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

[AtlantaRN]

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!!!!

[Em1995]

Can you tell us more about nebulized lasix? What mg of lasix and in what vehicle? Are there any articles about this? It sounds interesting....and, effective!

Thanks!

[sharona97, BSN, RN]

I'm a nurse , albeit not a hospice nurse at this tme. Just wanted to comment on the lidocaine nebs, which I personally use for respiratory sx's. It does numb the epi/glottis area but I was switched fro m the oral apparatus (usual neb inhaler) TO A 2-PRONGED nasal apparatus. During an attack the blast (even tho it's a misty one( but when you are air hungry, I am swallow the thing to get relief)this allows the medication to of course go down I think deeper into toh bronchioles. It's interesting to hear this being used on the activlely dying. Are you using at first sign of secretions? Or even with the tenacious secretions? It does settle things down well for me thus the anxiety goes waaaaaay down when I can take that first complete breath. Just FYI from someone who uses this med/neb pretty often.

Sorry I misread the drug name on the post.

Sharona

[DeathzAngel2]

I think educating & prepping the family is also key to managing secretions. I always explain to the family that secretions are usually heard on expiration & don't mean the Pt is struggling to get air in... it's just "noise". I tell them that we will try to dry them up but sometimes nothing helps & that it doesn't bother the Pt. Once the family understands, they panic less when secretions occur. I am not an advocate of suctioning unless the family is adamant about it. But I will explain that swabbing out the mouth with spongettes is usually just as effective in clearing the "reachable" secretions in the mouth. Suctioning is uncomfortable & deep suctioning to really get the mucus is worse.

I have used nebulized Morphine for Pts who are SOB rather than for increased secretions at EOL. The Morphine we are instructed to nebulize is the injectible form, without preservatives. It must be kept refrigerated after opening. The family is taught how to draw it up & utilize in the HHN.

For an actively dying Pt with secretions, SL Morphine, Lorazepam, Levsin or Atropine along with positioning, as you all mentioned, have been most effective. However, sometimes nothing takes the "death rattle" away except a celestial discharge.

[aimeee, BSN, RN]

Celestial discharge. Great term.

[rnboysmom]

Atlanta RN

I agree with all others, the essential goal is patient (and family) comfort. if your clinical coordinator is upset that you spent 4 hours on symptom control----shame on her!!!! She should be supporting your efforts. We start scope patches only if the patient is just starting the process with congestion (they can take up to 24 hours to kick in) Levsin is often a quicker alternative, and you have to stay at bedside and get aggressive with it at times. Encourage the MD to give you wide parameters to control symptoms. My staff are excellent with symptom control, but I admit that I have never used nebulized Lasix for these symptoms--I would be very appreciative if someone knows dosing parameters. We have utilized nebulized dilaudid with good results as it controls some very severe dyspneic symptoms from those with tenacious secretions.

[Second]

I would like to hear more about the aerosolized lasix. THis is new to me. How does it work. DOes it come pre-packaged. Any evidenced based articles? I am asking only because we use everything else mentioned here but sometimes we are still stuck with heavy secretions that don't want to move and sound awful -- I'd love to introduce the idea to our docs who are usually open to new ideas, but I need more info. Thanks.

[hospicemom]

we dont suction either. too invasive as well as the fact the secretions will just come back. plus, usually the secretions are deep airway, not upper airway. sounds worse than it is. scope patch on at first sign of secretions works well usually.

[mim-o]

i just got the royal ream out for using roxanol via nebulizer - any experience any one?

I'm home health-NOT Hospice. Although I must admit there are times I wish I was(because I sure needed to be). I have patient that refused Hospice due to lack of understanding (that seems to happen alot and I always try to educate to allow patient to make INFORMED choice). Severe COPD, TPN via pump, bed sores etc etc etc......MD informed patient and family less than 6 months..Anyway primary MD ordered roxanol 10mg EVERY HOUR prn for breathing via nebulizer-works wonders physically and psychologically for patient and breaks the increased SHOB -increased anxiety and vice versa cycle.

[NurseDutch]

Hospice is about comfort care, and someone dying on their own secretions, is NOT comfort. You did what is best for your patient. Another thing that may help is Levsin and we also use Atropine eye drops (but give them sublingually) it really works. Works a lot faster then Scoplamine which can take 4-6 hours to start working, and by then patient too congested, or has died.