Questions about neonate drug withdrawal management - page 2

by Race Mom 9,160 Views | 14 Comments

Mom had one prenatal visit (total) at 38 weeks, in which she was prescribed tylenol 3. She had a prior script for Norco (from another Dr.) but was told not to take both. Well, baby is in withdrawal. We are a level II/well baby... Read More


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    Knowing when to "rock the boat and report issue" in a professional capacity is a learning experience for all. I've learned to document just the facts using neutral language. Only report what you have first hand knowledge of from being assigned patient care or fully witnessed that are serious breeches in care or professional standards.

    Patient falls, severly infiltrated IV's up 1/2 arm, wrong IV med dispensed as mislabled by pharmacy (observed manufacturer label peeking out underneath pt label) etc all get instant incident report.

    Grey areas involving OTHER professionals decision making need to be reported verbally to nurse manager first and concern addressed to medical director of unit before submitting it on paper to give time for correction.

    Review policy and procedure manual. What standards are listed regarding care for neonatal drug withdrawal management? If no policy exists, offer to help write one "to better care for next infant in the unit"

    If required to do NAS scoring: what are treatment parameters based on results? How did care of this infant deviate from established policy? Remember these are "policy guidelines" not absolutes. Doctos intimate knowledge of providing perinatal care or lack thereof highly influenced decision made here.

    Since you state did not directly care for newborn, you don't have firsthand knowledge of care activities nor conversations with doctors and can really only report hearsay---not a good thing.

    What you can do is
    a. Review unit policies.
    b. Talk with supervisor/manager and discuss how to best care for neonates undergoing drug withdrawal.
    c. Ask for case conference re lessons learned from this patients care "to take foward for next patient".
    d. Observe for fallout from newborns care, readmission to unit etc.
    e. Ask for inservice on manadatory reporting issues in your state, working with CYS, community resources, working with social services etc

    All these ideas will help you to prepare for the next time need to handle a patient care issue. Forumulate in your mind what you MAY do and repercussions each would entail. Free think hypothetical "what if" situations with co-workers to get angles. Then pick best action based on facts at hand next time.

    Hope this helps.
    Race Mom likes this.
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    Wow Karen, you are so knowledgable and I really do appreciate all the time you have taken to help.
    We don't have a policy/procedure on the books, so I was thinking about offering to help write one.
    As far as what was said with reguards to treatment etc, this was not hearsay. I went into the nursery as the nurse and resident were pondering what they could do for this baby. I told the resident he needed morphine...and so the conversation started there. I referenced material from the AAP and presented it to him within 30 minutes of our initial conversation re: POC. He read it, made notes on it, called his attending, thanked me for the information, made himself a copy, and said he was still not going to treat with medication. The staff wasn't even doing NAS scores. I was the one to initiate them, going over each score with the nursery nurse, who concurred my scores.
    I do appreciate that the resident was open to the information/education that was given to him that night.
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    In my nursery, that resident would still be considered irresponsible. It's great that you want to write a policy, since it sounds like you need one.

    Maybe also get some other nurses involved and have a little inservice, discussing how to use the narcotic weaning form, what to look for in a withdrawal baby, how much morphine is a correct dose and how to wean, and how to report your concerns if the (new) policy is not being used correctly. It may take a while for others to follow your lead, and older nurses can be resistant--sometimes--but in the long run, your patients will really benefit.

    Dawn
    Race Mom likes this.
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    We withdraw opiate kiddos all the time...and it's sad. We NAS them from the get-go and the usual orders are to start morphine 0.05mg/kg q4h for 3 scores of 8 or higher in 24 hours. Sometimes we add phenobarb too if the morphine alone is not bringing their scores down.

    Peds residents are not always familiar with wellbaby stuff, and they are still learning, as you said. I have heard some say they don't want to give 'too much morphine' if baby is not on a monitor. I have had to gently remind them that babies can die from withdrawal...and that the standard is .05mg/kg and that will not be 'too much.' Our NPs are really good about this, though.

    If the kid's first score was 19, there is no way under the sun he should have gone home. It is going to get worse before it gets better, as the drug in his system gets lower and lower.
    Race Mom likes this.
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    The baby would have been in our nursery for weeks. I can't believe that it was sent home while withdrawing. In the first place, he's miserable, and mom won't have any patience dealing with a baby suffering like that, so he's also a candidate for abuse. He will be very irritable, he'll eat all the time and he'll have a horrible diaper rash. And he will have sleep problems. As mom is presumably still on the meds, she will be miserable, too. Methadone is used in our nursery, and eventually the babies get to go to couplet care and home with mom.

    The problem with Norco, and all the other brands of hydrocodone, you don't have to be on long to be addicted, and they are routinely given. Then it's work to wean off. If you have chronic pain, someone has to care enough to help. Maybe this mom needs to go to a doctor or clinic where they deal with pain. The worst babies we have had unfortunately have had moms who have been on Vicodan for back pain, and then get changed over during the pregnancy to methadone. Some docs have no clue what that will do to a baby! So mom and baby both end up on methodone, and of course mom continues to breast feed.

    An incident report is a good idea. It will go to your manager and Risk management. You don't name names, just state the facts, mom on Rx meds, baby withdrawing, NAS 19 (and even some of the reasons for that score) and that infant was d/c'd with no care. Mention Social worker and CPS, too.Then Risk management do their follow-up, and hopefully this will go far enough that no other baby has to suffer. It's possible that the baby will have someone with brains do the follow-up visit, and realize that he is withdrawing, so maybe he will get the care he needs.


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