Nursing Dx

Taxonomy II: Role Relationships—Class 3 Role Performance (00105)
[Diagnostic Division: Food/Fluid]
Submitted 1992
Definition: Break in the continuity of the breastfeeding process as a result of inability or inadvisability to put baby to breast for feeding

Related Factors
Maternal or infant illness
Prematurity
Maternal employment
Contraindications to breastfeeding (e.g., drugs, true breast milk jaundice)
Need to abruptly wean infant

Defining Characteristics
SUBJECTIVE
Infant does not receive nourishment at the breast for some or all of feedings
Maternal desire to maintain lactation and provide (or eventually provide) her breast milk for her infant’s nutritional needs
Lack of knowledge regarding expression and storage of breast milk
OBJECTIVE
Separation of mother and infant

Desired Outcomes/Evaluation
Criteria—Client Will:
• Identify and demonstrate techniques to sustain lactation until breastfeeding is reinitiated.
• Achieve mutually satisfactory feeding regimen with infant content after feedings and gaining weight appropriately.
• Achieve weaning and cessation of lactation if desired or necessary.

Actions/Interventions
NURSING PRIORITY NO. 1. To identify causative/contributing factors:
• Assess client knowledge and perceptions about breastfeeding and extent of instruction that has been given.
• Encourage discussion of current/previous breastfeeding experience(s).
• Determine maternal responsibilities, routines, and scheduled activities (e.g., caretaking of siblings, employment in/out of home, work/school schedules of family members, ability to visit hospitalized infant).
• Note contraindications to breastfeeding (e.g., maternal illness, drug use); desire/need to wean infant.
• Ascertain cultural expectations/conflicts.

NURSING PRIORITY NO. 2. To assist mother to maintain or conclude breastfeeding as desired/required:
• Give emotional support to mother and accept decision regarding cessation/continuation of breastfeeding.
• Demonstrate use of manual and/or electric piston-type breast pump.
• Suggest abstinence/restriction of tobacco, caffeine, alcohol, drugs, excess sugar as appropriate when breastfeeding is reinitiated because they may affect milk production/let-down reflex or be passed on to the infant.
• Provide information (e.g., wearing a snug, well-fitting brassiere, avoiding stimulation, and using medication for discomfort to support weaning process).
NURSING PRIORITY NO. 3. To promote successful infant feeding:
• Review techniques for storage/use of expressed breast milk to provide optimal nutrition and promote continuation of breastfeeding process.
• Discuss proper use and choice of supplemental nutrition and alternate feeding method (e.g., bottle/syringe).
• Review safety precautions (e.g., proper flow of formula from nipple, frequency of burping, holding bottle instead of propping, formula preparation, and sterilization techniques).
• Determine if a routine visiting schedule or advance warning can be provided so that infant will be hungry/ready to feed.
• Provide privacy, calm surroundings when mother breastfeeds in hospital setting.
• Recommend/provide for infant sucking on a regular basis, especially if gavage feedings are part of the therapeutic regimen. Reinforces that feeding time is pleasurable and enhances digestion.
NURSING PRIORITY NO. 4. To promote wellness (Teaching/ Discharge Considerations):
• Encourage mother to obtain adequate rest, maintain fluid and nutritional intake, and schedule breast pumping every 3 hours while awake as indicated to sustain adequate milk production and breastfeeding process.
• Identify other means of nurturing/strengthening infant attachment (e.g., comforting, consoling, play activities).
• Refer to support groups (e.g., La Leche League, Lact-Aid), community resources (e.g., public health nurse, lactation specialist).
• Promote use of bibliotherapy for further information.

Documentation Focus
ASSESSMENT/REASSESSMENT
• Baseline findings maternal/infant factors.
• Number of wet diapers daily/periodic weight.
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.

IMPLEMENTATION/EVALUATION
• Maternal response to interventions/teaching and actions performed.
• Infant’s response to feeding and method.
• Whether infant appears satisfied or still seems to be hungry.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Plan for follow-up and who is responsible.
• Specific referrals made.