Quarterly Inservice Test #3: Oxygen

Oxygen is a gas in the air we breathe and is necessary to support life functions. The air we breathe or room air is 21% oxygen and 79% nitrogen and other gases. In normal conditions 21% oxygen is sufficient to support bodily functions. In cases of chronic illness or injury oxygen needs may increase and require the use of supplemental oxygen. In some cases such as in a fire or at high altitudes the concentration of oxygen in the air may be less than 21%. A client may suffer from HYPOXIA or a decrease in the supply of oxygen in the body tissues requiring supplemental O2.

REASONS FOR HYPOXIA-
1. respiratory insufficiency- This may be caused by environmental issues such as a fire or high altitude or damage to the lungs due to injury or a chronic disease like emphysema or CHF.
2. circulatory insufficiency- a reduced blood flow to the heart due to heart attack, heart failure, cardiovascular collapse or severe blood loss or shock
3. hemoglobin insufficiency- not enough oxygen in the red blood cells in cases such as carbon monoxide poisoning or too high a dose or over dosage of pain medicine.
4. cellular exchange problems- Insufficient oxygen is delivered to the cells due to problems such as drug or alcohol abuse or poisoning in the air.

Home oxygen sources

1. Oxygen tanks or compressed gas- An oxygen tank is a green cylinder with a regulator that controls the flow rate. Tanks come in many sizes depending on need. Small tanks are portable and can be placed on the back of a wheelchair in a rack made for the tank, they may be in a rolling stand that can be pushed around the home or facility or they may come in a padded pouch to go in a car on outings. Large tanks are for stationary use. If a client has an oxygen concentrator he will also have a tank in the home in case of emergency. Tanks have a regulator and gauge that will tell you how much O2 is left in the tank. When the reading is 200 PSI or less it is time to change the tank. There should be spares in the home, it is your responsibility to be sure there is enough back up oxygen or call the office so that we can get replacements before it becomes a problem. Never roll an oxygen tank, if you do not know how to handle an oxygen tank call the office for hands on training. Do not attempt to change regulators etc. if you have not been trained. Tanks must be replaced by the oxygen company when they are empty.

2 Liquid Oxygen- Rarely will you find liquid oxygen in the home, this oxygen source is stored in a cold thermally insulated container. There are usually two containers a very large stationary device and a smaller portable unit that you must fill from the larger unit. This system is expensive to maintain in the home and not usually used. If you encounter Liquid O2 please call the office for instruction. The stationary unit will also need refilling on a frequent basis. Be sure not to tip Liquid oxygen containers, the liquid oxygen will spill out and is so cold it will cause burns to your skin.

3 .Oxygen Concentrators- The most common form of home O2 is the oxygen concentrator, they are stationary electrical units that absorb the nitrogen from room air and provide a continuous flow of oxygen to the client. They are the most cost effective way to deliver O2 in a home setting and have the advantage of not needing to be refilled. The disadvantage is that they rely on electricity so they do not work in a power failure they are also not portable. Long tubing can be obtained to reach the clients living areas. Oxygen concentrators should be away from the wall as they pull in room air and the flow should not be blocked. Concentrators have one or two sponge like filters on the sides or the back of the machine. These filters trap dust in the air and need to be removed and washed with mild soapy water, rinsed and dried EVERY DAY OR EVERY VISIT. Keeping the unit too close to the wall or not cleaning the filter will alter the flow of oxygen to the client and may cause the unit to overheat and cause a fire hazard. The unit needs to be wiped down twice a week, unplug the unit while cleaning it for safety. There must be a backup oxygen tank in the home in case of a power failure and a portable if the client needs to leave home.

Oxygen humidifiers-
If a client is on oxygen occasionally they do not usually need a humidifier but if they are on for extended periods the oxygen should be humidified. A bottle attaches to the tank or concentrator, there will be two lines on the bottle and it is filled with water between the 2 lines. The water should not be filled above the top line as it will be forced into the tubing occluding O2 flow and can eventually be inhaled by the client. It must also not fall below the bottom line or it will not be effective. The bottle must be washed in mild soapy water every 2 or 3 days. The 02 tubing can attach directly to the machine or tank for the time it takes to clean the humidifier bottle without harm to the client.

Cool mist vaporizers or humidifiers-
Clients may have many types of humidifiers or vaporizers all of them require cleaning on a regular basis. Unplug the unit and wipe down all exposed parts and rinse out the water reservoir. White vinegar may be used to clean built up scum and mineral build up. It is also important to add water when needed.

Oxygen safety tips-
1. Oxygen is not combustible, rather it SUPPORTS combustion. That means that things will burn faster in an oxygen rich environment. A match will burn stronger with a larger flame etc. Things can catch fire and spread very quickly when oxygen is in use. If there is a fire GET OUT OF THE HOUSE and then call for help.
2. The top of the O2 green tank has a valve if it breaks off or if the tank is punctured it can take off around the room, much like a helium balloon that is punctured. This is a very dangerous situation, if you do not know how to handle a tank ASK and be trained.
3. When deciding on placement of an oxygen device, keep it away from gas flames such a gas stoves and dryers or open gas wall heaters with a flame. Long tubing can be obtained so that the tank or concentrator can be in a safe location. Keep in mind that concentrators must be away from the wall, do not run the concentrator in a closet. Concentrators also give off heat and can be noisy so keeping them away from the client is good idea.
4. Oxygen and oil do not mix, do not use oil or grease to lubricate an oxygen device. Vaseline or petroleum jelly should not be used on the client’s lips or near oxygen. Water soluble lubricants should be used near the client on O2.
5. Do not roll or drag O2 tanks. If a portable tank is used in a car, be sure it is secured so it does not move or roll all around the car.
6. Do not smoke or allow smoking around oxygen
7. Keep oxygen sources and clients on O2 at least 5 feet from gas stoves, heaters with open flames, candles, lighted fireplaces and space heaters.
8. Do not use oxygen near cleaning fluids, paint thinner or aerosol sprays.
9. Avoid using extension cords to plug in your concentrator, if you must use an extension cord it needs to be a heavy duty cord.
10. Keep a fire extinguisher nearby, but if there is a fire get out as quickly as possible and then call 911. Let the fire dept know there is oxygen in the house.
11. When using Liquid oxygen keep the containers upright to avoid liquid O2 from spilling out. Liquid O2 is so cold it will damage your skin on contact.

Oxygen delivery devices-
There are 2 devices you will see in the home a nasal cannula and a mask.
Both should be washed in soapy water at least twice a week. They can also be soaked in 1/3 white vinegar and 2/3 water for 20 minutes and left to dry to disinfect the device, so there should always be a spare mask or cannula to use while the other is being cleaned and disinfected. The mask or cannula should be replaced every 4-6 weeks or after a cold, flu or other illness. DO NOT wash the long thin tubing connected to the oxygen source. That tubing is changed periodically per the oxygen supplier’s directions, there should be a spare set of tubing in the home at all times.
1. Nasal Cannula- The nasal cannula is a 2 pronged device that is gently inserted into the nostrils, it is connected to the long tubing coming from the oxygen source. The cannula tubing can go around the ears or be attached to the frame of eyeglasses. Check the skin under the tubing frequently and make sure the tubing is not tight. Skin breakdown is very common from long term cannula use, taping the tubing to eyeglasses during the day or while the client is awake decreases the potential for skin breakdown. Report skin breakdown to the nurse ASAP. The nasal passages and skin around the entrance to the nose can become dry and cracked from constant O2 use. Humidity from the water bottle attached to the O2 source can relieve much of the problem. DO NOT USE PERTOLEUM JELLY OR VASELINE ON THE SKIN AROUND A NASAL CANNULA. If you must lubricate the skin do so with KY type jelly that is water soluble. The client can also alternate with a mask and cannula as the mask does not rest in the nose.
2. Mask- There are several types of masks, the most common is the simple mask which fits over the mouth and nose. If you have other types of masks ask for instruction on their use. A mask is used for clients needing a high flow of oxygen and some clients feel more comfortable at night with a mask.

Remember that room air contains 21 % oxygen (O2), see the chart below of percentage of oxygen delivered at different flow rates. Most oxygen concentrators only go to 5 liters per minute or LPM’s. The flow meter is on the front of the concentrator. The flow rate is on the gauges on the regulator of an oxygen tank.

NASAL CANNULA FLOW RATES
1. 1 LPM- 24-25% O2
2. 2 LPM-27-29% O2
3. 3 LPM- 30-33% O2
4. 4 LPM- 33-37% O2
5. 5LPM- 36-41% O2
6. 6LPM- 39-45% O2

Oxygen masks usually deliver between 35-50% O2. If lower concentrations are desired, special masks such as a Venturi or Venti-mask can be used.

Chronic Obstructive Pulmonary Disease- (COPD)
COPD includes chronic bronchitis, emphysema and many other non specific respiratory diseases with similar symptoms. Chronic bronchitis may be seen in the children but this is mainly a disease of middle-aged or older adults. The most common cause is smoking but it may be caused by long term exposure to allergens, air pollution, infections or long term second hand smoke from living or working in a smoker’s environment.
Signs and symptoms of COPD-
1. usually an older person
2. heavy smoking history
3. persistent cough
4. shortness of breath
5. tires easily
6. tightness in chest
7. dizziness
8. Cyanosis or blue color of the arms, hands legs and feet.
9. Edema or swelling of the feet
10. wanting to sit upright all the time, cannot breathe lying down
11. History of repeated respiratory infections
12. Exposure to smoke or industrial gases
Signs and symptoms specific to Emphysema, including those above
1. rapid pulse
2. Puffy breathing
3. frequent wheezing
4. barrel- chest appearance

A person with COPD secretes excess mucous in his lungs and is unable to clear it or cough it up as a normal person could. A normal person breathes in reaction to carbon dioxide in the blood. A person with COPD has had high levels of carbon dioxide in his blood for a long time and his body no longer responds to it, too much oxygen for these clients can cause the person to stop breathing or have respiratory failure. A COPD patient still needs more than 21% O2 that room air delivers due to the high level of carbon dioxide in the blood, they are usually on 24% O2 NEVER more than 28%, or 1-2 LPM’s by nasal cannnula or they are on a Venti mask at 24-28%.REMEMBER DO NOT INCREASE THE O2 flow beyond 2LPM or beyond the recommendations of the doctor to avoid causing harm to the client. COPD clients are usually the most comfortable in an upright position either in a recliner or hospital bed with the head raised. They are often more anxious and short of breath at night and have difficulty sleeping. Encouraging fluids will keep secretions thinner and easier to clear.