Delegation Strategies in Nursing: Task Management and Prioritization, Exams of Nursing

Download Delegation Strategies in Nursing: Task Management and Prioritization and more Exams Nursing in PDF only on Docsity! 1 VATI RN COMPREHENSIVE PREDICTOR FOCUSED REVIEW ❖ Management of Care – (9) ➢ Advance Directives – (1) ▪ Legal Responsibilities: Purpose of a Living Will (RM FUND 9.0 Chp 4) • A living will is a legal document that expresses the client’s wishes regarding medical treatment in the event the client becomes incapacitated and is facing end- of-life issues. Most state laws include provisions that protect health care providers who follow a living will from liability. ➢ Assignment, Delegation and Supervision – (2) ▪ Delegation and Supervision: Delegating Tasks to an Assistive Personnel (RM FUND 9.0 Chp 6) • Examples of tasks nurses may delegate to Aps (provided the facility’s policy and state’s practice guidelines permit) ◆ Activities of daily living (ADLs) – bathing, grooming, dressing, toileting, ambulating, feeding (without swallowing precautions), positioning ◆ Routine tasks – bed making, specimen collection, intake and output, vital signs (for stable clients) ▪ Managing Client Care: Delegation Strategy for Effective Task Management (RM Leadership 7.0 Chp 1) • Consideration for selection of an appropriate delegate include the following: education, training, and experience; knowledge and skill to perform the task; level of critical thinking required to complete the task; ability to communicate with others as it pertains to the task; demonstrated competence; the delegatee’s culture; agency policies and procedures and licensing legislation (state nurse practice acts) ➢ Case Management – (1) ▪ Cardiovascular Disorders: Tetralogy of Fallot (RM NCC RN 10.0 Chp 20) • Tetralogy of Fallot – four defects that result in mixed blood flow: Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy ◆ Cyanosis at birth: progressive cyanosis over the first year of life. Systolic murmur. Episodes of acute cyanosis and hypoxia (blue or “Tet” spells) • Surgical procedures – shunt placement until able to undergo primary repair; complete repair within the first year of life ➢ Collaboration with Interdisciplinary Team – (1) ▪ Communicable Diseases, Disasters, and Bioterrorism: CDC Reportable Diagnoses (RM CH RN 7.0 Chp 6) • Anthrax. Botulism. Cholera. Congenital rubella syndrome (CRS). Diphtheria. Giardiasis. Gonorrhea. Hepatitis A, B, C. HIV infection. Influenza-associated pediatric mortality. Legionellosis/Legionnaires’ disease. Lyme disease. Malaria. Meningococcal disease. Mumps. Pertussis (whooping cough). Poliomyelitis, 2 paralytic. Poliovirus infection, nonparalytic. Rabies (human or animal). Rubella (German measles). Salmonellosis. Severe acute respiratory syndrome- associated coronavirus disease (SARS-CoV). Shigellosis. Smallpox. Syphilis. Tetanus/C. tetani. Toxic shock syndrome (TSS) (other than Streptococcal). Tuberculosis 5 ▪ Professional Responsibilities: Demonstration of Veracity (RM Leadership 7.0 Chp 3) • Veracity: the nurse’s duty to tell the truth ➢ Legal Rights and Responsibilities – (1) ▪ Professional Responsibilities: Rights of Clients (RM Leadership 7.0 Chp 3) • Client rights are the legal guarantees that clients have with regard to their health care ◆ Clients using the services of a health care institution retain their rights as individuals and citizens of the United States. The America Hospital Association (AHA) identifies client rights in health care settings in the Patient Care Partnership (www.aha.org) ◆ Residents in nursing facilities that participate in Medicare programs similarly retain resident rights under statutes that govern the operation of these facilities • Nurse are accountable for protecting the rights of clients. Situations that require particular attention include informed consent, refusal of treatment, advance directives, confidentiality, and information security. ❖ Safety and Infection Control – (5) ➢ Accident/Error/Injury Prevention – (2) ▪ Medications Affecting Urinary Output: Indications for the Use of a Diuretic (RM Pharm RN 7.0 Chp 19) • High-ceiling loop diuretics work in the ascending limb of loop of Henle – block reabsorption of sodium and chloride and prevent reabsorption of water. Causes extensive diuresis even with severe renal impairment • They are used when there is an emergent need for rapid mobilization of fluid – pulmonary edema caused by heart failure; conditions not responsive to other diuretics, such as edema caused by liver, cardiac, or kidney disease; or hypertension ◆ Unlabeled use – hypercalcemia ▪ Seizures: Maintaining Seizure Precautions (RM NCC RN 10.0 Chp 13) • Seizure precautions for any child at risk – pad side rails of bed, crib, and wheelchair; keep bed free of objects that could cause injury; have suction and oxygen equipment available ➢ Handling Hazardous and Infectious Materials – (1) ▪ Cancer Treatment Options: Implanted Internal Radiation Device (RM AMS RN 10.0 Chp 91) • Brachytherapy describes internal radiation that is placed close to the target tissue. This is done via placement in a body orifice (vagina) or body cavity (abdomen) or delivered via IV such as with radionuclide iodine, which is absorbed by the thyroid ◆ Brachytherapy provides radiation to the tumor and a limited amount to 6 surrounding normal tissues. Waste products are radioactive until the Isotope has been completely eliminated from the body. Waste products should not be touched by anyone. • Nursing Considerations 7 ◆ Place the client in a private room away from other clients when possible. Keep door closed as much as possible. Place a sign on the door warning of the radiation source. Wear a dosimeter film badge that records personal amount of radiation exposure. Limit visitors to 30-min visits, and have visitors maintain a distance of 6 feet from the source. Visitors and health care personnel who are pregnant or under the age of 18 should not come into contact with the client or radiation source. Weal a lead apron while providing care keeping the front of the apron facing the source of radiation. Keep a lead container in the client’s room if the delivery method could allow spontaneous loss of radioactive material. Tongs are available for placing radioactive material into this container. Follow protocol for proper removal of dressings and bed linens from the room. • Client Education ◆ Inform the client of the need to remain in an indicated position to prevent dislodgement of the radiation implant. Instruct the client to call the nurse for assistance with elimination. Instruct the client and family about radiation precautions needed in health care and home environments. ➢ Standard Precautions/Transmission-Based Precautions/Surgical Asepsis – (2) ▪ Acute Neurological Disorders: Priority Intervention for Meningitis (RM NCC RN 10.0 Chp 12) • The presence of petechiae or a purpuric-type rash requires immediate medical attention • Isolate the client as soon as meningitis is suspected, and maintain droplet precautions per facility protocol – droplet precautions require a private room or a room with clients who have the same infectious disease, ensuring that each client has his or her own designated equipment. Providers and visitors should wear a mask. Maintain respiratory isolation for a minimum of 24 hr after initiation of antibiotic therapy • Monitor vital signs, urine output, fluid status, pain level, and neurologic status • For newborns and infants, monitor head circumference and fontanels for presence of or changes in bulging • Correct fluid volume deficits and then restrict fluids until no evidence of increased ICP and serum sodium levels are within the expected range • Maintain NPO status if the client has a decreased level of consciousness. As the client’s condition improves, advance to clear liquids and then a diet the client can tolerate • Decrease environmental stimuli – provide a quiet environment; minimize exposure to bright light (natural and electric) • Provide comfort measures – keep the room cool; position the client without a pillow, and slightly elevate the head of the bed. The client can also be positioned side-lying to reduce neck discomfort 10 appearance of the injury. Numerous bruises at different stages of healing can indicate ongoing bearings. Be suspicious of bruises or welts that resemble the 11 shape of a belt buckle or other object. Assess for burns. Burns covering “glove” or “stocking” areas of the hands or feet can indicate forced immersion into boiling water. Small, round burns can be from cigarettes. Assess for fractures with unusual features, such as forearm spiral fractures, which could be a result of twisting the extremity forcefully. The presence of multiple fractures is suspicious. Assess for human bite marks. Assess for head injuries, level of consciousness, equal and reactive pupils, and nausea or vomiting. ➢ Mental Health Concepts – (2) ▪ Anxiety Disorders: Expected Findings for a Client who has Social Anxiety Disorder (RM MH RN 10.0 Chp 11) • Social anxiety disorder (social phobia) – the client experiences excessive fear of social or performance situations ◆ The client reports difficulty performing or speaking in front of others or participating in social situations due to an excessive fear of embarrassment or poor performance ◆ The client might report physical manifestations (actual or factitious) in an attempt to avoid the social situation or need to perform ▪ Personality Disorders: Antisocial Personality Manifestations (RM MH RN 10.0 Chp 16) • Antisocial – characterized by disregard for others with exploitation, lack of empathy, repeated unlawful actions, deceit, and failure to accept personal responsibility; sense of entitlement, manipulative, impulsive, and seductive, nonadherence to traditional morals and values; verbally charming and engaging ➢ Support Systems – (1) ▪ Neurocognitive Disorders: Planning Care for a Stage 2 Alzheimer’s Disease (RM MH RN 10.0 Chp 17) • Stage 2: Moderate ◆ Forgetting events of one’s own history. Difficulty performing tasks that require planning and organizing (paying bills, managing money). Difficulty with complex mental arithmetic. Personality and behavioral changes: appearing withdrawn or subdued, especially in social or mentally challenging situations; compulsive, repetitive actions. Changes in sleep patterns. Can wander and get lost. Can be incontinent. Clinical findings that are noticeable to others. • Nursing Care ◆ Perform self-assessment regarding possible feelings of frustration, anger, or fear when performing daily care for clients who have progressive cognitive decline. Nursing interventions are focused on protecting the client from injury, as well as promoting client dignity and quality of life. Provide for a safe and therapeutic environment – assess for potential injury, such as falls or wandering. Assign the client to a room close to the nurses’ station for 12 close observation. Provide a room with a low level of visual and auditory stimuli. Provide for a well-lit environment, minimizing contrasts and shadows. Have 15 • Nursing actions – assess neurovascular status of the affected body part every hour for 24 hr and every 4 hr after that. Maintain body alignment and realign if the client seems uncomfortable or reports pain. Avoid lifting or removing weights. Ensure that weights hang freely and are not resting on the floor. If the weights are accidentally displaced, replace the weights. If the problem is not corrected, notify the provider. Ensure the pulley ropes are free of knots, fraying, loosening, and improper positioning at least every 8-12 hr. Notify the provider if the client experiences severe pain from muscle spasms unrelieved with medications or repositioning. Move the client in halo traction as a unit, without applying pressure to the rods. This will prevent loosening of the pins and pain. Routinely monitor skin integrity and document. Use heat/massage as prescribed to treat muscle spasms. Use therapeutic touch and relaxation techniques. • Pin Site Care – pin care is done frequently throughout immobilization (skeletal traction and external fixation methods) to prevent and to monitor for manifestations of infection (drainage and redness [color, amount, odor], loosening of pins, tenting of skin at pin site [skin rising up in]). Pin care protocols (chlorhexidine) are based on provider preference and facility policy. A primary concept of pin care is that one cotton swab is designated for each pin to avoid cross-contamination. Pin care is provided usually once a shift, 1-2 times a day, per facility protocol. ➢ Nutrition and Oral Hydration – (1) ▪ Renal Disorders: Dietary Prevention of Nephrolithiasis (RM Nutrition 6.0 Chp 14) • The most common type of kidney stone is made of calcium oxalate. Contributing factors include inadequate fluid intake, elevated urine pH, and excess excretion through the kidneys of oxalate, calcium, and uric acid. Kidney stone formation is more influenced by the amount of oxalate in the client’s system than calcium. A client who has an ileostomy has an increased risk of kidney stones • Preventative nutrition – excessive intake of protein, sodium, calcium, and oxalates (rhubarb, spinach, beets) can increase the risk of stone formation • Therapeutic nutrition – increasing fluid consumption is the primary intervention for the treatment and prevention of kidney stones. Daily fluid intake should be at least 1,500 mL to 3,000 mL. At least 8-12 oz (240-360 mL) of fluid, preferably water, should be consumed before bedtime because urine becomes more concentrated at night. Recommendation for calcium oxalate stone formation is to limit animal protein, excess sodium, alcohol, and caffeine use. Low potassium can contribute to calcium stone formation. Foods high in oxalates include spinach, rhubarb, beets, nuts, chocolate, tea, wheat bran, and strawberries, and should be limited in the diet. Avoid megadoses of vitamin C, which increase the amount of oxalate excreted. Recommendation for prevention of uric acid stones is to limit foods high in purines, which include lean meats, organ meats, whole grains, and legumes. 16 ❖ Pharmacological and Parenteral Therapies – (7) ➢ Adverse Effects/Contraindications/Side Effects/Interactions – (1) 17 ▪ Medications for Psychotic Disorders: Screening for Extrapyramidal Adverse Effects (RM MH RN 10.0 Chp 24) • Acute dystonia – severe spasm of the tongue, neck, face, and back. Crisis situation that requires rapid treatment ◆ Nursing considerations – begin to monitor for acute dystonia anywhere between 1-5 days after administration of first dose. Treat with an antiparkinsonian agents such as benztropine. IM or IV administration diphenhydramine can also be beneficial. Stay with the client and monitor the airway until spasms subside (usually 5-15 min) • Pseudoparkinsonism – bradykinesia, rigidity, shuffling gait, drooling, tremors ◆ Nursing considerations – observe for pseudoparkinsonism for the first month after the initiation of therapy. Can occur in as little as 5 hr following the first dose. Treat with an antiparkisonian agent, such as benztropine or trihexyphenidyl. Implement interventions to reduce the risk for falling. • Akathisia – inability to sit or stand still. Continual pacing and agitation ◆ Nursing considerations – observe for akathisia for the first 2 months after the initiation of treatment. Can occur in as little as 2 hr following the first dose. Manage with antiparkinsonian agents, beta blockers, or lorazepam/diazepam. Monitor for increased risk for suicide in clients who have severe akathisia • Tardive dyskinesia (TD) – late EPS, which can require months to years of medication therapy for TD to develop. Involuntary movements of the tongue and face, such as lip smacking and tongue fasciculations. Involuntary movements of the arms, legs, and trunk ◆ Nursing considerations – evaluate the client every 3 months, if TD appears, dosage should be lowered, or the client should be switched to another type of antipsychotic agent. Once TD develops, it usually dose not decrease, even with discontinuation of the medication. There is not a treatment for TD. Teach client that purposeful muscle movement helps to control the involuntary TD. • Neuroendocrine effects – gynecomastia, weight gain, menstrual irregularities ◆ Nursing considerations – monitor weight. Some clients gain 100 lb or more. Advise the client to observe for these manifestations and to notify the provider if they occur. • Neuroleptic malignant syndrome – sudden high fever, blood pressure fluctuations, diaphoresis, tachycardia, muscle rigidity, drooling, decreased level of consciousness, coma, tachypnea ◆ Nursing considerations – this life-threatening medical emergency can occur within the first week of treatment or any time thereafter. Stop antipsychotic medication. Monitor vital signs. Apply cooling blankets. Administer antipyretics. Increase the client’s fluid intake. Administer dantrolene or 20 term administration of chemotherapeutic agents, antibiotics, and total parenteral nutrition. ➢ Expected Actions/Outcomes – (1) ▪ Parkinson's Disease: Effects of Levodopa (RM AMS RN 10.0 Chp 7) 21 • When given orally, medications such as levodopa are converted to dopamine in the brain, increasing dopamine levels in the basal ganglia. Dopaminergics may be combined with carbidopa to decrease peripheral metabolism of levodopa, requiring a smaller dose to make the same amount available to the brain. Side effects are subsequently less. Due to medication tolerance and metabolism, the dosage, form of medication, and administration times must be adjusted to avoid periods of poor mobility ◆ Nursing considerations – monitor for the “wearing-off” phenomenon and dyskinesias (problems with movement), which can indicate the need to adjust the dosage or time of administration or the need for a medication holiday ➢ Medication Administration – (4) ▪ Bipolar Disorder: Teaching the Client About a Mood Stabilizer (RM Pharm RN 7.0 Chp 9) • Expected pharmacological action – lithium produces neurochemical changes in the brain, including serotonin receptor blockade. There is evidence that the use of lithium can show a decrease in neuronal atrophy and/or an increase in neuronal growth • Therapeutic uses – lithium is used in the treatment of bipolar disorders. Lithium controls episodes of acute mania, and helps prevent the return of mania or depression • Nursing Administration ◆ Monitor plasma lithium levels during treatment (At initiation of treatment, monitor levels at least 5 days after starting lithium therapy and after any dosage change, until therapeutic level has been achieved; then every 1 to 3 months, depending on length of treatment and stability. Older adult clients often require more frequent monitoring. Lithium blood levels should be obtained in the morning, usually 12 hr after the last dose. During initial treatment of a manic episode, levels should be between 0.8 to 1.4 mEq/L. Maintenance level range is between 0.4 to 1.0 mEq/L. Plasma levels at or greater than 1.5 mEq/L can result in toxicity). Care for clients who have a toxic plasma lithium level in an acute care setting, and provide supportive measures. Hemodialysis can be indicated. Monitor CBC, serum electrolytes, renal function tests, and thyroid function tests during lithium therapy. Advise clients that effects begin within 7 to 14 days. Advise clients to take lithium as prescribed. Lithium must be administered in 2 to 3 doses daily due to a short half-life. Taking lithium with food will help decrease GI distress. Encourage clients to adhere to laboratory appointments needed to monitor lithium effectiveness and adverse effects. Emphasize the high risk of toxicity due to the narrow therapeutic range. Provide nutritional counseling. Stress the importance of adequate fluid and sodium intake. Instruct clients to monitor 22 for manifestations of toxicity and when to contact the provider. Clients should withhold medication and seek medical attention if experiencing diarrhea, vomiting, or excessive sweating. Conditions that cause dehydration, such as exercising in hot weather or diarrhea, put client at risk for lithium toxicity. 25 ➢ An IV line is inserted and maintained until full recovery. Electrodes are applied to the scalp for electroencephalogram (EEG) monitoring. The client receives 100% oxygen during and after ECT until the return of spontaneous respirations. Ongoing cardiac monitoring is provided, including blood pressure, electrocardiogram (ECG), and oxygen saturation. Clients are expected to become alert about 15 min following ECT. ▪ Cystic Fibrosis: Client Teaching about Pancrelipase (RM NCC RN 10.0 Chp 19) • Pancrelipase treats pancreatic insufficiency associated with cystic fibrosis ◆ Nursing considerations – monitor stools for adequate dosing (1-2 stools/day). Administer capsules with all meals and snacks. Client can swallow or sprinkle capsules on food. Increase dosage of enzymes when eating high-fat foods. ▪ Electrolyte Imbalances: Safe Potassium Administration (RM AMS RN 10.0 Chp 44) • IV potassium supplementation – never administer by IV push (high risk of cardiac arrest). The maximum recommended rate is 10 mEq/hr. ❖ Reduction of Risk Potential – (6) ➢ Potential for Complications of Diagnostic Tests/Treatments/Procedures – (2) ▪ Cardiovascular Diagnostic and Therapeutic Procedures: Priority Intervention Postangiography (RM AMS RN 10.0 Chp 27) • Nursing Actions – assess vital signs every 15 min x 4, every 30 min x 2, every hour x 4, and then every 4 hr (Follow facility protocol). Assess the groin site at the same intervals for: bleeding and hematoma formation. Thrombosis (Document pedal pulse, color, temperature). Maintain bed rest in supine position with extremity straight for prescribed time (a vascular closure device can be used to hasten hemostasis following catheter removal. Older adult clients can have arthritis, which can make lying in bed for 4-6 hr after the procedure painful. The provider can prescribe medication). Conduct continuous cardiac monitoring for dysrhythmias. (Reperfusion following angioplasty can cause dysrhythmias). Administer antiplatelet or thrombolytic agents as prescribed to prevent clot formation and restenosis (Aspirin, Clopidogrel, ticlopidine, Heparin, Low molecular weight heparin [enoxaparin], GP IIb/IIa inhibitors, such as eptifibatide). Administer anxiolytics and analgesics as needed. Monitor urine output and administer IV fluids for hydration (Contrast media acts as an osmotic diuretic). Perform/assist with sheath removal from vessel (Apply pressure to arterial/venous sites for the prescribed period of time [varies depending upon the method used for vessel closure], observe for vagal response [hypotension, bradycardia] from compression of nerves, apply pressure dressing) • Client education – instruct the client to do the following (leave the dressing in place for the first 24 hr following discharge; avoid strenuous exercise for the prescribed period of time; immediately report bleeding from the insertion site, chest pain, shortness of breath, and changes in the color or temperature of the 26 extremity; restrict lifting to less than 10 lb (4.5 kg) for the prescribed period of time). Clients who have stent placement will receive anticoagulation therapy for 27 6-8 weeks. Instruct the client to: (take the medication at the same time each day. Have regular laboratory tests to determine therapeutic levels. Avoid activities that could cause bleeding. (Use soft toothbrush. Wear shoes when out bed). Encourage the client to follow lifestyle guidelines (manage weight. Consume a low-fat/low- sodium diet. Exercise regularly. Stop smoking. Decrease alcohol intake) • Complications ◆ Cardiac tamponade – can result form fluid accumulation in the pericardial sac ➢ Manifestations include hypotension, jugular venous distention, muffled heart sounds, and paradoxical pulse (variance of 10 mm Hg or more in systolic blood pressure between expiration and inspiration) ➢ Hemodynamic monitoring reveals intracardiac and PAPs are similar and elevated (plateau pressures) ➢ Nursing actions – notify the provider immediately. Administer IV fluids to combat hypotension. Obtain a chest x0ray or echocardiogram to confirm diagnosis. Prepare the client for pericardiocentesis (Verify informed consent. Gather materials. Administer medications as appropriate). Monitor hemodynamic pressures. Monitor heart rhythm. Changes indicate improper positioning of the needle. Monitor for reoccurrence of manifestations after the procedure ◆ Hematoma formation – blood clots can form near the insertion site ➢ Nursing actions – assess the groin at prescribed intervals and as needed. Hold pressure for uncontrolled oozing/bleeding. Monitor peripheral circulation. Notify the provider ◆ Restenosis of treated vessel – clot reformation in the coronary artery can occur immediately or several weeks after procedure ➢ Nursing actions – assess ECG patterns and for occurrence of chest pain. Notify the provider immediately. Prepare the client for return to the cardiac catheterization laboratory ◆ Retroperitoneal bleeding – bleeding into retroperitoneal space (abdominal cavity behind the peritoneum) can occur due to femoral artery puncture ➢ Nursing actions – assess for flank pain and hypotension. Notify the provider immediately. Administer IV fluids and blood products as prescribed ▪ Disorders of the Eye: Identifying Postoperative Risk (RM AMS RN 10.0 Chp 12) • Infection – infection can occur after surgery ◆ Client education – manifestations of infection that the client should report include yellow or green drainage, increased redness or pain, reduction in visual acuity, increased near production, and photophobia • Bleeding – bleeding is a potential risk several days following surgery 30 of leakage of cerebrospinal fluid). Maintain the client in a high-Fowler’s position. 31 Monitor fluid balance, especially greater output than intake (DI). Encourage deep breathing exercises, but limit coughing as this increases intracranial pressure and can cause a leak of cerebrospinal fluid (CSF). Assess for manifestations of meningitis. Administer replacement hormones. ➢ Hemodynamics – (1) ▪ Electrocardiography and Dysrhythmia Monitoring: Identifying the Need for Anticoagulation Therapy (RM AMS RN 10.0 Chp 28) • Clients who have atrial fibrillation of unknown duration must receive adequate anticoagulation for 4-6 weeks prior to cardioversion therapy to prevent dislodgement of thrombi into the bloodstream ➢ Medical Emergencies – (1) ▪ Emergency Nursing Principles and Management: Priority Assessment (RM AMS RN 10.0 Chp 2) • ABCDE Principle ◆ A = airway/cervical spine ◆ B = breathing ◆ C = circulation ◆ D = disability ◆ E = exposure ▪ Head Injury: Identifying Indications of a Skull Fracture (RM AMS RN 10.0 Chp 14) • Skull fractures can occur following forceful head injury. The brain might be damaged as a result. The client can have localized pain at the site of the fracture, and swelling can occur. The nurse should be alert for drainage from the ears or eyes (cerebral spinal fluid [CSF]) ➢ Unexpected Response to Therapies – (2) ▪ Assessment and Management of Newborn Complications: Neonatal Abstinence Syndrome (RM MN RN 10.0 Chp 27) • Long-term complications – feeding problems; central nervous system dysfunction (cognitive impairment, cerebral palsy); attention deficit disorder; language abnormalities; microcephaly; delayed growth and development; poor maternal- newborn bonding • Expected findings – monitor the neonate for abstinence syndrome (withdrawal) and increased wakefulness using the neonatal abstinence scoring system that assesses for and score the following: ◆ CNS: High-pitched, shrill cry; incessant crying; irritability; tremors; hyperactivity with an increased Moro reflex; increased deep-tendon reflexes; increased muscle tone; disturbed sleep pattern; hypertonicity; convulsions ◆ Metabolic, vasomotor, and respiratory findings: Nasal congestion with flaring, frequent yawning, skin mottling, retractions, apnea, tachypnea greater than 60/min, sweating, temperature greater than 37.2° C (99°F) 32 ◆ Gastrointestinal: Poor feeding; regurgitation (projectile vomiting); diarrhea; excessive, uncoordinated, constant sucking ◆ OPIATE WITHDRAWAL: Manifestations of neonatal abstinence syndrome