Sunday, November 25, 2018

MANAGE NURSING CARE AT HOME, "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.


The material in italics here comes from Ting and I (Cooper, 2011); the non-italicized portions have been added subsequently.


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.


     “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 Some suggestions require a computer, and some do not:

1.    “Access to Education and Resources”
He contrasts illness-specific sites like and with more general sites like and Each has its strengths.

2.    “Daily Care”
He lists for shopping and for meals right away and 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:,,, and               

4.    “Personal Emergency Response Systems”
Examples given are and

5.    “Medication Reminders”
A full-service pharmacy is Reminder services include and, 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 and the site offer storage for the multitudinous appointments often associated with caregiving.

8.    “Support Communities”
Sites such as 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.


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.


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.


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.


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?

         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:


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

Our book is available from,, and How to Manage Nursing Care at Home

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