Concept Map

Issue/Problem: Issue/Problem:

Disturbed sleeping patterns for infant. Maternal knowledge deficient for care
of infant.

Neonate with Neonatal Abstinence Syndrome (NAS)

Medical Diagnosis/Reason for Seeking Healthcare

Issue/Problem: Issue/Problem:

Inadequate bonding between infant Ineffective infant feedings.

and mother.
 Nursing Process
Supporting data (subjective and objective): Infant sleeps less than one hour after feedings.
When awake, infant is irritable, jittery, restless, and produces a prolonged high pitch cy immediately
after waking. Infant is easily startled and becomes agitated upon receiving care.

Nursing Diagnosis (NANDA)/related to/as evidenced by: Disturbed Sleep Pattern r/t
overstimulation from own activity and care environment AEB sleeping less than one hour
after feedings, prolonged high-pitch cry, irritability, exaggerated Moro reflex, and agitation
when awake.
Short-Term Goals: Long-Term Goals:
1. The infant will sleep for periods of 2 hours 1. The infant will sleep for periods of 4 hours or
or more after feedings within 3 days. more 6 months after birth.
2. The infant will decrease crying by at least 1 2. The infant will not exhibit signs of withdrawal
hour a day within the first week after birth. such as high-pitched cry, jitteriness, or agitation 6
months after birth.

Priority Nursing Interventions with Rationale

1. The infants care is organized so that the infant is not disturbed while sleeping or when it is otherwise unnecessary.
Rationale: it is difficult for drug-exposed infants to return back to sleep after being woken (McKinney, 2018).
2. The infant will be placed in the quietest corner of the nursery with a sign placed close by reminding staff and visitors the
importance of having the area quiet as possible. Rationale: Noise and activity can easily overstimulate drug-exposed
infants (McKinney, 2018).
3. The infant’s crib will have a blanket partially covering it to decrease light exposure and the lights in the nursery will be
kept as low as possible. Rationale: Darker environments decrease visual stimuli and promotes a more restful area for
adequate sleep (McKinney, 2018).
4. During feeding and sleep, the infant will be kept in a flexed position while also being swaddled. Rationale: The drug-
exposed infant can become startled, awakened, and agitated by its own movements (McKinney, 2018).
5. The infant’s hands will be positioned near its mouth and a pacifier may also be used. Rationale: Sucking on hands
and/or pacifier can allow the infant to self-comfort and have a calming effect on the infant (McKinney, 2018).
6. All activity will be stopped if the infant displays any signs of increased stress. Rationale: Stopping the activity when signs
of stress begin to manifest in the infant allows the infant to rest before becoming overstimulated (McKinney, 2018).
7. The mother will be encouraged and assisted with holding and feeding the infant. Rationale: The mother’s participation
in care helps her bond with her infant and gain comfort in providing care (McKinney, 2018).
8. The common behaviors in drug-exposed infants and the routine care of the newborn will be explained and
demonstrated to the mother. Rationale: Explanation of the infants’ behaviors can help reassure the mother when
providing care. The mother needs to learn these concepts to ensure adequate care of newborn after discharge
(McKinney, 2018).
9. The mother will be taught that some withdrawal behaviors can last up to 6 months and using sources of support from
family and local support groups is highly encouraged. Rationale: Ongoing support will be important for mothers with
addiction problems and support for her infant will help her care more effectively for her new infant (McKinney, 2018).

Evaluation of Goals: Evaluation of Goals:

Short-Term Goals: Long-Term Goals:

1. The infant slept for longer than 2 consecutive hours
after each feeding and obtained goal within 3 days.
The current goal and interventions will be
continued.
2. The infant decreased crying by 1.5 hours a day
within the first week after birth. The current goal
and interventions will be continued.
1. At 6-month checkup, the caregiver reports the infant has
been sleeping throughout the night without wakening. The
goal has been met and interventions will continue.
2. At 12-month checkup, the caregiver reports the infant has not
exhibited signs of withdrawal for the past 6 months. The goal
has been met and interventions will continue.