Oxygen Therapy

Home Oxygen Care

- Use of oxygen in the home would be required if the patient is unable to maintain an oxygen saturation (SaO₂) of 88% or more. Patients with COPD, emphysema and advanced cardiac disease may require home oxygen therapy. Home oxygen benefits the patient by improving their exercise tolerance and they don't tire as easily. Oxygen therapy at home may also be used for hospice patients to assist in the management of dyspnea. Nasal cannula or face masks are most commonly used for administering oxygen in the home. If a patient has a tracheostomy, a T-tube or trach collar would be used - There are three types of home oxygen therapy delivery systems available: compressed gas cylinders or tanks, liquid oxygen systems, and oxygen concentrators. - The oxygen therapy system in the home should be in an area that is well ventilated, free of clutter, and at least 10 feet away from a heat source. With the compressed gas cylinders, the patient must be taught how to turn the cylinder valve with a wrench and how to check the pressure gauge to ensure there is an adequate supply of oxygen. The oxygen concentrator needs to be close to a power source. There is an alarm that goes off until the desired pressure inside the concentrator is reached. For the liquid oxygen system, the patient must be taught how to refill the portable tank, being careful not to overfill the ambulatory unit. If the ambulatory unit is overfilled, there will be too much pressure in the tank and it won't work properly. Before and after the refilling, the connectors should be wiped with a clean, dry, lint-free cloth - There are similar safety concerns with home oxygen delivery as there are in the hospital. The most common include fire, equipment malfunction, and pressure hazards. Instruct the patient and family that there is to be no smoking while using oxygen, and no-smoking signs should be posted near home entrances. Caution patients about using electrical equipment such as razors or radios when oxygen is in use. The electrical equipment must be well grounded and functioning properly. Both have the potential to cause sparks if they malfunction and could result in fire. Teach children receiving oxygen therapy not to play with electric or friction toys because they can also cause sparks. If an oxygen concentrator is being used, there should be a backup system for electrical failures. The patient and family need to know whom to call if there is equipment malfunction

Simple Face Mask

- an oxygen delivery apparatus used for patients who require a moderate flow rate for a short period of time via a plastic mask that fits snugly over the mouth and nose - this device requires a fairly high oxygen flow to prevent rebreathing of carbon dioxide. About 75% of the inspired volume is room air that the patient breathes through the holes in the side of the mask. An accurate FiO₂ is difficult to estimate FiO₂: 40% to 60% — Flow: 5 to 8 L - usually used for patients who require a moderate flow rate for a short period of time. It is composed of a plastic mask that fits snugly over the patient's mouth and nose. The mask has holes (vents) on each side that are used for exhalation and for air entrainment if the flow rate is too low. An adjustable elastic strap that fits over the patient's head holds the mask in place. A piece of tubing connects the mask to the oxygen source. Extension tubing is usually added to allow the patient more freedom of movement. - has the ability to deliver oxygen concentrations of 40% to 60% with flow rates from 5 to 8 L/min. Because carbon dioxide can build up in the mask at low flow rates, do not use a flow rate lower than 6 L/min with this type of mask. When using this mask, consider humidification to keep the patients' mucous membranes from becoming dry

Venturi Mask

- an oxygen-delivery apparatus consisting of a mask with holes on each side that allow exhaled air to escape and color-coded entrainment ports that are adjustable to allow regulation of the concentration of oxygen delivered - delivery of a precise concentration of oxygen - this device uses different size adaptors to deliver a fixed or predicted FiO₂. The FiO₂ delivered depends on the flow rate and/or entrainment port size. It is used for patients who have COPD when an accurate FiO₂ is essential and carbon dioxide buildup must be kept to a minimum. Humidifiers usually are not used with this device FiO₂: 24% to 50% — Flow: 4 to 10 L - most often used for critically ill patients who require administration of a specific concentration of oxygen

Partial non-breather mask

- an oxygen-delivery apparatus similar to a nonrebreather mask, but with a two-way valve allowing the patient to rebreathe exhaled air - may also be used to deliver an FiO₂ of 60% to 75% with a flow rate of 6 to 11 L/min. The partial rebreather mask has ports, so most of the expired air escapes. There is no inspiratory valve, so some of the exhaled air returns to the bag and mixes with the inspired air. While partial rebreather masks are used infrequently, it is important to check provider orders carefully to determine which kind of rebreather mask to use.

Non-rebreather Mask

- an oxygen-delivery apparatus used to deliver high flow rates and high concentrations of oxygen via a mask that fits snugly over the patient's mouth and nose FiO₂: 80% to 95% — Flow: Liter maintaining reservoir bag 2/3 full - the reservoir bag allows a higher FiO₂ to be administered. At flow rates slower than 6 L/min, the risk of rebreathing carbon dioxide increases. A valve closes during expiration so that exhaled air does not enter the reservoir bag and is not rebreathed. The valves on the side ports of the mask allow exhalation but close on inspiration to prevent inhalation of room air.

What precautions is necessary when administering oxygen to a patient with COPD

- assess frequently for any changes in their condition - when patients with COPD receive oxygen at too high a flow rate, carbon dioxide narcosis (a complication that causes confusion, tremors, convulsions, and coma) can result

Flow Meter

- attaches to the oxygen outlet and regulates the amount of oxygen delivered to the patient - it is important to confirm that the flow meter is attached to the oxygen outlet, designed by a green "oxygen" label, and not the air outlet, designated by a yellow "air" label, before initiating oxygen therapy

Nasal Cannula

- common oxygen delivery device consisting of length of tubing with two small prongs that are inserted into the patient's nares - device most often used to administer oxygen therapy. It consists of a length of tubing, usually 7 to 14 feet long, with two small prongs to insert into one of the patient's nares. It also has a plastic piece at the neck that slides up under the patient's chin to tighten the tubing and keep it in place. It is available in a range of sizes and can be used for various age groups - delivers oxygen concentrations of 24% to 44% with flow rates from 1 to 6 L/min through the cannula. The exact concentration inspired depends on the flow rate and on the patient's rate and pattern of breathing and the depth of respirations. A nasal cannula is usually used for patients who are noncritical with minor breathing problems and for patients who cannot or will not wear an oxygen mask. Because this device administers low-flow oxygen, humidification is usually not required until the liter flow rate exceeds 4 L/min. FiO₂: 24% to 28% — Flow: 1 to 2 L FiO₂: 32% to 36% — Flow: 3 to 4 L FiO₂: 40% to 44% — Flow: 5 to 6 L

Pieces of Equipment needed for Oxygen Therapy

- flow meter - extension tubing - an oxygen delivery device - and if the flow rate is more than 4L/min, sterile water for humidification

Care of patients receiving oxygen therapy

- having a patient in semi or high fowler's position helps facilitate lung expansion - turning and repositioning, coughing and deep breathing will also promote ventilation - since the goal of oxygen therapy is to prevent or relieve hypoxia, delivering oxygen should help prevent or resolve the manifestations of hypoxia - with effective oxygen therapy for patient's who have hypoxia, vital signs and oxygen saturation should move closer to normal or to the patient's baseline readings - if a patient is not improving with oxygen therapy, check to make sure equipment is functioning properly, correct oxygen delivery device is in use, and the flow rate is set correctly - if the equipment and flow rate are appropriate, you might have to adjust the oxygen's flow rate - because oxygen is considered a medication, you must obtain an order from the provider before adjusting the flow rate - perform a respiratory assessment along with a complete set of vital signs, including oxygen saturation indicated via pulse oximetry - after assessing your patient, also document the patient's skin color, level of consciousness, and other signs and any manifestations of hypoxia - perform skin assessment where the oxygen delivery device comes into contact with the patient's skin - inspect nose, the ears, and under the chin for redness, irritation, and skin breakdown - consider padding pressure areas when initiating oxygen therapy - keeping the patient's skin and clear and dry can also help reduce the risk of skin irritation and breakdown - since oxygen tends to cause drying of the mucous membranes consider humidification if the flow rate is 4 L/min or more - increasing the patient's fluid intake, and providing oral care frequently can also help alleviate dryness of the mucous membrane

Intervention: nasal and upper airway mucosa drying

- if oxygen flow rate is greater than 4 L/min, use humidification - at rates greater than 5 L/min, nasal mucous membranes dry, and pain in frontal sinuses may develop - assess patient's fluid status and increase fluids if appropriate - provide frequent oral care

Before initiating oxygen therapy:

- make sure all equipment is checked - the oxygen should be turned on and the flow meter and regulator checked to make sure they are functioning properly - the gauge indicating the level of oxygen in the tank should also be checked to make sure there is an adequate amount remaining

Intervention: continued hypoxia

- notify health care provider - obtain health care provider's orders to follow up SpO2 monitoring or ABG determinations - consider measures to improve airway patency, including but not limited to coughing techniques and oropharyngeal or orotracheal suctioning

Inpatient Settings

- oxygen is usually stored in large holding tanks outside of the building and piped in to patient rooms via outlets on the wall that are located behind the patient's bed

Homecare Settings

- oxygen is usually supplied in small portable tanks

Indications for Oxygen Therapy

- oxygen therapy is indicated for patients who are at risk for developing hypoxia - this includes patients who are recovering from surgery and may be in pain or still sedated - also includes patients who have a respiratory illness that causes excessive secretions to accumulate in the lungs or conditions that reduce the circulation of blood through the lungs *if hypoxia is left untreated, the patient's condition can deteriorate, resulting in a decrease in activity level, an increase in confusion, a decrease in level of consciousness, and possibly coma

Safe Patient Care: Oxygen Administration

- patients with sudden changes in their vital signs, LOC, or behavior may be experiencing profound hypoxia. - patients who demonstrate subtle changes over time may have worsening of a chronic or existing condition or a new medical condition - excessive amounts of secretions, signs of respiratory distress (increased work of breathing, increased respiratory rate), presence of rhonchi on auscultation, excessive coughing, or decrease in patient pulse oximeter can indicate need for suctioning

Critical Elements

- position the patient to facilitate respiration - apply correct oxygen delivery device - set or adjust oxygen flow to correct rate - provide for humidification of oxygen when required - remove flammable articles from the room

Intervention: Skin Breakdown

- provide appropriate skin care - do not use petroleum based gel around oxygen because it's flammable

Oxygen Therapy

- to give the patient more freedom to move around, connect a piece of extension tubing to the oxygen delivery device - one end of the tubing connects the flow meter and the other end connects to the end of the tubing on the oxygen delivery device - many different types of oxygen-delivery devices are used to administer oxygen. The device used often depends on why the patient is receiving oxygen, the flow rate (L/min) prescribed, and the length of time the patient will receive oxygen therapy - depending on the flow rate prescribed, humidification might be required. This is usually accomplished by attaching a bottle of sterile water to the oxygen-delivery equipment. As the oxygen bubbles through the water, it picks up moisture and helps keep the patient's mucous membranes from becoming dry. Be sure to replace the sterile water at least every 24 hours or according to the facility's policy. With high flow rates (FiO₂ of 4 L/min or more), humidification is required.

The flow meter consists of several basic parts:

1. the two metal prongs fit into the wall outlet 2. the green collar behind the prongs twists to release the flow meter from the wall outlet, allowing it to be removed 3. the cylinder portion of the flow meter has numbers and lines indicating how many liters of oxygen are being delivered per minute (L/min) 4. the knob opposite the prongs and the green collar adjust the flow rate. as you turn the knob, a ball approximately the size of a small pea moves up and down the cylinder, indicating the flow rate 5. when setting the flow rate, align the middle of the ball with the number corresponding to the amount of oxygen being administered for example, if the patient is to receive 2 L/min, line up the middle of the ball with the line next to the number 2 6. at the bottom of the flow meter is a green adapter commonly called a "Christmas tree." - this adapter connects the extension tubing and oxygen delivery device to the flow meter

Step by Step: Venturi Mask

1. After you introduce yourself, confirm that you have the right client using two identifiers 2. Leave the room to gather your supplies. Perform hand hygiene 3. Verify the order for oxygen therapy, the delivery device, and the flow rate 4. Remove the mask and extension tubing, if it is needed, from the packaging and connect the two pieces of tubing 5. attach the color coding adaptor and fit the white plastic shield over the adaptor 6. attach the tubing to the bottom of the color coded adaptor 7. make sure the flowmeter is securely attached to the oxygen source on the wall outlet 8. Connect the extension tubing to the flowmeter. adjust the flow rate to a high flow 9. Adjust the specific flow rate for the precise FiO2 prescribed - the flow rate should be indicated on the color coded adapter or on the barrel of the mask depending on the brand of mask used 10 Place the mask on the clients face from the nose downward 11. place the elastic band around the clients head and adjust as necessary, so that the mask fits snugly and forms a secure seal 12. Perform hand hygiene 13. Raise side rails (as appropriate) and lower bed to lowest position - ensures patient safety 14. Be sure nurse call system is accessible and within patient's reach. Instruct the patient on its use - helps decrease incidence of falls; alerts the nurse when the patient needs assistance 15. document the clients response to oxygen therapy, the oxygen delivery device used, the size of entrainment port, and the flow rate 16. continue to assess your client for any changes in condition 17. to prevent irritation and skin breakdown, provide skin care to the face where it contacts with the mask

Step by Step: Non-rebreather Mask

1. Ensure privacy, and place your supplies near the patient's bedside. Introduce yourself. perform hand hygiene 2. Use two identifiers to confirm that you have the right patient 3. Verify the order for oxygen therapy, the delivery device, and the flow rate 4. Remove the mask and the extension tubing, if it is needed, from the packaging and connect the two pieces of tubing 5. make sure the flowmeter is securely attached to the oxygen source on the wall outlet. Connect the extension tubing to the flowmeter 6. adjust the flow rate to the prescribed flow rate in liters per minute. it should be high enough to keep the reservoir bag partially inflated 7. Place the mask on the patient's face from the nose downward 8. place the elastic band around the patient's head and adjust as necessary, so that the mask fits snugly and forms a secure seal 9. Perform hand hygiene 10. Raise side rails (as appropriate) and lower bed to lowest position - ensures patient safety 11. Be sure nurse call system is accessible and within patient's reach. Instruct the patient on its use - helps decrease incidence of falls; alerts the nurse when the patient needs assistance 12. document the patient's response to oxygen therapy, the oxygen delivery device used, and the flow rate 13. Continue to assess your patient for any changes in condition 14. to prevent irritation and skin breakdown, provide skin care to the face where it contacts the mask

Step by Step Viewing - Nasal Cannula

1. Ensure privacy, place your supplies near the patient's bedside, introduce yourself. Perform hand hygiene 2. Use two identifiers to confirm you have the right patient 3. Verify the order for oxygen therapy the delivery device, and the flow rate 4. Remove the nasal cannula and the extension tubing, if it is needed, from the packaging and connect the two pieces of tubing 5. Make sure the flowmeter is securely attached to the oxygen source. Connect the extension tubing to the flowmeter 6. Adjust the flow rate to the prescribed flow rate in liters per minute 7. Insert the cannula's prongs into the patient's nares 8. Then gently bring the cannula's tubing up and around the patient's ears, being careful not to pull on it 9. Bring the tubing down under the chin and secure it with the plastic slide 10. if necessary, pad the tubing at the ears and under the chin to prevent irritation and breakdown from the oxygen tubing 11. Provide skin care to the nares every 4-8 hours or according to your agency's policy, using water soluble products only 12. Avoid petroleum based products, as they are combustible and difficult to remove from the mucosa 13. Gather and dispose of all waste. Perform hand hygiene 14. Raise side rails (as appropriate) and lower bed to lowest position - ensures patient safety 15. Be sure nurse call system is accessible and within patient's reach. Instruct the patient on its use - helps decrease incidence of falls; alerts the nurse when the patient needs assistance 16. Document the patient's response to oxygen therapy, the oxygen delivery device used, and the flow rate 17. Continue to assess your patient for any changes in condition 18. To prevent irritation and skin breakdown, provide skin care where it contacts the face

Step by Step: Simple Mask

1. Introduce yourself, confirm you have the right client using two identifiers. Leave the room to gather your supplies 2. Perform hand hygiene, verify the order for oxygen therapy, the delivery device, and the flow rate 3. Remove the mask and the extension tubing, if it is needed, from the packaging and connect the two pieces of tubing 4. make sure the flowmeter is securely attached to the oxygen source on the wall outlet 5. Connect the humidifier to the flowmeter if the oxygen flow rate is more than 4 liters per minute - by adding humidification to the oxygen, the client doesn't become dry. Connect the extension tubing to the flow meter 6. adjust the flow rate that is prescribed in liters per minute 7. place the mask on the clients face from the nose downward 8. place the elastic band around the clients head and adjust as necessary, so that the mask fits snugly and forms a secure seal 9. perform hand hygiene. 10. Raise side rails (as appropriate) and lower bed to lowest position - ensures patient safety 11. Be sure nurse call system is accessible and within patient's reach. Instruct the patient on its use - helps decrease incidence of falls; alerts the nurse when the patient needs assistance Document the clients response to oxygen therapy, the oxygen delivery device used, and the flow rate 12. Continue to assess your client for any changes in condition 13. To prevent irritation and skin breakdown, provide skin care to the face where it contacts the mask 14. change the mask, tubing, humidifier, and sterile water according to your facility's policy

Unexpected Outcomes

1. Patient experiences skin irritation or breakdown (e.g, at ears, bridge of nose, other pressure areas) 2. Patient experiences continued hypoxia 3. Patient experiences nasal and upper airway mucosa drying

Oxygen Safety Guidelines

1. treat oxygen as a medication 2. "Oxygen in Use" sig is on patient's door 3. Ensure that oxygen is set at prescribed rate 4. Smoking is not permitted. Avoid electrical equipment that may result in sparks - must be kept 10 ft fro open flames and at least 5 feet from electrical equipment or heat source 5. Store oxygen cylinders upright. Secure with chain or holder - prevents tipping and falling while stationary or when patient is being transported 6. Check oxygen available in portable cylinders before transporting or ambulating patients - gauge on cylinder should register in green range, indicating that oxygen is available. have backup supply available if level is low 7. tubing extensions should be not added if patient is ambulatory - adding tubing length increases fall hazard and also decreases amount of delivered oxygen 8. Check for tight seal when delivering oxygen via mask - when using a mask, a tight seal around the mouth is necessary to prevent air from entering and decreasing the FiO2. If a tight seal is required, a nasal cannula cannot be added

Signs and Symptoms of Hypoxia

Early: - restlessness - confusion - anxiety - elevated blood pressure - increased heart rate - increased respiratory rate - dyspnea Late: - decreased level of consciousness - decreased activity level - hypotension - bradycardia - metabolic acidosis - cyanosis Chronic - clubbing of the fingers and toes - peripheral edema - right sided heart failure - respiratory acidosis - oxygen saturation <87%

Hazards of Oxygen Therapy

Most Common: - fire, equipment malfunction, and pressure hazards *nurse's responsibility to provide education to the patient and family about the safe use of oxygen - it is important that oxygen is NOT used round fire or in an environment where there's a potential for sparks - it is recommended that oxygen delivery systems be kept 10 feet from any open flames - caution patients when using electrical equipment in such as razors or radios when oxygen is in use - display an "oxygen in use" sign on the patient's door or the front door of the home to notify visitors *always handle oxygen tanks with caution * keep them upright and secured with a chain or in an appropriate holder to keep them from falling and the valve rupturing * store empty oxygen tanks upright as well and secure them appropriately

Goals and Expected Outcomes

Patients vital signs remain stable or return to baseline - when there is no underlying cardiovascular disease, patients adapt to decreased oxygen levels by increasing pulse and blood pressure - this is a short term adaptive response - once signs of hypoxia are reduced or controlled, patient's vital signs usually return to normal Patient's work of breathing decreases - pulmonary conditions such as pneumonia or asthma cause varying degrees of airway narrowing - with improved oxygenation, patient's airways are open, and work of breathing decreases Patient experiences increased lung expansion - improved oxygenation helps resolve collapsed and constricted airways, improves work of breathing, and thus improves lung expansion Patient's LOC returns to baseline - improvement in oxygenation relieves hypoxia and improves patient's mental status Patient verbalizes improved levels of comfort, and subjective sensations of anxiety, fatigue, and breathlessness decreases - increased oxygen levels in the blood reduce patient's anxiety, fatigue, and breathlessness Patient's ears, nares, and nasal mucosa remain intact - intact skin indicates no device related pressure to underlying skin and mucous membrane

Hypercapnia

increased levels of carbon dioxide