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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