What to do??????????secretions.....

  1. Ok, i've only been back in hospice for 3 months, but I have questions...

    10 yrs ago, when I did hospice, our agency had a portable suction setup so should a patient be unable to handle secretions, we could suction their oral airway...So, last night when the assisted living facility for my end stage alzheimers patient called and said "she has brown secretions dripping from the side of her mouth," I called my DME provider, went out with a bulb suction, cleaned her mouth with bulb suction...waited for suction, got machine, used yankers...situation resolved....Called MD this morning, got an order for scopolamine patch.....

    Called my administrator to let her know about the fiasco with the suction setup delivery (long story, and not important at this point...it got done); she said I should have only done bulb suction (patient still with audible expiratory rhonci), with yankers, airway was cleared..... And when I talked about the scopolamine patch, she said "if it's not a problem to get it today, that is fine, but i would wait until the comfort pack gets there on monday." *****frankly, i'm trying to offset another middle of the night call********

    She said suctioning is for people that are actively bleeding from the oral cavity, not for secretions... It's not like I tried to intubate the patient, just wanted to clear her mouth. I don't want to do the wrong thing, and I was called by the assisted living facility to clear her oral cavity. I don't want to irritate my manager, but I want to do the right thing for my patient...***her RR was 24-26, and was 16-18 after yankers.****

    Maybe i'm just having trouble adjusting to hospice from the critical care nursing setting. I mean, the assisted living place can't even give medication rectally, let alone use bulb suction (so they will be calling me out for that)...

    What do you all think? As for the scopolamine patch, I was following the logorhythm from the hospice pharmacia book that we use.

    Any input is greatly appreciated. I mean, isnt' it about treating the symptoms, airway clogged with secretions = clear airway.....

    Any input is greatly appreciated. I just don't want to have to field calls all through the night when an assisted living facility is telling me a patient is in distress, and I don't want my company to be charged for an ambulance being called just to clear her oral cavity.

    thanks!!!!
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  2. 32 Comments

  3. by   CANRN
    We rarely use suctioning. Usually scop patches and atropine drops. For secretions not managed with these, we can use Levison, robinol and what we have just started using with amazing results is Lasix in a nebulizer. Bulb suction would have cleared out the oral airway and then use these other interventions. But you got the job done, the patient was comfortable and that is all that matters
  4. by   AtlantaRN
    thank you. i just want to do the right thing, and i'm so used to the hospital setting.

    linda
  5. by   EmptytheBoat
    Linda, you did well, suctioning with a yanker should be routine
    to clear oral cavity of excess secretions.
  6. by   wonderbee
    My, I can see that coming from an ICU background, it's going to be a big transition when I start my hospice job tomorrow. Linda, I can relate. My intervention would be to clear the airway with suction and a yankauer too.
  7. by   AtlantaRN
    I was called out last night at 10:20 with secretions again, I had placed a scopolamine patch yesterday at 3pm...I'm just getting home and it's 6:23am...

    She is still holding on. This is the first death their adult son has encountered, and he had gone from anger, to bargaining, to anger, to acceptance in the last 8 hours. I'm on call til 8:30am, but frankly I can't even see straight. I hope the administrator doesn't get upset with me (she was not happy that I was out there for 4 hours last night). We tried yanker suction again but secretions were just too darned thick and tenacious. Son was just so upset when her respirations were so loud, he was so frightened. Spent most of the night explaining what was happening. Hands turned blue about 2am, I thought we were in the home stretch. Now chene stokes breathing, they have church friends coming in to sit with the patient. They are going home to get some sleep also. I just couldn't leave them, they were just so frantic.

    linda
  8. by   CANRN
    Our manager has always said "if your gut tells you that you should not leave, then you should not leave!" she always backs us. What about crisis care? you could have put this patient on crisis care because you were there four hours and all you needed was 8 of nursing. you could have had another nurse go in, to make the 8.
    I went into hospice after being an ER nurse for 7 years, believe me! I understand the transition well! LOL
    Hang in there, it does get easier. I can't imaging going back into a hospital setting now!
  9. by   mc3
    I was taught not to suction patients at all. It's invasive, it can cause them much discomfort, and actually increase the amount of mucous the body produces in response. Much better to reposition them, use scop patches (can use 3 at a time q48 hrs if need be), use levsin or atropine drops. I try to be as non-invasive as possible. Also, when I start to hear even a tiny amt of fluid in an actively dying patient, I start the scope patches...
    mc3
    :angel2:
  10. by   AtlantaRN
    I dont understand why it's on the form for equipment if suctioning isn't indicated? I had her in high fowlers, now because of her size, I started with 1 scop patch, and added a second when I went out last night. What got me was before I made the first visit at 3pm yesterday, my administrator told me NOT to get the scop patch because she was "actively dying." ??????well, am I not suppossed to TREAT this ACTIVE DYING? I mean WHY have the hospice pharmacia, and have the logorhythms to choose meds to help...her response was "the comfort pack will arrive on monday." well, she was dead by 9am... I'm to meet with the administrator at noon tomorrow and I have several concerns...

    My job is to treat the patient and aleviate the symptoms; I don't want to be neglegent...I want to TREAT the patient, but I feel like my hands are being tied.

    In regards to the suction, administrator said she needed to "get with me" about when it is appropriate...she said with hemataemesis it is warranted...but an oral cavity filled with secretions that patient is unable to expectorat is thicker than hemataemesis....but maybe she is looking at the quantity of fluids rather than the thickness and tenacity of thick oral fluids.

    I guess i'll find out tomorrow. I had been looking forward to going full time, but I don't like feeling like my hands are tied. I'm sure as an administrator, it is great to have home hospice patients that are all stable with long term chronic conditions, as this is where our bread and butter is....but I have to treat the ones we get on friday and die on monday too (i felt really awful that I didn't at least have the comfort pack).

    thank you for your input.
  11. by   BeExcellent
    Hang in there. Hospice is often much more art than science. If pt did better after you suctioned then that is that. Pt was better. It is so hard to be new in hospice because you develop what you know and what works with time. It is also much more difficult to successfully intervene with a pt in assisted living. Usually u don't have someone to give atropine gtts every 2 hours until scopPatch kicks in. Is (was) Crisis Care an option? U get to anticipate audible respiratory secretions. Those with resp.dx are most likely gonna get juicy. I explain to all that secretions (mucous and spit) will pool around the epiglotis when pt gets to weak to swallow own secretions. If you listen airway is usually not so juicy on inhale but on exhale air goes through pooled secretions. Sounds bad but usually airway not compromised. Suctioning can stimulate vomiting/gag which is very unpleaasant for all. Also almost impossible to clear secretions because of location. It is a judgement call. Goal is to dry up the pooled secretions. I thought CANnurse had good suggestions. Lasix neb was interesting. Never tried that one.
  12. by   ginger58
    Quote from mc3
    I was taught not to suction patients at all. It's invasive, it can cause them much discomfort, and actually increase the amount of mucous the body produces in response. Much better to reposition them, use scop patches (can use 3 at a time q48 hrs if need be), use levsin or atropine drops. I try to be as non-invasive as possible. Also, when I start to hear even a tiny amt of fluid in an actively dying patient, I start the scope patches...
    mc3
    :angel2:
    I have to agree. If I sx I like to use a soft catheter well lubricated versus a Yankauer. Secretion intervention medicinally really was too late. I was taught that when you hear rhonchi it's time to start the Scop or whatever. Scop can take half to one day to start working. Did you have any MS or Roxanol to give? Some times turning them on the left side helps. Elevate HOB helps a little.
  13. by   AtlantaRN
    what is difficult for me is i've done hospital nursing for 10 yrs, and everything is available...quickly. on saturday, my administrator didn't want me to get the scop patches, she said "the comfort pack will be there on monday." yikes, she was dead early monday morning.

    with hospice, especially with this last dear lady, she was in assisted living, and they wouldn't even use a bulb suction to clean out her mouth. I was being sent out there daily to place a levaquin pill in her rectum daily, because family wouldn't do it (but by early monday morning, family was wiping out her mouth and very hands on)...she was end stage alzheimers, who had what I believe to be aspiration pneumonia. When I first met her on saturday morning, her assisted living caregiver was brushing her teeth, and had filled her mouth with ************water**************.............
    and she is unable to cough and spit at this point.........what part of nothing by mouth didn't the ALcaregiver get........at that point we went into the mouth swabs ONLY and WHY. My administrator had admitted her on Friday afternoon and went into the nothing by mouth at that time......

    BTW: scopolamine patches did decrease her secretions, to the point that i was unable to suction anything her mouth because it had turned to solids. but bless her heart, but late saturday night her lungs were filled with secretions.

    as for crisis care, yes, that I how we will go, because I was out there for an 8 hour stretch (once she got quiet at 6am, the family was more calm, and we had talked for an 8 hour stretch about what all was happening to her). When her fingers turned blue for the first time, they were a deep deep blue color, and when they then turned pale blue and the color was her hands, somehow her son thought she was improving, but he was educated, and I explained about shunting and how her body was shunting blood to the vital organs, and that is why her hands were sooo cold. by 6am, I was beat, could barely talk because I talked for 8 hours, and sooo tired. I wouldn't have left if I didn't think they were at a good place. They were so distressed when her respirations were so loud, that was between 1a-3a.

    thank you all for your help.
  14. by   BeExcellent
    I think of Indiana Jones saying, "It had to be snakes." Nothing worse than juicy secretions. "It had to be secretions."

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