11. oxygen therapy 2.pptx

Oxygen therapy
By zewdie oltaye
Hawassa University School of
nursing
June 2015

oxygen therapy
• is the administration of or methods to
supplement or augment oxygen when tissue
oxygenation is impaired.
• is the administration of oxygen as a medical
intervention, in both chronic and acute patient
care.
• Oxygen is essential to allow aerobic metabolism
to produce energy from the intake of food.
Oxygen therapy is the administration of oxygen at
a concentration greater than that found in the
environmental atmosphere.

Indication for oxygen therapy
• Additional oxygen is indicated for numerous clients who have hypoxemia.
• Some clients need oxygen therapy to maintain adequate arterial blood oxygen levels.
- Acute respiratory failure
• a, With carbon dioxide retention – the most common causes are chronic bronchitis,
chest injuries
• b, With out carbon dioxide retention the most common cause are asthma,
pneumonia, pulmonary edema and pulmonary embolism.
• Acute myocardial infarction
• Cardiac failure
• Shock, particularly hemorrhagic, bacteraemic and cardiogenic
• High metabolic demands of healing tissues can limit the body’s oxygen supply
Eg.sepsis, trauma, burns
• States where is a reduced ability to transport oxygen, e. g Anemia
• During cardio respiratory resuscitation
• During anesthesia for surgery.
• Oxygen therapy is used to reverse hypoxemia. This action can help to accomplish
three functional goals.
• Improved tissue oxygenation
• Decreased work of breathing in dyspenic clients
• Decreased work of the heart in clients with cardiac disease

oxygen therapy
• Manipulation oxygen cylinder
• Responsibility of Securing gauge & flow meter to cylinder
• volume of cylinder
• Lids direction for opening & closing
• preparing humidifier & oxygen delivery sets
• How do you know the amount of o2 in the cylinder?
• a 60 kg pt receiving 10 l/m of o2from a 20 litter cylinder
with current pressure reading of 2000 p.
-what is the total amount of o2 in the cylinder ------
- for how long he can use this o2

OXYGENATION
OXYGEN – A PRESCRIBED DRUG
• MUST INDICATE DURATION OF O2 THERAPY
• THE O2 % CONCENTRATION MUST BE PRESCRIBED
• THE FLOW RATE MUST BE PRESCRIBED

BASIC COMPONENTS OF A OXYGEN DELIVERY
SYSTEM
• OXYGEN CYLINDER
• A REDUCTION GAUGE
• FLOW METER
(LITRES/MIN)
DISPOSABLE TUBING OF
VARYING DIAMETER AND
WIDTH
• DELIVERY (MASK
,CANNULA etc...)
• HUMIDIFIER (TO WARM
AND MOISTEN THE O2)

METHODS OF ADMINISTERING OXYGEN
• SIMPLE SEMI-RIGID MASKS
• NASAL CANNULA
• FIXED PERFORMACE MASKS OR HIGH-FLOW MASKS
(VENTURI)
• PAEDIATRIC CIRCUITS - HEADBOX OR HOOD
- O2 TENT/COT
• MECHANICAL VENTILATION
• CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)

HUMIDIFICATION OF OXYGEN
• NORMAL AIR TRAVELLING THROUGH THE AIRWAYS IS
WARMED, MOISTENED AND FILTERED BY EPITHELIAL CELLS
OF THE NASOPHARYNX
• THE AIR ENTERING THE TRACHEA WILL HAVE A RELATIVE
HUMITY OF 90% AND A TEMPERATURE OF BETWEEN 32-36 C
• OXYGENATION WILL CAUSE DEHYDRATION OF THE MUCUS
MEMBRANES AND PULMONARY SECRETIONS

HEALTH AND SAFETY ISSUES WITH O2
• MEDICAL GAS
CYLINDERS HAVE TO
CONFORM TO COLOUR
CODING
• CURRENTLY OXYGEN
CYLINDERS ARE BLACK
WITH WHITE
SHOULDERS.

HEALTH AND SAFETY ISSUES WITH OXYGEN
• OXYGEN IS
COMBUSTIBLE/እሳት/
• OIL AND GREASE AROUND
CONNECTIONS SHOULD BE
AVOIDED
• ALCOHOL, ETHER AND
INFLAMMATORY LIQUIDS
SHOULD BE KEPT SEPARATE
FROM O2
• NO ELECTRICAL DEVICES NEAR 02
TENT
• NO SMOKING
• FIRE EXTINGUISHER NEEDS TO BE
AVAILABLE
• CARE WITH USING
DEFIBRILLATOR NEAR HIGH
OXYGEN CONCENTRATIONS

Dangers of oxygen treatment
• Fire: Oxygen promotes combustion.
• Pulmonary oxygen toxicity: High
concentrations of oxygen(>60%) /may damage
the alveolar membrane when inhaled for
more than 24-48 hours.
• severe cerebral vasoconstriction and epileptic
like fits
• Retinopathy prematurity

Oxygen administration sets.
• Nasal Cannula
• Used for patients with normal breathing rate
and depth ( for supplementary o2)
• 2-6 LPM for adults or ¼-1/2 for children
• 21%- 44% concentration of O2 delivered

Nasal Cannula
Advantages
 Easy to use
 No rebreathing
 Better tolerated
 Disposable
 Low cost
Disadvantages
 Flow > 3 L / min not
tolerated
 Gastric distension
 Drying of mucosa
 O2 wastage

Nasal cannula
O2 flow rate L/min FiO2
1 0.24
2 0.28
3 0.32
4 0.36
5 0.40
6 0.44

6 0.6
7 0.7
8 0.8
9 0.8+
10 0.8+
5-6 0.4
6-7 0.5
7-8 0.6
Mask with reservoir bags
Face mask

Simple face mask
• FiO2 0.35-0.50
• 5-12 L/ min
Advantages
• Easy to apply
• Disposable
• Inexpensive
Disadvantages
• Uncomfortable
• Must be removed for
eating
• Prevent radiant
heat loss
• Block vomitus

Partial rebreathing mask
• 6-10L /min
• FiO2 0.35-0.60
• Has no valves
• Inspiration –O2 flows to
mask and patient
• Expiration – source O2 and
expired gas enters the bag
Non rebreathing mask
• 6-10L/min
• FiO2 0.55-0.70
• Has 2 one way valves
• Insp - inspiratory valve
opens provides O2 to
patient
• Exp- expiratory valve
opens divert exp gas to
atmosphere
• Large air leaks

Large capacity devices
• A reservoir bag is attached to
the mask
• O2 can accumulate
throughout the respiratory
cycle
• Rebearthing is possible
•FIO2 = 0.6 – 0.9

BVM ventilation
• Bag-valve-mask (BVM) device
Used during
• severe respiratory distress
• respiratory arrest.
With oxygen flow rate of 15 L/min
 adequate mask to face seal a BVM device
with an oxygen reservoir can deliver nearly
100% oxygen.

Components of a BVM device
• An adult BVM devices
a. Self-refilling bag, disposable or easily cleaned
b. No pop-off valve
c. An outlet valve that is a true valve for non
rebreathing
e. Transparent face masks in appropriate sizes

Steps BVM ventilation
BY one-person
i. Hold your index finger over the lower part of the mask
and secure the upper part of the mask with your
thumb (C-clamp) to maintain the seal.
ii. Use remaining fingers to pull lower jaw into the mask.
iii. Make sure that your fourth and fifth fingers are not
putting pressure on the neck.
iv. Squeeze the bag, using one hand, until the patient’s
chest rises, once every 5 seconds for adults and once
every 3 seconds for infants and children.
v. Deliver each breath over a period of 1 second.

One-person BVM ventilation
When using the device to assist respirations, -
deflate the bag as the patient tries to breathe in.
• If the patient’s chest does not rise and fall,
- try to reposition the head or
- use an airway adjunct.

c…
• In a patient with a possible spinal injury,
reposition the jaw rather than the head.
• If too much air is escaping from under the mask,
reposition the mask for a better mask seal.
• Try another airway device if all troubleshooting
fails.
• The BVM device may also be used
- in conjunction with an endotracheal tube
- or with other airway adjuncts (OPA)

Steps in two-person BVM ventilation
• Provider 1 kneels above the patient’s head;
• Provider 2 will bag the patient while provider 1 holds
the seal.
• The patient’s neck should be maintained in an
extended position unless cervical spine injury is
suspected.
Provider 2
 opens the patient’s mouth and suctions as needed,
then inserts an airway adjunct.
 selects the proper mask size.
 places the mask on the patient’s face.
- The top should be over the bridge of the nose and
the bottom should be in the groove between the lower
lip and the chin.

Ongoing assessment for effectiveness
ventilation with BVM
- The chest rise & fall
- if not :
- the rate at which you are ventilating is
- too slow
- too fast
- If the patient chest doesn’t rise and fall,
reposition the head ,
use an airway adjunct

1. Indication that artificial ventilation is adequate
• Equal chest rise and fall with ventilation
• Ventilating delivered at the appropriate rate
– 12 breaths per minute for adults
– 20 breaths per minute for infants and children
• Heart rate returns to normal

2. Indication that artificial ventilation Inadequate
• Minimal or no chest rise and fall;
• Ventilations are delivered too fast or too slow
for patients age
• Heart rate does not return to normal.
if chest is not rising and falling,
 reposition the head,
 use an airway adjunct

Monitoring oxygen treatment
• Oxygen treatment can be monitored by blood
gas measurements or
• non-invasively by pulse oximetry.
• Blood gas analysis provides accurate
information on the pH, Pao2, and Paco2.
• Oximetry provides continuous monitoring of
the state of oxygenation.

Stopping oxygen treatment
• Oxygen should be stopped when arterial
oxygenation is adequate with the patient
breathing room air (Pao2>8 kPa, Sao2>90%). In
patients without arterial hypoxemia but at risk
of tissue hypoxia, oxygen should be stopped
when the acid-base state and clinical
assessment of vital organ function are
consistent with resolution of tissue hypoxia.

Summary
• Oxygen is a life saving treatment.
• It should be treated like any other drug
• it should be prescribed in writing, with the
required flow rate and with clear method of
delivery
• correct hypoxemia
• Careful monitoring of treatment is essential
and will detect those patients at risk of carbon
dioxide retention.

CPR
• IS Sequences of procedures performed to
restore the circulation of oxygenated blood
after a sudden pulmonary and/or cardiac
arrest
• CPR is a combination of artificial ventilation &
artificial circulation
38

Goal
• to support or restore
• effective oxygenation
• Ventilation
• Circulation
39

Sequences to follow
1. Formerly is DRs ABCD
2. Currently is DRs C-A-B-D (not A-B-C-D)
for adults & pediatrics
• Check for Danger
• Check Response(if unresponsive)
Send for help
• Give CPR
• Check Airways
• Check for Breathing
• Apply a Defibrillator
40

why BLS changed from A-B-C to C-A-B
• In 2010, the (AHA) issued revised guidelines for CPR
• Among the highlights and the changes :
 A-B-C changed to C-A-B.
• is the biggest change in the BLS sequence
for adults and pediatric patients (children and infants)
excluding newborns).
• no more "looking, listening and feeling," as the
performance of these steps is inconsistent and time
consuming.
• The key to saving a cardiac arrest victim is ACTION, not
assessment.
• All victims in cardiac arrest need chest compressions.41

C..
• ABCs of CPR, which instructed people to open a
victim's airway by tilting their head back, pinching
the nose, seal the mouth and breathing into the
victim's mouth, and then assessing for circulation
& chest compressions,
=> "This approach was causing significant delays.“
In starting chest compressions, which are essential
for keeping oxygen-rich blood circulating through
the body , allows all rescuers to begin chest
compressions right away/immediately
42

C..
• In the first few minutes of a cardiac arrest, victims
will have oxygen remaining in their lungs and
bloodstream, so starting CPR with chest compressions
can pump that blood to the victim's brain and heart
sooner.
• Research shows that rescuers who started CPR
with opening the airway took 30 critical
seconds longer to begin chest compressions
than rescuers who began CPR with chest
compressions.
43

C..
• Starting with compressions will only delay
ventilations for about 18 seconds as the
provider delivers 30 compressions prior to
opening the airway and ventilating.
• The most critical part of treatment for VF and
pulse less VT is:
- the new CPR sequence and early defibrillation
44

Check for Danger(Hazards/Risks/Safety
• to you
• to others
• to casualty
• For example; electrical wires, gases, aggressive
relatives, water, etc.
• Remove yourself and the casualty to an area
of safety
45

Check the casualty for
- a Response
- immediate recognition
- activation
• Use the COWS Method
 Can you hear me?
 Open your eyes
 What is your name?
 Squeeze my hand Gently , squeeze shoulders
46

If casualty is
Unresponsive
Check for breathing
not breathing
no normal breathing ( i.e. , only gasping ).
 Call/ send /for help & to bring AED
 supine position on flat prim surface
47

Check for Circulation
• Check pulse :
1. If definite pulse present with in 10 s
Give 1 breath
• for adults Q 5-6 s/10- 12 bpm
• for pediatric age group
Q 3 S/ 20bpm/ &
add compressions
- if the pulse remains <6o bpm
with poor perfusion despite
adequate oxygenation & ventilation
• Recheck pulse Q 2m 51

2. If pulse is absent or unsure
• Start compression
- Place hand/s in the center of the chest
between the nipple line on the lower half
of the sternum
- Give one cycle of chest compressions
following open airway& ventilate
52

2 Person CPR
• While rescuer A is performing compressions,
rescuer B maintains open airway and performs
ventilations.
• C:V Ratio is still 30:2 for adults & 15:2 for
children
• Switch compressors every 2 minutes chest
compressions are fatiguing.
53

CPR In Children
• Modifications of CPR in Children include:
– Amount of air for breaths
– Depth of compressions (at least 1/3 the depth of
the chest or approximately 2 inches)
– Chest compressions may be done with one hand
– 2 person CPR in children the ratio becomes 15:2
– Apply defibrillator as soon as possible
54

Infant CPR
• Determine unresponsiveness (stimulate , rub or slap the
bottom of the feet) do not “shake and shout”
• If the infant is unresponsive, check for a brachial pulse
• If there is no pulse,
• or the rate is < 60 with signs of poor perfusion,
• begin chest compressions.
• After 30 compressions open the airway and give 2
breaths.
• When performing breathing in an infant give just
enough air to achieve visible chest rise.
• Apply the AED as soon as it is available

Chest compressions for infants (under
one year) may be performed by:
A) Two fingers technique
- Is recommended when there is a single rescuer
- Compressions are performed with two middle
fingers, placed on the sternum just below the
nipples line
- Slight neck extension and the placement of
rolled towel beneath the upper thorax and
shoulders may be necessary to ensure that the
work of compression is focused on the heart
56

B) Two thumb encircling hands technique
• provides optimum chest compressions when there
are two rescuers
• The thorax is encircled with both hands and cardiac
compressions are performed with the thumbs
• The thumbs compress over the lower half of the
sternum, avoiding the xiphoid process, while the
fingers squeeze the thorax.
• This technique is recommended b/s:
- Coronary perfusion pressures were improved
with circumferential compression
57

Check Airways
 After one cycle of 30 chest compressions, open the airway
and give 2 breaths
 Airway open ? If not open :open
1. Using - ahead tilt & chin lift
58

Open airway
59
2. jaw thrust for pts with:
suspected spinal cord ,
head, neck and facial trauma

open Airway
3. basic airway adjuncts
.e.g. OPA
4. Clear of obstructions
- Suction any secretions
5. RX Chocking
Remove foreign body by:
- finer sweep
- McGill forceps
60

Check for BREATHING
• LLF/Look, listen and feel /for adequate breathing
for 5 – 10s
• is chest rising and falling?
• can you hear or feel air from mouth or nose?
Or abnormal breathing such as agonal breathing.
• Agonal breathing occurs shortly after the heart stops
in up to 40% of cardiac arrests
• W /c is described as heavy , noisy , or gasping
breathing
• Recognize as a sign of cardiac arrest .
 Then -give 2 rescue breathes with mouth to mouth,
pocket mask/BVM
61

continue high quality CPR
High quality CPR :
Improves a victim's chances of survival
It includes
1. Push hard & fast :
 Compress at a rate of at least 100 x /m
 with a depth of at least 5cm( 2 inches) for
adults & children &
about 4cm( 1.5 inches ) for infants
63

C..
2. Allow complete chest recoil after each
compressions
3.Minimize interruptions in compressions(try to
limit interruptions to < 10 s
4. Give effective breaths that make the chest rise
5. Avoid excessive ventilation
6. One cycle of CPR : 30 c then 2b
for 5cycles,( 2minutes)
7. Rotate compressors Q 2 m with rhythm checks
64

summary
CPR method C:v Rate of
c/m
Depth of comp
rations
Pulse check Hand
position
for c
Adult 1 R 30:2 100 4-5 cm carotid
Adult 2 Rs 30:2 100 4-5 cm carotid
Child 1 R 30:2 100 1/3 APD Carotid , femoral
Child 2 Rs 15:2 100 1/3rd APD Carotid, femoral
Infant 1 R 30 :2 100 1/3 – 1/2 APD/4cm Brachial, femoral
Infant 2 R 15:2 100 1/3- ½ APD/4cm Brachial, femoral
New born
neonate
3:1 120 1/3- ½ APD/4cm Umbilical , Brachial
,femoral 65

Neonatal resuscitation algorithm

Defibrillator /AED/ arrives
• Defibrillation is a process in which an
electronic device gives an electric shock to the
heart.
• This helps re-establish normal contraction
rhythms in a heart having dangerous
arrhythmia or in cardiac arrest.
70

Types of Defibrillators
•
1. Manual
– Has the capability for rhythm analysis by the
operator and will charge and deliver a shock at the
command of the operator.
2. Semi-Automatic
• Electronically detects life-threatening
rhythms, but requires your intervention in
order to deliver the shock
SAFETY FIRST!!!
71

Defibrillation Fact
• Defibrillation is the only technique that is effective
in returning a heart in VF to its normal rhythm.
• The time to defibrillation is the major predictor of
outcome
• A person’s chance of survival decreases by 10%
for each minute that passes without defibrillation
• The optimal time for defibrillation in hospital
settings is less than 3 minutes
• The probability of survival after 10 minutes is
extremely low
72

STEPS TO FOLLOW manual defibrillator
1. Consent
2. Check pulse manually
If no pulse , start compression
3. Turn on defibrillator
4. Attach the leads & Check the rhythm
If shock able (VF , pulse less VT)
6. Select joules
360J for monophasic
150 - 200 j for biphasic for adults
2-4j/kg for children
73

step
7. Dry the chest ,reduce chest hair, remove ECG
leads & oxygen tubing's
8. Apply wet pads ? over Rt. Upper ( base of the
heart & Lt. lower chest (apex of the heart ),there
will be no water b/n pads
9. Position the paddle on the base & apex
10. CLEAR Q one (no one is touching the patient &
the bed & you )
11.Charge the joule
12. press shock button ( give 1 shock,)
74

Steps….
resume CPR immediately for 2 m
check rhythm Q 2minutes
• If not shock able (Asystole /PEA)
- resume CPR immediately for 2 m ->
- give adrenaline 1mg IV Q 5m
- consider atropine 1mg x3 dose
- check rhythm Q 2minute
• continue BLS
75

Cardiac Muscle Contraction
• Heart muscle:
– Is stimulated by nerves and is self-excitable
(automaticity)
– Contracts as a unit
• Cardiac muscle contraction is similar to
skeletal muscle contraction

Heart Physiology: Sequence of
Excitation
• Sinoatrial (SA) node generates impulses about
75 times/minute
• Atrioventricular (AV) node delays the impulse
approximately 0.1 second
• Impulse passes from atria to ventricles via the
atrioventricular bundle (bundle of His)

Heart Physiology: Sequence of
Excitation
• AV bundle splits into two pathways in the
interventricular septum (bundle branches)
– Bundle branches carry the impulse toward the
apex of the heart
– Purkinje fibers carry the impulse to the heart
apex and ventricular walls

Cardiac Intrinsic Conduction
Figure 17.14a

SA node generates impulse;
atrial excitation begins
Impulse delayed
at AV node
Impulse passes to
heart apex; ventricular
excitation begins
Ventricular excitation
complete
SA node AV node Purkinje
fibers
Bundle
branches
Figure 17.17
Heart Excitation Related to ECG

Electrocardiography
• Electrical activity is recorded by
electrocardiogram (ECG)
• P wave corresponds to depolarization of SA node
• QRS complex corresponds to ventricular
depolarization
• T wave corresponds to ventricular repolarization

Electrocardiography
Figure 17.16

ECG Graph Paper
0.2 sec
0.04 sec
Time
Paper speed 25mm/sec

Steps to Rhythm Interpretation
• Determine the rate
• Determine the regularity of the rhythm
• Evaluate the P waves
• Evaluate the PR interval
• Evaluate the QRS complex
• P wave/QRS relationships
• Evaluate the T wave
• Interpret the Rhythm and Evaluate It’s
Clinical Significance

Determine Regularity
R to R
Paper and Pencil Method
P to P

Determine Regularity
Is the rhythm regular or irregular?

Evaluate the P Waves
Are the P waves present? Are they regular?
Is there one P wave preceding each QRS?
Are they all the same in shape and size.

Evaluate the QRS Complex
Are the QRS complexes all alike in duration and shape?
Do the QRS complexes measure within the normal
duration of 0.04-0.12 seconds.

P Wave/QRS Relationships
• .
Is there a P wave before every QRS complex?
Is there a QRS complex after every P wave?

Evaluate the T Wave
Are the T waves of normal configuration, and
are they upright?
Are the T waves elevated or depressed from
the isoelectric line?

Rhythms Originating From the SA
Node
• Sinus Rhythm
• Sinus Bradycardia
• Sinus Tachycardia
• Sinus Arrhythmia
• Sinus Arrest

Rhythms Originating From the Atria
• Atrial Tachycardia
• Atrial Fibrillation
• Atrial Flutter

Rhythms Originating From the
Ventricles
• Ventricular Tachycardia
• Ventricular Fibrillation
• Ventricular Standstill (Asystole)

Single Ventricular Beat Followed by
Asystole

ventricular fibrilation.
No organized Rhythm
No pulse

MX of Ventricular Fib.
• Immediate defibrillation 200 biphasic (or as
prescribed by manufacturer) or 360
monophasic
• Immediate effective CPR for 2 min
• Evaluate rhythm, repeat defibrillation with
high dose.
• Adrenaline 1 mg IV and repeat every 3 – 5 min

MX of ventricular Fib.
• Evaluate rhythm
• Defibrillation
• Amiodarone 300 mg I/V push or lidocaine
• Evaluate rhythm
• Defibrillation
• Adrenaline 1 mg every 3 min
• Mg 2mg IV in suspected Torsade de Pointes,
alcoholism or malnutrition

Asystole
No electrical activity
No pulse

MX of asystole
• Not shakable
• CPR
• Treat underlying cause.(6H,5T)
• Hypovolemia,hypoxia,Hypo/hyperkalemia,
Hydrogen ion(acidoses),hypoglycemia
,hypothermia.
• Trauma,tamponade,thrombo embolism,
tension pneumothorax , Toxins.

11. oxygen therapy 2.pptx

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