- Imbalanced Nutrition less than Body Requirements Related to Inadequate knowledge of infant nutrient requirements and Insufficient breast milk production as evidenced by Inadequate head circumference growth for age and gender and Neonatal weight gain < 30 g (1 ounce) per day
- Ineffective Breastfeeding Related to Inadequate knowledge of breastfeeding techniques and Ineffective infant suck-swallow response as evidenced by Inability to latch on to breast correctly by the infant and Insufficient emptying of each breast during breastfeeding
- Insufficient Breast Milk Production related to Ineffective latching on to the breast and Insufficient opportunity for suckling at the breast as evidenced by Breast milk expressed is less than the prescribed volume for an infant and Infant frequently seeks to suckle at the breast
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: Verbalizes unable to breast feed the infant Objective data: -Hypoglycaemia Inadequate height increases for age and gender -Inadequate head circumference growth for age and gender -Lethargy -Pale mucous membranes -Poor stool or urine output | Imbalanced Nutrition less than Body Requirements Related to Inadequate knowledge of infant nutrient requirements and Insufficient breast milk production as evidenced by Inadequate head circumference growth for age and gender and Neonatal weight gain < 30 g (1 ounce) per day | The infant will progressively gain weight toward the desired goal with an average weight gain of 1 ounce per day. The infant will be free from any signs of malnutrition, such as poor weight gain, lethargy, and < 6 wet diapers per day. | 1. Encourage the mother to breastfeed more frequently. Newborn babies should breastfeed 8-12 times per day in the first month. With frequent breastfeeding, breast milk production is stimulated, which ensures adequate nutrition and breast milk intake. 2. Encourage the mother to eat healthy and well-balanced meals. Nutrients in the food and drinks that the mother consumes will pass to the infant via breast milk. When breastfeeding, mothers are encouraged to eat healthy foods like lean meats, whole grains, fruits, and vegetables and avoid sweets, caffeine, and salty foods. Remind the mother that she will need to consume 400-500 extra calories per day while breastfeeding. 3. Encourage the mother to limit caffeine intake while breastfeeding. Caffeine is found in drinks like tea, coffee, soda, and energy drinks. Too much caffeine in breast milk can make the breastfeeding infant fussier and have trouble sleeping. It is recommended that breastfeeding mothers drink no more than two cups of caffeine a day. 4. Encourage vitamins and supplements. Postnatal vitamins may be recommended while breastfeeding. DHA, vitamin D, iron, iodine, and vitamin B12 are necessary for both mom and baby. 5. Monitor the baby for any signs of malnutrition. Inadequate weight gain is the main indicator of poor infant nutrition. Refusal to feed, trouble sucking the breast, gagging/spitting up breast milk, irritability, fever, and lethargy are warning signs that can indicate a medical condition or make breastfeeding difficult. | Patient maintained weight in desired goal range. Patient recognized the factors that are contributing to being under or overweight. Patient identified appropriate nutritional needs/requirements. Patient consumed adequate nutrition. Patient verbalized the appropriate management of nutrition at home. |
| Subjective Data: Verbalizes unable to breast feed the infant Objective data: -Infant frequently crying -Infant constipation -Infant frequently seeks to suckle at the breast -Infant rejects breast -Inadequate infant weight gain -Unsustained suckling at the breast -Prolonged breastfeeding time | Ineffective Breastfeeding Related to Inadequate knowledge of breastfeeding techniques and Ineffective infant suck-swallow response as evidenced by Inability to latch on to breast correctly by the infant and Insufficient emptying of each breast during breastfeeding | The mother will achieve effective breastfeeding with adequate breast milk intake for the infant. The mother will efficiently demonstrate breastfeeding techniques and proper breastfeeding positioning and latching. | 1. Provide emotional support as needed and allow the patient to express her expectations. Nurses play a vital role in the establishment and continuation of breastfeeding. Expressing support and allowing the patient to voice concerns promotes understanding and will determine the most appropriate plan of care. 2. Encourage skin-to-skin contact immediately after delivery. Skin-to-skin holding promotes early breastfeeding initiation, improved milk supply, and breastfeeding duration. 3. Promote comfort and relaxation during breastfeeding. Discomfort can lead to poor let-down reflexes and premature discontinuation of breastfeeding. 4. Assist in proper breastfeeding positioning. Proper positioning can promote effective breastfeeding and reduce discomfort. Instruct the mother on multiple positions. 5. Refer the patient to lactation consultants. Lactation consultants are available inpatient as well as in the community to address ongoing breastfeeding issues after discharge. | The mother achieved effective breastfeeding with adequate breast milk intake for the infant. The mother efficiently demonstrated breastfeeding techniques and proper breastfeeding positioning and latching. |
| Subjective Data: Verbalizes she doesn’t produce milk and Baby is keep crying Objective data: -Delayed milk production -Infant frequently crying -Infant frequently seeks to suckle at the breast -Infant rejects breast -Inadequate infant weight gain | Insufficient Breast Milk Production related to Ineffective latching on to the breast and Insufficient opportunity for suckling at the breast As evidenced by Breast milk expressed is less than the prescribed volume for an infant and Infant frequently seeks to suckle at the breast | The mother will increase their daily caloric and fluid intake. The mother will increase breastfeeding frequency and duration while maintaining the correct breastfeeding position. The infant feeds for 5-10 minutes on each breast. | 1. Massage the breast. Massaging the breast prior to feeding can stimulate the nerves to increase oxytocin and milk production. 2. Breastfeed when the baby is hungry. This may be as often as 8-12 times a day in the beginning. Follow the baby’s cues and feed when they are hungry instead of trying to follow a schedule. 3. Pump in between feedings. Pumping in between nursing sessions or when away from the baby can help build the milk supply. 4. Provide strategies on how to increase milk supply. Offering and emptying both breasts during breastfeeding, drinking adequate fluids, and ensuring latch-on can help increase breast milk supply. | The mother increased her daily caloric and fluid intake. The mother increased breastfeeding frequency and duration while maintaining the correct breastfeeding position. The infant feeds for 5-10 minutes on each breast. |