What is a home care nurse?
Home care nurses may work alone in the community, or care for people in their private homes or residential care settings. Nurses may also work in nursing homes, where people need a higher level of personal and nursing care.
Common home nursing procedures
The watchword for most home nursing interventions is hygiene. It isn’t always easy to maintain the kind of sterile fields and aseptic conditions that can be assured in a hospital setting in a person’s own home. Home care nurses may have to contend with a wide variety of living conditions, and while most people are able and willing to keep their homes and selves clean and tidy, a home care nurse may need to perform clean procedures in homes which are not hygienic, and to contend with pets, mess and difficult patients or family members.
There are various types of injection that a home care nurse may need to administer. The most common are likely to be insulin injections, given subcutaneously one or more times per day. Other common subcutaneous injections include anticoagulant injections like enoxaparin for people at risk of blood clots especially after an operation. A subcutaneous (‘sc’, ‘subcut’, or ‘subQ’) injection is given into the layer of fat under the skin. Some patients at home may be prescribed continuous subcutaneous infusions or fluids, particularly those having palliative or end-of-life care. Continuous subcutaneous infusions commonly contain relaxant and opioid medications, anti-sickness medications and medications to help keep the airways clear.
Some injections are administered intramuscularly. These include some vaccinations, B12 injections, some relaxant medications, and epinephrine (adrenaline) injections for anaphylaxis.
Here is an Injections 101 guide that goes into further detail on how you can safely administer injections as a home nurse.
Urinary catheter insertion
Inserting a urethral urinary catheter carries a high risk of causing infection, and asepsis must be maintained throughout the procedure. A patient may need a catheter due to urinary retention, for strict fluid balance, or for other medical reasons. Some people may have catheters to manage incontinence, but as the risk of recurrent urinary tract infection associated with long-term catheters is fairly high, a risk-benefit analysis should be performed. Incontinence in the context of skin breakdown, moisture lesions and pressure damage which is not manageable with less invasive methods may require a long-term catheter. Some people who suffer from urinary retention can perform intermittent self-catheterisation, independently inserting and removing a catheter several times a day to drain the bladder.
As for any nursing procedure, informed consent should be sought. Catheterisation is an invasive and intrusive procedure and requires particular sensitivity.
Equipment required for catheter insertion:
- A self-retaining urinary catheter – there are a number of different lengths and gauges. The gauge or ‘French’ size of the catheter relates to the diameter of the urethra. A 12- or 14-Fr sized catheter is suitable for most people. Longer catheters may be available for men and shorter lengths for women to accommodate the longer urethra of the penis. A self-retaining catheter has a balloon which is inflated usually with 10ml of sterile water or saline introduced through a special port on the catheter. Most catheters come packaged with pre-filled syringes for this purpose.
- Lubricant – this must be sterile and may come in a pre-filled syringe which makes it possible to introduce the lubricant into the urethra. Some lubricants intended for catheterisation also have a numbing agent (lidocaine) for more comfortable catheterisation.
- Fluid for meatal cleaning – ideally 0.1% chlorhexidine solution, but sterile saline is also acceptable.
- Catheter bag – there are several types of catheter bag – some designed for accurate urine output measurement, and others which are comfortable for someone to walk around with or those with larger capacities for overnight purposes.
- A catheterisation pack – these usually comprise:
- Sterile gloves (x2 pairs), and a sterile apron
- A sterile receptacle for initial urine flow
- Sterile gauze/swabs
- 2x sterile fields
If catheterisation packs aren’t available, all the required items can be assembled separately.
It’s useful to have a clean, dry area for setting up. A sterile field is essential – it may be the inside of the catheterisation pack. Maintaining sterile conditions, open all the required equipment and ‘pour’ onto the sterile field using a ‘no touch’ technique. The patient should be positioned in a supine position – for female catheterisation the legs should be apart and ‘flopped’ outwards to allow good access to the urethra. Maintaining the patient’s privacy and dignity is always paramount.
Hands should be washed and dried, sterile gloves applied, and the first sterile field placed to facilitate effective cleaning of the genitals while creating minimal mess. The genitals should be clean and ideally 0.1% chlorhexidine solution should be used for cleaning the meatus. If a foreskin is present, it should be gently retracted – it is essential to return the foreskin to its original position after catheterisation to prevent paraphimosis. When the urethral meatus is clean, the sterile lubricant should be introduced into the urethra. If the lubricant contains a numbing agent, it may be recommended to leave it for a certain length of time to work – this should be detailed in the brand’s packaging. Identifying the urethral meatus can be difficult in some people depending on their anatomy, and trying slight changes in position may help.
Hands should be washed and dried again, fresh sterile gloves donned, and a new sterile field created around the genitals. Asepsis should be maintained when the catheter is inserted. The catheter should be introduced into the urethral meatus and inserted.
For more information on urinary catheter insertions, read more here.
Nasogastric tube (NGT) feeding
NG tubes are used in nursing homes for administering liquid food, fluids and medications usually for people with a compromised swallow reflex. They are usually for short-term use.
NG tube feed can be given as a bolus, with a prescribed amount of special feed given at intervals throughout the day, or administered throughout the day with a pump. A syringe compatible with NG tubes is used to aspirate stomach contents before administering anything through an NG tube. This is to check correct placement. The length of the NG tube is also marked and recorded, so that it’s clear whether it has been pulled out at all. NG tubes can be easily dislodged by accidental or deliberate pulling, coughing or vomiting.
For more information on NGT feeding, read more here.
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Nasogastric tube re-insertion
Nasogastric tube insertion should only be attempted by someone who is trained and competent, as the risks associated with improper placement are high – the most common serious adverse effect from NG tube use is that fluid can enter the lung causing aspiration pneumonia. Confirming the tube placement is therefore essential, usually by aspirating a small amount of fluid from the tube. Measuring the pH of this aspirate and testing the pH can confirm that the tip of the tube is correctly in the stomach. The pH of the aspirate should be less than 5. This should be repeated every time anything is introduced via NG. If aspirate cannot be obtained or if the pH is not less than 5, an x-ray may be required to confirm position.
An NG tube is a fine, soft tube inserted through the nostril and passed down the oesophagus into the stomach, then secured to the nose.
- An appropriate (fine bore) NG tube with lubricant (according to manufacturers’ recommendations)
- A glass of water and straw (if the patient has a safe swallow)
- Disposable gloves and apron
- Vomit bowl and tissues/wet wipes
- A syringe for aspirating and pH paper
Estimate the insertion length of the NG tube by measuring the patient from nostril to the approximate level of the xiphoid sternum, with allowance for the tube to be looped behind the ear.
Explain the process and gain consent. The patient should know that they can stop the process with a non-verbal sign, such as raising a hand. As with any procedure, hands should be clean and appropriate personal protective equipment (PPE) worn.
NG tubes have a fine guidewire to help them stay reasonably rigid during insertion. The tip should be lubricated slightly and advanced into one nostril. If there is any significant resistance in the nostril, it can be useful to try the other nostril. As the tube reaches the back of the throat, if the patient Is able to swallow safely they should drink water with a straw while the tube is being advanced. Insert the tube to the required length. If there are any problems – such as excessive coughing, choking sounds, or feeling the tube coil at the back of the throat – stop and remove the tube, and try again if the patient is still willing.
When the tube is inserted to the expected length, aspirate with a syringe, and check the pH of the aspirate. If less than 5, feeding may commence. If there are any concerns about placement, do not administer anything via the NG and try to have the position confirmed by X-ray. The guidewire will need to be removed before feeding commences, or to aid collection of aspirate.
Stoma bag drainage
A stoma bag is a special bag for collecting faeces from a colostomy or ileostomy – an opening made from the bowel to the exterior wall of the abdomen. There are various types of stoma bag; some which attach to a flange which remains stuck to the skin for a period of time, some with an integral flange; some where the bag is a closed, fully disposable system, and others which can be emptied.
Stoma bags should be changed or emptied before they are completely full, as a sudden influx of stool or gas can cause the bag to burst or leak. To drain a stoma bag you need:
- Appropriate PPE
- Disposable dry wipes (kitchen roll or similar can be used)
- A receptacle to drain the stool – straight into the toilet is ideal, but in a care home washable or disposable bowls may be easier
Different brands of stoma bag may differ slightly in their design, but the most common type has an opening which is rolled up and secured by Velcro. When unrolled, the stool empties easily from the bag. The opening is then cleaned, re-rolled and secured with the Velcro.
Find out about the different types of stoma and pick up practical care tips that you can advice your patients when it comes to living with a stoma bag here.
Stoma bag change
The stoma bag needs to be changed as the faeces that drains into a stoma bag can be very liquid, and any which gets on the patient’s skin can damage the skin. The visible part of the stoma is bowel tissue which is not damaged by faeces, so the opening of the flange of the stoma bag needs to be carefully cut to size to allow the stoma to drain without damaging the skin around it. To change a stoma bag you need:
- Adhesive remover if required
- Clean dry wipes – kitchen roll or similar is okay.
- Clean, warm water
- A new stoma bag
Cut the opening of the flange to size. The patient may already have a template, or you can make one. Remove the old stoma bag by carefully peeling away the adhesive part while supporting the skin. Adhesive remover can help. Clean the stoma and skin carefully with warm water and dry thoroughly.
The backing can be peeled away from the adhesive part of the flange of the new bag, and the bag carefully fitted over the stoma. The adhesive portion needs to be fully secure without gaps or wrinkles. The flange will be slightly mouldable with the warmth of the skin.
Dispose of the stool and old stoma bag appropriately.
A 2-part stoma bag has a separate flange which remains on the skin and attaches to disposable bags. The sizing and fitting of the flange is the same as with a 1-piece stoma bag, and the bag attaches according to the manufacturer’s guidance.
Thinking of being a home nurse?
Home care nursing is a rewarding, sometimes challenging job, where the tasks and situations are as varied as the patients themselves. Nurses who work in the community get to meet patients in their own environments, which in itself can give a guide to the patient’s wellbeing and support needs. There’s never a dull day in community and home care.
Find out some reasons on why you should consider being a home care nurse here and join us to deliver care in the comfort of our patients’ homes.
If you are looking for a job with flexible hours, rewarding hourly rates, and a fast approval rate of 1-2 days, being a Homage Care Pro will be a great fit for you.