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Policies and Procedures
Title: SUBCUTANEOUS THERAPY -
INTERMITTENT AND CONTINUOUS

I.D. Number: 1074
Date Revised: January 2015 [X] SHR Nursing Practice Committee Date Effective: January 2000 Scope: SHR & Affiliates
Any PRINTED version of this document is only accurate up to the date of printing 24-Mar-15. Saskatoon Health Region (SHR) cannot guarantee the currency or accuracy of any printed policy. Always refer to the Policies and Procedures site for the most current versions of documents in effect. SHR accepts no responsibility for use of this material by any person or organization not associated with SHR. No part of this document may be reproduced in any form for publication without permission of SHR.
DEFINITIONS

Subcutaneous Therapy
– The establishment of temporary subcutaneous access for
repeated/intermittent medication doses and/or continuous subcutaneous infusion of medication.
Hypodermoclysis (HDC) – Refers only to the infusion of isotonic fluids into the subcutaneous space for
rehydration or for the prevention of dehydration. For all other uses, the term subcutaneous therapy
1. PURPOSE

1.1 To minimize the risks of infection and other complications associated with the insertion and maintenance of subcutaneous therapy.
2. POLICY

2.1 A practitioner order is required for medication/fluid therapy as per the SHR policy "Ordering of Medications" #7311-60-004. 2.2 RN/RPN/GN/GPN/LPN/GLPN Role
2.2.1 Initiate and maintain intermittent subcutaneous access. 2.2.2 Administer intermittent subcutaneous medication via established access. 2.2.3 Initiate and maintain continuous subcutaneous infusions (medications/fluids). 2.3 Subcutaneous Site Change
2.3.1 The site will be changed: • every 2 days for clients who receive higher volumes associated with HDC or • every 7 days for low-volume medication infusions. Note: The dwell time of the subcutaneous access device is variable, based on fluid
volume and the integrity of the site. The subcutaneous site is rotated as
clinically indicated based on the integrity of the site.
Note: In the community, palliative care clients will have one site per medication
and those sites can be used indefinitely as long as they are healthy. Page 1 of 9 Policies & Procedures: Subcutaneous Therapy – Intermittent and Continuous I.D. # 1074 2.3.2 The maximum volume for intermittent subcutaneous medication is 2 mL. 2.3.3 The subcutaneous site will be assessed each shift or visit for complications such as redness, tenderness, edema, bruising, burning, bleeding and leaking. 2.3.4 Each site will be labeled with the date it was initiated, medication name and concentration, and initials of nurse. 2.4 Tubing and Solution Change
2.4.1 All tubing and solution will be changed every 96 hours, with site change or immediately if contamination or system integrity is suspected. Refer to SHR Nursing Policy & Procedure Manual: Intravenous and/or Peripheral Saline Lock Insertion and Maintenance #1118 or the Long Term Care Intravenous Policy. 2.4.2 Medications mixed on the unit will hang no longer than 24 hours. Refer to SHR Nursing Policy & Procedure Manual: Medication Administration #1170 or the Long Term Care Medication Administration Policy.
Note:
Stability of medication in solutions may require more frequent change. Refer to

SHR IV Medication Reference Manual. 2.4.3 All tubing will be label ed with the date and time it was initiated, date and time to be discarded or changed, and initials of nurse. 2.5 Contraindications
2.5.1 Clients with an increased risk of pulmonary congestion or edema, existing fluid overload, and reduced local tissue perfusion may not tolerate continuous subcutaneous infusions. 2.5.2 Clients with anticoagulation and clotting disorders may not tolerate subcutaneous access due to bleeding at the injection site. 2.6 Special Considerations
2.6.1 Hand hygiene will always be performed as per policy before and after palpating
catheter insertion sites as well as before and after inserting, replacing, accessing or
repairing a subcutaneous catheter or dressing a subcutaneous site. 2.6.2 Site selection for subcutaneous access should include areas with adequate subcutaneous tissue with intact skin such as the upper arms, subclavicular chest wall, abdomen, upper back, and thighs. Avoid skin folds or line of clothes (i.e. waistline). Refer to Appendix A for Subcutaneous Insertion Sites. 2.6.3 Subcutaneous infusion of large volume solutions must contain electrolytes:  0.9% sodium chloride (normal saline)  0.45% sodium chloride (half normal saline)  Dextrose 5% and 0.9% sodium chloride (D5NS)  Dextrose 3.33% and 0.3% sodium chloride (2/3 1/3)  Lactated Ringers 2.6.4 In palliative care, subcutaneous is the route of choice when oral route is not possible. Page 2 of 9 Policies & Procedures: Subcutaneous Therapy – Intermittent and Continuous I.D. # 1074 2.6.5 In the community, the RN will preload and label the medications for the client/family
3. PROCEDURES
3.1 Initiation of Subcutaneous Access
3.1.1 Gather supplies:  Non-sterile gloves  Chlorhexidine 2% or Chlorhexidine 2%/Alcohol 70%  Subcutaneous infusion device (23-25 gauge)  Adapter for intermittent needleless access  Transparent, semi-permeable dressing 3.1.2 Perform hand hygiene and don gloves. 3.1.3 Cleanse selected insertion site.
Note:
Antiseptic must be allowed to air dry before catheter insertion.

3.1.4 Remove white plastic clamp and needle guard from device.
Note:
Do not pre-prime the subcutaneous infusion device.

3.1.5 Be sure bevel is pointed upwards and not covered by the cannula. If bevel is not upwards, rotate white safety shield until bevel is up. 3.1.6 Grasp a fold of skin and while holding the pebbled sides of wings, insert needle at a 30-45o angle to full length in one quick, smooth movement. Refer to Appendix B for subcutaneous device insertion.
Note:
When inserting needle, insert in same direction as venous return (i.e. towards the

shoulder joint in arm; towards the hip in leg; any direction in the chest avoiding breast tissue; towards the umbilicus in the abdomen). When using the abdomen, avoid the 2-inch diameter around the umbilicus and direct the needle laterally to prevent pinching when the client sits or bends. 3.1.7 Ensure needle is able to move freely between the skin and underlying tissue. 3.1.8 There should be no blood returning into the tubing. If blood return is noted, activate safety device, remove catheter and access a new site using a new set. 3.1.9 To activate the safety mechanism, grasp white safety shield and pull in a straight continuous motion while supporting the device by applying pressure to wings. The shield will come off exposing the injection cap. Dispose of shield in sharps container. 3.1.10 Do not apply tape to wings. Cover with a sterile, transparent, semi-permeable 3.1.11 Replace injection cap with needleless adapter and secure any loose tubing. 3.1.12 Remove gloves and perform hand hygiene. 3.1.13 Label site with date of insertion, initials of nurse inserting device, and the name and concentration of medication that will be infused. Page 3 of 9 Policies & Procedures: Subcutaneous Therapy – Intermittent and Continuous I.D. # 1074 3.1.14 Document insertion and ongoing care of subcutaneous access in the Nursing Care Plan (acute care) or the myPLAN 1.0 (long term care) and Nursing Progress Notes q 3.1.15 Refer to Appendix C for Subcutaneous Infusion Guidelines. 3.2 Using Subcutaneous Access Site for Intermittent Subcutaneous Medication Administration

3.2.1 Assess condition of site as per 2.3.2 and look for blood in tubing. Change site as
3.2.2 If administering more than one medication, use a separate site for each medication. Ensure each site is labelled with the name and concentration of the medication administered/injected. 3.2.3 Do not prime the subcutaneous device tubing. For the initial access of the tubing/line
for an intermittent medication when using a newly inserted device, draw up and administer an extra 0.3 ml of medication.

Note:
This allows for tubing dwell volume (priming) and provides the patient with the

full dose of medication. Subsequent doses with an existing device do not require the extra 0.3 ml. 3.2.2 Prior to accessing any port or cap, clean the surface with an alcohol swab for 15 seconds using friction and a twisting motion. Al ow to dry. 3.2.3 Attach labelled medication syringe and inject slowly.
Note:
Tissue swelling is expected with subcutaneous injection. Do not massage site.


Note:
Do not flush the subcutaneous infusion device before or after use.

3.2.4 Document medication administration as per policy on the Medication Administration 3.3 Initiation and Maintenance of Continuous Subcutaneous Infusions

Note:
Refer to standard text: Perry, A., Potter, P. & Ostendorf, W. (2014). Clinical Nursing

Skills & Techniques, pp. 580-584. Note the following exceptions to/clarifications of the textbook information: 3.3.1 Complete & attach a medication label to the infusion bags with medication added by a nurse. Document medication administration as per sector policy on the appropriate medication administration record. 3.3.2 Deliver continuous subcutaneous administration of medications/fluids by infusion 3.3.3 Refer to Appendix D for Medication Infusion Rate Guidelines. Infusion rates greater than 25 mL/hr may not be tolerated. 3.3.4 Monitor patient for systemic fluid overload, local and/or dependent edema, cellulitis, erythema, pain and leaking at site q shift and prn. 3.3.5 Document solution type and volume infused on fluid balance record. Page 4 of 9 Policies & Procedures: Subcutaneous Therapy – Intermittent and Continuous I.D. # 1074 4. REFERENCES
BD Saf-T-Intima. First Choice Integrated Safety IV Catheter System for Subcutaneous Infusion Therapies. Hidden Talents of BD Saf-T-Intima. Retrieved August 19, 2014 from the World Wide Capital Health Regional Pharmacy Services. (February, 2005). Palliative Care Medications Commonly Used Subcutaneously. [On-line]. Available: Hospital Pharmacists' Special Interest Group in Palliative Care. (2009). Care Beyond Cure: Management of Pain and Other Symptoms, 4th Edition. Montreal, Quebec. Chapter 7: Innovative Routes of Therapy, pp. 120-122. Infusion Nurses Society. (2011). Infusion nursing standards of practice. Journal of Infusion Nursing, 34(1S), S84-85. Infusion Nurses Society. (2011). Policies & Procedures for Infusion Nursing, 4th Edition. Continuous Subcutaneous Access, pp.153-154. Paliative Care Tips. (May, 2004). Commonly Administered Sub-Cutaneous Medications in Palliative Care. [On-line]. Available: Perry, A., Potter, P. & Ostendorf, W. (2014). Clinical Nursing Skills & Techniques, 8th Edition. St. Louis, MO: Elsevier Mosby. pp. 580-584. Scales, K. (2011). Use of hypodermoclysis to manage dehydration. Nursing Older People, 23(5), Victorian Paediatric Palliative Care Program. Insertion and Maintenance of BD Saf-T-Intima. Retrieved May 7, 2014 from the World Wide Web: Winnipeg Regional Health Authority Palliative Care Program (February, 2010). Procedure for Subcutaneous Insertion, Removal, Medication Administration and Fluid Administration for Community Palliative Care Patients. [On-line]. Available:
Related Policies:
SHR Nursing Policy & Procedure Manual Intravenous and/or Peripheral Saline Lock Insertion and Maintenance #1118; Medication - Administration #1170; Medication Administration Record (MAR) #1091 SHR Long Term Care Nursing Policy & Procedure Manual Intravenous Policy Medication Administration Policy Infection Prevention & Control Manual Hand Hygiene #20-20 SHR IV Medication Reference Manual Medication Specific Monographs Page 5 of 9 Policies & Procedures: Subcutaneous Therapy – Intermittent and Continuous I.D. # 1074 Appendix A
SUBCUTANEOUS INSERTION SITES
Winnipeg Regional Health Authority Pal iative Care Program (February, 2010). Procedure for Subcutaneous Insertion, Removal, Medication Administration and Fluid Administration for Community Pal iative Care Patients. [On-line]. Available: Page 6 of 9 Policies & Procedures: Subcutaneous Therapy – Intermittent and Continuous I.D. # 1074 Appendix B
Use of a Subcutaneous Infusion Device BD Saf-T-Intima. First Choice Integrated Safety IV Catheter System for Subcutaneous Infusion Therapies. Hidden talents of BD Saf-T-Intima. Retrieved August 19, 2014 from the World Wide Web: Page 7 of 9 Policies & Procedures: Subcutaneous Therapy – Intermittent and Continuous I.D. # 1074 Appendix C
SUBCUTANEOUS INFUSION GUIDELINES
SUBCUTANEOUS INFUSION THERAPY: RECOMMENDED DELIVERY METHODS
Continuous Infusion
Subcutaneous Infusion
*Chlorpromazine (Largactil) *Dexamethasone (Decadron) *Dimenhydrinate (Gravol) Diphenhydramine (Benadryl) Furosemide (Lasix) *Haloperidol (Haldol) Hydromorphone (Dilaudid) Hyoscine Butylbromide Insulin (Regular) *Lorazepam (Ativan) *Metoclopramide (Maxeran) *Methotrimeprazine (Nozinan) *Midazolam (Versed) Naloxone (Narcan) Octreotide Acetate (Sandostatin) *Ondansetron (Zofran) *Potassium Chloride *Prochlorperazine (Stemetil) Scopolamine Hydrobromide *NOT an officially approved method of administration. Adapted from Capital Health Regional Pharmacy Services, Hospital Pharmacists' Special Interest Group in Palliative Care, Palliative Care Tips & SHR IV Medication Reference Manual. Page 8 of 9 Policies & Procedures: Subcutaneous Therapy – Intermittent and Continuous I.D. # 1074 Appendix D
MEDICATION INFUSION RATE GUIDELINES – CONTINUOUS
Medication
dose mg/hr
rate mL/hr
(1000 mg/500 mL) * If you need to change by 0.1 mg increments, mix 1 mg narcotic/10 mL of solution MEDICATION CONCENTRATION GUIDELINES
Concentration Amount of
2/3 – 1/3 or
Medication
NS Solution
0.25 – 5 mg/hr Or 125 mg/500 mL Or 250 mg/500 mL Or 250 mg/250 mL Or 500 mg/250 mL When range indicates a change in concentration (e.g. from 5 mg/hr to 6 mg/hr), finish the bag
that is hanging if patient can tolerate the infusion volume. Change concentration in next bag to
accommodate the new range i.e. 125 mg narcotic: 250 mL solution (1:2) Adapted from Potter, P. & Perry, A. (2009). Canadian Fundamentals of Nursing, 4th Edition. Toronto, ON: Mosby Elsevier. pp. 685-687. Page 9 of 9

Source: https://www.saskatoonhealthregion.ca/about/nursingmanual/1074.pdf

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