The Use Of Subcutaneous Infusions With Terminal Patients

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When the oral route is unavailable, the subcutaneous route is the preferred method. Intravenous is more invasive and are no more effective and the injections can be very painful to patients. The subcutaneous route is not reserved only for the dying patient, but should be considered anytime a patient cannot take fluids or medications by mouth. This route helps the patient be more comfortable.

The main reasons for continuous subcutaneous infusions for the terminal patients are nausea and vomiting, inability to swallow (dysphagia), extreme weakness or if a patient is unconsciousness. This route of giving fluids is easily used at home during the last days of life if the patient is unable to manage oral medications. The use of the subcutaneous infusions in terminal care is a major advance, especially to help control symptoms so the patient can be home.

This route of administering fluids is safer and the patient can still be ambulant. It allows the ability to give fluids and or medications, with no risk of air embolus and less risk of infection. When pain medications are given, such as morphine, the patient does not develop a tolerance to them as they can with the IV morphine.

In 1979, a portable pump was developed by Wright. Later that year, Russel suggested that the infusions could be used with terminal malignant disease. The use of the subcutaneous infusions are rarely required just for pain control. The only contraindication to the use of these infusions are if the patient has severe thrombocytopenia.

Thrombocytopenia is when the blood has an abnormally low amount of platelets. This can cause mild to serious bleeding. This bleeding can occur inside the body or underneath the skin or surface of the skin.

Special needles are used for the subcutaneous infusions. Sub Q Sets are available with a 27 gauge x 1/2 cm needles and come 30/case. There are different sizes and lengths to accommodate different patients and some sets, such as the Medtronic sets, are also used for the Insulin Pump patients.

The preparation of the family and patient is very important. Most patients do not have a problem with the infusions and quickly adapt to them. The infusion pump is small, unobtrusive, and easy to use. Many patients soon forget that it is even there. The cannula can be left in for 72 hours or longer, if there is not inflammation or redness.

The different facilities and hospices have protocols to follow for the insertion and care of the infusions. The comfort of the patient is the main idea for the subcutaneous infusions and should always be the main focus.

Patient Nutrition By Enteral Feedings

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Maintaining good nutrition is of the up most importance for all patients. If a person is ill, recovering from surgery or has an unexplained weight loss, the body has to work extra hard to restore good health. The body needs protein, fat, carbohydrates, vitamins, minerals, and water, in order to maintain and build body tissue and provide energy for body functions.

The patient usually gets these nutrients from eating a balanced diet. However, because of special problems, the patient may require receiving this nutrition in a liquid form through a tube. If this happens, a formula is calculated specifically for the individual patient in order to maintain their nutritional needs.

A majority of patients have a naso-gastric enteric feeding tube placed through the nose, reaching the stomach or small intestine. There are different size tubes to accommodate the difference in the sizes of the patients. Wolf-Pak has pumps for the continuous feedings and syringes for the water flushes.

After insertion of the tube, the physician will order the feedings or will ask the dietician to consult on the feedings. There are two different methods of feeding that can be given to the patient through these tubes. Bolus feedings is when there is a large amount of formula administered over a 15-30 minute time. This feeding is repeated several times a day, according to the orders. The other method is to use a machine, such as a Kangaroo Pump, and give the formula over an 8-24 hour period.

A different method of receiving feedings, is through a gastrostomy feeding tube. This tube is inserted by the physician through the abdomen into the stomach. With this method, the tube bypasses the esophagus and mouth. The feedings can be given through the gastrostomy tube the same way, by bolus or by continous feedings.

In certain cases, the physician may feel that it is necessary to place a jejunostomy tube. This tube in placed through the abdomen also, but goes directly into the small intestine or the jejunum. Feedings done with this tube bypasses the esophagus, mouth, and the stomach. The feedings given through the jejunostomy tube are usually given by the continuous method.

Even though the tube feedings are given, there is also need for plain water flushes to be given with a syringe 6 times a day. The orders by the physician or the dietician should include the tube feeding and the water flush amount. To help prevent reflux, keep the head of the bed elevated 30 degrees or more.

The patient should always be checked for residual stomach contents before starting tube feedings, unless the feeding tube used does not allow for this. If the patient is on continuous feeding, it is suggested that they be checked every 8 hours for residual stomach content. Typically, if the residual content is less than 250 ml, put the fluid back into the feeding tube and resume the feeding as scheduled.

If the residual content is greater than 250 ml and less than 400 ml, put the fluid back into the feeding tube and resume the tube feeding and recheck after 4 hours. At that time, if the residual content is greater than 250 ml, stop the feeding and call the physician. If the residual content is greater than 400 ml at any time, stop the feeding immediately and call the physician. Do not put the feeding back into the feeding tube.

If a continuous feeding is being given be sure to keep the pump plugged into the wall outlet to keep the battery charged. The battery typically last for 18 hours. Make yourself familiar with the protocols and policies of the facility for the administration of the enteral tube feeding. The main concern is the safety and the nutritional status of the patient.

The Use Of The Huber Needle

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Huber Needle

There are several reasons for a patient to require the implant of a venous access port. If a vascular access will be needed for longer than a 6 week period, an implanted port is highly recommended. The procedure for implanting the venous access port is done in the operating room. Treatments such as chemotherapy, total parenteral nutrition or long term antibiotics, which need to be given to the patient on a regular basis, requires a stable venous access. In addition to these treatments, frequent blood samples will be required to be drawn. The Huber needle, is what is used to access these implanted ports.

The Huber needle is a hollow needle with a beveled tip. The implanted venous access is under the skin and this needle makes it easy to go through the skin and the silicon septum of the port. These needles come in different sizes in order to accommodate the size of the patient and the port. The use of the Huber needle, prevents the patient from having to endure many needle sticks, because the needle is left in the port for more than one use.

The Huber needles come straight or curved. When the port is only needing to be flushed, the straight needle is used. These are also used for any short-term application. The curved needles are the ones that are used for the delivery of such things as, medications, nutritional fluids, and chemotherapy. The curved needle is convenient, because it can be left in place for a few days, according to the policy of the facility and prevents the patient from having as many needle sticks.

The history behind the Huber needle, may be a slight bit surprising. This widely used needle was actually invented by a dentist in Seattle. He made the needle hollow and curved, making it more comfortable for his patients to endure injections. The Huber needle is today, the only needle that is used to access the implanted venous access port devices.

Most of the patients that have conditions requiring an implanted venous access port, have to have blood drawn several times a day. After a short period of time, their veins collapse. With the use of the implanted port and the Huber needles, the job can be done without having to go through the skin every time.

The Huber needle is safe and can be kept in place for several days. It makes life a lot better for the patient. The reality of having chemotherapy and being stuck so many times in a day, is made a slight bit easier by its use. The administration of the chemotherapy often damages the skin and tissues around peripheral insertion sites. A port that is surgically inserted in the chest wall, helps the patients by only having to endure one needle stick versus many.

Proper use of the Huber needle protects the patient from pain and infection. Huber needles optimize access to the port through the septum of the implanted port. The fluid flows through the reservoir of the port into the vascular system of the patient. Every facility has policies and procedures for the use of the Huber needles, be familiar with them and always follow the regulations.

Providing Nutrition With Enteral Feedings

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Malnourished patients should be considered for enteral feedings. If the patient cannot maintain an adequate intake, the enteral feedings can be a life-saving procedure. Critically ill patients, post-operative patients that can only take limited amounts, and patients with problems such as severe pancreatitis, may require some assistance with nutrition in order to get better. There are instances when the enteral feedings are given along with the parenteral nutrition. This is done in order to reduce the likeliness of cholestasis and to maintain the gut function. Different routes are available for achieving this feeding. Nasogastric tubes are the most common form of delivery and are easy to insert. These tubes must be checked routinely because all though they are easy to insert they are also easy to become displaced.

Peg tubes are more common with patients that have had a stroke, Parkinson’s disease, motor neurone disease or esophogeal cancer. These tubes are inserted surgically directly through the stomach wall. There is a form of this tube that is referred to as the percutaneous jejunostomy tube. This tube is inserted through the stomach into the jejunum, using a surgical technique.

After the tube is inserted and the orders are received by the physician, you will need a feeding set, in order to start the feedings. One type of this is the gravity feeding set. This set will hold 1200ml and comes with a drip chamber, roller clamp, hanger, and a top-fill opening. This bag is leak proof and cuts down on formula spills and also waste. They come 30/case. A different type of tubing is the EnteralLife Infinity set. It comes with a 500ml delivery set and is compatible with the EnteralLife pump. This set has a large top fill opening and is leak proof. These sets do require an enteral infusion pump to operate and come 30/case.

The type and amount of the enteral feeding is usually ordered by the physician or in some cases, the physician will order for the dietician to regulate the enteral feedings. Oral, enteral, or parenteral nutritional support should be considered for any patient that is malnourished or at risk or becoming malnourished. Potential swallowing problems should always be taken into consideration when making the determination as to the route of the nutrition.

One of the complications that can arise from these feedings is infection from contamination of the enteral feeding. The feeding sets and feeding should be discarded every 24 hours to minimize the risk of bacteria growing. Other complications can include the erosion or displacement of tubes, reflux, and aspiration. Enteral feedings can be highly beneficial to the malnourished patient. Assess the patient per protocol and monitor the feeding, so that the patient will receive the correct amount of feeding safely.

Central Line Dressing Kits Improve Care

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There are different types of sites for intravenous IV infusion. A lot depends on the condition of the patient and what type of infusions the patient needs. The peripheral IV site is the most common. The implanted venous port is surgically implanted in the chest wall and requires accessing with a Huber needles. The central venous catheter or central line, as it is often called, is a long line catheter, that is usually inserted into the chest wall. It is placed in a vein and is fed through this vein until it reaches the superior vena cava or the right atrium.

A central line is used for giving treatment for infections, heart, infusing blood, large amounts of fluids, kidney dialysis, cancer, nutrition or pain. This catheter can be left in place for an extended length of time. Because of this, it is very important that the central line dressing be changed per the hospital protocol, in order to decrease the chance of infection.

Anytime the central line dressing is changed, aseptic technique must be used. The use of the central line dressing change kits help to prevent infections. Everything that is needed is in the kit, which saves the nurse’s time. Technique does not have to be broken in order to gather more supplies and it is less time consuming. The site needs to be closely monitored. The handling of the line needs to be kept at a minimum, in order to reduce the risk of the line and site becoming contaminated. Any redness or discharge from the site should be reported immediately to the physician.

The Dressing Change Kits for central lines usually include these items:

  • 1 mask
  • 1 pr sterile gloves
  • 1 drape 17″ x 19″
  • 1 tape measure
  • 1 Triple Swabsticks
  • 2 alcohol prep pads
  • 2 gauze sponges
  • 1 pre-split sponge
  • 1 non-stick pad
  • 1 roll of take
  • 1 tegaderm transparent dressing 4″ x 4 3/4″
  • 1 label

 These kits are sterile, latex free, and come 30/case from Wolf-Pak.

In the United States alone, physicians place more than 5 million central lines per year. The complications that can arise from the insertion of these IV’s are mechanical, infections, and thrombolytic. Use of the central line dressing change kits for changing of the sites, per the protocol of the facility will improve the care of the patient. The nurse has the vital role to safeguard the patient against the risks that are associated with the central line IV’s.

The Convenient IV Kits

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The infamous IV tray that used to be on every medical floor at the hospital has now been replaced with the convenient IV start kits. Everything that is needed is in this one sterile pack and can be easily obtained when needed. The use of the IV start kit saves on time and contains all the necessary supplies to start the IV. All that has to be done, is to grab the kit and an IV catheter and you are ready to go to the patient’s room.

The start kit includes these components:

  • 1 pair of latex free exam gloves.
  • 1 alcohol prep pad
  • 1 latex free tourniquet
  • 2 2 x 2″ gauze sponges
  • 1 roll tape
  • 1 transparent dressing 2-3/8″ by 2″
  • 1 PVP pad
  • 1 dressing change label

These kits are convenient and cost effective. They come 50/case. The nurses start the majority of the IV’s, so the nurses and IV’s seem to go hand in hand. When starting an IV, know the anatomy of the patient and don’t go rooting around looking for that magical vein. Remember that the ventral side of the forearm is sometimes the best place to look. Initially, do a survey, but don’t go in blindly.

Because you don’t see a vein does not mean there is not one there. Practice is the best way to sharpen your skills. When palpating for a vein, close your eyes and feel. If you have a patient that has really good veins, close your eyes and palpate. This will help you to learn how a vein feels by touch and when you have a patient that does not have good veins, it will be easier for you to feel their veins.

The vein you choose should feel round, firm, and engorged. Sometimes veins feel and look suitable, but when an IV catheter is inserted, they have irregular or narrow lumens. The advancement of the IV cannula will be difficult in this situation. Because of the fact that the arteries are deeper than the veins, they are rarely damaged when starting peripheral IV’s.

Always follow the protocol of the facility when starting the IV. The IV Start kit will save time in gathering the necessary equipment and will also let the patient know that you are prepared. This gives them more confidence in the IV therapy process. It is not the end of the world, if you miss an IV, nobody gets them all. Tell the patient you are sorry and go get someone to start the IV for the patient. Most hospitals have a policy that no more than 2 IV sticks are made and then the physician is called.

Dial-a-Flow Medicals Uses

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The world of the nurse has changed a great deal over the past few years. Today, the nurse no longer has to stand and count drops for the infusion of IV fluids. The nurse’s routine changed a lot when the intravenous pumps (IV) became available. But with the hustle and bustle of the hospitals, the problem still arises, that there is just not enough IV pumps to go around. The Wolf-Pak Extension set, known to a lot of nurses as Dial-a-Flow sets, can be used in place of the IV pump when needed, this provides the safety of controlling the IV fluids for the patient. These help to prevent the patient from receiving more fluid than they are supposed to.

The Wolf-Pak Extension set is 18″ long and has an IV Rate Control Regulator. The really nice thing about these sets are that they are latex free, so there is no concerns when a patient is admitted that has latex allergies. They also feature non-DEHP tubing. This means that these extensions are not manufactured with DEHP. This is a plasticizer that is used in the manufacture of some IV tubing, that effects some people when they are exposed to it. The Dial-A-Flow system is a highly cost effective alternative to IV pumps.

The extension set being 18″ long, it allows for space between the IV line and the patient. The usual placement of the extension tubing is between the IV catheter that is inserted in the patient and the regular IV line that is connected to the infusion bag. The regulator on the extension tubing has bold printing on it making it is easy to read and it is easily adjusted to provide the amount of flow of the fluid that is ordered for the patient.

The Dial-a-Flow functions by gravity and helps to prevent the accidental free flow of solution to the patient. This helps prevent fluid overload. It will help to provide a more consistent flow of the fluid than a regular roller clamp does. These also help with the prevention of the tubing getting crimped or the roller clamp drifting.

The flow regulator will adjust from 0-250 ml/hr. This makes allowances for the rate that is ordered for the patient. These are designed to regulate the flow of the fluid, but because of the fact that they are manually regulated, they are not considered “infusion pumps”. The Wolf-Pak Extension sets come 50/case.

The age of the patient, severity of the illness, type of therapy, clinical setting, policy and procedures of the facility, and the knowledge of the nurse, should always be taken into consideration before using the flow regulators. The Dial-a-Flow should be checked during the infusion to ensure that the prescribed delivery rate is being delivered correctly. They do not replace the nurse’s responsibility to monitor the infusion of the therapy.