Imbalanced Nutrition Less than Body Requirements

ASSESSMENT SUBJECTIVE • “Hindi kasi ako magatas, simula pa noong unang panganak ko wala na akong nilalabas na gatas.” as verbalized by the mother of the newborn. OBJECTIVE • Noted feeding cues (rooting, tonguing) • Noted smaller than normal newborn size from lesser intake of nutrients • Noted bottlefeeding of formula milk without any previous breastfeeding NURSING DIAGNOSIS Imbalanced nutrition related to: less than body requirements related to inability to procure needed nutrients as evidenced by bottle-feeding of formula milk secondary to preterm birth and pulmonary edema PLANNING SHORT-TERM GOALS After 20 to 40 minutes of nursing intervention, the mother will be able to: • Be informed regarding factors for imbalanced nutrition 510 minutes. • Identify and discuss possible interventions to achieve needed nutrition for 5-10 minutes. • Understand the need for breastfeeding and assess for milk production towards breastfeeding accomplishment for 510 minutes. • Perform lactation massage upon demonstration for beneficial and possible stimulation of milk production for 5-10 INTERVENTION RATIONALE Assess for the factors of having For further identification of an imbalanced nutrition of the causative and contributing newborn with the mother. points regarding lack of nutrients and intake. Without estimation, not exact Weight is vital that it needs to weight of the newborn. be accurate, which will be a basis for nutrient requirements for the preterm newborn Look for further physical signs of poor nutritional intake. The newborn may resemble to be sluggish and fatigued. Vital signs may show tachycardia and elevated BP. Demonstrate lactation massage procedure to the mother for a return demonstration to stimulate milk production to encourage and promote breastfeeding to preterm newborn Breast milk is the best for newborns, infants, and toddlers which includes all needed nutrients in achieving good health and development Demonstrate proper attachment To promote a successful of the newborn to the mother’s breastfeeding of the mother to breasts for breastfeeding. her newborn. EVALUATION GOAL PARTIALLY MET - The mother had been informed regarding causative and contributing factors for the newborn’s imbalanced nutrition. - Identification and discussion of needed interventions were achieved for needed nutrition of the newborn. - The mother understood the need for breastfeeding and was assessed for milk production. Explain the need for bottle- Formula milk only serves as a feeding with formula milk substitute but does not provide termination. satisfaction and essential nutrients for the newborn - Lactation massage for milk production stimulation was performed by the mother. Explain the importance of breastfeeding aside from nutritional means in accordance to mother-child dyad. - Newborn was assessed regarding nutritional status and formula milk Continuous attachment of newborn to bottle interferes with the relationship and closeness of the mother with her newborn.. • Noted pulmonary edema from previous hospitalization records. VITAL SIGNS • T = 36.3°C • PR = 136 bpm • RR = 44 cpm • BP = NOT APPLICABLE • Ht. = 45 cm • Wt. = 2.4 kg minutes. consumption. After 15 to 30 mins. of nursing intervention, the newborn will be able to: - The mother was not able to produce breast milk with performed lactation massage method and therefore did not give immediate breastfeeding of the newborn. • Be assessed regarding imbalanced nutrition with usual formula milk consumption for 10-15 minutes. • Be given breast milk upon assessment and milk production stimulation from lactation massage from the mother’s claimed absence of milk production for 5-10 minutes. LONG-TERM GOALS After one week of nursing intervention, the mother will be able to: Report given immediate breastfeeding to newborn upon milk - The weight and changes with nutrition of the newborn did not increase or improve, satisfaction of the newborn for breastfeeding was not achieved, and motherchild dyad is affected upon reported continuous bottlefeeding with formula milk. production from continuous lactation massage for 5-10 minutes. After one week of nursing intervention, the newborn will be able to: •Gain needed or have an increase in weight and positively anticipated changes in nutrition for 10-15 minutes. •Be breastfed by the mother with an increase in production and consumption to satisfy newborn for 510 minutes.