1. Oxygen Therapy Fundamentals of nursing
Instructor: R. Hanock
Reading assignment: Fundamentals textbook (Burton)
pages: , (skills 28-3, 28-4 & 28-5)

2. Objectives: O2 Therapy
At the completion of this unit: The student will be able to:
Describe nursing interventions & routines that facilitate safe oxygen administration
Describe the various equipment items & methods of O2 delivery utilized to facilitate improved oxygenation.
State the S&S and underlying factors related to COPD, hypoxemia, & oxygen toxicity.
Explain assessment and documentation principles relating to the care of patients receiving O2 therapy.

3. Anatomy Overview Upper airway: nose, mouth, pharynx, & upper trachea
Lungs
Left lung - two lobes
Right lung - three lobes
> bronchi divide into bronchioles
> bronchioles terminate at the alveoli
Nose, mouth, pharynx, and trachea compose the upper airway. These structures transport air to the lungs
Trachea – divides into right & left main bronchi feeding the right & left lung with inspired air.
Bronchi subdivide into smaller airways. In each lobe of the lung, bronchi divide into bronchioles.
The bronchioles divide into alveoli. Alveoli are the terminal respiratory units where exchange of oxygen & carbon dioxide take place.

4. Oxygen Therapy
Oxygen is a medication and requires a physician order. Apply the 5 rights to medication administration Facilities often have protocols in place of MD orders. (I.e.: weaning protocols) Nursing responsibility: Always ensure that O2 is set to the prescribed rate. The universal color for O2 receptacles & equipment is _______________________

5. Oxygen Administration
Supplement oxygen in inspired air
Delivered by nasal cannula, mask, tent, croupette, or catheter
Requires humidification,
flow rate prescribed by
physician
Oxygen is essential to life. An optimum level of oxygen must be maintained in the blood to sustain cellular functioning.
Used to supplement oxygen in inspired air - Inspired air is 21% oxygen.
Can be delivered by nasal cannula, mask, tent, croupette, or catheter
Requires humidification, flow rate prescribed by a physician
Pure oxygen is a therapeutic agent, which can have adverse effects when given improperly. Therefore, the nurse must be familiar with the indications for oxygen use & the various types of equipment for oxygen delivery as well as possess skill in its use.

6. Ambu-Bag used for resuscitation
Provides ventilation in emergency situations

7. Oxygen Administration
Flow rates: 1-6 L/minute
1 L/min = 24%, 3L/min = 32%, L/min=44%
PTs with COPD given only 1-2 L/minute to prevent respiratory depression
Common flow rates are 4-6 L/min
COPD patients are given only 2 to 3 L/min to prevent causing respiratory arrest
Sign of oxygen toxicity is a dry cough

8. Position  Lung Expansion  Increased
surface area for gas exchange  Improved gas exchange (ventilation)

9. Nasopharyngeal (P.626, FIG 28-5) Oropharyngeal
Artificial Airways
Nasopharyngeal (P.626, FIG 28-5)
Oropharyngeal
Endotracheal tubes (p.626 FIG 28-5)
Tracheostomy (P.627 FIG
28-8)
Nasopharyngeal—inserted through the nose to keep the tongue from blocking the airway
Oropharyngeal—inserted through the mouth into the posterior pharynx to keep the tongue from blocking the airway
Used for unconscious patients and patients recovering from anesthesia
Maintain a patent airway and facilitate suctioning
Endotracheal tubes—used during anesthesia or during emergency situations to protect the airway and control gas exchange of unstable patients unable to ventilate effectively on their own
In general, removed after 48 to 72 hours
Tracheostomy—performed for patients requiring longer-term airway support

10. Pulse oximetry * Measuring oxygen saturation of hemoglobin
Monitors PTs at risk for hypoxemia
Physicians order or nurses discretion
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Oxygen saturation is the percentage of oxygen attached to the hemoglobin that the molecule is capable of holding.
Used to monitor any patient at risk for hypoxia
Measures changes in serum oxygen continuously
Attached to fingers, toes, ears, or skin
Helps track changes in oxygen therapy

11. Pulse Oximetry Devices:
measure the O2 saturation
levels of arterial blood by
use of light waves.
(skill 17-8, p. 371)

12. Common causes of airway obstructions Choking: airway occlusion
Disease processes (commonly neurological deficits)
Respiratory secretions
Common airway obstructions
Choking; obstruction by the tongue, foreign bodies, or food
Heimlich maneuver used to clear foreign objects
Respiratory secretions
Complete or partial obstruction
Present with different disease states such as pneumonia, or COPD.
Usually can be cleared by coughing; can be facilitated by postural drainage

13. Aspiration precautions
Keep upright during and after meals
Avoid thin liquids
Crush medications or use liquid forms
Keep suction set up at bed side
Place food in unaffected side of mouth (CVA clients)
Tuck chin to chest when swallowing

14. Nubulizer Treatments Hand held nebulizer
Nebulizer is a medication delivery system: air compressor, medication cup, mask or hand-held mouth piece
Vapor (mist) is inhaled into airways direct affects  less systemic affects
Review p.636, skill 28-4

15. Metered-Dose Inhaler/Multi-Dose Inhaler (MDI)
May be used with or without a spacer, requires
assessment
Measured doses of medication
Deliver dose during deep
inhalation
Medications dispersed in
mist
Compliance problems:
complex task for some

16. Incentive spirometer Teaching your patient about incentive spirometry
p.620: Patient Teaching Connection

17. Incentive Spirometer: Components
Piston Type Sphere Type
Nursing Instruction: Lift the spheres or piston as high as you can and hold them up for as long as you can with the deepest and longest inhalation that you are capable of. Perform 10 deep breathes every hour while you are awake and are not fatigued.

18. Equipment: Delivery Systems
Ps , table 28-4
Nasal cannula
Masks
Simple face mask
Partial rebreather
Nonrebreather
Venturi mask
Face tent
Nasal cannula: most comfortable, use during meals.
Masks cover the nose & mouth are sealed around the edges & provide the most consistent effective method of oxygen delivery.

19. Nasal Cannula: Low O2 Flow Delivery

20. Delivers 40 to 60% O2 concentrations
Simple Face Mask:
Delivers 40 to 60% O2 concentrations

21. Partial-Rebreather and Non-Rebreather Masks
Difference is with the ports & valves
Reservoir bag
Partial rebreather: CO2 is
Exhaled into reservoir bag and
Side ports (valves/vents) close
during Exhalation  CO2 is then
Inhaled.
Non-rebreather: the
Reservoir valves close and side
Vents open during exhalation.
CO2 is not available during
Inhalation.

22. Venti-Mask: Delivers 24-80% O2
Dial to change O2 concentration delivery

23. Tracheostomy with direct attachment Collars are frequently used
Tracheostomy shortens
The airway  less work
To breathe and
Expectorate secretions
Direct attachment used
When on ventilator.

24. T-Piece Attached to Tracheostomy

25. Oxygen & Humidity Tents
- For infants & young children
Cool saturated air to keep respiratory tract well hydrated
Used for croup, pneumonia, or other upper respiratory diseases

26. Does not deliver precise O2 concentrations
Face Tent
Does not deliver precise O2 concentrations

27. Patient Care Concerns Psychological Safety Fire Hazards
Pressure Hazards
Malfunctioning Equipment
Oxygen administration, although a common procedure, May make some patient’s anxious, which may increase difficulty in breathing.
Fire hazards: although oxygen itself is not explosive, it supports combustion. This means that extremely rapid burning takes place in the presence of high oxygen concentration, almost as if the oxygen itself were explosive “no smoking” 2. inspect all electrical equipment Avoid wool blankets.

28. Equipment Flow meter Regulator Pressure gauge Humidifier Sterile water
Humidification is provided by containers of sterile water, which may be prefilled & are disposable. The are attached to the o2 delivery equipment. O2 flows through them & picks up moisture. The water must be sterile to prevent infection from organisms that can grow in a moist environment. O2 is slightly soluble in water.

29. Pin index safety system
Most small O2 transport cylinders utilize the pin system to ensure proper placement of the O2 regulator.
The pin locations are located at 2 & 5.

30. Oxygen Regulators
Bourdon Gauge
 Brass
 Steel
 Aluminum

31. Oxygen Regulators Grab n GO  Brass Tank Construction  Steel
 Aluminum

32. Humidification of Oxygen
Moderate & high levels of O2 are drying and irritating to the mucous membranes of the airways.
A humidification device must be attached to the flow meter to humidify O2.

33. Oxygen Cylinder Storage
All cylinders must be stored securely!
Transport:
Rolling Stands
Bed stands
Storage:
Stationary Holders
Use the appropriate device for the task.

34. Magnetic Fields
Steel Cylinders and regulators may become projectiles when near a strong magnetic field.
Exercise extreme caution when near a Magnetic field

35. DOs and DON'Ts with Oxygen Equipment
Don't allow smoking around oxygen.
Do maintain oxygen equipment as the supplier & JCAHO instruct. Work closely with the respiratory therapy department.
Don't use equipment which is visibly dirty, in poor repair, or damaged.
Do use plugs, caps and plastic bags to protect "off duty" equipment from dust and dirt.

36. Oxygen Therapy Safety Precautions
Oxygen tanks contain oxygen under pressure
Oxygen supports combustion

37. Potential Physiological Problems
> Loss of stimulus to breath for those with Chronic Obstructive Pulmonary Disease (COPD) 1 – 2 L/Minute only > Oxygen is drying to respiratory membranes > Lung tissue damage occurs from continued use of high concentrations of O2.
When individuals with COPD have experienced impaired gas exchange for a long time they often have increased blood carbon dioxide. Their respiratory mechanisms may adapt to this abnormal state. The normal stimulus to breathing that changes CO2 levels creates is lost. In these individuals, the low oxygen level becomes the major stimulus for breathing. Abruptly changing the oxygen level without altering the CO2 level may result in the loss of stimulus for breathing, & the pt experiences decreased respiratory rate & may even progress to apnea. Therefore oxygen is initially administered at low levels & with caution for those who have COPD.
Drying of respiratory membranes: give good oral hygiene

38. Hypoxemia Impaired gas exchange
Resp. Insufficiency: ↓ oxygen level in blood caused by resp system abnormalities
Results in inability to meet cellular oxygen needs (hypoxia) &/or inability to remove excess carbon dioxide (hypercapnia).

39. Hypoxemia
Onset can be rapid or gradual while early signs are without difficulty breathing i.e.: dyspnea, labored respirations, SOB
Health threat: prolonged hypoxemia & hypercapnia starves tissues of O2 & causes acidosis  tissue necrosis  tissue death
Obstruction of the airway
Tongue, mucous secretions
Foreign body
Aspiration, vomitus
Burns, COPD
Near drowning
Restriction of the thoracic cage
Chest injuries, flail chest
Pneumothorax
Extreme obesity, diseases
Decreased neuromuscular function
Depressed central nervous system: drugs including sedatives, anesthetic agents, and analgesics, brain trauma; CVA
Coma (diabetic, uremic, brain injuries)
Diseases (multiple sclerosis, myasthenia gravis, poliomyelitis, Guillain-Barré syndrome)
Disturbances in diffusion
Diseases (pulmonary fibrosis, emphysema)
Trauma (contusion)
Emboli (fat embolus, pulmonary embolus)
Tumors, benign and malignant
Respiratory distress syndrome
Environmental causes
High altitude

40. Early S&S of HYPOXEMIA
1. Confusion, restlessness, irritability, anxiety
Confusion – change in mental status - (The first sign, occurs before other symptoms)
Tachypnea (rapid breathing) will become labored if prolonged (compensatory mechanism)
4. SOB: moving to later stage, becoming too fatigued to continue compensating.
Restlessness, irritability, confusion
Difficulty in breathing (dyspnea)
Rapid breathing (tachypnea), stridor

41. Later S&S HYPOXEMIA
5. Cyanosis 6. Retractions – inward muscle movement of intercostal spaces; neck & abdomen muscle involvement 7. Acid-base balance disturbance 8. ↓ oxygen saturation
Abnormal lung sounds
Cyanosis, retractions, arrhythmias
Acid–base balance disturbance
Decreased oxygen saturation

42. Oxygen Toxicity
O2 Toxicity may develop when O2 concentrations of > 50% are administered for > than 48 to 72 hrs.
Prolonged use of high O2 concentrations reduces surfactant production & causes lung tissue damage
a) alveolar collapse
b) reduced lung elasticity
Early sign of O2 toxicity = dry cough

43. Procedures for O2 admin
Assessment, Check physician orders, & consult with respiratory therapy
- Resp assessment: rate, depth, sat, lung sounds, subjective data
Auscultate - compare areas, side to side
Planning
Implementation
Evaluation

44. Documentation Data from respiratory assessment
Oxygen flow rate & method of delivery
Amount prn oxygen used
Time & location of blood gas sampling
Location of oximetry probe & range of saturation
Description of sputum expectorated
Coughing and deep breathing exercises
Time & evaluation of respiratory treatments

45. Documentation Date/Time
Nursing DX: Impaired gas exchange: Dyspnea on exertion
S: “Walking makes me short of breath”.
O: Respirations 34 & shallow after 30 min rest period. (continue with data collection)
A: Dyspnea unrelieved by rest.
P: Administer O2 3L/min via nasal cannula per protocol. Dr. Wilson notified. Reassess in 30 min.

46. Documentation: Narrative
Date/Time
Complained of mild dyspnea on ambulation. Respirations 34 & shallow after 30 min rest. O2 at 3L/min. started via nasal cannula per standing order. (include all data from resp assessment) Dr. Wilson notified.
Nancy Nurse LPN

47. Closure: O2 Administration
Critical Thinking: why did I make the background of this presentation green?
Review questions:
chap. 28, p
questions 1-6.
2) Video activity
3) Lab activity review
4) Review activities work-sheet