NUR 315 Exam 3 - Discharge Teaching

Role of discharge teaching

• Provides anticipatory guidance for patients' needs after discharge

• Serves as checkpoint of family's understanding and knowledge gaps

• Empowers family to be involved in decision-making

• Identifies risk factors

• Establishes referrals as soon as possible

• Prevents inappropriate discharge and/or readmission and unknowing harm

• Support maximum wellness

How to teach

Identify the Teaching Audience

• Mother, Legal guardian(s), Support person present, Support person/people for after hospital discharge

Tailoring the Teaching Approach

• Use small teaching moments from admission to discharge rather than "all at once"

  • Better retention

  • Allows more time for questions and clarifications

• Assess health literacy and readiness to learn, extent and recency of maternal-infant care experiences, family/cultural dynamics, what is realistic for the family

Health self-advocacy

• Care of body, mind, spirit all necessary to improvement adjustment

  • Takes several weeks to feel a sense of normalcy

  • Takes several months to feel adjusted to the new normal

• Use your support people as much as possible so you can rest, heal, and care for your baby

  • Sleep when ever the baby sleeps - other things can wait.

Resumption of daily activities

• No driving for 2 weeks after delivery - No driving if taking narcotics

• Do not lift anything heavier than baby or diaper bag for 2 weeks

• Shower as often as you like - Avoid tub bath or swimming until after postpartum check-up

• Gradually resume normal activities, short, mild exercise and increase as tolerated; ambulate - Bleeding could slightly increase after times of activity

Nutrition and elimination

• Can take several months to return to pre-pregnancy weight

  • Do not lose more than 2 lb per week

• Continue taking prenatal vitamins

• Drink water to meet thirst (extra water intake does not increase breastmilk)

• Well-balanced diet high in protein and fiber - add 500 cal/day if breastfeeding

• Bowel function should return to normal in a few days - Use stool softeners, do not strain

Uterine and pelvic floor changes

• Uterus should be midline and firm

• Afterpains (mild contractions) spontaneously and with breastfeeding

• Involution of uterus; non-palpable by 2 weeks after delivery

  • Quicker with primiparous women

  • Takes longer in multiparous women

• Pelvic floor and vaginal tone are reduced (instruct on Kegel exercises)

How to do kegels

• Find the right muscles by stopping urination in midstream. You can do Kegels in any position, although it may be easier lying down.

• Perfect your technique. Imagine you are sitting on a marble and tighten your pelvic muscles as if you're lifting the marble. Try it for three seconds at a time, then relax for a count of three.

• Maintain your focus. Tighten only your pelvic floor muscles. Be careful not to flex the muscles in your abdomen, thighs or buttocks. Avoid holding your breath.

• Repeat three times a day. Aim for at least three sets of 10 to 15 repetitions a day.

Pericare and bleeding

• Empty bladder frequently

• Use peri bottle with clean warm water to rinse perineum

• Sitz bath frequently to expedite healing

• Bleeding patterns over 2-6 week time frame: Bright red to dark red to brown to yellow-white

• Bleeding may increase with activity

• Small clots okay, golf-ball or larger not ok

Resumption of menses and sexual activity

• If not breastfeeding, menses may return 4-6 weeks after delivery

• Breastfeeding tends to delay the return of menses until weaning occurs

• Ovulation and fertility can return at any time

• Nothing in the vagina for 6 weeks

  • No body parts or other objects

  • No tampons

  • No douching

Breast care

• Wear well-fitting bra without underwire

• Breastfeed frequently

• Ensure correct latch and proper milk transfer

• Lanolin cream or olive oil to soothe chafing

• OTC pain relievers, ice packs, cabbage leaves, shredded potatoes...

• Frequent milk removal, massage, and positioning for clogged ducts

• Seek help if you feel lactation is not going well or infant is not feeding well

Psychosocial adjustment

• Normal to experience a wide range of emotions - Baby blues vs. Postpartum depression

• Allow yourself to modify plans and expectations

• Ask for and accept help

• Identify support system - Talk with others that can understand

Maternal care contact the provider if:

• Temperature 100.4 or greater

• Chills, malaise, and flu-like symptoms

• Unrelieved pain in back, side, or incision

• Bloody or purulent drainage from incision

• No bowel movement for four days or longer

• Frequent urgency or burning on urination

• Hot, firm, red area of the breast

• Persistent headache despite taking analgesics

• Unilateral swelling in legs

• Bleeding remains heavy despite rest

• Saturating more than a pad in an hour

• Passing multiple clots or clots egg size or bigger

• Foul-smelling vaginal bleeding

• Social withdrawal

• Persistent baby blues or depression

Normal newborn appearance: skin

• Tailor the teaching to specific characteristics the newborn

• It is common for newborns to develop blemishes or rashes

• Dry, peeling skin (desquamation) will resolve on its own

Normal newborn appearance: breasts, genitalia

• Mild breast engorgement, Witch's milk: drops of newborn "breastmilk"

• Redness and swelling of genitalia, blood-tinged, mucus-like discharge

• Resolves within a few days

Normal newborn appearance: head shapes

• Egg-shaped, pointed, or flattened head from birth - Molding resolves within a week or so

• While the newborn is awake, hold or place the newborn in a variety of positions to prevent placing repeated pressure on the same part of the head

Normal newborn appearance: eyes and ears

• Visual acuity about 8-10 inches away from face (feeding distance is perfect!)

• Eye color gray-blue or brown at birth

• Eye color does not finalize until about 6-12 months after birth

• Occasional crossing of eyes until about 4 months after birth

Basic newborn care

• Dress in one more layer than an adult would wear

• Infants are sensitive to overheating or becoming too cool

• File rather than cut nails to prevent accidental clipping of the skin

• Use mild non-perfumed soaps and detergents

• How to use a suction bulb

Newborn hygiene

• Sponge bathe until umbilical cord falls off and circumcision heals

• Do not bathe everyday

• Test water temperature before bathing (set water heater <120 degrees)

• Keep umbilical cord dry, no special cleaning needed

• Uncircumcised males: do not forcibly retract foreskin, clean with mild soap and water

• Circumcised males: Clean by squeezing warm water over area until healing is complete

• Females: Clean from front to back to prevent contamination

Newborn hygiene

• Sponge bathe until umbilical cord falls off and circumcision heals

• Do not bathe everyday

• Test water temperature before bathing (set water heater <120 degrees)

• Keep umbilical cord dry, no special cleaning needed

• Uncircumcised males: do not forcibly retract foreskin, clean with mild soap and water

• Circumcised males: Clean by squeezing warm water over area until healing is complete

• Females: Clean from front to back to prevent contamination

Diapering

• Change diaper in a safe place and do not leave unattended

• Clean thoroughly between skin folds

• Expect 6-8 wet diapers in 24 hours

• Typical stool color, consistency, and frequency

• Stools may become less frequent as the weeks progress

Soothing the baby

ABOUT CRYING

• Reasons babies cry

  • Hungry, wet, hot, cold, overstimulated, bored, need for human contact

• Never shake the baby

  • Discuss shaken baby syndrome

    • A severe form of child abuse caused by violently shaking an infant, leading to brain damage, subdural hemorrhage, and retinal hemorrhages

WAYS TO SOOTHE

• Check diaper

• Feed

• Rock, go for walk or car ride, massage or pat baby

• Swaddle

• Talk

• Background noise

• Skin-to-skin

Feeding the baby

• Breastfed babies feed on demand, bottle fed babies every 4 hours or less

• At least 6+ wet diapers per day and 3+ poopy diaper per day

• Basic principles of a good latch reach out for help if concerned

• How to prepare formula

Jaundice

• Jaundice causes yellowing of the skin and eyes.

• In most cases, the appearance of jaundice self-resolves.

• Small, frequent feeds and some (limited) time in the sunlight help

• Concerning jaundice causes poor feeding, prolonged sleep, true lethargy

• Contact pediatrician if there are any concerns!

Sleep patterns

• Newborns sleep approx. 16 hours per day for a few hours max.

• Neither realistic nor healthy for newborn to sleep through night

• Bedtime routines can help newborn differentiate night and day

  • Day: Light on, wake for feedings, make noise, keep eye contact

  • Night: Dim lights, keep room quiet, decrease stimulation

Safe sleep environment

• Always place infant on back for sleeping until 1 year old

• No toys, extra blankets, etc. Nothing in the crib but the baby.

• Firm, flat mattress

• Crib or bassinet with 4 immovable, tall sides and narrow slats (2 and 3/8")

• Do not share sleeping surface

• Do consider sharing the sleeping room 6 months to 1 year+

• Keep the baby's hands free from the swaddle once able to roll over

• Make contingency plans for safe sleeping surfaces

Sudden Infant Death Syndrome and accidental suffocation and strangulation in bed

Sudden Infant Death Syndrome (less common)

• Cause is unknown

• Possible cause: immature or damaged medulla oblongata does not detect rising CO2 levels, resulting in prolonged apnea

• Diagnosed when other causes of death are ruled out by autopsy

• Preventing SIDS:

  • Breastfeed/offer small, frequent feeds

  • Eliminate or reduce smoke exposure

  • Discourage excess use of alcohol, sedatives, illegal drugs, etc

  • Share sleeping room

  • Consider pacifier use

Accidental Suffocation and Strangulation in Bed (more common)

• Preventing ASSB:

  • All SIDS prevention recommendations, plus...

  • No crib "spires" or cut-outs

  • No attachments, crib bumpers, pacifier cords, stuffed animals, blankets, pillows, loose blankets, positioners, etc

  • No nearby electrical cords, blinds, baby monitor cords

  • Do not leave sleeping baby in car seat after the drive is done

  • Do not sleep with baby in arms, especially rocking chairs/couches

Infant car seat safety

• Do not leave the infant unattended in the car

• Do not have infant in front seats or in seats with air bags

• Use a car seat every time the infant is in a vehicle

• Keep rear-facing in leveled car seat until 2 years old and as long as the weight-limit of the car seat allows

• Okay if infant falls asleep while you are driving, but remove and put in safe sleeping environment once home

• Encourage car seat technician to inspect for proper installation

• Correctly harness the baby

Newborn care when to contact provider

• Vomiting (note color and if projectile)

• Lethargic and hard to wake up

• Frequent loose stool with excess fluid, mucus or unusually foul odor

• No stool for 48 hours

• No wet diapers for 12 hours

• Changes in typical behavior

• Unusual or high-pitched cry

• Temperature <97.5 F or >100.4 F

• Patches of white found in the baby’s mouth (possible thrush, a fungal infection)

• Erythema, purulent drainage around umbilical cord or bleeding more than a few drops

• Purulent drainage or bleeding from circumcision

• 911 if experiencing respiratory distress like oral cyanosis, central cyanosis, difficulty breathing or if unresponsive