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.

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