7 Bronchopulmonary Dysplasia (BPD) Nursing Care Plans

Disorganized Infant Behavior

Some of the abnormalities in pulmonary function seen in BPD resolve in the first 2 years after birth, but airflow limitation persists into childhood, adolescence, and even adulthood. Symptoms such as wheezing and dyspnea are similar to those of asthma but are less likely to be responsive to bronchodilator therapy than asthma. Sleep-disordered breathing is elevated among former premature children with BPD. Survivors of severe BPD, especially those who still require mechanical ventilation at 36 weeks postmenstrual age, face additional challenges (Chiafery & D’Angio, 2020).

Nursing Diagnosis

• Disorganized Infant Behavior

May be related to

• Environmental stimulation

Possibly evidenced by

• Alterations in heart rate, respiration
• Color changes
• Erratic body movements
• Difficulty with feedings, or prolonged periods of wakefulness

Desired Outcomes

• The infant will demonstrate a quiet alert state and the ability to habituate to environmental stimuli.
• The infant will demonstrate smoother transitions between sleeping and waking.

Nursing Assessment and Rationales

1. Assess the infant’s behavioral states (periods of quiet and active sleep, habituation, orientation, and self-consoling ability).
This provides information about the infant’s unique abilities to adjust to environmental stimulation and allows the planning of individualized supportive care. Infants who had been born prematurely are at a higher risk of obstructive sleep apnea (OSA) during childhood. They are also more likely to have other sleep disorders such as periodic limb movements of sleep compared with their term counterparts (Kheirandish-Gozal & Gozal, 2021).

Nursing Interventions and Rationales

1. Introduce one caregiving intervention at a time and notice the infant’s responses. 
This avoids overstimulation and additional environmental maladaptation. Less mature or ill infants can tolerate only one activity at a time. Allow the infant to rest once they show stress signals, such as finger splaying, grimacing, tongue extension, worried alertness, spitting up, back arching, gaze aversion, yawning, hiccuping, color changes, or changes in cardiac or respiratory functioning.

2. Continue to stay with the infant after procedures/caregiving to assess response; if maladaptive responses happen, use “time-out” to enable the infant to adjust.
This prevents or minimizes maladaptive responses which often occur up to 20 minutes after caregiving is completed. According to a study on the possibility of disorganized behavior in premature infants admitted to NICUs, body reactions and the position of limbs are the most common reactions indicative of disorganized infant behavior (Taghinejad et al., 2021).

3. Introduce and promote Kangaroo care to the parents.
Kangaroo care, a holding technique where the infant has skin-to-skin contact with the parent, has been shown to reduce parental stress, improve infants’ physiologic parameters, and promote parent-infant bonding. Additionally, the technique may prevent infection, and reduce energy consumption to improve weight gain and improve infant brain development (Chiafery & D’Angio, 2020).

4. Perform caring measures in a cluster, while not overstimulating the infant.
This promotes longer periods of alert and/or deep sleep which will improve the body’s own natural defenses. Providing rest periods will allow the infant to recover before doing the next caregiving. Clustering care also avoids sudden sleep interruption and promotes stability and adaptive behaviors.

5. Facilitate handling by providing containment: holding the infant’s arms and legs in a flexed position, close to their midline using the caregiver’s hands and/or positioning aids such as rolled blankets; premature or ill infants should be positioned prone or side-lying, maintaining soft flexion.
This promotes flexion and enhances the infant’s motor and physiologic systems. During a calm, waking state of the preterm infant, skin-to-skin contact should be established. The infant’s setup can be inspired by the sustained diagonal flexion position, with a support band and a nursing pillow to support the mother’s arm. The preterm infant is effectively curled up against the mother’s chest and held in the crook of the mother’s arm without rocking (Provasi et al., 2021).

6. Alter the physical environment by decreasing light and sound.
This prevents or decreases maladaptive behaviors; both light and sound levels in the NICU have been implicated in interfering with sleep and stable physiological functioning. The NICU environment deprives infants of sensory stimulation. While the sound environment in the womb is rhythmic, periodic, organized, and predictable, in the NICU the sound environment is aperiodic, unorganized, and unpredictable. A review of music therapy revealed that music or auditory stimulations that incorporated musical elements based on the acoustic rhythmic intrauterine environment have positive effects on preterm infants, calming and relaxing the infant and decreasing its stress level (Provasi et al., 2021).

7. Provide a pacifier and/or fingers for the infant to suck on; provide objects to encourage hand grasping such as blankets, tubing, and fingers during caregiving.
This promotes self-consoling or gentle behaviors which facilitate organization and adaptive behaviors. Oral stimulation may increase saliva production and swallowing practice, which may facilitate synchrony between swallowing and breathing. These involvements have been shown to have multiple beneficial effects on feeding development.  A training session with a rhythmical pulsating nipple allows preterm infants to practice non-nutritive rhythmic sucking and to mature more quickly (Provasi et al., 2021).

8. Assist parents in learning their infant’s signals or cues and interpreting them appropriately.
This promotes a positive parenting role and minimizes the infant’s maladaptive behaviors, promoting improved long-term growth and development. Auditory, tactile, visual, and vestibular (ATVV) intervention is a multimodal sensory stimulation intervention for preterm infants to improve parent-preterm interaction. This intervention incorporates not only rhythmical stimulation but also eye-to-eye contact when the infant is alert and talking to the adult, light stroking or massage of the infant for the first ten minutes of the interaction, and rhythmic vestibular or a slow rocking motion while attempting eye-to-eye contact. ATVV increases periods of alertness, shortens hospital stays, enhances parent-infant interaction, and enhances behavioral organization at term age (Provasi et al., 2021).

9. Provide a primary care team to work collaboratively with the parents in developing an individualized plan of care reviewed daily and discussed at intervals with the parents.
The supporting and enhancing NICU sensory experiences (SENSE) program includes skin-to-skin care, infant massage, auditory exposure, olfactory exposure, kinesthetic/vestibular exposure, and visual exposure. The program also includes parental education fostering an understanding of individualizing care related to infant behavioral signs. The SENSE program is intended to increase maternal confidence in addition to bettering infant neurobehavior with less asymmetry (Provasi et al., 2021).

10. Provide individualized feeding support determined by the infant’s own needs and strengths; the feeding focus should be positive and pleasurable, with attention to the infant’s cues or signals.
This promotes positive feeding experiences that facilitate weight gain and feeding competency. Guidelines for feeding term infants recommend starting complementary food at around six months. Compared to term infants, preterm infants have unique and diverse needs and variances in their degree of prematurity making a range of ages to introduce complementary food more appropriate than a specific age. A better understanding of the role of the optimal time of introduction to breast/bottle, spoon, and solid food and also the role of duration of experience with certain food textures could support families in the prevention and early intervention of feeding disorders (Hübl et al., 2020).

11. Provide an optimal level of family support through the use of family-centered caregiving principles: enhanced involvement of parents in all aspects of caregiving and decision-making.
This promotes feelings of belonging and control which enhances the parent-infant relationship. Parental involvement has been shown to decrease the length of hospital stay. Family-integrated care of NICU infants at risk for developing BPD has been shown to improve a number of NICU outcomes, including lowering the amount of time on respiratory support (Chiafery & D’Angio, 2020).

12. Instruct and encourage parents in caregiving activities throughout the NICU stay, at level parents are comfortable with.
This promotes improved parental confidence, enhances parenting skills, and improves parent-infant relationships/interactions. Programs that include content on general neonatal physiology, infant development, parent interventions to promote development and bonding and orientation to the NICU environment help support the parents. The Creating Opportunities for Parent Empowerment (COPE) program for parent education and behavioral interventions has been shown to diminish maternal stress and facilitate better cognitive growth among hospitalized infants (Chiafery & D’Angio, 2020). 

13. Encourage parents to personalize infant bed space by bringing in clothes, blankets to be used over isolettes/cribs, and pictures from home.
This promotes positive parental identity and feelings of control and decreases NICU stimulation. Additionally, the precarious conditions of the infant, the cold and sterile environment of the NICU, and the ambiguity of the maternal role in the hospital setting make the mothers more vulnerable to depressive symptoms, even in the case of moderately preterm infants (Trumello et al., 2018).

14. Assist parents in making the hard transition from hospital to home. Allow them sufficient time for learning and communication of needs and feelings.
This promotes feelings of control and mastery through education and opens communication. This will enhance the parent-infant relationship and foster the child’s growth and development. Several studies have evaluated programs designed to ease the transition to home for premature infants. Most programs included some form of enhanced education while the infant remained hospitalized and in-home support, through physical or virtual visits (Chiafery & D’Angio, 2020).