COMPLEX CARE POLICIES
Bowel care is the care and management process of eliminating faecal matter from a client’s body. Bowel care can encompass personal hygiene, assistance with toileting, medications to promote bowel function and administration of the same.
Care Staff with appropriate competency training and assessment provide bowel care to our clients. NurseCare Australia considers it imperative to involve our clients in all aspects of their service delivery
and the direction of their services to their ability. The dignity of risk is an essential part of this choice and control.
Scope
This policy applies to all NurseCare Australia staff working with clients with complex bowel care requirements.
Definitions
Principles of complex bowel care
NurseCare Australia’s principles of complex bowel care include:
- following all care instructions noted in the Complex Bowel Care Plan with identified
- following personal hygiene and infection management procedures
- maintaining the client’s dignity, respect, and consent throughout all activities
- observing and recording changes to bowel habits
- reporting issues arising from the delivery of complex bowel
- administering laxatives, enemas, or suppositories, including non-routine medication as required
- identifying when to seek advice from a health practitioner (e.g., general practitioner, medical specialists, nurse consultants, registered/enrolled nurse, or allied health practitioner).
- Aligning with the required for the high intensity skills descriptor for complex bowel
Roles and responsibilities
Registered/enrolled nurse
It is the role and responsibility of the registered/enrolled nurse to:
- develop a rapport with the participant.
- offer privacy when toileting or changing the participant.
- encourage fluid and nutritional intake (e.g., 1500 ml of fluid daily)
- follow all procedures and the Care Plan to promote continence.
- assist the participant when transferring, ambulating, or walking to the toilet.
- maximise mobility and passive exercises.
- toilet the participant as per the Care Plan
- complete the Daily Fluid Intake and Output Form and the 7-Day Bowel Management Chart, as required.
- report concerns or changes to the registered/enrolled nurse or the Director or Care Manager
- recognise and report participant verbalisations and behaviours indicative of discomfort.
- report any signs/symptoms of the participant’s bladder and bowel discomfort to the registered/enrolled nurse or the Director or Care Manager
Care staffs consult with the participant, their carer or advocate to identify and remove or minimise exposure to conditions that may lead to an unsafe environment.
Bowel care equipment
Equipment required to provide appropriate bowel care may include, but is not limited to:
- disposable gloves (powder free)
- personal protective equipment (gloves, face shields and masks)
- disposable aprons
- lubricant (water-based)
- gauze swabs.
- incontinence pads or Kylie
- commode
- a medical waste receptacle or bag
- medications.
Administration of enemas
When administering an enema, the care staff will:
- explain to the participant the steps that will be taken to administer the enema.
- obtain the participant’s verbal consent.
- check the Medication Administration Chart to confirm the date and time the enema is due to be administered.
- gather all the equipment needed to administer the enema.
- wash and dry hands and put on disposable gloves.
- place a protective disposable mat or waterproof cover under the participant.
- request the participant lies on their left side with their gently knees drawn up, if possible.
- warm the enema by placing it in a bowl of hot water.
- lubricate the end of the enema tube using water or a smear of paraffin wax.
- insert the tip of the enema nozzle into the rectum (this may cause the participant some discomfort but should not cause pain)
- gently squeeze the enema into the rectum
- stop if there is pain and immediately call the registered/enrolled nurse or the Director or Care Manager
- dispose of all PPE and disposable may immediately as per the Management of Waste Policy and Procedure and the Infection Management Policy and Procedure
- be ready to assist the participant in going to the toilet, as they may need to go shortly after the enema is administered.
Participant lies on their left side for enema administration.
Administration of suppositories
When administering a suppository, the support worker will:
- explain to the participant the steps required to administer the suppository.
- get the participant’s verbal consent.
- check the Medication Administration Chart to confirm the date and time that the suppository is due to be administered.
- have the participant lie on their left side with the knees drawn up, if possible
- insert the suppository into the rectum.
- suppositories may take some time to have a result.
- assist the participant in going to the toilet when they ask or 30 minutes after administering the suppository.
- dispose of all PPE and disposable mat immediately following waste and infection management procedures
Stoma Care
Purpose of ileostomy and colostomy stomas and related equipment, and consumables such as stoma bags, skin sealants, barriers, or powders.
- Common methods to clean and protect skin around the stoma.
- Characteristics of a healthy stoma and how these can change over time.
- Indicators and action required to respond to common health problems at the stoma site, such as wetness or signs of infection or inflammation.
- Reporting responsibilities, including handover, recording observations and incident reporting
Recordkeeping
Support workers will:
- assess the bowel movement using the Bristol Stool Chart (which provides a visual guide to the type of stool passed)
- write in the participant’s Progress File Notes when the enema or suppository was given.
- update the bowel record (7-Day Bowel Management Chart)
- update the Daily Fluid Intake and Output Form
- complete and sign the Medication Administration Chart relating to the enema or suppository administration.
8.5.1 Bristol stool chart
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The Complex Bowel Care Plan is developed with the involvement of the client, their family, carer or advocate, the Director or Care Manager, and a health practitioner (e.g., general practitioner, medical specialists, nurse consultants, registered/enrolled nurse, or allied health practitioner).
The Complex Bowel Care Plan includes details such as:
- a bladder and bowel assessment are undertaken within seven days of the client’s commencement of our service.
- signs and symptoms of gastric problems, including
- frequency and patterns of bowel movements
- signs and symptoms of irregular bowel habits (e.g., constipation or diarrhoea)
- monitoring and recording care
- detailed instructions on medication selection for bowel care
- instructions regarding medication administration procedures for bowel care
- emergency management options and procedures
NurseCare Australia conducts appropriate bladder and bowel assessments and updates the client’s Complex Bowel Care Plan every 12 weeks or if a change in the client’s condition affects continence.
Any of the following signs require immediate referral to the general practitioner or local hospital:
- vomiting blood or faecal matter
- diarrhoea or vomiting that is more than a one-off
- bleeding from the bowel
- fresh(red) or old (black*) blood in faeces
- unusual pain before, during or after a bowel action
***** Note: Black faeces can occur when a person is taking iron supplements. *****
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NurseCare Australia trains support workers according to their Staff Training Plan or the Training Plan
– Complex Bowel Care and information relating specifically to each participant’s needs and their
Complex Bowel Care Plan. The training includes:
- basic anatomy of the digestive system
- importance of regular bowel care
- an understanding of stool characteristics indicating healthy bowel functioning with related signs and symptoms (using the Bristol Stool Chart, a recognised evidence-based practice tool)
- when to refer a participant to a health practitioner (e.g., overflow, impaction, perforation, infection, or blockage)
- Relationship between nutrition, hydration, dietary fibre, probiotics, and bowel motions and stoma management
- administering enemas and suppositories, digital stimulation, and massage
- nutrition and hydration requirements
- alteration in bowel habits that may result from decreased mobility, altered nutrition, medications, and decreased fluid intake.
- recognising, responding to, and reporting problems (e.g., constipation, diarrhoea and faecal incontinence, blockages, signs of deteriorating health or infection)
- safe work practices to prevent and control infection.
- how to correctly wear appropriate personal protective equipment (PPE)
- waste management
- record-keeping and documentation
Submit your Files Here for Complex Bowel Care :
Scope
This policy applies to all NurseCare Australia care staff providing clients with complex pressure care and wound management.
Definitions
Principles of complex wound management
Skin is the largest body organ; skin integrity means being whole, intact, and undamaged. When the skin has integrity, it performs important functions, including:
- protecting the body from harmful temperatures, chemicals, radiation, and pathogens
- maintaining fluid and electrolyte balance and optimal inner body temperature
- conveying pleasant and unpleasant sensations
- communicating individuality by its texture, colour, and characteristics
NurseCare Australia care staff will assess a wound and document using the Wound Assessment and Treatment Form.
A registered/enrolled nurse or health practitioner will document written procedures on wound care in the Care Plan. Appropriately qualified and trained staff are responsible for:
- developing Wound Management Care Plans, including identified outcomes
- documenting wound care policies and procedures
- identifying training needs of support workers
- providing relevant competency-based training and assessment processes for support
- workers to ensure they are competent to perform prescribed duties, tasks, and interventions.
- monitoring, reviewing, evaluating, and adapting (as required) the service, plans and outcomes with the participant, their family, carer, or advocate.
- attending to complex wound care management, including dressing selection and changes
- supervising and guiding support workers in the provision of skincare
- work only within the scope of their practice and prior experience.
- history of diabetes
Roles and responsibilities
The Director or Care Manager is responsible for the overall clinical management of high intensity supported client care. A relevant health practitioner oversees the client’s care plan (e.g., registered/enrolled nurse). The Wound Management Care Plan is regularly reviewed, and updated procedures and information are provided to the client and their carer/advocate. The client’ s desired level of involvement is respected and maintained.
NurseCare Australia ensures each client requiring pressure care or complex wound management receives relevant and proportionate support for their individual needs.
Care staff receive training specifically to satisfy each client’s needs and requirements, which their wound management regime may impact (e.g., showering, toileting, and mobility). Further training specific to complex wound management includes:
- common skin integrity risks
- common indications of infection and required responses
- implications of a prolonged or worsening infection
- purpose and methods for positioning and turning a participant to manage pressure area risks
- specific techniques for wound dressings
Prevention of skin damage and pressure ulcers
To prevent skin damage to clients, our care staff will:
- undertake daily (or regular) assessment and review of the skin
- avoid dryness or maceration of the skin
- use an emollient soap substitute on dry or vulnerable skin
- use non-soap skin cleansers when cleaning skin following incontinence
- dry skin thoroughly using a patting technique (a rubbing motion will not be used)
- moisturise skin at least twice daily
- smooth(not rub) barrier cream or moisturiser on, in the direction of body hair
- avoid the use of powder (i.e., talcum powder)
- protect skin from friction (e.g., when sliding down in bed or a chair)
- avoid vigorous massage over bony prominences
- avoid overheating (e.g., when using plastic surfaces, ensure regular repositioning)
- employ correct lifting and manual handling techniques and devices (e.g., slide sheets)
- use disposable continence aids rather than reusable
- maintain optimal nutrition with adequate protein, calories, carbohydrates, fat, vitamins and minerals
- maintain optimal hydration
- use a no-sting or hydrogel barrier cream or film for incontinent client
In addition, for skin tear prevention, staff will:
- provide adequate lighting
- keep edges of furniture and equipment smooth and unobtrusive
- pad wheelchair arms, footrests, bed rails, walking frames,
- ask the client to wear long-sleeve shirts and long pants to protect their limbs
For clients at risk of pressure ulcers, staff will:
- monitor for signs which predispose the client to pressure ulcers, this includes blistering, swelling, dry patches, a change in colouring, shiny or warm areas all of which may indicate a tendency to development of pressure ulcers
- provide pressure-relieving surfaces (e.g., high-specification foam mattress or cushion)
- recommend using dense specialised sheepskin
- keep the client mobile by regularly re-positioning their body (24 hours/7 days a week)
- reposition a client who sits for long periods at 15-minute intervals (dependent on tissue tolerance to pressure)
- use a dynamic support surface if the client ‘bottoms out’
- avoid positioning the client directly on bony prominences or existing wounds
- use foam wedges and pillows to reduce pressure on bony prominences, avoiding foam rings and doughnuts.
- avoid using restrictive devices and restraints, if possible
- limit the length of time the bedhead is elevated
- use skin products that maintain the skin’s natural pH level
- elevate the foot of the bed 20 degrees if the client slides down the bed
- aim to reduce the Braden Scale score by managing all risk factors
Clients with diabetic foot ulcers will be referred to a podiatrist or orthotic specialist, as pressure off- loading may be enhanced by using:
- crutches, walkers, wheelchairs
- custom-made shoes or inserts (e.g., orthotics, diabetic boots, total contact casts)
Wound assessment
Wound assessment and management are a specialised area of nursing and will only be undertaken by skilled and experienced practitioners. A registered/enrolled nurse must assess the client’s wound care needs. The registered/enrolled nurse will consult evidence-based, best practice guidelines when selecting available wound dressing products and recommending wound-specific techniques for each client.
Support staff must evaluate and document:
- cause, site, type, and classification of wound
- wound depth: superficial, partial, or full thickness
- wound size: trace and calculate area on the first presentation, then on each review/dressing change
- wound edge: sloping, punched out, raised, rolled, undermining, purple,
- wound bed: necrotic, sloughy, infected, granulating, epithelialization
- exudate :serous, haemoserous, purulent
- surrounding skin: oedema, cellulitis, colour, eczema, maceration, capillary refill time
- any signs of infection: heat, redness, swelling, pain, odour, delayed healing
- pain: associated with disease, trauma, infection, wound care practices, products
- wound healing and health outcomes: including pain management and the management of any infections
- potential or actual psychosocial impact of the wound
- any changes to the Wound Management Care Plan: including rationales for the
- any adverse events associated with the management of skin integrity
- by taking a photograph of the wound and ensuring the date of the photo is noted on the photo
Wound management procedure
As part of the support delivered by NurseCare Australia, care staffs delivering wound care services will consult with the registered/enrolled nurse to understand the required skin and wound management care.
Dressings
The type of wound dressing will depend upon the goal and holistic needs of the client. Wound dressings should:
- maintain a moist wound healing environment (note: dry gangrene or eschar are best left dry until revascularisation)
- manage wound exudate and protect peri-ulcer skin
- remain in place to minimise shearing, friction, pressure, and skin irritation
- be non-adherent to reduce skin damage when the dressing is removed
Hydrocolloid dressings can improve wound healing compared to paraffin gauze or wet/dry dressings. Hydrocolloids are generally more cost-effective and are the dressing for pressure ulcers. Alginate dressings are more effective than other modern dressings for debriding necrotic tissue. Topical antimicrobial dressings may be beneficial when wounds are chronically or heavily colonised.
Wound management steps
When providing wound management care, our care staffs will:
- perform appropriate hand hygiene
- wear appropriate PPE
- place a clean, sterile drape around the wound area, if available
- cleanse wound site with normal saline
- irrigate the wound with a neutral, non-irritating, non-toxic solution, and cleanse
- remove necrotic or dead tissue
- apply ointment (i.e., wound healing cream as directed in the Care Plan)
- apply a dressing as directed in the Care Plan
- ensure effective pain management during and before dressing wounds
- educate the client and their family, carer, or advocate regarding their wound care requirements and progress
Pressure ulcers are usually complex wounds that require a general practitioner or registered/enrolled nurse assessment. For pressure ulcers with poor progress in healing (or a stage 3-4 ulcer), the client should use an alternating pressure, low air loss, continuous low-pressure system, or air- fluidised bed.
Documentation
All wounds are documented using the Wound Assessment and Treatment Form. Skin integrity and risk of pressure injuries will be assessed using the Braden Scale Risk Assessment Tool, a widely used and validated assessment tool.
As part of NurseCare Australia’s collaborative care framework, the client, their family, carer, or advocate are provided with comprehensive education regarding their wound management regime. The client is encouraged to communicate their medical needs to their general practitioner and the NurseCare Australia care staff involved in their ongoing care.
Equipment in the home
Equipment needed in the home environment to provide appropriate wound care management may include, but is not limited to:
- personal protective equipment
- pressure area descriptor chart
- disposable gloves (powder free)
- disposable apron
- gauze
- normal saline or distilled water
- cotton-tipped swabs
- basic dressing pack
- additional dressing requirements, as per the client’s Wound Management Care Plan
Common consumables used in complex wound management and their function, such as, types of dressings.
The Wound Management Care Plan is developed with the involvement of the client, their family, carer or advocate, the Director and relevant health practitioners e.g., general practitioner, medical specialists, nurse consultants, registered/enrolled nurse) The care requirements are developed and overseen by a health practitioner (e.g., general practitioner, registered/enrolled nurse) and specific instructions are provided for the care staff to implement. A health practitioner will regularly review the client’s health status, wound management, and care.
The health practitioner understands that clients are at risk of pressure ulcers if they have:
- restricted mobility
- history of pressure ulcer/s
- indwelling catheter in situ due to incontinence
The Care Plan identifies how risks and emergencies are managed to maximise the client’s safety and wellbeing. The client’s Wound Management Care Plan is reviewed monthly as required by the client's condition or when there is a change in the client conditions. The care plan will also consider information received from the client, their carer or advocate, our staff and health professionals inform their care. Outcomes of the review are recorded in the client’s Notes. If the Care Plan is adjusted, the client will be provided an updated version.
care staffs document all aspects of pressure care and complex wound management, including assessments, treatments, management plans, implementation, and evaluation methods.
Staff use the following documentation methods to record information concerning pressure care and complex wound management:
- progress or file notes
- Wound Assessment Treatment Form
- skini ntegrity assessments (e.g., Skin Assessment Form)
- Waterlow scores
- risk assessments (e.g., Risk Assessment Form – Module 1)
care staffs contact the registered/enrolled nurse and the Director or Care Manager to request a change to the Wound Management Care Plan. Any changes must be discussed and agreed upon with the client, their family, carer, or advocate.
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NurseCare Australia’s training system complies with the high-intensity support skills descriptor for providing complex wound management. All our staff follow procedures and exercise judgment about when to request an ambulance.
NurseCare Australia provides appropriate training to our care staffs who work with clients requiring skin and wound care. Additional training is provided relating to each client’s specific needs, skin type and required wound support.
Complex wound management training completed by our care staffs includes:
- basic understanding of skin and vascular system anatomy
- hand hygiene
- correct PPE to be worn
- wound cleaning and aseptic technique
- stomacare requirements and procedures
- preferred method of communication techniques to be able to explain identified risks to the client, their family, carer or advocate and other care staffs
- the impacts of associated health conditions and complications that impact pressure injuries and complex wounds
- factors that predispose the client to pressure ulcers such as unable to reposition independently, diabetes, use of steroids or other drugs which reduce circulation and thin the skin
- factors that may require immediate attention (e.g., infection, ulceration, reduced blood flow)
- positioning the client to relieve pressure on affected areas or wounds
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Submit your files here for Complex-Wound-Management:
Scope
This procedure applies to all NurseCare Australia staff who work directly with clients requiring enteral feeding and management.
Definitions
Principles of enteral feeding and management
Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure that uses a tube (PEG tube) to pass into a client’s stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is inadequate (e.g., due to dysphagia or sedation).
Enteral feeding and management procedure
NurseCare Australia care staffs will:
- follow personal hygiene and infection management procedures.
- confirm the need and consent for enteral feeding.
- introduce food via a tube according to the Care Plan
- monitor the rate and flow of feeding and take appropriate action to adjust, if required.
- keep the stoma area clean.
- monitor and report signs of infection.
- check that the tube is correctly positioned.
- confirm monitoring equipment is in operation.
- follow correct procedures when responding to a malfunction.
- document a request to review the Mealtime Support Plan, as required.
- liaise with health practitioners so they can explain or demonstrate requirements.
- recognise and respond to symptoms that could require health intervention.
Roles and responsibilities
The Director or Care Manager is responsible for the overall clinical and medication management of a high intensity supported client’s care.
The client’s enteral feeding Care Plan, mealtime preparation and mealtime support plan are overseen by the relevant health practitioner/s (e.g., dietitian, speech therapist, occupational therapist, nurse consultant, registered/enrolled nurse). The Care Plan is regularly reviewed, and updated requirements and procedures will be provided to the client, their family, or their carer/advocate.
NurseCare Australia ensures that each client’s desired level of involvement in their care is respected and maintained. It is NurseCare Australia’s responsibility to provide nutrition, fluids, and medications relevant and proportionate to the individual needs of each client requiring enteral feeding and management.
Registered/enrolled nurse
A registered/enrolled nurse may:
- replace a PEG tube
- supervise and guide the care staff in the provision of nutritional or enteral stoma care
- only work within the scope of their practice and prior experience
***** Note: The nasogastric tube replacement is considered high risk and will only be done by a qualified health practitioner (i.e., general practitioner or medical specialist or registered/enrolled nurse). In some cases, registered/enrolled nurses may respond when PEG tubes become dislodged, but this is only appropriate when the balloon device tube is in position and stable (after the balloon device replaces the initial tube). There is active oversight by a qualified health practitioner. *****
Care staffs
care staffs may:
- perform any task on the Care Plan, apart from those nominated above, that a registered/enrolled nurse performs.
- assist with the administration of enteral feeds and flushes, once assessed as being competent in this skill.
- clean stoma site
- observe and report if the stoma site is red, painful, or
- observe and report if tubing becomes
care staffs MUST:
- follow the Care Plan as provided by NurseCare Australia
- report to the Director or Care Manager of any changes or variations to
- never change any care or feeding plan
- take part in training on the use of equipment, manual handling, and risk management as determined by NurseCare Australia
- report any issues arising from the delivery of care to the Director or Care Manager for further advice.
- identify and report to the Director or Care Manager any gaps in their ability to deliver the required supports.
Observe, document and report.
Should the following conditions or symptoms be observed by the care staff they will document what they have observed and report the same to the registered/enrolled nurse and the Director or Care Manager, who will then arrange a medical review. The conditions/symptoms include:
- skinbreakdown or excoriation about the stoma site
- sign sof infection – redness, swelling, bleeding, discharge, odour
- folliculitis(inflamed hair follicle)
- tube placement is too tight or too
- gastric fluid leaking from the stoma site
- tube or device displacement, discolouration, or
- diarrhoea, constipation, nausea, vomiting
- an incorrect port (balloon port) is used to administer feed or
Processes for using enteral feeding tubes.
The Enteral Feeding Care Plan is developed with the involvement of the client, their carer or advocate, the Director or Care Manager and a health practitioner (e.g., general practitioner, medical specialists, speech therapist, occupational therapist, dietician, or nurse consultants)
The Enteral Feeding Care Plan includes details, such as:
- signs and symptoms of gastric problems
- frequencyand patterns of feeds
- signs to check before and after a feed
- monitoring and recording
- detailed instructions on feed and medication selection and administration procedures
- emergency management options and procedures
- how to manage risks, incidents, and emergencies, including:
- required actions and
- escalation to ensure client wellbeing and
Our care staffs will confirm the client’s consent before administering feeds detailed in the Enteral Feeding Care Plan (as agreed with the client or their carer or advocate). care staffs will complete the daily fluid intake and output form for each client to inform the enteral feeding care plan on an ongoing basis. The client’s health status is regularly reviewed by the Director or Care Manager and a qualified health practitioner (e.g., general practitioner, medical specialists, nurse consultants, registered/enrolled nurse, or allied health practitioner).
The client’s enteral feeding Care Plan is reviewed quarterly or when there are changes in the client’s condition. NurseCare Australia develops care strategies that act upon relevant information from the client, their family, advocate, our staff, and health professionals.
Staff follow NurseCare Australia documentation procedures for:
- PRN medication
- monitoring and recording of
- emergency management procedures
- recording changes requested by health practitioners(e.g., general practitioner, medical specialists, nurse consultants, registered/enrolled nurse, or allied health practitioner)
- documenting and informing the Director or Care Manager, the client, their carer, or advocate when a change in enteral feeding management is requested.
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A care staff who provides support and management for enteral feeding must have all relevant additional qualifications and experience. Staff are trained to be aware of associated health conditions and complications that interact with enteral feeding, e.g., severe epilepsy, severe dysphagia, and complex physical disability.
NurseCare Australia staff are provided training (according to their training plan), relating specifically to each client’s needs and the client’s support plan/mealtime preparation and delivery plan. Staff are trained in behaviours of concern, such as when a client frequently dislodges their feeding tubes (becoming a high-risk client) and all associated risks.
NurseCare Australia’s training program instructs our care staffs to manage different enteral feeding equipment, components, and functions. care staffs receive training specifically related to each client’s needs and the type of feeding support they require (e.g., enteral, PEG). Training includes:
- basic anatomy of the digestive system
- equipment components, function, cleaning, and maintenance procedures
- stomacare requirements and procedures
- communication techniques that can be used to explain risks to client, their carer or advocate and other care staff
- impacts of associated health conditions and complications that interact with enteral
- symptomsthat may occur with enteral/PEG feeding (e.g., dehydration, reflux)
- factors that may require immediate adjustment (e.g., rate, flow, and quantity of food)
- positioningof the client during and after the PEG feed
- identifying and minimising client exposure to enteral feeding risk factors (e.g., gastro, constipation)
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Submit your Files Here for ENTERAL FEEDING:
Scope
The Tracheostomy Management Policy and Procedure apply in conjunction with the Ventilator Management Policy and Procedure, the Stoma Care Policy and Procedure, the Management of Waste Policy and Procedure and the Infection Management Policy and Procedure. All policies are followed by all NurseCare Australia care staffs who care for and manage clients with a tracheostomy.
Definitions
Principles of tracheostomy management
A tracheostomy is a surgical opening in the trachea below the larynx. A tube is placed in the windpipe (trachea) to assist breathing. Without a steady flow of air (oxygen) through the tracheostomy, it will result in a lack of oxygen and eventual death.
A tracheostomy can be done for one of several reasons, including to:
bypass an obstructed upper airway (an object obstructing the upper airway will prevent oxygen from the mouth from reaching the lungs)
- clean and remove secretions from the airway.
- efficiently and more safely deliver oxygen to the lungs.
- to facilitate a mechanical ventilator
The procedure outlined in this policy and the Tracheostomy Care Plan informs staff on how to implement best-practice care, including when:
- dealing with a tracheostomy emergency
- changing a tracheostomy tube
- removing a tracheostomy tube
- suctioning
- oral hygiene
- decannulation
- humidification
Roles and responsibilities
NurseCare Australia’s Director or Care Manager is responsible for the overall clinical management of all high intensity supported client care.
Care required (outside of the documented procedure) will be performed by a qualified health practitioner (e.g., general practitioner, medical specialists, nurse consultants, registered/enrolled nurse, or allied health practitioner). If any situation occurs that may be a risk to the clients tracheostomy care such as abnormal secretion and breathing problems, care staffs will contact the relevant health professional.
In some cases, our care staffs may respond in an emergency, but only with active oversight by a health practitioner (e.g., general practitioner, registered/enrolled nurse). Roles and responsibilities of others involved in supporting the tracheostomy needs of the client including carers, health practitioners and other workers.
clients with a tracheostomy are cared for by care staffs competent in tracheostomy management, including airway emergencies. Our care staffs are trained to identify and minimise client exposure to risk factors.
Staff use a tracheostomy kit when working in home environments. The kit has the necessary equipment to maintain the care and safety of the client’s tracheostomy, including blocked or partially blocked tracheostomy.
Emergency equipment and extra tracheostomy tube and insertion equipment will be available so that in the event of an emergency an obstructed tracheostomy tube may be cleared or replaced if that is required.
Infection prevention protocols including hand hygiene and use of personal protective equipment will be followed when providing tracheostomy care,
Figure 1. Tracheostomy tube
Observations
Vital signs, respiratory rate, respiratory pattern (including auscultation), oxygen saturation, heart rate, blood pressure and temperature level of consciousness are all monitored at a frequency dictated by the clinical condition.
Continuous pulse oximetry for clients with a new tracheostomy or any respiratory compromise will be conducted. clients who require continuous pulse oximetry will be cared for in a suitable clinical environment where staff can continually observe the client.
Care staffs will monitor sputum and record the amount, colour and consistency using the Tracheostomy and Ventilator Observation Chart.
Care staffs have understanding and skill in stoma care and common risks, problems and signs of infection or deteriorating health such as, sore skin, leakage, ballooning, pancaking, bleeding, hernia, and prolapse.
Minimum frequency tracheostomy checks and care.
General care and hygiene
To prevent sore mucous membranes and lips, a high standard of frequent oral hygiene is required for clients with a tracheostomy. Topical products prevent and treat oral infections in and around the oral cavity.
clients are shaved as usual, with care taken around the tracheostomy tube not to dislodge it, introduce soap, water, or shaving cream into the tracheostomy, or cut the securing tapes.
When showering or bathing clients, care is taken to ensure water is not introduced into the tracheostomy tube.
Dressing change
A minimum of two care staffs (competent in tracheostomy care) must undertake tracheostomy tie changes. care staffs will:
- perform daily tie changes when undertaking stoma care or as required if ties become wet or soiled.
- secure new ties before removing the old ties, as there is a potential risk for tracheostomy tube dislodgement when changing ties.
- keep old ties in situ until the clean ties are secured.
- re-secure loose ties immediately
- Where two workers are working together one of the workers will take the lead
Scope of worker responsibilities, including supervision and delegation arrangements and activities requiring more than one worker.
When existing ties are removed before securing the tube with clean ties, the second worker must hold the tracheostomy tube (to ensure it remains in place until the ties are secured) and will not remove their hand until the new tracheostomy ties are secured. The second worker then inserts the new ties into the flange and secures them around the client’s neck.
When changing ties, our care staffs will:
- inform the client, family, carer, or advocate that the tracheostomy ties are about to be changed
- perform appropriate hand hygiene and wear required PPE (e.g., sterile gloves, safety glasses)
- prepare two equal lengths of ties long enough to go around the client’s neck
- correctly position the client(i.e., they should be sitting up in a chair or bed, if able); otherwise, the client will be lying down with their neck gently extended by placing a small, rolled towel under their shoulders.
- insert a clean tie into the holes on each side of the
- tie a single loop on each side approximately 5 centimetres from the flange on the tracheostomy tube, and then tie both sides together in a secure bow.
- check the tension of the ties (allowing one finger to fit snugly between the skin and the ties)
- re-tie into a double (reef) knot to secure
- cutoff the excess length of ties (leaving approximately three centimetres)
- remove old ties
- recheck tension of new ties
- dispose of waste as per the Management of Waste Policy and Procedure
- remove PPE and perform hand hygiene
- observe the client’s neck to check skin integrity
Suctioning a tracheostomy.
Suctioning the tracheostomy tube is necessary to remove mucus, maintain the client’s airway and avoid tracheostomy tube blockages. The care staff will encourage the client to cough up secretions before suctioning whenever possible.
The frequency of suctioning is based on the client’s assessments. Indications for suctioning include:
- audible or visual signs of secretions in the tube
- signs of respiratory distress
- suspicion of a blocked or partially blocked tube
- inability by the client to clear the tube by coughing out the secretions
- vomiting
- desaturation on pulse oximetry
- change sin ventilation pressures (in ventilated)
- request by the client/family/advocate for suction
Tracheal damage may be caused by suctioning and will be minimised using the correct size suction catheter, appropriate suction pressures, and only suctioning within the tracheostomy tube.
When suctioning a tracheostomy tube, care staffs will perform the steps in Table 1. How to suction a tracheostomy tube. Before performing suctioning, care staffs will review the Tracheostomy Care Plan to determine:
- timing for suctioning episode
- depth of insertion of the suction catheter
- pressure setting for the tracheal suctioning.
Staff will use pre-measured suction catheters (where available) to ensure accurate suction depth. To avoid tracheal damage, care staffs will be aware of the limits of suctioning pressure. The episode of suctioning (including passing the catheter and suctioning the tracheostomy tube) will be completed within five to 10 seconds.
Table. How to suction a tracheostomy tube
Tracheostomy care in the home
Tracheostomy kit
care staffs providing tracheostomy care in the client’s home require a tracheostomy equipment kit which consists of:
- one tracheostomy tube of the same size in-situ (with introducer if applicable)
- one tracheostomy tube; a size smaller (with introducer if applicable)
- spare inner tubes for double-lumen tracheal tubes (if applicable)
- additionalties (cotton or Velcro)
- scissors
- resuscitation bag and mask (appropriate size for the client)
- personal protective equipment
- a one-way valve (community use only)
- wall or portable suction
- appropriate size suction catheters
- sodium chloride ampoule (0.9%) and syringe (1 ml)
- one heat moisture exchanger (HME) filter or tracheostomy bib
- fenestrated gauze dressing
- cotton wool applicator sticks
- water-based lubricant for tube changes
- mucous trap with a suction catheter for emergency suction
- occlusive tape (i.e., sleek)
- syringe(10 ml) if cuffed tube in situ
Suction equipment
Suction equipment required to perform tracheostomy care includes:
suction machine and tubing.
- suction machine and tubing.
- suction catheters.
- clean water to flush the suction tubing.
- appropriate PPE (e.g., gloves, apron)
- protective face visor
- humidification devices (if applicable)
Management of speaking valves
A speaking valve allows a client with a tracheostomy tube to vocalise. A speech pathology assessment must assess the client’s ability to vocalise and evaluate possible communication problems. The speech pathologist is responsible for establishing phonation and evaluating voice quality.
The benefits of a speaking valve include:
- improved client vocalisation and communication
- reduced potential for infection (when compared to digital occlusion)
- possible improvement of secretion management
Identified contradictions of a speaking valve include:
- upper airway obstruction and oedema
- medical instability
- severe aspirations or copious secretions
- severe dysarthria (muscular speech weakness)
- unconscious clients
Only a registered/enrolled nurse or care staff deemed competent in tracheostomy care can perform the speaking valve management procedure. The procedure includes:
- deflating the cuff
- removing the valve during sleep or rest periods (it is only used when a clientwishes to talk)
- removing the speaking valve and delivering nebulizers via the tracheostomy tube using a tracheostomy mask and nebulizer reservoir
Tracheostomy emergency airway management
Registered/enrolled nurses and senior care staffs responsible for responding to clients requiring breathing assistance using an artificial airway are provided with ongoing education and training to manage emergency airway situations and undertake difficult airway drills.
Emergency airway management includes:
- monitoring vital signs of consciousness (i.e., respiratory rate, respiratory pattern (including auscultation) in critical care areas, at a frequency dictated by the client’s clinical condition (not less than every six hours)
- conducting continuous pulse oximetry for clients with a new tracheostomy or any respiratory compromise
- ensuring clients who require continuous pulse oximetry are continually observed in a suitable clinical environment.
- monitoring sputum and recording the amount, colour and type on the Tracheostomy and Ventilator Observation Chart
Signs and symptoms for immediate intervention
The following signs and symptoms will be reported immediately to the registered/enrolled nurse and the Director or Care Manager:
- unexplained dyspnoea (i.e., difficult, or laboured breathing)
- severe coughing
- bleeding around the tracheostomy site
- haemoptysis(i.e., the coughing up of blood)
- changes in consistency and colour of secretions
- erythema or soreness around the stoma, including superficial reddening of the skin (usually in patches) because of injury or irritation that causes dilatation of the blood capillaries.
- oxygen desaturation
- no breath sounds due to ineffective humidification of the air
- decreased or gurgling breath sounds due to dislodgement of tracheostomy tube
- signs of a blocked tracheostomy tube such as, blood or phlegm in the tube, breathing difficulties
Signs of respiratory distress
Our staff are trained to recognise the following signs of respiratory distress:
- Difficult laboured or noisy breathing: Incomplete tracheostomy tube occlusion, no breath sounds are heard; however, partial obstruction air entry is diminished and often noisy
- Use of accessory muscles: A sign of airway obstruction; in complete airway obstruction, clients often develop a seesaw breathing pattern in which inspiration is concurrent with the outward movement of the abdomen and inward movement of the chest wall vice-versa
- No or limited expired air from the tracheostomy tube, reduced chest movement or air entry upon auscultation: All indicate a lack of air movement into and out of the respiratory tract.
- Pale/cyanosed skin colour: Central cyanosis is a sign of late airway
- Anxiety/agitation: The clientwill become anxious and agitated as they struggle to breathe and become hypoxic.
- Increasedpulse/respiratory rate: Increased respiratory and pulse rates are signs of illness and indicate that the client may suddenly deteriorate.
- Clammy/diaphoretic skin: Associated with increased work of breathing from an occluded airway and stimulation of the sympathetic nervous system, causing vasoconstriction.
- Stridor: High pitched breath sounds caused by an obstruction above or at the level of the larynx
- Pulsingof tracheostomy tube (danger of eroding into an innominate artery).
- Inability to pass a suction catheter down the tracheostomy tube (deflate the cuff and replace the tracheostomy tube).
Emergency equipment
In an emergency, the following equipment may be required:
- humidified oxygen with a tracheostomy mask
- suction and selection of suction catheters
- two cuffed tracheostomy tubes; one the same size as the client currently has inside and one a size smaller
- a10-millilitre syringe to deflate/inflate the cuff
- gloves
- eye protective equipment and other PPE, as deemed deemed necessary.
Emergency procedures
Respiratory arrest
- The tube should be used for ventilation and not be removed unless obstructed.
- If removing a cuffed tube is necessary, the cuff should be deflated using a 10-millilitre syringe before removal.
- Emergencyventilation of an uncuffed ShileyTM tracheostomy tube can be affected by ensuring the inner tube is in place and attaching the Air Viva bag with the mask removed.
- Some leakage is expected if the chest is rising and falling.
- The tube should be replaced with a cuffed tube.
- Clients with a total laryngectomy will be ventilated via the tracheostomy tube.
Dislodgement of a tracheostomy tube
- Gently replace the tube if possible
- Check the client is breathing spontaneously.
If respirations have ceased.
- Ring emergency services on 000 and ask for an ambulance
- Establish the client’s airway by covering the stoma with dressing if using the airway and commence resuscitation for a client with a tracheostomy.
- Resuscitatevia a stoma if the client has a laryngectomy
If breathing present.
- Replace tube if possible.
- Closely monitor the client’s respiratory status
- Place the client in the recovery position.
- Apply oxygen
Diagram. Emergency management response
NurseCare Australia’s Tracheostomy Care Plan is developed and reviewed by a health practitioner (e.g., general practitioner, medical specialists, nurse consultants, registered/enrolled nurse) with the involvement of the client, their carer or advocate, and the Director or Care Manager. The Care Plan details how care staffs are to provide care for a client’s tracheostomy. The Care Plan identifies how risks, incidents and emergencies are managed. The plan also outlines the actions and escalations required to maintain the client’s safety and wellbeing.
The client’s health status and Tracheostomy Care Plan are reviewed by the Director or Care Manager, or a qualified health practitioner (e.g., general practitioner, medical specialists, nurse consultants, registered/enrolled nurse) every three months, at a minimum, or whenever there is a change in the client’s condition.
The review aims to ensure strategies are in place to act upon information received from the client, their carer or advocate, our staff and health professionals (e.g., general practitioner, medical specialists, or nurse consultants). Adjustments to the Care Plan are discussed with the client and their carer or advocate. The Care Plan details how risks, incidents and emergencies are managed to ensure client safety and wellbeing. Staff must ensure that they read the advanced care directive where a client has one in place.
NurseCare Australia’s clients are ensured their desired level of involvement in their care is respected and always maintained. NurseCare Australia ensures each client requiring tracheostomy care receives tracheostomy and ventilation support relevant and proportionate to their individual needs. Before providing care and support for tracheostomy care, care staffs will request consent from the client, their carer or advocate.
The care plan may also list information on the communication devices or protocols to be used with clients who have limited speech capacity due to their tracheostomy.
[catf_dg id="1253"]
[catf_dg id="1255"]
Workers will be trained in the specific needs of each client they support including the appropriate use of equipment. All NurseCare Australia staff who provide direct care to clients are trained and assessed in tracheostomy management procedures. Education provision includes all parts of tracheostomy care, including airway emergencies, within practice limitations.
Skills competency assessment is conducted by a designated assessor (e.g., nurse educator, clinical nurse consultant or senior physiotherapist) with the appropriate clinical expertise.
Staff may be required to undertake additional qualifications to enhance their professional development (e.g. Registered Training Organisation courses in specialist CPR, administering medication to clients requiring high risk supports etc.).
Workers who provide tracheostomy supports are reviewed annually to confirm the worker has current skills and knowledge. Where a worker has not delivered this support for more than three months the worker will complete refresher training.
Our registered/enrolled nurses and care staffs are required to have a thorough knowledge of:
- anatomy of the respiratory system
- skin and stoma care
- equipment types, components, and functions, including speaking valves (PMV)
- common risks and indicators of malfunction
- indications that suctioning is
- common complications and action required (e.g., when to inflate and deflate cuffs and understanding when to involve a health practitioner)
- signs of infection, both in the respiratory system and the stoma site
- techniques to respond to tube blockages such as
- humidification management
- first aid techniques to check and clear
- how to administer CPR and place a person in a recovery position
[catf_dg id="1258"]
Submit your files here for TRACHEOSTOMY CARE:
Scope
This policy applies to all NurseCare Australia staff undertaking urinary catheter management and caring for clients.
Definitions
There are three urinary catheters commonly encountered which are explained below.
Principles of urinary catheter management
NurseCare Australia principles of urinary catheter management are:
follow infection management procedures.
- replace and dispose of catheter bags safely.
- monitor catheter position- drainage and timing of drainage.
- monitor skin condition around the catheter.
- maintain charts and records
Role and responsibilities
Registered/enrolled nurse
Our registered/enrolled nurse will:
only work within the scope of their practice and prior experience
- attend to catheter care management, including the insertion or changing of catheters, only
if they have extensive practical experience in inserting or changing a catheter in both male
and female participants.
- supervise and guide support workers in the provision of catheter care.
Care Staffs
Our care staffs will:
- follow the Urinary Catheter Management Care Plan as provided by NurseCare Australia
- report to the registered/enrolled nurse and Director or Care Manager of any changes or variations to seek advice.
- never change the Care Plan
- take part in training on the use of equipment, manual handling, and risk management as determined by NurseCare Australia
- report any issues arising from the delivery of personal care to the Director or Care Manager for further advice.
- identify and report to the Director or Care Manager any identified gaps in their skills required to deliver supports.
care staffs may:
- perform any task on the Urinary Catheter Management Care Plan, apart from those that must be performed by a registered/enrolled nurse (as nominated above)
- undertake catheter care as follows:
-
empty the drainage bag.
o change the drainage bag.
o clean around the catheter entry site
o ensure no apparent kinks are in the catheter tubing.
- attach the night bag to the day bag (afternoon staff)
- observe and report if:
o urine is not clear, has an unusual odour.
o there is debris in the urine, or urine output is reduced.
o the catheter entry site is red.
The Urinary Catheter Management Care Plan will be reviewed regularly. The client will be provided information regarding adjusted procedures using their preferred communication method (where applicable).
The Care Plan includes:
- maintaininginfection management procedures
- managinga specific type of catheters (i.e., IDC, suprapubic, intermittent)
- replacingand disposing of catheter bags safely
- maintainingcharts/records (i.e., output and intake, bag changes)
- monitoringcatheter position
- monitoringskin condition around the catheter
- recognising, responding, and reporting blockages, dislodged catheters, and deteriorating health or infection signs.
The client’s health status is regularly reviewed by the Director and a qualified health practitioner (e.g., general practitioner, medical specialists, nurse consultants, registered/enrolled nurse, or allied health practitioner).
The care staff will obtain the client’s consent before commencing urinary catheter management care.
Our staff will consult with the client, their family, carer, or advocate to identify, recognise, and respond to or report problems relating to urinary catheter care (e.g., irritation, dehydration, infection, blockages, and signs of deteriorating health). Our care staff will involve a qualified health practitioner (e.g., general practitioner, medical specialists, nurse consultants, registered/enrolled nurse) if any risk factors are present with the client.
Equipment
When providing urinary catheter care, the following equipment is required:
- disposable gloves (powder free)
- disposable apron
- goggles/facemask
- lubricant(water-based)
- catheters(i.e., indwelling, suprapubic, intermittent)
- urine bags (i.e., leg and overnight)
- leg tape
- stand for an overnight bag
- bag or receptacle for medical waste
care staffs using equipment will ensure that it is cleaned or that single use disposable equipment is used if that is noted in the care plan and the equipment is available.
Catheters are generally necessary when someone cannot empty their bladder. If the bladder is not emptied, urine can build up and lead to pressure in the kidneys. The pressure can lead to kidney failure, which can be dangerous and may result in permanent damage to the kidneys.
Catheter types
A urinary catheter is a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag. Urinary catheters’ sizes and types vary; they can be made of rubber, plastic (PVC) or silicone.
Urinary catheter tube
The three most common types of urinary catheters include:
- Indwelling or Suprapubic: A thin, flexible tube continuously drains urine from the bladder via the urethra (indwelling) or an insertion site in the lower abdomen above the pubic bone (suprapubic). It is kept in the bladder via a balloon inflated with a specified amount of sterile water
- Intermittent:Involves inserting and removing a catheter into the bladder via the urethra several times a day, emptying contents into a container (then emptied in the toilet) or directly into the toilet
- External:This catheter is placed outside the It is typically necessary for men who do not have urinary retention problems but have serious functional or mental disabilities, such as dementia. A device that looks like a condom covers the penis head, and a tube leads from the condom device to a drainage bag.
Catheter care and equipment
When providing catheter care, our care staffs will:
- perform strict hand hygiene when attending to catheters, including emptying the drainage bag
- ensure the correct positioning of the catheter tubing so that it is not tugged or pulled by securing the tube to the thigh with an appropriate catheter strap.
- wash the catheter entry point daily, using downward strokes away from the entry area to avoid introducing microorganisms into the body.
- monitorthe skin and record any redness or swelling
- encourage adequate fluid intake to promote a healthy urine outpput
- empty the drainage bag regularly, never allowing it to overfill as backflow may occur, which sends urine back towards the bladder and may cause infection and pain.
- record the dates for when the catheter will need to be replaced by a registered/enrolled nurse (usually six to 12 weeks, depending on the type of catheter)
- record when the catheter bag is emptied, and the urine volume may also need to be recorded.
Urinary catheter drainage bag procedure
Two types of bags are used to drain urine – a leg bag and an overnight bag. Different brands have different interlocking clamps and access to drainage. The client’s Care Plan lists the specific type of urinary drainage bags that care staffs will use. care staffs will check that catheters are functioning. care staffs will check bag placement, check urine levels and draining and/or replacing catheter bags.
Leg bag
The leg bag is:
- asterile bag that must always stay connected unless being changed (weekly)
- is worn under clothing and is usually attached to the leg above the knee with a pair of straps.
- strapped securely to prevent the bag from trailing or dragging on the catheter
- emptied into the toilet when it is over half full (or every two hours) as indicated on the bag (it is never to be more than three-quarters full)
Before changing the leg bag, the care staff will:
- Wash hands
- Put on appropriate PPE.
- Hold the catheter firmly at the Y joint, tightening to reduce urine leakage.
- Carefully twist the leg bag out of the catheter (ensuring not to pull on the catheter).
- Remove the used leg bag.
- Connect a new leg bag, ensuring not to touch the tip of the bag, so it remains
sterile.
- Use bottom clamps to close and secure to the participant’s leg, as desired.
- Discard the used bag according to the Management of Waste Policy and
Procedure and the Infection Management Policy and Procedure.
- Remove PPE.
- Wash hands
Overnight bag
Before removing the leg, bag and putting it on an overnight bag, the care staff will:
- Wash hands
- Put on appropriate PPE.
- Empty the leg bag (without removing the leg bag from the catheter).
- Confirm the night bag clamp is closed and attach it to the outlet of the leg bag.
- Open the leg bag clamp.
- Check the night bag is hanging on the bed or the nightstand, so gravity enables the correct flow of urine down the catheter through the leg bag and into the night bag.
- Remove PPE.
- Wash hands
The next morning, the care staff will:
- Wash hands
- Put on appropriate PPE.
- Clamp the leg bag closed (the leg bag is changed weekly unless otherwise specified in the Care Plan).
- Remove the night bag
- Record the amount of urine, if required, and empty
- Clean the overnight bag with warm soapy water (detergents or sterilising agents are not used as they may damage the bag) and rinse with white vinegar, if required.
- Store the overnight bag
- Remove PPE
- Wash hands
Intermittent catheter procedure
The procedure involves passing an intermittent catheter down the urethra into the bladder. care staffs will refer to a client’s Urinary Catheter Management Care Plan to determine the specific size and type of intermittent catheter. The Catheter Care Form will outline catheterisation times and other necessary information.
Male catheters
care staffs will undertake the following procedure:
- Wash and dry hands.
- Wear required PPE.
- Adjust the participant’s clothing so that the penis is accessible.
- Use soap and water (or moistened towelettes) to wash and dry the area.
- If the participant is not circumcised, the foreskin will be pulled back, and the area washed.
- Place the unopened catheter packet with the clear side facing downwards on a flat surface.
- Peel back from the coloured end of the catheter for five centimetres.
- Gently grasp hold of the funnel to stabilise the catheter and prevent it from flicking out of the packet.
- Slowly peel the paper side of the packet and remove it altogether (without touching the catheter). The catheter should remain in a clear packet.
- Drop lubricant onto the tip of the catheter and along the tube for about five centimetres.
- Without touching the catheter (grasp hold of it through the packet), pick it up and hold
it like a pen in their dominant hand and then peel back the clear packet to reveal the tip of the catheter.
- With the non-dominant hand, grasp the penis and hold it at an angle.
- Gently but firmly, push the catheter into the penis five centimetres. Hold the shaft of the penis firmly so that the catheter does not fall out.
- Peel back the paper to expose another five centimetres of the catheter to be inserted.
- Continue to insert the catheter in this way.
- Resistance may be encountered where the catheter reaches the neck of the bladder and the closed sphincter muscle. The catheter is not to be forced. The support worker
will ask the participant to cough, bear down (as though they want to pass urine), or deep breathe while applying gentle pressure against the resistance and continuing to insert the catheter.
- Remove the paper entirely and wait for the urine to flow.
- Return the penis to its natural position and hold onto the catheter until the urine flow stops.
- Ensure urine flow is directed into the toilet or container.
- Press gently over the bladder area as more urine may flow out when the urine has stopped.
- Gently pull the catheter out and dispose of it in the bin or according to the Care Plan.
- Replace the foreskin, if necessary.
- Wash and dry the area thoroughly.
- Discard catheters and packaging as per the Infection Management Policy and Procedure and the Management of Waste Policy and Procedure.
- Remove PPE.
- Wash and dry hands well.
Female catheters
care staffs will undertake the following procedure:
Wash and dry their hands.
- Wear appropriate PPE.
- Assist the participant in a comfortable position and adjust clothing to access the urethra.
- Use soap and water (or moistened towelettes) to wash the area and then dry.
- Place the unopened catheter packet on a flat surface, the clear side facing downwards.
- Peel back from the coloured end of the catheter for five centimetres.
- Gently grasp hold of the funnel to stabilise the catheter and prevent it from flicking out of the packet.
- Slowly peel the paper side of the packet and remove it entirely without touching thecatheter, and the catheter will remain in the clear packet.
- Drop lubricant onto the catheter’s tip and about five cm along the tube.
- Without touching the catheter (grasping hold of it through the packet), pick it up and hold it like a pen in their dominant hand and peel back the clear packet to reveal the tip of the catheter.
- Using the non-dominant hand, the worker gently parts the labia to expose the urethra.
- Gently insert the catheter into the urethra and push it until urine begins to drain gently.
- If the catheter appears stuck, remove the catheter, and try again.
- Hold on to the catheter until the flow of urine stops.
- Make sure to direct the flow of urine into the toilet or container.
- When the flow has stopped, ask the participant to cough and press gently over the bladder as more urine may flow out.
- Gently pull the catheter out, place it in a bowl, or dispose of it in the bin.
- Wash and dry the area.
- Discard packaging as per the Infection Management Policy and Procedure and the Management of Waste Policy and Procedure.
- Remove PPE.
- Wash and dry hands
Care of skin and urethral care
The urethra and general genital area have soft membranes that are easily harmed. Therefore, the skin surrounding the urethra will be cared for by observing:
- redness or swelling
- infection(discoloured mucus or pus, strong odour, pain, or abnormal discomfort)
If any of the above are noted, our care staffs will document them appropriately and inform the registered/enrolled nurse and the Director or Care Manager.
Problems and complications in urinary catheter management
The client’s fluid intake, including alcohol and caffeine (which increase the amount of urine they produce), is monitored and calculated using the Daily Fluid Intake and Output Form. The client may require extra catheterisation. Urethral strictures may become a problem; if this is the case, the registered/enrolled nurse and the Director or Care Manager will be informed.
Managing urinary bypassing of a catheter.
Urine may be coming from the client’s urethral opening or leaking around the catheter insertion point. Should this occur, a care staff will assess the catheter for patency and:
- blocked catheter tubing (sediment or blood will be visible in the tube)
- kinked tubing
- over-full drainage bag
- clamped catheter
The care staff will assess for faecal impaction or constipation. A full rectum can cause pressure on the bladder, leading to unstable bladder contractions and occluding or blocking the catheter.
If a care staff follows the above steps and urinary bypass is still evident, they will notify the registered/enrolled nurse and the Director or Care Manager as the catheter may require changing.
Observe, document and report.
If specific conditions or symptoms are identified, observations will be documented and reported to the supervising registered/enrolled nurse and the Director or Care Manager who will arrange a medical review. Conditions and symptoms may include:
- persistence or worsening pain in the lower abdomen
- a persistent, localised pain
- new pain since catheter insertion
- minor bleeding post-insertion and ongoing 12 hours after being initially reported and
- absence of urine flow – if there has been no urine collected in the drainage bag for more than four hours or the client’s abdomen is swollen and tender, the registered/enrolled nurse and Director or Care Manager will be contacted immediately to organise an urgent medical review.
- strong odour or cloudy urine
- blood in
- chills or fever above 38 degrees
- lower back pain
- abnormal leakage around the catheter
- swelling at the catheter insertion site, especially in men
- disorientation or change in mental status.
The Urinary Catheter Management Care Plan will be reviewed regularly. The client will be provided information regarding adjusted procedures using their preferred communication method (where applicable).
The Care Plan includes:
- maintaining infection management procedures
- managing a specific type of catheters (i.e., IDC, suprapubic, intermittent)
- replacing and disposing of catheter bags safely
- maintaining charts/records (i.e., output and intake, bag changes)
- monitoringcatheter position
- monitoringskin condition around the catheter
- recognising, responding, and reporting blockages, dislodged catheters, and deteriorating health or infection signs.
The client’s health status is regularly reviewed by the Director and a qualified health practitioner (e.g., general practitioner, medical specialists, nurse consultants, registered/enrolled nurse, or allied health practitioner).
The care staff will obtain the client’s consent before commencing urinary catheter management care.
[catf_dg id="1280"]
[catf_dg id="1283"]
Our care staffs receive training from a health practitioner or experience care staff who covers information that specifically relating to each client’s needs and the type of urinary catheter support required, including the following:
- basic understanding of the urinary system for males and females
- appropriate and monitoring of hydration
- types of catheters
- procedures and challenges in inserting catheters in males and females (intermittent catheters only)
- common complications associated with using different types of
- indicators of complications that require intervention and understanding of when to involve a health practitioner.
- infection management procedures
- identify how to respond/report signs of deteriorating
- emergency management of a catheter
[catf_dg id="1285"]
Submit your files for Module 1 - Urinary Cathether:
Scope
The policy applies to all NurseCare Australia staff who provide our clients with stoma care and support.
Definitions
Principles of stoma care
Stoma care procedures will only be performed by NurseCare Australia staff who have the required knowledge and have been appropriately trained in stoma care.
When providing stoma care to clients, our staff will:
- follow personal hygiene and infection management procedures
- monitor the skin condition and keep the stoma area clean
- replace and dispose of bags as required
- maintain charts and records as per the Information Management Policy and Procedure
- be trained to recognise, respond to, and report any problems such as blockages, signs of deteriorating health or infection
Roles and responsibilities
A client’s Stoma Care Plan is overseen by the Director or Care Manager and relevant health practitioners (e.g., general practitioner, registered/enrolled nurse). Any change to a Stoma Care Plan is conducted by the Director or Care Manager and health practitioners.
NurseCare Australia ensures that care staffs are trained in infection management procedures per the Infection Management Policy and Procedure and the Management of Waste Policy and Procedure.
care staffs will consult with the client, their family or advocate to identify, recognise, respond, and report any identified issues or problems. If any risk factors are identified, the care staff will immediately involve a qualified health practitioner (e.g., general practitioner, registered/enrolled nurse)
Equipment in the home
The equipment in the home to provide stoma care may include:
- appropriate PPE (e.g., mask)
- disposable gloves (i.e., powder free)
- disposable apron
- stoma bags and other appliances (e.g., flange extenders, washers, belts, filter covers, stoma measurement guides)
- relevant stoma products (e.g., adhesive remover, barrier wipes, protective pastes, hydrocolloid powder, filler paste, ostomy deodorant, thickening agents)
- toilet paper or disposable soft cloth for cleaning faeces
- medical waste receptacle
The Stoma Care Plan is developed with the client, their family, carer or advocate, the Director or Care Manager, our staff and relevant health practitioners (e.g., general practitioner, medical specialists, nurse consultants, registered/enrolled nurse)
A client’s Stoma Care Plan is reviewed monthly or as needed to ensure relevant and current strategies are in place to provide safe care.
If required, a Manual Handling Care Plan will be developed with the client’s involvement and implemented as care staffs require.
[catf_dg id="1306"]
[catf_dg id="3464"]
Care staffs will receive training relating specifically to each client’s needs and the type of stoma care support they require, including:
- basic anatomical knowledge of the eliminatory system
- skin and stoma care
- common conditions associated with stomas
- equipment and related functions
- procedures for safe positioning and monitoring
- personal hygiene and infection control procedures
- replacing and disposing of stoma bags
- maintaining charts/records
- monitoring the client's skin condition and keeping the stoma area clean
- recognising and reporting problems such as blockages, signs of deteriorating health or infection
[catf_dg id="3611"]
Submit your files here for Stomacare:
Scope
This policy applies to all NurseCare Australia staff caring for clients with diabetes
Definitions
Principles of diabetes management
Diabetes care is performed by care staffs with appropriate diabetes management training and knowledge. Principles of diabetes management and care include:
- supporting the client to implement the Diabetes Care Plan, which is overseen by a health practitioner (e.g., general practitioner, registered/enrolled nurse)
- identifying and minimising the risk of hypoglycaemic and hyperglycaemic episodes
- monitoring and recording blood glucose levels (BGLs)
- following procedures to calculate dose requirements and administer
- following emergency procedures and exercising judgement as to when to call an
- knowing how much medication (insulin) to administer to a client in various
- demonstrating the application of first aid, including correct positioning and cardiopulmonary resuscitation
Roles and responsibilities
The Director or Care Manager is responsible for the overall clinical and medication management of our clients’ high-intensity support activities. Changes to a Care Plan and medication management are the responsibility of the Director or Care Manager and relevant health practitioners.
NurseCare Australia trains our staff to identify and minimise client exposure to risks of hyperglycaemia and hypoglycaemia and implement appropriate control methods. The care staff will consult with a client, their family, carer, or advocate to identify and remove or minimise risks to these conditions.
care staffs observe the client to identify early indicators of hyperglycaemia or hypoglycaemia and take appropriate action as required, including monitoring, and recording BGLs and emergency management.
Staff follow the medication emergency procedures outlined in the Management of Medication Policy and Procedure and the Subcutaneous Injections Policy and Procedure. The Medication Incident Report Form will be completed in an incident involving medication.
When responding to an accident, incident or emergency, our staff follow the procedures outlined in the Reportable Incident, Accident and Emergency Policy and Procedure.
Waste will be managed as per the Management of Waste Policy and Procedure.
Identified risks will be managed as per the Risk Management Policy and Procedure. The client’s Diabetes Care Plan will be reviewed for all such events.
Hypoglycaemia emergency treatment
Care staffs will follow the emergency hypoglycaemia treatment procedure outlined in Diagram 1.
Hypoglycaemia emergency treatment procedure
Emergency diabetes management plan
In an emergency, care staffs implement the management plan outlined in Diagram 2.
The emergency diabetes management plan
Equipment in the home
Equipment in the home environment required for diabetes management may include, but is not limited to:
- appropriate personal protective equipment
- disposable gloves (powder free)
- lancet or needled device for finger
- glucometer
- tests trips
- tissues
- medications
- needles and syringes (for insulin administration)
- clinical sharps container
- bag or receptacle for medical waste
A client’s Diabetes Care Plan is overseen by relevant health practitioners (e.g., general practitioner, registered/enrolled nurse) and the Director or Care Manager. The Diabetes Care Plan is regularly reviewed. The client, their family, carer or advocate and care staffs are informed of any new information, adjustments, or updated procedures.
The Diabetes Care Plan is developed with the client, their family, carer or advocate, the Director or Care Manager, and any relevant health practitioners (e.g., general practitioner, medical specialists, nurse consultants, registered/enrolled nurse). Included in the plan is how to:
- support a client to implement their Care Plan
- identify and respond to hypoglycaemic episodes
- monitor and record blood glucose levels (BGLs)
- follow procedures to calculate dose requirements and administer medication (insulin)
- follow detailed instructions on medication selection and administration procedures
- implement emergency management options and procedures
The care staff will request the client’s consent before taking a BGL and administering medications. The care staffs may support the client to calculate the dose of diabetes medication, following instructions outlined in the support plan. The instructions will be provided by the health practitioner. Prior to injecting, the calculation and dose are double-checked, following arrangements established by a qualified health practitioner.
The client’s health status will be regularly reviewed by the Director and a qualified health practitioner (e.g., general practitioner, registered/enrolled nurse). The client’s Diabetes Care Plan is reviewed monthly or as required to ensure current strategies reflect all updated information from the client, their family, carer or advocate, our staff and health professionals.
[catf_dg id="1333"]
[catf_dg id="1339"]
NurseCare Australia’s training system complies with the high-intensity support skills descriptor for providing diabetes management, including how to follow procedures, administer medications, exercise judgement. and identify when an ambulance must be called. Training is delivered by an appropriately qualified health practitioner such as a GP or allied health practitioner or by a registered nurse who regularly delivers training to care staffs. Workers must also have a basic understanding of the client’s related health conditions.
NurseCare Australia trains our care staffs in diabetes management in conjunction with the Subcutaneous Injections Policy and Procedure. clients with diabetes require support to implement their Diabetes Care Plan and often need regular injections, which some cannot administer.
Staff are trained to identify the associated health conditions and complications that impact a client’s BGL and understand the basic anatomy of the human body. care staffs also receive training relating specifically to each client’s needs relating to their Diabetes Care Plan. The training provided also includes:
- informing difference between the two types of Diabetes - Types 1 and 2
- underlying factors that can affect BGLs
- Common health-related risks and complications associated with diabetes, including reduced ability to heal from cuts or wounds, changes in behaviour, weight fluctuation, and deteriorating
- methods of managing insulin levels, including different types of insulin (i.e., fast, or slow release)
- variables that affect insulin delivery (e.g., timing, site selection and rotation)
- timing and type of medication such as slow and fast acting insulin
- understand the risks associated with incorrect
- risks and common symptoms of low or unstable blood sugar levels
- related responses to low or unstable blood sugar levels
- how to seek expert advice and information from our multidisciplinary team
- factors that increase the risk of hyperglycaemia/hypoglycaemia and appropriate methods of control
- emergency management of hypoglycaemia and the potential side effects
- impact of variables such as food intake
When caring for clients with diabetes, our care staffs are trained to:
- follow all medication and documentation procedures
- complete the Injection Record as necessary
- complete the Insulin Administration Form, as required
- monitor and record a client’s BGLs
- follow emergency management procedures
- record changes requested by a health practitioner (e.g., general practitioner, registered/enrolled nurse)
- understand and have skills in the use of equipment including injectable medication device, syringes, pens, and pumps
- document medication using the appropriate Medication Administration Chart
- inform the Director or Care Manager, the client, their family, carer, or advocate when there has been a request for a change to the diabetes management
[catf_dg id="1345"]
Submit your files here for DIABETES MANAGEMENT :
Scope
All NurseCare Australia staff must implement this policy when preparing and delivering client meals.
Definition
Principles of Dysphagia
Ensure staff know dysphagia symptoms and risks.
Relevant staff are trained to improve their knowledge and develop skills to support clients who may have dysphagia. Staff must understand how to identify and respond to early signs and symptoms of dysphagia and a referral to a speech therapist or occupational therapist will be sought as early as possible.
Support clients with possible swallowing difficulties to be assessed for dysphagia.
When a client shows any sign or symptom of swallowing difficulty, staff should support them to promptly consult a GP and a speech pathologist to assess their swallowing and mealtime assistance needs and review their general health.
Support clients with dysphagia to have a mealtime management plan.
A client with dysphagia must have a mealtime management plan written by a health professional. A speech pathologist can prescribe and recommend specific actions to eat and drink safely, develop a mealtime management plan for their needs, and specify a plan review timeframe. A dietitian may
contribute to the mealtime management plan by ensuring enough nutrition and hydration in the recommended modified meals.
Mealtime management plans may include recommendations to:
- assist the client with menu and meal planning if
- improve the seating and positioning supports for a person’s safe positioning during
- prepares food and fluids of the required texture and tests the prepared food
- supports the client to explore ways to enjoy meal time and feeding, for example, timing, frequency, choice of environment and social company.
- provide specific mealtime assistance techniques, including any reminders about a safe rate of eating, or a safe amount of food in each mouthful.
- respond to coughing or choking and make sure risks are monitored while a person is eating or
- use feeding equipment for people with severe dysphagia, including assistive technology such as spoons, plates, cups, and straws; and tube feeding equipment for those with severe or profound difficulty swallowing who require tube feeding.
- Support clients with oral hygiene consistent with the care
Support people with dysphagia to eat and drink safely during mealtimes.
NurseCare Australia must ensure that:
- staff receive the necessary training and support to implement a mealtime management plan or other mealtime recommendations for swallowing safely and mealtime management.
- meals for clients with dysphagia, and medication is taken orally, are prepared as directed, and health professionals recommend mealtime supports and assistance.
- trained staff are available to monitor people with dysphagia during
- staff are trained in how to respond if a clientstarts to choke during mealtimes, including when they should call an ambulance.
- staff have knowledge and techniques to deal with suspected choking including how to promptly identify choking and clear airways of food.
- Staff are made aware of the food and fluid preparation requirements set out in the International Dysphagia Diet Standardisation Initiative (IDDSI)
- meal time safety issues for people with dysphagia are regularly considered in staff meetings and addressed in day-to-day procedures, clients’ documentation, and plans for transition to
Ensure mealtime management plans are regularly reviewed.
Mealtime management plans are to be reviewed regularly, and we support the client with dysphagia in arranging this. The speech pathologist who develops a mealtime management plan will include how often it should be reviewed and specify the circumstances in which you should request a review.
Ensure medications are regularly reviewed.
NurseCare Australia supports a client with dysphagia to have their medications regularly reviewed by a GP, the prescribing medical practitioner, or a pharmacist to assess whether the medications affect their swallowing.
The review can also determine if the medications are suitable for managing swallowing risks. Several medications impact swallowing, particularly medications for epilepsy or mental health conditions. Refer to the NDIS Commission’s Practice Alert: Medications associated with swallowing problems.
Principles of mealtime preparation and delivery
When providing meal delivery and preparation support to clients, our staff will:
- read, interpret, and implement Mealtime Support Plans
- follow food preparation procedures
- monitor client eating to identify and respond to risks
- determine postural requirements for the client
- assistin supporting the client during mealtimes
Roles and responsibilities
The Director or Care Manager is responsible for managing high-intensity support care. The client’s Mealtime Support Plan is overseen by a relevant health practitioner (e.g., general practitioner, medical specialists, speech pathologist, dietitian). The Mealtime Support Plan is regularly reviewed, and any adjustments to procedures are discussed and agreed upon with the client, their family, carer, or advocate.
The Director or Care Manager is responsible for:
- ensuring that our team provide healthy food options within
- confirming each client undergoes regular mealtime
- ensuring every client has a current Mealtime Support Plan
- assessing risks associated with client
- confirming that staff report choking or swallowing-related incidents via our incident reporting system
- investigating incidents according to the Reportable Incident, Accident and Emergency Policy and Procedure
- supervising staff when they complete a Nutrition and Swallowing Risk Checklist on a 12-monthly basis (or as required) for the client.
Our care staffs are responsible for:
- adhering to established procedures and protocols relating to nutrition
- supporting the client during mealtimes
- consistent implementation of all recommendations from health care professionals relating to safe mealtimes, appropriate support, adequate nutrition, and hydration
- offering healthy food options within services
- ensuring clients are provided with a relaxed, social environment during
- implement behaviour support recommendations for
- providing meals that are visually pleasing to enhance a client’s eating
- monitoring clients who may be at risk of dysphagia and following the recommended actions to reduce the risk of aspiration and choking.
- meeting the nutritional and hydration needs of the client.
- reporting choking or other mealtime incidents using the incident reporting
- contributing to the incident investigation, if required
Other professionals that may provide services as part of mealtime support include:
- Speech pathologist: A speech pathologist may complete a comprehensive assessment of a client’s eating, drinkingand swallowing skills and advise on the individual’s requirements and safe swallowing management. They may also assess the risk of any cognitive factors that could compromise the safety of the swallowing process. The speech pathologist will consider the client’s preferences, beliefs, best interests, and quality of life issues.
- Dietitian: The dietitian will consider any swallowing difficulties when advising on the client’s diet. They will outline nutrition and hydration requirements.
- Occupational therapist: The occupational therapist may complete a comprehensive assessment of an individual’s mealtimes and provide recommendations to assist with body positioning, mealtime independence, and assistive technology for eating and drinking.
- Clinical Nurse Consultant: The clinical nurse consultant may complete a comprehensive assessmentof a client’s mealtimes and provide recommendations to assist when receiving enteral The clinical nurse consultant may also advise on medication administration and other factors that require consideration concerning the client’s overall health and wellbeing.
- Training and development: The Director or Care Manager may be involved by organisingindividual and group staff training sessions throughout NurseCare Australia.
Mealtime support plan
The client’s Mealtime Support Plan is developed with the client, their family, carer or advocate, the Director or Care Manager and relevant health practitioners (e.g., occupational therapist, speech pathologist, dietitian).
Each client’s plan includes how care staffs can best provide mealtime assistance and support. The care staff will communicate with the client or their advocate regarding the delivery, management and monitoring of food preparation and mealtimes.
This policy is used in conjunction with the Enteral Feeding and Management Policy and Procedure. The client’s Mealtime preparation and delivery plans are regularly reviewed by the Director or Care Manager to ensure ongoing compliance and consistency in care levels. The Mealtime Support Plan identifies risks, incidents, and emergencies and how they are managed by NurseCare Australia to ensure the client’s safety and wellbeing.
The Director or Care Manager may adjust the Mealtime Support Plan based on information received from the client, their family, carer or advocate, our staff, and relevant health professionals. Any changes are documented in an updated Mealtime Support Plan.
NurseCare Australia ensures that care staffs are trained in emergency procedures, including:
- how to identify common risks and indicators (e.g., signs of choking or dysphagia)
- strategies to reduce the risk of choking and
- mealtime body positioning
care staffs understand when to involve the Director, Care Manager, or a qualified health practitioner (e.g., speech pathologist, dietitian) to provide safe care to the client.
The care staff is responsible for monitoring, charting, and recording client mealtime delivery, as outlined in the Information Management Policy and Procedure. Any incidents will be reported following procedures in the Reportable Incident, Accident and Emergency Policy and Procedure.
The care staff consults with the client and their carer or advocates to identify, recognise, and report problems (e.g., signs of choking, dysphagia and general discomfort while eating). The care staff will involve the Director or Care Manager if any of these risk factors are present for a client.
Equipment in the home
Equipment required to provide mealtime preparation and delivery in the home may include:
- adapted equipment (e.g., knives, forks, spoons, plates, bowls, and cups)
- resources for preparing and cooking food (e.g., kitchen, stove, oven, refrigerator, and freezer).
IDDSI Protocols
The client’s Mealtime Support Plan is developed with the client, their family, carer or advocate, the Director or Care Manager and relevant health practitioners (e.g., occupational therapist, speech pathologist, dietitian).
Each client’s plan includes how care staffs can best provide mealtime assistance and support. The care staff will communicate with the client or their advocate regarding the delivery, management and monitoring of food preparation and mealtimes.
This policy is used in conjunction with the Enteral Feeding and Management Policy and Procedure. The client’s Mealtime preparation and delivery plans are regularly reviewed by the Director or Care Manager to ensure ongoing compliance and consistency in care levels. The Mealtime Support Plan identifies risks, incidents, and emergencies and how they are managed by NurseCare Australia to ensure the client’s safety and wellbeing.
The Director or Care Manager may adjust the Mealtime Support Plan based on information received from the client, their family, carer or advocate, our staff, and relevant health professionals. Any changes are documented in an updated Mealtime Support Plan.
[catf_dg id="1370"]
[catf_dg id="1373"]
NurseCare Australia trains staff to support mealtime preparation and delivery. Staff are aware of associated health conditions and complications that can impact a client who requires meal preparation and delivery (including enteral feeding management).
Staff receive training specifically relating to the needs of each client needing mealtime preparation and delivery support. Further specific training involves:
- signs and symptoms of swallowing and feeding difficulties
- difficult, painful chewing or swallowing
- a feeling that food or drink gets stuck in their throat or goes down the wrong way
- coughing, choking, or frequent throat clearing during or after swallowing
- having long mealtimes, g., finishing a meal takes more than 30 minutes
- becoming short of breath when eating and drinking
- avoiding some foods because they are hard to swallow
- regurgitation of undigested food
- difficulty controlling food or liquid in their mouth
- drooling
- having a hoarse or gurgly voice
- having a dry mouth
- poor oral hygiene
- frequent heartburn
- unexpected weight loss
- frequent respiratory infections
- risk sassociated with eating and swallowing
- respiratory problems or choking as well as poor
- swallowing problems can allow food, drinks, or saliva to get into the lungs rather than the stomach, which can cause aspiration pneumonia
- accidental choking reduction by following expert advice from speech pathologists and other specialists
- minimising risk through early identification and management of swallowing problems
- risk sassociated with not following the mealtime plan
- food preparation methods/requirements for common conditions (e.g., people with dysphagia)
- awareness of procedures and methods when including medication in food, including an understanding of crushable and non-crushable medication
- understanding of common terminology related to mealtime preparation and modified
- using adapted equipment
- meal-related health topics (e.g., oral health, nutrition, and reflux)
- knowing when to respond to problems (e.g., signs of dysphagia or choking)
- implementing strategies to reduce the risk of choking and
- incident or identified risks reporting
- mealtime body positioning
[catf_dg id="1376"]
Submit your files here for DYSPHAGIA MANAGEMENT :
Scope
The policy applies to all NurseCare Australia staff undertaking subcutaneous injections as part of a client’s care. This policy will be used in conjunction with the Management of Medication Policy and Procedure and the Diabetes Management Policy and Procedure and Diabetes Care Plan.
Definitions
Principles of subcutaneous injections
Injections are given via the subcutaneous route, depositing a drug dose into adipose tissue immediately below the dermal layer. Sub cutaneous blood supply is less than blood supply to muscle. Medication given via subcutaneous injection is absorbed more slowly than drugs given via intramuscular injection.
Medications administered via subcutaneous injection include anticoagulants (e.g., heparin, tinzaparin, and insulin) and the medications administered are water-soluble and low volume (typically below two millilitres).
Subcutaneous injections are only administered by a care staff who has completed the necessary training and competencies to administer medication via subcutaneous injection.
care staffs are trained to:
- follow personal hygiene and infection management procedures as per the Infection Management Policy and Procedure
- confirm the client’s details (using the ‘Seven Rights’ process) and their need for an
- follow safe injecting procedures when using pumps and
- monitor the client for any adverse
- dispose of medical waste appropriately as per the Management of Waste Policy and Procedure
- maintain accurate and safe records of medication
Roles and responsibilities
The Director or Care Manager is jointly responsible for the overall clinical management of a high intensity supported client’s care with health practitioners (e.g., general practitioner, medical specialists, nurse consultants, registered/enrolled nurse). Any care required (outside of what is documented in the policy) must be performed by a qualified health practitioner (i.e., general practitioner, registered/enrolled nurse).
Sometimes, a care staff may respond when a client requires emergency procedures to be implemented. However, a health practitioner will participate in active oversight.
NurseCare Australia ensures care staffs have specific knowledge and training in subcutaneous injections. Our staff are trained to identify and minimise client exposure to risk factors (e.g., safe needle disposal, site rotation, adverse reactions, risk of injections, safe documentation). The care staff consults with the client, their carer, or advocates to identify and remove or minimise exposure to infection. Training also includes information on the impact of factors that affect take up of medication for example, injection site location, rotation, and timing. Staff are also trained to understand the indications of action required for common problems including signs of infection at the site of injection such as change in skin colour, swelling, itchiness or pain, signs of withdrawal and/or side effects from medication, and reactions to incorrect medication dose. Each care staff has their subcutaneous injection technique reviewed annually by the Director or Care Manager to ensure continued safe practice.
In an incident, accident, emergency or identified risk, our staff follow the Reportable Incident, Accident and Emergency Policy and Procedure, the Risk Management Policy and Procedure and the Subcutaneous Injections Care Plan, as required. The Director or Care Manager is responsible for ensuring the Medication Incident Report Form is completed in an incident involving medication. The Management of Medication Policy and Procedure, Diabetes Management Policy and Procedure and Diabetes Care Plan will be referred to as required. Staff will exercise their judgement in each situation.
Alterations to medications and medication administration can occur only when an order is received in writing by a health practitioner (e.g., general practitioner) or over the phone (Subcutaneous Injection Doctor’s Order and Administration Record must be completed). Changes are then carried out under appropriate supervision. All changes are documented and recorded according to the client’s Subcutaneous Injections Care Plan and the Information Management Policy and Procedure (this includes the order and administration of PRN medications documented in the Variations to regular medications administration form).
All waste will be disposed of safely and appropriately per the Infection Management Policy and Procedure and the Management of Waste Policy and Procedure.
Equipment in the home
Equipment in the home required to deliver subcutaneous injections may include, but is not limited to:
- appropriate personal protective equipment
- disposable gloves (powder free)
- insulin pen
- insulin vial/ampule
- lancet or needled device for finger
- glucometer
- test strips
- tissues
- other medications, as authorised and required
- needle sand syringes (for insulin administration)
- clinicalsharps container
Medication preparation and injection (insulin)
Insulin is a medication administered via subcutaneous injection into a client’s hypodermal layer of their skin. Insulin assists the body in metabolising the glucose in the blood after consuming foods. Some clients will fall into a coma without this medication and die without intervention.
Pen devices
care staffs follow the client’s Care Plan to ensure the correct injection technique and medication quantity are applied. Staff will use pen devices for individual use only and will not administer through clothing. When using a pen device, the following process is followed by the administering staff member:
1.Wash hands.
2.Wear appropriate PPE.
3.Fit a new needle to the top of the pen.
4.Resuspend cloudy insulin, if applicable.
5.‘Prime’ the pen ensures it works correctly and has no air bubbles.
6.Dial-up the required dose of insulin.
7.Insert the needle and push down the plunger to administer the insulin dose.
8.Leave the pen needle in situ after injecting the medicine for 10 seconds (or as per the manufacturer’s instructions) to allow the medicine to inject fully.
9.Counting past 10 seconds may be required for higher doses.
10.Remove the pen needle and discard it safely.
11.Replace the cap on the pen.
12.Remove PPE.
13.Wash hands.
1.1.1 Injecting technique
The injecting technique and site will be pre-assessed by a health practitioner (e.g., registered/enrolled nurse) when developing each client’s Subcutaneous Injections Care Plan. When choosing an injection site, staff will consider the requirements of the injectable medications specified in the Care Plan.
The abdomen is the preferred injection site for most clients due to the convenience, consistency, and reproducible absorption rates of injectable medications.
Below are the general guidelines staff follow when administering a subcutaneous injection:
1.Wash hands.
2.Wear appropriate PPE.
3.Clean the injection site with soap and water or an alcohol wipe.
4.Use thumb and index finger (or middle finger) to gently lift (not grab) the skin fold and avoid lifting the accompanying muscle.
5.Inject into the raised tissue at 90 degrees.
6.Keep the skin fold raised as the medication is administered.
7.Maintain a steady rate in injecting the solution.
8.Hold the needle in situ for 10 seconds per the Care Plan instructions.
9.Withdraw the needle and release the skin fold.
10.Observe for trauma, leakage, or pain at the site.
11.Dispose of the needle as per the NurseCare Australia Management of Waste Policy and Procedure and Infection Management Policy and Procedure.
Diagram. Possible subcutaneous injection sites
Note: Blue indicates the possible injection sites
Variable dose context
The Care Plan allows the care staff to calculate and draw up the required dose under clinical supervision. The plan identifies the health practitioner responsible for overseeing the injecting process. It outlines the procedure to be followed so the care staff can confirm the correct calculations and dose measurements before administering an injection.
care staffs responsible for administering high-risk medications need an understanding of the purpose of the medication. For example, staff who give insulin injections require appropriate diabetes awareness and management training.
Assessment, plan development and review
If a client requires subcutaneous injections, they will undergo an assessment with an appropriately qualified health practitioner. In consultation with the client, the health practitioner must develop an accurate Subcutaneous Injection Care Plan that can be utilised by the NurseCare Australia to guide support.
The Subcutaneous Injection Care Plan will address any incident or emergency concerning the injection. The plan will also promptly identify a clear path for escalating an incident or emergency.
Injection techniques
The Subcutaneous Injections Care Plan is developed in partnership with the client, their family, carer or advocate, the Director or Care Manager and appropriate health practitioners (e.g., general practitioner, medical specialists, nurse consultants, registered/enrolled nurse).
The Subcutaneous Injections Care Plan is reviewed annually, or as required, to ensure appropriate strategies are in place to act on information received from the client, their carer or advocate, our staff and health professionals (e.g., general practitioner, medical specialists, nurse consultants, registered/enrolled nurse)
Information in the Subcutaneous Injections Care Plan includes:
●written orders by the health practitioner (e.g., general practitioner)
●medication requirements, as noted on the Medication Administration Chart
●insulin medication and documentation procedures (refer to the Diabetes Management Policy and Procedure and Diabetes Care Plan)
●dose calculation, where required.
●medication checks and records to be followed by staff administering subcutaneous injections.
●the types of subcutaneous injections used (e.g., pens or pumps) which administer a pre- measured medication.
●injecting procedure, including size and type of needle and injecting angle
●safe disposal of needles
●signs of adverse reactions
●actions required when dealing with common symptoms of overdose and withdrawal.
●documents and records for subcutaneous injections to be retained in the client’s file.
●incident and emergency management related to subcutaneous injection (see the Reportable Incident, Accident and Emergency Policy and Procedure)
A qualified health practitioner will regularly review the client’s medication/s (e.g., general practitioner, medical specialists, nurse consultants, registered/enrolled nurse). The Subcutaneous Injections Care Plan identifies how risks, incidents and emergencies are managed to ensure the client’s safety and wellbeing.
The Seven Rights process
NurseCare Australia requires care staffs who administer medications to follow the ‘Seven Rights’ process and confirm the below information:
1.Right client
2.Right drug
3.Right route
4.Right dose
5.Right time
6.Right documentation
7.Right to refuse
The care staff will confirm consent from the client, their carer, or advocate before any subcutaneous injections.
[catf_dg id="3634"]
[catf_dg id="3481"]
NurseCare Australia’s training system complies with the high-intensity support activities skills descriptor for providing subcutaneous injections, including how to follow procedures and exercise judgement regarding when to respond to problems or report them (e.g., adverse reactions, signs of deteriorating health or infection).
A Subcutaneous Injection Training Plan and individual Staff Training Plans are developed and delivered by either the Director, Care Manager, who are both appropriately qualified health practitioner and a person who has the appropriate skills relevant to the client’s specific care needs. Staff Training Plans allow for ongoing training support and supervision for each care staff.
care staffs are trained to identify associated health conditions and complications impacting clients who require medication administration via subcutaneous injections. care staffs understand the basic anatomy of the integumentary system. care staffs are trained to identify injection site location, rotation, timing, and adverse effects of medications.
Only suitably qualified and trained staff may administer medications using subcutaneous injections as additional training, clinical reporting, and oversight are necessary due to the calculation and measurement of medication dosages. Appropriately qualified and trained staff will:
●administer medicines with pens and pumps
●understand different injection methods and related equipment
●check medication and recording requirements
●evaluate the impact of variables that affect take-up (e.g., site location and rotation related to specific medication and timing)
●dispose of needles safely
●identify signs of adverse reactions and action required, including common symptoms of overdose and withdrawal
●understand the common risks of injecting and related control methods
●implement quality check protocols when calculating and delivering a variable dose
[catf_dg id="3617"]
Submit your files here for Subcutaneous Injection:
Scope
The Ventilator Management Policy and Procedure apply to all staff who use ventilation equipment when providing care to a client. This procedure applies in conjunction with the Tracheostomy Management Policy and Procedure, the Stoma Care Policy and Procedure, the Management of Waste Policy and Procedure, and the Infection Management Policy and Procedure.
This policy is followed by all NurseCare Australia staff who care for and manage clients who use a ventilator. Care required (outside of this documented procedure) will be performed by a qualified health practitioner (e.g., general practitioner, medical specialists, nurse consultants, registered/enrolled nurse). In some cases, our staff may respond in an emergency, but there will be active oversight by a health practitioner (e.g., general practitioner, registered/enrolled nurse)
The policy ensures NurseCare Australia provides a safe, efficient, and effective ventilator management service to our clients while meeting their comfort requirements and needs. We work with our clients to achieve goals for receiving non-invasive and invasive mechanical ventilation supports. clients may require support to use ventilation accessory equipment such as Bilevel Positive Airway Pressure (BiPAP), and Continuous Positive Airway Pressure (CPAP) machines, humidifiers, airway clearance devices, suctioning, manual ventilation devices, and oxygen.
Definitions
Principles for ventilation management
Our principles for ventilator management include:
● improving oxygenation and ventilation
● confirming the need for ventilation and recognise the need for suctioning.
● following procedures to clear airways as required
● follow infection management procedures.
● setting up a ventilator for operation (i.e., identify, connect, or assemble components of ventilation equipment according to instructions and fit the breathing mask)
● starting ventilation and monitoring that it is working effectively.
● applying troubleshooting procedures to respond to alarms.
● recognising and responding to signs that airways are obstructed.
● implementing emergency procedures (e.g., deteriorating health or infection)
● maintaining equipment
● completing charts/records, as required
Roles and responsibilities
The Director or Care Manager is responsible for the overall clinical and medication management of high-intensity support activities for a client’s care.
Care required (outside of what is documented in the procedure) must be performed by a qualified health practitioner (e.g., general practitioner, medical specialists, nurse consultants, registered/enrolled nurse) In some cases, the care staff may respond when the client with a tracheostomy or ventilator requires emergency procedures to be implemented. However, a health practitioner will have active oversight (e.g., general practitioner, registered/enrolled nurse)
Registered/enrolled nurse
A registered/enrolled nurse will:
● supervise the ventilator management and care for clients.
● develop and review the Ventilation Management Care Plan
●coordinate care services.
Care Staffs
care staffs will monitor and manage the client’s respiratory condition by following procedures, which include:
●identifying, connecting, or assembling components of ventilation equipment according to instructions
●operating a ventilator and undertaking cleaning of equipment
●fitting the breathing mask and equipment on the client
●monitoring that the ventilation is working effectively.
●following trouble-shooting procedures to respond to alarms.
●maintaining equipment
●documenting care and client requirements
●reporting signs and symptoms (e.g., unexplained dyspnoea, severe coughing, bleeding around tracheostomy site, haemoptysis, changes in consistency and colour of secretions, erythema, or soreness around the stoma)
●implementing intervention strategies for signs of:
○respiratory distress
○pressure sores and discomfort
○common problems with ventilation
●engaging incident and emergency procedures, as required.
●assisting clients to fit and adjust their breathing masks
●monitoring ventilation circuits
●managing the inflation and deflation of the tracheostomy cuff
The care staff consults with the client and their advocate to identify and remove or minimise exposure to infection or deteriorating health. NurseCare Australia staff will take appropriate actions to identify early indicators of obstructed airways and implement emergency procedures.
Staff understand the indicators to initiate emergency procedures including the use of back up and manual ventilators. For example, loss of electricity or battery failure in the ventilator machine
When an incident, emergency or associated risk is identified, staff will follow the Reportable Incident, Accident and Emergency Policy and Procedure, the Risk Management Policy and Procedure and the Ventilator Management Care Plan, applying exercised judgement in each situation.
care staffs are provided access to a charged mobile phone during work hours. Staff are advised of each client’s emergency management and communication methods as detailed in their Care Plan (e.g., writing, sign language, communication aids). Staff are informed of the appropriate method of communication for each client.
care staffs comply with safety considerations outlined in the Tracheostomy Management Policy and Procedure and the Stoma Care Policy and Procedure. Alterations to the ventilator or ventilator settings occur only with written health practitioner orders and are carried out under registered/enrolled nurse supervision. A second ventilator is implemented with an external battery pack for ventilation periods exceeding 16 hours a day. A humidifier is mandatory for all clients requiring invasive and non-invasive ventilation.
NurseCare Australia has procedures, registers and reporting documents in place to ensure that appropriate care is provided to ensure our clients’ safety and wellbeing.
Management of Non-Invasive Insulation
clients who use non-invasive ventilation will be assisted to fit and adjust their breathing masks. clients who use BiPAP and CPAP ventilation will be assisted to use the equipment.
Diagram 1. Comparison of invasive and non-invasive methods of ventilation
Ventilator management equipment in the home
care staffs will ensure that home equipment supplies are maintained and will reorder stock if short. Before reordering stock, a care staff will require the Director or Care Manager’s approval or consent from the client, family, or advocate. The client’s Service Agreement will be reviewed to determine if equipment stock approval has already been given.
The consumables and equipment must be checked monthly to ensure they are within date and functioning correctly. If they are not in-date and not functioning correctly, this must be documented in the Care Plan and communicated to the registered/enrolled nurse and the Director or Care Manager. The client must also be advised.
care staffs maintain records of the equipment checks that they complete on respiratory equipment, Records are maintained of checks carried out on back-up ventilators, as well as oxygen levels in spare tanks and suction equipment,
The equipment in the home may include, but is not limited to:
- appropriatepersonal protective equipment
- continuousaccess to electricity supply
- ventilatorand equipment (e.g., cuff)
- oxygencylinder and tubing, adapters, and bags
- humidifier
- tracheostomykit (where applicable), including tracheostomy
- suctionunit, equipment, and
- sparebatteries for all equipment (back-up power supply via generator is discussed with the client)
- sodiumchloride – 10 millilitres (ml) x 5
- waterfor irrigation – 10 ml x 5
- syringes– 5 ml and 20 ml x 5
- lubricatingjelly
- scissors
- gloves
- Yankauersucker
- mobilephone with emergency contact numbers and charger
Daily equipment checks will be completed on all equipment used, including the ventilator. Ventilator settings must be checked against the client’s Care Plan requirements. The maintenance program for the ventilator will be noted, including the most recent date of ventilator service as required by our organisation’s equipment maintenance program.
Procedure
Securing of the endotracheal tube.
Securing the endotracheal tube (ETT) can be done in one of three ways:
- Tapes (e.g., Sleek or Transpore) are used only for clients who are in the process of being transported to ICU or an operating theatre.
- Cottonwhite tape, which is changed at least
- Anendotracheal tube attachment device (ETAD) (anchor-fast) is changed every five days or as required.
Assessing endotracheal tube position.
The care staff will assess the endotracheal tube position each shift as follows:
- Checkand document the level of the endotracheal tube at the lips (usually 19-23 centimetres).
- Ensuringequal bilateral chest movement and air entry on
- Verify the tip of the endotracheal tube is two to four centimetres above the carina on the chest x-ray.
- Repositionthe oral endotracheal tube to prevent pressure
Assessing and maintaining a tracheal cuff seal:
Assessing and maintaining a tracheal cuff seal will involve the following:
- Aminimum occlusion volume is achieved on the first inflation of the cuff at
- Thecuff pressure is measured via a cuff pressure
- Cuffpressure is documented once each shift or as
- Cuffpressure of 20-30 mmHg is usually required to maintain an adequate
- If a pressure > 30mmHg is required to eliminate a cuff leak, the registered/enrolled nurse will be contacted immediately, as a pressure > 40mmHg may cause mucosal injury.
- Listen for cuff leaks and monitor low ventilator pressure and tidal volume alarms, which may indicate an air leak.
- Undertakearterial blood gas (ABG) sampling and
- Performan initial ABG 15-30 minutes post-
- FurtherABG sampling is required when there is:
- deteriorationin oxygen saturation
- clinicalsigns of hypoxia
- significantchanges to ventilator settings
- changes inclient’s respiratory effort and ventilator observations (e.g., low tidal volume, increased or decreased minute volume)
Suction
Suctioning of the endotracheal tube is performed using a closed or in-line suction device only. It is replaced daily or overtly soiled, along with the suction tubing and receptacle liner. Regular suctioning is not recommended and will only be performed by care staffs when clinically necessary or at approximately eight hourly intervals.
The suction procedure is as follows:
- Explain the procedure to the client.
- Preoxygenate,the client with 100%
- Observe hand hygiene principles and use necessary
- Unlock the catheter and advance as far as possible without force or until the client
- Withdraw the catheter one to two centimetres to free it from the bronchial wall or
- Apply continuous suction while withdrawing the catheter in one continuous motion, not longer than 15 seconds.
- Use a maximum of two suction
- Flush the catheter via the irrigation port with a 10-millilitre syringe of normal
- Lock the suction
- Auscultate lung fields to assess the effects of
- Using the Tracheostomy and Ventilator Observation Chart, document the sputum’s colour, volume, and tenacity.
Humidification of the ventilator circuit
The air passing through the ventilator must be passed through either a heat moisture exchanger (HME) for a dry circuit or a heated water bath system for a wet circuit.
Changing from a dry to a wet circuit is not routinely undertaken unless there is:
- sticky sputum
- haemoptysis
- bronchospasm
- bronchorrhea(i.e., excessive discharge of watery mucus from the lungs)
Management of the ventilator circuit
Ventilator settings, including oxygen flow, partial pressure of oxygen and PEEP, are stated in the Care Plan. care staffs conduct ventilator setting checks every shift or, at a minimum, every 24 hours. The ventilator setting can only be changed with a registered/enrolled nurse or general practitioner’s input.
Ventilator maintenance
The maintenance of a ventilator varies depending on the make and model. When developing the Ventilator Management Care Plan, the registered/enrolled nurse will determine the maintenance schedule required for the ventilator and all associated equipment. It is the responsibility of the client, their family, carer, or advocate to ensure that the maintenance schedule of the ventilator is kept up to date. The registered/enrolled nurse may assist if the maintenance plan is not up to date or if a skilled technician requires additional maintenance.
care staffs will change all ventilator tubing and circuits, including Laerdal; wet or dry are changed weekly or frequently if soiled. The heat moisture exchanger is changed daily or more frequently if wet or soiled.
NurseCare Australia works with the clients, their family, carer, or advocate to ensure that the necessary consumable items (e.g., tubing, circuits) are always available for the care staff to use with the client. It is also advised that an emergency supply of consumables is kept in the client’s place of residence.
When the client leaves their residence for short trips, the care staff or registered/enrolled nurse accompanying the client will ensure that an emergency equipment bag travels with the client.
Mouth care
Mouth care is important in caring for a client using a ventilator. care staffs will provide mouth care following the instructions on the Mouth Care Plan. Mouth care includes swabbing the mouth, using a toothbrush with a suction catheter to remove any fluid or saliva in the mouth and applying lip balm to the client’s lips.
Emergency management
All staff must inform the registered/enrolled nurse and the Director or Care Manager if they are concerned about a client’s condition. In an emergency, such as those noted below, our staff will IMMEDIATELY call 000 and request an ambulance.
care staffs will follow emergency procedures to immediately start, operate and monitor the use of a back-up ventilator, resuscitation bags, oxygen requirements and suctioning equipment.
Table. Respiratory distress indicators and possible causes
Staff will implement the DRSABCD Action Plan and use the emergency cardiopulmonary resuscitation (CPR) procedure in an emergency. Refer to Table 2. DRSABCD Action Plan.
Table. DRSABCD Action Plan
Non-Invasive Ventilation
BiPAP and CPAP are both non-invasive ventilation therapies to support respiratory distress and insufficiency.
BIPAP therapy is often used to treat respiratory issues such as chronic obstructive pulmonary disease (COPD) or acute respiratory distress syndrome (ARDS). BiPAP delivers two levels of positive air pressure to the client’s airway: a higher-pressure during inhalation and a lower pressure during exhalation.
CPAP delivers a constant level of positive air pressure to the client’s airway during both inhalation and exhalation. The positive air pressure helps to keep the client’s airway open and prevent it from collapsing.
The choice between BiPAP vs CPAP therapy will depend on the individual client’s needs and medical conditions.
Comparison Between CPAP and Bi PAP Similarities:
Usage of a mask or nasal prongs to deliver air pressure to the client’s airway.
Both are non-invasive and can be used to treat a variety of respiratory conditions.
Requiring close monitoring of the client’s respiratory status, vital signs, and response to treatment
Both can be used in a hospital or home setting.
Differences:
BIPAP delivers two different pressure levels, while CPAP delivers a constant level of pressure.
BIPAP has a higher-pressure during inhalation and a lower pressure during exhalation, while CPAP delivers the same level of pressure during both inhalation and exhalation.
BIPAP is often used to treat more severe respiratory distress, such as in clients with COPD or ARDS, while CPAP is often used to treat sleep apnoea or less severe respiratory distress.
BIPAP may be more uncomfortable or difficult to tolerate for some clients due to the higher- pressure during inhalation.
Non-Invasive Ventilation High Intensity Supports Interventions
●Assess the client’s respiratory status, vital signs, and need for BIPAP/CPAP therapy.
●Assess the client’s comfort level and tolerance for the CPAP mask.
●Prepare the equipment to ensure that the BIPAP or CPAP machine is functioning properly and that the appropriate pressure settings have been selected based on the client’s needs. The nurse should also ensure that the mask or nasal prongs are properly fitted to the client’s face or nose.
●Administer the therapy, starting by placing the BIPAP/CPAP mask or nasal prongs on the client’s face or nose, ensuring a secure and comfortable fit. The care staffs then turn
on the BIPAP or CPAP machine and adjust the pressure settings as needed to achieve the desired therapeutic effect.
●Monitor the client’s respiratory status, vital signs, and response to therapy.
●Provide client education on the purpose of the therapy, how to use and care for the equipment, and how to recognize and report any complications or concerns.
●Document the therapy in the client’s Care Plan, including the duration and pressure settings of the therapy, the client’s respiratory status and response to therapy, and any complications or concerns.
NurseCare Australia’s Ventilator Management Care Plan is developed and reviewed by a health practitioner (e.g., general practitioner, medical specialists, nurse consultants, registered/enrolled nurse) with the involvement of the client, their carer or advocate, and the Director or Care Manager. The Care Plan details how supports are required to meet the client’s ventilation requirements.
The client’s health status and Care Plan are regularly reviewed, and updated procedures are discussed with the client and their family, carer, or advocate. The Care Plan details how risks, incidents and emergencies will be managed to ensure clients' safety and wellbeing.
A client’s Ventilator Management Care Plan is reviewed every quarter or as required to ensure strategies are in place to act upon information received from the client, their carer/advocate, staff,
and health professionals (e.g., general practitioner, medical specialists, nurse consultants. registered/enrolled nurses).
The Tracheostomy and Ventilation Observation Schedule is reviewed regularly and forms the Care Plan. Ventilator settings are noted in the Care Plan and MUST NOT be changed without a registered/enrolled nurse or general practitioner reviewing the client's condition.
The care staff will confirm consent (with the client or their carer or advocate) before providing care and support for ventilation.
If care staffs have any concerns relating to a client’s condition, they will immediately contact the registered/enrolled nurse and the Director or Care Manager.
[catf_dg id="1394"]
[catf_dg id="1396"]
NurseCare Australia trains our staff in ventilation management (invasive and non-invasive) using the employee’s Training Plan or the Training Plan – Ventilation Management.
Each care staff is competent in supporting a person dependent on ventilation. care staffs can implement emergency procedures (e.g., obstructed airway, knowing when to inflate and deflate cuffs). care staffs are trained to identify associated health conditions and complications that impact clients with a tracheostomy and require ventilation management (invasive or non-invasive).
Our care staffs understand the basic anatomy of the respiratory system, as well as:
- musculoskeletal problems associated with respiration
- signs of respiratory distress
- ventilator types and the main equipment components and functions
- basic principles of how a ventilator works (e.g., how to connect to a power supply, understanding of the ventilator settings and alarms, how to connect the exhalation valve and mask)
- Signs and symptoms of respiratory distress for example, drowsiness, reduced alertness, breathing rate, nose flaring, colour changes, wheezing, bracing upper body and large chest movements when breathing.
- various types of breathing masks and techniques for fitting
- howto avoid discomfort or pressure sores
- identifying common problems and taking action to address the
- observation parameters and procedures
- the nature and consequences of a client’s respiratory condition
- how to handle a client if they are not compliant when receiving ventilation care
- care of the equipment and equipment cleaning procedures
- incident and emergency procedures
- documentation procedures
[catf_dg id="1397"]
Submit your files here for Ventilation:
Scope
This policy is implemented by all NurseCare Australia staff who provide care to clients who may suffer seizures.
Definitions
Principles of seizure management
NurseCare Australia’s seizure management principles include:
●identifying and minimising exposure to seizure risk factors
●developing a Seizure Management Care Plan that is overseen by an appropriate health practitioner (e.g., general practitioner, registered/enrolled nurse)
●ensure staff record a description of types, frequency and patterns of seizures, triggers; signs to look for before and after seizures.
●risks to look for and action required to respond to risks, incidents, and emergencies for clients who have a high risk of seizures.
●training our care staffs to:
○understand and follow all care procedures.
○exercise judgement in emergencies, including knowing when to call an ambulance
○administer PRN medication (if qualified) as outlined in the PRN Care Plan
○to position a client in the event that they have a seizure.
○how to apply first aid including cardio-pulmonary resuscitation
Roles and responsibilities
A client’s Seizure Management Care Plan is overseen by the Director or Care Manager and an appropriate health practitioner (e.g., general practitioner, registered/enrolled nurse). The Director or Care Manager under the direction and an appropriate health practitioner, conduct any changes to the plan and medication management.
Care Plan
The Seizure Management Care Plan is developed to ensure the client’s wellbeing and safety. The Care Plan is developed with the involvement of the client, their family, carer or advocate, the Director or Care Manager and a health practitioner (e.g., general practitioner, medical specialists, nurse consultants, registered/enrolled nurse).
The Seizure Management Care Plan includes details such as:
●types of seizures experienced by the client
●signs and symptoms of seizures
●seizure frequency and patterns
●seizure triggers
●signs to check before and after a seizure
●monitoring and recording requirements
●detailed instructions on medication selection and administration procedures
●information on how to manage risks, incidents, and emergencies
●emergency management options and procedures
●Common medication used to manage seizures and related contraindications and side effects
care staffs will confirm the client’s consent before administering medications detailed in the Seizure Management Care Plan (as previously agreed with the client, family, carer, or advocate). care staffs will complete the Seizure Record Form as required, and completed forms is used during Seizure Management Care Plan reviews. The clients’ care plan will, if indicated by the clients conditions, include information on triggers or conditions that can increase risk of seizure for the clients. This may include constipation, dehydration, high temperature, aspiration, and other issues that may be indicated by the clients history. A client’s Seizure Management Care Plan is reviewed monthly, or when there is a change in client’s condition, Care strategies developed are based on recent information from the client, their family or advocate, our staff and health professionals.
Staff follow NurseCare Australia’s documentation procedures for:
●PRN medication
●monitoring and recording of seizures
●recording emergency management procedures
●Common medication used to manage seizures and related contraindications and side effects.
●handling, storing, administering, and recording administration of post-seizure medication.
●recording changes requested by health practitioners (e.g., general practitioner or registered/enrolled nurse)
●informing the Director or Care Manager, the client, their carer, or advocate when a change in seizure management has been requested.
A Manual Handling client Care Plan or a PRN Care Plan is developed with the client if necessary, and care staffs are trained in plan requirements.
●Common types, symptoms, and patterns of seizures
●Common triggers or conditions that can increase risk of seizure such as constipation, dehydration, high temperature, aspiration, and related methods of control.
●Common risks associated with seizures.
●The impact of associated health conditions on epilepsy
●Observation parameters to identify early indicators of seizure onset, monitor seizures and observe following a seizure.
●Expectations for handling, storing, administering, and recording use of post-seizure related medication.
●When and how to involve or get advice from the health practitioner, or emergency services.
●Reporting responsibilities, including handover, recording observations and incident reporting
NurseCare Australia ensures that our care staffs are trained to identify and minimise client exposure to seizure risk factors. Our Director or Care Manager will consult with the client and their carer or advocate to identify and remove or minimise exposure to potential risks (e.g., burns, falls or other risks related to seizures).
The care staff will observe the client identify early seizure indicators and take all required and appropriate actions, including monitoring and recording seizure data. Staff will follow infection control and waste disposal procedures outlined in the Infection Management Policy and Procedure and the Management of Waste Policy and Procedure.
Equipment in the home may include:
Equipment required for seizure management in the home includes, but is not limited to:
● disposable gloves (powder free)
● disposable apron
● appropriate PPE (e.g., mask, face shield)
● medications and associated equipment
● lubricant (water-based)
● incontinence pad or Kylie
● medical waste receptacle or bag.
Seizure emergency management pathway
Staff are trained to manage seizures using the emergency management pathway outlined in Diagram 1
Diagram 1. Seizure emergency management pathway
Ventilator management equipment in the home
care staffs will ensure that home equipment supplies are maintained and will reorder stock if short. Before reordering stock, a care staff will require the Director or Care Manager’s approval or consent from the client, family, or advocate. The client’s Service Agreement will be reviewed to determine if equipment stock approval has already been given.
The consumables and equipment must be checked monthly to ensure they are within date and functioning correctly. If they are not in-date and not functioning correctly, this must be documented in the Care Plan and communicated to the registered/enrolled nurse and the Director or Care Manager. The client must also be advised.
care staffs maintain records of the equipment checks that they complete on respiratory equipment, Records are maintained of checks carried out on back-up ventilators, as well as oxygen levels in spare tanks and suction equipment,
The equipment in the home may include, but is not limited to:
- appropriatepersonal protective equipment
- continuousaccess to electricity supply
- ventilatorand equipment (e.g., cuff)
- oxygencylinder and tubing, adapters, and bags
- humidifier
- tracheostomykit (where applicable), including tracheostomy
- suctionunit, equipment, and
- sparebatteries for all equipment (back-up power supply via generator is discussed with the client)
- sodiumchloride – 10 millilitres (ml) x 5
- waterfor irrigation – 10 ml x 5
- syringes– 5 ml and 20 ml x 5
- lubricatingjelly
- scissors
- gloves
- Yankauersucker
- mobilephone with emergency contact numbers and charger
Daily equipment checks will be completed on all equipment used, including the ventilator. Ventilator settings must be checked against the client’s Care Plan requirements. The maintenance program for the ventilator will be noted, including the most recent date of ventilator service as required by our organisation’s equipment maintenance program.
Procedure
Securing of the endotracheal tube.
Securing the endotracheal tube (ETT) can be done in one of three ways:
- Tapes (e.g., Sleek or Transpore) are used only for clients who are in the process of being transported to ICU or an operating theatre.
- Cottonwhite tape, which is changed at least
- Anendotracheal tube attachment device (ETAD) (anchor-fast) is changed every five days or as required.
Assessing endotracheal tube position.
The care staff will assess the endotracheal tube position each shift as follows:
- Checkand document the level of the endotracheal tube at the lips (usually 19-23 centimetres).
- Ensuringequal bilateral chest movement and air entry on
- Verify the tip of the endotracheal tube is two to four centimetres above the carina on the chest x-ray.
- Repositionthe oral endotracheal tube to prevent pressure
Assessing and maintaining a tracheal cuff seal:
Assessing and maintaining a tracheal cuff seal will involve the following:
- Aminimum occlusion volume is achieved on the first inflation of the cuff at
- Thecuff pressure is measured via a cuff pressure
- Cuffpressure is documented once each shift or as
- Cuffpressure of 20-30 mmHg is usually required to maintain an adequate
- If a pressure > 30mmHg is required to eliminate a cuff leak, the registered/enrolled nurse will be contacted immediately, as a pressure > 40mmHg may cause mucosal injury.
- Listen for cuff leaks and monitor low ventilator pressure and tidal volume alarms, which may indicate an air leak.
- Undertakearterial blood gas (ABG) sampling and
- Performan initial ABG 15-30 minutes post-
- FurtherABG sampling is required when there is:
- deteriorationin oxygen saturation
- clinicalsigns of hypoxia
- significantchanges to ventilator settings
- changes inclient’s respiratory effort and ventilator observations (e.g., low tidal volume, increased or decreased minute volume)
Suction
Suctioning of the endotracheal tube is performed using a closed or in-line suction device only. It is replaced daily or overtly soiled, along with the suction tubing and receptacle liner. Regular suctioning is not recommended and will only be performed by care staffs when clinically necessary or at approximately eight hourly intervals.
The suction procedure is as follows:
- Explain the procedure to the client.
- Preoxygenate,the client with 100%
- Observe hand hygiene principles and use necessary
- Unlock the catheter and advance as far as possible without force or until the client
- Withdraw the catheter one to two centimetres to free it from the bronchial wall or
- Apply continuous suction while withdrawing the catheter in one continuous motion, not longer than 15 seconds.
- Use a maximum of two suction
- Flush the catheter via the irrigation port with a 10-millilitre syringe of normal
- Lock the suction
- Auscultate lung fields to assess the effects of
- Using the Tracheostomy and Ventilator Observation Chart, document the sputum’s colour, volume, and tenacity.
Humidification of the ventilator circuit
The air passing through the ventilator must be passed through either a heat moisture exchanger (HME) for a dry circuit or a heated water bath system for a wet circuit.
Changing from a dry to a wet circuit is not routinely undertaken unless there is:
- sticky sputum
- haemoptysis
- bronchospasm
- bronchorrhea(i.e., excessive discharge of watery mucus from the lungs)
Management of the ventilator circuit
Ventilator settings, including oxygen flow, partial pressure of oxygen and PEEP, are stated in the Care Plan. care staffs conduct ventilator setting checks every shift or, at a minimum, every 24 hours. The ventilator setting can only be changed with a registered/enrolled nurse or general practitioner’s input.
Ventilator maintenance
The maintenance of a ventilator varies depending on the make and model. When developing the Ventilator Management Care Plan, the registered/enrolled nurse will determine the maintenance schedule required for the ventilator and all associated equipment. It is the responsibility of the client, their family, carer, or advocate to ensure that the maintenance schedule of the ventilator is kept up to date. The registered/enrolled nurse may assist if the maintenance plan is not up to date or if a skilled technician requires additional maintenance.
care staffs will change all ventilator tubing and circuits, including Laerdal; wet or dry are changed weekly or frequently if soiled. The heat moisture exchanger is changed daily or more frequently if wet or soiled.
NurseCare Australia works with the clients, their family, carer, or advocate to ensure that the necessary consumable items (e.g., tubing, circuits) are always available for the care staff to use with the client. It is also advised that an emergency supply of consumables is kept in the client’s place of residence.
When the client leaves their residence for short trips, the care staff or registered/enrolled nurse accompanying the client will ensure that an emergency equipment bag travels with the client.
Mouth care
Mouth care is important in caring for a client using a ventilator. care staffs will provide mouth care following the instructions on the Mouth Care Plan. Mouth care includes swabbing the mouth, using a toothbrush with a suction catheter to remove any fluid or saliva in the mouth and applying lip balm to the client’s lips.
Emergency management
All staff must inform the registered/enrolled nurse and the Director or Care Manager if they are concerned about a client’s condition. In an emergency, such as those noted below, our staff will IMMEDIATELY call 000 and request an ambulance.
care staffs will follow emergency procedures to immediately start, operate and monitor the use of a back-up ventilator, resuscitation bags, oxygen requirements and suctioning equipment.
Table. Respiratory distress indicators and possible causes
Staff will implement the DRSABCD Action Plan and use the emergency cardiopulmonary resuscitation (CPR) procedure in an emergency. Refer to Table 2. DRSABCD Action Plan.
Table. DRSABCD Action Plan
Non-Invasive Ventilation
BiPAP and CPAP are both non-invasive ventilation therapies to support respiratory distress and insufficiency.
BIPAP therapy is often used to treat respiratory issues such as chronic obstructive pulmonary disease (COPD) or acute respiratory distress syndrome (ARDS). BiPAP delivers two levels of positive air pressure to the client’s airway: a higher-pressure during inhalation and a lower pressure during exhalation.
CPAP delivers a constant level of positive air pressure to the client’s airway during both inhalation and exhalation. The positive air pressure helps to keep the client’s airway open and prevent it from collapsing.
The choice between BiPAP vs CPAP therapy will depend on the individual client’s needs and medical conditions.
Comparison Between CPAP and Bi PAP Similarities:
Usage of a mask or nasal prongs to deliver air pressure to the client’s airway.
Both are non-invasive and can be used to treat a variety of respiratory conditions.
Requiring close monitoring of the client’s respiratory status, vital signs, and response to treatment
Both can be used in a hospital or home setting.
Differences:
BIPAP delivers two different pressure levels, while CPAP delivers a constant level of pressure.
BIPAP has a higher-pressure during inhalation and a lower pressure during exhalation, while CPAP delivers the same level of pressure during both inhalation and exhalation.
BIPAP is often used to treat more severe respiratory distress, such as in clients with COPD or ARDS, while CPAP is often used to treat sleep apnoea or less severe respiratory distress.
BIPAP may be more uncomfortable or difficult to tolerate for some clients due to the higher- pressure during inhalation.
Non-Invasive Ventilation High Intensity Supports Interventions
●Assess the client’s respiratory status, vital signs, and need for BIPAP/CPAP therapy.
●Assess the client’s comfort level and tolerance for the CPAP mask.
●Prepare the equipment to ensure that the BIPAP or CPAP machine is functioning properly and that the appropriate pressure settings have been selected based on the client’s needs. The nurse should also ensure that the mask or nasal prongs are properly fitted to the client’s face or nose.
●Administer the therapy, starting by placing the BIPAP/CPAP mask or nasal prongs on the client’s face or nose, ensuring a secure and comfortable fit. The care staffs then turn
on the BIPAP or CPAP machine and adjust the pressure settings as needed to achieve the desired therapeutic effect.
●Monitor the client’s respiratory status, vital signs, and response to therapy.
●Provide client education on the purpose of the therapy, how to use and care for the equipment, and how to recognize and report any complications or concerns.
●Document the therapy in the client’s Care Plan, including the duration and pressure settings of the therapy, the client’s respiratory status and response to therapy, and any complications or concerns.
The Seizure Management Care Plan is developed to ensure the client’s wellbeing and safety. The Care Plan is developed with the involvement of the client, their family, carer or advocate, the Director or Care Manager and a health practitioner (e.g., general practitioner, medical specialists, nurse consultants, registered/enrolled nurse).
The Seizure Management Care Plan includes details such as:
●types of seizures experienced by the client
●signs and symptoms of seizures
●seizure frequency and patterns
●seizure triggers
●signs to check before and after a seizure
●monitoring and recording requirements
●detailed instructions on medication selection and administration procedures
●information on how to manage risks, incidents, and emergencies
●emergency management options and procedures
●Common medication used to manage seizures and related contraindications and side effects
care staffs will confirm the client’s consent before administering medications detailed in the Seizure Management Care Plan (as previously agreed with the client, family, carer, or advocate). care staffs will complete the Seizure Record Form as required, and completed forms is used during Seizure Management Care Plan reviews. The clients' care plan will, if indicated by the clients conditions, include information on triggers or conditions that can increase risk of seizure for the clients. This may include constipation, dehydration, high temperature, aspiration, and other issues that may be indicated by the clients history. A client’s Seizure Management Care Plan is reviewed monthly, or when there is a change in client’s condition, Care strategies developed are based on recent information from the client, their family or advocate, our staff and health professionals.
Staff follow NurseCare Australia’s documentation procedures for:
●PRN medication
●monitoring and recording of seizures
●recording emergency management procedures
●Common medication used to manage seizures and related contraindications and side effects.
●handling, storing, administering, and recording administration of post-seizure medication.
●recording changes requested by health practitioners (e.g., general practitioner or registered/enrolled nurse)
●informing the Director or Care Manager, the client, their carer, or advocate when a change in seizure management has been requested.
A Manual Handling client Care Plan or a PRN Care Plan is developed with the client if necessary, and care staffs are trained in plan requirements.
●Common types, symptoms, and patterns of seizures
●Common triggers or conditions that can increase risk of seizure such as constipation, dehydration, high temperature, aspiration, and related methods of control.
●Common risks associated with seizures.
●The impact of associated health conditions on epilepsy
●Observation parameters to identify early indicators of seizure onset, monitor seizures and observe following a seizure.
●Expectations for handling, storing, administering, and recording use of post-seizure related medication.
●When and how to involve or get advice from the health practitioner, or emergency services.
●Reporting responsibilities, including handover, recording observations and incident reporting
[catf_dg id="1421"]
[catf_dg id="1425"]
NurseCare Australia’s training system complies with the high-intensity support skills descriptor for providing seizure management, including that staff follow all care and medication administration procedures and exercise judgement and know when it is appropriate to call an ambulance.
care staffs receive training regarding the client’s specific needs and the type of seizure care support they require. Training includes:
●types of seizures
●types and patterns of common seizure
●how to respond to seizure alerts and alarms including alarms included in wearable health technology appliances
●conditions that can increase risk of seizure such as constipation, dehydration, high temperature, aspiration, and related methods of control for these conditions.
●common patterns or clusters of seizures
●seizure triggers and symptoms
●appropriate seizure management and control procedures
●impact of epilepsy
●parameters that guide decisions regarding the dosage of PRN medication and when to administer
●identifying potential side effects of medications
●related health risk complications associated with epilepsy.
●factors that increase client risks and appropriate methods of control
●first aid techniques to check and clear airways, administer CPR, and place a person in a recovery position.
●interpretation of advice regarding when to request an ambulance.
[catf_dg id="1427"]
Submit your files here for Submit your files here for SEIZURE MANAGEMENT:
CLINICAL PRACTICE GUIDELINES PAIN MANAGEMENT
Definition
Pain can affect physical, emotional and mental wellbeing.
Acute pain lasts for a short time and occurs following trauma or surgery or trauma. It acts as a warning to the body to seek help. Although it usually improves as the body heals, in some cases, it may not.
Chronic pain lasts beyond the time expected for healing following surgery, trauma or other condition. It can also exist without a clear reason at all. Although chronic pain can be a symptom of other diseases, it can also be a disease in its own right characterised by changes within the central nervous system. PRN medication is the term for medicines that are taken “as needed”, which may include an analgesic (e.g. ibuprofen or paracetamol), as opposed to daily medications. The clients care plan will note if PRN medication is permissible.
Care Plan
clients pain management will be included in their care plan, developed in collaboration with a health practitioner to guide the patient’s care staff. The plan is regularly reviewed and updated as required. It may include equipment or products to be utilised, e.g. hot or cold packs, syringe drivers or transcutaneous electrical nerve stimulation machines.
Responsibilities
Registered nurse:
- Assess the client’s pain initially on admission to the service.
- Assess the client’s pain regularly as part of a planned regular review.
- Provide information on pain management strategies, products and equipment.
- Assist referral to a general practitioner, if the pain is undiagnosed, for a specific diagnosis, review and treatment strategy.
- Refer the client to a local specialist pain clinic, where indicated.
- Document pain management strategies as part of the care plan.
- Only registered nurses can administer intravenous medication.
- Only registered nurses can administer high-risk medicines such as anticoagulants,insulin, chemotherapy agents, narcotics and sedatives.
Care staff:
care staffs who are providing clinical care to clients with chronic pain will be trained and assessed as competent in pain management strategies by a registered nurse.
● Identify, monitor and report signs of pain and record in notes.
- Provide non-medicine related relief (e.g. warm/cold pack, assistance with mobility).
- Provide PRN painkiller medication, only as authorised by a registered nurse and if in the care plan, or with medical advice from the general practitioner or after-hours doctor.
Principles
Pain management
- Pain needs to be assessed regularly, and the presence of pain (or inadequately controlled pain) should be investigated.
- Pain monitoring charts will be implemented as required.
- The pain management care plan must be evaluated and updated if there is a change in the client’s needs or health status.
- The client will be referred to a pain clinic or pain specialist if required.
- care staffs will support the informed selection and safe use of complementary, alternative and self- selected, non-prescription medicines and therapies used by clients.
- Follow guidelines for medication administration (see Medication Management Policy and Procedure).
- Better pain relief with lower medication doses may be possible by combining medications of different classes (multi-modal) or other treatments.
- Non-medicine treatments and therapies and a combination of treatments and therapies can be effective.
Medication
- care staffs are appropriately qualified and authorised to administer medicines.
- If a client has a PRN medication in the form of a painkiller, the registered nurse will authorise the administration of the medication as per the PRN medication form signed by the treating doctor.
- care staffs may only assist a person with PRN analgesia once they have reviewed the client’s care plan. The client care plan must be followed.
- In all other circumstance where PRN is not in place; the client should seek medical advice from the general practitioner or after-hours doctor.
- All clients will have a current, accurate and reliable record of all medicines selected, prescribed and used.
- All medicines, including self-administered medicines, are to be stored safely and securely in a manner that maintains the quality of the medicine.
- Unwanted or expired medicines are disposed of safely to avoid accidental poisoning, misuse and toxic release into the environment.
- Consideration must be given to age-related changes in medication sensitivity, efficacy, metabolism and potential for side effects.
Assessment and Planning
Where chronic pain is an identified concern, a pain assessment will be conducted by a registered nurse. The assessment considers:
- personal details
- cardio-respiratory status
- cognitive status
- mobility and falls risk
- pain mechanisms
- central nervous system sensitisation
- neuro-psychological contributions
- impact of pain and (potential) treatments
- behaviours
- pain history
- general medical history
- relevant co-morbidities/diseases
- recent falls
- associated symptoms
- comprehensive physical examination.
Identifying client Pain
The best indicator of pain is the client’s own report. Therefore, clients who can report pain, including those with mild to moderate dementia, need to be asked regularly about the presence of pain.
Pain Behaviours
There are two different types of pain behaviours:
- Protective:
- Trying to prevent or reduce pain, e.g. limping, holding, rubbing.
- Trying to stop you from touching or moving a part of the body (called
“guarding”).
- Being unwilling to move or undertake an activity such as rolling over.
- Communicative:
- Providing information about pain.
- Facial expressions.
- Vocal sound, e.g. ouch or groan.
Facial Expressions
- Grimacing, tighter face, wrinkled nose.
- Brow lowering, closed or tightened eyes, upper lip or cheek raising.
- Wincing, squinting or narrowing of eyes.
- Mouth opening.
Vocalisation
- Moaning, groaning, grunting, crying.
- Specific sounds or words for pain (e.g. ow, ouch, that hurts).
- Gasping or noisy breathing.
- Body movements.
- Flinching or pulling away.
- Thrashing or rocking.
- Refusing to move or moving slowly.
- Bracing or avoiding certain body positions.
- Rubbing, holding, or guarding the sore area.
- Limping.
- Clenched fists.
- Going into foetal position or knees pulled up when lying in bed.
- Stiff or rigid body.
- Shaking or trembling.
Changes in Interpersonal Interactions
- Not wanting to be touched or not allowing people near.
- Decreased social interactions and communication.
- Difficult to console or reassure.
- Changes in activity patterns or routines.
- Sleep changes.
- Sudden cessation of common routines or decreased activity.
- Mental status changes which could be due to pain and cannot be attributable to another cause (e.g. delirium due to medication).
clients who Can Communicate Successfully
Use the six-step identification and assessment procedure:
- Regularly provide the client time and opportunity to discuss their concerns, including pain. Ask the client what their pain is like while resting, as well as moving. Use words like “sore”, “hurting”, “aching”, as well as “pain”.
- Be watchful for signs of pain (see above: Pain behaviours) when the client is resting and moving.
- If the client reports pain, explain the need for further assessment, involve the client and the family if appropriate.
- A qualified staff member can use the Modified clients’ Verbal Brief Pain Inventory (M-RVBPI)*. This is a “multi-dimensional scale”, that provides an overall understanding and documentation of the severity, location and effects of the pain.
- Monitor progress and response to treatment using a pain severity (or “intensity”) scale.
- Document and communicate within the care team.
clients who Cannot Communicate Successfully
Use the following six-step identification and assessment
- Observe the client for possible signs of pain, including:
- facial
- vocal sounds, e.g. ouch or groan*
- body or limb movements that cause distress
- changes in behaviour
- change in movement, e.g. walking is more unsteady
- changes in activity pattern or routine.
- Look for causes of pain or discomfort such as:
- injury
- pressure area
- constipation
- oral problems, e.g. tooth decay
- recent fall.
- Clinical examination by a nurse and a doctor, physiotherapist or another health professional, as appropriate.
- Explain the situation and ask a family member, or familiar caregiver, to help interpret the client’s behaviour and responses. Use a standard well-validated observational or behavioural tool, e.g. Abbey Pain Scale or Pain Assessment in Advanced Dementia (PAINAD scale).
- Use the information to begin multidisciplinary pain assessment and management and ensure information is communicated between the nurse, doctor and allied health clinicians, as relevant. This may result in a trial of pain medication or other approaches.
- Ongoing monitoring by observation and regularly repeating the use of the pain scale.
Pain Management Strategies
- Consult with all involved health professionals to ensure a coordinated approach.
- Follow actions documented in the care plan.
- Only appropriately trained staff will administer, or assist clients, with all prescribed pharmacological and non-pharmacological pain management treatments.
- care staffs will implement the pain monitoring charts as required.
- On commencement of service clients that use regular analgesia, report pain or take regular S4 or S8 medications must be monitored for seven days utilising the pain monitoring tool, i.e. type, duration, length, site, current management and effective strategies.
- clients with a PRN order and who are given PRN regularly (four or more times in 24 hours) must be referred to the medical officer for a review of pain management
strategies/analgesia.
- Evaluate the client after each analgesia to monitor effectiveness.
Pain Medicines
The main types of pain medicines are:
- paracetamol – often recommended as the first medicine to relieve short-term pain
- aspirin – for short-term relief of fever and mild-to-moderate pain (e.g. headache)
- non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, which relieve pain and reduce inflammation (redness and swelling)
- opioid medications (e.g. codeine, morphine and oxycodone) which are reserved for severe or cancer pain
- local anaesthetics
- some antidepressants
- some anti-epileptic medicines.
Non-Medicine Treatments
Non-medicine treatments and therapies, and a combination of treatments and therapies can
be effective, examples include:
- warm or cold packs (no extreme temperatures and never leave on long)
- heat packs to relieve chronic muscle or joint injuries
- physical therapies and exercise, e.g. walking, stretching, or strengthening may help reduce pain, maintain mobility and improve mood
- gentle massage for soft tissue pain
- relaxation and stress management techniques (e.g. meditation and yoga) or consider playing relaxing music
- transcutaneous electrical nerve stimulation (TENS) therapy which involves minute electrical currents passing through the skin via electrodes, prompting a pain-relieving response from the body
- cognitive strategies to help the client learn to change how they think and, in turn, how they feel and behave with chronic pain (this is a valuable strategy for learning to self- manage chronic pain, i.e. “less pain” rather than “no pain”).
Concerns and Symptoms
Side Effects of Pain Medication
Side effects are listed below for common medications:
- Paracetamol – side effects are rare when taken at the recommended dose and for a short time. Paracetamol can cause skin rash and liver damage if used in large doses for a long time.
- Aspirin – the most common side effects are nausea, vomiting, indigestion and stomach ulcer. Some people may experience more serious side effects such as an asthma attack, tinnitus (ringing in the ears), kidney damage and bleeding.
- Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) – can cause headache, nausea, stomach upset, heartburn, skin rash, tiredness, dizziness, ringing in the ears and raised blood pressure. They can also make the risk of heart failure or kidney failure worse, by increasing the risk of heart attack, angina, stroke and bleeding. NSAIDs should always be used cautiously and for the shortest time possible.
- Opioid pain medicines such as Morphine, Oxycodone and Codeine – commonly cause drowsiness, confusion, falls, nausea, vomiting and constipation. They can also reduce physical coordination and balance. Importantly, these medicines can lead to dependence and slow down breathing, resulting in an accidental fatal overdose.
Observe, Document and Report
- Update the care plan following completion of pain assessment/pain monitoring.
- Record all pain management strategies implemented in the client’s care plan.
- Identify any changes to the client’s pain levels in the Progress Notes.
- Review the pain management plan at least three-monthly, or as care needs or health status changes, to determine if:
o current strategies are effective
o other strategies should be introduced
o pain has impacted on the client’s quality of life.
- Update the care plan if required after review.
- Monitor all clients who have commenced a new order of analgesia.
- Report changes in condition, adverse reactions and pain levels.
Pain Management Assessment Guidance
The registered nurse conducting the assessment will consider the following:
- Personal details:
o Age, psychosocial profile.
o Anxiety or depression as a comorbid state.
o client’s understanding of pain.
- Cardio-respiratory status:
o Sleep-disordered breathing.
o Hypertension.
- Cognitive status, including impairment/dementia, especially if behaviour such as aggression or sundowning (confusion later in the day) occur.
- Mobility, including falls risk.
- Potential pain mechanisms, i.e. what type of pain is the client experiencing? o Acute or chronic or cancer related.
o Nociceptive – ongoing tissue damage (e.g. arthritic conditions, cancer). o
Neuropathic – damage or disease of the somatosensory nervous system (e.g. post shingles pain).
o Mixed pattern (e.g. back pain with nerve injury, cancer with treatment-related nerve injury).
- Is there central nervous system sensitisation (hyperalgesia)?
o Prolonged, severe pain (e.g. musculoskeletal).
o Prolonged opioid exposure (opioid-induced hyperalgesia) will increase pain sensitivity.
- Are there any neuro-psychological contributions (e.g. anxiety) which can heighten the pain experience?
- Impact of pain and (potential) treatments:
o Limiting physical function, i.e. mobility.
o Sleep disturbance.
o Distress, including mood disorder.
- Behaviours such as hitting, aggression or wandering.
Pain History
Determine the client’s pain history by using the following processes:
● OPQRST approach as below:
Temporal: General medical history.
- Relevant co-morbidities or diseases (e.g. arthritis, cancer, vascular, neurological, gastrointestinal, renal, dementia, diabetes).
- Recent falls.
- Associated symptoms (e.g. nausea, dizziness).
- Weight loss, night sweats, general malaise.
Physical examination
Comprehensive examination covering:
- Sites of reported pain and referred pain.
- Musculoskeletal system and signs of arthritis or inflammation or signs of fragility fracture.
- The neurological system, including weakness and sensory changes, loss or weakness in bladder or bowel control.
- Degree of frailty.
- Blood tests.
- Imaging.
- The physical impact of pain.
- Spontaneous movement.
- Comfort on movement.
- Impact of pain on activities of daily living.
- Avoidance of activity.
- Functional assessment of activities of daily living (e.g. psychosocial factors). ● Participant’s beliefs and understanding about the cause(s) of pain (e.g. fear, hypervigilance).
- Participant’s cognitive state:
o presence of anxiety or depression
o effect on sleep (duration/quality)
o suicidal thoughts
o family and cultural expectations and beliefs about pain
o coping resources (resilience).
- Impact on relationships.
- Impact on social activities.
- Review of medications and other treatments.
- Treatments that have been tried (i.e. dose, adherence, side effects, outcomes). ● Reasons for discontinuation.
- Allergies.
- Effectiveness of current treatments.
- Prognosis – consider the interpretation of assessment and investigation findings: o in discussion with the participant or advocate, as well as regular care staff o in the context of overall care priorities and balance of likely benefits and harms o to understand necessary and unnecessary care.
NurseCare Australia ensures that our care staffs are trained to identify and minimise client exposure to seizure risk factors. Our Director or Care Manager will consult with the client and their carer or advocate to identify and remove or minimise exposure to potential risks (e.g., burns, falls or other risks related to seizures).
The care staff will observe the client identify early seizure indicators and take all required and appropriate actions, including monitoring and recording seizure data. Staff will follow infection control and waste disposal procedures outlined in the Infection Management Policy and Procedure and the Management of Waste Policy and Procedure.
Equipment in the home may include:
Equipment required for seizure management in the home includes, but is not limited to:
● disposable gloves (powder free)
● disposable apron
● appropriate PPE (e.g., mask, face shield)
● medications and associated equipment
● lubricant (water-based)
● incontinence pad or Kylie
● medical waste receptacle or bag.
Seizure emergency management pathway
Staff are trained to manage seizures using the emergency management pathway outlined in Diagram 1
Diagram 1. Seizure emergency management pathway
Ventilator management equipment in the home
care staffs will ensure that home equipment supplies are maintained and will reorder stock if short. Before reordering stock, a care staff will require the Director or Care Manager’s approval or consent from the client, family, or advocate. The client’s Service Agreement will be reviewed to determine if equipment stock approval has already been given.
The consumables and equipment must be checked monthly to ensure they are within date and functioning correctly. If they are not in-date and not functioning correctly, this must be documented in the Care Plan and communicated to the registered/enrolled nurse and the Director or Care Manager. The client must also be advised.
care staffs maintain records of the equipment checks that they complete on respiratory equipment, Records are maintained of checks carried out on back-up ventilators, as well as oxygen levels in spare tanks and suction equipment,
The equipment in the home may include, but is not limited to:
- appropriatepersonal protective equipment
- continuousaccess to electricity supply
- ventilatorand equipment (e.g., cuff)
- oxygencylinder and tubing, adapters, and bags
- humidifier
- tracheostomykit (where applicable), including tracheostomy
- suctionunit, equipment, and
- sparebatteries for all equipment (back-up power supply via generator is discussed with the client)
- sodiumchloride – 10 millilitres (ml) x 5
- waterfor irrigation – 10 ml x 5
- syringes– 5 ml and 20 ml x 5
- lubricatingjelly
- scissors
- gloves
- Yankauersucker
- mobilephone with emergency contact numbers and charger
Daily equipment checks will be completed on all equipment used, including the ventilator. Ventilator settings must be checked against the client’s Care Plan requirements. The maintenance program for the ventilator will be noted, including the most recent date of ventilator service as required by our organisation’s equipment maintenance program.
Procedure
Securing of the endotracheal tube.
Securing the endotracheal tube (ETT) can be done in one of three ways:
- Tapes (e.g., Sleek or Transpore) are used only for clients who are in the process of being transported to ICU or an operating theatre.
- Cottonwhite tape, which is changed at least
- Anendotracheal tube attachment device (ETAD) (anchor-fast) is changed every five days or as required.
Assessing endotracheal tube position.
The care staff will assess the endotracheal tube position each shift as follows:
- Checkand document the level of the endotracheal tube at the lips (usually 19-23 centimetres).
- Ensuringequal bilateral chest movement and air entry on
- Verify the tip of the endotracheal tube is two to four centimetres above the carina on the chest x-ray.
- Repositionthe oral endotracheal tube to prevent pressure
Assessing and maintaining a tracheal cuff seal:
Assessing and maintaining a tracheal cuff seal will involve the following:
- Aminimum occlusion volume is achieved on the first inflation of the cuff at
- Thecuff pressure is measured via a cuff pressure
- Cuffpressure is documented once each shift or as
- Cuffpressure of 20-30 mmHg is usually required to maintain an adequate
- If a pressure > 30mmHg is required to eliminate a cuff leak, the registered/enrolled nurse will be contacted immediately, as a pressure > 40mmHg may cause mucosal injury.
- Listen for cuff leaks and monitor low ventilator pressure and tidal volume alarms, which may indicate an air leak.
- Undertakearterial blood gas (ABG) sampling and
- Performan initial ABG 15-30 minutes post-
- FurtherABG sampling is required when there is:
- deteriorationin oxygen saturation
- clinicalsigns of hypoxia
- significantchanges to ventilator settings
- changes inclient’s respiratory effort and ventilator observations (e.g., low tidal volume, increased or decreased minute volume)
Suction
Suctioning of the endotracheal tube is performed using a closed or in-line suction device only. It is replaced daily or overtly soiled, along with the suction tubing and receptacle liner. Regular suctioning is not recommended and will only be performed by care staffs when clinically necessary or at approximately eight hourly intervals.
The suction procedure is as follows:
- Explain the procedure to the client.
- Preoxygenate,the client with 100%
- Observe hand hygiene principles and use necessary
- Unlock the catheter and advance as far as possible without force or until the client
- Withdraw the catheter one to two centimetres to free it from the bronchial wall or
- Apply continuous suction while withdrawing the catheter in one continuous motion, not longer than 15 seconds.
- Use a maximum of two suction
- Flush the catheter via the irrigation port with a 10-millilitre syringe of normal
- Lock the suction
- Auscultate lung fields to assess the effects of
- Using the Tracheostomy and Ventilator Observation Chart, document the sputum’s colour, volume, and tenacity.
Humidification of the ventilator circuit
The air passing through the ventilator must be passed through either a heat moisture exchanger (HME) for a dry circuit or a heated water bath system for a wet circuit.
Changing from a dry to a wet circuit is not routinely undertaken unless there is:
- sticky sputum
- haemoptysis
- bronchospasm
- bronchorrhea(i.e., excessive discharge of watery mucus from the lungs)
Management of the ventilator circuit
Ventilator settings, including oxygen flow, partial pressure of oxygen and PEEP, are stated in the Care Plan. care staffs conduct ventilator setting checks every shift or, at a minimum, every 24 hours. The ventilator setting can only be changed with a registered/enrolled nurse or general practitioner’s input.
Ventilator maintenance
The maintenance of a ventilator varies depending on the make and model. When developing the Ventilator Management Care Plan, the registered/enrolled nurse will determine the maintenance schedule required for the ventilator and all associated equipment. It is the responsibility of the client, their family, carer, or advocate to ensure that the maintenance schedule of the ventilator is kept up to date. The registered/enrolled nurse may assist if the maintenance plan is not up to date or if a skilled technician requires additional maintenance.
care staffs will change all ventilator tubing and circuits, including Laerdal; wet or dry are changed weekly or frequently if soiled. The heat moisture exchanger is changed daily or more frequently if wet or soiled.
NurseCare Australia works with the clients, their family, carer, or advocate to ensure that the necessary consumable items (e.g., tubing, circuits) are always available for the care staff to use with the client. It is also advised that an emergency supply of consumables is kept in the client’s place of residence.
When the client leaves their residence for short trips, the care staff or registered/enrolled nurse accompanying the client will ensure that an emergency equipment bag travels with the client.
Mouth care
Mouth care is important in caring for a client using a ventilator. care staffs will provide mouth care following the instructions on the Mouth Care Plan. Mouth care includes swabbing the mouth, using a toothbrush with a suction catheter to remove any fluid or saliva in the mouth and applying lip balm to the client’s lips.
Emergency management
All staff must inform the registered/enrolled nurse and the Director or Care Manager if they are concerned about a client’s condition. In an emergency, such as those noted below, our staff will IMMEDIATELY call 000 and request an ambulance.
care staffs will follow emergency procedures to immediately start, operate and monitor the use of a back-up ventilator, resuscitation bags, oxygen requirements and suctioning equipment.
Table. Respiratory distress indicators and possible causes
Staff will implement the DRSABCD Action Plan and use the emergency cardiopulmonary resuscitation (CPR) procedure in an emergency. Refer to Table 2. DRSABCD Action Plan.
Table. DRSABCD Action Plan
Non-Invasive Ventilation
BiPAP and CPAP are both non-invasive ventilation therapies to support respiratory distress and insufficiency.
BIPAP therapy is often used to treat respiratory issues such as chronic obstructive pulmonary disease (COPD) or acute respiratory distress syndrome (ARDS). BiPAP delivers two levels of positive air pressure to the client’s airway: a higher-pressure during inhalation and a lower pressure during exhalation.
CPAP delivers a constant level of positive air pressure to the client’s airway during both inhalation and exhalation. The positive air pressure helps to keep the client’s airway open and prevent it from collapsing.
The choice between BiPAP vs CPAP therapy will depend on the individual client’s needs and medical conditions.
Comparison Between CPAP and Bi PAP Similarities:
Usage of a mask or nasal prongs to deliver air pressure to the client’s airway.
Both are non-invasive and can be used to treat a variety of respiratory conditions.
Requiring close monitoring of the client’s respiratory status, vital signs, and response to treatment
Both can be used in a hospital or home setting.
Differences:
BIPAP delivers two different pressure levels, while CPAP delivers a constant level of pressure.
BIPAP has a higher-pressure during inhalation and a lower pressure during exhalation, while CPAP delivers the same level of pressure during both inhalation and exhalation.
BIPAP is often used to treat more severe respiratory distress, such as in clients with COPD or ARDS, while CPAP is often used to treat sleep apnoea or less severe respiratory distress.
BIPAP may be more uncomfortable or difficult to tolerate for some clients due to the higher- pressure during inhalation.
Non-Invasive Ventilation High Intensity Supports Interventions
●Assess the client’s respiratory status, vital signs, and need for BIPAP/CPAP therapy.
●Assess the client’s comfort level and tolerance for the CPAP mask.
●Prepare the equipment to ensure that the BIPAP or CPAP machine is functioning properly and that the appropriate pressure settings have been selected based on the client’s needs. The nurse should also ensure that the mask or nasal prongs are properly fitted to the client’s face or nose.
●Administer the therapy, starting by placing the BIPAP/CPAP mask or nasal prongs on the client’s face or nose, ensuring a secure and comfortable fit. The care staffs then turn
on the BIPAP or CPAP machine and adjust the pressure settings as needed to achieve the desired therapeutic effect.
●Monitor the client’s respiratory status, vital signs, and response to therapy.
●Provide client education on the purpose of the therapy, how to use and care for the equipment, and how to recognize and report any complications or concerns.
●Document the therapy in the client’s Care Plan, including the duration and pressure settings of the therapy, the client’s respiratory status and response to therapy, and any complications or concerns.
The Seizure Management Care Plan is developed to ensure the client’s wellbeing and safety. The Care Plan is developed with the involvement of the client, their family, carer or advocate, the Director or Care Manager and a health practitioner (e.g., general practitioner, medical specialists, nurse consultants, registered/enrolled nurse).
The Seizure Management Care Plan includes details such as:
●types of seizures experienced by the client
●signs and symptoms of seizures
●seizure frequency and patterns
●seizure triggers
●signs to check before and after a seizure
●monitoring and recording requirements
●detailed instructions on medication selection and administration procedures
●information on how to manage risks, incidents, and emergencies
●emergency management options and procedures
●Common medication used to manage seizures and related contraindications and side effects
care staffs will confirm the client’s consent before administering medications detailed in the Seizure Management Care Plan (as previously agreed with the client, family, carer, or advocate). care staffs will complete the Seizure Record Form as required, and completed forms is used during Seizure Management Care Plan reviews. The clients' care plan will, if indicated by the clients conditions, include information on triggers or conditions that can increase risk of seizure for the clients. This may include constipation, dehydration, high temperature, aspiration, and other issues that may be indicated by the clients history. A client’s Seizure Management Care Plan is reviewed monthly, or when there is a change in client’s condition, Care strategies developed are based on recent information from the client, their family or advocate, our staff and health professionals.
Staff follow NurseCare Australia’s documentation procedures for:
●PRN medication
●monitoring and recording of seizures
●recording emergency management procedures
●Common medication used to manage seizures and related contraindications and side effects.
●handling, storing, administering, and recording administration of post-seizure medication.
●recording changes requested by health practitioners (e.g., general practitioner or registered/enrolled nurse)
●informing the Director or Care Manager, the client, their carer, or advocate when a change in seizure management has been requested.
A Manual Handling client Care Plan or a PRN Care Plan is developed with the client if necessary, and care staffs are trained in plan requirements.
●Common types, symptoms, and patterns of seizures
●Common triggers or conditions that can increase risk of seizure such as constipation, dehydration, high temperature, aspiration, and related methods of control.
●Common risks associated with seizures.
●The impact of associated health conditions on epilepsy
●Observation parameters to identify early indicators of seizure onset, monitor seizures and observe following a seizure.
●Expectations for handling, storing, administering, and recording use of post-seizure related medication.
●When and how to involve or get advice from the health practitioner, or emergency services.
●Reporting responsibilities, including handover, recording observations and incident reporting
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NurseCare Australia’s training system complies with the high-intensity support skills descriptor for providing seizure management, including that staff follow all care and medication administration procedures and exercise judgement and know when it is appropriate to call an ambulance.
care staffs receive training regarding the client’s specific needs and the type of seizure care support they require. Training includes:
●types of seizures
●types and patterns of common seizure
●how to respond to seizure alerts and alarms including alarms included in wearable health technology appliances
●conditions that can increase risk of seizure such as constipation, dehydration, high temperature, aspiration, and related methods of control for these conditions.
●common patterns or clusters of seizures
●seizure triggers and symptoms
●appropriate seizure management and control procedures
●impact of epilepsy
●parameters that guide decisions regarding the dosage of PRN medication and when to administer
●identifying potential side effects of medications
●related health risk complications associated with epilepsy.
●factors that increase client risks and appropriate methods of control
●first aid techniques to check and clear airways, administer CPR, and place a person in a recovery position.
●interpretation of advice regarding when to request an ambulance.
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