Rwandan National Neonatal Protocol: Discharge Planning with Merab Nyishime.
Introduction.
I am Merab Nyishime.
I am a nurse working with Partners in Health.
Today we are going to revise the chapter related to discharge planning.
Overview.
By the end of this chapter, participants will be able to describe the four assessments that
should be made when deciding whether to discharge a patient.
Recognize three danger signs that would prevent discharge.
Identify three examples of infants who should have rendezvous.
Model appropriate caregiver discharge counseling.
Considerations in discharge planning.
There are five main considerations when discharging a patient: feeding, respiratory condition,
temperature, neurological status and danger signs.
All should be assessed before discharge.
The discharge criteria for nutrition and hydration are as follows: the infant is not on intravenous
fluids, the infant is receiving at least eight feeds per day or a total of more than
120 mL/kg/day, or is demand breast-feeding well.
The infant has gained at least 15 g/kg/day for at least three days and weighs more than
birth weight.
The mother or caregiver is confident about feeding and looking after the infant.
The infant is passing urine and stool normally.
From a respiratory prospective, a newborn can be discharged if there are no signs of
respiratory distress.
Premature or low birth weight babies should show no apnea for three days without caffeine
or aminophylline.
In terms of thermoregulation, an infant who maintains a normal temperature of between
36.5 degrees Celsius and 37.5 degrees Celsius without the use of an incubator or radiant
heater for at least three days can be discharged.
Newborn with hypoxic ischemic encephalopathy who are on anticonvulsant can be discharged
once they have been off anticonvulsant medication for 48 hours without seizures.
Patients should only be discharged if they do not display any danger signs such as fever,
jaundice, convulsions, or abdominal distension.
There are several important steps that should be followed for each patient when planning
for discharge.
The caregiver must be advised about warning signs for illness, and safe methods of newborn
care, including sleeping positions and not covering the newborn's face.
Community support systems should be offered as needed.
Medications or supplements must be prescribed or given to the caregiver.
Preterm infants of less than 35 weeks or those with a birth weight under two kilogram should
be given iron therapy.
For HIV exposed newborns, prophylaxis should be provided and follow-up must be scheduled.
Iron therapy should be given to all premature or low birth weight newborns
whether or not they are anemic.
Newborns who are not anemic should be given a preventative dose of 2 mg/kg/day elemental
iron for 2 weeks to 6 months.
Anemic infants should be given a treatment dose of 4 mg/kg/day for 3 months, then transitioned
to the preventive dose for another 3 months.
Iron is available in different forms, many concentrations, with different amounts of
elemental iron.
Be sure to pay close attention to the concentration of elemental iron and ensure a proper dosing
according to the protocol.
Review the exact dosing and administration with the caregiver prior to discharge.
Keep in mind that overdosing on iron can be very dangerous.
Infants with certain concerns should be seen for follow-up at the outpatient clinic 1 to
2 weeks after discharge. This includes low birth weight and preterm infants, infants with concern for feeding
difficulty, severe birth asphyxia, confirmed meningitis, or other concerns for vulnerability,
or those born to hiv-positive mothers.
Contact details, weight, head circumference, final diagnosis, prescribed medicines, and
discharge examination should all be recorded for the follow-up visit.
Case studies.
We will review the contents of this chapter by looking at a final case study.
Oscar, a newborn patient, was born at 30 weeks gestation, weighing 1,300 grams.
His parents are asking you when he will be able to go home.
What do you tell Oscar's parents?
You can tell them that Oscar can go home when he is eating well, and regularly voiding and
stooling, gains at least 15 g/kg/day for at least 3 days, and has exceeded his birth weight,
has no respiratory distress, and no apnea for 3 days without caffeine or aminophylline,
and has a normal temperature without an incubator or other external heat source for at least
three days.
On discharge, Oscar should be scheduled for rendezvous because he is preterm and
low birth weight.
You are ready to discharge Oscar as he has met all the criteria.
He is eating well and regularly voiding and stooling.
He is gaining weight well, and weighs more than his birth weight.
He has not been on caffeine or external heating device, and shows no signs of
respiratory distress.
What danger signs would you assess for prior to discharge?
Assess for fever, jaundice, seizure, and abdominal distension before discharge.
Counsel the mother to return to the health center or hospital for feeding difficulty,
skin that is hot or cold to the touch, yellow skin, seizure, or lethargy.
Summary.
Now that you have finished this chapter on discharge planning, you should be able to
describe the four assessments that should be made when deciding whether to discharge
a patient.
Recognize three danger signs that would prevent discharge.
Identify three examples of infants who should have rendezvous.
Model appropriate caregiver discharge counseling.
Remember these key points from the chapter; prior to discharge, patients should be assessed
for nutrition and hydration, respiratory, temperature, and danger signs.
The following danger signs will prevent discharge; fever, jaundice, convulsion, and abdominal
distension.
Infant with high risk criteria should be followed up in one to two weeks at the outpatient clinic.
Appropriate discharge counseling is important to ensure caregivers can adequately support
a patient at home and know when to bring the patient back in.
Thank you so much.
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