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INEFFECTIVE BREATHING PATTERN Nursing Care Plan

Stuart, 23 years old, diagnosed with pneumonia 3 months ago. Because of having not enough money for hospitalization. His state got worse day...

DISORGANIZED INFANT BEHAVIOR Nursing Care Plan

Disorganized infant behavior is define as disintegrated physiologic and neuro-behavioral responses of infant to the environment. Physiologic is something that is normal, that is due neither to anything pathologic nor significant in terms of causing illness. Neurobehavioral is relating to an approach to studying behavior that stresses the importance of nerve brain function. 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 neonetal 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. This is a nursing care plan sample about disorganized infant behavior of baby boy Rewad, 8 months old.

Assessment:

Objectives:
- Increase pulse rate
- Tachypnea
- Gasping
- Paling around nostrils
- Perioral duskiness

Diagnosis:

Disorganized infant behavior related to tachypnea secondary to gasping.

Planning:
The infant will manifest increase signs of stability as evidenced by the following indicators: Exhibit smooth, stable respirations; pink, stable color; consistent tone; improve posture; calm, focused alertness; well-modulated 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 parents 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:

- Reduce or eliminate contributing factors.

- Observe for responses that are different from baseline and have been associated with neonatal pain responses. Monitor facial responses like open mouth, brow bulge, grimace, chin quiver, nasolabial furrow, taut tongue. Motor responses like flinch, muscle rigidity, clenched hands, withdrawal.

- 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. 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. Facilitate developmental care that includes attention to behavioral cues and reducing environmental stimuli, has shown to be effective in reducing pain from minor procedures.

- 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 over exhaustion; 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.

- Observe and record infant’s readiness for participation with feeding. Check for hunger cues such as transitioning to drowsy or alert state, mouthing, rooting, or sucking, bringing hands to mouth, crying that is not relieved with pacifier or non-nutritive sucking alone.

- Look for regulated breathing patterns, stable color, and stable digestion. Promote nurturing environment in support of a co-regulatory feeding experience. Decrease environmental stimulation. Provide comfortable seating (be especially sensitive to the needs of postpartum mothers like 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 like breastfeeding, bottle-feeding, and gavage.

- 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 such as 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 like 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. 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 like 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. Institute quiet time for 10 minutes to lower noise. Move more vulnerable infants out of unit traffic patterns. 

- 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. 

- 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 and avoid the supine position. Swaddle baby, if possible, to maintain flexion. Create a nest using soft bedding such as natural sheepskin, soft cotton, and flannel. Avoid oversized diapers to allow you to perceive normal hip alignment. Avoid tension on lines or tubing. 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 and avoid stroking. Initiate all interactions and treatments with one sense stimulus at a time, 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 if needed, instead of routine suctioning or postural drainage. Use minimal adhesive tape and remove any carefully.

- 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 like 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. Swaddle the infant or place him or her in a nest made of blankets. Ensure that the transport equipment like 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. Teach caregivers to continually observe the changing capabilities to determine the appropriate positioning and bedding options, for example infant may fight containment.

- Initiate health teaching and referrals as indicated.

Evaluation:

The infant manifested increased signs of stability as evidenced by the following indicators: Exhibited smooth, stable respirations; pink, stable color; consistent tone; improved posture; calm, focused alertness; well-modulated sleep; responsive to visual and social stimuli. Demonstrated self-regulatory skills as sucking, hand to mouth, grasping, hand holding, hand and foot clasping, tucking.
The parents described techniques to reduce environmental stress in agency, at home, or both. Described situations that stress infant. Described signs/symptoms of stress in infant. Describe ways to support infant’s efforts to self-calm.

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