5.6 Discharge instructions


Instruction must be given to all discharged patients, regardless of their duration of stay or the type of facility in which they received treatment (CTC, CTU, and ORP).

5.6.1 Treatment

The goal of home therapy is to avoid dehydration and malnutrition. Thus, treatment consists of providing ORS for the patient to drink and regular meals.

Oral rehydration solution

– Explain that patients lose a lot of fluid with cholera and ORS serves to replace that fluid.
Explain that ORS does not stop the diarrhoea (which the patient may view as a failure of treatment) and that ORS must be given as long as the diarrhoea persists.
– Demonstrate how to prepare ORS, how much to give, and when.

Table 5.6 – Amount of ORS after each stool

AgeAmount of ORS
Under 2 years50-100 ml (10 to 20 teaspoons) after each loose stool
2 to 10 years100-200 ml (½ to 1 glass) after each loose stool
Over 10 yearsat least 200-250 ml (at least 1 glass) after each loose stool

– WHO/UNICEF ORS sachets are packaged to provide a 1 litre of solution. In some countries, ORS sachets are designed for less than 1 litre. Check packaging information.
– Indicate that patients who want more ORS than prescribed should receive as much as they want.
– Explain that vomiting may occur if ORS is given too rapidly. Demonstrate how to give ORS to avoid vomiting and what to do if vomiting occurs (Section 5.4.3).
– Indicate that once prepared, ORS can be kept for 24 hours in a covered container. After that, a new solution must be prepared.

Feeding

Patients should be given a normal, non-restricted diet. For breast-fed children increase the frequency of feedings. Breast milk does not replace ORS, which is given between feedings.

Zinc supplementation

– Instruct the mother on how to give zinc and demonstrate:
• Place a whole or half tablet (depending on age) in a teaspoon. Add a little ORS or clean water to dissolve it and give the entire content of the spoon to the infant.
• For older children tablets can be chewed.
– Tablets are to be given daily until there are no more tablets in the blister pack, even if the diarrhoea ends.

5.6.2 Follow-up

Instruct the patient or the attendant regarding signs of dehydration or failure of treatment require returning immediately to the health facility:
– Refusal to drink
– Repeated vomiting preventing ORS intake
– Increased frequency of diarrhoea leading to signs of dehydration:
• Dry mouth, intense thirst;
• New appearance of sunken eyes;
• Change in behaviour: irritable (persistent crying/fussing), or the contrary, listless and difficult to awaken.

5.6.3 Additional advice

– Encourage the patient to send family members or neighbours to the treatment facility if they present with symptoms of cholera.
– Provide instructions on hygiene (hand-washing, use of potable water, and food preparation, etc.).

5.6.4 Practical tips

Preparation of one litre of ORS

1. Wash your hands with soap and water.
2. Pour the entire packet of ORS into a clean container (mixer bowl or jar).
3. Measure 1 litre of clean water.
4. Pour the water into the container.
5. Mix well until the salts completely dissolve.

Number of ORS sachets

Give enough ORS for 2 days of treatment. Depending on the age, 1 to 2 sachets of ORS will suffice per patient and per day. It is helpful to add 2 additional sachets in case of loss or to start treatment for a family member, particularly if access to a treatment facility is difficult.

Volume for dilution

Patients do not always know how to measure one litre, and under- or over-dilution of ORS is common. Ensure that the family has the means to measure a litre of water to correctly prepare ORS at home.

For example:
– Indicate on a bottle used locally the quantity representing 1 litre
or
– Provide a 1-litre bottle together with ORS sachets
or
– Provide a cup of known volume (e.g. 250 or 500 ml), explaining that 1 sachet of ORS is mixed in two 500 ml cups of water or four 250 ml cups of water.
Depending on the context, sachets of ORS and blister-packs of zinc can be accompanied by illustrative leaflets.