Questions about composing a teaching plan for pts on Lovenox

[Jedi of Zen]

Hello all,

I am doing my summer clinical on an orthopedic unit. I am supposed to construct a teaching plan for a topic (ie, out of a list that we have been given) related to ortho issues/concerns. Then, I am eventually required to actually teach this plan to a patient who is being discharged.

A lot of these patients have had hip or knee replacements, and consequently get sent home on Lovenox in order to prevent clots/DVTs. So I am thinking about doing my teaching plan based on teaching about Lovenox, since that is one of our options. The facility has their own teaching materials (brochures and the like) that they normally use; however, so far we have not been clearly told whether or not we'll be expected to use the facility's materials in our teaching plan, or whether we'll be expected to construct our own materials.

Either way will be okay with me, but I do have a few questions about things that I should tell my patient, and I was wondering if you guys have any thoughts or websites you could recommend:

1. Since Lovenox is given via injection, will this patient be sent home with a sharps box? If so, how should the patient be instructed to dispose of the sharps box? The facility may have their own normal instructions about this, but I don't know what those instructions are and/or if we'll be going on those instructions. So I'm trying to at least get an idea of how patients at home (ex. diabetics, or any type of pt who does self-injections, etc.) would typically dispose of a sharps box.

2. After the patient does the daily injection, should he/she be instructed to apply a band-aid alone to the site? Or would it be better to apply a 2x2 gauze and tape? What about cotton balls? My guess is that a gauze and tape along with pressure for at least a minute would be best. But again, I don't know if the facility normally supplies the patient with these materials, or if they are expected to acquire them at a drugstore, or what.

3. If the patient is going to self-administer the shot, what site(s) are acceptable to use? I have heard my family doctor, for example, say that he only tells patients to use the thigh for self-admin. of sub-q's. But I have heard of diabetics giving themselves insulin shots in the abdomen. And I know heparin - if not Lovenox - is best absorbed in the abdomen. So...abdomen it is, then?

I know that these questions may seem quite elementary, but I'm running into vague and conflicting information in my books about these matters. And, my instructor still hasn't told us whether or not we'll be going with our facility's normal instructions/material for patients or if we'll be doing everything entirely from scratch.

Any input/assistance is welcome. Thanks for your time!

[Daytonite, BSN, RN]

excellent questions! normally, patients are given some medical supplies by the nursing staff when they are sent home with the exception of sharps containers. i have never seen sharps containers sent home with a patient. patients going home on injections qualify for skilled nursing and i would be asking the doctor about home health services. if the patient's insurance allows for home health services, all your concerns are solved because home health agencies provide all the supplies the patient needs including nurses to give the injections if that is what is needed. otherwise,

1. since lovenox is given via injection, will this patient be sent home with a sharps box? sharps boxes can be obtained from a number of commercial suppliers. one is waste management (http://www.wastemd.com/) who has a program where patients buy and pay for the shipping of the disposal and destruction of the sharps container. when the container is full they simply pack it up in the pre-paid mailing box provided and drop it in the mail. it is likely that certain pharmacies in your area also provide this service, but you need to call around to a pharmacist or two to find out which pharmacies these are. if so, how should the patient be instructed to dispose of the sharps box? i can tell you about waste management's system because it is the one i use. once i close the lid on the container it is so tight that it can't be re-opened. the container is placed in a heavy plastic bag that comes with the kit and sealed with a twist tie. this is then placed in the corrugated mailing box which has 3 flaps. i secure it with sealing tape, but tape to seal it shut does come with the kit. the facility may have their own normal instructions about this, but i don't know what those instructions are and/or if we'll be going on those instructions. so i'm trying to at least get an idea of how patients at home (ex. diabetics, or any type of pt who does self-injections, etc.) would typically dispose of a sharps box. when i was getting iv chemotherapy by home health nurses the iv cartridges were disposed of in huge sharps containers here at my house. those containers were removed and taken back to the pharmacy by the pharmacy delivery guys when my chemotherapy was completed. they were just placed in brown paper grocery bags and carried out to their delivery vans.

2. after the patient does the daily injection, should he/she be instructed to apply a band-aid alone to the site? bandaids are not usually placed over lovenox injection sites unless the patient continues to bleed from the injection site for some reason. or would it be better to apply a 2x2 gauze and tape? what about cotton balls? my guess is that a gauze and tape along with pressure for at least a minute would be best. you don't want to do anything to aggravate bleeding. but again, i don't know if the facility normally supplies the patient with these materials, or if they are expected to acquire them at a drugstore, or what. lovenox usually comes in a pre-filled syringe. if the facility supplies anything it will be alcohol wipes. however, a pharmacy can supply both the lovenox and the alcohol wipes.

3. if the patient is going to self-administer the shot, what site(s) are acceptable to use? the abdomen i have heard my family doctor, for example, say that he only tells patients to use the thigh for self-admin. of sub-q's. but i have heard of diabetics giving themselves insulin shots in the abdomen. and i know heparin - if not lovenox - is best absorbed in the abdomen. so...abdomen it is, then? for lovenox, the abdomen; insulin is a whole other ball game

http://www.upmc.com/healthmanagement/managingyourhealth/healthreference/procedures/?chunkiid=33267 - patient instruction sheet on subcutaneous injection from the university of pittsburgh medical center health library

http://www.drugs.com/pro/lovenox.html this page includes drawings showing how and explaining where lovenox should be injected:

• subcutaneous injection technique
  • patients should be lying down and lovenox injection administered by deep sc injection. to avoid the loss of drug when using the 30 and 40 mg prefilled syringes, do not expel the air bubble from the syringe before the injection. administration should be alternated between the left and right anterolateral and left and right posterolateral abdominal wall. the whole length of the needle should be introduced into a skin fold held between the thumb and forefinger; the skin fold should be held throughout the injection. to minimize bruising, do not rub the injection site after completion of the injection.