Patients Name: Baby Boy

Final Diagnosis: Live singleton male term 38-39 wks. age of gestation by Ballard Score, born via NSD with a BW of 2.87 kg appropriate
for gestational age

ASSESSMENT EXPLANATION OF GOALS and INTERVENTION RATIONALE EVALUATION

PROBLEM OBJECTIVES
Objective: The mother's nipple STO: • Assess breast • Normal nipple and • Within 4 hours of nursing
• observ appears to be larger in • Within 4 hours or nipple breast structure or intervention the infant already
able size and the baby's lips of nursing structure early detection and shows signs of satisfaction on
signs is small enough to intervention treatment of breastfeeding, he sleeps after
of catch and latch the infant must abnormalities with breastfeeding
inadeq nipples. Unstained feed continuing support
uate latch by the baby now successfully on are important foe
infant results to ineffective both breast and successful
intake breastfeeding appear to be breastfeeding
(pale satisfied, does • The infant must
skin) not cry and arc. have a “competent
• 0- • Infant should • Evaluate and suck” in order to
1(urine be able to record the achieve successful
-stool) urinate mother's ability breastfeeding. The
• Baby LTO: to position, jaws must
cries • Within 24 hours infant's ability compress the milk
and good to properly sinuses beneath
arcs breastfeeding grasp and the areola and
when pattern must be compress the must be well back
at the obtained and areola with lip, on the areola with
breast maintained tongue and jaw the tongue over
the lower gum,
Nursing Dx: forming a trough
Ineffective around the breast
breastfeeding and the lips must
related to be flanged and
inability to sealed around the
latch by the breast
baby • Provide support • Normal position is
on positioning sometimes
and attaching inapplicable to this
 of infant and situation and so
mother in support from
breastfeeding practitioners are
needed
• Teach mother • Correct positioning
to correctly and getting the
position the infant to latch on
infant in order is critical for
for him to latch getting
and encourage breastfeeding off
mother to to good start.
continue and
immediately try
to breastfeed
per demand
• Discourage the • The use of bottle
use of bottle and formulated
and formulated milk will
milk discourage the
infant to keep
trying to latch in
mother's breast
and may lead to
malnourishment