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Sep.24.2020

Oxygen Equipment: Home Management Education - 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.

The goal of oxygen use in a prehospital setting is to treat hypoxemia, but excess oxygen use can cause hyperoxia, causing worse outcomes.undefined#ref2">2

OVERVIEW

Oxygen is a medication used in and out of the hospital setting. Home oxygen therapy may be short-term or long-term for the patient who is hypoxemic, who has respiratory complications, or who is experiencing activity intolerance. Short-term oxygen therapy may be administered via a nasal cannula or a simple face mask. When a patient has a permanent tracheostomy tube, a T-piece or tracheostomy collar is used for oxygen administration. Oxygen administered directly into the trachea via a tracheostomy tube or transtracheal catheter should be humidified.3

Long-term oxygen therapy is usually administered via an oxygen-conserving device (OCD) (i.e., oxygen concentrator). OCDs reduce the amount of oxygen that the patient uses, enabling the use of a smaller and lighter unit and reducing the overall cost of the therapy.1 There are three types of OCDs.

  • 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 that is percutaneously inserted into the trachea, bypassing anatomic dead space by reducing the flow rate of oxygen and allowing the patient to speak.3

There are three types of oxygen delivery systems available for home use (Table 1)Table 1: compressed oxygen cylinders, liquid oxygen systems, and oxygen concentrator systems.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 flowmeter. 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. 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 the prescribed flow rate. Oxygen concentrators deliver a lower percentage of oxygen to the patient. As the flow rate of oxygen increases, the patient may need a different concentrator. Portable oxygen cylinders that can be filled from a stationary oxygen concentrator unit are also available. Home delivery of oxygen is not needed with a concentrator unit. The patient, however, should have a backup electrical source in case of a power failure.

Home oxygen equipment is designated as durable medical equipment (DME) in the home care setting. When initiating and managing ongoing oxygen therapy, the nurse should collaborate with the patient, practitioner, caregiver(s), family, DME supplier, and payer. A patient who requires home oxygen should be given extensive instructions on how to use oxygen therapy efficiently and safely (Box 1)Box 1. To enhance home safety, an oxygen home risk assessment should be performed, including assessing smoking materials, other fire risks, and the functioning of smoke detectors in the home.4

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Provide frequent teaching sessions and written or pictorial instructions to reinforce previous learning of the teaching plan. Have the patient and family perform a return demonstration to confirm that learning has occurred.
  • Instruct the patient and family on how to appropriately clean, disinfect, and maintain all oxygen delivery systems and supplies. Verify instructions using the manufacturer's guidelines and the DME supplier's instructions.
  • Instruct the patient and family to check the mask and tubing by placing hands or face over the mask or cannula to feel the airflow.
  • Instruct the patient and family to check the mask to ensure that it is not too tight; a tight mask can leave indentations on the skin.
  • Instruct the patient and family to apply a cotton or gauze sponge at pressure points if needed.
  • Educate the patient and family on oxygen safety measures related to fire and smoking. Instruct the patient and family never to smoke when using oxygen.
  • Educate the patient and family to use the accurate oxygen flow rate when using an oxygen device (Table 4)Table 4.
  • Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

  1. Perform hand hygiene before patient contact.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. 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.
  5. Assess the patient's and caregiver's knowledge of the purpose of oxygen and the ability to observe for signs and symptoms of hypoxemia.

Preparation

  1. Determine where the appropriate resources for equipment and assistance are located in the patient's community, including maintenance and repair services as well as a medical equipment supplier.
  2. Determine whether a portable tank is necessary to allow the patient to move around freely.
  3. Ensure that equipment and oxygen supplies are delivered to the patient before discharge.

PROCEDURE

  1. Perform hand hygiene.
  2. Verify the correct patient using two identifiers.
  3. Explain the procedure to the patient and ensure that he or she agrees to treatment.
  4. Place the oxygen delivery system in a clutter-free environment that is well ventilated, smoke free, away from combustible materials, and at least 6 feet from an open flame.1
    Do not place an oxygen concentrator system in a closet.
  5. Demonstrate the steps for preparing and completing oxygen therapy. Refer to the instruction manual for the specific model as needed.
    Rationale: Demonstrating the steps is a reliable technique for teaching psychomotor skills and enables the patient to ask questions.
    1. Compressed oxygen cylinders
      1. To turn the oxygen on, turn the cylinder valve counterclockwise with a wrench until the valve appears loose and oxygen is flowing from the tank.
      2. Check the status of the cylinder by noting the amount of oxygen remaining 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.
        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. To refill the ambulatory 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 off the flow selector 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 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.
          Be aware that overfilling will cause the ambulatory unit to malfunction because of high pressure in the tank.
        7. Disengage the ambulatory unit. If the unit does not separate easily, wait until the valves warm to disengage.
          Rationale: If the unit does not separate easily, it is most likely because the valves from the reservoir and ambulatory unit are frozen together.
          Do not touch any frosted areas because contact with the skin may cause skin damage from frostbite.
        8. Wipe both of the 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. (Be aware that an alarm will sound for a few seconds until the desired pressure inside the concentrator is reached.)
  6. Perform hand hygiene.
  7. Connect the oxygen delivery device (e.g., nasal cannula) to the oxygen delivery system (Figure 5)Figure 5.
  8. Document the oxygen saturation before using the oxygen.
  9. Adjust the oxygen flow rate (L/min) to the prescribed rate.
  10. Place the oxygen delivery device (e.g., nasal cannula), ensuring a proper fit on the patient.
  11. Perform hand hygiene.
  12. 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.
    Instruct the patient that exceeding the prescribed amount of oxygen can be harmful (e.g., if the patient has chronic obstructive pulmonary disease).
  13. Have the patient and caregiver perform each step with guidance. Provide written material for reinforcement and review the material with the patient and caregiver.
    Rationale: A return demonstration allows for correction of any errors in technique and a discussion of their implications.
  14. Instruct the patient and caregiver on the required system cleaning.
  15. Instruct the patient and caregiver 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.
  16. Discuss emergency plans for power loss, natural disaster, acute respiratory distress, or depleted oxygen administration supply. Instruct the patient and caregiver to call 911 in cases of emergency and to notify the practitioner and home care organization.
  17. Instruct the patient and family on safe home oxygen practices.1
    1. Place "No Smoking" or "Oxygen in Use" signs at each entrance to the home.
    2. Do not allow smoking in the house.
    3. Keep oxygen tanks at least 8 feet away from registers and 6 feet away from open flames.1
    4. Store oxygen tanks upright in a location where they will not fall over.
      Rationale: Instructing the patient on safe home oxygen practices ensures the safe use of oxygen in the home and prevents injury to the patient and family.
  18. Perform hand hygiene.
  19. Document the procedure in the patient's record.

MONITORING AND CARE

  1. Document oxygen saturation after oxygen use.
  2. Monitor the rate at which oxygen is delivered.
  3. Monitor the response to oxygen at the frequency determined by the practitioner.
  4. Ask the patient and caregiver if they are experiencing any difficulties with home oxygen.
    Rationale: Asking the patient and caregiver whether they are experiencing any difficulties allows the nurse to determine the patient's and caregiver's ability to deal with stressors that are associated with home oxygen use and the patient's risk for inappropriate oxygen use.
  5. Ask the patient and caregiver to state safety guidelines, emergency precautions, and emergency plans.
    Rationale: Having the patient and caregiver repeat safety and emergency information allows the nurse to determine their knowledge of what to do in cases of power failure and equipment failure or if the patient's status worsens.
  6. Communicate the patient's and caregiver's learning progress to other health care personnel who are involved in the patient's care.
  7. Verify that the patient or caregiver is cleaning the equipment as instructed.

EXPECTED OUTCOMES

  • Patient receives oxygen at prescribed rate.
  • Patient and caregiver verbalize purpose and correct use of home oxygen.
  • Patient and caregiver demonstrate how to maintain oxygen system.
  • Patient and caregiver verbalize how to obtain additional oxygen supplies.
  • Patient and caregiver verbalize safety guidelines for oxygen use.
  • Patient and caregiver verbalize emergency plan of care.

UNEXPECTED OUTCOMES

  • Patient has signs and symptoms associated with hypoxemia.
  • Patient or caregiver uses unsafe practices with oxygen therapy, uses oxygen around fire or cigarette smoking, or sets incorrect flow rate.
  • Patient or caregiver is unable to manage oxygen therapy at home.

DOCUMENTATION

  • Oxygen saturation before and after use of oxygen
  • Education
  • Prescribed oxygen flow rate
  • Type of oxygen delivery system and related supplies
  • Validation of patient and caregiver learning
  • Unexpected outcomes and related interventions

PEDIATRIC CONSIDERATIONS

  • Keep oxygen equipment and matches out of the reach of any children in the home. Playing with fire and manipulating dials or flow meters can have disastrous effects.
  • Consider that home oxygen therapy for a child places complex demands on family members and often creates stress, especially when the child is a premature infant. Ensure that home visits by a nurse and other health care personnel, as well as referrals to support groups, are in place to help family members better cope with the demands of caring for a child who requires oxygen at home.

OLDER ADULT CONSIDERATIONS

  • Consider that an older adult has a less efficient respiratory system and less surface area for gas exchange and thus is at greater risk for cerebral hypoxia, which is evidenced by confusion caused by decreased oxygen levels.
  • Consider that an older adult may be unable to recognize respiratory problems or problems with the oxygen delivery system.
  • Ensure that the patient has frequent contact with a designated caregiver.
  • Ensure that the patient understands what signs and symptoms require a call to the practitioner.
  • Ensure that the older adult patient can perform tasks related to home oxygen therapy, such as placing the nasal cannula on the face.
  • Ensure that the older adult patient is cognitively able to use oxygen safely in the home.

REFERENCES

  1. American Thoracic Society (ATS). (2020). Patient education: Oxygen therapy. Retrieved July 30, 2020, from https://www.thoracic.org/patients/patient-resources/resources/oxygen-therapy.pdf
  2. Branson, R.D. (2018). Oxygen therapy in COPD. Respiratory Care, 63(6), 734-748. doi:10.4187/respcare.06312
  3. Heuer, A. J. (2017). Chapter 56: Respiratory care in alternative settings. In R.M. Kacmarek, J.K. Stoller, A.J. Heuer (Eds.), Egan’s fundamentals of respiratory care (11th ed., pp. 1284-1311). St. Louis: Elsevier.

ADDITIONAL READINGS

American Lung Association. (2020). Supplemental oxygen. Retrieved July 29, 2020, from (Level VII)

Adapted from Perry, A.G., Potter, P.A., Ostendorf, W.R. (Eds.). (2018). Clinical nursing skills & techniques (9th ed.). St. Louis: Elsevier.

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