Disorganized infant
behavior is defined 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 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. 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, and 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 non-stimulating
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 the 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, and 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. Make a quiet
time for him for 10 minutes to lower the 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 the 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. Abled to describe the current situation that stresses the infant. Abled to describe the signs and symptoms of stress manifested in infant. Describe ways to support infant’s efforts to self-calm.
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nursing care plan you are free to check it out in our NCP LIST page.
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