Nursing Care Plan Preterm Infant | Risk for Disorganized Infant Behavior

Nursing diagnosis: Risk for disorganized infant behavior may be related to prematurity (immaturity of CNS system, hypoxia), environmental overstimulation, invasive/painful procedures and therapies, separation from parent(s).

Desired Outcomes: Exhibit organized behaviors that allow the achievement of optimal potential for growth and development as evidenced by modulation of physiological, motor, state, and attentional-interactive functioning.

Nursing intervention rationale:
1. Determine infant’s chronological and develop mental age; note length of gestation. Assess individual behaviors using appropriate tool (e.g., assessment of Preterm Infant Behavior Scale).
Rationale: Useful in choosing interventions to meet specific needs of infant and reduce detrimental environmental stimuli. The APIB scale measures five areas of developmental behaviors, autonomic, motor control, state differentiation, attention maintenance and social interaction, self-regulation.


2. Provide a primary nurse for each shift. (Assign one primary nurse per baby to provide information to parents.)
Rationale: Promotes continuity of care and follow-through with developmental program. Enhances recognition of subtle changes in infant’s behavior and condition. Consistent and predictable care enables infant to develop trust in caregiver, environment, and self and facilitates coping. Multiple caretakers confuse the infant, increase distress during feeding, cause irritability, and upset usual attention. Note: Having one nurse responsible for giving information helps to reduce instances of parents’ being uninformed or misunderstanding.

3. Create womblike atmosphere whenever possible by covering Isolette for extended periods, playing recorded placental or maternal heart sounds, and surrounding infant with rolled blankets or manufactured “nesting” device.
Rationale: Providing dark, quiet environment reduces stress, promotes adaptation, and has been found to correlate positively with weight gain, early weaning from oxygen or ventilators, and earlier discharge. Recorded maternal heart sounds tend to reduce or eliminate infant’s perception of noise from the Isolette. Nesting position facilitates hand-to-mouth behavior for self-consoling.

4. Cover top of radiant warmer with plastic wrap, if appropriate.
Rationale: Reduces environmental stress from air currents, which startle the infant as personnel move past the warmer.

5. Reposition infant using rolled diapers placed at the back and front, if infant is in lateral position, or at sides, if infant can tolerate a prone position.
Rationale: Neuromuscular immaturity can impair infant’s ability to seek a position of comfort or to relieve stress through repositioning. Rolled diapers surrounding baby provide a sense of security and have a calming effect. Prone position promotes sleep and optimal relaxation.

6. Change infant’s position periodically (especially if infant has nasal CPAP or endotracheal tube).
Rationale: Provides kinesthetic stimulation. Neuromuscularly immature infant is unable to reposition self or move about in the Isolette.

7. Interact with infant at face level (en face interaction), allowing eye contact. Provide colorful linens and changing designs or pictures on side of incubator, and encourage parents to make mobiles of construction paper and string once infant reaches postconception age of 40 wk.
Rationale: Visual stimulation is best provided by objects placed 7–9 in from face. Black and white faces and a checkerboard design promote visual attention. Infant may become habituated to stimuli that do not change. Involving parents in creating stimuli for infant helps ensure that the process continues after discharge.

8. Hold infant in ventral position (e.g., baby held to shoulder to burp) when possible, uncover eyes periodically if infant is receiving phototherapy.
Rationale: Enhances visual stimulation/orientation.

9. Assess infant for physiological signs/behavioral cues indicating stress (e.g., apnea, color change, bradycardia, sneezing, yawning), irritability or apathy, change in muscle tension, disorganized motor activity and sleep-wake cycles, measured change in sensory acuity), noting causative factors and eliminating or reducing stressors when possible.
Rationale: Disorganization of the autonomic system is often associated with prematurity, resulting in some infants lacking the developmental capability of dealing with more than one sensory input at a time. Familiarity with the infant’s usual behavioral responses and personality traits is necessary for identifying subtle changes that indicate stress and the need for intervention to modify causative factors.

10. Provide rocking or water beds, if indicated.
Rationale: Kinesthetic stimulation in preterm infants of 34 weeks’ gestation has been shown to improve sleep, decrease heart rate, reduce frequency of state changes, and increase head size and biparietal diameter.