviate discomfort • Improved her
fatigue After 4 days of comfortable position. sense of well-
nursing being
• VS taken interventions, the 7. Provide comfort 7. To relieve stress and • Reestablished
as client will: measures (touch, enhance non- and
follows: 1. Show signs quiet environment, pharmacological pain maintained a
PR: 82 of improved dim light, light music). management. normal
bpm physical 8. Encourage the client 8. Verbalizing concerns sleeping
RR: 16 activity to express concerns may promote pattern
cpm 2. Have an when unable to sleep. relaxation. • Achieved 7-8
T: 37.1 improved 9. Provide a warm bath 9. Vasodilation of the hours of
BP: sense of before the client goes veins causes sleep per day
120/90 well-being to sleep. drowsiness, causing
3. Be able to the client to fall
reestablish asleep.
and 10.Expose perineum on 10.To provide comfort.
maintain perilight for 15 mins
normal
sleep Dependent:
pattern 1. Prescribe sedatives as 1. To induce sleep.
4. Achieve 7-8 ordered.
hours of
sleep per
day
NCP 2
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Ineffective Short term goal: Independent: Short term goal:
“Gusto na kayko breastfeeding After 3 hours of 1. Identify factors that 1. Some conditions After 3 hours of
mupatotoy sa bata related to nursing contribute to may preclude nursing
pero dili mugawas knowledge intervention, the ineffective breastfeeding. intervention, the
ang gatas.” deficit as mother will be able breastfeeding. mother is able to
evidenced by to 2. Assess the structure of 2. Early detection verbalize and
Objective: infant’s • verbalize and nipples and breasts. and treatment of demonstrate her
• VS: inadequate demonstrate abnormalities. understanding in
➢ BP: milk intake her 3. Provide emotional 3. Helps verbalize proper
140/90 understanding support and allow needs and makes breastfeeding, have
mmHg in proper clients to voice their her feel better. positive self-
➢ PR: 85 breastfeeding, expectations and esteem, hold her
bpm • Manifest worries. baby properly, and
➢ RR: 20 positive self- 4. Promote comfort and 4. Discomfort and explain alternative
cpm esteem relaxation increased tension methods if the baby
➢ Temp: • Hold her baby are linked to is unable to
36.9 properly decreased "let- breastfeed.
• Does not • Explain down reflex and Additionally, the
know how to alternative premature infant manifested
breastfeed method if discontinuance of signs or adequate
infant is breastfeeding. milk intake.
unable to Anxiety and fear
breastfeed can reduce milk
Infant will: production.
• Manifest signs 5. Provide necessary 5. For effective
of adequate health teaching about breastfeeding.
milk intake breastfeeding such as
proper positioning,
when to breastfeed,
and how to get a good
attachment.
6. Observe infant’s ability 6. To determine if
to suck. the infant is
competent in
sucking.
7. Support baby’s head, 7. For the safety of
neck, and back while the baby and to
the mother is breastfeed
breastfeeding. properly.

8. Encourage mother to 8. Provides

continue trying. emotional support
to the mother.
9. Alternate 9. For adequate milk
breastfeeding from intake.
either breast.
10.Teach mother to 10.Teaching mother
observe infant will build her
behavioral cues and confidence and
breastfeeding knowledge base.
responses.
11.Increase fluid intake. 11.To stay hydrated
12.Eat healthy foods and 12. Prevents
increase caloric intake. inadequate
nutrient intake for
the infant.
13.Encourage maternal 13.Boosts the
support from husband mother's
and other family confidence in
members. achieving effective
breastfeeding.
14.Encourage mother to 14. To avoid
use the bathroom and interruption.
change baby’s diaper
before breastfeeding.
15.Evaluate adequacy of 15.To monitor the
infant intake. improvement.
16. Evaluate and record 16.The let-down
signs of oxytocin reflex is an
release. indication of
oxytocin release
and is necessary
for transfer of milk
to infant.

Dependent:
1. Administer 1. To provide
multivitamins/ nutrition and
medicine to infant as health
attending physician’s maintenance
order. necessary for
breastfeeding.
NCP 3
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Low self- Short Term Goal: Independent: Short Term Goal:
“Pamati nako nag esteem After 3 hours of 1. Determine client’s level 1. Unplanned After 3 hours of
fail ko as a mother related to nursing of anxiety and source of cesarean births nursing
and wife kay wala perceived interventions, the concern. Encourage the can damage a interventions, goals
nako nakaya ang failure at a client will: client/couple to share client's self- were met.
vaginal delivery.” life event as • Discuss any unmet needs. esteem, making The client:
evidenced concerns her feel • Shared her
“Gibuhat man gyud by related to inadequate and a concerns and
nako ang tanan verbalization her/his role in failure as a perception of
pero wala gyud of negative and 2. Determine the client/ woman. her birth
nako nakaya.”, as feelings perception of couple’s response to 2. To identify other experience.
verbalized by the the birth cesarean birth. concerns. • Shared her
patient 2 days after experience. 3. Explain the normalcy of understanding
the birth of her first • Verbalize such feelings. 3. Helps the woman of the
baby. understanding realize that it is circumstance
of the not her fault. that led to
Objective: circumstance 4. Review client/couple 4. Help them see current
• Anxious that led to role in birth the big picture of situation.
• VS: current experience. Identify pregnancy and • Expressed
➢ PR: 58 situation. positive prenatal and how their positive self-
bpm • Express antenatal behaviors. activities have appraisal.
➢ RR: 17 positive self- helped the result.
cpm appraisal.
➢ T: 37.1 5. Encourage partner's 5. Encourages
➢ BP: presence/participation. verbalization of
140/90 concern and
provides
emotional
support.
6. Differentiate vaginal 6. Emphasis is
and cesarean births. placed on the
Maintain a positive outcome rather
attitude and provide than the birth
postpartum care process, implying
similar to the care given that cesarean
to clients after vaginal birth was needed
birth. 7. Reduces
7. Help the client/couple emotions of
find coping methods inadequacy and
and build new ones as promotes
needed. positive role
adaption.
8. Misinformation
8. Provide correct can enhance
client/infant status. feelings of
helplessness/loss
of control.
Collaborative:
1. If the client's 1. They may need
reactions are further
maladaptive, refer to professional
professional help.
counseling.