ineffective Breastfeeding
Taxonomy II: Role Relationships—Class 3 Role Performance (00104)
[Diagnostic Division: Food/Fluid]
Submitted 1988
Definition: Dissatisfaction or difficulty that a mother, infant, or child experiences with the breastfeeding process
Related Factors
Prematurity; infant anomaly; poor infant sucking reflex
Infant receiving [numerous or repeated] supplemental feedings with artificial nipple
Maternal anxiety or ambivalence
Knowledge deficit
Previous history of breastfeeding failure
Interruption in breastfeeding
Nonsupportive partner/family
Maternal breast anomaly; previous breast surgery; [painful nipples/breast engorgement]
Defining Characteristics
SUBJECTIVE
Unsatisfactory breastfeeding process
Persistence of sore nipples beyond the first week of breastfeeding
Insufficient emptying of each breast per feeding
Actual or perceived inadequate milk supply
OBJECTIVE
Observable signs of inadequate infant intake [decrease in number of wet diapers, inappropriate weight loss/or inadequate gain]
Nonsustained or insufficient opportunity for suckling at the breast; infant inability [failure] to attach onto maternal breast correctly
Infant arching and crying at the breast; resistant latching on
Infant exhibiting fussiness and crying within the first hour after breastfeeding; unresponsive to other comfort measures
No observable signs of oxytocin release
Desired Outcomes/Evaluation
Criteria—Client Will:
• Verbalize understanding of causative/contributing factors.
• Demonstrate techniques to improve/enhance breastfeeding.
• Assume responsibility for effective breastfeeding.
• Achieve mutually satisfactory breastfeeding regimen with infant content after feedings and gaining weight appropriately.
Actions/Interventions
NURSING PRIORITY NO. 1. To identify maternal causative/ contributing factors:
• Assess client knowledge about breastfeeding and extent of instruction that has been given.
• Encourage discussion of current/previous breastfeeding experience(s).
• Note previous unsatisfactory experience (including self or others) because it may be affecting current situation.
• Do physical assessment, noting appearance of breasts/ nipples, marked asymmetry of breasts, obvious inverted or flat nipples, minimal or no breast enlargement during pregnancy.
• Determine whether lactation failure is primary (i.e., maternal prolactin deficiency/serum prolactin levels, inadequate mammary gland tissue, breast surgery that has damaged the nipple, areola enervation-irremediable) or secondary (i.e., sore nipples, severe engorgement, plugged milk ducts, mastitis, inhibition of let-down reflex, maternal/infant separation with disruption of feedings-treatable).
• Note history of pregnancy, labor and delivery (vaginal or cesarean section), other recent or current surgery; preexisting medical problems (e.g., diabetes, epilepsy, cardiac diseases, or presence of disabilities).
• Identify maternal support systems; presence and response of SO(s), extended family, friends.
• Ascertain mother’s age, number of children at home, and need to return to work.
• Determine maternal feelings (e.g., fear/anxiety, ambivalence, depression).
• Ascertain cultural expectations/conflicts.
NURSING PRIORITY NO. 2. To assess infant causative/contributing factors:
• Determine suckling problems, as noted in Related Factors/ Defining Characteristics.
• Note prematurity and/or infant anomaly (e.g., cleft palate).
• Review feeding schedule, to note increased demand for feeding (at least 8 times/day, taking both breasts at each feeding for more than 15 minutes on each side) or use of supplements with artificial nipple.
• Evaluate observable signs of inadequate infant intake (e.g., baby latches onto mother’s nipples with sustained suckling but minimal audible swallowing/gulping noted, infant arching and crying at the breasts with resistance to latching on, decreased urinary output/frequency of stools, inadequate
weight gain).
• Determine whether baby is content after feeding, or exhibits fussiness and crying within the first hour after breastfeeding, suggesting unsatisfactory breastfeeding process.
• Note any correlation between maternal ingestion of certain foods and “colicky” response of infant.
NURSING PRIORITY NO. 3. To assist mother to develop skills of adequate breastfeeding:
• Give emotional support to mother. Use 1:1 instruction with each feeding during hospital stay/clinic/home visit.
• Inform mother that some babies do not cry when they are hungry; instead some make “rooting” motions and suck their fingers.
• Recommend avoidance or overuse of supplemental feedings and pacifiers (unless specifically indicated) that can lessen infant’s desire to breastfeed.
• Restrict use of breast shields (i.e., only temporarily to help draw the nipple out), then place baby directly on nipple.
• Demonstrate use of electric piston-type breast pump with bilateral collection chamber when necessary to maintain or increase milk supply.
• Encourage frequent rest periods, sharing household/childcare duties to limit fatigue and facilitate relaxation at feeding times.
• Suggest abstinence/restriction of tobacco, caffeine, alcohol, drugs, excess sugar because they may affect milk production/ let-down reflex or be passed on to the infant.
• Promote early management of breastfeeding problems. For example:
Engorgement: Heat and/or cool applications to the breasts, massage from chest wall down to nipple; use synthetic oxytocin nasal spray to enhance let-down reflex; soothe “fussy baby” before latching on the breast, properly position baby on breast/nipple, alternate the side baby starts nursing on, nurse round-the-clock and/or pump with piston-type electric breast pump with bilateral collection chambers at least 8 to 12 times/day.
Sore nipples:Wear 100% cotton fabrics, do not use soap/alcohol/ drying agents on nipples, avoid use of nipple shields or nursing pads that contain plastic; cleanse and then air dry, use thin layers of lanolin (if mother/baby not sensitive to wool); provide exposure to sunlight/sunlamps with extreme caution;
administer mild pain reliever as appropriate, apply ice before nursing; soak with warm water before attaching infant to soften nipple and remove dried milk, begin with least sore side or begin with hand expression to establish let-down reflex, properly position infant on breast/nipple, and use a variety of nursing positions.
Clogged ducts: Use larger bra or extender to avoid pressure on site; use moist or dry heat, gently massage from above plug down to nipple; nurse infant, hand express, or pump after massage; nurse more often on affected side.
Inhibited let-down: Use relaxation techniques before nursing (e.g., maintain quiet atmosphere, assume position of comfort, massage, apply heat to breasts, have beverage available); develop a routine for nursing, concentrate on infant; administer synthetic oxytocin nasal spray as appropriate.
Mastitis: Promote bedrest (with infant) for several days; administer antibiotics; provide warm, moist heat before and during nursing; empty breasts completely, continuing to nurse baby at least 8 to 12 times/day, or pumping breasts for 24 hours; then resuming breastfeeding as appropriate.
NURSING PRIORITY NO. 4. To condition infant to breastfeed:
• Scent breast pad with breast milk and leave in bed with infant along with mother’s photograph when separated from mother for medical purposes (e.g., prematurity).
• Increase skin-to-skin contact.
• Provide practice times at breast.
• Express small amounts of milk into baby’s mouth.
• Have mother pump breast after feeding to enhance milk production.
• Use supplemental nutrition system cautiously when necessary.
• Identify special interventions for feeding in presence of cleft lip/palate.
NURSING PRIORITY NO. 5. To promote wellness (Teaching/ Discharge Considerations):
• Schedule follow-up visit with healthcare provider 48 hours after hospital discharge and 2 weeks after birth for evaluation of milk intake/breastfeeding process.
• Recommend monitoring number of infant’s wet diapers (at least 6 wet diapers in 24 hours suggests adequate hydration).
• Weigh infant at least every third day as indicated and record (to verify adequacy of nutritional intake).
• Encourage spouse education and support when appropriate. Review mother’s need for rest, relaxation, and time with other children as appropriate.
• Discuss importance of adequate nutrition/fluid intake, prenatal vitamins, or other vitamin/mineral supplements, such as vitamin C, as indicated.
• Address specific problems (e.g., suckling problems, prematurity/ anomalies).
• Inform mother that return of menses within first 3 months after infant’s birth may indicate inadequate prolactin levels.
• Refer to support groups (e.g., La Leche League, parenting support groups, stress reduction, or other community resources as indicated).
• Provide bibliotherapy for further information.
Documentation Focus
ASSESSMENT/REASSESSMENT
• Identified assessment factors, both maternal and infant (e.g., is engorgement present, is infant demonstrating adequate weight gain without supplementation).
PLANNING
• Plan of care/interventions and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Mother’s/infant’s responses to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Referrals that have been made and mother’s choice of participation.
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effective Breastfeeding [Learning Need]*
*This nursing diagnosis is difficult to address, as the Related Factors and Defining Characteristics are in fact the outcome/evaluation criteria that would be desired.We believe that normal breastfeeding behaviors need to be learned and supported, with interventions directed at learning activities for enhancement.
Taxonomy II: Role Relationships—Class 3 Role Performance (00106)
[Diagnostic Division: Food/Fluid]
Submitted 1990
Definition: Mother-infant dyad/family exhibits adequate proficiency and satisfaction with breastfeeding process
Related Factors
Basic breastfeeding knowledge
Normal breast structure
Normal infant oral structure
Infant gestational age greater than 34 weeks
Support sources [available]
Maternal confidence
Defining Characteristics
SUBJECTIVE
Maternal verbalization of satisfaction with the breastfeeding process
OBJECTIVE
Mother able to position infant at breast to promote a successful latch-on response
Infant is content after feedings
Regular and sustained suckling/swallowing at the breast [e.g., 8 to 10 times/24 h]
Appropriate infant weight patterns for age
Effective mother/infant communication pattern (infant cues, maternal interpretation and response)
Signs and/or symptoms of oxytocin release (let-down or milk ejection reflex)
Adequate infant elimination patterns for age; [stools soft; more than 6 wet diapers/day of unconcentrated urine]
Eagerness of infant to nurse
Desired Outcomes/Evaluation
Criteria—Client Will:
• Verbalize understanding of breastfeeding techniques.
• Demonstrate effective techniques for breastfeeding.
• Demonstrate family involvement and support.
• Attend classes/read appropriate materials as necessary.
Actions/Interventions
NURSING PRIORITY NO. 1. To assess individual learning needs:
• Assess mother’s knowledge and previous experience with breastfeeding.
• Monitor effectiveness of current breastfeeding efforts.
• Determine support systems available to mother/family.
NURSING PRIORITY NO. 2. To promote effective breastfeeding behaviors:
• Initiate breastfeeding within first hour after birth.
• Demonstrate how to support and position infant.
• Observe mother’s return demonstration.
• Keep infant with mother for unrestricted breastfeeding duration and frequency.
• Encourage mother to drink at least 2000 mL of fluid per day or 8 oz every hour.
• Provide information as needed.
NURSING PRIORITY NO. 3. To promote wellness (Teaching/ Discharge Considerations):
• Provide for follow-up contact/home visit 48 hours after discharge; repeat visit as necessary to provide support and assist with problem-solving, if needed.
• Recommend monitoring number of infant’s wet diapers (at least 6 wet diapers in 24 hours suggests adequate hydration).
• Encourage mother/other family members to express feelings/ concerns, and Active-listen to determine nature of concerns.
• Review techniques for expression and storage of breast milk to help sustain breastfeeding activity.
• Problem-solve return-to-work issues or periodic infant care requiring bottle feeding.
• Refer to support groups, such as La Leche League, as indicated.
• Refer to ND Breastfeeding, ineffective for more specific information as appropriate.
Documentation Focus
ASSESSMENT/REASSESSMENT
• Identified assessment factors (maternal and infant).
• Number of daily wet diapers and periodic weight.
PLANNING
• Plan of care/interventions and who is involved in the planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Mother’s response to actions/teaching plan and actions performed.
• Effectiveness of infant’s efforts to feed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-term needs/referrals and who is responsible for followup actions.
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