Rx for comfort measures?

leslie :-D · Feb 28, 2006

there is no standard care plan for someone on comfort measures.

each client should have their own individualized plan, so......

one pt. might get 20mg mso4 q4h; another might get 10mg mso4 q3-4h; and another might get 5mg mso4 q3h.

much of the planning entails the pathophysiology, comorbidities, stage of disease i.e., late stage......there is much to consider and should not be developed casually.

any thorough comfort regimen will involve the analgesic, anxiolytic, bowel stimulant, nsaid, and prns. now that's not written in ink but does reflect what i normally try to implement with ea pt i get.

right now i'm trying to help 3 kids w/homework so i might be overlooking some important interventions and if i did, please don't hesitate to let me know.

leslie

doodlemom · Feb 28, 2006

Our standing orders have Roxanol .25-1 ml sl q 1-2 hrs prn and ativan .5-2 mg q 4 hr prn, among numerous other meds - Roxanol and ativan are the ones we use the most

Just wondering · Feb 28, 2006

Thank you both for your response. I had a pt who was on comfort measures and she appeared to be in respiratory distress. Her condition was declining for the past week so I placed a courtesy call to the family, they came in @1am. She was mottling to her lower extremities, I upped her 02, her sats kept dropping and was also inaccurate due to poor peripheral. Called the doc and got an order of morphine 2mg Sq every hour prn for distress. Oral suction a couple of times....at that point she was rattling (I don't know the appropriate term). We made her very comfortable including the family. I was very informative to everything I did and the family consented to the med. The family also made a request to contact the priest, and gratefully they too had an answering service. It was a comfortable environment b/c to me sometimes with family members, their most memory could be when their loved one was passing and everything that went on in that room. We provided them with refreshments and coffee. This is a new workplace for me and there is no exact care plan for comfort care for CNAs. So throughout this situation I was informing the CNAs the purposes for everything being done with comfort care and its importance. I posted this med question b/c I don't have that experience like many of you in the nurses shoes. School is half the education, the real world is the other half and it counts the most. And it all paid off when the daughter was leaving and she gave me a hug and said "thank you."

just me

Just wondering · Feb 28, 2006

Repeat

QuigRN · Feb 28, 2006

Like Earle58 said, each comfort care is standardized to the individual. One consideration might be a scopolomine patch for what you described as gurgling; it helps dry up the secretions. Some people enjoy soft music in the background. I always try to implement some comfort measures for the families, too, such as offering drinks, meals, hugs. I'm sure others can think of more.

leslie :-D · Feb 28, 2006

Like Earle58 said, each comfort care is standardized to the individual. One consideration might be a scopolomine patch for what you described as gurgling; it helps dry up the secretions. Some people enjoy soft music in the background. I always try to implement some comfort measures for the families, too, such as offering drinks, meals, hugs. I'm sure others can think of more.

thank you quig......ita about the scope patch; or levsin gtts are also good for increased secretions. if i don't have to suction, i try not to as it is a very invasive intervention.

also roxanol (morphine concentrate) comes in 20mg/cc so you can give the mso4 sl rather than sc.

and yes!! don't forget anything you can offer the families. quig knows.

sounds like you did fine. but if you don't have to use injectables, then do sl as a first choice.

leslie

Just wondering · Mar 2, 2006

thank you quig......ita about the scope patch; or levsin gtts are also good for increased secretions. if i don't have to suction, i try not to as it is a very invasive intervention.
also roxanol (morphine concentrate) comes in 20mg/cc so you can give the mso4 sl rather than sc.
and yes!! don't forget anything you can offer the families. quig knows.
sounds like you did fine. but if you don't have to use injectables, then do sl as a first choice.
leslie

THANKS AGAIN!!!

leslie :-D · Mar 2, 2006

THANKS AGAIN!!!

my pleasure.

sounds like you're a natural for hospice care. something to consider?:balloons:

leslie

aimeee, BSN, RN · Mar 4, 2006

Sounds like you did a great job of making the patient, family, and other staff comfortable. Good work!

For terminal secretions we generally rely on Levsin (hyoscyamine) 0.125 tabs SL. It takes effect more quickly than the scopalamine patch and is more economical. Raising the head of the bed and repositioning the head/neck to allow pooled secretions to drain is often helpful.

As Leslie suggested, Roxanol (morphine sulfate liquid concentrate) in the 20 mg/ml concentration, is effective for reducing the air hunger that results as the body is shutting down. A 5 mg dose is just a couple drops, easily given under the tongue or in the cheek, and then you avoid pokes with a needle. 5 mg would be the normal starting dose for an opioid naive patient. While q4 hour prn would be the normal time frame, I often ask for the order to be written as q1 hour prn so you can give it more often if that amount proves to be ineffective since you can't have a range ordered in a facility.

This is the fast facts sheet on managing terminal secretions:

http://www.eperc.mcw.edu/fastFact/ff_109.htm

RNSUEIA · Mar 14, 2006

we typically use atropine gtts orally to dry secretions. 2-3 gtts per hour usually works well, and is less invasive than suctioning.

rosemadder · Mar 22, 2006

Our Hospice also uses the Atropine gtts for wet respirations (they are on our Standing Orders) and are very affective (I think that the Scop patch with the gtts work even better), we also have Standing orders for ABHR gel topically (Ativan-Benadry-Haldol-Reglan) for restlessness or nausea, if we're just treating nausea we have Ativan (works very well SL)...on our unit we have a scalding water faucet for melting meds and using SL (works great), and MSIR 7.5-15 mg (we melt it and give it SL if we need to). I would like to see some phenergan gel and tylenol gel as opposed to pills or supp but I'm still waiting on that. Overall, our list of standing orders is long and varied which leaves us lots of options for making our patients as comfortable as possible at all hours (when MDs can't be reached). I work on the inpatient unit so I have access to a large amount of stock meds but out in the home a symptom relief kit is delivered when the patient is admitted to Hospice so that emergency comfort is available 24/7.