RLE 002

Cebu Normal University

College of Nursing
Cebu City
Mission-Vision: “Care Using Knowledge and Compassion”

Theory-based (Betty Neuman)

NURSING CARE PLAN
Assessment 3 points Goals 2 points Interventions 4 points Bibliography
Diagnosis 3 points Theoretical Basis 2 points Evaluation 1 point 15 points

Name of Student:__________________________________________
Client’s Initials:___________________________________________ Stressor Classification: (Please check)
Age:______Gender: _____Civil Status:________Religion:_______ ______ Physiological (body structure and functions)
Allergies: ________________________________________________ ______ Psychological (mental processes and emotion)
Diet:_____________________________________________________ ______ Socio-cultural (relationships, social expectations)
Date of Admission:________________________________________ ______ Spiritual (influence of spiritual beliefs)
Diagnosis/Impression:_____________________________________ ______ Developmental (developmental processes over the
lifespan)
NURSING DIAGNOSIS NURSING GOALS NURSING OUTCOME
Assessment Diagnosis Mutual Planning Interventions Actual
(Goal attainable within the (with Rationale & Source) Evaluation
shift)
Subjective: Ineffective breastfeeding After 8 hours of nursing PRIMARY INTERVENTIONS
“Dili ra man mosakit related to maternal intervention, the patient Promotive:
akong totoy kung dili anxiety, fatigue, and pain will be able to: I: Discuss/demonstrate breastfeeding aids
mototoy si baby. Mahilak AEB infant crying within  Verbalize such as infant sling, nursing pillows, or
gyud siya bisag bag o ra the first hour after understanding of footstool
gipatotoy” as verbalized breastfeeding; fussing causative or R: To promote let-down reflex
by pt. within one hour after contributing factors. S: Doenges, Moorhouse, Murr.
breastfeeding;  Demonstrate (2016).pp.81
Objective: unresponsive to other techniques to enhance
 Infant arching/crying at comfort measures. breastfeeding I: Encourage frequent rest periods and
the breast. experience. sharing childcare duties
 Infant crying within the Theoretical basis:  Assume responsibility R: To limit fatigue and facilitate relaxation
first hour after Full breasts occur from 3– of effective at feeding times
breastfeeding. 5 days after delivery when breastfeeding. S: Doenges, Moorhouse, Murr.,
 Infant fussing within the breast milk “comes
one hour after in”. The mother feels
breastfeeding. uncomfortable and her
 Infant is most of the breasts feel heavy, hot
time unresponsive to and hard. Sometimes they
other comfort are lumpy. The milk flows
measures. well, and sometimes drips
 Inadequate infant from the breast. This is
stooling. normal fullness. The baby
needs to be well attached,
and to breastfeed
frequently to remove the
milk. The fullness
decreases after a feed,
and after a few days the
breasts become more
comfortable as milk
production adjusts to the
baby's needs.
The most common
difficulty that mothers
describe is a feeling that
they do not have enough
milk. In many cases, the
baby is in fact getting all
the milk that he or she
needs, and the problem is
the mother's perception
that the milk supply is
insufficient.
In some cases, a baby
does have a low intake of
breast milk, insufficient for
his or her needs.
Occasionally, this is
because the mother has a
physiological or
pathological low breast-
milk production. Usually,
however, the reason for a
 Achieve mutually (2016).pp.81
satisfactory
breastfeeding regimen
with infant content
after feedings and Preventive:
output within normal I: Recommend avoidance of supplemental
range. feedings and pacifiers
R: This can lessen infant’s desire to
breastfeed/increase risk of early weaning.
S: Doenges, Moorhouse, Murr.
(2016).pp.81
I: Recommend abstinence/restriction of
tobacco, caffeine, alcohol, drugs, and
excess sugar, as appropriate.
R: These may affect milk production and
the let-down reflex of be passed on to the
infant.
S: Doenges, Moorhouse, Murr (2016.pp.81
SECONDARY INTERVENTIONS
Curative
I: Apply heat compress to the breasts, and
massage from chest wall down to nipple
R: To enhance let-down reflex
S: Doenges, Moorhouse, Murr(2016).pp.82
I: Use relaxation techniques before
nursing such as maintaining quiet
environment, assume a position of
comfort, and placing the infant on the
mother’s chest skin-to-skin.
R: To stimulate let-down reflex
S: Doenges, Moorhouse, Murr(2016).pp.82
TERTIARY INTERVENTIONS
Rehabilitative
I: Recommend monitoring the number of
infant’s wet/soiled diapers.
R: Stools should be yellow in color, and
the infant should have at least six wet
diapers a day to determine that the infant
low intake is a faulty
technique or pattern of
feeding. If the
breastfeeding technique or
pattern improves, the
baby's intake increases.
When a baby takes only
part of the milk from the
breast, production
decreases, but it increases
again when the baby takes
more.
is receiving sufficient intake.
S: Doenges, Moorhouse, Murr(2016).pp.83
I: Schedule a follow-up visit with the
healthcare provider 48 hr after hospital
discharge and 2 weeks after birth
R: To evaluate milk intake/breastfeeding
process and to answer the mother’s
questions.
S: Doenges, Moorhouse, Murr
(2016).pp.83

Symptoms which make a

mother think that her
breast milk is insufficient
include: the baby crying a
lot, and seeming not to be
satisfied with feeds; the
baby wanting to feed very
often or for a long time at
each feed;
the breasts feeling soft;
not being able to express
her milk. These symptoms
can occur for other
reasons, and they do not
necessarily show that a
baby's intake is low.

If a mother is worried
about her milk supply, it is
necessary to decide if the
baby is taking enough milk
or not. If the baby has a
low milk intake, then it is
necessary to find out if it
is due to breastfeeding
technique, or low breast-
milk production. If the
baby's intake is adequate,
then it is necessary to
 decide the reasons for the
signs that are worrying the
mother.

Bibliography:
Geneva. (1970, January 1). Management of breast conditions and other breastfeeding difficulties. Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK148955/
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Ineffective Breastfeeding. Nurse's Pocket Guide (13th ed.).pp.78-84. Philadelphia,
Pennsylvania: F.A. DAVIS
COMPANY
 Nursing Care Plan Product Assessment Rubric
Score
Criteria 4 3 2 1 0
Assessmen Cues are comprehensive Cues are comprehensive and Cues do not substantiate the No cues presented.
t and adequately inadequately substantiate the nursing diagnosis.
substantiate the nursing nursing diagnosis.
diagnosis.
Diagnosis It reflects the accurate The diagnosis selected reflects The diagnosis selected reflects No diagnosis identified.
interpretation of the the adequate interpretation of that no effort to interpret
subjective and objective the subjective and objective information was applied resulting
data analyzed. Problem- data analyzed but are not in a flawed plan of care. PES
Etiology (PE) format is always the best choice from the format is usually not complete or
observed. possible diagnoses that could be used correctly.
interpreted from the data. PE
format is used correctly.
Theoretical It sufficiently explained the It insufficiently explained the No theoretical basis
Basis nursing diagnosis. nursing diagnosis provided.
Goals The identified goal reflects the The identified goal barely reflects No goal formulated.
time-bounded measurable the time-bounded measurable
behavioral elements. The behavioral elements. The criteria
criteria identified generally are identified generally are
individualized and will lead to individualized and will lead to the
the control of the related factors control of the related factors that
that contribute to the nursing contribute to the nursing
diagnosis. diagnosis.
Interventio Specific Specific interventions Interventions developed can be Interventions developed are No interventions to be
ns interventions can can be linked to specific linked to specific outcomes but incomplete. Inappropriate implemented.
easily be linked outcomes. The may be independent. The interventions may be included in
to specific interventions are realistic interventions may not be the plan of care.
outcomes. The and usually appropriate realistic and appropriate to the
interventions are to the patient's current patient's current status.
realistic and status.
appropriate to
the patient's
current status.

Evaluation The subjective and objective data Subjective and objective

that measures the outcome is
collected and analyzed correctly.
data is selected to reflect
evaluation without
consideration of the
outcome criteria. Data
collection is not subjected
to analysis.
Bibliograph Updated (within 5-10 years) and References provided are
y accurate references are provided. not updated and inaccurate.