Oxygen therapy

Fundamental of Nursing -Unit vii

1. Oxygen Therapy B G I S Ariyarathne RN , BSc nsg Hon 1st class Tutor Trainee

2. Unit outcome Safely administer respiratory medication to the patient with ineffective breathing according to the medical prescription by following standardized nursing procedures

3. Specific outcomes Identify main sources of oxygen in clinical practice Identify oxygen administration devices Discuss potential harm from oxygen therapy List out nurse’s responsibilities when administrating oxygen

4. Oxygen Therapy Definition Oxygen is a colorless, odorless, tasteless gas that is essential for the body to function properly and to survive Oxygen therapy is the administration of oxygen at a concentration of pressure greater than that found in the environmental atmosphere

5. Oxygen Therapy Definition cont.. The air that we breathe contain approximately 21% oxygen Oxygen therapy is a key treatment in respiratory care

6. Purposes The body is constantly taking in oxygen and releasing carbon dioxide If this process is inadequate, oxygen levels in the blood decrease, and the patient may need supplemental oxygen The purpose is to increase oxygen saturation in tissues where the saturation levels are too low due to illness or injury

7. Assess need of oxygen therapy Need is determined by measurement of inadequate oxygen tensions or saturations, by invasive or noninvasive methods, or the presence of clinical indicators as previously described Arterial blood gases (ABG) Pulse oximetry Clinical presentation

8. Pulse oxymetry ABG

9. Indications for Oxygen therapy Acute Respiratory Failure Acute Myocardial Infarction Cardiac Failure Shock Hypermetabolic State Induced by t rauma, burns or sepsis

10. Indications cont : Anemia Cyanide poisoning During CPR During anesthesia for surgery

11. Oxygen A prescribed drug • Must be written legibly by the doctor • Prescription should be dated by the doctor • Doctor must indicate duration of oxygen therapy • The Oxygen concentration must be prescribed • The flow rate must be prescribed

12. Types of Oxygen ( i) Compressed oxygen cylinders stored as a gas under pressure in a cylinder equipped with a flow meter and regulator to control the flow rate

13. Types of Oxygen cont … (ii) Liquid oxygen system Liquid oxygen is made by super cooling oxygen gas, which changes it to liquid form. When in liquid form, the oxygen takes up much less room and can be stored in special thermos

14. Types of Oxygen cont.. (iii)Oxygen concentrator electrically operated medical device that extracts air from the room, separates the oxygen from other gases present, and delivers oxygen to the patient

15. Sources of oxygen: Oxygen cylinder 2. Oxygen wall outlets

16. Oxygen ( O2)cylinders Black with white shoulders Within the hospital environment oxygen is usually found in 3 main areas Critical care areas Operating theatres Most wards & treatment therapy areas

17. Oxygen (O2)cylinders Black with white shoulders In most areas the oxygen service is piped Cylinder oxygen is normally used as an emergency back up and for patient transport/transfer The approximate consumption rate of a Oxygen cylinder at 5L per min is 1.5hrs Large cylinder contain 6800l at 6l/min can use for 19 hrs

18. Oxygen cylinder size

19. Using oxygen cylinders : The oxygen cylinder is delivered with a protective cap to prevent accidental force against the cylinder outlet To release oxygen safety and at a desirable rate, a regulator is used A reduction gauge that shows the amount of oxygen in the tank

20. Using oxygen cylinders cont …. A flow meter that regulates the control of oxygen in liters per minutes Oxygen is moistened by passing it through a humidifier to prevent the mucous membranes of the respiratory tree from becoming dry.

21. Oxygen Regulator

22. Oxygen Regulator Before using regulator check for no signs of damage, loose connections or dirt or grease Regulators can be obtained from hospital medical equipment stores It is very expensive

23. Oxygen regulator To set flow turn knob by using oxygen key anti clockwise until ball rises to the flow rate required, watch for 2-3 seconds to ensure flow rate maintained, the ball should sit in the middle of the required rate

24. Oxygen regulator When not in use the flow of gas must be turned off by turning knob clockwise and the ball falls to zero. Oxygen regulator should be operated by qualified nursing/medical staff

25. Oxygen key

26. Humidifier bottle Fill the humidifier bottle with distilled water to the maximum fill line Do not overfill To be changed daily

27. Care of oxygen cylinder Always use cylinder of metal case to prevent danger of falling & breaking Oxygen cylinder should be placed at head end of the bed Any source of fire should be kept away from cylinder for fear of fire Oxygen cylinder should be placed at cool temperature

28. Care of oxygen cylinder When cylinder are empty , always marks i.e. “ empty “ & send for filling Inspect the apparatus at frequent intervals & make sure for its good working condition To test any leakage in the regulator soap may be used

29. Oxygen cylinders storage Storage is divided into two types, a MAIN store and smaller units, situated in convenient locations around the hospital and known as READY TO USE stores In addition to this have areas on ward where two or more cylinders hold, ready for administration to a patient, this refer to as a cylinder parking area

30. Oxygen cylinders storage cont …. Where ever medical gases are stored, they should be on their own and away from any other flammable gases or other materials

31. Storage of Oxygen

32. How to order oxygen gas cylinders Always should be keep stand by ready for use cylinder in ward/unit Before over all cylinders, need exchange empty cylinders There is a separated date for get down oxygen for the ward/unit Should be got down relevant day It is a responsibility of nurses’

33. How to order oxygen gas cylinders Write oxygen book to the chief pharmacist with the numbers of empty cylinders and request new cylinders from indoor dispensary Received cylinders must be checked and take over and to be stored proper way as ready for use

34. How to request oxygen gas cylinders for the ward/unit W d 34, 2020. 01.30. CP Please exchange following empty oxygen gas cylinders 23091 22031 Thank You …………………. Wd manager wd 34

35. How to transport oxygen gas with patient

36. Wall – outlet oxygen • The oxygen is supplied from a central source through a pipeline • Only a flow meter and a humidifier are required All bed spaces with access to piped oxygen should have a flow meter in situ so it can be used if necessary When oxygen is not in use flow meters should be switched off

37. Classification of Oxygen Delivery Systems 1. Low flow systems contribute partially to inspired gas client breathes Ex : nasal cannula , nasal catheter, simple mask , non-re breather mask , Partial rebreather mask

38. Classification of Oxygen Delivery Systems 2. High flow systems deliver specific and constant percent of oxygen independent of client’s breathing Ex: Venturi mask,, tracheostomy collar, T-piece

39. Oxygen inhalation devices Nasal Cannula Simple Mask Partial Re-Breather Mask Non-Re Breather Mask (NRBM) Venturi Mask Oxygen Hood Oxygen Tent AMBU Bag Tracheostomy Collar T-piece

40. How to select method S elected method depends on Required concentration of oxygen Desired variability in delivered oxygen concentration (None, minimal, moderate) Required ventilator assistance( mechanical ventilator, spontaneous breathing)

41. Nasal cannula (prongs): It is a disposable, plastic devise with two protruding prongs for insertion into the nostrils, connected to an oxygen source. Used for low-medium concentrations of Oxygen (24-44 %). Need nose breathing

42. Nasal cannula

43. Nasal cannula (prongs): cont.. Amount d elivered Fio2 (Fraction Inspired Oxygen) Low flow- 24-44 % 1 L/min=24 % 2 L/min=28 % 3 L/min=32 % 4 L/min=36 % 5 L/min=40 % 6 L/min=44%

44. Nasal cannula (prongs): cont.. Advantages Disadvantages Client able to talk and eat with oxygen in place • Easily used in home setting • Safe and simple • Easily tolerated • Delivers low concentrations Unable to use with nasal obstruction • Drying to mucous membranes, so flow greater than 4 L/min needs to be humidified • Can dislodge from nares easily • Causes skin irritation or breakdown over ears or at nares • Not good for mouth breathers • Patient’s breathing pattern affects exact FIO2

45. Nasal cannula (prongs): cont.. NURSING interventions : Be alert for skin breakdown over the ears and in the nostrils from too tight an application Observe for mucosal dryness Check frequently that both prongs are in clients nares

46. Nasal Catheter Flexible, lubricated oxygen catheter with multiple holes in distal 2 cm Advanced posteriorly into the pharynx through nostril No advantage over nasal cannula Hemorrhage and gastric distention can occur

47. nasal catheter

48. Face mask The Simple Oxygen Mask BLB mask (Boothby Levelace Bulbulian ) The Partial Re-Breather Mask The Non Re- Breather Mask The Venturi Mask

49. The simple Oxygen mask (Hudson’s mask) Simple mask is made of clear, flexible , plastic or rubber that can be molded to fit the face . It is held to the head with elastic bands. Some have a metal clip that can be bent over the bridge of the nose for a comfortable fit . It delivers 35% to 60% oxygen A flow rate of 6 to 10 liters per minute

50. The simple Oxygen mask It has vents on its sides which allow room air to leak in at many places, thereby diluting the source oxygen. Often it is used when an increased delivery of oxygen is needed for short periods (i.e., less than 12 hours )

51. Simple Oxygen Mask Cont.. Advantages Disadvantages: Can provide increased delivery of oxygen for short period of time Tight seal required to deliver higher concentration Difficult to keep mask in position over nose and mouth Potential for skin breakdown (pressure, moisture) Uncomfortable for patient while eating or talking Expensive with nasal tube

52. Simple Oxygen Mask Cont.. Nursing interventions: • Monitor client frequently to check placement of the mask • Secure physician's order to replace mask with nasal cannula during meal time

53. BLB mask (Boothby Levelace Bulbulian ) A mask used for administering oxygen to patients during anesthesia

54. The Partial Re Breather Mask: The mask is with a reservoir bag that must remain inflated during both inspiration & expiration It collects of part of the patients' exhaled air It is used to deliver oxygen concentrations up to 80 %

55. The oxygen flow rate must be maintained at a minimum of 6 L/min to ensure that the patient does not re-breathe large amounts of exhaled air The remaining exhaled air exits through vents

56. Partial Re Breather Mask : cont.. Advantages Disadvantages Client can inhale room air through openings in mask if oxygen supply is briefly interrupted Requires tight seal (eating and talking difficult, uncomfortable)

57. Partial Re Breather Mask: cont.. Priority Nursing Interventions Set flow rate so mask remains two- thirds full during inspiration Keep reservoir bag free of twists or kinks

58. Non Re- Breather Mask This mask provides the highest concentration of oxygen (95-100%) at a flow rate6-15 L/min. It is similar to the partial re-breather mask except two one-way valves prevent conservation of exhaled air. The bag has an oxygen reservoir

59. Non Re- Breather Mask When the patient exhales air the one-way valve closes and all of the expired air is deposited into the atmosphere, not the reservoir bag. In this way, the patient is not re-breathing any of the expired gas.

60. Non Re- Breather Mask

61. Non Re- Breather Mask

62. Non Re- Breather Mask Advantages Disadvantages  Delivers the highest possible oxygen concentration . Suitable for patient breathing spontaneous with sever hypoxemia Impractical for long term Therapy Malfunction can cause CO2 buildup suffocation Expensive Uncomfortable

63. Non Re- Breather Mask Priority Nursing Interventions Maintain flow rate so reservoir bag collapses only slightly during inspiration Check that valves and rubber flaps are function properly (open during expiration ) Monitor SaO2 with pulse oximeter

64. Venturi Mask It is high flow oxygen delivery device. Oxygen from 40 - 50% At liters flow of 4 to 15 L/min. The mask is constructed so that there is a constant flow of room air blended with a fixed concentration of oxygen

65. Venturi Mask cont.. Designed with wide- bore tubing and various color - coded jet adapters. Each color code corresponds to a precise oxygen concentration and a specific liter flow. It is used primarily for patients with chronic obstructive pulmonary disease

66. Venturi valve

67. Venturi Mask cont.. Advantages Disadvantages Delivers most precise oxygen Concentration Doesn’t dry mucous membranes uncomfortable Risk for skin irritation Produce respiratory depression in COPD patient with high oxygen concentration 50%

68. Venturi Mask cont … Priority Nursing Interventions • Requires careful monitoring to verify FiO2 at flow rate ordered • Check that air intake valves are not blocked

69. Oxygen Hood An oxygen hood is used for babies who can breathe on their own but still need extra oxygen. A hood is a plastic dome or box with warm, moist oxygen inside. The hood is placed over the baby's head

70. Oxygen Tent An oxygen tent consists of a canopy placed over the head and shoulders, or over the entire body of a patient to provide oxygen at a higher level than normal. Typically the tent is made of see-through plastic material.

71. Oxygen Tent cont.. It can envelop the patient’s bed with the end sections held in place by a mattress to ensure that the tent is airtight. The enclosure often has a side opening with a zipper.

72. Ambu bag A rtificial M anual B reathing U nit (or) Bag Valve Mask Ventilation is a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately

73. Ambu Bag

74. Tracheostomy Collar/ Mask Inserted directed into trachea Is indicated for chronic O2 therapy need O2 flow rate 8 to 10L Provides accurate FIO2 Provides good humidity Comfortable ,more efficient

75. Tracheostomy Collar/ Mask

76. T-PIECE Used on end of ET tube when weaning from ventilator Provides accurate FIO2 Provides good humidity

77. T- Piece

78. T- Piece

79. Artificial Airway

80. Oropharyngeal Airway

81. Oropharyngeal Airway Size: corner of mouth to angle of jaw

82. Nasopharyngeal Airway

83. Tracheostomy Vocal folds Thyroid cartilage cricoid cartilage Tracheal rings Balloon cuff

84. Endotracheal Airway Most effective and reliable method of assisted ventilation because:– The airway is isolated, ensuring adequate ventilation and O2 delivery Reduces aspiration chance

85. Endotracheal Airway cont …. Interposition of ventilations with chest compressions can be accomplished efficiently Inspiratory time and P eak I nspiratory P ressure(PIP) can be controlled P ositive E nd E xpiratory Pressure(PEEP) can be delivered .

86. Indications for Intubation Inadequate CNS control of ventilation Functional or anatomic airway obstruction Loss of protective airway reflexes Excessive work of breathing

87. Indications for Intubation cont …. Need of high PIP or PEEP Need of MV support Potential occurrence of any of the above if patient is transported

88. Endotracheal Tube A cuffed ET tube is generally indicated for children aged 8-10 yrs. or older In younger children normal anatomic narrowing at the level of cricroid cartilage provides a functional cuff ET tube size= age/4 + 4

89. Endotracheal Tube length= age/2 +12 or depth of insertion= tube size*3 ET tube 0.5 mm smaller and larger should be readily available.

90. Non cuffed ET tube

91. Cuffed ETT

92. Inhalation Therapy

93. Aerosol treatments Administering medications into the airways The method can be nebulizers or oropharengeal inhalers These devices deliver topical medications to the respiratory tract

94. Aerosol treatments cont Producing local and systemic effects The mucosal lining of the respiratory tract absorbs the inhalant almost immediately

95. Medications used to improve respiratory functioning Epinephrine injection Bronchodilators Salbutamol Theophylline Terbutaline Metaproterenol ( alupent ) Aminophyllin inj Corticosteroids Antihistamins

96. Metered dose inhalers

97. Spacers Provide greater benefits for children and patients with poor coordination Provides more dead air space for mixing medication

98. Dry Powder Inhaler

99. Nebulization Nebulizer is a type of inhaler that sprays a fine, liquid mist of medication. The medication is instilled into the nebulizer chamber

100. Nebulization cont.. two types of nebulizers- jet aerosol, ultrasonic jet – gas under pressure, ultrasonic- vibrations Nebulization improves clearance of pulmonary secretions and bronchodilation

101. Nebulizer

102. Tracheostomy tubes Disposable or reusable cuffed or non cuffed tube for airway maintenance Inner cannula disposable or reusable Fenestrated tube

103. Mechanical ventilation Mechanical ventilation is a method to mechanically assist or replace spontaneous breathing A ventilator is a device used to provide assisted respiration and positive-pressure breathing Mechanical ventilation is the use of mechanical device (machine) to inflate and deflate the lungs

104. CPAP Administering oxygen by CPAP(continuous positive airway pressure): 1. Non invasive CPAP 2.Nasal CPAP 2-Endotracheal CPAP

105. Non invasive CPAP

106. Nasal CPAP It consists of a single nasopharyngeal tube that deliveries 2-8 cm of positive pressure with or without o2. Nursing care : - Frequent suction . - Tube care. - Change the nasal tube

107. Endotracheal CPAP Continues Positive Airway pressure delivering via an ETT. Nursing care : Use sterile suctioning techniques - Mouth care - Change the ETT every seven days

108. Side Effects & Complication Of Oxygen Therapy Oxygen toxicity Retro lental fibroplasia Absorption atelectasis Infections

109. Oxygen Toxicity It is a condition which occurs due to inspiration of a high concentration of oxygen for a prolonged period of time Oxygen concentration greater than 50% over 24 to 48 hours can cause pathological changes in the lungs

110. Signs and symptoms of oxygen toxicity Non-productive cough Nausea and vomiting Substernal chest pain Fatigue Nasal stuffiness Headache Sore throat Hypoventilation Nasal congestion Dyspnea Inspiration pain

111. Retro lental fibroplasia Blindness due to vasoconstriction & Ischemia ( premature infants ) owing to the excessive administration of oxygen Normal Disease

112. Absorption Atelectasis During 100% oxygen delivery, nitrogen in alveoli is washed out and replaced by oxygen. In contrast to nitrogen, oxygen is extremely soluble in blood and diffuses very quickly into the pulmonary vasculature

113. Absorption Atelectasis cont.. So that not enough gas is left in the alveoli to maintain patency Alveolus collapses; this is known as absorption atelectasis

114. Absorption Atelectasis

115. Safety Precautions During Oxygen Therapy Oxygen is a highly combustible gas It can easily cause a fire in a patient’s room if it contacts a spark from an open flame or electrical equipment Oxygen is a therapeutic gas and must be prescribed and adjusted only with a health care provider’s order

116. Safety Precautions During Oxygen Therapy cont … Place an “Oxygen in Use” sign on the patient’s door and in the patient’s room. If using oxygen at home, place a sign on the door of the house No smoking should be allowed on the premises Keep oxygen-delivery systems 10 feet from any open flames

117. Safety Precautions During Oxygen Therapy Determine that all electrical equipment in the room is functioning correctly Accidental opening outlet could cause the tank to take off like a dangerous jet When using oxygen cylinders, secure them so they do not fall over Store them upright and either chained or secured in appropriate holders

118. Safety Precautions During Oxygen Therapy Check the oxygen level of portable tanks before transporting a patient to ensure that there is enough oxygen in the tank Do not use oil on oxygen equipment.( Rationale: Oil can ignite if exposed to oxygen)

119. Safety Precautions During Oxygen Therapy cont.. With all oxygen delivery systems, the oxygen is turned on before the mask is applied to the client Make sure the tubing is patent at all times and that the equipment is working properly

120. Nursing responsibilities for administration of oxygen Check the name & bed no. & other identification of patient Check the diagnosis & need for oxygen therapy Check the doctors order for the initiation of the therapy dosage etc

121. Nursing responsibilities for administration of oxygen cont.. Check the doctors order for specific precaution regarding the movement of the positioning of the patient Assess the patient for any sign of clinical analysis ex: cyanosis Check the patients vital sign

122. Nursing responsibilities for administration of oxygen cont.. Check the result of arterial blood gas analysis Note any signs of pulmonary dysfunction Check the patients mental state & the ability to follow instructions Check the articles available in the unit

123. Nursing responsibilities for administration of oxygen cont.. Check the oxygen cylinder for its accessories & their working condition Maintain a constant oxygen concentration for the client to breathe

124. Nursing responsibilities for administration of oxygen cont.. Give pain medications as needed, prevent chilling and try to ensure that the client gets needed rest Be alert to cues about hunger and elimination.( Rationale: The client’s physical comfort is important .) Provide good oral hygiene Lubricate nares Make relevant documents

125. Documentation Date and time oxygen started Method of delivery Oxygen concentration and flow rate Patient observation Add oronasal care to the nursing care plan

126. Summary Main sources of oxygen in clinical practice Oxygen administration devices Potential harm from oxygen therapy Nurse’s responsibilities when administrating oxygen

127. Assignment 1. Write nursing care of patient with Oxygen therapy via simple face mask

128. References Potter.P.A ., Perry. A.G. (2006). Fundamentals of nursing (6th ed ). Elsevier publishers. New delhi . Pp1121-1131. Taylor. C., Lillis.C ., Lemone.P . (1993). Fundamentals of nursing (2nd ed ). Lippincot company. Philadelphia. Pp942-993. Wong.M ., Elliot. M. (2009). The use of medical orders in acute care oxygen therapy. British journal of nursing. 18(8). Pp462-464. http://www.slideshare.net/mobile/aparnaA1/nursing management of patients with oxygen insufficiency

129. Thank You