The document provides information about a core skills study day on physiological observations and oxygen therapy led by Mr. Shibu Chacko from the Critical Care Outreach Team. It discusses monitoring temperature, pulse, blood pressure, respiration rate, oxygen saturation and various scores. It also covers different oxygen delivery systems including nasal cannula, face masks, non-rebreathing masks and venturi masks. The importance of humidification with prolonged oxygen therapy is highlighted along with monitoring patients on oxygen therapy.

1. Core skills Study Day
Mr. Shibu Chacko,
Critical Care Outreach Team

2. Sessions
Physiological Observations
Oxygen therapy

3. Critical Care Outreach Team
 4 Members
 8 am to 8 pm (7 days a week including
Bank Holidays)
 Bleep 725
 Site team at out of hours
 Extending to 24/7 soon!!!

4. Identification Data
 Full name ( Forename and Surname)
 Hospital No / NHS Number
 Date, time and Year

5. Temperature
 Normal Body temperature
 Equipment – Tympanic Thermometer
 Other thermometers
 Abnormalities
Hyperthermia
Hypothermia

6. Pulse / Heart rate
 What is pulse? Locations
 Tachycardia – Hypovolaemia, Sepsis,
Electrolyte abnormalities, pathological
Conditions
 Bradycardia – Reduced cardiac output
 Drugs, Thyroid problems, IHD
 Young fit athletes

7. Blood Pressure
 Pressure of blood with in arteries
 Systolic and Diastolic BP
 Pulse pressure
Resting pulse pressure = 40 mm Hg
High PP – Indicator of heart disease
Low PP – Indicates poor cardiac
function

8. MAP
 Average (mean) arterial blood pressure
during a single cardiac cycle
 Reflects the haemodynamic perfusion
pressure of vital organs
 Normal MAP
 How to calculate??

9. Hypertension
 Systemic arterial BP is elevated
 Two types
 Primary (90%) – No medical cause
 Secondary (10%) – Problems with
Kidneys, Heart, arteries,
endocrine system etc

10. Hypotension
 Abnormally low Blood pressure
 SBP <90 or DBP <60 mm of Hg
 Causes – Hypovolaemia, Sepsis, Heart
failure, Anaemia,
Bradycardia, Endocrine
 Treatment- How?

11. Respirations
 Process involves inspiration and expiration
 Normal rate?
 How to count respirations?
 Muscles of Inspiration – Diaphragm and
inter-costal muscles
 Expiration - a passive process
 Accessory muscles of breathing ??

12. Oxygen % (FiO2) / Flow rate
 Depend on the type of system using
 Main types
Uncontrolled systems
Controlled systems

13. Oxygen saturation
 O2 is carried in blood attached to Hb
 Monitors the % of Hb saturated with O2
 1 Hb molecule can carry 4 O2 molecule
 Normal value 95% and above
 If low, what to do???

14. AVPU
 Quick and easy method to assess LOC
 A – ALERT
 V- Responds to Voice
 P- Responds to Pain
 U- Unresponsive

15. Nausea and Pain score
 Nausea score
 0-3 (0 = No vomiting to 3 = frequent
vomiting)
 Pain score
 0-10 (0= No pain to 10 being the worst
possible pain)

16. MMEWS Score
 Early warning score
 To help to identify those patients who are
at risk of deteriorating
 Get help early

17. MMEWS Exercise: 1
 Temp: 37.5
 BP: 110 / 50
 Heart rate: 105 /mt
 Respirations 18
 Sats: 90 % on room air
 AVPU: A
 Urine output : 50 mls / hour
 What is the MMEWS?

18. MMEWS Exercise:2
 Temperature: 39.0 degrees
 BP: 77/40
 Heart rate: 135 /mt
 Respiration: 32/mt
 Saturation: 99 % on 15litres oxygen
 AVPU: V
 Urine output : 50 mls / hour
 What is the MMEWS?

19. Oxygen therapy

20. Objectives
 Understand the indications for oxygen
therapy
 Identify and understand the use of
different oxygen delivery systems
 Implications for humidification
 Be able to set up oxygen equipment.

21. Introduction
 Oxygen is a colorless, odorless, tasteless
gas that is essential for the body to
function properly and to survive
 Living cells must be fuelled with oxygen in
order to survive
 The respiratory system functions to supply
oxygen to the cells and remove carbon
dioxide from the tissues

22. Important Points
 Room air contains approx. 21% oxygen
 Illness and injury increase tissue oxygen
demand
 It should be prescribed.
 Failure to use correctly can be fatal
 Patients must receive this therapy in an
appropriate, safe and comfortable way
 Monitoring is essential

23. Aim of Oxygen Therapy
 Maintain patients Oxygen saturation levels
as close to a ‘normal’ value as is possible
given the patient’s current disease state
 Healthy patient has a saturation of > 95%
breathing room air

24. Indications for oxygen therapy
 Hypoxaemia.
 Acute hypotension.
 Breathing inadequacy.
 Trauma.
 Acute illness - Sepsis
 CO poisoning.
 Severe anaemia.
 During the peri-operative period.

25. Oxygen delivery methods
 All systems require
1. Oxygen supply.
2. Flow meter.
3. Oxygen tubing.
4. Oxygen Delivery device / system.
5. (Humidifier).

26. Oxygen Delivery Systems
 Two Types
• Uncontrolled / Variable
• Controlled / Fixed

27. Uncontrolled / Variable Systems
 Exact percentage of oxygen given
unknown

28. Types of Uncontrolled / Variable
systems
 Nasal cannula
 Simple face mask
 Non re-breathing masks

29. 1. Nasal Cannula
ADVANTAGES
1. Comfortable, well tolerated
2. Cheap and simple to use
3. Patient can E & D
4. Communication
5. Less claustrophobic
6. Administer Nebulisers
7. Preferred method for COPD
patients
0.5 – 4 litres per min

30. Disadvantages Nasal Cannula
 Drying effect with increased flows i.e.
headaches
 Easily dislodged if not fitted correctly
 May cause irritation
 Unable to artificially humidify
 Potential for pressure area breakdown

31. 2. Medium Concentration Mask
 Advantages
1. Simple to use
2. Sizes to fit average adults
3. Low cost
 Minimum 5 litres per min

32. Disadvantages
 Claustrophobic
 Interferes with eating and drinking
 Potential pressure area breakdown
 Oxygen percentage delivered will be
uncontrolled

33. 3.Non-rebreathing Mask / Bag
 For the acutely unwell patient.
 Effective short term treatment
Minimum 15 litres per min

34. Non-rebreathing mask
 Allows the delivery of high concentrations of
oxygen (85% at 15 litres/min).
 Has a reservoir bag to entrain oxygen.
 One way valves prevent room and expired air
from diluting the oxygen concentration.
 A tight seal is essential.
 Reservoir bag must be seen to expand freely

35. Disadvantages
 Unable to humidify
 Oxygen percentage delivered will be
uncontrolled
 Patient discomfort as tight seal needed
 High flows of oxygen can cause retention of
secretions
 Need to be set up properly – Do you know
how to?

36. Controlled / Fixed Systems
 Exact percentage of oxygen given is
known
 O2 concentration is determined by the O2
flow rate
 Systems entrain air using the Venturi
principle
 Can have fixed systems or changeable
systems to give different O2 %

37. 14 l/min air entrained14 l/min air entrained
2 l/min oxygen jet
2 l/min oxygen jet
30 l/min VENTURI PRINCIPLE
(The Bernoulli Effect)

38. Venturi Mask
 Mixes a specific volume of air and oxygen.
 Useful for accurately delivering low
concentrations of oxygen.
 Valves are colour coded and flow rate
required to deliver a fixed concentration is
shown on each valve.
 Can deliver oxygen concentrations
between 24-60%.

39. Venturi System
 Preferred method of
administration in COPD
patients if using
facemask
 Oxygen flow rate written
on the venturi
 Colour coded, adapters
can be changed

40. Disadvantages
 Nothing major
 Unable to humidify
 Noisy
 Change every 7 days

41. Humidification
 Low flow rates the body can humidify
 Patients requiring prolonged oxygen therapy
>6 hours or high flow MUST be humidified
 Prevents drying of mucous membrane and
destruction of airways
 Prevents the formation of tenacious sputum
 Aids in sputum clearance

42. Cold Water Humidification
 Cold water system used with
large bore tubing
 1.8 meters gold standard but
patients need to move!
 7 -14 sections of elephant
tubing.
 Oxygen flow rate written
above percentage

43. Complications with humidified
oxygen
 Bronchoconstriction
 Decreased lung function if over-humidified
 Increased risk of infection

44. Nasal Cannula
Simple Face Mask
Fixed Concentration Mask (Venturi System)
Quattro Humidification System
Non-Rebreather Mask & Bag
(High Concentration Mask)
•Uncontrolled Oxygen Delivery System
•Flow Rate: 0.5 – 4 lpm (litres per minute)
•Suitability: All patients who require
low flow oxygen therapy
Benefits: Cheap. Easy to use. Relatively
comfortable. Not claustrophobic. Patient
can eat, drink & talk. Can give nebulisers.
Disadvantages: Oxygen % is uncontrolled.
Needs clear nasal airway. Can’t humidify.
Dries mucous membranes. Headaches.
•Uncontrolled Oxygen Delivery System
•Flow Rate: Minimum 5 lpm
•Suitability: General purpose
Benefits: Cheap. Simple to use. Fits most
‘average’ sized adults
Disadvantages: Re-breathing of CO2 at
flows less than 5.0 lpm. Oxygen % is
uncontrolled. Claustrophobic. Interferes
with eating, drinking and talking.
•Controlled Oxygen Delivery System
•Flow Rate: Indicated on each venturi
(different colours for different O2 %)
•Should be the system of choice
Benefits: Oxygen % is controlled. Venturis
can be changed as patient improves. Oxygen
% delivered not dependent on respiratory
pattern. Cheap. Simple to use.
Disadvantages: Noisy. Claustrophobic.
Can’t be humidified.
•Controlled Oxygen Delivery System
•Flow Rate: Indicated for each oxygen percentage
•System of choice for patients requiring
oxygen for 6 hours or more (excluding cannula)
Benefits: Oxygen % is controlled. Oxygen
is humidified for greater patient comfort.
Disadvantages: More complex to set up
correctly. Noisy. Claustrophobic
•Uncontrolled Oxygen Delivery System
•Flow Rate: 15 lpm
•System of choice for acutely unwell patients
Benefits: Delivers high O2 concentrations.
Short term use in acute situations.
Disadvantages: Oxygen % is uncontrolled.
Short term use only. Must be set up
correctly. Can’t humidify. Claustrophobic
C Plowright (Nurse Consultant Critical Care) & J Kindred (Respiratory Nurse Specialist)
Feb 2011
Oxygen Delivery Systems
Please check at least daily for signs of development of pressure points on nose / ears

45. Monitoring of patients
 RESPIRATION RATES
 Oxygen saturations
 Probe position
 Arterial blood gases (gold standard)
 Document % oxygen, liters per min

46. Pulse Oximetry
 Measures arterial blood oxygen
saturations which equates to the % of
haemoglobin filled with O2
 Well perfused area
 No information about Co2 levels

47. Oxygen therapy in
Special Situations

48. Oxygen and Arterial Blood Gases
collection
Do not
remove O2
to take a
Blood Gas !

49. OXYGEN THERAPY & COPD
 Can have oxygen therapy
 In acute situations can have high flow, i.e.
Cardiac / Respiratory arrest
 Blood gases to be monitored
 Normal saturations 88 – 92 %
 CO2 kills slowly, but no O2 kills quickly

50. Oxygen Driven Nebulisers
 Asthmatic and
Acutely unwell
patients
 Not for COPD
patients'
 Flow rate 6-8 lpm

51. Care of patients
 Mouth care
 Hydration
 Pressure area care
 Observations
 NO SMOKING

52. Points to Remember
 Room air contains 21% oxygen
 Patients breathing pattern
 System used
 Oxygen flow meter, the ball sits in the
middle of the line
 Low flow meters may be used for
specific patients

53. Summary
 Oxygen is required for cell metabolism
 Oxygen requirements are higher in critically
ill patients
 Be aware of different delivery systems
 Always consider humidification
 Safety aspects
 Treat like any other drug.

54. Any Questions ?