Giving as-required injections for pain and symptom control in the community
Information for carers and relatives
Introduction As patients become more poorly, they often lose the ability to swallow oral medication or liquids. General pain relief and symptom control can be managed via a small device called a syringe pump. This is managed by the community nurses and gives the patient a regular amount of medication. At times patients may experience increased pain or troublesome symptoms that require extra medication often by a small injection. Sometimes relatives can be taught how to give injections to ensure comfort and control pain and other symptoms. This is similar to giving oral pain relief/other oral medication but the route of giving has changed as the patient is no longer able to swallow. There may be other occasions when injections are prescribed, e.g. if patients are suffering with nausea/vomiting, not tolerating oral medications or requiring injections without being on a syringe pump. The doctors, district nurses and Trinity community palliative care nurses will support you in this and teach you how it is done. You do not have to give these injections unless you feel able and comfortable. If at any time, you change your mind about giving these injections, let someone know and community nurses can take over the role.
What you will be taught/need to know
The nurses will use a needle to insert a device so that when you give the injection you only inject into the device/line, not into the patient.
What the medication(s)/injection(s) are for, how much and when to give it and any likely side effects.
Important points to remember If you are in any doubt, need advice, support or help then please contact either: (insert number) Royal trinity hospice District nurse team (in hours) Other
Patients experience symptoms or pain at any time during their illness and even at the end of their life. It may be that an injection you give to ease their discomfort comes close to the end of their life. This is quite normal, and you must not worry that the injection was in any way a cause of the end of the patient’s life/death. It is purely to help reduce pain or ease other symptoms and maintain comfort and a good dignified death.
Remember, if you feel unable to give any injection for any reason, please contact any of the above for help and advice or if you would like them to administer an injection for you.
Do not hesitate to ask any health care professional any question that will help you to care for the patient and for them to remain comfortable.
If you have given an injection and are not expecting a visit by a health care professional in the next 24 hours, please inform your community nursing team that an injection has been given.
Steps involved in administering injection 1
Wash and dry your hands thoroughly.
How to draw up the required amount of drugs into a syringe and how to give the injection.
2
Check the administration sheet for the time the last dose was given, making sure it is ok to give injection.
How to flush the device with 0.5 ml of water to ensure the entire drug is given to the patient.
How to document each injection given.
3 Check the site of the injection device for inflammation, redness, hardness or soreness. If you have any concerns with this or any problems in administering injections please contact your district nurse team or palliative care team.
Only give up to a maximum of 3 injections in any 24-hour period before contacting a doctor/out of hours practitioner for further help in any one day.
At each visit by a health care professional, the patient’s medication will be reviewed so that hopefully further injections may not be needed.
4 Assemble equipment - needles - syringes - prescription sheet - drug to be given and sterile water for injection - administration sheet
5 Drawing up medication - check the label for correct medication - attach the needle to the syringe - break open the vial of the drug to be given by snapping the top off - draw up the drug into the syringe and draw up water for injection to flush into a second syringe. If you have any air bubbles in the syringe, push the plunger in slightly to remove the bubble, do not worry about small bubbles.
Frequently asked questions: symptom control
6 Administer the drug via the injection site device/ line as previously taught.
Dealing with the breakthrough symptom may require giving an extra dose of medication, often called ‘as-needed,’ ‘breakthrough’ or ‘PRN’ medication. Such medications will be prescribed by the health care team. Sometimes we can predict what may occur (the common symptoms) and have plans in place in case they occur. This is why ‘as-needed,’ ‘breakthrough’ or ‘PRN’ medications are prescribed in advance. This is known as anticipatory prescribing and sometimes called ‘just in case’ medications.
7
Flush device/line with 0.5 ml of water.
8 Dispose of the syringes and needles in the sharps bin provided. 9 Write on the administration sheet the time, date, drug, dose, route and sign to record you have given it. 10 Wash your hands thoroughly. 11 If you have given 3 injections in a 24-hour period, contact a GP or Out of Hours service. 12 If you are not expecting a visit from your community nursing team within the next 24 hours then you must ring the district nurse team or palliative care team and inform them you have given injection(s), so they can plan a visit within 24 hours to review.
What is meant by ‘as-needed,’ ‘breakthrough’ or ‘PRN’ medication? Symptoms are often controlled with medications given at regular times, or continuously through a syringe pump, throughout the day and night. Sometimes the person may experience symptoms even when this is in place – these are called ‘breakthrough’ symptoms. The most common are pain, nausea/vomiting, anxiety/restlessness, noisy ‘rattly’ breathing and breathlessness.
How will I know which medication to give? If a person cared for at home is on any continuous or as-needed subcutaneous medication, this will be clearly prescribed on a medication authorisation and administration record left in the house. Usually, only members of the health care team will record on this, for example when a syringe driver or pump is reloaded or they have given any as-needed injections. For ‘as-needed’ medications, the nurse training you will give you further information that will help you to be able to give the best medication at the right time for a particular symptom. The nurse will write these detailed instructions in the “Carer’s direction to administer as required subcutaneous injections” form, so that you can check this every time you think an injection is needed. This will remind you exactly what medications to give, how much to give and how often you can give them. The nurse will show you how to complete the details of any medication you have given in your medication authorisation and administration record. A member of the visiting healthcare team will check this with you at every visit. How long does the medication take to work? You should check the patient after 30 minutes to see whether the symptom is getting better after giving an injection, but it may take up to one hour to be sure if it has helped or not. If, in that hour, the symptom for which you have given the injection is getting worse, not getting any better at all, or if you are worried for any reason, call your health care team straight away. It is likely that a doctor or nurse will want to come and visit the person you are caring for to see why the medication is not working.
How often can I give as-needed subcutaneous medications for breakthrough symptoms? Most of the medications that you will be shown how to use for breakthrough symptoms should not be given more than once every four hours. If you feel that a medication is required sooner than this, then you should contact the healthcare team, who will be able to advise you on the best next course of action. Can I give an unlimited number of doses of medication? No, you cannot give more than three (3) doses of medication for the same symptom in any 24-hour period. The reason for this is that, if someone needs frequent as-needed medication, the symptom might not be controlled well enough and a doctor or nurse should see the patient. They can then assess the person and the regular medication they are receiving to see if this needs to be changed to help control the symptoms. After you have given three doses of medication for the same symptom in less than 24 hours, you will need to let your healthcare team know straight away so that they can come to review the person you are caring for. You should not wait until the next dose is needed. What if I give too much medication? If you think you have made an error with the amount of drug you have given, you have given too many doses, or if you think you have given the correct doses but the person you are caring for is having unusual symptoms or you are concerned about their response to an injection, you should contact the health care team straight away. What are side effects of medication and are they avoidable? What do I do if they happen? Medications are given to help control symptoms and keep the person you are caring for as comfortable as possible, but they may also cause unwanted effects (also known as adverse or side effects). Your health care team will always consider the symptoms a person is experiencing and weigh up the benefit of a medication compared to the risk of side effects. The goal is to get the right dose to treat the symptoms, whilst keeping the side effects as low as possible. It is therefore important to closely follow the instructions you receive on how much medication to give, as it may be different for different people. If side effects occur, let the health care team know as soon as possible. Side effects vary for different medications, but can include experiences such as drowsiness, muddled thinking or constipation. Can the medications I am giving cause serious harm or make someone die more quickly? We do not expect any problems with the drugs that will be used because they are the same as those used in standard practice and are generally
well-tolerated. The drugs used are very commonly given to seriously ill patients to control symptoms and a nurse will give you training on how to give the injections. There may come a time when you are giving the injections when the person you are caring for is very ill and will soon die. This might mean that the time when they die is near to when you have last given them medication. It is very important for you to know that these two things are not related, and the medication has not ended their life. The nurse training you to give injections will discuss any worries or concerns you may have about this.
Frequently asked questions: Subcutaneous injections What is a subcutaneous injection? Subcutaneous means ‘just under the skin’. So, a subcutaneous injection means giving an injection just under the skin. There is a good blood supply under the skin and this carries the drug into the rest of the body. Subcutaneous injections are normally less painful than an injection into the muscle and are easier to give than an intravenous (in the vein) or intramuscular (in the muscle) injection. When a cannula is in place, subcutaneous medication can be given without the use of needles. The subcutaneous method is a safe and effective way of giving medications, especially when a person is experiencing swallowing problems or has nausea and/or vomiting. Where is a subcutaneous cannula inserted? The cannula can be inserted into the person’s abdomen (tummy) or chest, upper thigh or upper arm. If the person is confused or muddled and is likely to remove the cannula, it can be placed in the upper back. The nurse will secure the cannula using clear film, so that you can see the insertion site and it can be checked often. How do I care for the cannula? You will need to check the insertion site every time you give an injection using the cannula. If you notice that the cannula site is red, swollen, leaking or smelly, contact your health care team as it is likely the cannula will need to be changed. How will I know if the cannula is not working? What should I do if this happens? It is normal for a small lump to appear at the insertion site immediately after the injection has been given. This is the medication sitting in the tissue just under the skin. The small lump will disappear as the medication is absorbed into the bloodstream. If it does not, contact your health care team. If it is hard to inject medications or if the medications leak out onto the skin when you inject, then contact your health care team as this means the cannula is no longer working. Leave the cannula in place for them to remove. In the meantime, if there is a second cannula, this can be used until the other cannula is changed.
How to contact Trinity Royal Trinity Hospice 30 Clapham Common North Side London SW4 0RN Call 020 7787 1000 Email enquiries@royaltrinityhospice.london
www.royaltrinityhospice.london @trinityhospice RoyalTrinityHospice @royaltrinityhospice
If you would like this information in a different format, such as large print, please speak to the Communications team on 020 7787 1000 or email media@royaltrinityhospice.london Royal Trinity Hospice will always store your personal details securely. For full details see our privacy policy: www.royaltrinityhospice.london/privacy Charity no. 1013945 Date of publication May 2020