Improving Patient Outcomes with Sequential Compression Device therapy Lizy Patric BSN, RN, CMSRN 4W Objective 1. Discuss the importance of SCD therapy. 2. What does a complete and accurate SCD therapy order look like today? 3. List the components of VTE nursing risk assessment. 4. Discuss the current, research driven SCD protocol. 5. What are the obstacles facing SCD therapy? Every year more than 2.5 million people are diagnosed with deep vein thrombosis (DVT). Some underlying issues that may be responsible for a DVT diagnosis are the presence of a permanent cardiac pacemaker, internal cardiac defibrillators, and increased use of indwelling venous access catheters. Due to today's trend of same-day surgeries and shorter inpatient admissions, signs and symptoms of DVT do not develop until after discharge. Nursing education must stress the need for safe mobility as soon as possible. Those admitted to facilities for a more extended period are at very high risk due to active disease processes, limited mobility, and other comorbidities. Physicians' orders for SCD therapy used to lack the components listed below. However, research shows that effective SCD therapy can only happen with these components and other appropriate nursing interventions using clinical judgment. VTE Risk Assessment Every patient must undergo a thorough VTE risk assessment by a physician or independent, licensed practitioner on arrival. This assessment includes three categories: age, primary admitting diagnosis, and past medical histories that may contribute to VTE, such as the prominent family history of thrombosis, coagulopathy, blood clots, or homological disorders that lead to increased incidence of/or prolonged clotting. Evidence-based practice states that SCD therapy is most effective for moderately high-risk patients for developing VTE. This assessment is continuous and must occur as long as the patient has limited mobility. SCD Protocol Two clinical nurse specialists conducted research at their hospital to evaluate acute-care nurses' knowledge of safe, correct use of sequential compression device (SCD) therapy in preventing venous thromboembolism (VTE) in hospitalized adults. This descriptive correctional research used an investigator-developed, multiple-choice knowledge questionnaire based on evidencebased practices. It was administered to a target population of acute-care registered nurses and licensed practical nurses in the 394-bed, non-teaching, multi-campus community hospital to determine nurses' knowledge level. The researchers realized that safe, correct use of SCDs among nurses was inconsistent. One reason for the inconsistency was their educational deficiencies; another reason was that the physician's order for SCD therapy was incomplete. Based on their study results, a plan was developed for the nursing staff, and a physician-ordered, nurse-driven protocol was developed at the hospital to ensure safe and accurate SCD use. The proposed protocol is as follows: 1. A physician or licensed independent practitioner must order SCD therapy. This order must be based on their complete and comprehensive patient assessment. 2. Knee-length SCDs will be applied unless the physician explicitly orders thigh-length SCDs. 3. The physician or independent, a licensed practitioner must specify combination therapy with compression stockings. The order must specify knee-length or thigh-length compression hose/stockings. This is not the same order as an order for SCD therapy. 4. SCD therapy is contraindicated in patients with documented DVT. 5. A baseline skin and neuro assessment must be completed and documented before SCD sleeves are placed on the patient's legs. Skin and neuro assessment must be repeated every 8 hours or PRN per patient complaints. This assessment will include: • Presence and level of pain • Pallor • Palpable or Doppler pulses • Paresthesia • Paralysis • Skin abnormalities (under the sleeve) • Pain associated with movement or touch • Increasing edema of the extremity • S/S of possible blood clots to extremity such as swelling, redness, pain. 6. Report any deviation or abnormal assessment findings to the physician or independent, licensed practitioner. 7. Patient education will increase adherence to the treatment plan, and it must include: • Reason for SCD therapy – How SCD therapy aids VTE prevention • Must let patients know not to remove SCD device/sleeve without notifying staff. • They must report the nurse's pain or "pins and needles" sensation. • They must also know that the nurse will remove the sleeve/device every 8 hours to look at the skin and when bathing. • Document patient education and adherence in the patient's medical record. 8. Nurses must measure the patient for the correct fit of SCD sleeves. • Follow manufacturer recommendations to determine size – One size does NOT fit all • Use a tape measure to obtain accurate measurements • Should be able to fit two fingers between the SCD sleeve and the patient's leg • Resize the sleeve if a noticeable change in leg diameter has occurred due to edema or third-spacing 9. Assistive staff may reapply SCDs if they have had documented education on correct sleeve application. Assistive nursing staff must report observations and any patient complaints to the nurse. 10. Transcribe the SCD order into the ordering/charging system to charge for the therapy. Obtain appropriate equipment to provide SCD therapy. • Correctly sized SCD sleeves, SCD pump • Remove the SCD charge when CD therapy is discontinued • Return the SCD pump to the central supply • Sleeves are one-patient use only 11. If SCD therapy is interrupted for more than 2 hours, a physician order is needed to restart. 12. SCD therapy may be discontinued once the patient ambulates most of the day. Document discontinuation time in the patient's medical record. Poor patient and nurse compliance is the most prominent obstacle in SCD therapy. Patient complaints include sweating or itching from the sleeves, discomfort from sleeve inflation, etc. To ease sweating, initiate the cooling system on the SCD pump; to relieve itching, apply cornstarch. The discomfort from the sleeve is most likely because it needs to be resized due to third spacing or edema of the extremities. Nurse compliance can improve with proper education on executing SCD therapy and its importance. In the facility where research occurred, nurse compliance increased by 4% after the nursing staff received the appropriate education. High patient workloads and lack of available equipment are among the reasons for low nurse compliance. This research is part of a doctoral study conducted by Randy McClain at Walden university in 2020. References Bartzak, P. J. (2018). A renewed respect for sequential compression devices. Med-Surg Matters, dabeg27(3), 1–3. Retrieved from https://www.amsn.org/publications/med- surg-matters. Increasing compliance with sequential ... - scholarworks. (n.d.). Retrieved April 12, 2022, from https://scholarworks.waldenu.edu/cgi/viewcontent.cgi?article=10461&context=dissertation s Providing Effective End of Life Care Lizy Patric BSN, RN, CMSRN 4W Objective 1. How do we provide physical comfort at patients’ end of life? 2. How do we manage patients’ mental and emotional needs at their end of life? 3. What is the effect of morphine on a dying patient? 4. How do we manage their spiritual needs? 5. How do we provide support for practical tasks? "You matter because you are you, and you matter to the end of your life. We will do all we can not only to help you die peacefully, but also to live until you die." — Dame Cicely Saunders, nurse, physician and writer, and founder of the modern-day hospice movement (1918 - 2005). People who are dying need care in these four areas – physical comfort, mental and emotional needs, spiritual needs, and practical tasks. The patient’s family needs support for practical tasks and support for their emotional needs as well. As culturally competent healthcare professionals, we must understand that end of life care must be catered to the individual that is, the care provide will depend on their cultural, religious, spiritual, and personal preferences. Some may request continuous treatment till end of life, and some may request to be home surrounded by their family, etc. There are steps nurses can take to ensure a peaceful death while following their end-of-life wishes while they are dying. End-of-life care suggestions must be made to the patient’s care team to make sure these suggestions are appropriate for the situation. End of Life: Providing physical comfort The following factors are what we need to address to provide maximum physical comfort for patients at their end of life. 1. Pain 2. Breathing issues 3. Skin irritation 4. Digestive issues 5. Temperature sensitivity 6. Fatigue Pain – One of the nursing goals must be to relieve pain without worrying about possible long-term problems of drug dependence or abuse. Chronic pain can make a person understandably short-tempered or angry. Pain is easier to prevent than to relieve, and severe chronic pain is hard to manage. Consulting a palliative medical specialist may be required for effective pain management. Breathing issues – Shortness of breath or the feeling that breathing is difficult is a common experience at the end of life. Some nursing interventions to help relieve shortness of breath include raising the head of the bed, opening a window, using a humidifier, or using a fan to circulate air in the room. The patient may also have an abnormal breathing pattern also known as Cheyne-Stokes respiration. This abnormal pattern of breathing alternates between deep, heavy breaths and shallow or even no breaths. People are very close to dying may have noisy breathing called death rattle. In this case, turn the patient on one side or elevate their head. Skin irritation – To prevent any issues concerning the integrity of their skin, they must be bathed and moisturized regularly. Gently apply alcohol-free lotion to relieve dryness and itching. Dryness on certain parts of the face such as the lips and the eyes, can be a common cause of discomfort near death. Some nursing interventions to help relieve this include: o Applying a balm to the lips o Gently dabbing eye cream or gel around the eyes o Try placing a damp cloth over the person’s closed eyes o If the inside of the mouth seems dry, giving ice chips (if conscious) or wiping the inside of the person’s mouth with a damp cloth, cotton ball, or specially treated swab might help. Turn the patient every 2 hours to prevent bed sores. Try putting foams pads on their pressure points, using special mattresses will also help prevent bed sores. Digestive problems – Nausea, vomiting, constipation and loss of appetite are common issues at the end of life. Swallowing may also be an issue. If they loose their appetite, try gentling offering favorite foods in small amounts. Serve frequent, smaller meals rather than three large one. Help with feeding if the person wants to eat but is too tired or weak. Do not force a dying person to eat. Loosing appetite is a common and normal part of dying. A conscious decision to give up food can be a normal part of a person accepting that death is near. Temperature Sensitivity – When a person is close to death, they may not be able to tell you that they are feeling cold or hot. Watch for signs and intervene to ensure maximum comfort. Fatigue – It is common for people nearing death to feel tired. Ensure that the care you provide is simple. For instance, use a bed pan or commode instead of having them walk to the bathroom. Give your patient a bed bath or a sponge bath instead of having them walk. Managing Patients’ Mental and Emotional Needs Someone who is alert near the end of life might understandably feel depressed or anxious. There may be a need to contact a counselor, one that is familiar with end-of-life issues, to encourage conversations about feelings. Medication may be needed if anxiety or depression is severe. Ensure that you educate the patient’s family to not avoid the patient. Some people may experience mental confusion and may have strange or unusual behavior, making it harder to connect with their loved ones. This will only add to their sense of isolation. The following are what we can do to manage mental and emotional needs: o Provide physical contact – try holding their hands or a gentle massage o Set a comforting mood – some people prefer quiet moments with less people. Use soft lighting in the room. o Play music at a low volume – this can help with relaxation and lessen pain o Involve the dying person – If the person can still communicate, ask them what they need. o Be present – Visit with the person. Talk or read to them, even if they cannot talk back. If they can talk, listen attentively to what they have to say without worrying about what you will say next. Your presence can be the greatest gift you can give to the dying person. The Effect of Morphine on a Dying Patient Morphine is an opiate used to treat serious pain. Sometimes, morphine is also used to ease the feeling of shortness of breath. Evidence-based research shows that morphine given in clinical settings at the end of life does not hasten death when prescribed appropriately. Successfully reducing pain and addressing concerns about breathing can provide comfort to someone is close to dying. However, pain medication can make people confused or drowsy and even cause hallucinations. Spiritual Needs at the End of Life Spiritual needs may include finding meaning in one’s life, ending disagreements with others, or making peace with life circumstances. The dying person might find comfort in resolving unsettled issues with friends or family. Many people find solace in their faith whereas some struggle with their faith. Arrange for the patient to talk to a rabbi, minister, priest, or imam. There may be a time when a dying person who has been confused suddenly seems to be thinking clearly. Take advantage of this, however, understand that this is only temporary and not a sign of getting better. They may also have their version of a reality where they appear to talk to deceased relatives or spiritual figures, resist correcting them. Their reality comforts them. Providing Support for Practical Tasks Helping your dying patient with practical tasks relieves them and their caregiver. Ask the patient’s family to reassure the patient that their belongings are in good hands. For instance, “I’ll make sure to keep watering your violets” or “I’ll make sure your pet cat is taken care of” to give the dying patient a measure of peace. Help them with activities of daily living and other tasks such as picking up medication from the pharmacy, doing small daily chores, and picking up the mail, etc. As the patient’s healthcare provider, it is our responsibility to ensure they pass peacefully. References Anon, Providing care and comfort at the end of life. National Institute on Aging. Available at: https://www.nia.nih.gov/health/providing-comfort-end-life [Accessed March 3, 2022].
