Document Title and Code: - Nursing Matters



|Document Title and Code: |Use of Oxygen Policy NMA/UOP |

|Version: |3 |

|Authors: |Prepared by Nursing Matters & Associates. |

|Adapted for local use by: | |

|Issue Date: |July 2012. Reviewed and updated March 2017 |

|Review date: |March 2020 |

|Authorised by: | |

Policy Statement.

Apart from emergencies, oxygen is only administered following prescription from the resident’s general practitioner. The management of oxygen therapy in the Centre will comply with health and safety requirements and best practice.

Purpose:

The purpose of this policy is to outline the processes for safe and effective administration of oxygen to residents in the Centre.

Objectives:

1 To outline the procedure for administration of oxygen to residents of the Centre.

2 To ensure the safe handling, monitoring and use of equipment associated with oxygen therapy.

Scope:

This policy applies to all nursing, medical and maintenance staff who have a role in prescribing, administration and maintenance of oxygen therapy.

Important Points Oxygen Therapy.

1 Oxygen is a life saving drug for hypoxaemic residents.

2 Giving too much oxygen is unnecessary as oxygen cannot be stored in the body.

3 COPD residents (and some other residents) may be harmed by too much oxygen as this can lead to increased carbon dioxide (C02) level.

4 Other residents (e.g. cardiac / stroke) may also be harmed by too much oxygen.

5 Oxygen is a drug and like other drugs must be prescribed except for emergency situations.

6 Residents who require oxygen therapy should be assessed and monitored appropriately, with complete documentation in the chart. Oxygen should be discontinued when it is no longer necessary.

7 Prior to initiating oxygen therapy, a resident’s oxygen saturation rate must be taken using a pulse oximeter.

8 The aims of Oxygen therapy are:

• To correct or prevent potentially harmful hypoxaemia.

• To alleviate breathlessness (only if hypoxaemic).

Responsibilities:

|Actions |Responsible Person. |

|This policy will be disseminated to and read by all nursing and care staff. |Person in Charge or specify other person. |

|A record will be kept of all those who have signed the policy acknowledgement forms. |Person in Charge or specify other person. |

|Where a new version of this policy is produced, the previous version will be removed and filed away.|Person in Charge or specify other person. |

|Nurses will maintain their competence in the use and administration of oxygen therapy and |All registered nurses |

|communicate any competency / knowledge deficits to the Person in Charge or specify other person. | |

|Apart from emergency situations, oxygen will only be administered when prescribed by the resident’s |All registered nurses |

|general practitioner. | |

|All nursing staff have a responsibility to comply with both the procedure and health and safety |All registered nurses |

|requirements outlined in this policy when administering oxygen therapy. | |

|Flow meters on oxygen equipment in the Centre will be checked daily to ensure that there is an |(Enter name of designated person). |

|adequate supply of oxygen for regular and emergency needs. | |

|Oxygen cylinders will be stored and maintained in accordance with manufacturers’ instructions |(Enter name of designated person). |

|Empty and full oxygen cylinders will be stored separately so as to prevent confusion. |(Enter name of designated person). |

|Oxygen Concentrators will be cleaned weekly in accordance with the manufacturers’ instructions. |(Enter name of designated person). |

|All oxygen equipment will be cleaned and maintained in accordance with the requirements of this |All registered nurses |

|policy. | |

|All staff have a responsibility to comply with health and safety requirements in areas where oxygen | |

|is stored and / or used. |All staff. |

|Oxygen therapy administered to residents will be in accordance with the plan of care developed and |All registered nurses / designated nurse. |

|agreed by the resident and / or representative and other healthcare professionals involved in the | |

|resident’s care. | |

Use of Oxygen Therapy in the Centre.

1 Oxygen therapy may be required by residents in the following circumstances:

1 Long Term Oxygen Therapy (LTOT). This refers to the use of continuous oxygen therapy for a minimum of 15 hours daily, including night time use. Residents who may need LTOT include those with:

▪ Chronic Obstructive Pulmonary Disease (COPD).

▪ Severe chronic/brittle asthma.

▪ Interstitial lung disease.

▪ Bronchiectasis.

▪ Pulmonary vascular disease.

▪ Primary pulmonary hypertension.

▪ Pulmonary malignancy.

▪ Chronic heart failure.

▪ Secondary polycythaemia.

▪ Nocturnal hypoventilation due to obesity, neuromuscular/spinal/chest wall disease, obstructive sleep apnoea (with CPAP therapy).

▪ Palliative use for relief of dyspnoea (difficulty in breathing).

2 Short Burst Oxygen Therapy: This refers to the intermittent use of supplementary oxygen for those residents already on LTOT.

3 Emergency Oxygen Therapy to treat hypoxia.

2 Prescribing Oxygen.

1 Oxygen is a drug and therefore must be prescribed by a medical practitioner. The prescription must include mode of delivery, concentration (unless nasal cannulas are prescribed); target saturation, flow rate; frequency and duration.

2 In emergency situations, nurses can administer oxygen without a prescription.

3 The target saturation for most residents receiving oxygen is 94-98%. Those at risk of hypercapnic respiratory failure have a lower target rate usually of 88-92% (British Thoracic Guidelines, 2008).

Procedure for Administration of Oxygen.

1 Equipment.

Oxygen source: Oxygen Concentrator, oxygen cylinder or resident’s own portable oxygen equipment.

Portable Oxygen cylinder for emergency use only (specify where this is located/ stored).

Mask or nasal cannulas (as per prescription).

Tubing.

Oxygen hazard signs.

1 The nurse must verify the resident’s prescription sheet prior to the administration of oxygen using the TEN RIGHTS of medication administration, checking for:

▪ Right Resident.

▪ Right Reason (based on medical need or oxygen saturation levels).

▪ Right Drug.

▪ Right Route (via nasal cannulae or mask).

▪ Right Time.

▪ Right Dose (correct flow rate).

▪ Right Form.

▪ Right Action (ensure the oxygen is prescribed for the appropriate reason, and state to the resident the action of the oxygen therapy and why it is prescribed.

▪ Right Documentation.

▪ Right Response.

2 When oxygen therapy is being commenced for the first time, the nurse must provide an explanation of the procedure to the resident indicating the reason for, duration, frequency, demonstration of the device being used and answer any questions the resident may have. The resident’s verbal consent to proceed with therapy should be obtained.

3 Any resident prescribed oxygen therapy should be involved as far as is reasonable in the decision to use the therapy and care associated with it.

4 The nurse should assist the resident in an upright position as far as the resident can tolerate.

5 The nurse must wash his/her hands prior to administration. In particular, the nurse should ensure that his/her hands are dried after use of alcohol gels because of the danger of combustion.

6 The resident’s vital signs should be checked prior to the first dose of oxygen therapy and at predetermined intervals according to the resident’s care plan.

7 Use of Oxygen Concentrators.

8 (Check with manufacturer’s instructions for Concentrator used and adapt the procedure in accordance with instructions)

• Ensure the ventilation ports at the rear base of the device and at the air filter are not obstructed by blankets, curtains and so on.

• Press the power switch to the on position.

• After turning on the device, allow 10 minutes for the device to reach its specified performance.

• Adjust the flow to the prescribed setting by turning the knob on the flow meter until the ball is centred on the line marking the specific flow rate.

• Attach the mask to the concentrator and check to make sure that oxygen is flowing through the mask.

• Place the mask on the resident as detailed in point 8.12

• Document appropriate information and monitor the resident as detailed in 8.15 and 8.16.

9 When Using Resident’s Own Oxygen Equipment, nurses should:

• Ensure that the equipment is clean and in good working order.

• Ensure that they know the correct method / procedure and accessories for using the equipment.

• Where there is any doubt about the use and / or maintenance of any equipment, nurses should contact the manufacturers for information.

10 All tubing, mask / cannulas to be used must be checked to ensure they are clean and in good condition prior to connection. The nurse should use any mask / cannula in accordance with the manufacturer’s instructions.

11 When using a mask, it should be placed over the resident’s nose and mouth with the elastic strap over the ears to the back of the head. The elastic strap should be adjusted to ensure the mask is comfortable and secure enough to prevent it falling off. Padding may be used if the resident experiences discomfort with the mask or strap.

12 Where a nasal cannula is being used, the nasal prongs are placed in the resident’s nose and the other tubing is placed over the ears and either under the chin or to the back of the head. Residents using nasal prongs should be checked at frequent intervals for any nasal dryness or discomfort.

13 Hazard signs must be placed in all areas where oxygen therapy is in use.

14 The nurse should record the resident’s vital signs and flow rate in the resident’s nursing notes.

15 The resident should be checked at regular intervals to monitor his/her response to the treatment, comfort, skin condition around the device being used and functioning of the equipment.

Care Plan.

1 A care plan must be documented for all residents receiving oxygen therapy.

2 The care plan can be recorded under the section for treating the respiratory condition requiring oxygen therapy or written separately.

3 The care plan must include the following:

➢ Why oxygen therapy is in use and for how long.

➢ The Mode of Delivery of the oxygen (nasal prongs, facemask etc.).

➢ Identification of risks / potential problems associated with oxygen therapy individual to the resident such as dryness of the mouth; discomfort associated with the equipment in use; effect of the equipment on the face, nose or any area where the tubing or strapping may cause irritation to the skin; communication problems associated with mask usage; the effects of any restrictions on movement/mobility associated with oxygen therapy and so on.

➢ Where a humidifier is in use, the care plan should address the need to wipe any excessive moisture from the resident’s face at regular intervals. Humidification of oxygen should be considered if the oxygen is to be administered for longer than 12 hours.

➢ Methods for monitoring the resident’s response to the therapy such as vital signs, breathing pattern, relief of symptoms associated with the respiratory condition.

➢ Mouth care, with particular reference to not using any form of petroleum jelly or oil based compounds. Water based products should be used.

➢ Creams, oils and lubricants that must not be used while the resident is in receipt of oxygen therapy.

4 The care plan should identify the goals of care and how evaluation against these goals will measured and how often.

5 A date for review of the resident’s need for oxygen therapy should be documented. This review should take place in accordance with changing condition and needs and at least every four months.

6 The nurse writing the care plan should liaise with the resident’s prescriber regarding the need for any special tests that may be required such as blood values, oximetry or blood gas values.

7 As with all other aspects of care planning, the resident as far as she is able and with the residents informed consent his/her resident’s representative, where applicable, should be involved in the care planning process.

Health and Safety.

1 Oxygen equipment is checked weekly by (Insert name of person(s) responsible).

2 Oxygen equipment should not be use if there is any damage to the plug or power cord.

3 Extension cords or adaptors should not be used.

4 A record of maintenance and servicing of oxygen equipment must be kept by (Insert name of person(s) responsible).

5 Oxygen therapy should never be used where there are naked flames or smoking in the area where it is being used.

6 Oil or grease must never be used to lubricate oxygen equipment.

7 Staff handling oxygen equipment should ensure that their hands and clothing are clean and free from oil and grease or any other easily combustible material.

8 Oxygen equipment must be kept clean and free of dust, grease or general atmospheric debris which is a potential fire hazard.

9 Where Oxygen cylinders are used, the following steps should be followed:

handle oxygen cylinders carefully. It is sensible to use a purpose-built trolley to move them;

keep cylinders chained or clamped to prevent them from falling over;

store oxygen cylinders when not in use in a well-ventilated storage area or compound, away from combustible materials and separated from cylinders of flammable gas, e.g. propane and butane;

only store as many cylinders as you need;

return empty cylinders to the supplier;

treat empty cylinders with the same caution as you would a full one.

(Health and Safety Executive, UK, 2013)

1 Where any equipment is found to be faulty, this should be reported to (Insert name of person(s) responsible) who will then report it to the manufacturer/supplier.

2 Maintenance of Oxygen Equipment.

(Provide details of how oxygen equipment is maintained in the Centre).

3 Any concerns regarding health and safety issues associated with oxygen use and equipment should be reported to the Person in Charge or specify other named person.

Infection Control:

All oxygen delivery equipment must be plugged out prior to cleaning.

1 Residents who require oxygen therapy should have their own administration equipment. Inhalation equipment should never be shared between residents. Nursing staff should refer to the manufacturers’ instructions for cleaning of individual residents’ portable oxygen.

2 Masks are for single resident use only. Masks should be cleaned daily with hand hot water and left to air dry. Where a detergent in required to remove any debris, it should be well rinsed afterwards with hand hot water.

3 Oxygen tubing must be changed once a week or sooner if it is damaged or soiled.

4 Resident’s portable oxygen equipment must be cleaned once weekly or more frequently if required. Resident’s equipment must be cleaned according to the manufacturer’s instructions.

5 All concentrators must be cleaned once a week using the following procedure: (Check with manufacturer’s instructions for Concentrator used and adapt the procedure in accordance with instructions).

6 Remove the filter cabinet from the back of the concentrator.

7 Using a mild detergent and a damp cloth wipe clean the filter chamber.

8 Ensure no excess water remains and allow the filter to air dry.

9 Make sure the filter is completely dry before re insertion on the cabinet.

10 The exterior case of the device should also be cleaned using a damp cloth.

11 Nebulisers must be cleaned and maintained according to the manufacturers’ instructions.

12 Nebuliser chambers must be for single resident use only and cleaned after each use in the following way:

• Empty the chamber of any residual drug.

• Disassemble and rinse all parts in hand hot water.

• Where a detergent is required, use a mild detergent and rinse thoroughly.

• Dry with a paper towel and reassemble.

13 Nebuliser chambers typically have a shelf life of 30 days, but may need to be replaced sooner if damaged (CREST, 2006).

Use of Emergency Oxygen.

1 In Emergency situations, oxygen is given so that oxygen saturation is maintained at normal levels and not just for breathlessness.

2 Where a resident is breathless, the resident’s vital signs, that is temperature, pulse, blood pressure and respiratory rate must be taken, including a pulse oximeter reading.

3 Prior to administration of oxygen in an emergency situation, a pulse oximeter reading should take place.

4 In emergency situations, oxygen is commenced and the resident transferred to hospital via ambulance.

5 Guidelines for Oxygen Saturation Rates in Emergencies, while awaiting Ambulance.

The British Thoracic Society (2008) recommends the following:

2 The target range of oxygen saturation is 94% to 98% for the resident unless she has known COPD; morbid obesity; chest wall deformities or neuromuscular disorders. These predispose the resident to risk of hypercapnic (high carbon dioxide levels) respiratory failure or those receiving terminal palliative care.

3 Some people, especially people aged over 70 years, may have oxygen saturation measurement below 94% and do not require oxygen therapy if they are otherwise clinically stable.

4 For most patients with known chronic obstructive pulmonary disease (COPD) or other known risk factors for hypercapnic respiratory failure (eg, morbid obesity, chest wall deformities or neuromuscular disorders), a target saturation range of 88–92% is suggested pending the availability of blood gas results. This means that these saturation rates should be the target for these acutely ill residents while awaiting emergency services.

5 High concentration reservoir mask (non-rebreathe mask) should be used for high-dose oxygen therapy;

6 Nasal cannulas (preferably) or a simple face mask can be used for medium-dose oxygen therapy. The maximum flow rate for nasal cannula is 4L per minute (McGloin, S. 2008).

7 28% Venturi mask should be used for residents with definite or likely COPD.

8 Tracheostomy masks for residents with tracheostomy or previous laryngectomy.

9 Venturi masks can be substituted with nasal cannulas at low flow rates (1–2 l/min) to achieve the same target range once the resident has stabilised.

10 The flow rate from simple face masks should be adjusted between 5 and 10 l/min to achieve the desired target saturation. Flow rates below 5 l/min may cause carbon dioxide rebreathing and increased resistance to inspiration.

11 Residents with COPD with a respiratory rate of 30 breaths/min should have the flow rate set to 50% above the minimum flow rate specified for the Venturi mask and/or packaging (increasing the oxygen flow rate into a Venturi mask increases the total gas flow from the mask but does not increase the concentration of oxygen which is delivered).

(British Thoracic Society, 2008).

12 Where oxygen is administered in an emergency, it does not need to be prescribed, but a record of the amount, delivery device and vital signs should be recorded in the resident’s nursing narrative notes.

References.

Nettina, S. (2006) Lippincott Manual of Nursing Practice Handbook. Lippincott Williams & Wilkins.

1. Clinical Resource Efficiency Support Team (CREST) (2006). Guidelines for the Prevention of Infection and Decontamination of Respiratory Equipment in Northern Ireland.

2. Dougherty, L. and Lister, S. (Eds.) (2004). The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 6th Edition. Blackwell Publishing, Oxford.

British Thoracic Society (2008) Guideline for emergency oxygen use in adult patients.

accessed at:

McGloin, S. (2008) Administration of oxygen therapy. Nursing Standard. 22(21). 46-48.

Smith, T. (2004). Oxygen therapy for older people. Nursing Older People. 16(5). 22-28.

Department of Health (UK) (2008) Oxygen Cylinders and their regulators: top tips on care and handling. Accessed at: .uk

National Patient Safety Agency (2009) Oxygen Safety in Hospitals. Accessed at:

Health and Safety Executive. Take Care with Oxygen

University of Manchester NHS Foundation Trust (2009) Oxygen Prescribing and Administration Policy. Accessed at: uhsm.nhs.uk/.../MMP%20Appendix%2014%20Oxygen%20Prescribing%20and%20Admini...

11. Royal Marsden (2015) Manual of Clinical Nursing Procedures Online Edition. Accessed 02/05/2017

Irish Thoracic Society, 2015. Irish Guidelines on Long Term Oxygen Therapy ( LTOT ) in Adults 2015. , (1)

13. Health and Safety Executive (2013) Oxygen Use in the Workplace. Accessed 02/05/2017 at

.uk/pubns/indg459.htm

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