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Oct.28.2020

Oxygen Equipment (Home Health Care) - CE

ALERT

Use caution in the presence of oxygen. Oxygen is a fire hazard because it lowers the temperature at which materials catch fire in the presence of an ignition source, such as a spark or heat from a light source.undefined#ref3">3

The goal of oxygen use is to treat hypoxemia, but excess oxygen use can cause hyperoxia, causing worse outcomes.2

OVERVIEW

Home oxygen therapy may be needed for short-term or long-term use. Short-term oxygen therapy may be administered via a nasal cannula or a simple mask. In most cases, long-term oxygen therapy is administered via an oxygen-conserving device (OCD). When a patient has a permanent tracheostomy tube, a T-piece or tracheostomy collar is used. Oxygen that is administered directly into the trachea via a tracheostomy tube or transtracheal catheter should be humidified. OCDs reduce the amount of oxygen that the patient uses, enabling him or her to use a smaller and lighter unit and reducing the overall cost of the therapy.1

There are three types of OCDs: reservoir nasal cannula, demand oxygen delivery system, and transtracheal oxygen catheter.

  • Reservoir nasal cannulas store oxygen in a chamber during the expiratory phase of respiration for delivery during the early phase of inhalation.
  • Demand oxygen delivery systems deliver a burst of oxygen during the early phase of inhalation through a nasal cannula.
  • Transtracheal oxygen catheters deliver oxygen through a catheter percutaneously inserted into the trachea, allowing the patient to speak, and bypassing anatomic dead space by reducing the flow rate of oxygen.

There are three types of oxygen delivery systems available for home use: compressed oxygen cylinders, liquid oxygen systems, and oxygen concentrator systems (Table 1)Table 1.1,2

  • Compressed oxygen cylinders come in a wide variety of sizes. Ideally, the patient should have the lightest cylinder possible that provides oxygen for the longest period of time (Figure 1)Figure 1. Compressed oxygen cylinders require a regulator and flow meter. The size of the cylinder and the oxygen flow rate determine how long the compressed oxygen cylinder will last (Table 2)Table 2. The tanks are replaced on a regular basis by an oxygen supply company.
  • Liquid oxygen systems store oxygen in a liquid state in a cryogenic storage unit. Therefore, they are more convenient than oxygen cylinders because they take up less space. The patient uses a small ambulatory liquid oxygen unit that is filled from a home storage unit (Figure 2)Figure 2. The liquid oxygen system’s longevity depends on the prescribed flow rate (Table 3)Table 3. The storage unit is refilled as needed by an oxygen supply company.
  • Oxygen concentrator systems extract oxygen from the room air and supply oxygen to the patient at a prescribed flow rate. Oxygen concentrators deliver a lower flow of oxygen to the patient than does an oxygen tank. As the flow rate of oxygen increases, the patient may need a different concentrator if oxygen needs increase. Portable oxygen cylinders that can be filled from the stationary oxygen concentrator unit are also available. Home delivery of oxygen is not needed with a concentrator unit.

Home oxygen equipment is designated as durable medical equipment (DME) in the home setting. A patient who requires home oxygen should be given extensive instructions on how to use oxygen therapy efficiently and safely. To enhance home safety, The Joint Commission’s National Patient Safety Goals for oxygen therapy in the home setting requires completion of a home risk assessment to identify associated risks.3 In addition, patient education about the safe use of oxygen in the home should be provided (Box 1)Box 1. When initiating and managing ongoing oxygen therapy, the nurse should collaborate with the patient, practitioner, family, caregiver(s), DME provider, and payer.

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Instruct the patient, family, and caregivers on how to appropriately clean, disinfect, and maintain all oxygen delivery systems and supplies. Verify instructions using manufacturer’s guidelines and DME provider’s instructions.
  • Instruct the patient, family, and caregivers to check mask and tubing by placing hands or face over mask or cannula to feel airflow.
    • Instruct the patient, family, and caregivers to check mask to ensure that it is not too tight; a tight mask can leave marks on the skin.
    • Instruct the patient, family, and caregivers to apply a cotton or gauze sponge at pressure points if needed.
  • Instruct the patient, family, and caregivers on oxygen safety, oxygen’s combustibility, and risk of fire.
  • Instruct the patient, family, and caregivers never to smoke when using oxygen and not to use it near open flames (Box 1)Box 1.
  • Instruct the patient, family, and caregivers on how to connect the oxygen delivery system to the oxygen source.
  • Instruct the patient, family, and caregivers on how to check the oxygen flow.
  • Instruct the patient, family, and caregivers to use only a water-based gel and to avoid the use of petroleum, oil, or grease products.2
  • Instruct the patient, family, and caregivers to post “No Smoking” signs throughout the home.3
  • Instruct the patient, family, and caregivers on signs and symptoms of skin breakdown and appropriate preventive interventions.
  • Instruct the patient, family, and caregivers not to use materials or devices that may produce a spark (i.e., wool clothing, wool blankets, electric razors, blow-dryers).2
  • Instruct the patient, family, and caregivers on emergency measures and when to contact the nurse or practitioner.
  • Instruct the patient, family, and caregivers on signs and symptoms of hypoxemia.
  • Instruct the patient, family, and caregivers on oxygen tube safety and fall prevention.
  • Instruct the patient, family, and caregivers on how to contact the DME company.
  • Instruct the patient, family, and caregivers on how to obtain and store equipment and supplies.
  • Instruct the patient, family, and caregivers on proper storage of liquid oxygen.
    • In a well-ventilated area
    • Out of high-traffic areas
    • Away from heat sources
  • Instruct the patient, family, and caregivers on the importance of the presence of smoke detectors in the home.
  • Instruct the patient, family, and caregivers on the effects of cold liquid oxygen on the eyes and skin.
  • Instruct the patient, family, and caregivers to set flow rate and how to read content gauge.
  • Instruct the patient, family, and caregivers to check tubing for kinks that can cut off the flow of oxygen.
  • Instruct the patient, family, and caregivers to wash the nasal cannula, face mask, or reservoir daily with soap and water. Replace as needed.
  • Have the patient, family, and caregivers perform a return demonstration to confirm learning has occurred.
  • Encourage questions and answer them as they arise.

PROCEDURE

  1. Perform hand hygiene.
  2. Introduce yourself to the patient, family, and caregivers.
  3. Verify the correct patient using two identifiers.
  4. Explain the procedure to the patient, family, and caregivers and ensure that the patient agrees to treatment.
  5. Verify the practitioner’s order and assess the patient for pain.
  6. Conduct a home oxygen safety risk assessment before starting oxygen therapy in the home and when home health services are initiated.3
    1. Determine whether there are smokers or smoking materials in the home.
    2. Ensure that the home has functioning smoke detectors.
    3. Assess whether there are other fire safety risks in the home, such as the potential for open flames.
  7. Implement strategies to improve patient, family, and caregiver adherence to oxygen safety precautions when unsafe practices are observed in the home. This includes notifying the licensed independent practitioner ordering the oxygen.
  8. If an oxygen concentrator is used, assess the home environment for adequate electrical service and a backup electrical source in the event of a power failure.
  9. Assess the patient’s, family’s, and caregivers’ knowledge of the purpose of oxygen and the ability to observe for signs and symptoms of hypoxemia.
  10. Determine where appropriate resources for equipment and assistance are located in the patient’s community, including maintenance and repair services, as well as a DME supplier.
  11. Ensure that equipment and oxygen supplies are available to the patient. Determine whether a portable tank is necessary to allow the patient to move around freely.
  12. Place the oxygen delivery system in a clutter-free environment that is well ventilated, away from combustible materials, and at least 6 ft (2 meters) from an open flame.2
    Do not place an oxygen concentrator system in a closet ( Box 1)Box 1.
  13. Demonstrate the steps for preparing and completing oxygen therapy. Refer to the instruction manual for the specific model as needed.
    Rationale: A demonstration is a reliable technique for teaching psychomotor skills and enables the patient, family, and caregivers to ask questions.
    1. Compressed oxygen cylinders
      1. To turn the oxygen on, turn the cylinder valve counterclockwise two to three turns with a wrench.
      2. Check the status of the cylinder by noting the amount of oxygen displayed on the regulator gauge.
        Rationale: Checking the status verifies that an adequate oxygen supply is available for the patient’s use.
      3. Store the wrench in a safe place.
    2. Liquid oxygen systems
      1. Check the liquid system by depressing the button at the lower right corner and reading the dial on the stationary oxygen reservoir or the ambulatory tank.
        Rationale: Checking the liquid system verifies that an adequate oxygen supply is available for the patient’s use.
      2. Collaborate with the DME supplier to provide instructions for refilling the ambulatory tank.
        Rationale: Ambulatory tanks of liquid oxygen need to be filled when empty.
        Fill ambulatory tanks only when they are empty. If cold oxygen from the reservoir mixes with warmer oxygen left in the ambulatory tank, the ambulatory tank will malfunction.
      3. Refill the liquid oxygen tank.
        1. Wipe both of the filling connectors with a clean, dry, lint-free cloth.
          Rationale: Wiping the filling connector removes dust and moisture from the system.
        2. Turn the flow selector off on the ambulatory unit.
        3. Attach the ambulatory unit to the stationary reservoir by inserting the female adapter from the ambulatory tank into the male adapter of the stationary reservoir (Figure 3)Figure 3.
        4. Open the fill valve on the ambulatory tank (e.g., lever, button, key) and apply firm pressure to the top of the stationary reservoir by holding the ambulatory tank firmly in place (Figure 4)Figure 4.
          Rationale: Applying firm pressure to the top of the stationary reservoir prevents oxygen from leaking during the filling process. If oxygen leaks during the filling process, the connection between the ambulatory tank and the reservoir tank may ice up, causing them to stick together.
        5. Stay with the unit as it is filling; it will make a loud hissing noise.
        6. Disconnect the ambulatory unit from the stationary reservoir when the hissing noise changes and a vapor cloud begins to form from the stationary unit.
          Rationale: Overfilling causes the ambulatory unit to malfunction because of high pressure in the tank.
        7. Disengage the ambulatory unit. If the unit does not separate easily, the valves from the reservoir and ambulatory unit are frozen together. Wait until the valves warm to disengage.
          Do not touch any frosted areas; contact with the skin may cause skin damage from frostbite ( Box 1)Box 1.
        8. Wipe both filling connectors with a clean, dry, lint-free cloth.
          Rationale: Ice often forms during the filling process. Wiping the filling connectors removes moisture from the oxygen system.
    3. Oxygen concentrator systems
      1. Plug the concentrator into an appropriate outlet.
      2. Turn on the power switch.
      3. Ensure that the alarm sounds for a few seconds until the desired pressure inside the concentrator is reached.
  14. Perform hand hygiene.
  15. Connect the oxygen delivery device (e.g., nasal cannula) to the oxygen delivery system (Figure 5)Figure 5.
  16. Document the oxygen saturation before using the oxygen.
  17. Adjust the oxygen flow rate (liters per minute) to the prescribed rate.
  18. Place the oxygen delivery device (e.g., nasal cannula) on the patient (Table 4)Table 4.
  19. Perform hand hygiene.
  20. Instruct the patient and caregiver not to change the oxygen flow rate without direction from the practitioner. Provide written instructions that indicate when and how much oxygen to use.
    Rationale: The oxygen flow rate provides the prescribed amount of oxygen. Exceeding the prescribed amount of oxygen can be harmful, such as in cases where the patient has chronic obstructive pulmonary disease.
  21. Have the patient, family, and caregivers perform each step with guidance. Provide written material for reinforcement and review the material with them.
    Rationale: A return demonstration allows for correction of any errors in technique and a discussion of their implications.
  22. Instruct the patient, family, and caregivers on the required system cleaning.
  23. Instruct the patient, family, and caregivers to notify the practitioner if signs or symptoms of hypoxemia or respiratory tract infection occur (e.g., fever, increased sputum, change in color of sputum, foul sputum odor).
    Rationale: Respiratory tract infections increase oxygen demand and often affect oxygen transfer from the lungs to the blood, exacerbating the patient’s pulmonary disease.
  24. Discuss emergency plans for power loss, natural disaster, and acute respiratory distress. Instruct the patient, family, and caregivers to call 9-1-1 in cases of emergency and to notify the practitioner and home health organization.
  25. Instruct the patient, family, and caregivers on safe home oxygen practices.2
    1. Place “No Smoking” and “Oxygen in Use” signs at each entrance to the home.
    2. Do not allow smoking in the house.
    3. Keep oxygen tanks 6 ft (2 meters) away from open flames.7
    4. Store oxygen tanks upright.
      Rationale: Instructing the patient, family, and caregivers on safe home oxygen practices ensures the safe use of oxygen in the home and prevents injury to the patient, family, and caregivers ( Box 1)Box 1.
  26. Document oxygen saturation after oxygen use.
  27. Monitor the rate at which oxygen is delivered.
  28. Monitor the response to oxygen at the frequency determined by the practitioner.
  29. Ask the patient, family, and caregivers about any challenges they face that are associated with home oxygen.
    Rationale: Asking the patient, family, and caregivers about any challenges helps determine their ability to deal with stressors that are associated with home oxygen use and indicates the patient’s risk for inappropriate oxygen use.
  30. Ask the patient, family, and caregivers to state safety guidelines, emergency precautions, and emergency plan.
    Rationale: Having the patient, family, and caregivers repeat given information determines their knowledge of what to do if there is a power failure or equipment failure or if the patient’s status worsens.
  31. Communicate the patient’s, family’s, and caregivers’ learning progress to other members of the health care team who are involved in the patient’s care.
    Rationale: Interdisciplinary communication ensures that all members of the care team are kept abreast of the patient’s progress toward goals and any changes to the plan of care.
  32. Verify that the patient, family, or caregivers are cleaning the equipment as instructed.
  33. Discard or store supplies and perform hand hygiene.
  34. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

  • Patient’s level of oxygenation remains at baseline.
  • Patient, family, and caregivers use safe practices with oxygen therapy.
  • Patient, family, and caregivers can manage oxygen therapy at home.
  • Equipment functions appropriately.
  • Skin breakdown does not occur.
  • Mobility remains at baseline or increases.
  • Back-up system is put in place in case of power failure.

UNEXPECTED OUTCOMES

  • Patient has signs and symptoms associated with hypoxemia.
  • Patient, family, or caregivers use unsafe practices with oxygen therapy, uses oxygen around fire or cigarette smoking, or sets incorrect flow rate.
  • Patient, family, or caregivers are unable to manage oxygen therapy at home.
  • Equipment malfunctions and fails.
  • Skin breakdown occurs.
  • Mobility is decreased.
  • No back-up system is put in place.

DOCUMENTATION

  • Performance of the home oxygen safety risk assessment
  • Oxygen saturation before and after use of oxygen
  • Prescribed oxygen flow rate
  • Type of oxygen delivery system and related supplies
  • Return demonstrations
  • Practitioner contact and orders received
  • Patient’s adherence to practitioner orders
  • Implementation of strategies to address adherence
  • Education
  • Patient’s progress toward goals
  • Unexpected outcomes and related interventions
  • Assessment of pain, treatment if necessary, and reassessment

OLDER ADULT CONSIDERATIONS

  • An older adult has a less-efficient respiratory system and less surface area for gas exchange, so he or she is at greater risk for cerebral hypoxia, which is evidenced by confusion caused by decreased oxygen levels.
  • An older adult may be unable to recognize respiratory problems or problems with his or her oxygen delivery system.
    • The patient should have frequent contact with a designated caregiver.
    • The patient should understand what signs and symptoms require a call to the practitioner.
  • The older adult patient should be able to perform tasks related to home oxygen therapy, such as placing the nasal cannula on the face.
  • The older adult patient should cognitively be able to safely use oxygen in the home.

REFERENCES

  1. American Thoracic Society (ATS). (2020). Patient education: Oxygen therapy. Retrieved August 14, 2020, from https://www.thoracic.org/patients/patient-resources/resources/oxygen-therapy.pdf (Level VII)
  2. Dugdale, D.C., III. (2020). Oxygen safety. Retrieved on August 19, 2020, from https://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000049.htm (Level VII)
  3. Joint Commission, The. (2020). National patient safety goals for the home care program. Retrieved August 19, 2020, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2020/npsg_chapter_ome_jul2020.pdf (Level VII)

ADDITIONAL READINGS

American Lung Association. (2020). Oxygen therapy. Retrieved August 19, 2020, from

New York State Office of Fire Prevention and Control. (n.d.). Home oxygen fire safety. Retrieved August 3, 2020, from https://www.health.ny.gov/prevention/injury_prevention/children/toolkits/fire/docs/home_oxygen_fire_safety.pdf

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports

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