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The document provides an assessment, diagnosis, analysis, goal, nursing intervention, and rationale for a client. It discusses: 1. The client's risk for infection after an episiotomy and goals of reducing infection risk through hand washing, wound care, and antibiotics. 2. The client's effective breastfeeding and goals of maintaining breastfeeding techniques through education and support. 3. The client's readiness for enhanced family processes and goals of learning attachment behaviors through determining family roles and open communication.
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- 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 koas 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. 51
- 2. Assessment Diagnosis Analysis Goal Nursing Rationale Evaluation Intervention S: Effective After 2 days of Assess mothers 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 infants lip to Effectiveness: hour. areola Demonstrate how to To promote support and effective Yes Infants 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 52
- 3. crying. feeding experience for infant and mother. 53
- 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 childs 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 childs life in which family can share thoughts, ideas, and feelings Readiness to openly and non enhanced family judge mentally. processess 54
- 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. 55