36C25018R0234-007.pdf

EQUIPMENT MAINTENANCE FORM rev 10/15

PATIENT NAME: ________________________________ PHONE: __________________________

ADDRESS: ________________________________ LAST 4: __________________________

________________________________ Rx: _______LPM ________HPD VIA:_______________

EMERG. CONT.: ________________________________ PHONE: __________________________

SUPPLIES DELIVERED

CANNULA # _________ MASK # _________ HUMIDIFIER # _________ TUBING# _________ NEBS # _______

NEEDS ASSESSMENT

YES NO HELP

_____ _____ _____ Understands and performs procedures well _____ _____ _____ Understands emergency procedures and back-up systems.

_____ _____ _____ Understands safety measures including storage of tanks.

_____ _____ _____ Understands infection control / cleaning procedures / changing of disposable tubing.

_____ _____ _____ Understands routine equipment maintenance procedures / filter cleaning.

_____ _____ _____ Has Patient had unscheduled physician visits or hospital admission since last visit?

_____ _____ _____ Has emergency contact changed since last year?

_____ _____ _____ Have No Smoking Signs been posted?

_____ _____ _____ Does Pt. have Fire Safety Plan? Can they explain what it is?

_____ _____ _____ Are smoke detectors / fire extinguishers in place and operational? (Pt.. should check every 30 days).

_____ _____ _____ Is patient or anyone smoking, or are any flammable substances near oxygen? (If YES detail below) _____ _____ _____ Is patient smoking while wearing oxygen? IF YES – NOTIFY VA or MD IMMEDIATELY AND DOCUMENT DETAILS IN COMMENTS SECTION (i.e. Who did you notify? Any action to be taken?

_____ _____ _____ Are any smoking materials present in the home? If YES enter detail in comments below _____ _____ _____ Does home contain any electrical / open flame safety hazards?

_____ _____ _____ Has patient fallen since last visit?

Comments Actions Taken: ______________________________________________________________________________

CONCENTRATOR EQUIPMENT FUNCTION: _______ Acceptable _______ Unacceptable

Concentrator Check: _______% at highest LPM ______Flow Check at Patient LPM _______Alarm Battery (1 Yr. Life)

Current Hrs: _______ Prev. Hrs: _______ Total Hrs. used: _______ Avg. Usage/Day: _______ PM Hrs.: _______

FILTERS: _______Alarm Functioning_______Alarm Audible to Patient

Foam: CHECK CHANGE Felt: CHECK CHANGE Bacteria: CHECK CHANGE

Manufacturer: _________________________________ Model:____________________ Serial# ____________________

If not used as per Rx state reason: _____________________________________________________________________

Back-up System: Size: _____________________________________ # of Stored Tanks ________________________

Comments: _______________________________________________________________________________________

CONSERVER /

OTHER EQUIPMENT

SERIAL # FUNCTION CHECK (pressure, settings, alarms, function) Filters (cleaned change)

LIQUID O2:

RESERVOIR (TYPE) __________________________________________ SN#: __________________________

RESERVOIR (TYPE) __________________________________________ SN#: __________________________

PORTABLE (TYPE) __________________________________________ SN#: __________________________

PORTABLE (TYPE) __________________________________________ SN#: __________________________

Signature of Clinician / Technician: _____________________________________ Date: ______________________

Signature of Patient / Caregiver: _____________________________________ Date: ______________________

COMMON QUESTIONS ABOUT OXYGEN

WHAT IS OXYGEN AND HOW WILL IT HELP ME?

Oxygen is a gas found in the air we breathe and is necessary for our bodies in order to produce energy. The air we breathe contains 21% oxygen. This is adequate for people who have healthy lungs and a healthy heart. However, due to various disease states, some of us require supplemental oxygen. This should not be thought of as a handicap. Just as some people require supplemental vitamins; your body requires supplemental oxygen. By using your oxygen, you will be able to maintain a "normal" oxygen level in your body. Thus, you will have more energy and feel less short of breath.

WILL I HAVE TO USE OXYGEN FOR THE REST OF MY LIFE?

Oxygen is a drug and must be ordered by a physician. The amount of oxygen you use, the hours per day you should wear your oxygen, and the length of therapy will be determined by your doctor. Your doctor will make these determinations based on your diagnosis and your blood oxygen level. Your doctor will monitor your oxygen level and discuss your course of therapy with you.

IS IT DANGEROUS TO HAVE OXYGEN IN MY HOUSE? ISN'T OXYGEN EXPLOSIVE?

Oxygen is not explosive. Oxygen does, however, "feed" a fire. In other words, oxygen will allow a fire to burn more readily. Oxygen "supports combustion". It is not dangerous to have oxygen in your home as long as you follow the safety rules you have been instructed on.

MY DOCTOR TOLD ME TO WEAR MY OXYGEN 24 HOURS A DAY BUT I'M AFRAID THAT IF I

USE IT TOO MUCH I MIGHT BECOME ADDICTED. IS OXYGEN ADDICTIVE?

Remember, oxygen is a requirement of your body just as food and water are. Your doctor has ordered oxygen because your blood oxygen level is low. When your oxygen level improves, your doctor may cut your usage down, or maybe even take you off oxygen altogether. You will be able to come off oxygen safely without any withdrawal symptoms. Oxygen is not an addictive drug.

DO I HAVE TO STAY CONFINED TO MY HOUSE?

Absolutely not. If your doctor requests that you wear your oxygen continuously, you will be provided with portable units so you may venture out of the house. You should not feel self conscious. Millions of Americans are on home oxygen therapy. Seeing someone in public on oxygen is as common as seeing someone in an arm or leg cast. It hardly even attracts a second look.

IF I AM HAVING A HARD TIME BREATHING, CAN I INCREASE MY OXYGEN LITER FLOW?

NO!!! You should never adjust your oxygen unless specifically told to do so by your doctor. Too much oxygen is just as bad as not enough.

IS IT ALL RIGHT TO WEAR MY OXYGEN WHEN I TAKE A SHOWER?

Yes. The water will not hurt the oxygen tubing. The concentrator, however, should not be brought in the bathroom with you. It is best to leave the door open a crack and run extension tubing into the bathroom with you.

CAN I COOK WHILE WEARING MY OXYGEN?

If it is necessary for you to cook, only do so on an electric range. It is suggested that you run your oxygen tubing under your blouse or sweater. Do not allow tubing to dangle over the stove.

THE OXYGEN MAKES MY NOSE FEEL DRY. WHAT CAN I DO ABOUT THIS.

Most people are able to tolerate low levels of oxygen without discomfort. Others complain of dry noses or dry throats. If you are suffering from either of these, there are a few things you can do. You might want to try purchasing a room humidifier. If you are not on fluid restriction, you should drink lots of water. You might try lubrication your nose with a water soluble jelly. DO NOT USE VASELINE OR ANY OTHER PETROLEUM BASED PRODUCTS. If none of the above suggestions help, contact your oxygen provider for other suggestions.

O2Quest. Rev 3/2006

OXYGEN OPERATING INSTRUCTIONS

DOCTOR’S PRESCRIPTION:

Oxygen at ____________ liters per minute, ____________ hours per day. Via _________________

CONCENTRATOR INSTRUCTIONS:

1. CONCENTRATOR PLACEMENT

a. Well ventilated area (NOT IN CLOSET)

b. Away from walls, drapes, curtains, bedspreads, etc.

c. Away from combustible materials (grease, lotions, solvents, etc)

d. At least 8 feet from heat sources (smoking, matches, stoves, heaters, toasters, hair dryers, etc)

2. CONCENTRATOR USE

a. Plug into appropriate electrical outlet. DO NOT plug into extension cords or multi-use adapters.

b. DO NOT use as a table NEVER place anything on top of concentrator (drinks, plants, books, covers, etc)

c. TURN ON concentrator with power switch

1. Motor should begin to run

2. ALARM will sound for a few seconds until pressure is reached

d. ADJUST LITER FLOW

1. Rotary Flow Control: turn the knob until prescribed liter flow appears

2. Flow “Tub”: adjust the knob until the MIDDLE OF THE BALL is at the prescribed liter flow.

e. Fit the nasal cannula to the face

1. Insert the 2 prongs into nose; prongs must point upward and curve into the nostrils

2. Slide tubing over and behind each ear

3. Slide adjuster upward under the chin NOT TOO TIGHT!

f. Use the concentrator:

1. AT THE PRESCRIBED LITER FLOW – NO MORE / NO LESS

2. FOR THE NUMBER OF HOURS EACH DAY AS PRESCRIBED

3. FOR THE PRESCRIBED ACTIVITIES

3. CLEANING AND DISINFECTION

a. Wipe concentrator cabinet with a clean, damp cloth, NEVER SPRAY ANYTHING ON OR INTO

CONCENTRATOR

b. Clean AIR INLET FILTER WEEKLY

1. Remove filter element.

2. Wash in warm, soapy water.

3. Rinse completely.

4. Squeeze in paper towel to dry.

5. Replace filter element.

c. Nasal Cannula: Discard every 2 weeks. More frequently if you have a cold.

d. Oxygen Tubing: Discard every month.

e. Humidifier Jars:

1. Refill with distilled water as necessary. Discard any remaining water before refilling.

2. Clean every week

a. Wash in warm soapy water and rinse with water

b. Soak in a 1-to-3 mixture of white vinegar and water for 30 minutes and rinse with water.

c. Discard vinegar/water after each use.

d. Discard the jar every 2 weeks.

4. PRECAUTIONS:

a. NEVER SMOKE WHILE USING OXYGEN

b. KEEP AWAY FROM OPEN FLAME

c. USE ONLY IN WELL VENTILATED AREA

d. NEVER USE OIL BASED PRODUCTS (Vaseline, Chapstick, Oily lotions / creams)

e. NEVER CHANGE LITER FLOW WITHOUT DOCTOR’S PERMISSION

f. CLEAN CONCENTRATOR AND SUPPLIES AS DIRECTED

5. TROUBLE SHOOTING:

a. IF ALARM SOUNDS

1. Make sure plug is in outlet

2. Make sure outlet has power (check fuse / circuit breaker)

3. Check concentrator Circuit Breaker

4. Use Back-up Oxygen Supply

b. NO OXYGEN FLOWING FROM CANNULA:

1. Check for Loose Tubing Connections

2. Check for loose Humidifier jar.

3. Check for Bubbles in Humidifier or place cannula in glass of water and check for bubbles.

4. Check for Blocked Inlet Filter

CYLINDER INSTRUCTIONS

1. CYLINDER PLACEMENT

a. Store in a well ventilated are (NOT IN CLOSET).

b. Away from walls, drapes curtains, bedspreads, etc

c. Away from combustible materials (grease, lotions, solvents, etc)

d. At least 8 feet from heat sources (smoking, matches, stoves, heaters, toasters, hair dryers, etc)

e. Place on FLAT, HARD surface supported with a stand, cart, or chain. Store extra unsecured tanks lying flat on the floor

2. CYLINDER USE

a. DO NOT cover or drape anything around cylinder

b. TURN ON cylinder by turning cylinder valve in a counterclockwise (toward the left) direction. Open valve 2-3 turns.

c. ADJUST LITER FLOW

1. Gauge Flowmeter: turn the flow adjustment knob (usually to the right) while observing the position of the indicator needle on the FLOW GAUGE until prescribed liter flow is indicated by the needle.

2. “Tube” Flowmeter: adjust the flow adjustment knob till the MIDDLE OF THE BALL is at the prescribed liter flow.

d. Fit the nasal cannula to face:

1. Insert the 2 prongs into the nose; prongs must point upward and curve into nostrils

2. Slide tubing over and behind each ear

3. Slide adjuster upward under the chin. NOT TOO TIGHT!

e. Use the Oxygen:

1. AT THE PRESCRIBED LITER FLOW – NO MORE / NO LESS

2. FOR THE NUMBER OF HOURS EACH DAY AS PRESCRIBED

3. FOR THE PRESCRIBED ACTIVITIES

3. CLEANING AND DISINFECTION

a. Cylinder and Regulator

1. Wipe cylinder and regulator with a clean damp cloth. NEVER SPRAY ANYTHING ON OR INTO

REGULATOR

2. Nasal Cannula: Discard every 2 weeks. More frequently if you have a cold.

3. Oxygen Tubing: Discard every month.

4. PRECAUTIONS

a. NEVER SMOKE WHILE USING OXYGEN

b. KEEP AWAY FROM OPEN FLAME

c. USE ONLY IN WELL VENTILATED AREA

d. NEVER USE OIL BASED PRODUCTS:

1. Vaseline

2. Chapstick

3. Oily lotions / creams

e. NEVER CHANGE LITER FLOW WITHOUR DOCTOR’S PERMISSION

f. CLEAN OXYGEN SUPPLIES AS DIRECTED.

g. CAUTION: USE OF PORTABLE OXYGEN WHILE SLEEPING / NAPPING IN A NON-EMERGENCY

SITUATION IS DISCOURAGED. (CONSERVING DEVICES SHOULD NEVER BE USED WHILE SLEEPING /

NAPPING)

5. TROUBLESHOOTING – NO OXYGEN FLOWING FROM NASAL CANNULA

a. Check for LOOSE TUBING CONNECTIONS.

b. Place nasal cannula in glass of water and check for bubbles.

c. Cylinder is turned off or Cylinder is empty.

d. Liter flow has been turned off.

Call your equipment provider’s office (phone number is provided in patient’s handbook) to obtain supplies or if you have problems or questions.

VA VISN 11 O2 Instr. Rev11//2017

OXYGEN SAFETY

Oxygen is a DRUG and is effective and safe only when used as prescribed by your physician. Never change your oxygen liter flow without first consulting your physician.

FIRE SAFETY:

Oxygen is NOT FLAMMABLE and WILL NOT EXPLODE. However, oxygen DOES SUPPORT COMBUSTION. This means that oxygen will make things burn faster and ignite easier.

Oxygen should be used and stored in a WELL VENTILATED area because oxygen will accumulate around the user and immediate surroundings.

Never use or store oxygen in a confined space such as a cabinet or closet.

DO NOT use petroleum based ointments or lotions in or around your nose such as Vaseline, Vicks, Chapstick, etc. Oxygen can react violently with these oily substances and can cause burns.

Take care to AVOID OPEN FLAMES while using oxygen. This includes matches, fireplaces, BBQ’s, stoves, space heater, etc.

DO NOT SMOKE within 8 feet of the oxygen patient or the oxygen system.

Before permitting anyone in room to smoke, remove cannula, shut off oxygen supply and allow adequate time to let oxygen accumulated in immediate vicinity to evaporate.

Avoid “Friction” toys and electrical appliances which produce sparks such as electric razors.

A SMOKE DETECTOR (Test monthly) and FIRE EXTINGUISHER are recommended when using oxygen in the home

Plan an EVACUATION ROUTE for you and your family in the event of a fire.

OXYGEN STORAGE AND HANDLING:

Oxygen tanks should always be stored in a stand or cart to prevent tipping or falling. Store extra unsecured tanks lying flat on the ground. DO NOT allow tanks to stand or lean in an upright position while unsecured.

Do not store oxygen systems in unventilated areas such as closets or cabinets.

Do not store oxygen systems near heat or ignition sources.

Do not store oxygen systems in the trunk of a car.

While transporting oxygen in a vehicle, make sure containers are secure and positioned properly.

Oxygen should be transported in the passenger compartment of a vehicle with the windows open slightly (2-3 inches) to permit adequate ventilation.

CONCENTRATOR SAFETY:

Concentrators are electrical devices which should only be plugged into a properly grounded or polarized outlet.

DO NOT USE EXTENSION CORDS.

DO NOT USE MULTI-OUTLET ADAPTERS (such as power strips).

Avoid using power sources which create heat or sparks.

Use a power supply or electrical circuit which meets or exceeds the amperage requirements of the concentrator.

CAUTION: when walking near oxygen concentrator and / or portable system use care as oxygen tubing can cause tripping and / or falling.

LIQUID OXYGEN SAFETY:

Avoid direct contact with liquid oxygen as it can cause sever burns due to its extremely cold temperature.

Avoid touching any frosted or icy connectors of either the stationary reservoir or portable unit.

Avoid contact with any stream of liquid oxygen while filling portable unit.

Keep portable unit in an upright position. Do not lay it down or place on its side.

O2 Safety Rev 4/2009

VA RESPIRATORY EQUIPMENT CLEANING INSTRUCTIONS

OXYGEN SUPPLIES

HUMIDIFIER

1. Refill with distilled water as necessary. Discard any remaining water before refilling.

2. Clean humidifier every 3 days:

a. Wash in warm soapy water and rinse with water

b. Soak in a 1-to-3 mixture of white vinegar and water for 30 minutes and rinse with water.

c. Discard vinegar/water after each use.

d. Discard humidifier every 2 weeks weekly.

NASAL CANNULA Discard every 2 weeks.weekly

OXYGEN TUBING Wipe with damp cloth if soiled. Do not attempt to soak/clean tubing.

Discard every 30 days.

HAND-HELD NEBULIZERS

NEBULIZER

1. After each treatment, disassemble nebulizer, “T” piece and mouthpiece, wash with warm soapy water and rinse thoroughly under warm tap water.

2. Allow to dry on a clean paper towel.

3. Once each day, after rinsing, soak for 30 minutes in a 1-to-3 mixture of white vinegar and water and rinse thoroughly with water. Discard vinegar/water after each use.

4. Allow to dry on a clean paper towel.

5. Discard set up after two weeks.

TUBING

1. Wipe with damp cloth if soiled. DO NOT attempt to soak/clean tubing. Discard after two weeks

ASPIRATORS (Suction Machines)

CANISTER

1. Discard contents daily into toilet.

2. Wash container daily in warm, soapy water.

3. Disinfect every 3 days by soaking canister in a 1-to-3 mixture of white vinegar and water for 30 minutes and rinse with water. Discard vinegar/water after each use.

TUBING AND SUCTION REQUIREMENTS

1. Suction up a small amount of water after each use to clear the tubing and attachments.

2. Soak suction tubing daily in warm, soapy water.

3. Soak suction instruments daily in a 1-3 mixture of white vinegar and water for 30 minutes and rinse with water. Discard vinegar/water daily.

4. Ensure that canister top is replaced securely on canister and unused ports plugged.

I have been left a copy of the above instructions and fully understand these procedures:

Patient / Caregiver Signature ______________________________ Date: ________________

VA VISN 11 Rev 11/20175/2008

INITIAL PLAN OF SERVICE

Patient: _______________________________________ Last 4: ______________________________________

Address: _______________________________________ Equipment:___________________________________

_______________________________________ Rx: ______________________________________

City, St, Zip _______________________________________ DOB: ________________Sex: ______M ______F

Phone: _______________________________________

DNR: _________None __________ Copy on File

1. Do any of the following safety concerns exist in the home? _______None

____ Tripping Hazards (i.e. throw rugs, uneven floors, etc)

____ Use of extension cords ____ Evidence of Smoking /materials (list below) ____ Smokers in the home

____ Lack of water/electric ____ Frequent Elect Outages ____ Outlets grounded Yes No

____ Lack of smoke detectors ____ Lack of fire extinguishers ____ Pests/Dusty/Dirty Environment

____ Does Patient have a Fire Safety Plan? Can they explain what it is? Yes No

Other _____________________________________________________________________________________________________________________

Action Taken: ______________________________________________________________________________________

2. Does the patient admit to any physical limitations that may affect proper use of the services provided? ______ None

____ Poor eyesight ____ Weakness ____ Shortness of breath ____ Dizziness or Blackouts

____ Unable to hear alarms ____ Limited dexterity ____ Coughing / wheezing episodes ____ Difficulty rising or stooping

____ History of stroke / CVA ____ Limited communications ____ History of falls ____ Forgetful / disoriented

____ Arthritis ____ Language Barrier ____ Unaddressed pain ____ Limited ambulation

____ Pertinent Allergies / Sensitivities: ____________________________________________________________________________________________

Other: _______________________________________________________________________________________________________________________

Action Taken: ___________________________________________________________________________________________________________________

3. Does the patient have capable and willing caregiver support _____ Yes _____ No _____ None Needed

4. Diagnosis: __________________________

5. Emergency Contact: _____________________________________Telephone: ______________________________

Problems / Needs Identified Goals Actions / Interventions

1. Patient / Caregivers have a knowledge deficit in operating and maintaining equipment listed

2.

3.

1. Patient will demonstrate safe use, storage, and cleaning of equipment

1. Patient was instructed on the safe use, cleaning, and storage of equipment per policy.

_______ Patient / Caregiver able and willing to learn needed skills, and Patient / Caregiver provided return demonstration of safe and proper use of the equipment listed above.

COMMENTS: _______________________________________________________________________________________________________________

Client Signature: ____________________________________FCC Representative: _________________________________ DATE: ________________

IPOS Rev 11/17 (Inclusive)

Your Responsibilities Of Using Home Oxygen

* Use your oxygen as prescribed

* Always use oxygen CAREFULLY AND SAFELY. Oxygen is a safe gas when used properly. It will not burn or explode. However, it does support and rapidly accelerate combustion, making fire (including sparks) more hot and violent.

* Notify the Home Oxygen Clinic of problems or possible needs for change. You may have up to three different settings for your oxygen – one while you are at rest, one while you are active and another while sleeping. Unless you are instructed otherwise NEVER use more or less oxygen than stated on your prescription. Too much oxygen can be just as harmful as too little, i.e. Hypoxic Drive.

* Keep your home oxygen appointments. Your appointments are to evaluate your need for home oxygen and keep your prescription current (make sure you are not getting too much or too little therapy). Home Oxygen Prescriptions have to be renewed just like your medication prescription once a year.

* Keep appointments with the Home Oxygen Company, and allow them into your home for equipment service and deliveries.

* The instructions provided for you by the Home Oxygen Company will include information such as equipment care, emergency preparedness, and more.

* Allow the Home Oxygen Company to post No‐Smoking Signs at the entrance to your home. Even if you do not allow smoking into the home, it would alert emergency personnel that there is oxygen in the home if there was ever a fire emergency.

* NEVER SMOKE (this includes E‐Cigs) while oxygen is in use‐‐‐‐‐smoking stops the good that comes from Oxygen Therapy and is a FIRE HAZARD. Smoking E‐Cigs instead of burning cigarettes DOES NOT eliminate the fire risk. Smoke inhalation of any kind (including cigarette/cigar/pipe and secondhand smoke) stops the benefits of oxygen. NEVER allow smoking around you, even if you are NOT using your oxygen. For veterans who need help to stop smoking, the hospital offers smoking cessation classes and other ways to help you stop smoking; just ask your healthcare provider.

* Working Smoke Detectors are required not only because of the safety warning in the event of fire, but they may be a warning of conditions that may interfere with your breathing. Check smoke detector batteries once a month. Having a fire extinguisher in reach is highly recommended (check expiration dates)

* Never use oxygen within 10 feet of an open flame or heat source (space heaters, stoves, candles, fireplaces, or anyone smoking, E‐cigarettes, electric razors/trimmers/blow dryers, toasters, electric blankets, burning trash or leaves, fire pits, welding equipment, grills, fireworks.)

*Don’t be in an enclosed environment with a smoker. (i.e. in a car)

*You should be extra cautious that the electrical appliances you use are in good condition. An old appliance can potentially generate a spark which could ignite when exposed to oxygen.

* Avoid using extension cords with your oxygen equipment and don’t plug into an outlet that has other appliances plugged into it.

* Never store or use any flammable products like alcohol, cleaning fluid, paint thinner, or aerosol sprays of any kind within 10 feet of oxygen equipment.

* Never use oil or grease on or near connections of your equipment.

* Secure oxygen cylinders in a stand or rack or lay them flat to prevent them from tipping over. Store oxygen in a cool, dry, ventilated area (not a closed closet).

They should NOT be stored in an area where the temperature goes above 125 degrees Fahrenheit.

* Never store oxygen equipment in the trunk of your car. Try to park in the shade or crack a window.

* Never use oily or petroleum based lotions or creams hair products or lip balms while using oxygen. It can react violently with oxygen and increase the chances of igniting. (No Chapstick or Carmex. You can use Burt’s Bees or Blistex but always check ingredients as they may change)

* Never leave your oxygen supply running when not in use.

* Never allow untrained people to adjust your equipment.

*Always “crack” the oxygen cylinder valves before attaching the regulators in order to get rid of the dirt and debris from the outlet port of the valve.

The Department of Veterans Affairs has the right NOT TO PAY for oxygen and oxygen equipment to veterans who do not follow safety precautions or fail to keep appointments. The potential of a fire and injury to yourself and others is increased if you do not follow safety precautions. If there is any evidence of smoking while oxygen is in use it may be necessary to consider stopping the payment for your oxygen therapy. You could then be switched to another vendor at your expense.