Initial Feeding

Assessment

• Maternal status, including age and maturity, relationships with significant others, previous bonding history, parity, level of prenatal breast feeding preparation, knowledge or previous experience, and physical condition (actual or perceived, inadequate milk supply, nipple shape and comfort level).

• Psychosocial status including apprehension level, body image and perceptions, stressors such as family and career, sociocultural views of breastfeeding and emotional support from significant others.

• Neonatal status including satisfaction and contentment, growth rate, age weight relationship, neurologic status, respiratory status, suck reflex, and presence of factors that interfere with proper sucking (Cleft lip or Palate).

Diagnosis

• Ineffective Breastfeeding related to limited maternal experience

Planning

• The Mother will be able to properly position neonate during breast feeding, uses appropriate techniques to encourage attachment to nipple.

• The Mother will be able expresses decreased anxiety and continued enthusiasm for breast feeding.

• The Neonate will be able to feed successfully on both breasts and appears satisfied for at least two hours after feeding.

InterventionsInterventions

1. Assess the mother’s knowledge.

2. Educate the mother in breast care and breast feeding techniques.

3. Teach techniques for

Rationale1. To help direct your

interventions2. To reduce anxiety and help

ensure proper nutrition of neonate.

3. These measures reduce

encouraging the let down reflex:• Warm shower• Breast massage• Relaxation and guided

imagery• Infant sucking• Holding neonate close

to breast4. Evaluate the position of the

neonate’s tongue during breastfeeding.

5. Sprinkle glucose water in the nipple before feeding if needed.

anxiety and promote let down reflex.

4. To produce proper sucking motion the neonate’s tongue must be down during breast feeding, with the nipple directly on top.

5. When making preliminary attempts at breastfeeding, the neonate may open his mouth on tasting glucose water. The mother can then direct and attach the neonate’s open mouth to the nipple.

Evaluation

• Mother properly positions neonate during breast feeding, and uses appropriate techniques to encourage attachment to nipple.

• Mother expresses decreased anxiety and continued enthusiasm for breast feeding.

• Neonate feeds successfully on both breasts and appears satisfied for at least two hours after feeding.

• Neonate’s nutritional needs are met.

Bathing

Assessment

• Assess skin most specifically the color, temperature; include nail beds

• Assess temperature both the baby and environment• Assess for contributing factors such as environmental sources of

heat loss and knowledge of caregiver

Diagnosis

• Ineffective thermoregulation related to newborn transition to extrauterine environment

Planning

• Infant will have a temperature between 36.4 C to 37 C• The parents will explain techniques to avoid heat loss at home.• Demonstrate how to conserve heat during bathing.

InterventionIntervention

1. Reduce/Eliminate sources of heat loss:

Evaporation: Provide a warm environment when bathingConvection: Avoid drafts on infantConduction: Provide a warm to lukewarm water for bathing. And promote skin-to-skin contact.

2. Teach caregiver why infant is vulnerable to temperature.fluctuations3. Demonstrate how to conserve heat during bathing.4. Wrap & dry infant in two blankets right after bathing.

Rationale1. This is to conserve heat.

2. This is to help the caregiver achieving the right temperature for infant.3. This is to prevent heat loss during bathing.4. Drying and wrapping infant reduce the likelihood of heat loss.

Evaluation

• The parents or caregiver is able to explain the techniques to avoid heat loss at home.

• The parents or caregiver is able to demonstrate how to conserve heat during bathing.

Sleeping Position

Assessment

• Assess for respiratory rate• Assess for Sleeping activity

Diagnosis

• Risk for ineffective airway clearance related to sleeping position

Planning

• To be able to maintain a clear airway and prevent complications

InterventionIntervention

1. Position the newborn on the side or back to sleep.

Rationale1. To decrease the risk of SIDS.

Evaluation

• The newborn is able to establish a patent airway and prevent complications.

Vitamin K & other Immunizations

Assessment

• Assess for skin integrity• Assess for swelling of injection site• Assess weight for gestational age of neonate

Diagnosis

• Alteration in Comfort: Pain related to Immunization Administration

Planning

• The neonate will be able to manifest decreased restlessness/irritability

Intervention

Interventions1. Perform comprehensive pain assessment in the injections site, characteristics, quality, severity2. Investigate changes in frequency or description of pain

3. Provide comfort measures e.g. repositioning4. Use of cold pack.

Rationale1. Assessment of neonate involves observational skills and may require enlisting the aid of parent2. May signal worsening of condition or development of complications.3. Repositioning prevents affected part from being touched.4. Cold pack promotes vasoconstriction which helps blood clotting.

Evaluation

• Manifest decreased restlessness/irritability

WorksheetIn

NCM 101

Submitted To:Ms. Maricel Planada R.N.

Submitted By:

Ms. Ana Marie V. BusaBSN II-C