00115 Disorganized Behavior Risk Of Infant

Domain 9: coping/stress tolerance
Class 3: neurocomported stress
Diagnostic Code: 00115
Nanda label: disorganized behavior risk
Diagnostic focus: organized behavior
approved 1994 • Revised 2013, 2017

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « disorganized behavior risk of infant is defined as: susceptible to suffering a disintegration of the modulation pattern of physiological and neurocomportal functioning systems, which can compromise health .

Risk factors

  • erroneous interpretation of the child’s signals by the caregiver (a)
  • Food intolerance
  • Inappropriate knowledge of behavioral signals by the caregiver (a)
  • Inadequate containment in the environment
  • Inadequate physical environment
  • Insufficient sensory stimulation in the environment
  • Malnutrition
  • Pain
  • Deprivation/sensory deprivation
  • Sensory overestimulation

Risk population

  • Infants exposed to teratogens in the uterus
  • Girls with low postmestrual age
  • Premature infants

Associated problems

  • Congenital disorder
  • Imaduro neurological operation
  • Deterioration of infant motor functioning
  • Congenital genetic diseases
  • Invasive procedure
  • Oral deterioration

Suggestions of use

  • The usefulness of this diagnosis is greater for infants, especially premature
  • An immature neurological development and a greater number of environmental stimuli or harmful stimuli create a situation in which the infant must use energy to adapt more than for its growth and development.

Suggested alternative diagnostics

  • NOC Results

    • Knowledge: Care of the premature infant: degree of understanding expressed about care for a premature baby born between 24 to 37 weeks (at term) gestation
    • Knowledge: Care of the infant: degree of understanding expressed about the care of a baby from birth to its first year of life
    • Child development: 1, 2, 4, 6 and 12 months: milestones of physical, cognitive and psychosocial progress per month, two months, three months, four months, six months and 12 months of age ( note < /B>: Noc states a separate result for each age group).
    • Neurological status: Central and nervous peripheral systems to receive, process and respond to internal and external stimuli
    • Coordinated movement: Muscles capacity to work voluntarily to achieve an intentional movement
    • Organization of the premature child: extrauterine integration of physiological and behavioral function of the infant born after a gestation of 24 to 37 weeks (term)

    Evaluation objectives and criteria

    • See the objectives and evaluation criteria for disorganized infant behavior.

    NIC Interventions

    • Care of the infant: Provide appropriate development and family focused on children under one year old
    • Development care: structure the environment and offer care in response to the states and behavioral indications of the premature neonate
    • Teaching: Child stimulation (0 to 4 months, 5 to 8 months and 9 to 12 months): teach parents and caregivers to provide appropriate sensory activities for development with the purpose of promoting development and movement during the First year of life
    • Teaching: infant security: 0 to 3, 4 to 6, 7 to 9 and l 0 to l 2 months: instruction on security during the first year of life
    • Risk identification: Analysis of possible risk factors, determination of health risks and prioritization of risk reduction strategies for a person or group
    • Kangaroo mother: Promotion of closeness between parents and a physiologically stable premature infant, through the preparation of parents and the creation of an adequate environment for physical contact skin to skin
    • Management of the environment: comfort: manipulation of the patient’s environment to provide optimal comfort
    • Management of the environment: attachment process: manipulate the patient’s environment to facilitate the development of the parents/infant relationship
    • Neurological monitoring: Patient data collection and analysis to prevent or reduce neurological complications
    • Position: Deliberate placement of the patient or a part of his body to promote physiological and psychological well -being
    • Surveillance: Collection, interpretation and synthesis of patient data, continuously and with an end, to make clinical decisions
    • Newborn surveillance: measurement and interpretation of the physiological state of the neonate during the first 24 hours after childbirth

    Nursing Activities

    • See nursing activities for disorganized infant behavior

    Valuations

    The following assessments must be done 24 hours after delivery:

    • (NIC) Newborn surveillance:
      • Perform the Apgar test one and five after birth
      • Monitor the neonate temperature until it stabilizes
      • Monitor the frequency and respiratory pattern
      • Monitor the respiratory state, observing dyspnea signs: tachiapnea, nasal flutter, grunts, retractions, snoring or crepitations
      • Watch if it suffers dyspnea, hypoglycemia and respiratory anomalies, if the mother is diabetic
      • Monitor the color of the neonate
      • Check the signs of hyperbilirubinemia
      • Neonate capacity to suck
      • Monitor the first feed in the neonate
      • Neonate weight
      • Register the first evacuation and intestinal movement of the neonate
      • Monitor the umbilical cord
      • Monitor the response of male neonates to circumcision