Screening and teaching for discharge
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Screening and Teaching for Discharge . Patsy J. Hammonds, RN, C, MS, CNA. Objectives. Provide recent birth and admission statistics Identify admission criterion for Level I, II, and III nurseries Evaluate the knowledge level of the parents and their educational needs

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Screening and teaching for discharge l.jpg

Screening and Teaching for Discharge

Patsy J. Hammonds, RN, C, MS, CNA


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Objectives

  • Provide recent birth and admission statistics

  • Identify admission criterion for Level I, II, and III nurseries

  • Evaluate the knowledge level of the parents and their educational needs

  • Evaluate the needs of the infant prior to and following discharge.

  • Identify screening measures necessary for appropriate discharge

  • Provide information on SIDS to increase the parents awareness of how to be proactive in the care of their infant

  • Provide information on infant care and safety issues that are relevant to the care of an infant being discharge from the hospital

  • Identify home care needs and red flags


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General Birth and Admission Statistics for 2006-2007

  • 4.3 million infants born in the US

  • 148,403 infants born in GA

  • 21,007 Preterm infants born in GA

  • 14,209 LBW infants <2500gms in GA

  • 2,682 VLBW infants <1500gms in GA

    The data above was obtained from the Georgia Department of Human Resources, Division of Public Health http://health.state.ga.us

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Statistics Continued

  • 10-12% of all infants (preterm and term) are admitted to Level II or Level III Nurseries

  • Average LOS <1500grams: 2-4 months; LOS >1500 grams: 17-30 days

  • Neonatal survival for 23-25 weeks gestation is 11-76%

  • 27% of infants <1000gms at birth who have normal Head Ultrasounds at discharge have severe to moderate CP or other severe neurodevelopmental challenges.

    Kelly M. Journal of Pediatric Health Care “The Medically Complex Premature Infant in Primary Care” November/ December (2006) 20 (6)367-373


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>34 weeks, healthy

Absence of prenatal care

Birth trauma

Murmur

Hyperbilirubinemia

Infant of a Diabetic Mother (IDDM)

Infection risk factors (GBS, PROM, elevated temperature…(etc.)

Substance abuse

Temperature control issues

Weight loss >8%

Need for further non-oxygen observation (TTN, transition)

Need for Admission into a Level I, Newborn Nursery


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RDS (minimal-moderate O2 need)

Spontaneous pnuemothorax

TTN

Feeding issues (cleft’s, etc.)

Apnea of prematurity

<34 weeks gestation or <2250 grams**(This is changing in some instances as insurance companies are refusing to pay for the low birth weight infants in the Intermediate Nurseries)

Infection

Narcotic withdrawal

IV therapy for glucose management

Perinatal challenges during birth (asphyxia, etc.)

Monitoring (arrhythmias, etc.)

Need for Admission into a Level II Intermediate Care Nursery


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Respiratory distress or respiratory failure

Prematurity (<1250 grams or <30 weeks gestation

Cardiac deficit

Diaphragmatic hernia

Hematologic issues (DIC, hemolytic disorders, etc)

Neurologic deficits (seizure activity, depressed skull fracture, etc)

Congenital anomalies requiring supportive or diagnostic care

Abdominal wall defects (i.e. gastroschisis, omphalocele)

Neurologic defects (i.e. hydrocephalous, myelomeningocele)

Post operative monitoring

Need for Admission into a Level III NICU Nursery


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WHEN SHOULD YOU START DISCHARGE PLANNING???

Discharge planning should start the day of delivery.

Waiting until the day of discharge is too late!!!


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Remember to plan ahead!Keep families informed. Educate them as you help them to prepare for their transition home.


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Using a team approach is the best way to plan.

  • Parents

  • Physicians

  • Nurses

  • Patient Care Coordinator

  • Lactation

  • Respiratory Therapy

  • Speech-Language

  • Physical/Occupational Therapy

  • Nutrition

  • Pharmacists


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Parents

  • Most important members of the discharge team, they are the one’s that are taking the infant home

  • Must learn to care for the infant

  • Must be prepared with the necessary items at home to care for the infant

  • Must be versed on special needs that the infant may have


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Physicians and Nurses

  • Provide the level of care that the infant needs

  • Observe the infant’s and parents status day to day.

  • Interact with the family unit daily

  • Bring in other team members as needed and have periodic meetings as necessary throughout the stay, keeping the family informed as the infant makes progress, with the ultimate goal being discharge.


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Limited financial resources/no insurance

Documented substance abuse during pregnancy/positive drug screen

Documented signs/symptoms of abuse/neglect/domestic violence

Terminal stages of illness

New diagnosis of Cancer

History of postpartum depression

No prenatal care/limited prenatal care

Adoption/surrogate birth

Teen pregnancy

HIV/AIDS

Patient unable to care for self or infant

Extended length of stays for either vaginal or cesarean births

Patient Care Coordinationchecks on many things…


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If the infant requires home nursing or home care equipment, be sure to keep in close contact with your facility’s discharge planner or case manager.

It may take several days to weeks for approval and arrangement of home care and equipment.


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Lactation be sure to keep in close contact with your facility’s discharge planner or case manager.

  • Preterm baby

  • Infants with a dysfunctional suck

  • Multiple gestation

  • Baby in NICU or Intermediate Nursery

  • H/O breast reduction/augmentation

  • Flat or inverted nipples

  • Baby weight loss greater than 10%

  • Patient’s request

  • Lactation will see all families, including bottle feeding infants to help with feeding difficulties


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Respiratory Therapy be sure to keep in close contact with your facility’s discharge planner or case manager.

  • Collaborate with the physician and the nursing staff to treat infants with any breathing problems

  • Participate with the group as the infant and the family is prepared for discharge


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Speech and Language Therapy be sure to keep in close contact with your facility’s discharge planner or case manager.

  • Baby with poor coordination with feeds (i.e. suck, swallow, breath and initiation)

  • Baby with any oral motor abnormality

  • Baby greater than 34 weeks with feeding problems


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Physical/Occupational Therapy be sure to keep in close contact with your facility’s discharge planner or case manager.

  • Baby with hypersensitivity and/or compromised neurological status

  • Baby with poor tone or abnormal resistance to movement and greater than 34 weeks


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Pharmacists be sure to keep in close contact with your facility’s discharge planner or case manager.

  • Reviewing discharge medications

  • Helping secure special medications for the preterm infant being discharged home


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Newborn metabolic screening* be sure to keep in close contact with your facility’s discharge planner or case manager.

Hearing screening*

Eye exams*

Hepatitis B vaccine*

Car seat test*

Synagis*

Safety*

Feeding and elimination*

Baby care*

Red Flags*

Discharge Packet, Information and Teaching


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Home phototherapy be sure to keep in close contact with your facility’s discharge planner or case manager.

CPR instruction

Lactation instruction and support

Discharge summary

Babies Can’t Wait or other developmental assistance programs

Home health arrangements if necessary (O2, feeding, equipment, apnea monitor, phototherapy, etc.)

Follow-up with Pediatrician, and Specialist visits as needed.

Discharge Packet, Information and Teaching


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Georgia Newborn Screening Program be sure to keep in close contact with your facility’s discharge planner or case manager.

  • Effective January 1, 2007

  • The Georgia Newborn Screening Panel has expanded its screening tool from 13-29 tests.

  • There will be a $40.00 fee for specimens.

  • Georgia Newborn Screening website for updates: http://health.state.ga.us/programs/nsmscd/

    Georgia Department of Human Resources, Division of Public Health, Newborn Screening Program http://health.state.ga.us/programs/nsmscd/


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Why do we do Newborn Screening? be sure to keep in close contact with your facility’s discharge planner or case manager.

  • Newborn screening can identify potentially fatal diseases or ones that may cause extensive brain damage within the first few days of life.

  • All are treatable with diet and/or medications and it is important to get treatment early.

  • It is a test required by Georgia Law.


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Phenylketonuria be sure to keep in close contact with your facility’s discharge planner or case manager.

Congenital Hypothyroidism

Maple Syrup Urine Disease

Galactocemia

Tyrosinemia

Homocustinuria

Congenital Adrenal Hypoplasia

Biotinidase Deficiency

Medium Chain Acyl-CoA Dehydrogenase Deficiency (MCADD)

Sickle Cell Anemia (3 types)

Isovaleric acidemia

Glutaric acidemia type I

3OH-3-CH3 glutaric aciduria

Multiple carboxylase deficiency

Methylmalonic acidemias (2 types)

3 Methylcrotonyl-CoA carboxylase deficiency (3MCC)

Propionic acidemia

Beta- ketothiolase deficiency

Very long-chain acyl-CoA dehyrogenase deficiency (VLCAD)

Long-chain L-3-OH acyl CoA dehydrogenase deficiency (LCHAD)

Trifunctional protein deficiency

Carnitine uptake defect

Citrulinemia

Argininosuccinic acidemia

Cystic fibrosis

Newborn Screening as of January 1, 2007


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Newborn Hearing Screening be sure to keep in close contact with your facility’s discharge planner or case manager.

  • Can be done within a few hours after birth (results can be affected by debris and fluid in the ear canals)

  • Allows for early treatment if hearing loss is found

  • Early treatment can improve the baby’s language and brain development

  • May be delayed if currently on or recently on antibiotic therapy

  • Hearing screening and follow-up are tracked by the State just like the Metabolic Screening


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Infant Eye Exams be sure to keep in close contact with your facility’s discharge planner or case manager.

Eye exams when applicable:

  • Infant birth weight less than 1300 grams (gestational age < 30 weeks)

    • Perform initial eye exam at 4-6 weeks of age

    • Continue Q1-2 week follow-up until satisfactory development

  • Infant birth weight less than 1800 grams (gestational age <36 weeks) and received Supplemental Oxygen

    • Perform initial eye exam at 5-7 weeks of age

    • Continue Q1-2 week follow-up until satisfactory development

  • Infants with prolonged Supplemental Oxygen exposure see above guidelines


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    Hepatitis B Vaccine be sure to keep in close contact with your facility’s discharge planner or case manager.

    All infants should get their first Hepatitis B vaccine prior to discharge from the hospital and should complete the series by 6-18 months of age.


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    Immunizations be sure to keep in close contact with your facility’s discharge planner or case manager.

    American Academy of Pediatrics 2008 Guidelines.


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    Infant Car Seat Safety be sure to keep in close contact with your facility’s discharge planner or case manager.

    • 98 % of infants under the age of 1 year are restrained when riding in vehicles

    • 80% of child restraint devices are used incorrectly

    • Motor vehicle accidents remain the leading cause of death in children under 4 years of age

    • Infants should be in rear facing car seats that are secured in the back seat until 1 year of age AND20 pounds


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    3-M’s of Infant Car Seat Safety be sure to keep in close contact with your facility’s discharge planner or case manager.

    Measurement Mounting Mobility

    **According to the AAP, infants <2500 grams or <37 weeks

    gestation at birth should be tested.


    Definition of sudden infant death syndrome sids l.jpg
    Definition of Sudden Infant Death Syndrome (SIDS) be sure to keep in close contact with your facility’s discharge planner or case manager.

    The sudden and unexpected death of an apparently healthy infant usually under one year of age which remains unexplained after a:

    --complete medical history

    --death scene investigation

    --postmortem examination

    SIDS is a diagnosis of Exclusion


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    What We Know be sure to keep in close contact with your facility’s discharge planner or case manager.

    • The cause(s) of SIDS remains unknown

    • SIDS cannot be predicted or prevented

    • No one is to blame for a SIDS death

      • Not parents

      • Not caregivers

      • Not emergency personnel or other health care providers


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    What Happens be sure to keep in close contact with your facility’s discharge planner or case manager.

    • Baby is usually healthy or may have had sniffles or a cold

    • Baby is put down for a nap or night

    • Found dead minutes to hours later

    • No sign of struggle or distress

      SIDS can happen in any family


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    Facts about SIDS be sure to keep in close contact with your facility’s discharge planner or case manager.

    • The leading cause of death in infants between one month and one year of age in the U.S.

    • Happens in about one of every 1000 live births

    • Happens most often between two and four months of age

    • Happens most often in the winter

    • Incidences of SIDS doubles in the African American population and triples in the Native American population


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    SIDS is be sure to keep in close contact with your facility’s discharge planner or case manager.NOT Caused By:

    • Suffocation

    • Vomiting or choking

    • Child abuse

    • Disease or illness

    • Immunizations


    Maternal risk factors l.jpg
    Maternal Risk Factors be sure to keep in close contact with your facility’s discharge planner or case manager.

    • Young--- less than 19 years of age

    • Tobacco use doubles the risk of SIDS

    • Substance use is associated with increased risk

    • Limited or late prenatal care

    • Short intervals between pregnancies


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    Infant Risk Factors for SIDS be sure to keep in close contact with your facility’s discharge planner or case manager.

    • Male gender

    • Infant age

    • Low birth-weight

    • Multiple births

    • Premature birth

      Babies can die of SIDS without having risk factors!


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    Multifactorial SIDS Theory be sure to keep in close contact with your facility’s discharge planner or case manager.

    Infant’sPhysiologicResponses

    SIDS

    Development

    Environment


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    Infant’s Physiologic Responses be sure to keep in close contact with your facility’s discharge planner or case manager.

    • Oxygen reduced, carbon dioxide increased

    • Arousal response deficit

    • Subtle brainstem dysfunction

    • Slow development


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    Development—Age Vulnerability be sure to keep in close contact with your facility’s discharge planner or case manager.

    • 2-4 months-------75%

    • 4-6 months-------15%

    • Respiratory system is unstable in all infants

    • May take less of an environmental stress to trigger SIDS at this age


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    Environmental Factors be sure to keep in close contact with your facility’s discharge planner or case manager.

    • Sleep positions

    • Smoking

    • Bedding

    • Swaddling

    • Season

    • Minor Respiratory Symptoms

    • Drug use

    • Poverty

    • Limited prenatal care


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    Ten Ways to Reduce the Risk of SIDS be sure to keep in close contact with your facility’s discharge planner or case manager.

    • Always place a baby on his or her BACK TO SLEEP even for naps.

    • Never allow smoking around a baby.

    • Place a baby on a firm, flat surface to sleep.

    • Remove all soft things such as loose bedding, pillows, and stuffed toys from the sleep area.

    • Never place a baby on a sofa, waterbed, soft chair, pillow or bean bag.

    • Take special precautions when a baby is in bed with you. (Infant should sleep alone, no co-bedding)

    • Make sure a baby doesn’t get too hot.

    • Keep baby’s face and head uncovered during sleep.

    • Share this information with everyone who cares for the baby

    • Consider using a pacifier at nap and bedtime once breastfeeding has been well established.


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    Smoking be sure to keep in close contact with your facility’s discharge planner or case manager.

    • Respiratory infections are frequent infants who are exposed to smoke from cigarettes.

    • Smoking is one factor associated with Sudden Infant Death Syndrome

    • Parents who smoke should be encouraged to quit, otherwise to smoke only outside the home as smoke is absorbed by the infant even when the smoking occurs in another room in the house.

    • Advise the parents not to smoke in the car or closed spaces around the infant.


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    Synagis be sure to keep in close contact with your facility’s discharge planner or case manager.

    • Synagis is given to the infant to protect them from RSV.

    • Respiratory syncytial virus (RSV) is the most common cause of bronchiolitis and pneumonia among infants and children under 1 year of age.

    • During their first RSV infection, between 25% and 40% of infants and young children have signs or symptoms of bronchiolitis or pnuemonia.

    • The majority of children hospitalized for RSV infection are under 6 months of age.

    • Indications: Siblings school age or in day care, smokers in the home, congenital heart disease, or less than 35 weeks.

      **Synagis is not a vaccine or an immunization.


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    Baby Care be sure to keep in close contact with your facility’s discharge planner or case manager.

    • Discuss circumcision with the OB or Pediatrician.

    • Do not clean the umbilical stump with alcohol or soap and water.

    • Fold the diaper down below the umbilical stump to allow for drying.

    • It is not necessary for daily baths.

    • The infant should not be submerged in a bath tub until the umbilical stump and/or the circumcision is completely healed.

    • Be sure to wash hands before and after diaper changes.

    • Check and change diapers prior to and after feedings.


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    Feeding and Elimination be sure to keep in close contact with your facility’s discharge planner or case manager.

    • 6-8 wet diapers per day

    • 1-3 stools per day (more if breast feeding)

    • Wash your hands before and after each feeding

    • Discuss with your Pediatrician or Lactation Consultant regarding a breast feeding plan

    • DO NOT BOTTLE PROP

    • Do not microwave breast milk or formula

    • Do not give infant water

    • Do not dilute ready to feed formula, and always prepare the concentrated formula, and powdered formula according to directions

    • Do not give infant honey or sugar


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    RED FLAGS- be sure to keep in close contact with your facility’s discharge planner or case manager. When to Call or See the Pediatrician

    • Labored or difficulty with breathing

    • Bleeding from orifices

    • Changes in skin color (yellowing of skin or bluish/gray tinge

    • Excessive vomiting

    • Refusal to feed several times in a row

    • Excessive lethargy or weakness

    • Signs of pain (excessive crying or screaming)

    • Fever greater than or equal to 100.4 degrees

    • Irritated eyes with drainage


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    Safety be sure to keep in close contact with your facility’s discharge planner or case manager.

    • Protect infant from infection by limiting exposure to crowds, sick individuals, or toddlers for the first month.

    • Dress the infant appropriately for the temperature, do not overdress.

    • Avoid direct sun exposure (>15 minutes).

    • Stress the importance of car seat restraint.

    • Reinforce that seats must be used properly.

    • Encourage parents to examine toys and small objects for loose parts that could obstruct airways as well as rattles that contain small objects that could choke the baby if the rattle breaks.


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    Safety be sure to keep in close contact with your facility’s discharge planner or case manager.

    • If pacifier is needed, encourage a one-piece pacifier that cannot come apart and cause choking

    • Never tape or tie the pacifier to the infant

    • Advise parents to remove items from a baby’s reach that can be harmful and put all medication/toxic substances out of reach of children

    • Check the crib to be sure that the slats are no greater than 23/8 inches apart

    • The mattress should be firm, pillows, bumper pads, wedgies, and stuffed animals should not be used in the crib

    • Adjust the hot water supply to the faucets to the lowest tolerable setting (approximately 120 degrees)


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    Time for the Baby Bird to fly be sure to keep in close contact with your facility’s discharge planner or case manager.


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    Any Questions??? be sure to keep in close contact with your facility’s discharge planner or case manager.


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    Time to Hit the Road be sure to keep in close contact with your facility’s discharge planner or case manager.


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