Nursing Diagnosis: Application to Clinical Practice
11th Edition

Risk for Impaired Parent-Infant Attachment
DEFINITION
Risk for Impaired Parent-Infant Attachment: State in which there is a risk for a disruption of a nurturing, protective, interactive process between a parent/primary caregiver and infant
RISK FACTORS
Refer to Related Factors.
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RELATED FACTORS
Pathophysiologic
Related to interruption of attachment process secondary to:
  • Parental illness
  • Infant illness
Treatment-Related
Related to barriers to attachment secondary to:
  • Lack of privacy
  • Equipment
  • Intensive care monitoring
  • Restricted visitors
  • Structured “visitation”
Situational (Personal, Environmental)
Related to unrealistic expectations (eg, of child, of self)
Related to unplanned pregnancy
Related to disappointment with infant (eg gender, appearance)
Related to life event stressors associated with new baby and other responsibilities secondary to:
  • Health issues
  • Relationship difficulties
  • Substance abuse
  • Economic difficulties
  • Mental illness
Related to lack of knowledge and/or available role model for parental role
Related to physical disabilities of parent (eg, blindness, paralysis, deafness)
Related to being emotionally unprepared due to premature delivery of infant
Maturational
Adolescent
Related to difficulty delaying own gratification for the gratification of the infant
Focus Assessment Criteria
Refer to Impaired Parenting for assessment of attachment behaviors.
Goal
The parent will demonstrate increased attachment behaviors, such as holding infant close, smiling and talking to infant, and seeking eye contact with infant.
Indicators
  • Be supported in his or her need to be involved in infant’s care.
  • Begin to verbalize positive feelings regarding infant.
General Interventions
Assess Causative or Contributing Factors
Maternal
Unwanted pregnancy
Prolonged or difficult labor and delivery
Postpartum pain or fatigue
Lack of positive support system (mother, spouse, friends)
Lack of positive role model (mother, relative, neighbor)
Inability to prepare emotionally for an unexpected delivery
Inadequate Coping Patterns (One or Both Parents)
Alcoholic
Drug addict
Marital difficulties (separation, divorce, violence)
Change in lifestyle related to new role
Adolescent parent
Career change (eg, working woman to mother)
Illness in family
Infant
Premature, defective, ill
Multiple birth
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Eliminate or Reduce Contributing Factors, if Possible
Illness, Pain, Fatigue
Establish with mother what infant care activities are feasible.
Provide mother with uninterrupted sleep periods of at least 2 h during the day and 4 h at night.
Provide relief for discomforts.
  • Episiotomy
    • Evaluate degree of pain.
    • Assess for hematomas and abscesses.
    • Provide with comfort measures (ice, warm compresses, analgesics*).
  • Hemorrhoids
    • Prevent and treat constipation.
    • Provide comfort measures (compresses with witch hazel, suppositories,* analgesics*).
  • Breast engorgement of nursing mother
    • Encourage woman to nurse as frequently as possible.
    • Apply warm compresses (shower) before nursing.
    • Apply cold compresses after nursing.
    • Try hand massage, hand expressing, or breast pump between nursing.
    • Offer mild analgesics.
  • Breast engorgement of non-nursing mother
    • Offer analgesics as ordered.
    • Apply ice packs.
    • Encourage use of a good supporting brassiere that covers the entire breast.
Lack of Experience or Positive Mothering Role Model
Explore with mother her feelings and attitudes concerning her own mother.
Assist her to identify someone who is a positive mother; encourage her to seek that person’s aid.
Outline the teaching program available during hospitalization.
Determine who will assist her at home initially.
Identify community programs and reference material that can increase her learning about child care after discharge (see References/Bibliography).
Lack of Positive Support System
Identify parent’s support system; assess its strengths and weaknesses.
Assess the need for counseling.
Encourage parents to express feelings about the experience and about the future.
Be an active listener to the parents.
Observe the parents interacting with the infant.
Assess for resources (financial, emotional) already available to the family.
Be aware of resources available both within the hospital and in the community.
Counsel the parents on assessed needs.
Refer to hospital or community services.
Barriers to Practicing Cultural Beliefs That May Affect the Family Unit During Hospitalization
Support mother-infant-family beliefs.
Integrate culture and traditions into routine care.
Identify community resources.
Elimination of Institutional Barriers That Inhibit Individualizing of Care
Sensitize staff to practicing family-centered care.
Use families to review practice and policies.
Encourage cultural sensitization of staff.
Provide Opportunities for the Process of Mutual Interaction
Promote Bonding in the Immediate Postdelivery Phase
Encourage mother to hold infant after birth (may need a short recovery period).
Provide skin-to-skin contact if desired; keep room warm (72°F to 76°F) or use a heat panel over the infant.
Provide mother with an opportunity to breast-feed immediately after delivery, if desired.
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Delay administration of silver nitrate to allow for eye contact.
Give family as much time as they need together with minimum interruption from staff (the “sensitive period” lasts from 30 to 90 min).
Encourage father to hold infant.
Facilitate the Attachment Process During the Postpartum Phase
Check mother regularly for signs of fatigue, especially if she had anesthesia.
Offer flexible rooming-in to the mother; establish with her the care she will assume initially and support her requests for assistance.
Discuss future involvement of the father in the infant’s care (if desired, plan opportunities for father to participate in his child’s care during visits).
Provide Support to the Parents
Listen to the mother’s replay of her labor and delivery experience.
Allow for verbalization of feelings.
Indicate acceptance of feelings.
Point out the infant’s strengths and individual characteristics to the parents.
Demonstrate the infant’s responses to the parents.
Have a system of follow-up after discharge, especially for families considered at risk (eg, phone call or a home visit by the community health nurse).
Be aware of resources and support groups available within the hospital and community; refer the family as needed.
Assess the Need to Support the Parents’ Emerging Confidence in Child Care
Observe the parents interacting with the infant.
Support each parent’s strengths.
Assist each parent in those areas in which he or she is uncomfortable (role modeling).
Have handouts and audiovisual aids available for parents to view at odd hours.
Assess for level of knowledge in growth and development; provide information as needed.
Help parents understand infant’s cues and temperament.
See References/Bibliography for recommended printed material on parenting and child care.
When Immediate Separation of the Child from the Parents is Necessary Because of Prematurity or Illness, Provide for Bonding/Attachment Experiences, as Possible
Invite parents to see and touch infant as soon as possible.
Encourage parents to spend prolonged time with infant.
Support activities such as skin-to-skin holding, containment of infant with parental hands in the isolette, and basic caregiving activities.
If infant is transported to another facility and separated from mother:
  • Have staff make frequent calls to mother.
  • Encourage family to spend time in NICU; bring back verbal reports and pictures of infant.
  • Explore family and community resources to provide means of rejoining mother and infant as soon as possible.
For Adoptive Parents:
Counsel adoptive parents that many emotions are normal on first interaction with their children.
Counsel adoptive parents about the possibility of postadoption depression.
Encourage adoptive parents to seek parenting classes before receiving their infant.
Initiate Referrals, as Needed
Consult with community agencies for follow-up visits if indicated.
Refer parents to pertinent organizations (see References/Bibliography).
Rationales
  • Research indicates that there is a “sensitive period” during the newborn’s first minutes and hours of life during which the child is beautifully equipped to meet and interact with the parents. Close contact at this time and in the days to follow is most beneficial to the bonding process (Klaus & Kennell, 1976).
  • The period from birth to 3 days is important for the father-child relationship.
  • Seeing, touching, and caring for the infant promotes attachment (Klaus & Kennell, 1976).
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  • When caring for families of high-risk newborns, nurses can foster attachment and reduce anxiety by letting parents know through frequent communication that they are welcome partners in their child’s care.
  • In a longitudinal study of the interaction between 49 premature infants and their mothers, Zahr (1991) found that maternal rating of the infant’s temperament and availability of support system were the most significant variables that correlated with a positive mother-infant interaction at 4 and 8 months postpartum.
  • Parents are reluctant to form attachments to a sick infant because of their fear of loss. This reluctance creates tremendous guilt.
  • Parents must be given the opportunity for grief work in the case of an ill or impaired infant before attachment can begin.
  • The use of birthing rooms enhances the bonding process because of the decrease in interruptions.
  • In a research study of 24 first-time adoptive mothers, Koepke, Anglin, Austin, and Delesalle (1991) found that adoptive mothers began developing affectional ties to their babies at much the same time and in as individual a way as birth mothers. Adoptive mothers may be as susceptible as birth mothers to periods of sadness and maternal depression.
Footnote
*May require a primary care professional’s order.