00116 Disorganized Infant Behavior

Domain 9: coping/stress tolerance
Class 3: neurocomported stress
Diagnostic Code: 00116
Nanda label: disorganized infant behavior
Diagnostic focus: organized behavior
approved 1994 • Revised 1998, 2017

NANDA Nursing Diagnosis Definition

The Nanda nursing diagnosis « disorganized infant behavior ” is defined as: disintegration of physiological and neurocomportal functioning systems.

Definite characteristics

Attention-Interaction System

  • Deterioration of the response to sensory stimuli

Motor System

  • Alteration of primary reflexes
  • Exaggerated alarm response
  • Movements that show impatience
  • Extended fingers
  • Squeered fists
  • Behavior of getting your hands to the face
  • Hyperextension of the limbs
  • Motor tone deterioration
  • Keep your hands on the face
  • tremor
  • involuntary microcontractions
  • Uncoordinated movements

Physiological

  • Abnormal skin color
  • Bradycardia
  • arrhythmia
  • Inability to tolerate the range of nutrients
  • Inability to tolerate the volume of nutrients
  • Oxygen deaturation
  • Tachycardia
  • Extemporary signals

Regulation problems

  • Deterioration of the ability to inhibit shock
  • Irritable mood

STATE-ORGANIZATION SYSTEM

  • Active-dissemination
  • Diffuse Activity in the Electroencephalogram (EEG) with the eyes closed
  • Irritable crying
  • Quiet-disregard
  • State oscillation

Related factors

  • erroneous interpretation of the child’s signals by the caregiver (a)
  • Overestimulator environment
  • 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

  • Congènito 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 the presence of 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

    • Child development: one month and two months: milestones of physical, cognitive and psychosocial progress per month and two months of age. ( Note : Noc enunciates them separately for each age group).
    • Neurological state: capacity of peripheral and central nerve systems to receive, process and respond to internal and external stimuli
    • Organization of the premature child: extrauterine integration of the functions and behaviors of the infant with a gestation of 24 to 37 weeks (at term)
    • Dream: natural periodic suspension of consciousness during which the body recovers
    • Thermoregulation, neonate: balance between production, gain and heat loss during the first 28 days of life

    Evaluation objectives and criteria

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    • The neurological state is normal, as evidenced by the following indicators (specify from 1 to 5: seriously, substantially, moderately, slightly or not compromised):
      • Consciousness, central motor control, sensory function or cranial motor, sensory core function, and autonomous function
      • Respiratory pattern
      • Rest-sueño pattern
    • The thermoregulation is not compromised, as stated by the following indicators (specify from 1 to 5: severe, substantial, moderate, light or none)
      • Increase in cutaneous temperature
      • Changes in skin coloration
      • Muscle spasms
      • hyperthermia and hypothermia
      • Reduction of cutaneous temperature

    Other examples

    The infant will be able to:

    • Do not experience convulsive activity
    • Do not experience restlessness or lethargía
    • Show neurochonductual operation organized in all systems
    • Use thermogenesis without chills
    • Do not show any delay in the expected development range: a month (for example, holds the head a few moments) and two months (it shows some head control in vertical position). Note : A book on child development or pediatrics should be consulted to obtain a complete list of development milestones for each age.
    • Show adequate muscle function (such as tone and muscle contraction; control, stability and speed of muscle movement)
      Parents or caregiver will be able to:
    • Recognize the child’s behavioral signals that indicate stress
    • Modify the environment in response to infant behaviors
    • Demonstrate adequate management techniques to promote normal development

    NIC Interventions

    • Infant care: Provide appropriate development and family -centered care and children under one year of age
    • Newborn care: neonate management during transition to extrauterine life and the subsequent stabilization period
    • Development care: structure the environment and offer care in response to the states and behavioral indications of the premature neonate
    • Management of the environment: manipulate the patient’s environment seeking a therapeutic and aesthetic benefit, as well as psychological well -being
    • Sleep improvement: facilitation of regular sleep-vigilia cycles
    • Neurological monitoring: Patient data collection and analysis to prevent or reduce neurological complications
    • Position: Deliberate placement of the patient or a part of the body to improve physiological and psychological well -being
    • Temperature regulation: normalize or maintain body temperature in normal values ??
    • Newborn surveillance: measurement and interpretation of the physiological state of the neonate during the first 24 hours of childbirth

    Nursing Activities

    Valuations

    • Determine if the infant is reaching development milestones
    • Evaluate the presence of signs of stress and maladjustment
    • Identify the self -regulatory behaviors of the neonate (for example, suction, mouth movements)
    • Monitor the presence of causal environmental factors (lights, manipulations, noise, etc.)
    • Evaluate the presence of causal internal factors, such as pain and hunger
    • Monitor the sleep pattern

    Patient and family education

    • Instruct parents about the needs and skills of the infant
    • Prove the careful management of the baby
    • Model the appropriate response to the behavioral indications of the neonate
    • Instruct parents about normal growth and development
    • Prepare parents to acquire the necessary skills to take care of a premature baby (for example, food, skin care)

    Others

    • Use lamb skin, water bed or other mattress or pads protectors for neonates who do not tolerate frequent positions of position
    • Encourage parents to take the infant and participate in their care as much as possible
    • Provide a consistent caretaker
    • Help parents identify the abilities and limitations of their baby
    • Observe the presence of pain signs, and intervene quickly to treat it or to eliminate painful stimuli (for example, administer analgesia before painful procedures)
    • Space interventions and handling to allow the infant an uninterrupted dream of three to four continuous hours
    • Place the neonate in a correct body alignment
    • Provide limits during all treatments and activities (for example, wrap it in a blanket or hug it)
    • (NIC) environment management:
      • Avoid exposure to currents, overheating or unnecessary cooling
      • Control or prevent undesirable or excessive noise, whenever possible
      • Reduce environmental stimuli, as required (for example, speak quietly next to the bed, limit conversations, open and close the incubator slowly and without noise, not hit the incubator, place rolled blankets near the Neonate head to absorb sound, cover the incubator or heater during sleep periods)

    At home

    • Although this nursing diagnosis is especially useful for premature infants in UCIN, previous interventions can be adapted for home care, once the infant leaves the hospital.
    • Determine if in the environment there is a balance between stimuli (for example, lighting, sound) that prevents both overload and sensory deprivation
    • Help parents find support groups in the community