Nursing Process

Associate Degree Nursing Program Nursing Process Paper Maslow's Needs and |Assessment: Subjective |Nursing Diagnosis |Outcome Criteria/Goals |Nursing Interventions/ Nursing |Rationale plus |Evaluation/ | |Rationale for Need |Data and Objective Data |(Include the related |(Needs to be |Orders |Reference |Actual Outcome | | |(Designate Which) |to reason) |measureable) |(Individualize to patient/family)| | | | | | | | |Gulanick p. 19 and Mayo brochures on | | | | | | | |breastfeeding | | | |1. mother states she |Deficient knowledge: |Mother will demonstrate |1. Provide information on local |1. Allows patient to interact with others who|Outcome partially met. | |Teaching need. |does not belong to a |breast-feeding, |correct latching on |breastfeeding support groups, |have similar needs and a wealth of |We had one effective | | |support group for |related to lack of |technique by the end of |such as LLLI by dismissal. |information. |teaching session, but | |Maslow need: Safety |breastfeed ing moms. (s) |experience and lack of|my shift. | |mother needs more | |and security. | |exposure. | |2. Demonstrate the proper |2. Incorrect latching on is the primary |practice, more | | |2. mother states has only| | |latching on technique during my |reason for pain in breastfeeding, and lack of|self-confidence, and a| |Rationale: |observed pictures of | | |shift, and have mother try it |information can lead to feelings of |lot more sleep efore | |Safety and security |latching on, has never | | |herself. Offer feedback, and |helplessness. |she tries again. | |evolve from the |done so herself. (s) | | |repeat. | | | |absence of fear and | | | | |3. A lactation consultant has the most | | |anxiety, both of which|3. mother states she | | |3. Arrange for a visit from a |experience in teaching and answering | | |may be present as a |would like to have a | | |lactation consultant while at |questions about breastfeeding and will be | | |first-time mom |visit from a lactation | | |hospital. |seen as a competent authority. | | |attempts to |consultant (s) | | | | | | |breastfeed. | | | |4. Encourage repetition of |4. Repetition assists in remembering and in | | | |4. other states she is | | |information/skill during teaching|building confidence in new skills. | | | |overwhelmed and tired. | | |session. | | | | |(s) | | | | | | Associate Degree Nursing Program Nursing Process Paper |Maslow's Needs and |Assessment: Subjective Data |Nursing Diagnosis Outcome Criteria/Goals |Nursing Interventions/ Nursing Orders|Rationale plus |Evaluation/ | |Rationale for Need |and Objective Data (Designate|(Include the related|(Needs to be |(Individualize to patient/family) |Reference |Actual Outcome | | |Which) |to reason) |measureable) | | | | | | | | | |Gulanick p. 111 | | | |1. mother’s perineum is in |Risk for infection |Mother’s perineum and |1. Change pads often and teach |1. Use of correct cleaning technique and |Outcome met. Mother | |Mother need. |direct contact with a bloody |related to |the site of her |perineal cleansing technique to avoid|dry pads decreases the chances of spreading|demonstrated good | | |pad at all times. (o) |disruption of tissue|episiotomy repair will |infection during my shift. germs from anal area and deprives them of a|hand-washing technique, | |Maslow need: | |integrity of |remain free of infection| |moist environment to reproduce in. |good peri care during | |Physiological |2. mother has been observed |perineum secondary |during my shift, and |2. Instruct mother on the importance | |bathroom breaks, and | | |not to wash hands during |to interventions at |mother will voice |of hand washing for her own health as|2. Frequent hand washing with correct |ordered a good meal and | |Rationale: |trips to the bathroom (o) |time of delivery. |understanding of |well as that of her baby during my |technique reduces the spread of germs. plenty of fluids during | |This is a basic need | | |rationale for and |shift. | |my shift. | |for survival. If |3. mother complains of pain | |demonstrate proper hand | |3. It is important for mother to be able to| | |mother is fighting an |and swelling in perineum (s) | |washing technique and |3. Teach mother to recognize signs |differentiate normal pain and swelling from| | |infection, it will | | |good peri care. and symptoms of infection during my |signs of infection, and to know when to | | |prevent her from |4. mother has been on sips | | |shift. |contact her physician. | | |interacting with baby |and chips for past 36 hours | | | | | | |and caring for her new|(o) | | |4. Encourage intake of protein- and |4. Optimal nutrition will speed the healing| | |family. | | |calorie-rich foods during my shift |process, and fluids pro mote diluted urine | | | | | | |and encourage fluid intake of |and frequent emptying of bladder, reducing | | | | | | |2000-3000 mL daily during my shift |risk of infection in the perineal area. | | Associate Degree Nursing Program Nursing Process Paper Maslow's Needs and |Assessment: Subjective Data |Nursing Diagnosis |Outcome Criteria/Goals |Nursing Interventions/ Nursing Orders|Rationale plus |Evaluation/ | |Rationale for Need |and Objective Data (Designate|(Include the related to |(Needs to be |(Individualize to patient/family) |Reference |Actual Outcome | | |Which) |reason) |measureable) | | | | | | | | | |Gulanick p. 97 and Mayo brochures on | | | | | | | |breastfeeding | | | |1. mother states that prior |Risk for disturbed sleep|Mother will achieve |1. During my shift, instruct mother |1. This helps patients who would need to |Outcome partially | |Psychosocial need. |to the birth of her baby she |pattern related to the |optimal amounts of sleep|to avoid large fluid intake bef ore |void during the night, as mother did up |met. Complete | | |had not been sleeping well. |addition of a newborn to|as evidenced by rested |bedtime |until the birth. |evaluation of the | |Maslow need: |(s) |the household. appearance, | | |outcome will not be | |Physiological | | |verbalization of feeling|2. During my shift, create an |2. Allowing mother to rest whenever |able to be done as | | |2. mother is in a hospital | |rested, and improvement |environment conducive to sleep or |possible will give her the strength she |the behaviors extend| |Rationale: |setting, semi-private room, | |in sleep pattern.. |rest. Dim lights, limit visitors, |needs to care for baby and make good |to the period when | |This is a basic need |appears exhausted. o) | | |take baby to nursery. |choices. |parents return home | |for survival. If | | | | | |with baby. Father | |mother is |3. mother is nursing baby at | | |3. During my shift, suggest to mother|3. A new mother needs to get sleep when she|is participating in | |sleep-deprived it will|90 minute intervals (o) | | |that she nap whenever baby is |can. Allowing baby to wake her at night |care for baby, and | |affect her behavior | | | |napping, and to allow baby to wake |will eventually lead to baby sleeping |both parents slept | |and prevent her from |4. father appears | | |her for feedings at night. |longer at a time in the evenings. |soundly for an hour | |interacting with baby |well-rested, is supportive, | | | | |during my shift. | |and caring for her new|and voices eagerness to help | | |4. During my shift, encourage father |4. Involving father will give him a sense | | |family. |with baby cares (o, s) | | |to take baby for walks or to rock and|of responsibility for the baby and for the | | | | | | |play with baby to allow mother to |care of mother and will promote bonding | | | | | | |sleep. |with baby and rest for mother. | | Associate Degree Nursing Program Nursing Process Paper Maslow's Needs and |Assessment: Subjective Data |Nursing Diagnosis |Outcome Criteria/Goals |Nursing Interventions/ Nursing Orders|Rationale plus |Evaluation/ | |Rationale for Need |and Objective Data (Designate|(Include the related to |(Needs to be |(Individualize to patient/family) |Reference |Actual Outcome | | |Which) |reason) |measureable) | | | | | | | | | |Gulanick p. 109 and Olds’ textbook, p. 935| | | |1. baby is swaddled but not|Risk for ineffective |Baby will maitain an |1. Within the next 20 minutes |1. Heat loss tends to be greatest from the|Outcome met. | |Baby need. |wearing hat. (o) |thermo-regulation and |a xillary temperature of |procure and apply a covering for |top of the head. |Baby’s temperature | | | |cold stress related to |36. 4 – 37. degrees |baby’s head, and explain rationale to| |remained within | |Maslow need: |2. baby has not had her |extremes of age |Celsius during my shift. |parents for doing so. |2. One of the physical principles of heat |normal range during | |Physiological |first bath yet and needs one |(infant). | | |loss effects is evaporation: skin cools as|my stay and | | |on my shift. (o) | | |2. keep baby dry and covered as much |a result of water evaporation. Monitoring |throughout bath and | |Rationale: | | | |as possible during bath. Take |before and after bath will allow me to |assessments. | |This is a basic need |3. baby will be partially | | |axillary temp before and after bath. |react as needed if baby gets too cold. | | |for survival. If baby|exposed during her bath and | | | | | | |gets too cold, her |later during my infant | | |3. Use a radiant heater above |3. Another physical principles of heat | | |body’s effort to |assessments (o) | | |isolette during all procedures that |loss effects is radiation: loss of warmth | | |return to homeostasis | | | |involve uncovering baby. |to cooler surrounding air. | | |takes precedence over |4. baby is in the isolette | | | | | | |everything else. |in an open part of the room | | |4. Encourage mother to hold baby skin|4. Mother’s body temperature helps | | | |(potential for draft). (o) | | |to skin when nursing and to otherwise|regulate baby’s body temperature. | | | | | | |cuddle baby when awake during her |Additionally, skin to skin contact | | | | | | |stay at the hospital. |facilitates bonding as an added benefit. | |