1. X. LIST OF IDENTIFIED PROBLEM
Assessment Diagnosis Analysis Goal Nursing Rationale Evaluation
Intervention
S: Risk for infection After 7-8 hours of Assess the client To identify and Efficiency:
r/t skin nursing perception, level of assess the different
“madi pay unnay traumatized 2˚ to Pathogen intervention, the understanding needs. intervention to be Yes, because 7-8 hours of
naimbag dyay dait episiotomy. client will be able done. nursing intervention, the
ko”as verbalized to identify ways Assess signs and client is able to identify ways
by the patient. to reduce risk of symptoms of to to reduce risk of infection.
Open wound infection. infection. infection.
Emphasize the It serves as a live first
O: importance of hand line of defense Effectiveness:
Episiotomy washing technique. against infection.
repair. Yes
Poor hygiene
pinkish in Maintain aseptic
color technique when
Swollen caring wound. Promotes fast
healing. Adequacy:
With Risk for
minimal Emphasized
infection necessity of taking Premature Yes
discharge
antibiotics as discontinuation of
treatment when client Appropriateness:
ordered.
begins to feel well,
Yes
may result in return
of infection.
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2. Assessment Diagnosis Analysis Goal Nursing Rationale Evaluation
Intervention
S: Effective After 2 days of Assess mother’s To know the Efficiency:
breastfeeding r/t Breast milk is nursing intervention knowledge about learning needs of
“napapasuso ko maternal infant present the client will breastfeeding. the client. Yes, because after 8
naman ng husto ang satisfaction and continue to hour of nursing
aking baby” as success with maintain and Identify cultural To know what intervention the
verbalized by the breastfeeding enhanced effective beliefs/ practices aspect this will client verbalized:
client. process. Position of the techniques for regarding lactation. affect breastfeeding
infant to the breastfeeding. Understanding of
O: mother
Educate father about Enlisting support of breastfeeding
benefits of father or associated techniques and
Mother was able to breastfeeding and with higher ratio of demonstrate
position infant how manage successful effective techniques
breast. common lactation breastfeeding at for breastfeeding.
Attachment of
challenges. 6months.
Fed infant every 2-4 infant’s lip to Effectiveness:
hour. areola Demonstrate how to To promote
support and effective Yes
Infant’s suckling at position infant. breastfeeding.
the breast is Suckling of Adequacy:
appropriate. Encourage mother to To be able for a
infant is not
drink at least 2000 mother to have Yes
noisy
ml of fluid/day or 6- enough fluid for she
8 oz. every hour. is lactating. Appropriateness:
Effective Provide information Early recognition of Yes
breastfeeding as needed about early infant hunger
infant feeding cues promotes timely
versus late cue of more rewarding
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3. crying. feeding experience
for infant and
mother.
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4. Assessment Diagnosis Analysis Goal Nursing Rationale Evaluation
Intervention
S: Readiness for Family adapts to After 3days of Determine family To determine the Efficiency:
enhanced family change nursing intervention composition. attribute of
“Gagawin naming process r/t ability to the client will be affection, strong Yes, because after 3
mag asawa ang put child’s need able to participate in emotional ties a days of nursing
lahat para maibigay first. Able to provide all learning appropriate sense of belonging intervention the
ang the needs of their attachment or and durability of client participated in
pangangailangan n newly born child parenting behaviors. membership. learning appropriate
gaming anak” as technique in
verbalized by the Establishes attachment and
client. Identify members of family parenting behaviors.
Willingly accepted participating
their responsibility who need to be
O: numbers of family directly involved / Effectiveness:
and how they define taken into
Evidence of family. consideration when Yes
attachment. Good attachment developing plan of
for parenting care to improve Adequacy:
Family resilience is emotions family functioning.
evident. Yes
Respect for family Note stage of family To determine status Appropriateness:
Early acceptance development. of the family.
members is evident.
and good Yes
Established family Promotes a warm
preference of their
nurse relationship. caring atmosphere
child’s life
in which family can
share thoughts,
ideas, and feelings
Readiness to openly and non
enhanced family judge mentally.
processess
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5. Stress importance of Facilitates ongoing
continuous open expression of open
dialogue between honest feelings and
family members. opinions and
effective problem
solving.
Involve family When individuals
members in setting are involved in the
goals and planning decision making,
for the future. they are more
committed to
carrying out a plan
to enhance family
interactions as life
goes on.
Allows individual
Identify parenting
family members to
skills already being
realize that some of
used and additional
what has been done
ways of handling
already. Helpful and
different behaviors.
encourages them to
learn new to
manage family
interactions in a
more effective
manner.
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