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Nursing Problem or Cues

Ineffective Breastfeeding Subjective: Nahihirapan ako magpadede kasi konti lang yung lumalabas, as verbalized by the patient. Objective: Nonsustained insufficient opportunity for sucking at the breast. Infant mobility failure to attach into maternal breast correctly. Patient has difficulty in breast feeding.

Ineffective Breastfeeding related to Interruption in Breastfeeding Immediate Cause: Interruption in Breastfeeding Intermediate Cause: Ineffective Breastfeeding techniques Root Cause: Knowledge Deficit

Goals and Objectives

Althroughout the 8 hrs shift, the patients breastfeeding will be effective. Objectives: After nursing interventions, the patient will: 1.identify contributing factors of ineffective breastfeeding.

Nursing Interventions


Effectiveness: 1.Were the nursing interventions effective in patients breastfeeding? _Yes _No, why?

1.Assess client knowledge about breastfeeding and encourage discussion of current or previous breastfeeding experiences. 2.Health teaching about breastfeeding techniques

1.To know the clients level of awareness and what are the problems during her experience in breastfeeding.

Efficiency: 2.Were the breastfeeding techniques apply effectively? _Yes _No, why? Adequacy: 3.Were the number of interventions sufficient? _Yes _No, why? Acceptability 4.Were the interventions accepted by the patient without

2.increase knowledge about breastfeeding techniques like proper positioning of breast, cleaning of breast, feeding time, breast pump, stimulation, etc. 3.develop skills of adequate breastfeeding.

2.For the patient to be aware of different ways of breastfeeding techniques.

3.Give instructions with each feeding during hospital stay.

3.For the patient to apply skills of adequate breastfeeding.

4.have increase milk production

4.Health teaching regarding: a.increase fluid intake b. sinabawang malunggay increase milk supply b.Malunggay is a rich source of calcium, iron, phosphorus and vitamins A, B, and C.

any signs of rejection from the patient and family members? _Yes _No, why? Appropriateness 5.Were the interventions suitable to the client situation? _Yes _No, why?

Drug Name Generic Name: Cephalexin Brand Name: Keflex

Mechanism of Action Antibacterial AgentsCephalosporins Cephalexin like the penicillins, is a betalacto antibiotic.By binding to a specific penicillinbinding proteins located inside the bacterial cell wall, it inhibits the third and the last stage of bacterial cell wall synthesis. Cell lysis is then mediated by bacterial cell wall autolytic enzymes such as autolysins, it is possible that cephalexin interferes with an autolysin inhibitor.

Indication For the treatment of respiratory tract infections caused by Streptococcus Pneumoniae and Streptococuus pyogenes

Nursing Responsibility Hypersensitivity to Pain of injection 1.The drug should cephalosporins site, be taken with or hypersensitiviy, GI without disturbances, food.(Maybe taken leucopenia, with meals to thrombocytopenia, reduce GI anaphylactic discomfort) reactions, nephro toxicity 2.Before administration, ask patient if he is allergic to penicillins and cephalosporins. 3.Tell patient to take entire amount of drug exactly as prescribed, even after he feels better. 4.Advise patient to notify prescriber if rash develops or signs and symptoms of superinfection appear.


Adverse Effects

Treatment/ Infusion
D5 Lactated Ringers

Hypertonic Solution

Replacement therapy particularly in extracellular fluid deficit accompanied by acidosis

Renal failure, liver dysfunction, diabetes mellitus, lactic acidosis, alkalosis hyperkalemia

Nursing Responsibilities
1.Never stop hypertonic solutions abruptly. 2. Dont give concentrated solutions. I.M or subcutaneously 3.Monitor glucose level carefully. 4.Check vital signs frequently. Report adverse reactions. 5.Monitor fluid intake and output and weight carefully. Watch closely for signs and symptoms of fluid overload. 6.Monitor patient for signs of mental confusion.