Attachment 06 - Oxygen Therapy Management.pdf

VA SAN DIEGO HEALTHCARE SYSTEM NURSING SERVICE

SAN DIEGO, CA CLINICAL

September 4th 2015

OXYGEN THERAPY MANAGEMENT

1. PURPOSE:

a. To outline the management of patients receiving / requiring oxygen therapy (e.g.

nasal cannula, simple mask, Venturi mask, or non-rebreather mask) with or without oximeter use.

b. To outline the procedure to ensure safe oxygen storage within San Diego VA Healthcare System.

2. POLICY:

a. Continuous oxygen saturation monitoring is only available in Intensive Care Unit (ICU), Direct Observation Unit (DOU), Emergency Department (ED), Post Anesthesia Care Unit (PACU), Operating Room (OR), Spinal Cord Injury (SCI) and Special Procedure Areas.

b. Continuous oxygen monitoring is also available on the medical-surgical remote telemetry units if ordered by the provider and in conjunction with telemetry.

Documentation of readings are done every 4 hours with vital signs.

c. Use of the high flow oxygen delivery system is limited to the ICU, DOU, ED, and Palliative Care and SCI Units.

d. A provider’s order is required for oxygen therapy and oxygen titration. The order must include the type of delivery device, initial flow rate and/or FiO2, and any titration parameters.

e. If a patient exhibits signs or symptoms of hypoxia, the registered nurse (RN) or respiratory therapist (RT) may administer oxygen as needed to bring oxygen saturation between 88-92% or the prescribed parameter. This may be delivered via 28% Venturi mask at 4 L/min, nasal cannula at 2–6 L/min, or simple mask at 5 L/min. The provider is notified immediately and an order for oxygen must then be entered.

f. Inpatients requiring a non-rebreather mask require ICU or DOU level of care (with the exception of the Palliative Care Unit).

3. DEFINITIONS:

a. FiO2: Fractional concentration of inspired oxygen, the percent concentration of oxygen in the gas entering the lungs, ventilator, or a blood oxygenator.

b. High Flow System: Has flow rates sufficient to keep air entrainment from diluting the selected FiO2.

c. Pulse oximetry: Is a non-invasive method of monitoring the percentage saturation of hemoglobin with oxygen. The pulse oximeter consists of a probe attached to the patient's finger, toe, nose, forehead or ear lobe, which is linked to a computerized unit. The unit displays the percentage of hemoglobin saturated, a calculated heart rate, and in some models a graphic display of the blood flow past the probe.

Audible alarms may be available in some models. An oximeter detects hypoxemia before the patient becomes clinically cyanotic.

d. SpO2: Pulse oximetry saturation; the saturation of oxyhemoglobin (SpO2).

e. Fire Protective Cabinet: a green metal cabinet with 1 inch thick walls and a locking door in the front. This cabinet is resistant to direct flame and heat for a minimum of 30 minutes.

4. RESPONSIBILITIES:

a. See Nursing Service policy “Nursing Role Differentiation” in DocuShare.

b. Only an RN, graduate nurse trainee (GNT), or RT can initiate oxygen therapy without a provider’s order.

c. Only an RN, GNT, student nurse extern (SNE), or RT can titrate oxygen with a provider’s order.

d. Only licensed nurses (RNs, LVNs), GNTs, SNEs, and graduate vocational nurses (GVN) can maintain and discontinue oxygen therapy.

e. Licensed nurses, graduate nurses, telemetry technicians, nursing assistants, health technicians, student externs, student technicians, and respiratory therapists are responsible for collecting pulse oximetry data, according to this procedure.

f. Operation of the high flow oxygen delivery system is limited to a respiratory therapist (RT) or RN in the ED, ICU, DOU, or SCI and Palliative Care Units.

5. PROCEDURES:

a. Oxygen delivery systems are applied according to the manufacturer’s instructions and used in the following manner (see chart below).

Delivery System Oxygen Liter Flow and

Concentration

Special Considerations

Nasal Cannula: oxygen is delivered through plastic cannulas in the patient’s nares.

1–6 L/min 24–44%

• Humidification is required if liter flow is greater than 4 L/min

• Use with caution in COPD patients at flow rates greater than 2 L/min

• The nasal cannula DOES NOT need to be removed for daily activities such as eating

Simple Mask: oxygen flows through an entry port at the bottom of the mask and exits through large holes on the sides of the mask.

5-12 L/min 35-50%

• No bubble humidifier required

Venturi Mask: mask is connected to a Venturi device, which mixes a specific volume of air and oxygen.

3–15 L/min:

24–50%

• No bubble humidifier required

• Increase of flow does not increase

FiO2

Oxygen Aerosol Devices:

a face mask, hood, tent, or tracheostomy tube or collar is connected to wide-bore tubing that receives aerosolized oxygen from a jet nebulizer.

6–15 L/min in flow meter. FiO2 selection: 28 – 100% oxygen concentration on the aerosol bottle.

• Oxygen Aerosols are used to deliver specific FiO2 with high humidity

• If FiO2 equal to or greater than 50% is required, a high flow device is required to supply oxygen at more than 15 LPM in order to provide the required FiO2

• Increase in liters per minute (LPM) does not increase FiO2

Non–rebreather mask: on inhalation, a one-way valve opens, directing oxygen from a reservoir bag into the mask.

On exhalation, gas exits the mask through the one-way expiratory valve and enters the atmosphere. The patient only breathes oxygen from the bag.

10 –15 L/min:

delivers between 70– 100% oxygen concentration

• Mask should fit snugly

• The bag must be visualized to verify the oxygen liter flow is sufficient to keep the reservoir bag inflated during inspiration

High-Flow Oxygen Delivery System: integrates the use of an oxygen/air blender, a 70 L/min flow meter and a heated humidifier.

The minimum flow is 30 L/min up to 70 L/min.

The FiO2 is selected by a dial on the oxygen blender.

• The FiO2 is weaned to below 50% before changing to another oxygen delivery system

• The liter flow must not be weaned below 30 L/min

• This can be administered by an aerosol mask, but is usually administered by a heated/humidified nasal cannula

b. Initial Assessment:

(1) Determine patient’s general oxygenation status by observing:

(a) Patient’s general appearance including level of consciousness, speech pattern, and posture.

(b) Condition of nasal and oral mucosa.

(c) Skin color and temperature; lips and nail bed color.

(d) Respiratory rate, rhythm, depth, and pattern; ease of inspiration/expiration and accessory muscle use.

(e) Presence of adverse signs/symptoms including cyanosis, shortness of breath, wheezing, rales, and rhonchi.

(f) Oxygen saturation determined by pulse oximetry or arterial blood gas.

(2) Review oxygen therapy administration device and flow rate or FiO2 and ensure that the oxygen delivery device/humidifier is connected to a green oxygen outlet.

(3) In areas where wall oxygen is not available procure a portable oxygen tank from the fire protective cabinet.

c. Ongoing Monitoring:

(1) Monitor the patient for the following:

(a) Signs/symptoms of hypoxemia

(1) Restlessness, confusion, lethargy, and coma.

(2) Tachycardia and dysrhythmias.

(3) Tachypnea and use of accessory muscles.

(4) Altered blood pressure.

(5) Cyanosis.

(b) Signs/symptoms of respiratory distress

(1) Pursed lip breathing.

(2) Tripod positioning.

(3) Intercostal retractions.

(4) Use of accessory muscles.

(5) Speaking only one or two words between breaths.

(6) Coughing.

(2) Monitor oxygen delivery system:

(a) Observe the oxygen liter flow for the correct flow rate.

(b) Ensure humidifier bottles do not run dry as non-humidified oxygen may cause discomfort. Humidified bottles are changed when empty or weekly by RT.

(c) Evaluate patency of oxygen tubing as kinks/knots can cause disruption of oxygen flow.

(d) If using nasal cannula, assess nostrils for patency as an occlusion such as secretions or blood may negate the benefits of oxygen therapy.

(e) If using a partial non-rebreather mask, check for a snug mask fit as poor fit may dilute the oxygen concentration and ensure that the bag does not totally deflate during inhalation.

d. Comfort:

(1) Ensure proper position of tubing/mask/cannula.

(2) Assess the patient’s skin every shift for redness or pressure points from the oxygen delivery device (e.g. ears, nares, face). Pad pressure areas or use pressure relieving device (e.g. foam trach ties) as needed.

(3) Provide nasal/face care every shift while oxygen in use:

(a) Apply water-soluble lubricant to nares/lips. Do not use petroleum-based products.

(b) Keep patient’s face dry when mask in use.

(c) Provide oral hygiene every 4 hours.

(d) Provide patient with ice chips/lozenges as ordered.

(4) Clear oral, nasal, and tracheal secretions as appropriate.

e. Hydration:

(1) Offer fluids as necessary (unless contraindicated).

f. Safety:

(1) Use an oxygen tank for transporting and emergency purposes only.

(a) Oxygen tanks must be mounted on an appropriate bracket or trolley during transport.

(2) Never leave a tank standing unsupported or lying on the floor.

(3) Secure tanks when not in use in unit fire protective storage cabinet in approved locations.

(4) It is recommended that units keep only 12 oxygen tanks in their area at a time.

(5) Ensure oxygen tanks are replaced before they become empty by contacting respiratory therapy.

(a) A full tank has a white seal across the opening of the tank main valve.

(b) A partially used tank has a regulator on the tank which reads the amount of oxygen remaining.

(c) An empty tank has no seal across the valve opening and no regulator attached.

(6) Do not use petroleum-based products around patient’s face and oxygen source.

Use only water-soluble lubricants and creams.

(7) Turn oxygen off when not in use.

(8) Ensure oxygen tubing is connected to green oxygen wall flowmeter and not a yellow compressed air outlet.

(9) Prohibit patient or visitor smoking.

g. Pulse Oximetry:

(1) Validate with the patient’s provider the use of pulse oximetry in patients with known poor peripheral perfusion, hypotension, low hemoglobin less than 10 g/dL, sickle cell disease, elevated carbon monoxide levels, known low oxygen saturation, dysrhythmia (such as bradycardia or atrial fibrillation), infusion of vasoconstricting medications, tremors or shivering as these conditions may interfere with the accuracy of the pulse oximetry results.

(2) A provider’s order is required for continuous pulse oximetry monitoring except in the following situations:

(a) Patient requiring mechanical ventilation.

(b) Patient experiencing hemodynamic instability (e.g. dysrhythmias;

unstable vital signs).

(c) Patient experiencing respiratory insufficiency (e.g. severe shortness of breath; tachypnea).

(d) Patients undergoing special diagnostic or therapeutic procedures.

(e) Patients in units in which it is part of the standard monitoring routine.

(3) A single pulse oximetry reading is obtained on all patients requiring oxygen therapy as part of their routine vital signs and as needed with evidence of the patient experiencing hemodynamic instability or respiratory insufficiency.

(4) Apply pulse oximeter as follows:

(a) Actively identify the patient.

(b) Explain the procedure to the patient.

(c) If using an adhesive probe, ensure the patient is not allergic to adhesive.

(d) Choose a finger with adequate circulation (a strong pulse close to the site and brisk capillary refill). A toe may also be used if circulation to the distal lower extremities is adequate. If circulation to the fingers is inadequate, consider using the ear, forehead or bridge of nose.

(1) Avoid placing the sensor on an extremity with an arterial line, pressure dressing, restraint, or noninvasive BP cuff (pulsatile flow may be interrupted).

(2) Remove any fingernail polish or artificial nail on the digit used for monitoring.

(3) Determine the presence of an adequate waveform correlating with pulse.

(e) Select an appropriate sensor taking into account the patient’s activity, perfusion, available sites, and expected duration of monitoring. Ensure the manufacturer’s sensor is recommended for the site selected.

(f) Apply the sensor without allowing any gaps between the sensor and skin.

Make sure the sides are directly opposite each other.

(g) Check the radial/apical pulse rate and compare with the rate on the pulse oximeter.

(h) Shield the sensor from excess light (such as with a dry washcloth), and cover a cold extremity with a warm blanket for best pulse detection.

(i) Obtain SpO2 value and record.

(j) Compare SpO2 readings with previous readings and correlate them with changes in oxygen therapy and patient’s condition.

(5) For continuous pulse oximetry

(a) Remove oxygen sensor on a regular basis and check for signs of skin irritation or pressure (every 2 hours for spring tension sensor or every 4 hours for adhesive sensor).

(b) Ensure alarm limits for saturation and pulse rate are set appropriately for the patient's current condition and ensure alarms are turned on, functioning properly, and audible to staff.

(6) Cleaning of reusable equipment after obtaining pulse oximetry: Clean the pulse oximeter monitor and reusable sensor according to manufacturer’s recommendations between patients, whenever the device remains in a patient’s room for prolonged periods, when soiled, or when it has come in contact with potentially transmissible organisms.

h. Oxygen Titration:

(1) If during the titration process a higher flow delivery device becomes necessary, a new oxygen therapy order must be obtained (e.g. a change from nasal cannula to simple mask).

(2) If during the titration process a lower flow delivery device becomes necessary, a new oxygen therapy order is not required.

(3) If during the titration process the patient is weaned to room air, a new oxygen therapy order is not required unless greater than 24 hours has elapsed since last use of oxygen therapy.

(4) If during the titration process a COPD patient requires a higher FiO2 the treating physician is notified.

(5) Verify the provider’s order for oxygen titration parameters.

(6) Determine the baseline SpO2.

(7) If the SpO2 is greater than 92% or the prescribed parameter:

(a) Decrease the liter flow by 1 L/min.

(b) Recheck oxygen saturation within 1 hour of change/prn (not to exceed 1 hour schedule) and continue to decrease by 1 L/min. In non-critical care areas, oxygen concentration should be changed no more frequently than q 1 hour unless otherwise specified.

(c) Continue to decrease the liter flow and recheck saturation within 1 hour of change/prn (not to exceed 1 hour schedule) until the SpO2 can be maintained on room air.

(d) After the patient has been weaned to room air, recheck the SpO2 within 1 hour to ensure saturation has maintained above 92%.

(e) If SpO2 is greater than 92% and the patient is without complaints of discomfort, SOB, tachypnea, cyanosis, or accessory muscle use, discontinue the oxygen therapy.

(f) For the first 24 hours after the oxygen has been stopped, continue to recheck SpO2 with vital signs.

(g) If the oxygen remains off for at least 24 hours, obtain a written provider’s order to discontinue oxygen therapy.

(h) If the oxygen has been resumed at any time during the 24 hours that it was first discontinued, a new order does not need to be obtained.

(8) If the SpO2 is less than 92% or the provider’s prescribed parameter:

(a) Increase the liter flow by 1 L/min each minute until the SpO2 is 92% or to the provider’s prescribed parameter.

(b) Monitor the patient for changes in mental status, color, work of breathing, and need for suctioning.

(c) Continuously monitor the SpO2 until it stabilizes at 92% or to the provider’s prescribed parameter.

(d) If the SpO2 remains less than 92% or the provider’s prescribed parameter, after intervention, notify respiratory therapy and the patient’s provider.

(e) Monitor the patient for changes in mental status, color, work of breathing, and need for suctioning.

(f) Continue to monitor the SpO2 and notify the patient’s provider immediately if the patient acutely desaturates to levels less than 90% and is non-responsive to interventions such as increasing the O2 liter flow, suctioning, calming patient etc.

i. Patient/Family Education:

(1) Explain to the patient/family why oxygen is prescribed.

(2) Instruct the patient/family to call the nurse for:

(a) Soreness of nares, mouth, or throat.

(b) Shortness of breath.

(c) Disruption in oxygen delivery system/oximetry sensor (if continuously used).

(3) Instruct the patient and the family that no smoking is allowed while oxygen is in use.

(4) Instruct patient about importance of leaving oxygen delivery device on.

j. Reportable Conditions:

(1) Notify the patient’s provider immediately if the patient acutely desaturates to levels less than 90%, and is non-responsive to interventions such as increasing the O2 liter flow, suctioning, calming patient.

(2) Notify the patient’s provider for the following:

(a) Signs of oxygen toxicity: substernal chest pain that increases with deep breathing; dyspnea; dry cough; nasal stuffiness, sore throat, eye and ear discomfort; and restlessness.

(b) When there are no titration orders and the patient has continuous SpO2 readings above 97%, which may indicate a patient is receiving unnecessary oxygen.

(c) If SpO2 readings conflict with other oxygenation appraisals.

k. Documentation:

(1) Use of oxygen therapy and abnormal findings in daily RN assessment note (title of note varies per unit) in CPRS.

(2) SpO2 levels: CPRS Vitals or unit flow sheet.

6. REFERENCES:

a. American Association for Respiratory Care (2002). AARC guideline: Oxygen therapy for adults in the acute care facility. The Science Journal of the American Association for Respiratory Care. Retrieved from http://www.rcjournal.com/cpgs/otachcpg-update.html

b. Austin, M. A., et al. (2010). Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial. British Medical Journal, 341: 1– 8.

c. Cameron, L. et al. (2012). The risk of serious adverse outcomes associated with hypoxaemia and hyperoxaemia in acute exacerbations of COPD.

Postgraduate Medical Journal, 88: 684–689.

http://www.rcjournal.com/cpgs/otachcpg-update.html

d. National Patient Safety Agency. (2010). Safety in practice: Making oxygen use safer in hospitals. Nursing Times, 106(19), 10–11. Retrieved from http://www.nursingtimes.net/Journals/1/Files/2010/5/18/Safety%20in%20pra ctice%20-%20making%20oxygen%20use%20safer%20in%20hospitals.pdf

e. O’Driscoll, B. R., Howard, L. S. and Davison, A. G. (2008). BTS Guideline for Emergency Oxygen Use in Adult Patients. Thorax, 63 (Suppl VI).

f. Oxygen administration (2014). Lippincott’s nursing procedure and skills. Retrieved from http://procedures.lww.com/lnp/home.do?m=selection&d=187&setCookie=25

g. Oxygen Therapy (Short-Term). The Joanna Briggs Institute. Retrieved from http://ovidsp.tx.ovid.com/sp- 3.13.1a/ovidweb.cgi?&S=IAECFPPADGDDGGFDNCLKFDIBMHKIAA00&Li nk+Set=S.sh.23%7c1%7csl_190

h. Taylor, C. R., et al. (2015). Fundamentals of nursing: The art and science of nursing care. (8th ed.). Philadelphia, PA: Wolters Kluwer.

i. VA San Diego Healthcare System Nursing Service Administrative Policy: Nursing Role Differentiation, July 25, 2013.

j. Wijesinghe, M., Perrin, K., Healy, B., et al. (2011). Pre-hospital oxygen therapy in acute exacerbations of chronic obstructive pulmonary disease. Internal Medicine Journal, 41:618–22.

7. REVIEW DATE:

a. September 2018

8. FOLLOW-UP RESPONSIBILITY:

a. Nursing Practice Council

9. RESCISSION:

a. Oxygen Therapy Management, dated April 2015.

10. SIGNATURE:

X Sandra Solem, PhD., RN AD, Patient Care Services/Nurse Executive http://www.nursingtimes.net/Journals/1/Files/2010/5/18/Safety%20in%20practice%20-%20making%20oxygen%20use%20safer%20in%20hospitals.pdf http://www.nursingtimes.net/Journals/1/Files/2010/5/18/Safety%20in%20practice%20-%20making%20oxygen%20use%20safer%20in%20hospitals.pdf http://procedures.lww.com/lnp/home.do?m=selection&d=187&setCookie=256 http://procedures.lww.com/lnp/home.do?m=selection&d=187&setCookie=256 http://ovidsp.tx.ovid.com/sp-3.13.1a/ovidweb.cgi?&S=IAECFPPADGDDGGFDNCLKFDIBMHKIAA00&Link+Set=S.sh.23%7c1%7csl_190 http://ovidsp.tx.ovid.com/sp-3.13.1a/ovidweb.cgi?&S=IAECFPPADGDDGGFDNCLKFDIBMHKIAA00&Link+Set=S.sh.23%7c1%7csl_190 http://ovidsp.tx.ovid.com/sp-3.13.1a/ovidweb.cgi?&S=IAECFPPADGDDGGFDNCLKFDIBMHKIAA00&Link+Set=S.sh.23%7c1%7csl_190

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