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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