Screening and Screening and Teaching for Teaching for DischargeDischarge

Screening and Screening and Teaching for Teaching for DischargeDischarge

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

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

4.3 million infants born in the US148,403 infants born in GA 21,007 Preterm infants born in GA14,209 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

1

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

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 non-

oxygen 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.

ParentsPhysicians Nurses Patient Care CoordinatorLactationRespiratory TherapySpeech-LanguagePhysical/Occupational TherapyNutritionPharmacists

ParentsMost important members of the

discharge team, they are the one’s that are taking the infant home

Must learn to care for the infantMust be prepared with the necessary

items at home to care for the infantMust 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 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 TherapyCollaborate 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

PharmacistsReviewing discharge medicationsHelping secure special

medications for the preterm infant being discharged home

Discharge Packet, Information and TeachingNewborn 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

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

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 ExamsEye 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 VaccineAll 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

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

gestation at birth should be tested.

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 KnowThe cause(s) of SIDS remains unknownSIDS cannot be predicted or preventedNo one is to blame for a SIDS death

oNot parentsoNot caregiversoNot emergency personnel or other

health care providers

What HappensBaby is usually healthy or may have

had sniffles or a coldBaby is put down for a nap or nightFound dead minutes to hours laterNo 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:

SuffocationVomiting or chokingChild abuseDisease or illnessImmunizations

Maternal Risk FactorsYoung--- less than 19 years of ageTobacco use doubles the risk of

SIDSSubstance use is associated with

increased riskLimited or late prenatal careShort intervals between pregnancies

Infant Risk Factors for SIDS

Male genderInfant ageLow birth-weightMultiple birthsPremature birth Babies can die of SIDS without having risk

factors!

Multifactorial SIDS Theory

Infant’sPhysiologicResponses

Development Environment

SIDS

Infant’s Physiologic Responses

Oxygen reduced, carbon dioxide increased

Arousal response deficitSubtle brainstem dysfunctionSlow development

Development—Age Vulnerability

2-4 months-------75%4-6 months-------15%Respiratory system is unstable in

all infantsMay take less of an environmental

stress to trigger SIDS at this age

Environmental Factors 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

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