CUES/NEEDS NURSING RATIONALE GOALS AND INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES
SUBJECTIVE: Ineffective Breastfeeding After 1-2 hours After 1-2 hours of
• the client’s breastfeeding is considered of nursing nursing intervention,
mother r/t inability to the safest, intervention, the client partially
verbalized: latch on simplest, and the client will achieved the goal and
“wala pang secondary to least expensive be able to: was able to:
gatas na knowledge way to provide Short term:
lumalabas sa deficit complete A. “kailangan ko
kanya eh. neonate A. verbalize/ 1. Conduct health Help the client ipa-breastfeed
Pinapadede nourishment. It demonstrate teaching about understand the na yung baby
yung baby pero is both an understanding proper proper ko para maging
gamit yung advantage for of the proper breastfeeding, facilitation of healthy siya.”
syringe.” the baby and breastfeeding breast care and care care of the B. “Pinapadede na
the mother. For for the infant infant and to namin siya,
• “tinry na them mother it provide hinahayaan lang
naming helps in the satisfying namin na
mag uterine feeding time sumipsip siya sa
padede contraction, for both dede ng nanay
pero wala protection from mother and niya.” As
pang breast cancer, baby. verbalized by
lumalabas and the client’s
eh.” empowerment. 2. Inform the Promotes mother.
For the baby, is mother about the timely feeding
• the client gives passive early infant feeding experience for
verbalized: immunity (e.g rooting, lip infant and
“unang anak ko during the first smacking and mother
pa lang ito eh.” months of life, sucking
increase brain fingers/hands)
development
and it is full of 3. Encourage the Encourage let-
nutrients. mother to stroke down reflex
the neonate’s cheek
There are some with fingers or the
factors that can nipple
affect the
breastfeeding 4. Encourage the Encourage let-
process which mother to relax down reflex
eventually can during
bring bad breastfeeding
effects and
unsatisfying
feeding process
for both the
baby and the
mother. 5. Alternate the Every 15mins
breastfeeding from for the first 24
Sources: either breast hours; but
p.436, eventually, the
Maternal- best thing to do
Neonatal is to never
Nursing: made break the good
Incredibly latch on; the
Easy!; neonate
Lippincott doesn’t start to
Williams and receive fat-
Wilkins and-protein
rich hind milk
p.131, Nurse’s after 15 mins
Pocket Guide
Ed.11;
Doenges,
Moorhouse,
Murr
6. Always clean the To avoid
nipples and the contamination
areola before of the milk and
feeding have a clean
and safe
feeding
 process

7. Wear well-fitting To hold all the

and cotton-strapped breast tissues
supportive bras

1. Encourage Support from

maternal support loved ones
from the husband plays
and other family important
members factors to
successful
breastfeeding

2. Encourage Avoid
mother to use the interruption
bathroom and
change the babies
diapers before
breastfeeding

2. Eat healthy If maternal

foods and increase intake is poor,
caloric intake the nutrient
intake in her
breast milk
may become
inadequate
3. Increase fluid To maintain
intake adequate
hydration (one
8oz glass of
water each
time of
breastfeeding)

Sources:
p. 132, Nurse’s
Pocket Guide
Ed. 11;
Doenges,
Moorhouse,
Murr

p.258, A
Clinical
Handbook for
Contemporary
Maternal-
Newborn
Nursing;
Ladewig,
London,
Davidson
p.438, 440,
Maternal-
Neonatal
Nursing made
Incredibly
Easy!;
Lippincott
Williams and
Wilkins