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Dec.29.2020

Oxygen Tank Regulators (Home Health Care) - CE

ALERT

Never drop an oxygen tank or allow it to strike another surface. If the neck of the bottle or regulator is damaged, the tank may become a self-propelled projectile and can cause serious injury. Always secure tanks in a stand or carrier when upright.

Oxygen tanks can be heavy and cumbersome to handle. Do not drag, slide, or roll a tank. Use a portable carrier to move it to the point of use.undefined#ref1">1,3

To prevent the risk of fire, do not allow oxygen tanks, valves, regulators, and fittings to come into contact with oil, grease, or highly flammable liquids.

Always use an appropriate-shape tool when opening and loosening or closing and tightening the fittings on the oxygen tank.

Always read the label on the tank to confirm that it contains the desired gas. In the United States, oxygen tanks may be green, or they may be silver or chrome with green around the valve stem. In other countries, oxygen tanks are white, or black with white shoulders.

OVERVIEW

Oxygen tanks (also called cylinders) are used to provide supplemental oxygen when the patient is away from home or when the patient’s condition does not allow the use of a concentrator. Different sizes of oxygen tanks are identified by letter(s). Many sizes are available, including the E-cylinder (Figure 1)Figure 1, which is one of the most common sizes of tanks used in homes.

The regulator (sometimes called the adjustable regulator, flowmeter, or control valve) reduces, controls, and measures the flow of oxygen to the patient to ensure a safe and effective working pressure. The regulator and flowmeter usually are coupled together into one mechanical fitting on the oxygen tank. A yoke holds the regulator in place.

Additional safety features include the pin index system. Each gas uses a unique combination of pins on the regulator that corresponds to the holes on the valve stem (sometimes called the post valve or cylinder post) of the intended tank. The pin indexing system is used as a safety feature to prevent a cylinder containing another type of gas (such as air or nitrous oxide) from being connected to an oxygen regulator. A sealing washer (also called a washer, O-ring, or gasket) helps ensure a tight connection between the regulator and the valve stem (Figure 2)Figure 2.

The valve stem is opened and closed by means of an appropriate-shape wrench (also called a key) (Figure 3)Figure 3 or by turning a regulator knob. The regulator yoke is tightened or loosened with a T-bar; sometimes a wrench is used to provide extra leverage on the T-bar.

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Teach the patient and caregiver to change the regulator in a well-lit, uncluttered environment for good visibility of equipment.
  • Teach the patient and caregiver that there should be absolutely no smoking when oxygen is being used and that oxygen should not be used near an open flame.
  • Instruct the patient and caregiver to use oxygen according to the practitioner’s order.
  • Instruct the patient and caregiver to avoid using petroleum products while using oxygen.
  • Instruct the patient and caregiver to secure the oxygen cylinder in a cart or support stand.
  • Instruct the patient and caregiver to avoid storing oxygen near heat sources or open flames.
  • Encourage questions and answer them as they arise.

PROCEDURE

Application of Regulator

  1. Perform hand hygiene.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. Explain the procedure to the patient and ensure that he or she 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 care services are initiated.2
    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 and caregiver compliance with oxygen safety precautions when unsafe practices are observed in the home. This includes notifying the licensed independent practitioner ordering the oxygen.
  8. Prepare an area in a clean, convenient location, and assemble the necessary supplies.
  9. Inform the patient and caregiver about the impending attachment of the regulator to the oxygen tank.
  10. Ensure that the tank is secured in a support stand.
  11. Rationale: Using the support stand avoids damage to tank parts during transport and storage. Pressurized oxygen may turn the tank into a self-propelled projectile if damage occurs to the regulator, tank, or valve stem. 1
  12. Remove the protective seal from the valve stem of the oxygen cylinder, taking care not to lose the sealing washer. Inspect the opening to ensure that it is free of debris and dirt.
  13. If needed, use the wrench to open the valve stem on the top of the cylinder by turning it counterclockwise, and then close it quickly, which will produce a whooshing sound. If having difficulty remembering which direction to turn the wrench, the saying “righty-tighty, lefty-loosey” may help.
  14. Rationale: This action clears (cracks) the valve and eliminates any dust or foreign materials.
    Use only a wrench with a rectangular opening ( Figure 3)Figure 3 to open and close the valve stem.
    Rationale: Using a hexagonal wrench could result in inadvertent loosening of the retaining nut on the stem of the tank, which could cause injury or death.
  15. Place the regulator on the tank, making sure to align the pins on the regulator with the matching holes on the cylinder stem, and ensure that the sealing washer (Figure 2)Figure 2 is in place.
  16. Rationale: The Pin Indexing Safety System (PISS) uses two indexing pin and hole combinations for an oxygen cylinder: 2 and 5. This system is used to prevent connection errors and the delivery of incorrect gases. 1
  17. Hand tighten the regulator securely with the T-bar (Figure 4)Figure 4. If the T-bar is too difficult to tighten sufficiently by hand, use a wrench on the T-bar as a lever (Figure 5)Figure 5.
  18. Turn off the flowmeter.
  19. Slowly open the valve stem with the wrench (Figure 3)Figure 3 until the pressure gauge needle stops rising. Usually, one full turn is sufficient. The pressure gauge on a full E-cylinder reads approximately 2000 to 2200 psi.1
  20. Assess the system for any audible leaks. If a leak is heard, close the valve stem, turn on the flowmeter to bleed all pressure from the regulator, and then turn off the flowmeter. Retighten the connections, open the valve stem, and reassess for leaks.
  21. Check the pressure gauge to confirm a sufficient supply of gas. Do not use the tank for transporting a patient if the pressure gauge reads below 500 psi.1 To calculate the approximate amount of oxygen left in a tank at a given flow rate, use the following formula:1
  22. Tank life (in minutes) = (Tank pressure [in psi] – Safe residual pressure [500 psi]) × Cylinder factor ÷ Flow rate (L/min) 1
    Example: An E-cylinder oxygen tank pressure is 1000 psi. Residual safe pressure is 500 psi. The nurse wishes to transport a patient receiving oxygen at 4 L/min. Each cylinder size has its own cylinder factor ( Table 1)Table 1; the factor for an E-cylinder is 0.28. 1
    (1000 – 500) × 0.28 ÷ 4 = 35 minutes of reliable tank life 1
  23. Attach the nut and tailpiece (also called a Christmas tree adapter or a green nipple connector) to the regulator in a clockwise motion until the connection is finger tight.
  24. Connect the desired form of oxygen-delivery device to the flowmeter.
  25. Turn on the flowmeter to register the prescribed flow rate.
  26. To prevent an accidental readjustment of oxygen flow, never drape anything over the tank or the regulator.
    1. A tube-shaped regulator (Figure 6)Figure 6 may be used in any position. Turn the dial on the end until the desired flow rate appears in the window.
    2. A ball-type flowmeter (Figure 4)Figure 4 must be kept upright during use. Adjust the flow so that the middle of the ball is at the desired level.
    3. Rationale: Ball-type flowmeters are constructed to be used in an upright position. Laying them on their side will affect the accuracy of the reading but not the accuracy of the actual flow. An obstruction to the flow (e.g., crimped or pinched tubing) causes the ball to drop to the actual flow reaching the patient.
    4. A needle-gauge flowmeter (Figure 7)Figure 7 may be used in any position without affecting the accuracy of its reading.
    5. To avoid a falsely high flow reading, ensure that the flow is unobstructed.
  27. (Optional, per the organization’s practice.) When the tank is not in use, close the valve stem and bleed the system by turning the flowmeter on until the pressure gauge reads zero. This is most important when the tank is not secured in a holder.
  28. Rationale: Removing the pressure decreases the danger of the tank becoming a missile if it is inadvertently knocked over or dropped with the regulator in place.
  29. Whether or not the system is bled to relieve pressure, always secure the tank in an appropriate holder.
  30. Perform hand hygiene.
  31. Document the procedure in the patient’s record.

Removal of Regulator

  1. Perform hand hygiene.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. Explain the procedure to the patient and ensure that he or she agrees to treatment.
  5. Verify the practitioner’s order and assess the patient for pain.
  6. Prepare an area in a clean, convenient location and assemble the necessary supplies.
  7. Inform the patient and caregiver about the impending removal of the regulator from the oxygen tank.
  8. Ensure that the tank is secured in a support stand.
  9. Rationale: Using the support stand will avoid damage during transport and storage. Pressurized oxygen may turn the tank into a self-propelled projectile if damage occurs to the regulator, tank, or valve stem. 1
  10. Close the cylinder valve stem by turning it clockwise with an appropriate wrench.
  11. Turn on the flowmeter to bleed the system until the pressure gauge reads zero.
  12. Loosen the yoke by turning the T-bar (Figure 4)Figure 4 and remove the regulator. If the T-bar is too tight to loosen manually, use a wrench on the T-bar as a lever (Figure 5)Figure 5.
  13. Perform hand hygiene.
  14. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

  • Safe management of oxygen delivery equipment
  • Patient and caregiver understand home oxygen safety risk management
  • Oxygen delivery is performed safely as ordered by the practitioner

UNEXPECTED OUTCOMES

  • Injury or death of patient, nurse, or bystander
  • Faulty oxygen delivery
  • Fire or explosion
  • Damage to the valve

DOCUMENTATION

  • Performance of the home oxygen safety risk assessment
  • Implementation of strategies to address compliance
  • Education
  • Learning outcomes achieved by the patient
    • Percentage of the material patient can teach back
    • Specific areas needing reinforcement at next visit
  • Unexpected outcomes and related interventions
  • Physician contact and orders received
  • Respiratory assessment findings and effectiveness of oxygen therapy
  • Patient’s progress toward goals
  • Assessment of pain, treatment if necessary, and reassessment

OLDER ADULT CONSIDERATIONS

  • Older patients may need assistance changing a regulator due to changes in dexterity and vision. The nurse should assess the patient’s ability to safely perform the procedure steps and alert the prescribing practitioner if problems are found.

REFERENCES

  1. Boatright, J., Ward, J. (2016). Chapter 13: Therapeutic gases: Manufacture, storage and delivery. In D.R. Hess and others (Eds.), Respiratory care: Principles and practice (3rd ed., pp. 244-272). Burlington, MA: Jones & Bartlett Learning.
  2. Joint Commission, The. (2020). National patient safety goals for the home care program. Retrieved October 8, 2020, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2020/npsg_chapter_ome_jul2020.pdf (Level VII) or (Level D)
  3. Vines, D.L. (2017). Chapter 40: Storage and delivery of medical gases. In R.M. Kacmarek, J.K. Stoller, A.J. Heuer (Eds.), Egan’s fundamentals of respiratory care (11th ed., pp. 884-904). St. Louis: Elsevier.

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