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Assessment Nursing Diagnosis Goals & Expected Nursing Interventions Rationale for interventions Evaluation Evaluation
(Supporting data) (NANDA diagnostic statement) Outcomes (Strategies or actions for care) (Include source and page numbers) (Client’s response to
(Realistic, timed, nursing actions
measurable) & progress toward
achieving goals
& outcomes)
Subjective:
MOC states “I have no milk Ineffective Assess a feeding for proper Collect baseline data Baby L was able
because I had a c-section”; Baby will feed four technique to consume 20mL
MOC is using S&S to breastfeeding r/t times during shift, during four
supplement feedings. maternal breast supplementing with feedings
Determine effect of altered Maternal-infant response
anomaly AEB need for 20 mL of formula breastfeeding pattern on mother provides important
supplemental feedings per feed and infant by spending 30 information in determining
Objective:
and no observable minutes talking with mother. how serious the
maternal milk Observe mother-infant breastfeeding issue is. This
production interactions and maternal will dictate how to approach
feelings expressed. the problem and promote
Baby L is consuming 20-30 realistic follow-up.1
mL of formula per feeding; Measure I/Os
MOC’s breasts are very
tubular in shape, very little
mammary tissue present;
cannot express milk with
pump. Baby’s weight has
remained constant since birth
(6 lb, 5 oz)
Assessment Nursing Diagnosis Goals & Expected Nursing Interventions Rationale for interventions Evaluation Evaluation
(Supporting data) (NANDA diagnostic Outcomes (Strategies or actions for care) (Include source and page (Client’s response
(Realistic, timed, numbers) to nursing actions
statement) measurable) & progress toward
achieving goals
& outcomes)
1
Cox’s; pg. 149
Subjective:
Risk for infection R/T Baby will remain free Monitor vital signs every 4 hours Provides baseline and allows Baby L remained
from infection for for quick identifications of any free from infection
maturational factors and
duration of hospital deviations that could indicate
immature immune system stay. infection2
Institute aseptic precautions,
especially handwashing, around Protects baby from pathogens
infant.
Objective:
2
Cox’s pg. 54