CUES AND EVIDENCES

Subjective: Mother verbalized, ginadmay lang ang gatas na iya ma-inum taga breastfeeding, kadyto ra man gud kaau muinom Objectives: Temperature on admission: 38.8C VITAL SIGNS: T=36.5C PR=132bpm strong and regular RR=29cpm effortless, regular and rhyhtm Visible weakness Unable to suck well Thin

NURSING DIAGNOSIS
Altered nutrition: Less than body requirements related to inadequate food intake secondary to treatment regimen

OBJECTIVES

INTERVENTIONS

RATIONALE
To detect as well as evaluate & determine the need for intervention and health status. According to Nightingale, this is to maintain the well-being of a person. Establishes baseline. Aids in monitoring effectiveness of regimen. According to Abdellah, this is to observe patients health status. This is to provide adequate nutritional needs of the infant by mothers milk. According to Abdellah, this is to facilitate nutrition of all bod cells. This is to

EVALUATION
Within my care, client has a normal body temperature as evidenced by: Vital Signs within normal range: T=37C PR=110bpm strong and regular RR=24cpm abdominal breather without use of accessory muscles, regular in depth and rhythm Mother verbalized that breastfeeding the infant gives him optimum nutrition. Lips of the

At the end of my INDEPENDENT care, the client will Reassess have adequate temperature nutrition as regularly. (TPR q 4 evidenced by: hours) Vital Signs within normal range: T= 36-37.5 0C R=30--60cpm, Shallow & regular P= 100- 180 bpm, not bounding (awake) 80-160 bpm (asleep) strong and regular Mother verbalizes understanding on importance of breastfeeding the baby Neonate able to suck

Monitor weight

Encourage mother to breastfeed infant at least 8-12x a day

Teach mother proper breastfeeding position

 3kgs Breastfed Feeding duration <20mins. With D5IMB 500cc @13cc/hr Weak cry

well Demonstrate weight gain toward individually expected range Will increase intake of breast milk (increase in feeding duration) Mucous membranes moist and pink Demonstrate improved muscle tone

Teach mother on the importance of breastfeeding

ensure that there is adequate sucking of the infant on the mothers nipples This is to facilitate cooperation of the mother. Mothers milk is a very good source of nutrition for infants, it also helps boost the infants immune system. According to Watson, nursing is concerned with promoting and restoring health and preventing illness

neonate is well attached to the mothers nipple: good latch- on Weight gain not very evident. (was unable to weigh) Infant has increased duration of breastfeeding time (3045mins) Mucous membranes are moist and pink Demonstrat ed improved muscle tone (strong kick)