00116 Disorganized infant behavior

image_pdfDownload PDF

00116 Disorganized infant behavior

Definition of the NANDA label

Disintegration of physiological and neurobehavioral responses to the environment.

Disintegration of the physiological and neurobehavioral systems of functioning.

Defining characteristics

Regulatory issues

• Inability to inhibit startle.
• Irritability.

Organizational system

• Active-awake (worried look, nervous attitude).
• Diffuse / unclear dream.
• Oscillation of sleep state.
• Still-awake:
– Aversion to the gaze.
– Stare.
• Crying irritable or indicative of panic.

Attention-interaction system

• Abnormal response to sensory input (eg, difficulty calming down, lack of ability to maintain alertness).

Motor system

• Increased, decreased or flabby tone.
• Spread fingers, clenched fists, hands to the face.
• Hyperextension of the arms and legs.
• Tremors, exaggerated movements, contractions.
• Uncoordinated, jerky, nervous movements.
• Alteration of primary reflexes.


• Bradycardia, tachycardia or arrhythmias.
• Pale, cyanotic, mottled, or red in color.
• “Out of time” signs (eg, gaze, grasp, hiccup, cough, sneeze, sigh, loose jaw, open mouth, tongue hanging out).
• Food intolerances:
– Aspiration.
– Emesis.
• Oximetric reading:
– Desaturation.

Related factors


• Congenital or genetic disorders.
• Exposure to teratogens.


• Invasive or painful procedures.
• Prematurity.
• Malnutrition.
• Oral / motor problems.
• Pain.
• Alimentary intolerance.


• Disease.
• Immaturity of the neurological system.
• Gestational age.
• Post-conceptual age.


• Inadequate physical environment.
• Sensitive inadequacy.
• Sensory overstimulation.
• Sensory deprivation.

From the caregiver

• Wrong interpretation of the keys.
• Lack of knowledge of the keys.
• Contribution to environmental stimulation.

At risk population

• Low postconceptual age
• Prematurity
• Prenatal exposure to teratogen

Associated condition

• Congenital disorder
• Genetic disorder
• Infant illness
• Immature neurological functioning
• Impaired infant motor functioning
• Invasive procedure
• Infant oral impairment


• Adaptation of the child to hospitalization.
• Neurological status.
• Organization of the premature newborn.
• Dream.
• Thermoregulation: neonate.


• Surveillance.
• Presence.
• Pre-surgical teaching to parents.
• Change of position.
• Infant care.
• Improved sleep.
• Neurological monitoring.
• Environmental management.
• Encourage sleep.
• Temperature regulation.

This diagnosis will retire from the NANDA-I Taxonomy in the 2021-2023 edition unless additional work is completed to bring it up to a level of evidence 2.1 or higher.

image_pdfDownload PDF