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.

201
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 – ineffective breathing pattern

Inspiration and/or expiration that does not provide adequate ventilation
DEFINING CHARACTERISTICS
• Accessory muscle use
• Abnormal heart rate response to activity
• Altered respiratory rate or depth or both
• Assumption of 3-point position
• Decreased minute ventilation
• Decreased vital capacity
• Decreased tidal volume
• Dyspnea
• Nasal flaring
• Prolonged expiratory phase
• Pursed lip breathing
RELATED FACTORS
• INEFFECTIVE BREATHING PATTERN
• Anxiety
• Body position
• Chest wall deformity
• Musculoskeletal impairment
• Obesity
• Pain
• Respiratory muscle fatigue
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Activity/exercise
• Cardiac function
• Neurologic and mental status
• Respiratory function
EXPECTED OUTCOMES
The patient will
• Maintain respiratory rate within 5 of baseline.
• Regain arterial blood gases to baseline.
• Express feelings of comfort when breathing.
• Demonstrate diaphragmatic pursed-lipped breathing.
• Achieve maximal lung expansion with adequate ventilation.
• Maintain heart rate, rhythm, and blood pressure within expected
range during periods of activity.
• Demonstrate skill in conserving energy while carrying out ADLs.
SUGGESTED NOC OUTCOMES
Mechanical Ventilation Response: Adult; Respiratory Status: Airway
Patency; Respiratory Status: Gas Exchange; ADLs
INTERVENTIONS AND RATIONALES
Determine: Monitor and record respiratory rate and depth at least
every 4 hr to detect early stages of respiratory failure. Auscultate
breath sounds at least every 4 hr to detect decreased or adventitious
breath sounds. Report changes.
Perform: Administer oxygen, as ordered, to maintain an acceptable
level of oxygen at the tissue level.
Suction airway as needed to maintain patent airways.
Assist patient to Fowler’s position, which will promote expansion
of lungs and provide comfort. Support upper extremities with
pillows, providing a table and cover it with a pillow to lean on.
Turn and reposition patient at least every 2 hr. Establish a turning
schedule for the dependent patient. Post schedule at bedside and
monitor frequency. Turning and repositioning prevent skin
breakdown and improve lung expansion and prevent atelectasis.
Assist patient with ADLs as needed to conserve energy and avoid
overexertion.
Encourage active exercise: Provide a trapeze or other assistive device
whenever possible. Such devices simplify moving and turning for many
patients and allow them to strengthen some upper body muscles.
Inform: Teach patient the following measures to promote participation
in maintaining health status and improve ventilation: pursed lip
breathing, abdominal breathing, and relaxation techniques (deep
breathing, meditation, guided imagery), taking prescribed
medications (ensuring accuracy and frequency and monitoring side
effects); and scheduling of activities to allow for rest periods.
Teach caregivers to assist patient with ADLs in a way that maximizes
patient’s potential. This enables caregivers to participate in
patient’s care and encourages them to support patient’s independence.
Attend: Provide emotional support and encouragement to improve
patient’s self-concept and motivate patient to perform ADLs.
Involve patient in planning and decision making. Having the ability to
participate will encourage greater compliance with the plan for activity.
Have patient perform self-care activities. Begin slowly and increase
daily, as tolerated. Performing self-care activities will assist patient
to regain independence and enhance self-esteem.
Schedule activities to allow for periods of rest.
Manage: Refer to case manager/social worker to ensure that a home
assessment has been done and that whatever modifications were
needed to accommodate the patient’s level of mobility have been
made. Making adjustments in the home will allow the patient a
greater degree of independence in performing ADLs, allowing better
conservation of energy.
Refer patient for evaluation of exercise potential and development
of individualized exercise program. Gradual increase in exercise will
promote conditioning and ease breathing.
SUGGESTED NIC INTERVENTIONS
Airway Management; Anxiety Reduction; Oxygen therapy; Progressive
Muscle Relaxation; Respiratory Monitoring
Reference
Booker, R. (2005, January). Chronic obstructive pulmonary disease: Nonpharmacological
approaches. British Journal of Nursing, 14(1), 14–18.