Download Screening and Teaching for Discharge

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
 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
General Birth and
Admission Statistics for
2006-2007
1
 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
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 1176%
 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
Need for Admission into a
Level I, Newborn Nursery
 >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 nonoxygen observation
(TTN, transition)
Need for Admission into a
Level II Intermediate Care
Nursery
 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 III NICU Nursery
 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
WHEN SHOULD YOU
START DISCHARGE
PLANNING???
Discharge planning
should start the
day of delivery.
Waiting until the day
of discharge is too
late!!!
Remember to plan ahead!
Keep families informed.
Educate them as you help
them to prepare for their
transition home.
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
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
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.
Patient Care Coordination
checks on many things…
 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
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.
Lactation
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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
Respiratory Therapy
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
Speech and Language
Therapy
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
Physical/Occupational
Therapy
Baby with hypersensitivity and/or
compromised neurological status
Baby with poor tone or abnormal
resistance to movement and greater
than 34 weeks
Pharmacists
Reviewing discharge medications
Helping secure special medications
for the preterm infant being
discharged home
Discharge Packet,
Information and Teaching
 Newborn metabolic
screening*
 Hearing screening*
 Eye exams*
 Hepatitis B
vaccine*
 Car seat test*
 Synagis*
 Safety*
 Feeding and
elimination*
 Baby care*
 Red Flags*
Discharge Packet,
Information and Teaching
 Home phototherapy
 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.
Georgia Newborn
Screening Program
 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/
Why do we do Newborn
Screening?
 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.
Newborn Screening as of
January 1, 2007
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Phenylketonuria
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
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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 Hearing
Screening
 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
Infant Eye Exams
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
Hepatitis B Vaccine
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.
Immunizations
American Academy of Pediatrics 2008 Guidelines.
Infant Car Seat Safety
 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 AND 20 pounds
3-M’s of Infant Car Seat
Safety
Measurement
Mounting
Mobility
Definition of Sudden Infant
Death Syndrome (SIDS)
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
What We Know
 The cause(s) of SIDS remains unknown
 SIDS cannot be predicted or prevented
 No one is to blame for a SIDS death
o Not parents
o Not caregivers
o Not emergency personnel or other health
care providers
What Happens
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
Facts about SIDS
 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
SIDS is NOT Caused By:
Suffocation
Vomiting or choking
Child abuse
Disease or illness
Immunizations
Maternal Risk Factors
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
Infant Risk Factors for
SIDS
Male gender
Infant age
Low birth-weight
Multiple births
Premature birth
Babies can die of SIDS without having risk factors!
Multifactorial SIDS
Theory
Infant’s
Physiologic
Responses
SIDS
Development
Environment
Infant’s Physiologic
Responses
Oxygen reduced, carbon dioxide
increased
Arousal response deficit
Subtle brainstem dysfunction
Slow development
Development—Age
Vulnerability
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
Environmental Factors
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Sleep positions
Smoking
Bedding
Swaddling
Season
Minor Respiratory Symptoms
Drug use
Poverty
Limited prenatal care
Ten Ways to Reduce the
Risk of SIDS
 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.
Smoking
 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.
Synagis
 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.
Baby Care
 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.
Feeding and Elimination
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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
RED FLAGS- 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
Safety
 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.
Safety
 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)
Time for the Baby Bird
to fly
Any Questions???
Time to Hit the Road