Nursing diagnosis – INEFFECTIVE INFANT FEEDING PATTERN

INEFFECTIVE  INFANT  FEEDING  PATTERN

DEFINITION

Impaired ability of an infant to suck or coordinate the suck/swallow

response resulting in inadequate oral nutrition for metabolic needs

DEFINING CHARACTERISTICS

• Inability to coordinate sucking, swallowing, and breathing

• Inability to initiate or sustain effective suck

RELATED FACTORS

• Anatomic abnormality

• Oral hypersensitivity

• Neurological delay or impair-

• Prematurity

ment

• Prolonged NPO status

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Fluid and electrolytes

• Nutrition

• Growth and development

• Roles/relationships

EXPECTED OUTCOMES

The neonate will

• Not lose more than 10% of birth weight within first week of life.

• Gain 4–7 oz (113.5–198.5 g) after first week of life.

• Remain hydrated.

• Receive adequate supplemental nutrition until able to suckle suffi-

ciently.

• Establish effective suck-and-swallow reflexes that allow for

adequate intake of nutrients.

The parents will

• Identify factors that interfere with neonate establishing effective

feeding pattern.

• Express increased confidence in their ability to perform appropri-

ate feeding techniques.

SUGGESTED NOC OUTCOMES

Breast-Feeding Establishment: Infant; Breast-Feeding Maintenance;

Muscle Function; Nutritional Status: Food & Fluid Intake;

Swallowing Status

INTERVENTIONS AND RATIONALES

Determine: Weigh neonate at the same time each day on the same

scale to detect excessive weight loss early.

Continuously assess neonate’s sucking pattern to monitor for inef-

fective patterns.

Assess parents’ knowledge of feeding techniques to help identify

and clear up misconceptions.

Assess parents’ level of anxiety about the neonate’s feeding diffi-

culty. Anxiety may interfere with the parents’ ability to learn new

techniques.

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Monitor neonate for poor skin turgor, dry mucous membranes,

decreased or concentrated urine, and sunken fontanels and eyeballs

to detect possible dehydration and allow for immediate intervention.

Record the number of stools and amount of urine voided each

shift. An altered bowel elimination pattern may indicate decreased

food intake; decreased amounts of concentrated urine may indicate

dehydration.

Assess the need for gavage feeding. The neonate may temporarily

require alternative means of obtaining adequate fluids and calories.

If neonate requires intravenous nourishment, assess the insertion

site, amount infused, and infusion rate every hour to monitor fluid

intake and identify possible complications, such as infiltration and

phlebitis.

Perform: Remain with the parents and neonate during the feeding to

identify problem areas and direct interventions.

For bottle-feeding, record the amount ingested at each feeding; for

breast-feeding, record the number of minutes the neonate nurses at

each breast and the amount of any supplement ingested to monitor

for inadequate caloric and fluid intake.

Provide an alternative nipple, such as a preemie nipple. A preemie

nipple has a larger hole and softer texture, which makes it easier for

the neonate to obtain formula.

For breast-feeding, ensure that the neonate’s tongue is properly

positioned under the mother’s nipple to promote adequate sucking.

Alternate oral and gavage feeding to conserve the neonate’s

energy.

Inform: Teach parents to place the neonate in the upright position

during feeding to prevent aspiration.

Teach parents to unwrap and position a sleepy neonate before

feeding to ensure that the neonate is awake and alert enough to

suckle sufficiently.

Attend: Provide positive reinforcement for the parents’ efforts to

improve their feeding technique to decrease anxiety and enhance

feelings of success.

Manage: Assess neonate for neurologic deficits or other pathophysio-

logic causes of ineffective sucking to identify the need for referral

for more extensive evaluation.

SUGGESTED NIC INTERVENTIONS

Attachment Promotion; Breast-Feeding Assistance; Lactation Coun-

seling; Nonnutritive Sucking

Reference

Kelly, M. M. (2006, September–October). Primary care issues for the healthy

premature infant. Journal of Pediatric Health Care, 20(5), 293–299.

Nursing diagnosis – READINESS FOR ENHANCED ORGANIZED INFANT BEHAVIOR

READINESS  FOR  ENHANCED  ORGANIZED

INFANT  BEHAVIOR

DEFINITION

A pattern of modulation of the physiologic and behavioral systems

of functioning (such as autonomic, motor, state-organizational, self-

regulatory, and attentional–interactional systems) in an infant that is

satisfactory but that can be improved

DEFINING CHARACTERISTICS

• Use of some self-regulatory behaviors

• Definite sleep–wake states

• Responsiveness to visual and auditory stimuli

• Stable physiologic measures

RELATED FACTORS

• Pain

• Immaturity

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Elimination

• Role/relationships

• Neurocognition

• Sensation/perception

• Nutrition

• Sleep/rest

• Physical regulation

EXPECTED OUTCOMES

The parents will

• Express understanding of their role in infant’s behavioral develop-

ment.

• Express confidence in their ability to interpret infant’s behavioral

cues.

• Identify means to promote infant’s behavioral development.

• Express positive feelings about their ability to care for infant.

• Identify resources for help with infant.

The infant will

• Maintain physiologic stability.

• Maintain an organized motor system.

• Respond to information in an adaptive way.

SUGGESTED NOC OUTCOMES

Knowledge: Child Development: 1, 2, 4, 6, and 12 Months; Infant

Care; Neurological Status; Sleep

INTERVENTIONS AND RATIONALES

Determine: Monitor infant’s responses to ensure effectiveness of

preventive measures.

Perform: Demonstrate appropriate ways of interacting with the

infant, such as moderate stimulation, gentle rocking, and quiet

vocalizations, to help the parents identify the most effective methods

of interacting with their child.

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Inform: Explain to parents that infant maturation is a developmental

process. Further explain that infants exhibit three behavioral states:

sleeping, crying, and being awake and alert. Also explain that

infants provide behavioral cues that indicate their needs. Education

will help parents understand the importance of nurturing the infant

and prepare them to respond to the infant’s behavioral cues.

Explain to parents that their actions can help promote infant

development. Make it clear, however, that infant maturation isn’t

completely within their control. Explanation may decrease feelings

of anxiety and incompetence and help prevent unrealistic

expectations.

Help parents interpret behavioral cues from their infant to foster

healthy parent–child interaction. For example, help them recognize

when the infant is awake and alert, and point out to them that this

is a good time to provide stimulation.

Help parents identify ways they can promote the infant’s develop-

ment, such as providing stimulation by shaking a rattle in front of

the infant, talking to the infant in a gentle voice, and looking at the

infant when feeding him. This encourages practices that promote the

infant’s development. Sensory experiences promote cognitive devel-

opment.

Attend: Explore with parents ways to cope with stress caused by the

infant’s behavior to increase their coping skills.

Praise parents for their attempts to enhance their interaction with

the infant to provide positive reinforcement.

Manage: Provide parents with information on sources of support

and special infant services to encourage them to continue to foster

their infant’s development.

SUGGESTED NIC INTERVENTIONS

Attachment Promotion; Developmental Care; Environmental

Management: Attachment Process; Family Integrity Promotion:

Childbearing Family; Infant Care; Sleep Enhancement

Reference

Byers, J. F., et al. (2006, January–February). A quasi-experimental trial on

individualized, developmentally supportive family-centered care. Journal of
Obstetric, Gynecologic, and Neonatal Nursing, 35(1), 105–115.

Nursing diagnosis – RISK FOR DISORGANIZED INFANT BEHAVIOR

RISK FOR DISORGANIZED INFANT BEHAVIOR

DEFINITION

Risk for alteration in integration and modulation of the physiologi-

cal and behavioral systems of functioning (such as autonomic,

motor, state-organizational, self-regulatory, and attentional–interac-

tional systems)

RISK FACTORS

• Environmental overstimulation

• Oral or motor problems

• Invasive or painful procedures

• Pain

• Lack of containment or

• Prematurity

boundaries

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Elimination

• Role/relationships

• Neurocognition

• Sensation/perception

• Nutrition

• Sleep/rest

• Physical regulation

EXPECTED OUTCOMES

The parents will

• Identify factors that place infant at risk for behavioral disturbance.

• Identify potential signs of behavioral disturbance in infant.

• Identify appropriate ways to interact with infant.

• Identify their reactions to infant (including ways of coping with

occasional frustration and anger).

• Express positive feelings about their ability to care for infant.

• Identify resources for help with infant.

The infant will

• Maintain physiologic stability.

• Maintain an organized motor system.

• Respond to sensory information in an adaptive way.

SUGGESTED NOC OUTCOMES

Knowledge: Child Development: 1 Month, 2 Months, 4 Months,

6 Months, and 12 Months; Infant Care; Neurological Status;

Knowledge: Parent–Infant Attachment; Parenting; Preterm Infant

Organization; Sleep

INTERVENTIONS AND RATIONALES

Determine: Monitor infant’s responses to ensure effectiveness of pre-

ventive measures.

Perform: Demonstrate appropriate ways of interacting with the

infant to help parents identify and interpret the infant’s behavioral

cues and respond appropriately. For example, help them recognize

when the infant is awake and alert, and help them understand

when the infant needs more stimulation, such as being spoken to

or held.

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Inform: Explain to parents that infant maturation is a developmental

process and that their participation is crucial to their understanding

of the importance of nurturing the infant. Participation in the

process by the parents will both stimulate the developmental process

and alert to delays in development.

Explain to parents that their actions can help modify some of

their infant’s behavior; however, make it clear that infant maturation

isn’t completely within their control. This explanation may decrease

the parent’s feelings of incompetence.

Explain to parents that certain risk factors may interfere with the

infant’s ability to achieve optimal development. These risk factors

include overstimulation, lack of stimulation, lack of physical contact,

and painful medical procedures. Educating the parents will help

them understand their role in interpreting the infant’s behavioral

cues and providing appropriate stimulation.

Describe for the parents the potential signs of a behavioral distur-

bance in the infant: inappropriate responses to stimuli, such as the

failure to respond to human contact or tendency to become agitated

with human contact; physiologic regulatory problems, such as a

breathing disturbance in a premature infant; and apparent inability

to interact with the environment. Education will help the parents

recognize if the infant has a problem in behavioral development.

Attend: Explore with parents ways to cope with the stress imposed

by the infant’s behavior to increase their coping skills. Help parents

identify their emotional responses to the infant’s behavior to help

them recognize and adjust their response patterns. Explain that it is

normal for parents to experience feelings of inadequacy, frustration,

or anger if the infant does not respond positively to them.

Praise the parents when they demonstrate appropriate methods of

interacting with the infant to provide positive reinforcement.

Manage: Provide the parents with information on sources of support

and special infant services to help them cope with the infant’s long-

term needs.

SUGGESTED NIC INTERVENTIONS

Attachment Process, Infant Care; Newborn Monitoring; Parent

Education: Infant; Positioning; Surveillance

Reference

Swartz, M. K. (2005, March–April). Parenting preterm infants: A meta-

synthesis. The American Journal of Maternal Child Nursing, 30(2),
115–120.

Nursing diagnosis – DISORGANIZED INFANT BEHAVIOR

DISORGANIZED  INFANT  BEHAVIOR

DEFINITION

Disintegrated physiological and neurobehavioral responses of infant

to the environment

DEFINING CHARACTERISTICS

• Attention–interaction system—abnormal response to sensory stimuli

(e.g., difficulty soothing, inability to sustain alert status)

• Motor-system—altered primitive reflexes; finger splaying; jittery,

uncoordinated movement; increased or decreased tone; startles,
tremors, or twitches

• Physiological—arrhythmias, bradycardia, or tachycardia; desatura-

tion; feeding intolerances; skin color changes

• Regulatory problems—inability to inhibit startle; irritability

• State-organizational system—active or quiet awake; diffuse sleep

RELATED FACTORS

• Caregiver—Cue knowledge

• Postnatal—feeding intolerance;

deficit; cue misreading; environ-
mental stimulation contribution

invasive procedures; malnutri-
tion; motor and/or oral prob-

• Environmental—physical envi-

lems; pain; prematurity

ronment inappropriateness;
sensory deprivation, inappro-
priateness, or overstimulation

• Prenatal—congenital or genetic
disorders; teratogenic exposure

• Individual—gestational or

postconceptual age; illness;
immature neurological system

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Elimination

• Role/relationships

• Neurocognition

• Sensation/perception

• Nutrition

• Sleep/rest

• Physical regulation

EXPECTED OUTCOMES

The parents will

• Learn to identify and understand infant’s behavioral cues.

• Identify their own emotional responses to infant’s behavior.

• Identify means to help infant overcome behavioral disturbance.

• Identify ways to improve their ability to cope with infant’s

responses.

• Express positive feelings about their ability to care for infant.

• Identify resources for help with infant.

The infant will

• Begin to show appropriate signs of maturation.

SUGGESTED NOC OUTCOMES

Knowledge: Infant Care; Mobility; Neonate; Neurological Status;

Preterm Infant Organization; Sleep Thermoregulation

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INTERVENTIONS AND RATIONALES

Determine: Monitor infant’s responses to ensure effectiveness of pre-

ventive measures

Inform: Explain to parents that infant maturation is a developmental

process. Their participation is crucial to help them understand the

importance of nurturing the infant.

Explain to parents that their actions can help modify some of

infant’s behavior; however, make it clear that infant maturation isn’t

completely within their control. This explanation may help decrease

the parents’ feelings of incompetence.

Explain to parents that infant gives behavioral cues that indicate

needs. Discuss appropriate ways to respond to behavioral cues—for

example, providing stimulation that doesn’t overwhelm the infant;

stopping stimulation when the infant gives behavioral cues (such as

yawning, looking away, or becoming agitated); and finding methods

to calm the infant if she becomes agitated (such as swaddling, gentle

rocking, and quiet vocalizations). Monitoring responses aids in gaug-

ing effectiveness of meeting needs.

Help parents identify and cope with their responses to infant’s

behavioral disturbance to help them recognize and adjust their

response patterns. When the infant doesn’t respond positively, the

parents may feel inadequate or become frustrated. They need to

understand that these reactions are normal.

Attend: Explore with parents ways to cope with stress imposed by

infant’s behavior to help them develop better coping skills.

Praise parents when they demonstrate appropriate methods of

interacting with the infant to provide positive reinforcement.

Manage: Provide parents with information on sources of support

and special infant services to promote coping with infant’s long-term

needs.

SUGGESTED NIC INTERVENTIONS

Environmental Management; Neurologic Monitoring; Newborn

Care; Parent Education: Infant; Positioning; Sleep Enhancement

Reference

Beal, J. A. (2005, November–December). Evidence for best practices in the

neonatal period. The American Journal of Maternal Child Nursing, 30(6),
397–403.

Nursing diagnosis – RISK FOR SUDDEN INFANT DEATH SYNDROME

RISK  FOR  SUDDEN  INFANT

DEATH  SYNDROME

DEFINITION

Presence of risk factors for an infant under 1 year of age

RISK FACTORS

Modifiable

• Consistent disorientation to

• Delayed prenatal care

environment

• Infant overheating

Partially Modifiable

• Infant over wrapping

• Low birth weight

• Infants placed to sleep in a

• Prematurity

prone position

• Young maternal age

• Infants placed to sleep in side-

Nonmodifiable

lying position

• Ethnicity

• Lack of prenatal care

• Male gender

• Postnatal infant smoke expo-

• Seasonality of sudden infant

sure

death syndrome (SIDS) (winter

• Prenatal infant smoke

and fall)

• Soft underlayment (loose arti-

• Infant age of 2–4 months

cles in the sleep environment)

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Sleep/rest

• Roles/responsibilities

• Values/beliefs

EXPECTED OUTCOMES

The parents will

• Be receptive to teaching and guidance.

• Verbalize understanding of risk factors and provide all precautions

possible to prevent disorder.

• Verbalize feelings of preparedness and ability to handle emergen-

cies utilizing CPR techniques and services.

• Exhibit appropriate coping skills in dealing with high-risk infant.

The infant will

• Sleep alone in a crib on a firm sleep surface.

• Maintain normal body temperature as indicated by apnea monitor

worn during sleep.

SUGGESTED NOC OUTCOMES

Knowledge Infant Care; Knowledge Parenting; Parent Performance;

Risk Control; Risk Detection

INTERVENTIONS AND RATIONALES

Determine: Assess prenatal history; maternal history; parental experi-

ence; monitor heart rate, blood pressure; respiratory rate, quality,

depth of respirations, breath sounds; reflexes, response to touch. The

assessment information will assist in identifying appropriate

interventions.

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Perform: Position infant on back when placed in the crib. Incidence

of SIDS is higher when infant is placed in a prone position.

Elevate infant’s head slightly when placed in the crib to decrease

abdominal pressure on diaphragm and allow better expansion of lungs.

Place infant on a firm sleep surface to prevent him or her from

sinking into the mattress cover or blanket.

Maintain room at appropriate temperature and avoid wrapping

the infant in heavy blankets. Excessive heat has been identified as a

possible risk factor.

Inform: Educate parents about risk factors of SIDS because modifica-

tion of current practices can reduce risk and prevent occurrence.

Instruct caregivers on ways to maintain a safe environment in the

home. Provide written information to caregivers on all important

aspects of the infant’s care.

Teach parents to avoid having loose blankets, toys, or other arti-

cles in the crib to decrease risk of accidental suffocation.

Encourage mother to breast-feed because there is a lower

incidence of SIDS in babies who are breast-fed.

Teach parents how to correctly apply leads and set alarms of the

apnea monitor. The benefit of the monitor can be achieved only if it

is used correctly.

Instruct parents in CPR to reduce anxiety and promote confidence

in performing correct technique. Allow time for return

demonstrations to prepare parents to cope with infant when he or

she returns home.

Attend: Encourage parents in their efforts to care for the infant. Pro-

vide suggestions for coping mechanisms to help reduce the anxieties

associated with caring for a high-risk infant. Be aware that parents

may be sensitive to your unspoken feelings about the situation.

Encourage parents to interact with other parents managing high-

risk infants well. Peer support may help to reduce fear in the parents.

Involve parents in planning and decision making for their infant.

Investment in decision making will promote compliance with the plan.

Manage: Refer to case manager/social worker/home health agency to

ensure that parents receive adequate support in caring for the infant.

Refer parents to support group if one is available.

SUGGESTED NIC INTERVENTIONS

Family Support; Infant Care; Risk Control

Reference

Thogmartin, J. R., et al. (2001).  Sleep position and bed-sharing in sudden

infant deaths and examination of autopsy findings. Journal of Pediatrics,
138(20), 212–217.