Monday, August 14, 2006

OXYGEN THERAPY PROTOCOL FOR ADULT & PEDIATRICS

Excluding Neonatal
© DHMC, Respiratory Care Department

OBJECTIVE:
To provide oxygen therapy to patients who have a stable respiratory rate and pattern and monitor this therapy via pulse oximetry (SpO2 ).
PERSONNEL:
Therapy must be monitored by a Respiratory Care Practitioner (RCP) or Registered Nurse (RN).
POLICY and PROCEDURE:
Physician's initial order for oxygen therapy should include:
a. Initial flow rate or FiO2.b. Oxygen appliance.c. A target SpO2 of 90% will be used for titrating therapy, unless a different target SpO2 is specified in the order.

Orders for oxygen therapy must have documentation of hypoxemia, acute cardiac or neurologic injury or other clinical indication of hypoxia as specified by the physician in a written note. Patients admitted to the Emergency Department may have oxygen administered until the physician completes an evaluation.
Oxygen therapy will be titrated and weaned as appropriate for patients who meet the following conditions:
a. Cardiopulmonary stability including stable vital signs and respiratory pattern.b. Adequate tissue perfusion based on clinical assessment. It is recognized that, for some patients, SpO2 may not be a reliable measure of adequate tissue perfusion. c. Clinical Assessment of Tissue Perfusion includes but is not limited to:
Neurological changes such as behavior changes or changes in the level of conciousness.
Adequate cardiac function: Blood pressure, heart rate distal pulses, extremity temperatures and, for infants and children, capillary refill > 2 seconds..
Fluid status: input and output.

For COPD patients with documented CO2 retention, oxygen will be titrated from 0 - 2 LPM via nasal cannula or 21% to 28% via venti mask or aerosol to maintain SpO2 > 88 - 90% unless the physician specifies a different target SpO2.
For all other patients, oxygen will be titrated from 0 - 4 LPM via nasal cannula (0-2 LPM for infants) or 21% to 40% venti mask or aerosol to maintain SpO2 > 90% unless the physician specifies a different target SpO2.
The physician will be notified immediately for patients who cannot maintain adequate SpO2 based on this protocol. Appropriate treatment modalities will be discussed and a plan of action initiated based upon patient's medical history.
a. The physician may order a Respiratory Care Evaluation to assess these patients in the event that the physician cannot see the patient immediately. Such assessments may include ABG evaluation: (See Respiratory Therapy Evaluation Policy for a complete description ). The physician will be notified of the results of any patient evaluation and recommendations as covered by the Respiratory Therapy Evaluation Policy.

Notify Respiratory Care of any patient on the floors requiring oxygen > 40% by paging the therapist covering their area. This will alert Respiratory Care to those patients who may be at higher risk for respiratory complications.
Patients who use oxygen therapy at home will not be discontinued without a physician's order.
Oxygen will be discontinued when the patient meets the conditions defined in the Oxygen Therapy Policy.
a. SpO2 > 90% or target SpO2 b. Stable vital signs including respiratory rate and pattern.d. Does not desaturate with exertion.e. Adequate tissue perfusion
Neurological status: LOC
Cardiac status: BP, HR, distal pulses & extremitytemperatures.
f. Fluid status: assess I&O.g. Subjective: no c/o of SOB or dyspnea.
To continue oxygen therapy requiresthe following:
a. Target SpO2 provided by the physician. If not provided, > 90% will be the target SpO2. You must document a Room Air SpO2 < 90% or < target SpO2 ordered by M.D.b. Document that the therapy is continued in the patient's medical record.

To discontinue oxygen therapy requires the following:
a. Documentation of the Room Air SpO2 > Target SpO2 in the chart. b. Documentation that the therapy is discontinued in patient's medical record.

ADDENDUM:
Factors Affecting Clinical Performance of Pulse Oximeter:
Sensor position
Position on oxyhemoglobin dissociation curve
Patient hemodynamics
Motion artifact
Ambient light interference
Dysfunctional Hemoglobins
Patient temperature
LED (sensor light) peak wavelength variability
Exogenous dyes (i.e. methylene blue)
Nail polish
Digital clubbing
Remember:
Use non-arterial-line extremityInadequate pulsation may affect readingIn patients with Reynaud's Syndrome, pulse oximetry may not be reliable.
In patients with cardiac/pulmonary instability, pulse oximetry may not be a reliable indicator of medical conditions.Arterial blood gases are the most accurate indicator of oxygenation status.

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