Module 3: O2 Therapy

Question 1

Principles of Oxygenation

Answer 1

Oxygen therapy is used to treat hypoxia.
 Hemoglobin is the carrier of respiratory gases: oxygen
(O2), and carbon dioxide (CO2).
 Hemoglobin levels and acid-base status directly affect
oxygenation.
 Pain and anxiety increase a patient’s oxygen needs.
 Fever increases the body’s metabolic rate and, in turn,
oxygen demand.
 Treat oxygen as a medication.
 Contraindications to oxygen therapies include those that increase the patient’s risk for respiratory failure.

Question 2

Heated High Flow Nasal Cannula

Answer 2

Heated high-flow nasal cannula
 Prongs should not completely occlude the nares of
the patient.
 The temperature of the oxygen should be set at 37°C.
 FiO2 is titrated to maintain the desired oxygen
saturation levels
 Flow is titrated to maintain the desired respiratory
rate, work of breathing, and oxygen saturation levels.
 Heart rate, respiratory rate, and oxygen saturation
levels should be continuously monitored.

Know a patient’s normal range of vital signs and pulse
oximetry (SpO2) values.
 Be aware of environmental conditions.
 If a patient is to receive home oxygen therapy, complete an environmental assessment to determine respiratory hazards in the home.
 Document a patient’s smoking history.
 Long-term chronic lung diseases result in hypoxia.
 Know a patient’s most recent hemoglobin values and
past and current arterial blood gas (ABG) values.

Treat supplemental oxygen therapy as a medication.
 Provide education to patient and family about safe home oxygen therapy so they understand proper use of the equipment.
 Have working suction equipment available to help clear airway secretions.
 Most agencies require that a self-inflating resuscitation bag and appropriate-size mask be available in patient rooms, particularly in patients requiring mechanical ventilation.

Question 3

Applying an Oxygen-
Delivery Device

Answer 3

Oxygen-delivery devices
 High-flow
* Venturi masks
* Large-volume nebulizers
* Blender masks
* High-flow nasal cannula

 Low-flow
* Nasal cannula
* Simple face mask
* Nonrebreather
* Partial rebreather masks

Question 4

Oxygen Flowmeter

Answer 4

An oxygen flowmeter is a medical device used to regulate and measure the flow of oxygen from a supply system to the patient. The flow is typically measured in liters per minute (L/min). Oxygen flowmeters are an essential component of oxygen therapy equipment, ensuring that patients receive the correct amount of oxygen as prescribed by a healthcare provider.

Question 5

Heated High Flow Nasal Cannula

Answer 5

Heated High-Flow Nasal Cannula (HHFNC) therapy is an advanced respiratory support technique that delivers adequately warmed and humidified medical gas at high flow rates through a nasal cannula. It is increasingly used in various clinical settings, including intensive care units (ICUs), emergency departments, and during the postoperative period, for both adult and pediatric patients.

Components:

Air-Oxygen Blender: Allows for precise adjustment of the fraction of inspired oxygen (FiO2) to meet the patient’s oxygenation needs, ranging from 21% (room air) up to 100% oxygen.

Heater-Humidifier: Warms and humidifies the gas to near body temperature and 100% relative humidity, reducing the risk of mucosal dryness and irritation that can occur with traditional high-flow oxygen therapy.

High-Flow Generator: Capable of delivering gas flows exceeding conventional oxygen therapy rates, typically up to 60 liters per minute (L/min) for adults and proportionally less for children, depending on their size.

Nasal Cannula: Specially designed to deliver high-flow therapy comfortably. Unlike standard nasal cannulae, those used for HHFNC are broader and have larger prongs to accommodate the high flow rates.

Clinical Applications:
Hypoxemic Respiratory Failure: HHFNC is particularly beneficial for patients with acute hypoxemic respiratory failure, as it can improve oxygenation by reducing anatomical dead space, delivering a consistent FiO2, and generating a degree of positive end-expiratory pressure (PEEP) that can help keep alveoli open.

Respiratory Failure with Hypercapnia: While non-invasive ventilation (NIV) is typically preferred for hypercapnic respiratory failure, HHFNC can be an alternative for patients who do not tolerate NIV or as a step-down therapy from NIV.

Pre- and Post-extubation: HHFNC can be used to prevent or treat post-extubation failure in selected patient populations, providing adequate respiratory support while avoiding the need for re-intubation.

Question 6

Applying an Oxygen-
Delivery Device Delegation

Answer 6

Delegation
 Certain agencies allow the skill of applying a nasal cannula or oxygen mask to be delegated to AP. The nurse is responsible for assessing patient’s respiratory system, response to oxygen therapy, and setup of oxygen therapy, including adjustment of
oxygen flow rate. The nurse directs the AP by:
* Informing how to safely adjust the device and clarifying its correct placement and positioning
* Instructing to inform the nurse immediately about any
changes in vital signs; changes in pulse oximetry; changes in level of consciousness; skin irritation from the cannula, mask, or straps; or patient complaints of pain or breathlessness
* Instructing personnel to provide extra skin care around patient’s ears and nose to prevent skin breakdown

Question 7

Oxygen Delivery Unexpected Outcomes

Answer 7

Unexpected outcomes and related interventions
 Patient experiences skin irritation or breakdown, sinus
pain, or epistaxis.
* Increase humidification to oxygen-delivery system.
* Provide appropriate skin/wound care. Do not use petroleum-based gel around oxygen because it is flammable.

Unexpected outcomes and related interventions
 Patient experiences continued hypoxia.
* Notify health care provider.
* Obtain health care provider’s orders for follow-up SpO2 monitoring or ABG determinations.
* Consider measures to improve airway patency, including but not limited to coughing techniques and oropharyngeal or orotracheal suctioning.

Patient experiences nasal and upper airway mucosa
drying.
* If oxygen flow rate is greater than 4 L/min, use humidification. At rates greater than 5 L/min, nasal mucous membranes dry, and pain in frontal sinuses may develop.
* Assess patient’s fluid status and increase fluids if appropriate.
* Provide frequent oral care

Question 8

Administering Oxygen Therapy to
a Patient With an Artificial Airway

Answer 8

Patients with artificial airways require constant
humidification to the airway. An artificial airway
bypasses the normal filtering and humidification
process of the nose and mouth.
 Devices that supply humidified gas to an artificial
airway
 T tube
 Tracheostomy collar

Question 9

Delegation of Oxygen Administration to Pt with Artificial Airway

Answer 9

The skill of administering oxygen therapy to a patient
with an artificial airway cannot be delegated to AP.
The nurse directs the AP about:
* Patient-specific variations for application or adjustment of the
T tube or tracheostomy collar
* Immediately reporting to the nurse increase in anxiety,
changes in vital signs, and increase in airway secretions

Question 10

Artificial Airway Unexpected Outcomes

Answer 10

Unexpected outcomes and related interventions
 Patient experiences tracheal stoma or lip irritation;
thick, tenacious secretions; pressure areas on neck or
near stoma site.
* Implement measures to protect patient from MDRPI.
* Increase frequency of suctioning and airway care
 Patient experiences continued hypoxia.
* Determine if cause of continued hypoxia is functioning of oxygen-delivery device, obstruction of airway, oxygen flow rate, or a new clinical problem.
* Notify health care provider of continued or worsening
hypoxia.

Question 11

Using Incentive Spirometer

Answer 11

Incentive spirometer
 Helps a patient deep breathe
 Commonly used for patient recovery postoperatively
 Types: flow-oriented and volume-oriented

Question 12

Delegating Incentive Spirometer to AP

Answer 12

Delegation
 The skill of helping a patient to use incentive
spirometry can be delegated to AP. The nurse is
responsible for assessing and monitoring the patient,
evaluating the patient response, educating the patient
about the proper use of the IS, and evaluating that
education. The nurse directs the AP by:
* Informing about the patient’s target goal for incentive
spirometry
* Informing to immediately notify the nurse about any
unexpected outcomes such as chest pain, excessive sputum production, and fever

Question 13

Incentive Spirometer Unexpected Outcomes

Answer 13

Unexpected outcomes and related interventions
 Patient is unable to achieve incentive spirometry
target volume.
* Encourage patient to attempt incentive spirometry more frequently, followed by rest periods.
* Teach cough-control exercises.
* Teach patient how to splint and protect incision sites during deep breathing.
* Administer ordered analgesic if acute pain is inhibiting use of IS

Unexpected outcomes and related interventions
 Patient has decreased lung expansion and/or
abnormal breath sounds or decreased pulse oximetry
readings.
* Teach patient cough-control exercises.
* Provide help with suctioning if patient cannot cough up secretions effectively.
 Patient develops hyperventilation.
* Encourage longer rest periods between breaths.

Question 14

Care of a Patient Receiving
Noninvasive Positive Pressure Ventilation

Answer 14

Noninvasive positive pressure ventilation
(NIPPV or NPPV)
 Maintains positive airway pressure
 Improves alveolar ventilation without the need for an
artificial airway
 Types: continuous positive airway pressure (CPAP)
and bilevel positive airway pressure (BiPAP

Question 15

Delegation of NPPV to AP

Answer 15

Delegation
 The skill of caring for a patient receiving NIV cannot be
delegated to AP. However, the skills of patient positioning, therapeutic coughing, and CPAP/BiPAP mask application can be delegated to AP. The nurse directs the AP by:
* Informing about the need to immediately report to the nurse any changes in patient’s vital signs; oxygen saturation; mental status; skin color; or skin changes around mask area
* Informing about the need to immediately report to the nurse any machine or patient alarms
* Instructing on how to modify care
* Informing about the prescribed settings on the NIPPV
equipment and instructing personnel to immediately notify the nurse of any change in settings or patient comfort

Question 16

NPPV Unexpected Outcomes

Answer 16

Unexpected outcomes and related interventions
 Patient experiences hypoxia, hypercapnia, or other
signs of worsening respiratory function or barotrauma
(pneumothorax).
* Notify health care provider.
* Reassess patient.
* Determine correct settings and integrity of NIPPV. Consult with respiratory therapist.

Unexpected outcomes and related interventions
 Patient develops skin breakdown at mask sites or
sites where mask straps are located such as bridge of
nose, nasal septum, or ears.
* Notify health care provider.
* Place protective synthetic coverings on nasal bridge or areas of irritation/possible irritation to protect skin.
* Fit mask so it is tight enough to not cause air leak but loose enough to not cause skin breakdown.
* Reassess patient

Unexpected outcomes and related interventions
 Patient states sense of smothering or claustrophobia.
* Explain system to patient again.
* Demonstrate use of quick-release straps.
* Have patient demonstrate use of quick-release straps.

Question 17

Use of a Peak Flowmeter

Answer 17

Peak expiratory flow rate (PEFR) measurements
 Maximum flow that a patient forces out during one
quick, forced expiration
 Measured in liters per minute
 Used as an objective indicator of a patient’s current
status or the effectiveness of treatment

Question 18

Delegation of Peak Flow Meter

Answer 18

Delegation
 Initial assessment of the patient’s condition is a
nursing responsibility and cannot be delegated. The
skills of follow-up PEFR measurements in a stable
patient can be delegated to AP. The nurse instructs
the AP to:
* Report immediately to the nurse patient’s difficulty breathing or decrease in PEFR measurement

Question 19

Care of a Patient on a
Mechanical Ventilator

Answer 19

Mechanical ventilation
 Takes over the physical work of moving air into and
out of the lungs
 Does not replace or alter the physiological function of
the lung
 Types: positive pressure and negative pressure
 Patients should remain on mechanical ventilation only
as long as necessary

Alarms and settings
* Settings: amount of oxygen delivered, number of breaths per minute, amount of tidal volume delivered, time for inspiration and expiration, and pressure at which each breath is delivered
* Alarms: high-pressure, low-pressure, and low-exhaled
volume
 Ventilator-associated event (VAE)
* Deterioration in patient condition after he or she has been placed on mechanical ventilation
* Ventilator-associated pneumonia (VAP)

Question 20

Mechanical Ventilator Delegation

Answer 20

Delegation
 The skill of caring for a patient on a mechanical
ventilator cannot be delegated to AP. The nurse
directs the AP about:
* Reporting immediately to the nurse any change in the
patient’s respiratory status, vital signs, or oxygen saturation and if patient indicates breathlessness
* Informing the nurse immediately if any of the ventilator alarms sound
* Helping in daily care such as bathing and repositioning the patient