Module 6: Chelsea Flashcards Preview

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Flashcards in Module 6: Chelsea Deck (53)
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1
Q

Some of the drugs most often associated with substance use include:

A

-alcohol
-amphetamines
Ritalin
-barbiturates
Seconal, Nembutal, Amytal, Tuinal
-benzodiazepines
Xanax, valium, Ativan, Halcion
-cocaine
-opioids
morphine, codeine, methadone

2
Q

There are different approaches or models for caring for substance-using women and each of these approaches views the problem through a different lens.

A

For example:

  • We may see substance use as a disease and the only “cure” is abstinence.
  • We may believe people with substance-use problems are weak or flawed in some way and the answer lies in enforced treatment.
  • We may believe that drug use is part of our world and the goal is to reduce the harmful effects of the substances.
3
Q

Harm Reduction Model

A

A harm reduction model of care is a public health approach that aims to reduce the harmful consequences associated with recreational drug use and other high-risk activities. “Harm reduction is a set of practical strategies that reduce negative consequences of drug use, incorporating a spectrum from safer use, to managed use to abstinence.” (BC Women’s Hospital & Health Centre, 2006, p. 50). The harm reduction model also takes into account the impact of poverty, class, racism, trauma, and social inequalities on a person’s vulnerability to and capacity for dealing with substance use (BC Women’s Hospital and Health Centre, 2006).

4
Q

Some examples of harm reduction programs are:

A

heroin maintenance programs
safe injection sites
needle exchange programs
safer sex programs

5
Q

Some of the existing programs in Canada that provide services for women who use substances during pregnancy via a women-centered harm reduction model are:

A
  • Sheway
  • Fir Square Unit
  • Breaking the cycle
  • Motherfirst, Kidsfirst
6
Q

Sheway, Vancouver BC

A

Provides comprehensive health and social services to women who are either pregnant or parenting children less than 18 months old and who are experiencing current or previous issues with substance use. The program consists of prenatal, postnatal and infant health care, education and counseling for nutrition, child development, addictions, HIV and hepatitis C, housing and parenting. Sheway also assists in fulfilling basic needs, such as providing daily nutritious lunches, food coupons, food bags, nutritional supplements, formula, and clothing.

7
Q

Fir Square Unit, BC Women’s Hospital

A

The program helps women and their newborns stabilize and withdraw from substances, keeping mothers and babies together whenever possible and continuing to provide care from antepartum to postpartum and between hospital and community. Women at Fir Square have access to counseling and instruction to enhance critical life skills, parenting techniques, and coping mechanisms. Babies receive specialized care that meets their needs, if withdrawing from prenatal substance exposure to ensure the healthiest possible start. Babies room in with their mothers on the ward.

8
Q

Breaking the Cycle, Toronto

A

Breaking the Cycle (BTC) is an early identification and prevention program designed to reduce risk and to enhance the development for substance-exposed children (prenatal–6 years). They provide services which address maternal addiction problems and the mother-child relationship through a community-based cross-systemic model. Families receive integrated addictions counseling, health/medical services, parenting support, development screening and assessment, early childhood interventions, child care, access to FASD Diagnostic Clinic, and basic needs support in a single access setting in downtown Toronto, with home visitation and street outreach components.

9
Q

MotherFirst, KidsFirst, Regina

A

Provides support to vulnerable expectant and new mothers. Assists families in becoming the best parents that they can be, by providing support, enhancing knowledge and building on family strengths.

10
Q

What is it important for nurses to understand when working with this demographic?

A

What is important for nurses to understand is that women presenting with substance-use problems often are dealing with other problems such as poverty, unstable housing, abusive partners, mental health problems, social isolation, and fear of authorities. While we acknowledge that it is often difficult to care for women with substance use problems, we need to remember that the behaviors we might view as manipulative or disrespectful are behaviors they have developed in order to survive.

11
Q

The 12 determinants of health that have been identified are:

A
Aboriginal status
Early life
Education
Employment and working conditions
Food security
Health services
Gender
Housing
Income and its distribution
Social safety net
Social exclusion
Unemployment and employment security
12
Q

Income

A

The Canadian Perinatal Health Report (2008) supports the fact that socioeconomic status is a determinant of perinatal health. Infant mortality is widely regarded as a general indicator of population health. Infant mortality rates among low income groups in urban Canada were two-fold higher than the rates in the highest income groups.

Zhong-Cheng et al (2006) observed higher rates of preterm birth, small for gestational age, still-birth, neonatal death and post neonatal death among mothers of poorer neighborhoods.

The level of income shapes the basic living conditions, such as safe housing, the availability of healthy food, the extent of physical activity, tobacco use and access to education (Mikkonen & Raphael, 2010).

13
Q

Education and Employment

A

Education as a social determinant of health is often linked with other determinants such as income, employment security and working conditions. Zhong- Cheng et al (2006) identified that women with lower education levels are more vulnerable to adverse birth outcomes. This may be through lack of knowledge about antenatal care, nutrition and infant care.

14
Q

Social Support and Social Exclusion

A

Social support/exclusion can be at the individual or societal level. Lack of social support can lead to poor mental and physical health, increased risk of depression, and pregnancy complications (WHO). In Canada, groups that are often hard to reach or who do not access prenatal care and social supports include: substance-using women, immigrant women, aboriginal women, and women who are experiencing partner violence.

15
Q

Food Security and Housing

A

Food quality as well as quantity is influenced by economic conditions. Lower income or poorer people tend to replace healthy fresh food with processed, high fat, sugary foods. The WHO (2003) states that “the main dietary difference between social classes is the source of nutrients” (p. 26). Canada is, in global terms, a very rich country. However, more than one in five Canadian households are unable to find affordable healthy homes (Shapcott, 2009). Low-income families are often forced to live in illegal or substandard rental units.

16
Q

Aboriginal Health

A

Within Canada, there are three aboriginal populations: First Nations, Métis, and Inuit. When reviewing the literature there is overwhelming evidence of inequality and poverty among our aboriginal population. Aboriginal people have higher unemployment rates, lower education, experience more food insecurity, and experience a disproportionate burden of illness and early death than non-aboriginal people (Smylie, 2009).

It is well recognized that prenatal care is an important aspect of promoting maternal and neonatal health. Aboriginal women are less likely to receive prenatal care and attend prenatal classes (BC’s Aboriginal Health Project, 2006). Barriers to care include: financial barriers, services that are geared towards married non-aboriginal women, fear of medical providers, and lack of providers in their community.

17
Q

Gender

A

Neonatal nursing involves caring for women and their families. Before proceeding, let us first understand the difference between sex and gender. Sex refers to the biological differences between males and females, while gender goes beyond biology to address the social and economic context of our lives. Mikkonen and Raphael (2010) state that “women in Canada experience more adverse social determinants of health than men. The main reason for this is that women carry more responsibilities for raising children and taking care of the household. Women are also less likely to be full-time employed and are less likely to be eligible for employment benefits” (p.44). The high percentages of women living in poverty, the persistence of violence against women, and reduced federal spending on social support services are just a few of the key issues that both create and support women’s equality (Spitzer, 2009).

Gender also intersects with other factors such as race, culture and language. Aboriginal women as well as immigrant, refugee, and visible minority communities face racism as well as language and cultural barriers when seeking care.

Women’s greater exposure to poverty, discrimination, socioeconomic disadvantages and violence puts them at increased risk of health issues and substance abuse problems.

18
Q

Substance use can affect the developing fetus in 3 ways:

A

-directly on the fetus, a teratogen
birth defects
-alter function of the placenta
intrauterine growth restriction, microcephaly
-cause muscles of the uterus to contract
spontaneous abortion, or premature delivery

19
Q

After birth the newborn can be affect by the following complications:

A
withdrawal symptoms
respiratory distress
infections (HIV, hepatitis)
postnatal growth delay
feeding difficulties
long-term cognitive delays which may not manifest until school age
20
Q

Methadone

A

Methadone is a synthetic opioid used in the treatment of opioid dependency (heroin, morphine). When taken as prescribed in a daily dose methadone does not get a person high but it does stop opioid withdrawal. Methadone is the treatment of choice for the management of opioid dependence in pregnant women (Cleary, 2011).

Infants exposed to methadone antenatally do experience withdrawal and this can occur within 24 hours to up to 5–7 days after birth.

21
Q

Neonatal Abstinence Syndrome

A

Neonatal Abstinence Syndrome, also known as neonatal withdrawal, is a group of problems that occur in a newborn who was exposed to addictive illegal or prescription drugs while in the mother’s womb.

22
Q

Withdrawal symptoms may be evident between

A

1 and 7 days, but usually within 72 hours of birth

23
Q

Care of the substance-exposed infant centers around

A

creating a supportive environment, providing adequate fluids and nutrition, and promoting attachment. As is done for all newborns, assessing physiologic stability is included as part of the head-to-toe assessment.

24
Q

Alexa begins her assessment of Chelsea. She includes a routine physical assessment and assesses for signs and symptoms of substance-related problems. She uses the following mnemonic:

A
W - Withdrawal
I - Irritability
T - Tremors, temperature variations
H - Hyperactive, high pitched cry, hypotonia, hiccups
D - Diarrhoea, disorganized suck
R - Respiratory distress, rub marks, rhinorrhea
A - Apnoeic attacks
W - Weight loss, failure to gain weight
A - Alkalosis – respiratory
L - Lacrimation, lethargy

Others: vomiting; stuffy nose; yawning; skin mottling; arching of the back; intolerance to handling; sneezing; sensitive response to auditory stimuli, myoclonic jerks; exaggerated Moro responses; seizures.

25
Q

Difficulties arise when:

A

The behaviors seem to be contradictory: i.e., lethargy and hyperactivity.
The behaviors seem to be innocuous or insignificant: i.e., yawning or hiccupping.
The behaviors seem to be indicative of another problem, such as sepsis or respiratory distress: i.e., temperature instability or tachypnea.

26
Q

The most commonly used scoring tool to assess withdrawal in infants exposed to substances is the …

A

Finnegan Abstinence Scoring Sheet (or a modified form of this tool).

27
Q

Many infants being cared for in a hospital nursery will experience feeding problems.

A

The sources of these problems are varied, ranging from prematurity to oral aversion (due to suctioning, intubation, tube feeding, etc.) to respiratory distress and neurologic problems.

28
Q

How might you facilitate optimal feeding in a Hypersensitive infant and Sleepy/lethargic infant in regards to light.

A

The light in the room may have a significant impact on an infant’s feeding behavior. Typically, a brightly lit room assists in the arousal of the sleepy infant while a darkened room tends to calm an overstimulated or hypersensitive baby. In Chelsea’s case, she could become agitated (i.e., overstimulated) when attempting to eat orally so an effective strategy may be to feed her in a dimly lit room.

29
Q

How might you might facilitate optimal feeding in a Hypersensitive infant and Sleepy/lethargic infant in regards to noise?

A

Similarly, noise can have a profound impact on infant feeding. Loud noises that startle the infant are particularly disruptive. For infants like Chelsea, a quiet, calm environment is best as it allows the infant to focus on eating with a minimum of distractions. In contrast, sleepy infants may benefit from a more stimulating environment where there is music playing or people talking.

30
Q

How might you facilitate optimal feeding in an Hypersensitive infant and Sleepy/lethargic infant in regards to visual stimuli?

A

For some infants, visual stimuli can also be very disruptive to oral eating. Overhead mobiles or even the face of the parent/caregiver can be too much for some infants and will disrupt their feeding behavior. These infants are best fed facing away from the parent/caregiver (i.e., avoid eye contact) in a quiet, dimly lit room.

31
Q

How might you might facilitate optimal feeding in a Hypersensitive infant and Sleepy/lethargic infant in regards to temperature?

A

The temperature of the room can also affect infant feeding. Generally, a warm room is relaxing and induces sleep while a cool room is more alerting. The infant’s temperature can be manipulated by adjusting clothing or blankets to promote relaxation or stimulate arousal as necessary. An infant like Chelsea may benefit from being wrapped warmly in order to help calm her.

32
Q

There are a number of techniques that may be useful in modifying an infant’s state. Outline those that may be employed to calm an irritable, hypersensitive, disorganized infant.

A
  • Swaddle the infant to provide firm proprioceptive stimulation.
  • Hold the infant with hips and knees flexed, hands in midline.
  • Avoid talking to the infant while feeding.
  • Avoid making eye contact with infant.
  • Vertically rock infant slowly in an up-and-down position.
33
Q

Outline those techniques that may be employed to promote the arousal of a sleepy infant.

A

To promote arousal of a sleepy infant, the following techniques may be tried:

  • Make uneven, unpredictable movements in any direction (while supporting the head).
  • Rock the baby from side to side or in a rotary direction.
  • Play lively music.
  • Vary pitch, tone, and rhythm of voice when talking to infant.
  • Stroke palms or soles of the infant’s feet.
  • Unwrap the baby or change the diaper.
34
Q

How will you facilitate breast-feeding for Desiree and Chelsea? Some of the particular information to Chelsea and her mom include:

A

Setting an environment that is comfortable for both of them; trying to encourage mom to relax to facilitate let-down and not communicate stress to Chelsea; if Chelsea is unable to breast-feed because of her withdrawal, encourage mom to pump her breasts and save the milk for feeds.

Feeding Chelsea will require you to get to know her cues and teach them to mom. When Chelsea wakes, is she organized or frantic? Does she require minimal stimulation with feeds or is she able to handle some interaction?

35
Q

Draw upon your previous knowledge and suggest some of the ways Desiree might give Chelsea her breast milk.

A

Nasogastric (NG) or orogastric (OG) tube feedings, also referred to as gavage feedings, are frequently used for infants who have an inability to coordinate the suck/swallow sequence or have nutrient requirements that preclude nipple feedings alone.

36
Q

Should these alternatives still prove too stressful for Chelsea, what other option may be considered?

A

Another option is to infuse nutrients directly into the bloodstream via the “parenteral” method. Total Parenteral Nutrition (TPN) is usually used for infants who cannot tolerate food in their gastrointestinal tract.

37
Q

The following suggest that an infant may not be tolerating gavage feeds:

A
emesis
loose stools
irritability
firm abdomen
distended abdomen
38
Q

Doctor has ordered

total fluids 100 cc/kg/24 hr

Chelsea is 3kgs

Calculate Chelsea’s total fluids for the day

Total fluids =

A

___300___ml/day

39
Q

Calculate Chelsea’s hourly fluid intake

Hourly fluids =

A

12.5___ml/hr

40
Q

Calculate the amount that you would give with each feed

Feeds =

A

Feeds = 12.5 ml/hr × 3 hrs

37.5 ml/feed

41
Q

Describe the differences between prenatally acquired NAS and iatrogenic NAS. What are some of the similarities?

A

Prenatally acquired NAS occurs as a result of the abrupt discontinuation of opioids at birth. The infant became dependent as a result of exposure in utero through the dependency of the mother.

Iatrogenic NAS occurs as a result of rapid discontinuation as well. The opioids, in this case, were given in the NICU as analgesia and/or sedation.

42
Q

When would you expect Chelsea to start exhibiting some of the signs of NAS?

A

Chelsea was exposed to methadone in utero. According to the literature her symptoms probably will occur within the first 24-72 hours but could be delayed up to 96 hours because of the methadone.

43
Q

Use the framework: Pink, Warm, Sweet, Clean, Organized, and Attached to develop a plan of care for discharging Chelsea.

A

Your plans may vary from what is below. The goal of the plan is to have Desiree feel comfortable in all aspects of Chelsea’s care as they head for home.

Pink – safe sleeping practices, car seat safety
Warm – temperature regulation and appropriate clothing to maintain temperature
Sweet – monitor the number of diapers per day and the length of feeding
Clean – bathing techniques
Organized –recognize Chelsea’s cues and behaviours, monitor for signs of withdrawal
Attached – consoling methods, encourage developmentally supportive care

44
Q

A teratogen is an agent that can affect the development of an embryo or fetus

A

True

45
Q

Methadone makes you high

A

False

46
Q

Aboriginal status is one of the social determinants of health.

A

True

47
Q

Symptoms of Neonatal withdrawal are:

A
  • Tremors
  • Diarrhea
  • Irritability
48
Q

A safe injection site is an example of a Harm reduction Program.

A

True

49
Q

Lethargy can be a sign of

A
  • Feeding intolerance
  • Withdrawal
  • Hypoglycemia
50
Q

An infants health can be affected by:

A
  • Poverty
  • Stress
  • Substance use
  • Nutrition
51
Q

Prescribed drugs can cause no harm to a fetus.

A

False

52
Q

Iatrogenic acquired Neonatal Abstinence Syndrome can result from:

A

Discontinuation of opioids in the NICU.

53
Q

In order to support disorganized feeders you should:

A
  • provide a quiet environment

- pace feeding