Definition of the NANDA label
Disintegration of physiological and neurobehavioral responses to the environment.
Disintegration of the physiological and neurobehavioral systems of functioning.
• Inability to inhibit startle.
• Active-awake (worried look, nervous attitude).
• Diffuse / unclear dream.
• Oscillation of sleep state.
– Aversion to the gaze.
• Crying irritable or indicative of panic.
• Abnormal response to sensory input (eg, difficulty calming down, lack of ability to maintain alertness).
• 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:
• Oximetric reading:
• Congenital or genetic disorders.
• Exposure to teratogens.
• Invasive or painful procedures.
• Oral / motor problems.
• Alimentary intolerance.
• 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
• Prenatal exposure to teratogen
• 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.
• Thermoregulation: neonate.
• 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.