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DISORGANIZED INFANT BEHAVIOR Nursing Care Plan

Disorganized Infant Behavior

NANDA-I Definition
Disintegrated physiologic and neuro-behavioral responses of infant
to the environment
Defining Characteristics**
Autonomic System
Cardiac
Increased rate
Respiration
Pauses
Tachypnea
Gasping
Skin Color Changes*
Paling around nostrils
Perioral duskiness
Mottling
Cyanosis
Grayness
Flushing/ruddiness
Visceral
Hiccuping*
Straining as if producing
a bowel movement
Grunting
Spitting up
Gagging
Motor
Seizures
Sneezing*
Tremors/startles*
Yawning
Twitches*
Sighing*
Coughing*
Motor System
Fluctuating Tone
Flaccidity of:
Trunk
Face
Extremities

Hypertonicity
Extending legs
Arching
Saluting
Splaying fingers*
Airplaning
Extending tongue
Sitting on air
Fisting*
Hyperflexions
Trunk
Fetal tuck
Extremities
Frantic Diffuse Activity
State System (Range)
Difficulty maintaining state control
Difficulty in transitions from one state to another
Sleep
Twitches*
Whimpers
Makes sounds
Grimaces
Makes jerky movements
Fusses in sleep
Has irregular respirations
Awake
Eyes floating
Panicky, worried*, dull look
Glassy eyes
Weak cry
Strain, fussiness
Irritability*
Staring*
Abrupt state changes
Gaze aversion*
Attention–Interaction System
Attempts at engaging behaviors elicit stress
Impaired ability to orient, attend, engage in reciprocal social
interactions
Difficulty consoling
Related Factors**
Pathophysiologic
Related to immature or altered central nervous system (CNS)
secondary to:
Prematurity*
Perinatal factors
Hyperbilirubinemia
Hypoglycemia
Infection
Intraventricular hemorrhage
Congenital anomalies

Prenatal exposure to drugs/
alcohol
Decreased oxygen saturation
Respiratory distress
Related to nutritional deficits secondary to:
Reflux
Feeding intolerance*
Swallowing problems
Emesis
Colic
Poor Suck/Swallow
coordination
Related to excess stimulation secondary to:
Oral hypersensitivity
Frequent handling and position changes
Treatment Related
Related to excess stimulation secondary to:
Invasive procedures*
Movement
Lights
Medication administration
Restraints
Noise (e.g., prolonged alarm,
voices, environment)
Chest physical therapy
Feeding
Tubes, tape
Related to inability to see caregivers secondary to eye patches
Situational (Personal, Environmental)
Related to unpredictable interactions secondary to multiple caregivers
Related to imbalance of task touch and consoling touch
Related to decreased ability to self-regulate secondary to:
(Holditch-Davis & Blackburn, 2007)
Sudden movement
Noise
Prematurity*
Disrupted sleep–wake cycles
Fatigue
Stimulation that exceeds the
infant’s tolerance threshold
Environmental demands

Author's Notes
Disorganized Infant Behavior describes an infant who has difficulty regulating
and adapting to external stimuli due to immature neurobehavioral
development and increased environmental stimuli associated with neonatal
units. When an infant is overstimulated or stressed, he or she uses
energy to adapt; this depletes the supply of energy available for physiologic
growth. The goal of nursing care is to assist the infant to conserve
energy by reducing environmental stimuli, allowing the infant sufficient
time to adapt to handling, and providing sensory input appropriate to
the infant’s physiologic and neurobehavioral status.

Goal
The infant will demonstrate increase signs of stability as evidenced
by the following indicators:
• Exhibit smooth, stable respirations; pink, stable color; consistent
tone; improve posture; calm, focused alertness; wellmodulated
sleep; responsive to visual and social stimuli.
• Demonstrate self-regulatory skills as sucking, hand to mouth,
grasping, hand holding, hand and foot clasping, tucking.
The parent(s)/caregiver(s) will describe techniques to reduce environmental
stress in agency, at home, or both.
• Describe situations that stress infant.
• Describe signs/symptoms of stress in infant.
• Describe ways to support infant’s efforts to self-calm

Interventions
See Related Factors.
Reduce or Eliminate Contributing Factors, If Possible
Pain
• Observe for responses that are different from baseline and have
been associated with neonatal pain responses (Bozzette, 1993):
• Facial responses (open mouth, brow bulge, grimace, chin
quiver, nasolabial furrow, taut tongue)
• Motor responses (flinch, muscle rigidity, clenched hands,
withdrawal) (AAP, 2006)
• Pain management requires routine assessment using a reliable
pain-assessment tool which measures both physiologic
and behavioral indicators of pain.
• Develop strategies to minimize the number and frequency of
painful or stressful procedures in the NICU.
• Provide pharmacologic and/or nonpharmacologic pain relief
for all painful procedures, such as gavage tube placement,
tape removal, needle insertions, heel sticks, insertion and
removal of chest tubes, intubation, prolonged mechanical
ventilation, eye exams, circumcision, and surgery.
• Pharmacologic implications:
• Doses of effective medications to reduce pain may be close to
doses that cause toxicity in the neonate.
• Early administration of pain medication may reduce the
effective dose needed and thereby reduce toxicity.
• Treatment of pain must be guided by ongoing pain
assessments.
• Pain relief for circumcisions should be provided.
• Topical anesthetics can reduce pain for some procedures such
as venipuncture, lumbar puncture, and IV insertion. Due to a
risk of methemoglobinemia, in certain situations, use should
be on intact skin only, no more than once a day, and not with
other drugs known to cause methemoglobinemia.
• Nonpharmacologic interventions:
• Developmental care that includes attention to behavioral
cues and reducing environmental stimuli, has shown to be
effective in reducing pain from minor procedures.
• Facilitated tuck
• Swaddling
• Supportive bedding
• Side-lying position
• Kangaroo care
• Nonnutritive suck
• Oral sucrose solution combined with sucking has proved
effective at reducing pain from many minor procedures.
Disrupted 24-hour Diurnal Cycles
• Evaluate the need for and frequency of each intervention.
• Consider 24-hour caregiving assignment and primary caregiving
to provide consistent caregiving throughout the day and
night for the infant from the onset of admission. This is important
in terms of responding to increasingly more mature sleep
cycles, feeding ability, and especially emotional development.
• Consider supporting the infant’s transition to and maintenance
of sleep by avoiding peaks of frenzy and overexhaustion;
continuously maintaining a calm, regular environment and
schedule; and establishing a reliable, repeatable pattern of
gradual transition into sleep in prone and side-lying positions
in the isolette or crib.
Problematic Feeding Experiences
• Observe and record infant’s readiness for participation with
feeding.
Hunger Cues
• Transitioning to drowsy or alert state
• Mouthing, rooting, or sucking
• Bringing hands to mouth
• Crying that is not relieved with pacifier or nonnutritive
sucking alone
Physiologic Stability
• Look for regulated breathing patterns, stable color, and stable
digestion.
• Promote nurturing environment in support of a coregulatory
feeding experience.
• Decrease environmental stimulation.
• Provide comfortable seating (be especially sensitive to the
needs of postpartum mothers: e.g., soft cushions, small stool to
elevate legs, supportive pillows for nursing).
• Encourage softly swaddling the infant to facilitate flexion and
balanced tone during feeding.
• Explore feeding methods that meet the goals of both infant
and family (e.g., breastfeeding, bottle-feeding, gavage).
Support the Infant’s Self-Regulatory Efforts
• When administering painful or stressful procedures, consider
actions to enhance calmness.
• Support the flexed position with another caregiver.
• Provide opportunities to feed while shielding the infant from
other stresses.
• Consider the efficient execution of necessary manipulations
while supporting the infant’s behavioral organization.
• Consider unhurried reorganization and stabilization of the
infant’s regulation (e.g., position prone, give opportunities to
hold onto caregiver’s finger and suck, encase trunk and back of
head in caregiver’s hand, provide inhibition to soles of feet).
• Consider removing extraneous stimulation (e.g., stroking,
talking, shifting position) to institute restabilization. Consider
spending 15 to 20 minutes after manipulation; over time, the
infant’s self-regulatory abilities will improve, making the caregiver’s
intervention less important.
• Consider supporting the infant’s transition to and maintenance
of sleep by avoiding peaks of frenzy and over-exhaustion; by
continuously maintaining a calm, regular environment and
schedule; and by establishing a reliable, repeatable pattern of
gradual transition into sleep in prone and side-lying positions
in the isolette or crib.
• Consider initiating calming on the caregiver’s body and then
transferring the baby to the crib as necessary. For other infants,
this may be too arousing, and transition is accomplished more
easily in the isolette with the provision of steady boundaries
and encasing without any stimulation.
• A nonstimulating sleep space with minimal exciting visual
targets, social inputs, and so forth, may need to be made available
to facilitate relaxation before sleep. A regular sleep routine
helps many infants.
Reduce Environmental Stimuli
Noise (Merenstein & Gardner, 1998; Thomas, 1989)
• Do not tap on incubator.
• Place a folded blanket on top of the incubator if it is the only
work surface available.
• Slowly open and close porthole.
• Pad incubator doors to reduce banging.
• Use plastic instead of metal waste cans.
• Remove water from ventilator tubing.
• Speak softly at the bedside and only when necessary.
• Slowly drop the head of the mattress.
• Eliminate radios.
• Close doors slowly.
• Position the infant’s bed away from sources of noise
(e.g., telephone, intercom, unit equipment).
• Consider the following methods to reduce unnecessary noise
in the NICU:
• Perform rounds away from the bedsides.
• Adapt large equipment to eliminate noise and clutter.
• Alert staff when the decibel level in the unit exceeds 60 db
(e.g., by a light attached to a sound meter). Institute quiet
time for 10 minutes to lower noise.
• Move more vulnerable infants out of unit traffic patterns.
Lights
• Use full-spectrum instead of white light at bedside. Avoid
fluorescent lights.
• Cover cribs, incubators, and radiant warmers completely during
sleep and partially during awake periods.
• Install dimmer switches, shades, and curtains. Avoid bright
lights.
• Shade infants’ eyes with a blanket tent or cutout box.
• Avoid visual stimuli on cribs.
• Shield eyes from bright procedure lights. Avoid patches unless
for phototherapy.
Position Infant in Postures That Permit Flexion and Minimize
Flailing
• Consider gentle, unhurried reorganization and stabilization
of infant’s regulation by supporting the infant in softly tucked
prone position, giving opportunities to hold onto caregiver’s
finger and suck, encasing trunk and back of head in caregiver’s
hand, and providing inhibition to soles of feet.
• Use the prone/side-lying position.
• Avoid the supine position.
• Swaddle baby, if possible, to maintain flexion.
• Create a nest using soft bedding (e.g., natural sheepskin, soft
cotton, flannel).
• Avoid oversized diapers to allow you to perceive normal hip
alignment.
• Avoid tension on lines or tubing.
Reduce the Stress Associated With Handling
• When moving or lifting the infant, contain him or her with your
hands by wrapping or placing rolled blankets around the body.
• Maintain containment during procedures and caregiving
activities.
• Handle slowly and gently. Avoid stroking.
• Initiate all interactions and treatments with one sense stimulus
at a time (e.g., touch), then slowly progress to visual, auditory,
and movement.
• Assess child for cues for readiness, impending disorganization,
or stability; respond to cues.
• Support minimal disruption of the infant’s own evolving
24-hour sleep–wake cycles.
• Use PRN instead of routine suctioning or postural drainage.
• Use minimal adhesive tape. Remove any carefully.
Reduce Disorganized Behavior During Active Interventions and
Transport
• Have a plan for transport, with assigned roles for each team
member.
• Establish behavior cues of stress on this infant with the
primary
nurse before transport.
• Minimize sensory input:
• Use calm, quiet voices.
• Shade the infant’s eyes from light.
• Protect infant from unnecessary touch.
• Support the infant’s softly tucked postures with your hands
and offer something to grasp (your finger or corner of a soft
blanket or cloth).
• Swaddle the infant or place him or her in a nest made of blankets.
• Ensure that the transport equipment (e.g., ventilator) is ready.
Warm mattress or use sheepskin.
• Carefully and smoothly move the infant. Avoid talking, if possible.
• Consider conducting caregiving routines while parent(s) or
designated caregiver hold infant, whenever possible.
• Reposition in 2 to 3 hours or sooner if infant behavior suggests
discomfort.
Engage Parents in Planning Care
• Encourage them to share their feelings, fears, and expectations.
• Consider involving parents in creating the family’s developmental
plan:
• My strengths are:
• Time-out signals:
• These things stress me:
• How you can help me:
• Teach caregivers to continually observe the changing capabilities
to determine the appropriate positioning and bedding options,
for example infant may fight containment (Hockenberry &
Wilson, 2009).
Initiate Health Teaching and Referrals as Indicated
Review the Following Information Relating to Growth and
Development of the Infant and Family in Anticipatory
Guidance for Home
Health Concerns
• Feeding
• Hygiene
• Illness
• Infection
• Safety
• Temperature
• Growth and development
State Modulation
• Appropriate stimulation
• Sleep–wake patterns
Parent–Infant Interaction
• Behavior cues
• Signs of stress
Infant’s Environment
• Animate, inanimate stimulation
• Playing with infant
• Role of father and siblings
Parental Coping and Support
• Support network
• Challenges
• Problem solving
Discuss Transition to Community Supports (Nursing Respite,
Social and Civic Groups, Religious Affiliations)

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