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Assessment Diagnosis Inference Planning Intervention Rationale Evaluation

The patient presented with acute pain and inflammation in her right breast, making breastfeeding difficult. A diagnosis of mastitis was made based on the patient's symptoms and clinical findings. The plan included short term interventions like warm compresses, breast massage, proper latching techniques and pain medication to reduce inflammation and pain. Long term goals were for the patient to resume breastfeeding effectively within a week without signs of mastitis. Outcomes were evaluated through repeated pain assessments and resolution of symptoms.

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Clarissa Juvida
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117 views2 pages

Assessment Diagnosis Inference Planning Intervention Rationale Evaluation

The patient presented with acute pain and inflammation in her right breast, making breastfeeding difficult. A diagnosis of mastitis was made based on the patient's symptoms and clinical findings. The plan included short term interventions like warm compresses, breast massage, proper latching techniques and pain medication to reduce inflammation and pain. Long term goals were for the patient to resume breastfeeding effectively within a week without signs of mastitis. Outcomes were evaluated through repeated pain assessments and resolution of symptoms.

Uploaded by

Clarissa Juvida
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute pain Scientific Short term: Independent: Independent: Goal met:
related to Basis:
-“I hurt too inflammation Mastitis is -After 3 days - Assess the patient’s - To explore the Short term:
much to of breast inflammation of vital signs. Ask the patient mother’s
breastfeed any tissue as of the breast intervention to rate the pain from 0 to knowledge and After 3 days span of
longer. How evidence by tissue. It is the patient 10, and describe the pain personal feelings care the patient
can I be a good patient mainly will report he/she is experiencing. on her current was able to:
mother if I don’t reporting caused by decrease in situation. This can
breastfeed my pain in right plugged pain also enable the nurse - Report decreased
baby?” breast. ducts or milk to establish in pain. With pain
verbalized by stasis from - Verbalize rapport with the scale of 2/10.
the patient breastfeeding understandin mother.
. It is very g related to - Verbalized
-Patient wants rare a non- proper - Observe the mother - To assess any understanding
to stop her breastfeeding latching. when breastfeeding the latching problems related to proper
breastfeeding woman can infant. and provide realistic latching.
because of experience -Report solutions.
mastitis but it increased -Report increased
Objective: does happen. ability of ability of newborn’s
However, for newborn’s - Apply warm compress on - To reduce latching ability.
this nursing latching the inflammation, relieve
-Right breast care plan we ability. affected breast. Advise the pain and provide
reddened and are going to mother to do this every 2 comfort to the mother.
edematous, concentrate to 4 this can also help to
tender and warm on the Long term: hours. Breast massage empty the milk ducts Long term:
to touch. Slight lactating while gently while After 1 week of
fissure noted on mother who -After 1 week breastfeeding can also breastfeeding. nursing
right nipple. may of help. intervention the
experience intervention patient was able to
Mastitis the patient - Ask the mother to be free from signs
- To promote optimal
during will be able to reposition and symptoms of
patient comfort and
-V/S Taken: lactation. be free of herself in a more Mastitis and
reduce
comfortable resume
T:101.1° F signs and position. Encourage anxiety/restlessness. breastfeeding with
(38.4° C) symptoms of pursed lip effective emptying
PR: 90bpm Mastitis and breathing and deep of the breast.
BP: 96/50, resume breathing
breastfeeding exercises.
with effective
emptying of Dependent:
the breast. Dependent:
- Administer analgesics
and anti inflammatory - To provide pain
medications as relief to the patient.
prescribed

- Ask the patient to re-


rate her acute pain 30
minutes to an hour after - To assess the
administering the effectiveness of
analgesic. treatment.

Collaborative:
Collaborative:
- Make referrals to
neonatal nutritionists - It will prevent
and lactation specialists problems of
if necessary. malnutrition if there
is suspected
ineffective
breastfeeding.

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