Mangilit, Ayessa Laine B.

BSN2A

Patient: X Date of Admission: Oct 1,2021

Sex: F

Assessment Nursing Scientific Planning Nursing Interventions Rationale Evaluation

Diagnosis Explanation

Insufficient breast Primary Lactation After 48 hours of nursing Independent After 48 hours of nursing
Subjective: milk production Failure interventions the mother will: interventions the mother:
related to ↓ ● Establish rapport with ● To promote trusting
“Parang wala naman Ineffective ● Demonstrate proper the mother therapeutic nurse- ● Demonstrated proper
Ineffective sucking
nakukuha si baby ko na latching on the latching in patient relationship latching in
reflex of the infant
gatas sakin...Paano ba ‘to? breast, sucking breastfeeding breastfeeding
Hindi na ako nakakatulog reflex
kasi iyak siya ng iyak lagi ↓ ● Express satisfaction and ● To know on what extent ● Expressed satisfaction
kapag papadedehin ko” as Failure to stimulate comfort in ● Assess the knowledge of of health education and comfort in
verbalized by the mother. the release of breastfeeding the mother about breastfeeding breastfeeding
Prolactin hormone you will provide
● ●
↓ Verbalize at least three
ways on how to
Verbalized at least
three ways on how to
Deterioration of
improve breast milk ● Prolactin deficiency improve breast milk
Prolactin hormone ● Assess other causes that
Objective Data (Mother): production may not be the sole production
level may contribute to cause of insufficient
● G1P0T1A0L1 ↓ primary lactation failure. milk production. Other
● Facial expression Putting mother at Recommend making factors and conditions
appears worried, in increased risk of lifestyle changes if may contribute such as
pain, and disappointed. blocked milk ducts applicable and necessary anemia, stress, The infant :
●
●
Sunken eyes
Normal skin turgor
↓ The infant will be able to : medications etc.
● Executed competent
● Left breast is larger Insufficient Breast ● Execute competent sucking reflex
than the right breast Milk Production sucking reflex
● Minimal breast ● Breastfed comfortably
engorgement ● Breastfeed comfortably and successfully
● Dark brown areola, with and successfully without crying
suck marks, light without crying ● To not be able to reach
 bruising and cracks ● Provide a support system the nutritional ● Prevented from
● Everted nipples ● Prevent from further for the mother; it could be requirements needed further dehydration
dehydration having 4-6 the nurse or significant by your baby, may be having 4-6 wet
● Inadequate milk wet diapers each day others. frustrating, especially diapers each day
production upon nipple for a first time mother.
stimulation via breast Emotional support is
pump (15 oz/day) very crucial to prevent
the mother from any
stress because this may
just worsen the
Objective Data (Infant): mother’s condition.

● Ineffective sucking
reflex ● To further stimulate the
● 5 wet diapers within 24 ● Encourage unbounded breast tissue which will
hours ); Yellowish urine frequency and duration of enhance the milk
● 3 times to eliminate breastfeeding supply
(stool) in a day
● Frequently cries upon
breastfeeding ● Breastfeeding
● Promote exclusive and promotes mother-child
effective breastfeeding relationships as well as
for 6 months and skin-to-skin contact.
V/S of the Mother: discourage infant formula Nutrition brought by
Temp: 36. 7 ° C bottle-feeding breast milk cannot be
BP: 120/80 mmHg replaced by infant
PR: 78 bpm formula.
RR: 16cpm
O2Sat: 95%

V/S of the Infant:

Temp: 36.5 ° C ● Improper latching leads
BP: 90/45 mmHg ● Demonstrate proper to blockage of the milk
PR: 105 bpm position and latching ducts and therefore
RR: 40 cpm (Demonstrate an prevent milk supply to
O2Sat: 97% asymmetric latch aiming the mother’s breast
at the infant’s lower lip as
 far from the base of the
nipples, then bringing the
infant's chin and lower
jaw in contact with the
breast while the mouth is
widely open and before
the upper lip touches the
breast. This promote
effective breastfeeding )

● This technique will

● Teach the mother on how naturally enhance milk
to massage the breast supply on the mother’s
breast

● Continued breast
● Educate about the stimulation triggers the
necessity of using breast body that more milk
pump 8-12 times a day secretion is needed,
thus will improved milk
production.

● There were herbals that

● Discuss about the effects scientifically approved
of using herbals to be use to improve
milk production
however there are
herbs like oregano,
parsley, sage,
peppermint, and
jasmine that has milk
decreasing properties.
 ● There were noted
● Educate about the foods meals such as those
that may enhance milk protein-rich foods like
production after tofu, eggs, chicken, etc.
collaborating with a that may contribute to
dietician increased milk
production.

Dependent:
● These medications are
● Physician may prescribe approved by American
Domperidone or Academy of Pediatrics
Metoclopramide that was proven to
improve milk
production

Interdependent:
● Nutritionists or
● Consult a Dietician dieticians have more
regarding the proper expertise on how to
dietary regimen to individualize a good
improve milk production dietary for a specific
of the patient patient with a certain
condition.