Questions for non-novice hospice nurses!

leslie :-D · Sep 13, 2006

Okay... new hospice nurse (RN since 93 however) and having difficulty transitioning from curative to palliative care. (imagine that!)
Pain control: What do you most commonly use? Do you ever fear using too much Roxanol? How do you explain the difference between Roxanol and Morphine Sulfate? Our Medical Director tells me they are TOTALLY different drugs. Yet they are both MS, so I do not understand this. Yes, I know Roxanol is stronger... but that isn't what he meant.
Bowel regime: What do you do when you get a patient (new admit) and apparently he/she hasn't had a bm in 7-10 days? (eek!) Is unable to tell you.. and facility he has been at "hasn't paid attention?" (eek!) What would you have done? Ordered?
Skin Care: What products do you use most frequently for skincare and decubs?
Last but not least... (boohoo) HOW do I get supplies that I would LIKE to use, but aren't on in stock (perhaps expensive)??? And I work for a non-profit... (eek!) Help!

morphine is probably most commonly used.

roxanol is the manufacturer name for morphine sulfate concentrate.

it only comes in 20mg/ml.

but there is also a generic morphine sulfate concentrate, 20mg/ml.

they are NOT totally different drugs but morphine sulfate comes in different concentrations and can be given po, pr, im, sc, iv.

roxanol is only po/sl.

if pt is in pain, i do not worry about giving increased dosages.

but yes, it is possible to administer too high of a dose initially.

you would not start a pts' first dose of 50 mg, yet 50 mg is certainly not an unreasonable dose once lower dosages have been unsuccessful.

no bm x 7-10 days?

goal would be immediate evacuation then establish routine bowel regimen.

higher dosages of narcotics require more aggressive bowel regimen.

routine skincare would reflect needs of pt.

unscented is preferable.

as for decubs, depends on stage and presentation.

stage I, II, III or IV?

infected? eschar? fungating?

many considerations.

as for preference of supplies, you can always talk to facility wound/skin consult but they usually have their own established set of supplies.

you can always try and market the ones you like, with data to back it up.

but other than that....

i have frequently brought in my own skin cremes/lotions, as long as it is maintenance/routine skin care and doesn't treat anything medical.

have you been oriented already?

if you haven't, please, ask any and all questions during your training.

best of luck.

leslie

doodlemom · Sep 13, 2006

I agree with Leslie. Roxanol is just a brand name for a 20 mg/ml morphine sulfate concentrate. Morphine Sulfate is the generic name. MS can come in many forms - tablets, extended release ( MS Contin, oramorph), immediate relase SL tablets (MSIR), IV preparations, liquid concentrate including a generic 20 mg/ml preparation, etc... Roxanol is Morphine Sulfate. I generally do not fear using too much Roxanol. We usually start our narcotic naiive patients out at .25-.5 ml and see how they do and go up from there. It is used on a PRN so the patient only takes it when they need it. Of course it is possible to overdose just as with any narcotic, but if they are taking it when they need it - that's not an issue.

Enema/disimpaction for no BM in 7 days. We usually start people out with senna-s 1-3 tablets BID (depending on how much narcotic they are on - it could go up to TID.) Then we can add some lactulose or sorbitol if that is not working well enough. If that is still not working - then we could go from there.

The hospice that I currently work for (non-profit) uses a lot of expensive wound care supplies - which surpised me when I first started working there. The hospice that I used to work for (also non profit) some time ago would order some expensive supplies only if the physician or nursing facility insisted on it. Most of our patients had W to D dsg's if they were stage 3-4, tegaderm and duoderm for 1's and 2's. I have to admit, the newer, more expensive dressings make the nurses life a LOT easier. An argument could be made that the agency does not have to spend as much on nursing care if the dressings can be changed every few days, as opposed to every day. Also, it is easier on the family.

Really depending on what kind of wound you are talking about is what determines the care.

Welcome to hospice nursing. It is a continually changing specialty and you learn new stuff every day.

aimeee, BSN, RN · Sep 13, 2006

Pain control: What do you most commonly use? Do you ever fear using too much Roxanol? How do you explain the difference between Roxanol and Morphine Sulfate? Our Medical Director tells me they are TOTALLY different drugs. Yet they are both MS, so I do not understand this. Yes, I know Roxanol is stronger... but that isn't what he meant.

Same answer as the others. Roxanol is merely a brand name for a form of immediate release morphine sulfate liquid solution concentrated to 20mg/ml. We tend to refer to this particular concentration and delivery system for morphine sulfate by the brand name to distinguish it from the others. Always specify concentration, proper dose in milligrams, and proper dose in millileters to avoid any errors in dosage. Remember, there is no ceiling dose but start low and go slow for narcotic naive patients. For patients who are not narcotic naive, remember to use a conversion to help you select the proper starting dose.

Bowel regime: What do you do when you get a patient (new admit) and apparently he/she hasn't had a bm in 7-10 days? (eek!) Is unable to tell you.. and facility he has been at "hasn't paid attention?" (eek!) What would you have done? Ordered?

I can't tell because I would need to know much more...is the patient uncomfortable and feeling constipated? What diseases/conditions does he have? Does he have good active bowel sounds or are they distant or tympanic? Can I palpate a mass of stool? Is there a physical obstruction such as tumor blocking the progression of stool? Has the patient been eating? Does he have nausea and vomiting? Is he running a low grade temp? (often associated with impaction) Is he passing gas? Is he on a narcotic regimen or diuretics? Does a digital check for impaction find anything in the rectal vault? Does he have any bowel regimen at all right now?

Last but not least... (boohoo) HOW do I get supplies that I would LIKE to use, but aren't on in stock (perhaps expensive)??? And I work for a non-profit... (eek!) Help!

Whether you work for a for-profit or non-profit, the goal is still the same...to provide excellent care but as cost effectively as possible. Are you sure the supplies you want to use are actually superior? Or are you just accustomed to them? If you can show that there is actually a benefit to using them management is likely to approve their order...for instance a study that shows the wounds tend to heal more quickly and with fewer complications...this might mean having to provide nursing time and dressing changes for only 1 month instead of 2. So in the long run the product that is more expensive up front is actually more cost effective in the end analysis.