CHAPTER 3 WHAT? EQUIPMENT AND
SUPPLIES
You will probably be surprised
how much “stuff” is involved in providing skilled nursing care at home. The
particulars will depend on your patient’s condition. Here, we look at the
situation for our quadriplegic, ventilator-dependent, tube-fed patient.
EQUIPMENT
The material in italics here comes from Ting and I (Cooper,
2011); the non-italicized portions have been added subsequently.
Computer
Our computer and
computer skills aided us greatly once we replaced the nursing agency.
We pay the nurses on
Thursday or on their last shift of the week. The spreadsheet program on our
computer enables us to print out the details of date, shift, hours worked,
gross pay, deductions (FICA and Medicare), and net pay. Two copies are made,
one for the nurse, the other for her to sign and return to us for our records.
The insurers want
similar information, monthly. The federal government also wants much the same
information monthly, along with the deductions and the matching employer
“contributions” to FICA and Medicare.
Quarterly and annual
reports for the state and federal government are required as well. I do the
first draft. We have an accountant to prepare the final draft. The same happens
with the preparation of the IRS
W-2 income tax forms at the end of the year.
Fun!
“Leveraging the Power of Technology to Help
with Caregiver Duties” is the title of an excellent blog article
contributed by Nathan McVeigh (2015) to the blog lotsahelpinghands.com. Some
suggestions require a computer, and some do not:
1.
“Access
to Education and Resources”
He contrasts illness-specific sites like
cancercare.org and alz.org with more general sites like cargiveraction.org and
lotsahelpinghands.com. Each has its strengths.
2.
“Daily
Care”
He lists instacart.com for shopping and
postmates.com for meals right away and taskrabbit.com for tasks you want to
delegate.
3.
“GPS Technology”
For patients with dementia, such devices can be
attached to their clothes to help find the patients. Other devices allow you to
monitor patient conditions remotely. McVeigh lists:
resources.careinnovations.com/quietcare, mylively.com, lifelinesys.com/content,
and life360.com.
4.
“Personal
Emergency Response Systems”
Examples given are medicalert.com and
lifealert.com.
5.
“Medication
Reminders”
A full-service pharmacy is pillpack.com.
Reminder services include tabsafe.com and medminder.com, and there are phone
aps.
6.
“Wireless
Home Monitoring”
These are advertised on TV and can alert you to
a fall or an unauthorized departure.
7.
“Software
Applications and Health Tracking Tools”
Platforms such as healthvault.com and the
lotsahelpinghands.com site offer storage for the multitudinous appointments
often associated with caregiving.
8.
“Support
Communities”
Sites such as lotsahelpinghands.com provide
support for caregivers and family members. Various illnesses have their own
specific support groups.
Hospital Bed (Cooper, 2011)
A sturdy hospital-type
bed, where the upper third and the lower third can be raised or lowered
electrically has proved very valuable. The full-queen bed we use is wide enough
to allow easy movement of Tina onto her side and back. The width allowed me to
sleep or rest beside her during the year without overnight nurses. The head
rest is up for watching TV, being fed, talking on the telephone, and gastric
tube and tracheostomy care. It is down for disposable diaper changes, bed
baths, and shampoos.
For our other patient, a woman in her
nineties, a standard-width hospital bed was used, one roughly the width of a
standard single bed. When this patient was mobile, rails had to be installed on
both sides to keep her from climbing or falling out. Overnight, a belt around
her waist was used for added safety, and she was connected to a bed alarm that
would sound if she pulled it loose.
Hoyer Hydraulic Lift
Nurses tell me that
back injuries are endemic to their profession. Lifting and transferring
patients cause most of the injuries.
Tina weighs 125 pounds,
rather slender at 5’5”, lighter than the average adult patient. Still, the
Hoyer hand-pumped hydraulic lift is a back-saver. Pump, pump, pump and up she
rises, like Mary Poppins as she thinks happy thoughts. Open the faucet-like
valve, and down she comes, slowly if you are careful. Tina lands onto her bed
or into her wheelchair like a snowflake in the winter, a flower petal in the
spring, a glider in the summer, and a leaf in the fall.
For our elderly patient, when she was no
longer able to get much value from being transferred to her wheelchair when not
making a doctor visit, we used the lift
and her sling to “dangle” her above the bed, in a posture much like sitting
upright. This was believed to have cardio-vascular benefits and to keep some of
her muscles in use in ways that they were not used when she was supine in bed.
Pulse Oximeter
Using laser light,
these highly informative meters give pulse rate and the percentage oxygen
saturation of the blood. Some are smaller than a deck of cards.
Tina’s normal pulse
rate is 70 to 90 per minute. Lower than
that may indicate she is sleeping or may be a cause for concern. Higher than
that suggests agitation or a fever.
Tina’s normal oxygen
saturation percentage (pO2) is 98 to 100 percent, quite good, in
response to the additional 3 liters per minute of oxygen supplied to her by the
ventilator, mixed with the room air. Lower than that suggests the oxygen line
has become crimped or disconnected or that there is a leak. Without the line,
she registers 92–94 percent pO2. Breathing room air for minutes
without the ventilator, she can stay near 90 percent, the low end of the safe
range, but we do not know for how long, and we are not eager to test it. In an
emergency (say, a fire), she will be evacuated immediately, quite possibly
without the ventilator.
The primary goal of the ventilator and the
auxiliary oxygen supply is to keep the oxygen content of the blood high enough
[above 90%] to prevent cell death. The pulse oximeter, measuring the oxygen
content at fingers or toes, where it is likely to be least, provides this vital
information, along with monitoring heart rate, also vital. It does not tell how well carbon dioxide is being removed from the
blood, so it is not the complete story on how well the respiratory
equipment and the patient’s respiratory system are performing.
Ventilator
The ventilators we have
will not let Tina’s respiration rate fall below 10 per minute, a value she
often reaches during deep sleep. Usually, the “vent” monitors her natural
breathing pattern, adding input air as she starts to breathe in, withdrawing
air as she breathes out. It assists, rather than replaces, her normal
respiration.
The ventilator is one
of several pieces of equipment in Tina’s room that repay some familiarity with
electronics, mechanics, fluid flow and physiology, much of which I had
expertise in from my career in environmental science and engineering. The
ventilator displays a series of values for her breathing cycle, the most useful
to us being the breath rate, f. Values of between 10 and 20 per minute are of
no concern. Values in the 20s may indicate a problem. When she started to
develop pneumonia, the rate went to the 30s per minute. Time to call 911.
The
ventilator is a modern technological miracle. Sure beats an iron lung.
Ventilator and oxygen
flow settings for our two patients were somewhat different, the older patient
having been diagnosed as afflicted with COPD, chronic obstructive pulmonary
disorder, possibly due to smoking, which she only gave up in her forties.
Vacuum Pump
Respirator-dependent
patients need regular clearing of the airways, using suction provided by a
vacuum pump. A covered in-line catheter is best for this, as the covering
reduces the chance of contamination on the thin tube that goes through the
tracheostomy tube and into the windpipe, the trachea. Sometimes lavage is performed, introducing a few mL of saline
solution into the windpipe and then rapidly removing it with the catheter. This
loosens and partially dissolves mucus plugs that can block the airway. The
material withdrawn is collected in a canister associated with the pump, and the
canister is cleaned regularly, with soap and water and perhaps with a
vinegar/water 50/50 solution used to disinfect it.
Briefly
closing off the tubing coming from the pump and observing the vacuum gauge can
allow one to judge whether the pump is performing properly. Sometimes weak
vacuum is due to loose tubing connections, improper sealing of the top of the
canister to the bottom, or excessive moisture in the filter immediately
upstream from the pump, used to protect it from material or liquid escaping the
canister and into the line ahead of the pump.
Oxygen Concentrator
Tina’s supplementary oxygen flow to her through her
ventilator is 3 liters per minute (3 L/min). A liter is roughly a quart, and
there are 28.3 liters in a cubic foot. In one day, that means a volume of
oxygen of
(3 L/min)(60 min/hr)(24
hr/day)= 4320 L/day
about 150 cubic feet of oxygen. To supply this
with oxygen tanks would be awkward and expensive. Instead, the oxygen
concentrator strips most of the nitrogen from ambient air and sends the
remaining oxygen to the patient. It does so at the cost of electric power, and
if the power goes out, one needs to use back-up oxygen tanks.
Oxygen Tanks
For traveling and for loss-of-power situations, we needed
oxygen tanks.
The portable ones were filled to a pressure of about 2000 psi [pounds per
square inch] and contained just under 700 liters of oxygen at room temperature
and pressure [70oF, 14.7psig= 1 atm]. When used at 3L/min, these would give
about 210 minutes of flow or 3.5 hours. Monitoring Tina’s blood oxygen content
with a pulse oximeter allowed us to lower this flow to about 1L/min for trips, without
hazard.
Electrical Generators
We have two gasoline-powered electrical generators, one for 5000 watts and
the other for 4000 watts, our back-up to our back-up generator. They require
some attention during the year, with the addition of gasoline additive to
prevent fouling and with running the generators every month or two to assure
they are working and to keep the gas flow lines clear. We run extension cords
from the generators, and the cords have multi-outlet attachments.
Alternatively,
we could have installed a propane-powered back-up power supply system at a
cost of about $10,000, ten times what the two smaller generators cost in total.
Besides the cost disadvantage, it would have been too complex for us to repair
immediately if it, too, failed, and there is some concern about fire hazard in
having propane in the vicinity of oxygen supplies.
Washer–Dryer
A medium or large wash
is done each of our four shifts each day. Pads, sheets, pillow cases,
nightgowns, towels, all need washing and drying, with different frequencies.
When the washer needs
repair? Yes, we have a backup.
The addition of a
second patient meant we ran 6 to 7 loads per day.
Redundancy
When possible, we have
had back-ups for our equipment: two ventilators, large and small oxygen tanks
to supplement the oxygen concentrator, heating and air conditioning units in
Tina’s room to supplement the central heating and air conditioning, a
gasoline-powered 5,000-watt electrical generator to protect us from power
outages, the longest of which was 95 hours. Our previous special van had two
gas tanks.
The multitudinous
disposables used daily also need to be in abundance, taking into account the
possibility of delays in receiving shipments of them. We have a month or more
of all of these, including the crucial special complete nutrition liquid. This
much stuff required a room for storage, our dining room, and a sharp,
detail-oriented home manager, Barbara George, to track them.
Note that I soon bought a second, back-up
gasoline-powered generator once our elderly patient became
ventilator-dependent.
MEDICATIONS AND
NUTRITION
By our seventh year of
home care, we were using the gastric tube to administer the following
medications, vitamins, and foods the indicated number of times per day:
morphine sulfate* (eight), Carafate (sucralfate)* (four), Baclofen* (three),
balanced nutrition liquid* (five), protein supplement* (twice), Prozac* (once),
vitamins B6, B12, C*,
and MgO, K, Ca* (each once), Fe
(twice), yogurt (twice), Benadryl* (twice), Proloprim* (once), Ativan*
(once), cranberry juice (once), aspirin* (once).
None of these was given
against doctor’s orders. Those with asterisks were prescribed; some were
available over the counter. Keeping track of these was done by a matrix, a
“chart,” with rows being the items and their timing and the columns being the
dates, with the intersection initialed by the nurse giving the item. Each chart noted the four chemicals to which
Tina is allergic. A similar chart was developed for the many treatments needed
regularly.
We had doctors’ orders
for another dozen medications on a PRN
(as needed) basis. This way, we were not asking the nurses to give Tina
something not medically authorized.
In feeding, there are
two easy ways to go wrong: too much food or too little. For Tina, we started
with five cans of a 250-calorie balanced-nutrition drink. With the yogurt and
juice, the total was nearly 1,400 calories. After a year or so, my 125-pound
love had gained definite chub. Creases had formed in the skin on her back, and
they were getting irritated. We cut back by one can a day to four per day,
about 1,200 calories in all. Two feedings with whole cans were replaced by two
feedings with half cans plus water. Slowly, the former sylph returned. At roughly
4,000 calories per pound of weight gained or lost, losing ten pounds should
have taken about
(10
lb) x (4,000 cal/lb) / (250 cal/day) = 160 days,
probably not too different from what
transpired. Physicists love equations.
My mother represented the
other way to go wrong. She ate like a bird, a fussy bird, at that. In three
months she went from about 125 pounds to about 110, a loss of 5 pounds per
month. A similar estimate indicated she was getting 5 x 4,000 / 30 = 700 too
few calories a day. I summarized this for her: “Eat or die!” She started eating
more. “Eat and live!” became the rallying cry.
Yes, we know that a more accurate value for
calories to poundage is 3600 calories per pound. There are subtle effects of
metabolism that make even this number an approximation. Still, caloric intake
and patient activity determine weight gain or loss.
Prescriptions: Liquids Cost Us Much More Than
Pills
In three
cases we found that getting the same amount of active medicine in liquid form
was much more expensive than getting it in pill form.
One patient needed morphine for pain. The liquid form (a
solution) cost us about $2000 per year. The same dosing, obtained by crushing a
tablet and dissolving it in water, cost about $1000 per year. This was the cost
of our co-pay; the insurer paid much more.
The simple salt compound KCl, potassium chloride, cost us about $200 per
year as pills and cost our insurer about $1000 per year. The same dosage in
liquid form cost about three times as much. Again, the pill could be crushed
and dissolved in water; we did.
The third example was the medication that is available
over-the counter as Pepcid and as a prescription as famotidine. The monthly dose of
the liquid version of the prescription had a “usual and customary” cost of
$530, of which we would pay $45, and the insurer and drugstore would pay the
rest. A month of the prescription pills had a cost of $30 of which we would pay
$6. A month of the over-the-counter Pepcid pills would cost us $20 and would
not be covered by insurance. Note the
much higher cost of the liquid form, which is easily obtained at home by
dissolving two pills in a few ounces of water.
Side Effects
Powerful medications
rarely have only one effect on the body. The other effects, “side effects,” one
hopes will be benign or mild. We have to be watchful for them, especially
during the early applications of a given medicine.
Tina is allergic to a
few meds, and these are prominently listed at the top of each medication
scheduling chart. If a new drug being started is related to any of these, we
watch with particular care.
From the various
nursing and medical handbooks, one can read a listing of typical, unusual, and
rare side effects, with some highlighted as serious. In home care, the
prescribing physicians are relying on nurses and family to detect such adverse
reactions.
Less obvious is the
interaction of two or more drugs to aggravate the side effects of each. We
noticed Tina was losing her hair, which would have been very upsetting for her.
We spotted two of her drugs that had this as a rare side effect. Combined,
apparently, they were more of a problem. Checking with the doctor, we dropped
or found a substitute for one of the drugs, and this problem went away. Surprisingly, one or more of her medications
has led to a lovely waviness of her hair.
Drug interactions are
hard to detect and probably more common than most people think. The number of
combinations goes up rapidly with the number of drugs. For drug A and drug B,
there is only 1 combination, AB. For A and B and C, there are 3 combinations:
AB, AC, BC. For A and B and C and D, there are AB, AC, AD, BC, BD, CD, six
paired combinations. For N drugs, each new drug adds (N-1) more pairs. Note,
too, that three or more drugs lead to sets of triadic combinations: A and B and
C and D have: ABC, ABD, ACD, and BCD. No wonder surprises turn up! We traced
Tina’s only seizure episode to such a three-drug combination.
Did I mention that
physicists love equations?
SUPPLIES
A
surprising amount of material is needed to care for a bedridden patient.
For a patient getting a
disposable diaper change every four
hours, you need 6x30=180 diapers per
month. We bought them in cases of 60, and we averaged four cases per month
per patient, as there were times when the diapers needed changing more often.
We found that using a
liner along with the disposable diaper prevented leakage, and we used about 1 case of 200 liners per month.
Activities involving
contacting the patient were carried out with gloved hands for the mutual
protection of patient and caregiver. We used about 1500 gloves per patient per month, 50 per day. Gloves came in
packages of 1000.
Disposable
wipers were consumed at the rate of approximately 2 cases of about 500 pre-wetted wipers per month, 1000 per
month, 33 per day.
A
patient fed through a gastric tube needs a supply of parenteral
complete-nutrition feeding fluid. One of
our patients took about 1200 calories of this daily, and the other took about
1000 calories of much the same liquid daily. The latter received supplementary
cranberry juice and liquid yogurt, bringing her to near 1200 calories a day,
as well; she had shown weight gain over period of months when she had been
given 250 more calories per day. Excess weight is a problem for the patient,
especially for the skin over bony areas, and for the caregivers, who need to
roll and transfer the patient frequently.
Cleaning supplies are consumed in
prodigious amounts. We also ran
the washer-drier combination every shift, thus three or four times a day, even
with one patient. Adding a second patient led to washes 6 to 7 times per day.
Ventilator supplies ordered per patient monthly included:
· Disposable inner
cannula (30/month)
· In-line suction
catheter (15/month)
· Ventilator circuit
tubing (2/month)
· 50’ oxygen line
(2/month)
· Circuit filter
(2/month)
· Ventilator filter
(2/month)
· Flexible connector for
trach site (15/month)
· Tracheotomy ties
(20/month)
· Suction tubing
(4/month)
· Heat and moisture
economizers (HMEs, 30/month)
· Split gauze pads (4” x
4”, 100/month)
· Cotton-tipped
applicators
· Saline flushes (3mL
containers)
Inventory Management
Keeping track of supplies can be a headache. By the basic rule of organization that similar things should be kept
closer together than dissimilar things, one can put the material where
shortages and excesses become evident. We ordered supplies by using a computer
spreadsheet to help predict needs and record ordering and acquisition.
For each supplier we
made a monthly order (at staggered dates during the month), going down the list
of items they supplied, generally re-ordering what we had ordered the month
before.
A
better system of inventory management would be to set up the following tabulation
on a spreadsheet:
ITEM UNITS USE/MONTH ON HAND # MONTHS
Diapers, case (4x15) 4 3 0.75
Gloves, box
(1000) 1.5 2 1.3
Wipers, case
(500) 2 2 1.0
The variability of arrivals of supplies
suggests one should aim to have at least half-a-month’s worth on hand.
Redundancy of Suppliers
Where
feasible, it is prudent to have more than one supplier. Fortunately, some of
the material we used was also obtainable from the local supermarket in roughly
equivalent products.
###
Contact information:
Diane R. Beggin, RN
40 Sycamore Drive
Montgomery, NY 12549
DianeBegginRN@gmail.com
http://ManageNursingCareAtHome.com
Our book is available from amazon.com, bn.com, and OutskirtsPress.com: How to Manage Nursing Care at Home
###
Contact information:
Diane R. Beggin, RN
40 Sycamore Drive
Montgomery, NY 12549
DianeBegginRN@gmail.com
http://ManageNursingCareAtHome.com
Our book is available from amazon.com, bn.com, and OutskirtsPress.com: How to Manage Nursing Care at Home
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