Nursing Diagnoses for Neonatal Abstinence Syndrome

This final blog post will describe some of the problems (physiological, emotional, and social) that nurses look for when they are caring for mothers who are involved in substance use and infants who are diagnosed with NAS. 

Nursing Diagnoses
1. Ineffective Childbearing Process R/T Substance Abuse AEB lack of prenatal visits, mother does not report appropriate pre and postpartum lifestyle because of substance abuse, has limited support systems

This nursing diagnosis describes the mothers impaired ability to safely manage her pregnancy. This relates to her failure to obtain prenatal care before birth, her lifestyle of drug use that cannot safely support an infant, and the possibility that she is not well supported by friends, family or significant others. 

2. Risk for disturbed Maternal/Fetal Dyad R/T substance abuse AEB challenging feedings, mother unable to adequately care for her infant, involvement of social services
This nursing diagnosis describes the possible problems between the mother and infant that may occur after birth. Their relationship may be disrupted by the symptoms of NAS the infant will experience which can be very traumatic for both the baby and the mother. It also involves the mothers inability to provide the care the infant needs. Finally, the required involvement of social services may lead to removal of the infant from the mother's care. This can be traumatic for both the infant and the mother. Watch the video below to see an expectant mother's experience with NAS and her desire to get help for her next infant.

3. Ineffective breastfeeding R/T withdrawal symptoms, neonatal abstinence syndrome (NAS) AEB increased infant crying, infant crying at breast, failure to latch, infant irritability
This nursing diagnosis addresses the potential problems infants affected by NAS may have in breastfeeding. Often, the symptoms of NAS involve excessive crying, irritability and inability to self-calm which infants should normally be able to do in order to begin breastfeeding. Mothers of infants with NAS often have many challenges breastfeeding. Healthcare professionals must be available to help the mother and assist her with breastfeeding.

4. Disorganized infant behavior R/T prenatal substance abuse AEB tremors, jitteriness, hyperactivity, fever, sweating, nasal flaring, respiratory distress, poor feeding, myoclonic jerking, seizures, GI disturbances
This diagnosis describes the challenges the infant may have in adjusting to new life with the onset of traumatic withdrawal syndromes. The symptoms listed above could develop into dangerous conditions such as serious breathing complications, inability to self-regulate temperature, malnutrition, brain damage and extreme fatigue. For more information about symptoms of NAS click here for a link to an earlier blog post.

The challenges faced by the drug-addicted mother and her infant suffering from NAS are extensive and have emotional, physiological and social implications as explained above. Expectant mothers who are addicted to substances must seek support from their local birthing center, primary care provider, addiction support facilities, and other community resources to ensure safe pregnancy and delivery, and to ensure their newborn starts life with the highest quality care and attention.

Apps Related to Neonatal Abstinence Syndrome

The following apps may be useful for healthcare professionals who are working with infants suffering from Neonatal Abstinence Syndrome. The first two are related to scoring and determining treatment pathways based on published research. The second two could be recommended to parents who are dealing with NAS. The first is a feeding reminder and tracking app. Because treatment of withdrawal symptoms involves physical touch and comfort measures as well as medicine, it is important for parents to have reminders about feeding and comfort care. The last app may be helpful for parents who are seeking treatment or support during their recovery. Click the titles below to download each app!

Neonatal Drug Withdrawal Tools
FREE
Created by: Kyle Gunter PharmD BCPS
Category: Medical
"Neonatal Drug Withdrawal Syndrome also known as Neonatal Abstinence Syndrome (NAS) is an ever increasing problem among newborn infants. Recent studies have shown a three fold increase in NAS diagnosis over the past decade. The Neonatal Drug Withdrawal Tools App provides the busy clinician with a tool for treating NAS in a quick and intuitive manner. These protocols are based on published studies and provide an evidenced based method for treating neonatal drug withdrawal in newborns. This app is intended for Pediatricians, Neonatologists, Neonatal Nurse Practitioners, Pharmacists and other Pediatric Health Professionals."

Neonatal Abstinence Scoring Record Mobile App
FREE
Created by: Team Canvas
Category: Health Care & Social Services
"The Neonatal Abstinence Scoring Record mobile app allows hospitals and physicians to complete a medical Neonatal Abstinence Scoring Record using a Smartphone or Tablet. The app covers: System Signs and Symptoms for the Central Nervous System, Metabolic and Vascular Motor and Gastrointestinal. This app allows nurse to make notes and captures signature."

iBaby Feed Timer - Breastfeeding, Nursing, Bottle Feeding & Baby development log

$4.99

Created by: Fehners Software LLP

Category: Medical, Lifestyle

"Designed by and for breastfeeding mothers who want to track when and for how long their baby feeds, including a useful reminder for when a feed is due. It even tells you which breast to start on!

Baby Feed Timer does it all for you!
Tracks breastfeeds, bottle feeds, breast pumps, diapers, sleep, solid food, weight, length, notes and reminders(ideal for recording baby's temperature and medicine given)."

Addicaid

FREE
Created by: Twistor Labs, Inc.
Category: Medical
"Addicaid is a new way to begin or maintain your recovery. We cater to moderation management and sobriety. Find and rate meetings, track your progress with custom daily goals with the support of our intimate community. And when you're done clicking around there, you can stay inspired and motivated with our curated news, videos, and music feed. 

We have both 12-step and alternative support groups in our directory.

App features include:

Meetings
• List meetings so you can read them.
• Map out meetings so you can see them.
• Provides directions so you can get there.
• Save to calendar so you remember to go there.
• Check in to meetings so you can prove you were there.
• Favorite, comment, and tag meetings so people know what you think.

Social
• Comment on member goals to give and get community support.
• Add friends
• Public and private chats 
• SOS Alerts for times of need

Personal
• Journal entries
• Daily check-ins
• Custom goals with audio/text response

Resources
• Hotlines
• Inpatient treatment 
• Spending calculator 
• Eating regimen to reduce cravings 
• Relapse prevention tips"

Diagnosing Neonatal Abstinence Syndrome

Neonatal Abstinence Syndrome is identified and diagnosed through the use of several tools including clinical presentation scoring, maternal history, and toxicology screening of tissue samples.

Figure 1. Neonatal Abstinence Scoring System.

Clinical Presentation
After birth during the first few hours/days of life, a newborn is frequently assessed by nurses, pediatricians and other medical professionals. While there are many expected behaviors from newborns such as crying, fussing, acting hungry, etc. there are some behaviors that are abnormal and may mean there is a problem. Signs and symptoms of NAS will be further discussed in another blog post, but a scoring system (Figure 1) is used to standardize documentation of

concerning behaviors that may indicate NAS (Hudak, Tan, The Committee on Drugs, & The Committee on Fetus and Newborn, 2012).

Maternal History
Questions and information about drug use history is part of almost every single hospital admission assessment. Questions about current drug use, past drug use, and drug use by partners, family, and friends are all included in an intake assessment of the mother. However, drug use is frequently under-reported so clinicians also take into account a history of unexplained term fetal demise, severe mood swing, and inconsistency in prenatal care. Additionally, toxicology screenings are done if there is suspicion of drug use based on clinical presentation or history (Hudak, et al, 2012).

Figure 2. Urine Drug Screening 

Toxicology Screenings
There has been a movement to increase the analysis of the baby’s meconium (first bowel movement) to screen for drug substances. This method of screening provides a more longitudinal look at what kinds of substances might have been used even showing substances that were used as early as the second trimester. Baby and mother urine drug screenings are extremely popular but they usually only detect substances used within the last 24-72 hours. Additional samples can be taken from maternal hair, neonatal hair, and even umbilical tissue. These are less popular because of the relatively new technology required to perform and process the screening (Murphy-Oikonen, Montelpare, Southon, Bertoldo, & Persichino, 2010).

There are many factors that contribute to the diagnosis of NAS, and medical professionals are extremely careful to use a range of objective and subjective data to confirm this diagnosis. 

References

Hudak, M., Tan, R., The Committee on Drugs, & The Committee on Fetus and Newborn. (2012) Neonatal drug withdrawal. Pediatrics, 129(2), 540-560. doi: 10.1542/peds.2011-3212

Murphy-Oikonen, J., Montelpare, W., Southon, S., Bertoldo, L., Persichino, N. (2010). Identifying infants at risk for neonatal abstinence syndrome: A retrospective cohort comparison study of 3 screening approaches. Journal of Perinatal & Neonatal Nursing, 24(4), 366-372. doi: 10.1097/JPN.0b013e3181fa13ea

Figure 1 retrieved from http://img.medscape.com/pi/emed/ckb/pediatrics_cardiac/973235-978492-156.jpg 

Figure 2 retrieved from https://www.premierintegrity.com/Images/Protocols_445.jpg