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.

Interventions
Interventions
1. Assess the mother’s
knowledge.
2. Educate the mother in
breast care and breast
feeding techniques.
3. Teach techniques for
encouraging the let down
reflex:
Rationale
1. To help direct your
interventions
2. To reduce anxiety and help
ensure proper nutrition of
neonate.
3. These measures reduce
anxiety and promote let
down reflex.
 • Warm shower
• Breast massage
• Relaxation and guided
imagery
• Infant sucking
• Holding neonate close
to breast
4. Evaluate the position of the
neonate’s tongue during
breastfeeding.
5. Sprinkle glucose water in
the nipple before feeding if
needed.
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.

Intervention
Intervention Rationale
1.Reduce/Eliminate sources 1.This is to conserve heat.
of heat loss:
Evaporation: Provide a warm
environment when bathing
Convection: Avoid drafts on infant
Conduction: Provide a warm to
lukewarm water for bathing. And
promote skin-to-skin contact.
2.Teach caregiver why infant 2.This is to help the
is vulnerable to caregiver achieving the right
temperature.fluctuations temperature for infant.
3.Demonstrate how to 3.This is to prevent heat loss
conserve heat during during bathing.
bathing. 4.Drying and wrapping infant
4.Wrap & dry infant in two reduce the likelihood of heat
blankets right after bathing. 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

Intervention
Intervention Rationale
1.Position the newborn on 1.To decrease the risk of
the side or back to sleep. 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
Interventions Rationale
1.Perform comprehensive 1.Assessment of neonate
pain assessment in the involves observational skills
injections site, and may require enlisting
characteristics, quality, the aid of parent
severity 2.May signal worsening of
 2.Investigate changes in
frequency or description of
pain
3.Provide comfort measures
e.g. repositioning
4.Use of cold pack.
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

Workshee
t
In
NCM
101
Submitted To:
Ms. Maricel Planada R.N.

Submitted By:
Ms. Ana Marie V. Busa
BSN II-C