PS1006 SARASOTA MEMORIAL HOSPITAL DEPARTMENT POLICY TITLE: OXYGEN ADMINISTRATION (INCLUDING Job Title of Reviewer: EFFECTIVE DATE: REVISED DATE: POLICY TYPE: Director, Respiratory Care Services (Resp) (Pt. Care) 06/10/03 9/17 DEPARTMENTAL INTERDEPARTMENTAL DEPARTMENTS PROVIDING NURSING CARE 1 of 6 PURPOSE: POLICY STATEMENT: EXCEPTIONS: To establish protocol driven clinical pathways for the administration and management of oxygen therapy, including emergency management, by licensed personnel. 1. Nursing personnel and respiratory therapists will work collaboratively with the initiation, adjustment, and discontinuation of oxygen devices per physician orders and/or Respiratory protocols. This includes notification of the Respiratory Therapist by the nurse and contacting the physician as needed. 2. Oxygen may be temporarily administered without a physician s order by licensed personnel, within their scope of practice, when indicated by emergency circumstances. Any patient (infant/pediatric/adult) suffering from symptoms of hypoxia and/or respiratory distress, will be considered an emergency. Contacting the Rapid Response Team should be considered. 3. After initial emergency oxygen administration, a physician order must be obtained. Continuous pulse oximetry will be used by the respiratory therapist and/or RN to monitor effective outcome. In most instances, the goal for oxygenation saturations should be 94% or greater. 4. For patient condition changes, refer to SMH Policy (01.ADM.00) Chain of Command. This policy excluded Labor & Delivery Unit and the Neonatal ICU (refer to Nursing/Respiratory Department policy Guidelines for Newborn Delivery Team ). For patients requiring CPAP/BiPAP, refer to Nursing/Respiratory Policy 126.184/135.118 Prepared by: Wanda Turner \\smhfile01\paperless\department policies\nursing\nur_patientcare\126_167.doc 1/3/05
2 of 6 DEFINITIONS: 1. Low Flow Oxygen Device a. Nasal Cannula providing 0.5 6 LPM 2. High Flow Oxygen Device (will include) a. Venturi Mask (24-50% FI02) Adjust liter flow according to manufacturer s recommendations. b. Aerosol Generator Mask Adjust liter flow and venturi device to achieve desired FI02 (24-90% FI02) c. Partial Re-breather Masks Adjust liter flow to provide sufficient flow to keep the reservoir bag inflated during inspiration (60-70% FI02) d. Non- re-breather Masks Adjust liter flow to provide sufficient flow to keep the reservoir bag inflated. (90-100% FI02) e. High Flow Nasal Cannulas (different O2 delivery device) Nasal cannula providing 6-15 L/minute f. Heated, Humidified High flow Nasal Cannula (such as Opti-flow/vapotherm/etc.) Nasal Cannula providing up to 60Lpm FI02 21-100% PROCEDURE: Delineation of Responsibilities (Low Flow and High Flow) Low Flow High Flow Nurse Initiate (per policy with MD notification) Adjust (per MD order) Discontinue (per MD order) Initiate (per MD order)* Adjust (per MD order)* Discontinue (per MD order)* Nursing is not to initiate/adjust/discontinue heated, humidified high flow Respiratory Therapist Initiate * Adjust * Discontinue* (* Per physician order and/ or Respiratory Care Protocols) nasal cannula Initiate * Adjust * Discontinue * (*Per physician order and/or Respiratory Care Protocols)
3 of 6 CLINICAL GOALS: POTENTIAL COMPLICATIONS: 1. Treat hypoxemia 2. Decrease work of breathing 3. Decrease myocardial work 1. Oxygen toxicity 2. Hypoventilation (in patients with a hypoxic drive) 3. Absorption atelectasis (with high oxygen concentrations) 4. Pressure necrosis due to related equipment SPECIAL CONSIDERATIONS: 1. Patients with chronic lung disease may tolerate Sa02 s <92%. 2. Patients demonstrating signs/symptoms of cardiovascular stress (i.e., tachycardia, hypertension, chest pain, peripheral cyanosis, and arrythmias) may require Sa02 s greater than or equal to 94%. 3. Supplemental 02 should be titrated to obtain cardiorespiratory stability. 4. Patients demonstrating marginal Sa02 s at rest (i.e., 92-93%) may require oxygen with exercise. 5. Patients showing progressive drops in SaO2s should be monitored closely, and the physician should be notified of the change in the patient s condition. Notification of a Respiratory Therapist should be considered. EMERGENCY OXYGEN: 1. Methods of delivery of emergency oxygen: a. Emergency: Neonate or Small Infant 1. Oxygen is best delivered in this instance by free-flow oxygen set at 5 liters/minute. a) Connect oxygen b) Administer free-flow oxygen to infant by holding oxygen tubing to O 2 flow meter set at 5 liters/minute approximately one inch away from the infants face with a cupped hand or a resuscitation mask. c) If immediately available, may place a low-flow nasal cannula at 0.25 liters/minute-2
4 of 6 liters/minute. The Respiratory Therapist may initiate a humidified high-flow nasal cannula at 2-8 liters/minute or per MD order. Adjust blender fio2 to maintain pulse oximetry with ordered parameters b. Emergency: Large Infant or Child: 1. By mask or pediatric nasal cannula. a) Administer oxygen with adjustable pediatric mask or pediatric nasal cannula. b) Connect oxygen tubing to O 2 flow meter and adjust flow meter to deliver up to 1-6 liters per minute. c) Humidified oxygen nasal cannula should be used on infants less than 6 months of age. d) The Respiratory Therapist may initiate humidified high-flow nasal cannula at 2-8 liters/minute. Adjust blender fio2 to maintain pulse oximetry with ordered parameters. c. Emergency: Adult: 1. In the case of patients with a history of COPD that are CO2 retainers, maximum liter flow will be 2 liters per minute with a nasal cannula by a nurse or up to 6 liters per the respiratory therapist. The RN/respiratory therapist will then have the RC team leader notified STAT and the nurse will contact the physician in charge for a verbal order and other instructions. 2. For the non-copd patients, administer oxygen of up to 6 liters per minute by nasal cannula. 3. In the judgment of the RC team leader, if the patient needs a higher FIO 2 than specified above, a partial or non-rebreathing mask or other appropriate oxygen delivery device may be applied and the physician will be notified immediately. d. Additional Considerations: 1. In consideration of potential oxygen toxicity in infants, oxygen analysis is to be performed and monitored closely on all oxygen delivery systems. The patient is monitored by pulse oximetry guidelines and an ABG may be done as needed. 2. Pulse oximetry should be used by the respiratory therapist and/or RN to monitor effective outcome on all patients. Continuous therapy should consist of
5 of 6 proper temperature, humidity, and patient monitoring. 3. Documentation in the EMR per Respiratory Care Policies/flowsheets and nursing reassessment flowsheets. RESPONSIBILITY: It is the responsibility of the Respiratory Care Team Leaders to assure that this policy is understood and adhered to by all Respiratory Care personnel. It is the responsibility of the Clinical Managers/Directors to assure that this policy is understood and adhered to by all licensed Nursing personnel. REFERENCES: Respiratory Care Procedures CTH.003, 004,.005,.006. SMH Policies. (01.ADM.00). Chain of Command. (01.PAT.83) Rapid Response Team. SMH: Author. SMH Nursing/Respiratory Policies. Non-Invasive Positive Pressure (NPPV) Ventilation (CPAP/BiPAP). (126.184/135.118). Guidelines for Newborn Delivery Team (126.655/135.024) SMH: Author. AUTHOR(S): Donetta Dangleis, RRT, Respiratory Care Manager Benny Kruger, RN, MSN, CCRN, CNN, APN, Critical Care and Hemo Jessica DePaulo, MSN, RN, CCRN, APN, Critical Care Amy Alexander, BSN, RN, CPS, 10WT Chris Wirth, MSN, RN, APN, Pediatric Unit ATTACHMENT(S): None
6 of 6 APPROVALS: Signatures indicate approval of the new or reviewed/revised policy Date 9/15/17 Title: Mark Pellman, Director, Respiratory Services Title: Title: Title: Committee/Sections (if applicable): Clinical Practice Council 8/3/17 Pulmonary Council 8/17/17 Vice President/Administrative Director (if applicable): Name and Title: 9/21/17 Name and Title: Connie Andersen, Vice President, Chief Nursing Officer