Nursing diagnosis – READINESS FOR ENHANCED ORGANIZED INFANT BEHAVIOR

READINESS  FOR  ENHANCED  ORGANIZED

INFANT  BEHAVIOR

DEFINITION

A pattern of modulation of the physiologic and behavioral systems

of functioning (such as autonomic, motor, state-organizational, self-

regulatory, and attentional–interactional systems) in an infant that is

satisfactory but that can be improved

DEFINING CHARACTERISTICS

• Use of some self-regulatory behaviors

• Definite sleep–wake states

• Responsiveness to visual and auditory stimuli

• Stable physiologic measures

RELATED FACTORS

• Pain

• Immaturity

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Elimination

• Role/relationships

• Neurocognition

• Sensation/perception

• Nutrition

• Sleep/rest

• Physical regulation

EXPECTED OUTCOMES

The parents will

• Express understanding of their role in infant’s behavioral develop-

ment.

• Express confidence in their ability to interpret infant’s behavioral

cues.

• Identify means to promote infant’s behavioral development.

• Express positive feelings about their ability to care for infant.

• Identify resources for help with infant.

The infant will

• Maintain physiologic stability.

• Maintain an organized motor system.

• Respond to information in an adaptive way.

SUGGESTED NOC OUTCOMES

Knowledge: Child Development: 1, 2, 4, 6, and 12 Months; Infant

Care; Neurological Status; Sleep

INTERVENTIONS AND RATIONALES

Determine: Monitor infant’s responses to ensure effectiveness of

preventive measures.

Perform: Demonstrate appropriate ways of interacting with the

infant, such as moderate stimulation, gentle rocking, and quiet

vocalizations, to help the parents identify the most effective methods

of interacting with their child.

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Inform: Explain to parents that infant maturation is a developmental

process. Further explain that infants exhibit three behavioral states:

sleeping, crying, and being awake and alert. Also explain that

infants provide behavioral cues that indicate their needs. Education

will help parents understand the importance of nurturing the infant

and prepare them to respond to the infant’s behavioral cues.

Explain to parents that their actions can help promote infant

development. Make it clear, however, that infant maturation isn’t

completely within their control. Explanation may decrease feelings

of anxiety and incompetence and help prevent unrealistic

expectations.

Help parents interpret behavioral cues from their infant to foster

healthy parent–child interaction. For example, help them recognize

when the infant is awake and alert, and point out to them that this

is a good time to provide stimulation.

Help parents identify ways they can promote the infant’s develop-

ment, such as providing stimulation by shaking a rattle in front of

the infant, talking to the infant in a gentle voice, and looking at the

infant when feeding him. This encourages practices that promote the

infant’s development. Sensory experiences promote cognitive devel-

opment.

Attend: Explore with parents ways to cope with stress caused by the

infant’s behavior to increase their coping skills.

Praise parents for their attempts to enhance their interaction with

the infant to provide positive reinforcement.

Manage: Provide parents with information on sources of support

and special infant services to encourage them to continue to foster

their infant’s development.

SUGGESTED NIC INTERVENTIONS

Attachment Promotion; Developmental Care; Environmental

Management: Attachment Process; Family Integrity Promotion:

Childbearing Family; Infant Care; Sleep Enhancement

Reference

Byers, J. F., et al. (2006, January–February). A quasi-experimental trial on

individualized, developmentally supportive family-centered care. Journal of
Obstetric, Gynecologic, and Neonatal Nursing, 35(1), 105–115.

Nursing diagnosis – RISK FOR DISORGANIZED INFANT BEHAVIOR

RISK FOR DISORGANIZED INFANT BEHAVIOR

DEFINITION

Risk for alteration in integration and modulation of the physiologi-

cal and behavioral systems of functioning (such as autonomic,

motor, state-organizational, self-regulatory, and attentional–interac-

tional systems)

RISK FACTORS

• Environmental overstimulation

• Oral or motor problems

• Invasive or painful procedures

• Pain

• Lack of containment or

• Prematurity

boundaries

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Elimination

• Role/relationships

• Neurocognition

• Sensation/perception

• Nutrition

• Sleep/rest

• Physical regulation

EXPECTED OUTCOMES

The parents will

• Identify factors that place infant at risk for behavioral disturbance.

• Identify potential signs of behavioral disturbance in infant.

• Identify appropriate ways to interact with infant.

• Identify their reactions to infant (including ways of coping with

occasional frustration and anger).

• Express positive feelings about their ability to care for infant.

• Identify resources for help with infant.

The infant will

• Maintain physiologic stability.

• Maintain an organized motor system.

• Respond to sensory information in an adaptive way.

SUGGESTED NOC OUTCOMES

Knowledge: Child Development: 1 Month, 2 Months, 4 Months,

6 Months, and 12 Months; Infant Care; Neurological Status;

Knowledge: Parent–Infant Attachment; Parenting; Preterm Infant

Organization; Sleep

INTERVENTIONS AND RATIONALES

Determine: Monitor infant’s responses to ensure effectiveness of pre-

ventive measures.

Perform: Demonstrate appropriate ways of interacting with the

infant to help parents identify and interpret the infant’s behavioral

cues and respond appropriately. For example, help them recognize

when the infant is awake and alert, and help them understand

when the infant needs more stimulation, such as being spoken to

or held.

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Inform: Explain to parents that infant maturation is a developmental

process and that their participation is crucial to their understanding

of the importance of nurturing the infant. Participation in the

process by the parents will both stimulate the developmental process

and alert to delays in development.

Explain to parents that their actions can help modify some of

their infant’s behavior; however, make it clear that infant maturation

isn’t completely within their control. This explanation may decrease

the parent’s feelings of incompetence.

Explain to parents that certain risk factors may interfere with the

infant’s ability to achieve optimal development. These risk factors

include overstimulation, lack of stimulation, lack of physical contact,

and painful medical procedures. Educating the parents will help

them understand their role in interpreting the infant’s behavioral

cues and providing appropriate stimulation.

Describe for the parents the potential signs of a behavioral distur-

bance in the infant: inappropriate responses to stimuli, such as the

failure to respond to human contact or tendency to become agitated

with human contact; physiologic regulatory problems, such as a

breathing disturbance in a premature infant; and apparent inability

to interact with the environment. Education will help the parents

recognize if the infant has a problem in behavioral development.

Attend: Explore with parents ways to cope with the stress imposed

by the infant’s behavior to increase their coping skills. Help parents

identify their emotional responses to the infant’s behavior to help

them recognize and adjust their response patterns. Explain that it is

normal for parents to experience feelings of inadequacy, frustration,

or anger if the infant does not respond positively to them.

Praise the parents when they demonstrate appropriate methods of

interacting with the infant to provide positive reinforcement.

Manage: Provide the parents with information on sources of support

and special infant services to help them cope with the infant’s long-

term needs.

SUGGESTED NIC INTERVENTIONS

Attachment Process, Infant Care; Newborn Monitoring; Parent

Education: Infant; Positioning; Surveillance

Reference

Swartz, M. K. (2005, March–April). Parenting preterm infants: A meta-

synthesis. The American Journal of Maternal Child Nursing, 30(2),
115–120.

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.

Nursing diagnosis – risk prone health behavior

Risk prone health behavior
DEFINITION
Impaired ability to modify lifestyle/behaviors in a manner consistent
with a change in health status
DEFINING CHARACTERISTICS
• Demonstration of nonacceptance of health status to achieve optimal
sense of control
• Failure to take action to prevent future health problems
• Denial of health status change
• RISK-PRONE HEALTH BEHAVIOR
RELATED FACTORS
• Inadequate comprehension
• Inadequate social support
• Low self-efficacy
• Multiple stressors
• Negative attitude toward healthcare
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Behavior
• Communication
• Coping
EXPECTED OUTCOMES
The patient will
• Identify inability to cope and will adjust adequately.
• Express understanding of the illness or disease.
• Participate in healthcare regimen including planning activities.
• Demonstrate ability to manage health problems.
• Help perform self-care activities.
• Show ability to accept and adapt to a new health status and integrate
learning.
• Demonstrate new coping abilities.
SUGGESTED NOC OUTCOMES
Acceptance: Health Status; Adaptation to Physical Disability; Coping;
Health Seeking Behavior; Participation in Healthcare Decisions;
Psychosocial Adjustment: Life Change; Social Support; Treatment
Behavior: Illness
INTERVENTIONS AND RATIONALES
Determine: Assess patient’s present understanding of health status
and treatment to form the basis for any further planning. Assess
feelings about present health status. Do this in a safe, nonthreatening
environment to allow the patient to gain insight into and rationally
define fears, goals, and potential problems. Monitor patient
involvement in care-related activities.
Perform: Make changes in the environment that will encourage
healthy behavior.
• Knowledge
• Self-perception
Inform: Teach patient and caregiver the skills necessary to manage
care adequately. Teaching will encourage compliance and adjustment
to optimum wellness.
Teach patient how to find areas in which it is possible to maintain
control to avoid feelings of powerlessness and allow the patient to
feel like a member of the team’s effort to assist him or her.
Teach caregivers to assist patient with self-care activities 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 by listening
to the patient’s feelings. This will reassure the patient that you care.
Allow patient to grieve. Grieving is a normal and essential aspect
of any kind of negative change in health status. After working
through denial and isolation, anger, bargaining, and depression, the
patient will progress toward acceptance.
Provide reassurance that the patient’s feelings, under the circumstances,
are normal. By realizing that it is acceptable to grieve, the
patient will be willing to look for positive ways of coping.
Involve patient in planning and decision making. Having the ability
to participate will encourage greater compliance with the plan
for activity.
Discuss health problems with family members to encourage participation
in the patient’s care.
Manage: Refer to a mental health specialist if patient develops severe
depression or other psychiatric problem. Although trauma or illness
commonly causes some depression or other psychiatric disorders,
consultation with a mental health professional may help minimize it.
Arrange for an individual who has the same problem to meet
with the patient. This exposes the patient to suitable role models
and may encourage a supportive relationship to evolve.
SUGGESTED NIC INTERVENTIONS
Anxiety Reduction; Behavior Modification; Coping; Enhancement;
Counseling; Decision-Making Support; Mutual Goal-Setting; Role
Enhancement; Support System Enhancement
Reference
Telford, K., et al. (2006, August). Acceptance and denial: Implications for
people adapting to chronic illness: Literature review. Journal of Advanced
Nursing, 55(4), 457–464.