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Home Infusion Therapies for Obstetric Patients
CLINICAL ISSUES
Home Infusion Therapiesfor Obstetric Patients Cathy C. Romeo, RN,PhD, Patsy Jones, RN,MN
This article focuses on current indications for home intravenous therapy for the high-risk obstetric patient. Therapeutic indications and clinical care for obstetric patients in need of hydration/total parenteral nutrition, heparin infusion, terbutaline pump, and
antibiotic therapies are presented.
H
ome health care, a product of the 1970s, has become a booming business of the 1990s and promises to continue to flourish into the next millennium. One component of home health care, intravenous (IV) home infusion therapy, has expanded enormously since the idea was first introduced in 1974. Since this time, extensive literature has been accumulated documenting the safety, efficiency, and cost savings of home infusion therapy (Bernstein, 1991). When considering a patient for home infusion service, many clinical and psychologic factors must be considered. Some of these clinical factors include whether: the primary (as well as any secondary) illnesses 01 potential complications can be managed at home; adequate venous access can be maintained; the patient is in medically stable condition; home care is a financially viable option for the patient; the home is safe, clean, and free from hazards; the patient/family is willing to participate in care; and the patient/family has the ability to be adequately trained. Once the patient has been admitted to home care, the role of the agency providing home IV therapy generally is to investigate insurance coverage, deliver supplies, facilitate laboratory testing, manage minor complications, and provide 24-hour on-call response.
October 1994
Only recently has home health care branched into obstetric care. In the past, obstetric home health care was used primarily to serve women at risk of giving birth prematurely. However, during the past few years, obstetric home health care has expanded to include many high or potentially high-risk situations other than preterm labor. When caring for the obstetric patient in the home, the perinatal home-care nurse must complete a thorough physical and psychologic assessment to determine how best to care for the patient and to determine whether the patient is a candidate for home care. Physical assessment of the obstetric patient is no different whether the patient is in the hospital or in the home. The expectant mother needs to be evaluated for signs or symptoms of preterm labor, including dull, low backaches, abdominal cramping, pelvic pressure, changes in vaginal discharge, or actual uterine contractions. The patient's vital signs, urine, weight changes, and any adverse physical symptoms also must be evaluated. Fetal well-being, including fetal movement, assessment of fetal kick counts, and fetal heart rate, should be evaluated. Care must be taken to discover any adverse signs and symptoms that may be precursors to other high-risk conditions. From an IV infusion perspective, access to possible infusion sites must be examined. Patient education is a vital component of home therapy (see Table 1). The nurse must first assess the readiness and ability of the patient/family to receive and understand home-care information. Once this readiness has been established, the nurse must provide education related to the infusion, including line and pump management, signs and symptoms of infection, and dosage issues. Patients and their families also need to understand and be able to identify symptoms specific to the patient's condition that could be indicative of exacerbating problems. The home perinatal nurse should take advantage of the opportunity to provide additional education, including such topics as prepared childbirth, newborn care, and self-care after delivery. It often is beneficial to the patient if the perinatal home-care nurse has a lending library con-
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Table 1. Infusion Therapy:Patient Teaching Guide Checklist Learning Objective
General information:patient is able to verbalize a basic understanding of the following: Description of home care services Telephone contact procedure High risk status:patient verbalizes a basic understanding of the following: The high risk situation or disease state tkat requires therapy. Plan of care Medication information:patient has the ability to verbalize the following in regards to the prescribed medication/ solution: Dose/solution prescribed Desired action Route administered Rate/schedule of administration Side effects/allergic reactions Storage/handling of drug Aseptic technique: patient demonstrates the following proper aseptic techniques: Universal precautions Personal hygiene Handling and disposal of hazardous waste Handwashing Handling sterile equipment Equipment management: patient demonstrates: Safe and appropriate maintenance of equipment Procedures for reporting equipment malfunction Electrical safety precautions Maintenance:patient demonstrates proper care of the intravenous site: Flushing technique Dressing care Clamping Injection cap change Identification of IV complications
TPN today. One of the most common discomforts of pregnancy is nausea or vomiting, often referred to as “morning sickness.” In most cases, this morning sickness is a minor inconvenience that must be endured and is treated with a variety of home remedies until it subsides in the second trimester. But what about that small percentage of women ( I % of all pregnancies) who d o not stop vomiting? What happens when the vomiting during pregnancy becomes so severe that it results in electrolyte, metabolic, and nutritional imbalances? This is called intractable vomiting in pregnancy or hyperemesis gravidarum. Hyperemesis gravidarum is an uncommon occurrence with profound effects on maternal nutrition that threaten the well-being of the pregnant woman and her unborn child. Hyperemesis is a disease process that includes persistent vomiting before 20 weeks’ gestation. Clinical evidence of this process includes dehydration, altered electrolyte balances, ketonuria, acetonuria, depletion of nutrients, and a weight loss of 5% or more of prepregnant weight. Extreme cases of vomiting result in hypovolemia, hypotension, tachycardia, increases in hematocrit and blood urea nitrogen levels, decreased urinary output, and metabolic acidosis. Severe nutritional deprivation can result in hypoproteinemia and hypovitaminosis. Jaundice and hemorrhage can result from deficiencies in vitamins C and B complex and hypothrombinemia. The effects of hyperemesis gravidarum on the fetus can result in increased risk for central nervous system malformation, intrauterine growth retardation, or fetal anomalies. In addition, a decreased number of brain cells and other congenital anomalies have been associated with poor maternal nutritional status during the first trimester. Even mild cases of maternal malnutrition have been associated with an increased frequency of prematurity, low birth weight, and intrauterine growth retardation. Infants who are born at low birth weight are at risk for perinatal mortality and may experience long-term physical or developmental effects after birth (Long & Russell, 1993; Giotta, 1993).
Nausea and vomiting and hyperemesis gravidarum are the most common obstetric indications for hydration and
Role of the Nurse When caring for the woman suspected of having hyperemesis gravidarum, a thorough assessment is essential. This assessment should include the maternal nutritional status (prepregnant weight, ideal body weight, triceps skinfold, height, dietary history, and current nutritional and fluid intake), consideration of the normal physiologic changes that occur with pregnancy, obstetric/gynecologic history, identification of any coexisting disease entities, past medical and surgical history, and biochemical indices. It is important to remember that, because of changes in blood volume and metabolism that occur during pregnancy, care should be taken to use the proper normal serum values when interpreting laboratory data on pregnant patients (Hagar & Kolbow, 1990). The expected maternal weight gain during the first trimester is 2 kg (4pounds) and0.34-0.5 kg (0.9 pounds) per week during the second and third trimesters, with a
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taining books, videotapes, or audiotapes that can be used to supplement verbal educational content. The need for quality home care for the obstetric patient is continually increasing. From an infusion perspective, there are key therapies that are being made available to the home obstetric patient. These areas include hydration/total parenteral nutrition (TPN) , heparin infusion, terbutaline pump administration, and antibiotic therapy. Each of these areas is discussed here.
h & n m z o l c sHydration and TPN
Home Cure
total weight gain of 12.5 kg (approximately 25 pounds; Wiedner, 1993). These weight increases are associated with a positive fetal outcome. Patients at greater risk for malnutrition include those with weight loss greater than 1 kg/week for 4 consecutive weeks, a total weight loss of 6 kg o r more, a failure to gain weight, or an underlying diagnosis that would increase the basal energy requirement of the patient. When monitoring weight gain, it is important to note rapid weight increases that may be associated with edema, hypertension, and proteinuria. Indications f o r TPN Initial treatment using antiemetic or antihistamine drugs may be helpful during the early period of nausea and vomiting to lessen symptoms. However, their value becomes less important when the diagnosis of hyperemesis gravidarum is made and the primary goal of treatment is providing basic nutrient needs. When deemed necessary, IV therapy may be initiated in an outpatient setting to correct dehydration. A solution of dextrose with saline is commonly used. Potassium and vitamins are added if vomiting has been prolonged and oral intake is inadequate. If weight loss and vomiting continue (without oral intake), hyperalimentation should be considered. Enteral or parenteral hyperalimentation may be used. Parenteral nutrition has been used as the standard treatment during the past few years (Long & Russell, 1993). Use of parenteral nutrition during pregnancywas first reported in 1972. Since then, several studies have supporteQ its safety and effectiveness (Long & Russell, 1993). Within the last decade, TPN has been adapted successfullyfor home use. TPN is an administration of essential nutrients to restore depleted electrolytes and nutrient stores. TPN works by bypassing the normal digestive route and delivering nutrients directly into the bloodstream via intravenous catheter. The goal of TPN is to provide positive protein and energy balance while waiting for the return of adequate gastrointestinal function. The decision to initiate parenteral nutrition is based on the patient’s current nutritional status, the expected length of time the patient will be unable to receive nutrition by mouth, and estimated needs. Initiation of parenteral nutrition should not be delayed in the malnourished pregnant woman as a means of providing calories for fetal growth and maternal health. Selecting the vascular access site for intravenous infusion, whether it be for TPN or other therapeutic agents, is based on many factors, including the length of therapy, venous access, fluid status, and severity of illness. In general, peripheral lines are used for partial parenteral nutrition (PPN) when calorie and protein requirements can be met and the therapy is not of long duration (1-6 days). For example, if a woman was in good nutritional health before pregnancy, she might be a candidate for PPN, instead of TPN. Although PPN is appropriate for short-term use, maintaining a peripheral line is difficult in some people. It also must be considered that in PPN, the caloric and protein concentration must be limited, requiring a higher infusion volume to meet a patient’s needs. PPN
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generally is not appropriate for a patient o n fluid restrictions. The peripheral route should not be used in a patient with inadequate o r inaccessible peripheral veins or those whose calorie o r protein requirements are greater than can be safely supplied this way. The most common reason for difficulty in accessing peripheral veins are obesity, edema, and thrombosis. Central routes are used when extensive nutritional needs of longer duration are needed, the drug infusion is constant and irritating to the veins, or multiple therapies such as TPN and antibiotics are being used. When a central line becomes necessary for lengthy therapy, a newly available option is peripherally inserted central catheters. These catheters, which are inserted at the antecubital fossa, are moved to a central position. They can be used for several weeks to months (Brown, 1991). Benefits of a central line include the ability to use more concentrated TPN formulas, which are capable of providing more calories and protein per volume of fluid. The average volume requirements to meet caloric and protein needs with central hyperalimentation is 1.5-2 L of TPN per day with 500 mL of lipids. Risks related to central line placement include superficial thrombophlebitis, sepsis, and technical complications, such as pneumothorax. Metabolic complications of TPN include hyperglycemia, hypoglycemia, hypophosphatemia, and electrolyte imbalances. The theoretical concern that lipid infusions may induce premature labor, produce fatty infiltration of the placenta, or contribute to pulmonary complications in the neonate has not been documented in research at this time (Silberman, 1989). A major side effect of a peripheral insertion site is phlebitis. Other potential complications include air e m boli, fibrin sheath formation, Candida albicans infection, septicemia, hyperreflexia and spasticity, mediastinal hematoma, and subclavian vein thrombosis. N o adverse fetal effects have been reported. The risks and benefits of central TPN versus PPN must be appropriately evaluated. However, the risks associated with parenteral nutrition often are outweighed by the need to provide adequate nutrition to the nutritionally stressed mother and fetus (Hagar & Kolbow, 1990). Nursing Care and Monitoring of the Patient Requiring TPN When a patient is admitted to the hospital, TPN often is infused 24 hours a day. However, in the home there is a need to normalize a patient’s life-style as much as possible. Thus, TPN usually is infused in a cyclic or intermittent fashion. Nocturnal infusions allow the patient to maintain usual activities during the day without being attached to an infusion pump. As with any patient receiving TPN, the infusion rate should be increased gradually during the first 30-60 minutes of infusion and tapered during the last 30-60 minutes to avoid complications associated with hyperglycemia or hypoglycemia. Assessment of fetal and maternal well-being is essential. Fetal assessment by ultrasound confirms normal intrauterine development and dating and establishes a
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base-line for later evaluation of growth. Maternal weight change is considered the most important indication of maternal nutrition and fetal growth and thus must be carefully monitored. Glucose tolerance is monitored initially by regular finger sticks every 4-6 hours o r daily via serum glucose levels. Excessive glucose may lead to macrosomia with its concurrent problems. Lack of glucose may lead to fetal growth retardation, so careful glucose monitoring is a necessity. Serum electrolytes are measured daily until they are stable. Protein requirements can be met with amino acid solutions. The goal is to maintain a positive nitrogen balance. Positive nitrogen balance can be assessed through urine urea nitrogen or blood tests (Wiedner, 1993). When possible, oral intake should be encouraged to promote the transition from parenteral to oral nutrition. A daily dietary count should be maintained and parenteral calories reduced as oral intake increases. In summary, with adequate fluid and nutritional support, healthy outcomes of pregnancy are expected. However, any delays in nutritional support could put the life and health of the pregnant woman and her unborn child at risk.
Heparin Subcutaneous Therapy Heparin is another medication that can be safely infused in the home environment. Because pregnancy generally induces a hypercoagulability state, there is a predisposition for the risk of thromboembolism. Predisposing factors that increase the likelihood of thromboembolic complications during pregnancy include obesity, hospital admittance, prolonged bed rest, surgery, a previous history of thromboembolic disease, and recurrent pregnancy loss caused by autoimmune etiology. Heparin is an anticoagulant indicated for the prevention and treatment of venous thrombosis and pulmonary embolism and other clotting disorders. In a low-doseregimen, heparin can prevent thrombosis associated with cardiac arrhythmias, coagulation disorders, cardiovascular disease, and perioperative and postoperative immobilization (Cosico 8r Rothlauf, 1992). Heparin also is used in the treatment of recurrent spontaneous abortions caused by alloimmune and autoimmune etiologies (Branch, 1991). Because of the teratogenic effects during pregnancy and bleeding complications during delivery associated with the use of oral anticoagulants (such as warfarin), heparin is considered the drug of choice for anticoagulation therapy during pregnancy. With an existing clot, heparin usually is given intrave,nously. It often is given subcutaneously for prophylaxis purposes. Heparin may be administered continuously or intermittently. Because of its short half-life (90 minutes) continuous infusion often is preferred. The anticoagulant effect of heparin is comm m l y monitored by the activated partial thromboplastin time (aPTT). I t is recommended that the aPTT be kept at a level of 1.5-2.0 times the norm (Cosico & Rothlauf, 1992).
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BeneJts of Heparin Pump Therapy Benefits for use of an external, ambulatory pump include more stable and therapeutic blood levels, reduced drug toxicity, improved patient compliance, and cost savings. Home nursing care involves obtaining physicians’ orders regarding the rate of continuous infusion of scheduled and bolus dosages. The nurse sets up an infusion pump using sof-set catheters or bent needle sets. Catheters are changed every 3-4 days. Several techniques can be used by the home-care nurse in an attempt to prevent hematoma formation. First, ice is applied to the site for 15 minutes before needle insertion. After a wait of 30-60 minutes, the heparin infusion is started in the new site. After an additional 30-60 minutes, the old catheter is removed. Finally, pressure is applied to the site for 15 minutes after removal of the catheter or needle. This technique may help to decrease hematoma formation at the new and previous insertion sites (Mihelic, June 1993). The home nurse should visit every 2 days for a week and once a week for the remainder of the therapy to assess the patient’s condition and to assess laboratory values, including aPTT levels. Heparin doses should be adjusted according to aPTT levels per the physician’s orders. All pertinent information should be documented. Patient Education The nurse should provide pump education and evaluate the patient’s ability to operate the pump, change syringes or cartridges, and change sof-sets or bent needle sets using aseptic technique. The patient should be taught to watch for bleeding, including nosebleeds, hematuria, bleeding from the gums, and excessive bruising. The patient should be able to verbalize the side effects of heparin and when to call the home health-care agencyor physician. Adverse Reactions/Contraindications The major adverse reactions to heparin therapy include hemorrhage, idiosyncratic thrombocytopenia, and osteoporosis with spontaneous fractures. The risk of hemorrhage can be minimized by controlling the heparin dosage to achieve therapeutic blood levels and monitoring of anticoagulation effect. Idiosyncratic thrombocytopenia occurs in approximately 25% of patients receiving heparin therapy and is a result of heparin-induced platelet aggregation. Patients should be routinely monitored for thrombocytopenia with complete blood cell counts. Osteoporosis and spontaneous fractures have been reported in patients receiving 15,000 units daily for more than 3 months (Mihelic, June 1993). Patients who should not take heparin include those who have a sensitivity to the drug, active bleeding, hemophilia, purpura, thrombocytopenia, intracranial hemorrhage, bacterial endocarditis, active tuberculosis, or ulcerative lesions of the gastrointestinal tract. Recurrent Spontaneous Abortions It is estimated that recurrent spontaneous abortion will occur in approximately 15-25% of all diagnosed pregnan-
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cies. Because many spontaneous abortions occur before a pregnancy is confirmed, it is believed that the actual number of spontaneous abortions may be much higher (Mihelic, June 1993). Autoimmune disorders are being considered as a major culprit for many of these unexplained spontaneous abortions. Autoimmune disorders comprise a large group of diagnoses that disrupt the immune system of the body. The body in effect develops antibodies that attack its normally present antigens. Autoimmune disorders generally tend to appear during the reproductive years in women, so their association with pregnancy is not uncommon. Some of these disorders adversely affect the course of the pregnancy or are detrimental to the fetus. Since 1983 investigators have suggested that women with autoimmune disease such as antiphospholipid syndrome and a history of previous pregnancy losses should be treated during their pregnancy to improve their chances of delivering a live infant (Branch, 1991). Treatment modalities that have been used include oral doses of prednisone with low-dose aspirin and heparin infusion with or without low-dose aspirin. Heparin becomes a much more favorable treatment because of the potentially adverse side effects of corticosteroid usage. Heparin therapy can be given through subcutaneous injections or continuous subcutaneous infusion with the use of a Pump.
Telrbutaline Continuous Subcutaneous Infusion During the past 20 years, a number of drugs have been used for the treatment of preterm labor, including ritodrine hydrochloride, magnesium sulfate, and indomethacin. Terbutaline sulfate is a beta-mimetic agent that has been given orally, subcutaneously, or intravenously since the 1970s to inhibit labor. Even with widespread use of these drugs, there has been no decrease in the rate of preterm birth. However, if outcomes are measured by days gained in utero and not preterm birth (37 weeks’ gestation or less), it is probable that subcutaneous terbutaline therapy is effective.
Side Efects There is no drug that has only myometrial effect, so women taking beta-mimetic drugs have many undesirable side effects caused by the drug’s effect on other smooth muscles. Resultant side effects include tachycardia, vasodilation, bronchodilation, glycogenesis, and pulmonary edema. These side effects can interfere with therapy if women can not tolerate them o r are unwilling to take the drug. Another consideration is that receptor sites eventually become saturated with the drug, and uterine activity returns. Terbutaline pump therapy offers an option that lowers the daily dose, decreases undesirable side effects, and helps with compliance. The lower dose also increases the time of therapy before saturation of receptors.
October 1994
Terbutaline Subcutaneous Infusion Dosing The concept of subcutaneous infusion of terbutaline was first considered in 1985 by Lam at the University of California, San Francisco (Lam, 1989). The therapy is designed to infuse a combination of intermittent and continuous delivery of terbutaline with a small infusion pump. The total daily dose is low, approximately 3 mg/ day, and has fewer or no side effects when compared with oral or intravenous delivery. This type of treatment tends to increase patient compliance, lengthen the time women receive the drug, and allows the caregiver the option of titrating the terbutaline doses according to the amount and type of uterine activity. The low continuous infusion or basal rate keeps the uterus relaxed and decreases the incidence of low amplitude and high frequency waves (irritability), and the programmed boluses inhibit full uterine contractions. Initial scheduling of boluses was based on studies showing a circadian frequency distribution pattern of organized contractions that peak in the evening. The initial schedules for women on the pump programmed boluses of 0.25 mg at frequent intervals in the afternoon and evening, but only a basal rate was infused during the early morning hours when women were sleeping. Modifications in the schedule could be made for women with patterns of uterine activity in the early morning hours. Basal rates often were started at 0.05 mL/hour. Today, after 8 years of experience with this therapy, it is known that doses can be somewhat higher than initially thought. Many women with multiple gestations require higher basal rates and more frequent, if not regularly scheduled, boluses. Most perinatal home-care companies start patients on a low basal rate and program boluses at times of uterine activity or schedule a bolus every 4-6 hours throughout the day. Pharmacokinetic dosing may be done, but ultimately the dose is increased based on uterine activity data or reduced because of maternal side effects. Maternal tolerance is always considered when dosages need to be increased because of uterine activity. Indications and Contraindications f o r Pump Therapy Indications for terbutaline pump therapy for the obstetric preterm patient include:
gestational age between 20 and 35 weeks; confirmed preterm labor with more than four uterine contractions per hour and cervical change; intact membranes; patient motivated and willing to learn basic pump operations; patient in stable condition after receiving MgS04 or the lowest dose o f ritodrine; and patient unable to tolerate IV or oral doses Contraindications to terbutaline pump therapy include: fetal distress;
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Cervical dilation of 4 cm or more; maternal electrocardiogram abnormalities; abruptio placenta; ruptured membranes; patient inability to learn basic pump operations; and progressive preeclampsia.
patterns, tolerance for the drug, and life-style considerations. This therapy, when tolerated, liberates women from medication schedules every 2-4 hours and nighttime dosing.
Intravenous An tibiotic Therapies
Home care of preterm labor via terbutaline pump therapy allows nurses to make suggestions for dosage changes with their knowledge of the patient’s contraction
During the past 10 years, the number of infectious diseases for which outpatient intravenous treatment is appropriate has increased. Such infections include infections of bone and joint, soft tissue, respiratory tract, genitourinary system, heart, and infections associated with acquired immune deficiency syndrome. Other infections increasingly managed at home include Lyme disease, complicated urinary tract infections caused by multiple resistant bacteria, and pelvic inflammatory disease (Bernstein, 1991). Some infections require initial stabilization of the patient’s condition during a hospital stay, but most patients can begin their intravenous infusion treatment at home without hospital admittance. When caring for the pregnant woman with an infection it is important to remember that physiologic alterations that occur during normal pregnancy can result in significant effects on the pharmacokinetics of antimicrobial agents. For example, expanded blood volume occurs during pregnancy, which results in lower serum concentrations for many antimicrobial agents. Because of this approximately 50% increase in blood volume, there also is an increase in renal blood flow, with a resultant increase in the clearance of antimicrobial medication excreted via the kidneys. In addition, there is a significant percentage of blood in the fetal compartment, which is unavailable to the pregnant woman. The net result is a decreased amount of drug availability and increased dosage requirements. As a result of increased progesterone activation of hepatic metabolism, decreased gastrointestinal motility, and decreased gastric emptying, oral medications are absorbed in an unpredictable manner and thus may be less effective in their normal dosages. Guidelines for choosing antibiotic therapies for pregnant patients are based on laboratory culture and sensitivity results, consideration of side effects, toxicities, teratogenic effects, convenience, and cost. The most suitable antibiotics for home use are those that have pharmacokinetic properties that allow for no more than twicedaily dosing and have low toxicity. When caring for the patient in the home, the nurse should make sure that laboratory reports are made available to the physician. Most antibiotic therapies require weekly testing of complete blood cell counts, and differential serum chemistry screen levels. Some antibiotics with the potential for serious hematologic or renal toxicity require more frequent screening. The first dose of any parenteral drug should be given in the presence of a nurse to detect and treat any potential drug reactions. Home uses for IV antibiotic therapy for the obstetric patient are varied and often include conditions such as pelvic inflammatory disease, postpartum endometritis, acute urinary tract infections, or bacterial infections such
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Nursing Considerations Pump training is done by the perinatal nurse. There are three different pumps available that can deliver terbutaline in the prescribed doses. The Mini-Med 404 SP is the most widely used pump for terbutaline administration. It holds a 3-mL syringe and uses a sof-set subcutaneous catheter. Nurses who have been providing pump therapy in the past are well acquainted with the way this pump works and find it easy to use. Two new pumps made by Disetronic and CADD are available and simpler to learn to use and have the capacity of using 5- and 10-mLsyringes. With many patients exceeding dosages of 3 mg/day, the larger syringe allows the patient to change the syringe less often. Many patients receiving terbutaline therapy also are on home uterine activity monitoring. The nurse caring for such patients will titrate the dose based on the monitor strips, which are reviewed on a daily basis. Patient education is vital to the success of this therapy. Patients must be able to give a demand dose or extra dose when instructed by the nurse or physician. They must be able to change the syringes, understand alarms, suspend the pump, and change the subcutaneous catheter. Most patients are able to make programming changes with the nurse during telephone conversations. Patients must understand the side effects of this drug. They should be instructed in taking their pulse and should not have an extra bolus if their heart rate is more than 110 bpm. Any shortness of breath or chest pain should be reported to the nurse immediately. A demand dose should never be given more frequently than once an hour. Nursing care for these patients consists of one to two home visits a week for the duration of therapy. The following nursing actions occur during the visit: pulmonary assessment; catheter site change and assessment; review pump function and settings and check patient supplies; document fetal heart tones, nonstress test if ordered; assessment of blood pressure, maternal heart rate, and respiratory rate; and discuss bed rest, life-style changes, and emotional changes that occur during this time and review signs and symptoms of preterm labor.
Home Care
as Listeriosis. Patients receiving care in the h o m e should be monitored for clinical symptoms of such infections.
Conclusion In conclusion, current literature provides adequate data to support patient acceptance, safety, and efficiency of home IV infusion. As home health care continues to grow, it is important to b e mindful of the many benefits that home care can provide to the high-risk obstetric patient. Perinatal nurses with the appropriate educational and experiential background are in a most advantageous position to become leaders and advocates of quality obstetric care in the home.
References Bernstein, L. H . (1991). An update on home intravenous antibiotic therapy. Geriatrics, 46, 47-52. Branch, D. W. (1991). Antiphospholipid syndrome: Laboratory concerns, fetal loss, and pregnancy management. Seminars in Perinatoiog): 15,230-237. Brown,J . M . (1991). Peripherally inserted central catheters: Use in home care. Journal of Intratwnous Nursing, 12, 144147. Cosico, J . N., 8r Rothlauf, E. B. (1992). Indications, manage-
ment, and patient education: Anticoagulation therapy. MCN, 17,130-135.
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Giotta, M. P. (1993). Nutrition during pregnancy: Reducing obstetric risk. Journal of Perinatal and Neonatal Nursing, G, 1-12. Hagar, L. & Kolbow, P. (1990). The use of parenteral nutrition support during pregnancy. Dietitians in Nutrition Support, 12,1-10.
Lam, F. (1989). Miniature pump infusion of terbutdline: An option in preterm labor. Contemporary OB/GYN. Long, P . , 8r Russell, L. (1993). Hyperemesis gravidarum.Journa1 ofperinatal a n d Neonatal Nursing, 6, 21-28. Mihelic, J. P. (June, 1993). Continuous heparin infusion for treatment of deep vein thrombosis and recurrent spontaneous abortions. Unpublished presentation for Curaflex Infusion Services, Kansas City, M O . Silberman, H. (1989). Parenteral a n d elitera1 nutritzon (2nd ed.). Norwalk, CT: Appleton 8r Lange. Wiedner, L. C. (1993). Parenteral nutrition during pregnancy: A review. Support Line: A News Letter of Dietitians in Nutrition Support, 15,3-8.
Addressf o r correspondence: Cathy C. Romeo, RN, PhD, 1413 Rossiter Court, Silver Spring, MD 20905. Cathy C. Romeo is the Perinatal Program Managerfor CuraJlex Birthcare Services In Columbia, MD. Patsy Jones is the National Director of CuraJlex BtrthCare Services in Columbia, MD.
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Home Infusion Therapiesfor Obstetric Patients Cathy C. Romeo, RN,PhD, Patsy Jones, RN,MN
This article focuses on current indications for home intravenous therapy for the high-risk obstetric patient. Therapeutic indications and clinical care for obstetric patients in need of hydration/total parenteral nutrition, heparin infusion, terbutaline pump, and
antibiotic therapies are presented.
H
ome health care, a product of the 1970s, has become a booming business of the 1990s and promises to continue to flourish into the next millennium. One component of home health care, intravenous (IV) home infusion therapy, has expanded enormously since the idea was first introduced in 1974. Since this time, extensive literature has been accumulated documenting the safety, efficiency, and cost savings of home infusion therapy (Bernstein, 1991). When considering a patient for home infusion service, many clinical and psychologic factors must be considered. Some of these clinical factors include whether: the primary (as well as any secondary) illnesses 01 potential complications can be managed at home; adequate venous access can be maintained; the patient is in medically stable condition; home care is a financially viable option for the patient; the home is safe, clean, and free from hazards; the patient/family is willing to participate in care; and the patient/family has the ability to be adequately trained. Once the patient has been admitted to home care, the role of the agency providing home IV therapy generally is to investigate insurance coverage, deliver supplies, facilitate laboratory testing, manage minor complications, and provide 24-hour on-call response.
October 1994
Only recently has home health care branched into obstetric care. In the past, obstetric home health care was used primarily to serve women at risk of giving birth prematurely. However, during the past few years, obstetric home health care has expanded to include many high or potentially high-risk situations other than preterm labor. When caring for the obstetric patient in the home, the perinatal home-care nurse must complete a thorough physical and psychologic assessment to determine how best to care for the patient and to determine whether the patient is a candidate for home care. Physical assessment of the obstetric patient is no different whether the patient is in the hospital or in the home. The expectant mother needs to be evaluated for signs or symptoms of preterm labor, including dull, low backaches, abdominal cramping, pelvic pressure, changes in vaginal discharge, or actual uterine contractions. The patient's vital signs, urine, weight changes, and any adverse physical symptoms also must be evaluated. Fetal well-being, including fetal movement, assessment of fetal kick counts, and fetal heart rate, should be evaluated. Care must be taken to discover any adverse signs and symptoms that may be precursors to other high-risk conditions. From an IV infusion perspective, access to possible infusion sites must be examined. Patient education is a vital component of home therapy (see Table 1). The nurse must first assess the readiness and ability of the patient/family to receive and understand home-care information. Once this readiness has been established, the nurse must provide education related to the infusion, including line and pump management, signs and symptoms of infection, and dosage issues. Patients and their families also need to understand and be able to identify symptoms specific to the patient's condition that could be indicative of exacerbating problems. The home perinatal nurse should take advantage of the opportunity to provide additional education, including such topics as prepared childbirth, newborn care, and self-care after delivery. It often is beneficial to the patient if the perinatal home-care nurse has a lending library con-
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Table 1. Infusion Therapy:Patient Teaching Guide Checklist Learning Objective
General information:patient is able to verbalize a basic understanding of the following: Description of home care services Telephone contact procedure High risk status:patient verbalizes a basic understanding of the following: The high risk situation or disease state tkat requires therapy. Plan of care Medication information:patient has the ability to verbalize the following in regards to the prescribed medication/ solution: Dose/solution prescribed Desired action Route administered Rate/schedule of administration Side effects/allergic reactions Storage/handling of drug Aseptic technique: patient demonstrates the following proper aseptic techniques: Universal precautions Personal hygiene Handling and disposal of hazardous waste Handwashing Handling sterile equipment Equipment management: patient demonstrates: Safe and appropriate maintenance of equipment Procedures for reporting equipment malfunction Electrical safety precautions Maintenance:patient demonstrates proper care of the intravenous site: Flushing technique Dressing care Clamping Injection cap change Identification of IV complications
TPN today. One of the most common discomforts of pregnancy is nausea or vomiting, often referred to as “morning sickness.” In most cases, this morning sickness is a minor inconvenience that must be endured and is treated with a variety of home remedies until it subsides in the second trimester. But what about that small percentage of women ( I % of all pregnancies) who d o not stop vomiting? What happens when the vomiting during pregnancy becomes so severe that it results in electrolyte, metabolic, and nutritional imbalances? This is called intractable vomiting in pregnancy or hyperemesis gravidarum. Hyperemesis gravidarum is an uncommon occurrence with profound effects on maternal nutrition that threaten the well-being of the pregnant woman and her unborn child. Hyperemesis is a disease process that includes persistent vomiting before 20 weeks’ gestation. Clinical evidence of this process includes dehydration, altered electrolyte balances, ketonuria, acetonuria, depletion of nutrients, and a weight loss of 5% or more of prepregnant weight. Extreme cases of vomiting result in hypovolemia, hypotension, tachycardia, increases in hematocrit and blood urea nitrogen levels, decreased urinary output, and metabolic acidosis. Severe nutritional deprivation can result in hypoproteinemia and hypovitaminosis. Jaundice and hemorrhage can result from deficiencies in vitamins C and B complex and hypothrombinemia. The effects of hyperemesis gravidarum on the fetus can result in increased risk for central nervous system malformation, intrauterine growth retardation, or fetal anomalies. In addition, a decreased number of brain cells and other congenital anomalies have been associated with poor maternal nutritional status during the first trimester. Even mild cases of maternal malnutrition have been associated with an increased frequency of prematurity, low birth weight, and intrauterine growth retardation. Infants who are born at low birth weight are at risk for perinatal mortality and may experience long-term physical or developmental effects after birth (Long & Russell, 1993; Giotta, 1993).
Nausea and vomiting and hyperemesis gravidarum are the most common obstetric indications for hydration and
Role of the Nurse When caring for the woman suspected of having hyperemesis gravidarum, a thorough assessment is essential. This assessment should include the maternal nutritional status (prepregnant weight, ideal body weight, triceps skinfold, height, dietary history, and current nutritional and fluid intake), consideration of the normal physiologic changes that occur with pregnancy, obstetric/gynecologic history, identification of any coexisting disease entities, past medical and surgical history, and biochemical indices. It is important to remember that, because of changes in blood volume and metabolism that occur during pregnancy, care should be taken to use the proper normal serum values when interpreting laboratory data on pregnant patients (Hagar & Kolbow, 1990). The expected maternal weight gain during the first trimester is 2 kg (4pounds) and0.34-0.5 kg (0.9 pounds) per week during the second and third trimesters, with a
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taining books, videotapes, or audiotapes that can be used to supplement verbal educational content. The need for quality home care for the obstetric patient is continually increasing. From an infusion perspective, there are key therapies that are being made available to the home obstetric patient. These areas include hydration/total parenteral nutrition (TPN) , heparin infusion, terbutaline pump administration, and antibiotic therapy. Each of these areas is discussed here.
h & n m z o l c sHydration and TPN
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total weight gain of 12.5 kg (approximately 25 pounds; Wiedner, 1993). These weight increases are associated with a positive fetal outcome. Patients at greater risk for malnutrition include those with weight loss greater than 1 kg/week for 4 consecutive weeks, a total weight loss of 6 kg o r more, a failure to gain weight, or an underlying diagnosis that would increase the basal energy requirement of the patient. When monitoring weight gain, it is important to note rapid weight increases that may be associated with edema, hypertension, and proteinuria. Indications f o r TPN Initial treatment using antiemetic or antihistamine drugs may be helpful during the early period of nausea and vomiting to lessen symptoms. However, their value becomes less important when the diagnosis of hyperemesis gravidarum is made and the primary goal of treatment is providing basic nutrient needs. When deemed necessary, IV therapy may be initiated in an outpatient setting to correct dehydration. A solution of dextrose with saline is commonly used. Potassium and vitamins are added if vomiting has been prolonged and oral intake is inadequate. If weight loss and vomiting continue (without oral intake), hyperalimentation should be considered. Enteral or parenteral hyperalimentation may be used. Parenteral nutrition has been used as the standard treatment during the past few years (Long & Russell, 1993). Use of parenteral nutrition during pregnancywas first reported in 1972. Since then, several studies have supporteQ its safety and effectiveness (Long & Russell, 1993). Within the last decade, TPN has been adapted successfullyfor home use. TPN is an administration of essential nutrients to restore depleted electrolytes and nutrient stores. TPN works by bypassing the normal digestive route and delivering nutrients directly into the bloodstream via intravenous catheter. The goal of TPN is to provide positive protein and energy balance while waiting for the return of adequate gastrointestinal function. The decision to initiate parenteral nutrition is based on the patient’s current nutritional status, the expected length of time the patient will be unable to receive nutrition by mouth, and estimated needs. Initiation of parenteral nutrition should not be delayed in the malnourished pregnant woman as a means of providing calories for fetal growth and maternal health. Selecting the vascular access site for intravenous infusion, whether it be for TPN or other therapeutic agents, is based on many factors, including the length of therapy, venous access, fluid status, and severity of illness. In general, peripheral lines are used for partial parenteral nutrition (PPN) when calorie and protein requirements can be met and the therapy is not of long duration (1-6 days). For example, if a woman was in good nutritional health before pregnancy, she might be a candidate for PPN, instead of TPN. Although PPN is appropriate for short-term use, maintaining a peripheral line is difficult in some people. It also must be considered that in PPN, the caloric and protein concentration must be limited, requiring a higher infusion volume to meet a patient’s needs. PPN
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generally is not appropriate for a patient o n fluid restrictions. The peripheral route should not be used in a patient with inadequate o r inaccessible peripheral veins or those whose calorie o r protein requirements are greater than can be safely supplied this way. The most common reason for difficulty in accessing peripheral veins are obesity, edema, and thrombosis. Central routes are used when extensive nutritional needs of longer duration are needed, the drug infusion is constant and irritating to the veins, or multiple therapies such as TPN and antibiotics are being used. When a central line becomes necessary for lengthy therapy, a newly available option is peripherally inserted central catheters. These catheters, which are inserted at the antecubital fossa, are moved to a central position. They can be used for several weeks to months (Brown, 1991). Benefits of a central line include the ability to use more concentrated TPN formulas, which are capable of providing more calories and protein per volume of fluid. The average volume requirements to meet caloric and protein needs with central hyperalimentation is 1.5-2 L of TPN per day with 500 mL of lipids. Risks related to central line placement include superficial thrombophlebitis, sepsis, and technical complications, such as pneumothorax. Metabolic complications of TPN include hyperglycemia, hypoglycemia, hypophosphatemia, and electrolyte imbalances. The theoretical concern that lipid infusions may induce premature labor, produce fatty infiltration of the placenta, or contribute to pulmonary complications in the neonate has not been documented in research at this time (Silberman, 1989). A major side effect of a peripheral insertion site is phlebitis. Other potential complications include air e m boli, fibrin sheath formation, Candida albicans infection, septicemia, hyperreflexia and spasticity, mediastinal hematoma, and subclavian vein thrombosis. N o adverse fetal effects have been reported. The risks and benefits of central TPN versus PPN must be appropriately evaluated. However, the risks associated with parenteral nutrition often are outweighed by the need to provide adequate nutrition to the nutritionally stressed mother and fetus (Hagar & Kolbow, 1990). Nursing Care and Monitoring of the Patient Requiring TPN When a patient is admitted to the hospital, TPN often is infused 24 hours a day. However, in the home there is a need to normalize a patient’s life-style as much as possible. Thus, TPN usually is infused in a cyclic or intermittent fashion. Nocturnal infusions allow the patient to maintain usual activities during the day without being attached to an infusion pump. As with any patient receiving TPN, the infusion rate should be increased gradually during the first 30-60 minutes of infusion and tapered during the last 30-60 minutes to avoid complications associated with hyperglycemia or hypoglycemia. Assessment of fetal and maternal well-being is essential. Fetal assessment by ultrasound confirms normal intrauterine development and dating and establishes a
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base-line for later evaluation of growth. Maternal weight change is considered the most important indication of maternal nutrition and fetal growth and thus must be carefully monitored. Glucose tolerance is monitored initially by regular finger sticks every 4-6 hours o r daily via serum glucose levels. Excessive glucose may lead to macrosomia with its concurrent problems. Lack of glucose may lead to fetal growth retardation, so careful glucose monitoring is a necessity. Serum electrolytes are measured daily until they are stable. Protein requirements can be met with amino acid solutions. The goal is to maintain a positive nitrogen balance. Positive nitrogen balance can be assessed through urine urea nitrogen or blood tests (Wiedner, 1993). When possible, oral intake should be encouraged to promote the transition from parenteral to oral nutrition. A daily dietary count should be maintained and parenteral calories reduced as oral intake increases. In summary, with adequate fluid and nutritional support, healthy outcomes of pregnancy are expected. However, any delays in nutritional support could put the life and health of the pregnant woman and her unborn child at risk.
Heparin Subcutaneous Therapy Heparin is another medication that can be safely infused in the home environment. Because pregnancy generally induces a hypercoagulability state, there is a predisposition for the risk of thromboembolism. Predisposing factors that increase the likelihood of thromboembolic complications during pregnancy include obesity, hospital admittance, prolonged bed rest, surgery, a previous history of thromboembolic disease, and recurrent pregnancy loss caused by autoimmune etiology. Heparin is an anticoagulant indicated for the prevention and treatment of venous thrombosis and pulmonary embolism and other clotting disorders. In a low-doseregimen, heparin can prevent thrombosis associated with cardiac arrhythmias, coagulation disorders, cardiovascular disease, and perioperative and postoperative immobilization (Cosico 8r Rothlauf, 1992). Heparin also is used in the treatment of recurrent spontaneous abortions caused by alloimmune and autoimmune etiologies (Branch, 1991). Because of the teratogenic effects during pregnancy and bleeding complications during delivery associated with the use of oral anticoagulants (such as warfarin), heparin is considered the drug of choice for anticoagulation therapy during pregnancy. With an existing clot, heparin usually is given intrave,nously. It often is given subcutaneously for prophylaxis purposes. Heparin may be administered continuously or intermittently. Because of its short half-life (90 minutes) continuous infusion often is preferred. The anticoagulant effect of heparin is comm m l y monitored by the activated partial thromboplastin time (aPTT). I t is recommended that the aPTT be kept at a level of 1.5-2.0 times the norm (Cosico & Rothlauf, 1992).
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BeneJts of Heparin Pump Therapy Benefits for use of an external, ambulatory pump include more stable and therapeutic blood levels, reduced drug toxicity, improved patient compliance, and cost savings. Home nursing care involves obtaining physicians’ orders regarding the rate of continuous infusion of scheduled and bolus dosages. The nurse sets up an infusion pump using sof-set catheters or bent needle sets. Catheters are changed every 3-4 days. Several techniques can be used by the home-care nurse in an attempt to prevent hematoma formation. First, ice is applied to the site for 15 minutes before needle insertion. After a wait of 30-60 minutes, the heparin infusion is started in the new site. After an additional 30-60 minutes, the old catheter is removed. Finally, pressure is applied to the site for 15 minutes after removal of the catheter or needle. This technique may help to decrease hematoma formation at the new and previous insertion sites (Mihelic, June 1993). The home nurse should visit every 2 days for a week and once a week for the remainder of the therapy to assess the patient’s condition and to assess laboratory values, including aPTT levels. Heparin doses should be adjusted according to aPTT levels per the physician’s orders. All pertinent information should be documented. Patient Education The nurse should provide pump education and evaluate the patient’s ability to operate the pump, change syringes or cartridges, and change sof-sets or bent needle sets using aseptic technique. The patient should be taught to watch for bleeding, including nosebleeds, hematuria, bleeding from the gums, and excessive bruising. The patient should be able to verbalize the side effects of heparin and when to call the home health-care agencyor physician. Adverse Reactions/Contraindications The major adverse reactions to heparin therapy include hemorrhage, idiosyncratic thrombocytopenia, and osteoporosis with spontaneous fractures. The risk of hemorrhage can be minimized by controlling the heparin dosage to achieve therapeutic blood levels and monitoring of anticoagulation effect. Idiosyncratic thrombocytopenia occurs in approximately 25% of patients receiving heparin therapy and is a result of heparin-induced platelet aggregation. Patients should be routinely monitored for thrombocytopenia with complete blood cell counts. Osteoporosis and spontaneous fractures have been reported in patients receiving 15,000 units daily for more than 3 months (Mihelic, June 1993). Patients who should not take heparin include those who have a sensitivity to the drug, active bleeding, hemophilia, purpura, thrombocytopenia, intracranial hemorrhage, bacterial endocarditis, active tuberculosis, or ulcerative lesions of the gastrointestinal tract. Recurrent Spontaneous Abortions It is estimated that recurrent spontaneous abortion will occur in approximately 15-25% of all diagnosed pregnan-
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cies. Because many spontaneous abortions occur before a pregnancy is confirmed, it is believed that the actual number of spontaneous abortions may be much higher (Mihelic, June 1993). Autoimmune disorders are being considered as a major culprit for many of these unexplained spontaneous abortions. Autoimmune disorders comprise a large group of diagnoses that disrupt the immune system of the body. The body in effect develops antibodies that attack its normally present antigens. Autoimmune disorders generally tend to appear during the reproductive years in women, so their association with pregnancy is not uncommon. Some of these disorders adversely affect the course of the pregnancy or are detrimental to the fetus. Since 1983 investigators have suggested that women with autoimmune disease such as antiphospholipid syndrome and a history of previous pregnancy losses should be treated during their pregnancy to improve their chances of delivering a live infant (Branch, 1991). Treatment modalities that have been used include oral doses of prednisone with low-dose aspirin and heparin infusion with or without low-dose aspirin. Heparin becomes a much more favorable treatment because of the potentially adverse side effects of corticosteroid usage. Heparin therapy can be given through subcutaneous injections or continuous subcutaneous infusion with the use of a Pump.
Telrbutaline Continuous Subcutaneous Infusion During the past 20 years, a number of drugs have been used for the treatment of preterm labor, including ritodrine hydrochloride, magnesium sulfate, and indomethacin. Terbutaline sulfate is a beta-mimetic agent that has been given orally, subcutaneously, or intravenously since the 1970s to inhibit labor. Even with widespread use of these drugs, there has been no decrease in the rate of preterm birth. However, if outcomes are measured by days gained in utero and not preterm birth (37 weeks’ gestation or less), it is probable that subcutaneous terbutaline therapy is effective.
Side Efects There is no drug that has only myometrial effect, so women taking beta-mimetic drugs have many undesirable side effects caused by the drug’s effect on other smooth muscles. Resultant side effects include tachycardia, vasodilation, bronchodilation, glycogenesis, and pulmonary edema. These side effects can interfere with therapy if women can not tolerate them o r are unwilling to take the drug. Another consideration is that receptor sites eventually become saturated with the drug, and uterine activity returns. Terbutaline pump therapy offers an option that lowers the daily dose, decreases undesirable side effects, and helps with compliance. The lower dose also increases the time of therapy before saturation of receptors.
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Terbutaline Subcutaneous Infusion Dosing The concept of subcutaneous infusion of terbutaline was first considered in 1985 by Lam at the University of California, San Francisco (Lam, 1989). The therapy is designed to infuse a combination of intermittent and continuous delivery of terbutaline with a small infusion pump. The total daily dose is low, approximately 3 mg/ day, and has fewer or no side effects when compared with oral or intravenous delivery. This type of treatment tends to increase patient compliance, lengthen the time women receive the drug, and allows the caregiver the option of titrating the terbutaline doses according to the amount and type of uterine activity. The low continuous infusion or basal rate keeps the uterus relaxed and decreases the incidence of low amplitude and high frequency waves (irritability), and the programmed boluses inhibit full uterine contractions. Initial scheduling of boluses was based on studies showing a circadian frequency distribution pattern of organized contractions that peak in the evening. The initial schedules for women on the pump programmed boluses of 0.25 mg at frequent intervals in the afternoon and evening, but only a basal rate was infused during the early morning hours when women were sleeping. Modifications in the schedule could be made for women with patterns of uterine activity in the early morning hours. Basal rates often were started at 0.05 mL/hour. Today, after 8 years of experience with this therapy, it is known that doses can be somewhat higher than initially thought. Many women with multiple gestations require higher basal rates and more frequent, if not regularly scheduled, boluses. Most perinatal home-care companies start patients on a low basal rate and program boluses at times of uterine activity or schedule a bolus every 4-6 hours throughout the day. Pharmacokinetic dosing may be done, but ultimately the dose is increased based on uterine activity data or reduced because of maternal side effects. Maternal tolerance is always considered when dosages need to be increased because of uterine activity. Indications and Contraindications f o r Pump Therapy Indications for terbutaline pump therapy for the obstetric preterm patient include:
gestational age between 20 and 35 weeks; confirmed preterm labor with more than four uterine contractions per hour and cervical change; intact membranes; patient motivated and willing to learn basic pump operations; patient in stable condition after receiving MgS04 or the lowest dose o f ritodrine; and patient unable to tolerate IV or oral doses Contraindications to terbutaline pump therapy include: fetal distress;
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Cervical dilation of 4 cm or more; maternal electrocardiogram abnormalities; abruptio placenta; ruptured membranes; patient inability to learn basic pump operations; and progressive preeclampsia.
patterns, tolerance for the drug, and life-style considerations. This therapy, when tolerated, liberates women from medication schedules every 2-4 hours and nighttime dosing.
Intravenous An tibiotic Therapies
Home care of preterm labor via terbutaline pump therapy allows nurses to make suggestions for dosage changes with their knowledge of the patient’s contraction
During the past 10 years, the number of infectious diseases for which outpatient intravenous treatment is appropriate has increased. Such infections include infections of bone and joint, soft tissue, respiratory tract, genitourinary system, heart, and infections associated with acquired immune deficiency syndrome. Other infections increasingly managed at home include Lyme disease, complicated urinary tract infections caused by multiple resistant bacteria, and pelvic inflammatory disease (Bernstein, 1991). Some infections require initial stabilization of the patient’s condition during a hospital stay, but most patients can begin their intravenous infusion treatment at home without hospital admittance. When caring for the pregnant woman with an infection it is important to remember that physiologic alterations that occur during normal pregnancy can result in significant effects on the pharmacokinetics of antimicrobial agents. For example, expanded blood volume occurs during pregnancy, which results in lower serum concentrations for many antimicrobial agents. Because of this approximately 50% increase in blood volume, there also is an increase in renal blood flow, with a resultant increase in the clearance of antimicrobial medication excreted via the kidneys. In addition, there is a significant percentage of blood in the fetal compartment, which is unavailable to the pregnant woman. The net result is a decreased amount of drug availability and increased dosage requirements. As a result of increased progesterone activation of hepatic metabolism, decreased gastrointestinal motility, and decreased gastric emptying, oral medications are absorbed in an unpredictable manner and thus may be less effective in their normal dosages. Guidelines for choosing antibiotic therapies for pregnant patients are based on laboratory culture and sensitivity results, consideration of side effects, toxicities, teratogenic effects, convenience, and cost. The most suitable antibiotics for home use are those that have pharmacokinetic properties that allow for no more than twicedaily dosing and have low toxicity. When caring for the patient in the home, the nurse should make sure that laboratory reports are made available to the physician. Most antibiotic therapies require weekly testing of complete blood cell counts, and differential serum chemistry screen levels. Some antibiotics with the potential for serious hematologic or renal toxicity require more frequent screening. The first dose of any parenteral drug should be given in the presence of a nurse to detect and treat any potential drug reactions. Home uses for IV antibiotic therapy for the obstetric patient are varied and often include conditions such as pelvic inflammatory disease, postpartum endometritis, acute urinary tract infections, or bacterial infections such
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Nursing Considerations Pump training is done by the perinatal nurse. There are three different pumps available that can deliver terbutaline in the prescribed doses. The Mini-Med 404 SP is the most widely used pump for terbutaline administration. It holds a 3-mL syringe and uses a sof-set subcutaneous catheter. Nurses who have been providing pump therapy in the past are well acquainted with the way this pump works and find it easy to use. Two new pumps made by Disetronic and CADD are available and simpler to learn to use and have the capacity of using 5- and 10-mLsyringes. With many patients exceeding dosages of 3 mg/day, the larger syringe allows the patient to change the syringe less often. Many patients receiving terbutaline therapy also are on home uterine activity monitoring. The nurse caring for such patients will titrate the dose based on the monitor strips, which are reviewed on a daily basis. Patient education is vital to the success of this therapy. Patients must be able to give a demand dose or extra dose when instructed by the nurse or physician. They must be able to change the syringes, understand alarms, suspend the pump, and change the subcutaneous catheter. Most patients are able to make programming changes with the nurse during telephone conversations. Patients must understand the side effects of this drug. They should be instructed in taking their pulse and should not have an extra bolus if their heart rate is more than 110 bpm. Any shortness of breath or chest pain should be reported to the nurse immediately. A demand dose should never be given more frequently than once an hour. Nursing care for these patients consists of one to two home visits a week for the duration of therapy. The following nursing actions occur during the visit: pulmonary assessment; catheter site change and assessment; review pump function and settings and check patient supplies; document fetal heart tones, nonstress test if ordered; assessment of blood pressure, maternal heart rate, and respiratory rate; and discuss bed rest, life-style changes, and emotional changes that occur during this time and review signs and symptoms of preterm labor.
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as Listeriosis. Patients receiving care in the h o m e should be monitored for clinical symptoms of such infections.
Conclusion In conclusion, current literature provides adequate data to support patient acceptance, safety, and efficiency of home IV infusion. As home health care continues to grow, it is important to b e mindful of the many benefits that home care can provide to the high-risk obstetric patient. Perinatal nurses with the appropriate educational and experiential background are in a most advantageous position to become leaders and advocates of quality obstetric care in the home.
References Bernstein, L. H . (1991). An update on home intravenous antibiotic therapy. Geriatrics, 46, 47-52. Branch, D. W. (1991). Antiphospholipid syndrome: Laboratory concerns, fetal loss, and pregnancy management. Seminars in Perinatoiog): 15,230-237. Brown,J . M . (1991). Peripherally inserted central catheters: Use in home care. Journal of Intratwnous Nursing, 12, 144147. Cosico, J . N., 8r Rothlauf, E. B. (1992). Indications, manage-
ment, and patient education: Anticoagulation therapy. MCN, 17,130-135.
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Giotta, M. P. (1993). Nutrition during pregnancy: Reducing obstetric risk. Journal of Perinatal and Neonatal Nursing, G, 1-12. Hagar, L. & Kolbow, P. (1990). The use of parenteral nutrition support during pregnancy. Dietitians in Nutrition Support, 12,1-10.
Lam, F. (1989). Miniature pump infusion of terbutdline: An option in preterm labor. Contemporary OB/GYN. Long, P . , 8r Russell, L. (1993). Hyperemesis gravidarum.Journa1 ofperinatal a n d Neonatal Nursing, 6, 21-28. Mihelic, J. P. (June, 1993). Continuous heparin infusion for treatment of deep vein thrombosis and recurrent spontaneous abortions. Unpublished presentation for Curaflex Infusion Services, Kansas City, M O . Silberman, H. (1989). Parenteral a n d elitera1 nutritzon (2nd ed.). Norwalk, CT: Appleton 8r Lange. Wiedner, L. C. (1993). Parenteral nutrition during pregnancy: A review. Support Line: A News Letter of Dietitians in Nutrition Support, 15,3-8.
Addressf o r correspondence: Cathy C. Romeo, RN, PhD, 1413 Rossiter Court, Silver Spring, MD 20905. Cathy C. Romeo is the Perinatal Program Managerfor CuraJlex Birthcare Services In Columbia, MD. Patsy Jones is the National Director of CuraJlex BtrthCare Services in Columbia, MD.
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