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Nursing Diagnosis: Impaired Parenting Application of NANDA, NOC, NIC


Nursing Diagnosis: Impaired Parenting
Peggy A. Wetsch and Mary Markle


NANDA Definition: Inability of the primary caretaker to create, maintain, or regain an environment that promotes the optimum growth and development of the child

Defining Characteristics:
Infant/child
Poor academic performance; frequent illness; runaway; incidence of physical and psychological trauma or abuse; frequent accidents; lack of attachment; failure to thrive; behavioral disorders; poor social competence; lack of separation anxiety; poor cognitive development
Parental
Inappropriate child care arrangements; rejection of or hostility to child; statements of inability to meet child's needs; inflexibility in meeting needs of child or situation; poor or inappropriate caretaking skills; regularly punitive; inconsistent care; child abuse; inadequate child health maintenance; unsafe home environment; verbalization of inability to control child; negative statements about child; verbalization of role inadequacy or frustration; inappropriate visual, tactile, auditory stimulation; abandonment; insecure or lack of attachment to infant; inconsistent behavior management; child neglect; little cuddling; maternal-child interaction deficit; poor parent-child interaction

Related Factors:
Social
Lack of access to resources; social isolation; lack of resources; poor home environment; lack of family cohesiveness; inadequate child care arrangements; lack of transportation; unemployment or job problems; role strain or overload; marital conflict, declining satisfaction; lack of value of parenthood; change in family unit; low socioeconomic class; unplanned or unwanted pregnancy; presence of stress (e.g., financial, legal, recent crisis, cultural move); lack of or poor parental role model; single parent; lack of social support network; father of child not involved; history of being abusive; history of being abused; financial difficulties; maladaptive coping strategies; poverty; poor problem-solving skills; inability to put child's needs before own; low self-esteem; relocations; legal difficulties
Knowledge
Lack of knowledge about child health maintenance; lack of knowledge about parenting skills; unrealistic expectations for self, infant, partner; limited cognitive functioning; lack of knowledge about child development; inability to recognize and act on infant cues; low educational level or attainment; poor communication skills; lack of cognitive readiness for parenthood; preference for physical punishment
Physiological
Physical illness
Infant/child
Premature birth; illness; prolonged separation from parent; not desired gender; attention deficit hyperactivity disorder; difficult temperament; separation from parent at birth; lack of goodness of fit (temperament) with parental expectations; unplanned or unwanted child; handicapping condition or developmental delay; multiple births; altered perceptual abilities
Psychological
History of substance abuse or dependencies; disability; depression; difficult labor and/or delivery; young age, especially adolescent; history of mental illness; high number of or closely spaced pregnancies; sleep derivation or disruption; lack of or late prenatal care; separation from infant/child
NOTE: It is important to reaffirm that adjustment to parenting in general is a normal maturational process that elicits nursing behaviors to prevent potential problems and to promote health.
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
·         Child Development: 2 Months
·         4 Months
·         6 Months
·         2 Years
·         3 Years
·         4 Years
·         5 Years
·         Middle Childhood (6 - 11 Years)
·         Adolescence (12 - 17 Years)
·         Parent-Infant Attachment
·         Parenting
·         Parenting: Social Safety
·         Role Performance
·         Safety Behavior: Home Physical Environment
·         Social Support

Client Outcomes
·         Affirms desire to develop constructive parenting skills to support infant/child growth and development
·         Initiates appropriate measures to develop a safe, nurturing environment
·         Acquires and displays attentive, supportive parenting behaviors
·         Identifies strategies to protect child from harm and/or neglect and initiates action when indicated

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
·         Abuse Protection: Child
·         Attachment Promotion
·         Developmental Enhancement
·         Family Integrity Promotion
·         Parenting Promotion

Nursing Interventions and Rationales
·         Use active listening to explore parent's understanding of developmental needs and expectations of child and self within the context of cultural perspectives and influences. Interviewing with empathy while reserving judgment allows parent to more freely express frustrations and disappointments regarding negative feelings, needs, and parenting skills. Unrealistic expectations may be present when parent does not discern what is normal for the child (Denehy, 1992; Herman-Staab, 1994; Mrazek, Mrazek, Klinnert, 1995).
·         Examine characteristics of parenting style and behaviors, including the following:
o Emotional climate at home
o Attribution of negative traits to child
o Failure to support child's increases in autonomy
o Type of interaction with infant/child
o Competition with child for spousal/significant other attention
o Lack of knowledge/concern about health maintenance or behavioral problems
o Other behaviors or concerns
Children are at risk for neglect, abuse, and other negative psychosocial outcomes in families with dysfunctions (Mrazek, Mrazek, Klinnert, 1995).
·         Institute abuse/neglect protection measures if evidence of inability to cope with family stressors or crisis, signs of parental substance abuse, or significant level of social isolation apparent. Risk of abuse/neglect is higher in families with high levels of stress, substance abuse, or lack of social support systems (Devlin, Reynolds, 1994).
·         For mothers with toddlers, assess maternal depression, perceptions of difficult temperament in toddler, and low maternal self-efficacy. Self-efficacy is defined as one's judgment of how effectively one can execute a task or manage a situation that may contain novel, unpredictable, and stressful elements. A cyclic relationship among depression, perceived difficult temperament, and self-efficacy has been identified. Negative feelings about oneself and one's child are likely to negatively influence the parent-child relationship (Gross et al, 1994).
·         Appraise parent's resources and availability of social support systems. Determine single mother's particular sources of support, especially availability of her own mother and partner. Encourage use of healthy, strong support systems. Before adequate interventions and education can be initiated, understanding of the current support system and concerns must occur. The mother's partner and her mother are often important sources of support (Zacharia, 1994).
·         Model age- and cognitively appropriate caregiver skills by doing the following:
o    Communicating with child at an appropriate cognitive level of development
o    Giving child tasks and responsibilities appropriate to age or functional age/level
o    Instituting safety considerations such as assistive equipment
o    Encouraging child to perform activities of daily living (ADLs) as appropriate
These activities illustrate parenting and child-rearing skills and behaviors for parents and family (McCloskey, Bulechek, 1992).

Multicultural
·         Assess for the influence of cultural beliefs, norms, and values on the client's perception of parenting. What the client considers normal parenting may be based on cultural perceptions (Leininger, 1996).
·         Acknowledge racial/ethnic differences at the onset of care. Acknowledgement of racial/ethnicity issues will enhance communication, establish rapport, and promote treatment outcomes (D'Avanzo et al, 2001).
·         Approach individuals of color with respect, warmth, and professional courtesy. Instances of disrespect have special significance for individuals of color (D'Avanzo et al, 2001).
·         Give rationale when assessing black individuals about sensitive issues. Blacks may expect white caregivers to hold negative and preconceived ideas about them. Giving rationale for questions will help alleviate this perception (D'Avanzo et al, 2001).
·         Acknowledge that value conflicts from acculturation stresses may contribute to increased anxiety and significant conflict with children. Challenges to traditional beliefs and values are anxiety provoking (Charron, 1998). Less acculturated parents may experience conflict with their more acculturated children as the children demand greater independence and freedom (True, 1995).
·         Use a neutral, indirect style when addressing areas where improvement is needed (such as a need for verbal stimulation) when working with Native American clients. Using indirect statements such as "Other mothers have tried..." or "I had a client who tried 'X' and it seemed to work very well" will help to avoid resentment from the parent (Seiderman et al, 1996).
·         Acknowledge and praise parenting strengths noted. This will increase trust and foster a working relationship with the parent (Seiderman et al, 1996).
·         Validate the client's feelings regarding parenting. Validation lets the client know that the nurse has heard and understands what was said, and it promotes the nurse-client relationship (Stuart, Laraia, 2001; Giger, Davidhizer, 1995).
·         Facilitate modeling and role-playing to help family improve parenting skills. It is helpful for families and the client to practice parenting skills in a safe environment before trying them in real-life situations (Rivera-Andino, Lopez, 2000).

Client/Family Teaching
·         Explain individual differences in child temperaments and compare and contrast with reality of parents' expectations. Help parents determine and understand the implications of their child's temperament. Promoting parental understanding of temperament facilitates development of more realistic expectations (McClowry, 1992; Melvin, 1995).
·         Discuss sound disciplinary techniques, which include catching children being good, active listening, conveying positive regard, ignoring minor transgressions, giving good directions, use of praise, and use of time-out. Disciplinary methods are subject to a variety of opinions. Proper discipline provides children with security, and clearly enforced rules help them learn self-control and social standards. Parenting classes can be beneficial when parent has had little formal or informal preparation (Herman-Staab, 1994).
·         Foster acquisition of positive parenting skills. Parents may feel powerless. Helping them develop necessary skills or gain knowledge maintains the integrity of the parental role, and parents are then unlikely to use maladaptive coping styles (Baker, 1994).
·         Plan parental education directed toward the following age-related parental concerns:
o    Birth to 2 years   Transition, sleep, aggression
o    3 to 5 years   Transition, parent-child relationship, sleep
o    6 to 10 years   School, parent-child relationship, divorce
o    11 to 18 years   Parent-child relationship, divorce, school
Parents with children of any age may seek basic information about a variety of concerns, which can be anticipated and addressed by providing ongoing information and support (Jones, Maestri, McCoy, 1993).
·         Initiate referrals to community agencies, parent education opportunities, stress management training, and social support groups. The parent needs support to manage angry or inappropriate behaviors. Use of support systems and social services can provide an opportunity to decrease feelings of inadequacy (Campbell, 1992; Baker, 1994).
·         Provide information regarding available telephone counseling services. Telephone counseling services can provide confidential advice and support to families who might not otherwise have access to help in dealing with behavioral problems and parenting concerns (Jones, Maestri, McCoy, 1993).
·         Refer to care plan for Delayed Growth and development for additional teaching interventions.

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