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Nursing Diagnosis: Ineffective Breastfeeding Application of NANDA, NOC, NIC


Nursing Diagnosis: Ineffective Breastfeeding
Vicki E. McClurg and Virginia R. Wall

NANDA Definition: Dissatisfaction or difficulty a mother, infant, or child experiences with the breastfeeding process

Defining Characteristics: Unsatisfactory breastfeeding process; nonsustained suckling at the breast; resisting latching on; unresponsive to comfort measures; persistence of sore nipples beyond first week of breastfeeding; observable signs of inadequate infant intake; insufficient emptying of each breast per feeding; infant inability to latch on to maternal breast correctly; infant arching and crying at the breast; infant exhibiting fussiness and crying within the first hour after breastfeeding; actual or perceived inadequate milk supply; no observable signs of oxytocin release; insufficient opportunity for suckling at the breast

Related Factors: Nonsupportive partner/family; previous breast surgery; infant receiving supplemental feedings with artificial nipple; prematurity; previous history of breastfeeding failure; poor infant sucking reflex; maternal breast anomaly; maternal anxiety or ambivalence; interruption in breastfeeding; infant anomaly; knowledge deficit


NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
·         Breastfeeding Establishment: Infant
·         Breastfeeding Establishment: Maternal
·         Breastfeeding Maintenance
·         Breastfeeding Weaning
·         Knowledge: Breastfeeding
Client Outcomes
·         Achieves effective breastfeeding
·         Verbalizes/demonstrates techniques to manage breastfeeding problems
·         Infant manifests signs of adequate intake at the breast
·         Mother manifests positive self-esteem in relation to the infant feeding process
·         Mother explains a safe alternative method of infant feeding if unable to continue exclusive breastfeeding
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
·         Breastfeeding Assistance
Nursing Interventions and Rationales
·         Refer to care plan for Effective Breastfeeding
·         Assess for presence/absence of related factors or conditions that would preclude breastfeeding. Some conditions (e.g. certain maternal drugs, maternal HIV-positive status, infant galactosemia) may preclude breastfeeding, in which case the infant needs to be started on a safe alternative method of feeding (Riordan, Auerbach, 2000; Lawrence, 2000).
·         Assess breast and nipple structure. Normal nipple and breast structure or early detection and treatment of abnormalities with continuing support are important for successful breastfeeding (Vogel, Hutchison, Mitchell, 1999).
·         Evaluate and record the mother's ability to position, give cues, and help the infant latch on. Correct positioning and getting the infant to latch on is critical for getting breastfeeding off to a good start and contributes to breastfeeding success (Duffy, Percival, Kershaw, 1997; Brandt, Andrews, Kvale, 1998).
·         Evaluate and record the infant's ability to properly grasp and compress the areola with lips, tongue, and jaw. The infant must have a "competent suck" in order to achieve successful breastfeeding. The jaws must compress the milk sinuses beneath the areola. To do this the jaws must be well back on the areola with the tongue over the lower gum, forming a trough around the breast, and the lips must be flanged and sealed around the breast (Palmer, VandenBerg, 1998; Lau, Hurst, 1999; Hill, Kurkowski, Garcia, 2000).
·         Evaluate and record the infant's suckling and swallowing pattern at the breast. When the infant sucks adequately, there is muscular movement visible above the ears. When breast milk is actively flowing, infants suck at a rate of once per second, and swallowing increases as milk supply increases (Palmer, VandenBerg, 1998; Lau, Hurst, 1999; Hill, Kurkowski, Garcia, 2000).
·         Evaluate and record signs of oxytocin release. The let-down reflex (tingling sensation in the breasts, milk dripping from the breasts, and uterine cramping) is indication of oxytocin release and is necessary for transfer of milk to the infant (Uvnas-Moberg, Eriksson., 1996; Nissen et al, 1998; Neville, 1999).
·         Evaluate and record infant's state at the time of feeding. Infants breastfeed best when in the quiet-alert state. Difficulties arise when trying to breastfeed a sleepy infant or a ravenously hungry and crying infant (Brandt, Andrews, Kvale, 1998).
·         Assess knowledge regarding psychophysiology of lactation and specific treatment measures for underlying problems. Support and teaching must be individualized to the client's level of understanding. The mother must acquire knowledge and become cognitively and emotionally ready (Cox, Turnbull, 1998).
·         Assess psychosocial factors that may contribute to ineffective breastfeeding (e.g., anxiety, goals and values/lifestyle that contribute to ambivalence about breastfeeding). The attitude of the mother toward breastfeeding is critical in achieving successful lactation, influencing milk production, and facilitating the art of breastfeeding (Brandt, Andrews, Kvale, 1998).
·         Assess support person network. Social support is an important factor in successful breastfeeding (Trado, Hughes, 1996; Arlotti et al, 1998).
·         Promote comfort and relaxation to reduce pain and anxiety. Discomfort associated with breastfeeding can cause some women to discontinue breastfeeding prematurely. Promoting comfort and relaxation can lead to more successful breastfeeding (Lavergne, 1997).
·         Provide support by actively helping the mother to correctly position the baby to attain a good latch on the nipple and encouraging her to continue trying. Many problems that can lead to discontinuing breastfeeding can be prevented by giving a high level of practical and emotional support to the mother (Janken et al, 1999).
·         Bring infant to a quiet-alert state through alerting techniques (e.g., provide variety in auditory, visual, and kinesthetic stimuli by unwrapping the infant, placing the infant upright, or talking to the infant) or consoling techniques as needed. A variety of stimuli can bring the infant to a quiet-alert state. Repetition can soothe a crying baby, thus making it easier to initiate breastfeeding (Brandt, Andrews, Kvale, 1998).
·         Enhance the flow of milk. Teach the mother to massage breast or burp infant and switch to other breast when infant's swallowing slows down. The perception of inadequate milk supply can lead to early weaning. Infants should breastfeed from both breasts at each feeding. Breast massage can enhance the flow of milk and stimulate production (Riordan, Auerbach, 2000).
·         Evaluate adequacy of infant intake. Infant intake can be measured by objective criteria such as number and quality of feedings, infant elimination and weight gain appropriate for age, as well as test-weights when necessary (Meier et al, 2000)
·         Discourage supplemental bottle feedings and encourage exclusive, effective breastfeeding. Supplemental feedings can interfere with the infant's desire to breastfeed, increase the risk of allergies, and convey the subtle message that the mother's breast milk is not adequate (American Academy of Pediatrics, 1997; Chezem, Friesenl, 1998).
·         Acknowledge mother's feelings and support her decision to continue or choose an alternate plan. Mastering infant feeding is an important first step in mothering, and the mother needs to be empowered so that she feels competent and capable of making intelligent decisions (Brandt, Andrews, Kvale, 1998; Mozingo et al, 2000).
·         Make appropriate referrals and ensure close follow-up. Collaborative practice with neonatal nutritionists, physical or occupational therapist, home visiting nurses, or lactation specialists will help ensure feeding and parenting success (American Academy of Pediatrics, 1997; Pugh, Milligan, 1998; Locklin, Jansson, 1999).
·         If unsuccessful in achieving effective breastfeeding, help client accept and learn an alternate method of infant feeding. Once the decision has been made to provide an alternate method of infant feeding, the mother needs support and education (Brandt, Andrews, Kvale, 1998; Mozingo et al, 2000).


Multicultural
·         Assess for the influence of cultural beliefs, norms, and values on breastfeeding attitudes. The client's knowledge of breastfeeding may be based on cultural perceptions, as well as influences from the larger social context (Leininger, 1996).
·         Assess whether the client's concerns about the amount of milk taken during breastfeeding is contributing to dissatisfaction with the breastfeeding process. Some cultures may add semisolid food within the first month of life as a result of concerns that the infant is not getting enough to eat and the perception that "big is healthy" (Higgins, 2000; Bentley et al, 1999).
·         Assess the influence of family support on the decision to continue or discontinue breastfeeding. Women are the keepers and transmitters of culture in families. Female family members can play a dominant role in how infants are fed (Pillitteri, 1999).
·         Validate the client's feelings regarding the difficulty or dissatisfaction with breastfeeding. Validation lets the client know that the nurse has heard and understands what was said and promotes the nurse-client relationship (Stuart, Laraia, 2001; Giger, Davidhizer, 1991).
Client/Family Teaching
·         Provide instruction in correct positioning. "Correct positioning is perhaps the most critical single measure for getting breastfeeding off to a good start. Many problems can be attributed to carelessness or inattention to this simple aspect of breastfeeding" (Righard, 1998).
·         Reinforce and add to knowledge base regarding underlying problems and specific treatment measures. If mother understands rationale for recommended treatment, she may be more likely to comply with recommendations and less likely to perceive the problem as insurmountable (Cox, Turnbull, 1998; Susin et al, 1999).
·         Provide education to support persons as needed. Informational support providers help the mother achieve a more positive outcome (Trado, Hughes, 1996; Tarkka, Paunonen, Laippala, 1999; Zimmerman 1999).


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