Policy for the prescription and administration of Oxygen in Adults

Reference Number Version Name of responsible (ratifying) committee Date ratified Document Manager (job title) Date issued Review date Electronic location Related Procedural Documents Key Words (to aid with searching)

3.60 1 Formulary and Medicines Group 02.03.2010 Dr Sudheer Alapati: Consultant Respiratory Physician 11.03.2010 18/09/2010 Corporate Policies See section 15. References and Associated Documentation Normal oxygen saturation ranges; oxygen therapy; Humidification; Nebulised therapy; oxygen; prescription and administration; Oxygen; Adults

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CONTENTS QUICK REFERENCE GUIDE Page 3 1. Introduction 2. Purpose 3. Scope 4. Definitions 5. Normal oxygen saturation ranges 6. Indications 7. Contra indications 8. Cautions 9. Process 10. Transfer and transportation of patients receiving oxygen therapy 11. Peri-operatively and immediately post operatively 12. Nebulised therapy and oxygen 13. Humidification 14. Training requirements, monitoring compliance with, and effectiveness of Procedural documents 15. References and Associated documentation 16. Health and Safety Appendices A) B) C) D) E) F) G) H) I) J) K) L) M) N) O) P) Table 1 Critical illnesses requiring high levels of supplemental oxygen Table 2 Serious illnesses requiring moderate levels of supplemental oxygen if the patient is hypoxaemic Table 3 COPD and other conditions requiring controlled or low-dose oxygen therapy Table 4 Conditions for which patients should be monitored closely oxygen therapy is not required unless the patient is hypoxaemic Figure 1 Oxygen prescription for acutely hypoxaemic patients in hospital Example of Oxygen prescription chart Administering acute oxygen therapy Equipment used in the delivery of oxygen Flow Chart for oxygen administration Personnel who may administer oxygen Example of bedside observation chart and codes for oxygen delivery Example of nebuliser prescription chart Monitoring of patients Humidification Health and safety Oxygen Administration protocol (and weaning protocol)

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QUICK REFERENCE GUIDE This policy must be followed in full when developing or reviewing and amending Trust procedural documents. For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy. 1. Oxygen is a drug and therefore requires prescribing in all but emergency situations 2. In the emergency situation oxygen prescription is not required. Oxygen should be given to the patient immediately without a formal prescription or drug order but documented later in the patient’s record. 3. Oxygen will be prescribed according to a target saturation range. The system of prescribing target saturation aims to achieve a specified outcome, rather than specifying the oxygen delivery method alone 4. Take special care as there are air outlets which may be mistaken for oxygen outlets 5. Oxygen should be prescribed to achieve a target saturation of 94-98% for most acutely unwell patients or 88 –92% for those at risk of hypercapnic respiratory failure. 6. The patient's oxygen saturation and oxygen delivery system should be recorded on Vital PAC or the bedside observation chart (if VitalPAC unavailable) alongside other physiological variables as shown in Appendix K 7. Oxygen therapy should be increased if the saturation is below the desired range and decreased if the saturation is above the desired range (and eventually discontinued as the patient recovers). See Appendix I for more details 8. Patients requiring oxygen therapy whilst being transferred from one area to another should be accompanied by a trained member of nursing staff wherever possible. If this does not occur, clear instructions must be provided for personnel involved in the transfer of the patient and the oxygen prescription chart must accompany the patient. 9. When nebulised therapy is administered to patients at risk of hypercapnic respiratory failure (see section 8.1), it should be driven by compressed air. If necessary as decided by the doctor, supplementary oxygen should be given concurrently by nasal prongs at 1-4 litres per minute to maintain an oxygen saturation of 88-92% or other specified target range documented on oxygen/nebuliser prescription chart.

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INTRODUCTION The administration of supplemental oxygen is an essential element of appropriate management for a wide range of clinical conditions. 2. if the clinical indication is ongoing. The system of prescribing target saturation aims to achieve a specified outcome. however oxygen is a drug and therefore requires prescribing in all but emergency situations. Where specific clinical guidelines are required for oxygen administration within specialist areas (Critical Care. rather than specifying the oxygen delivery method alone. Respiratory High Care). 11.PURPOSE The aim of this policy is to ensure that: • • • All patients who require supplementary oxygen therapy receive therapy that is appropriate to their clinical condition and in line with national guidance (BTS Guideline. Those who administer oxygen therapy will monitor the patient and keep within the target saturation range 3. Failure to administer oxygen appropriately can result in serious harm to the patient.1. They should reflect wherever possible the principles within this policy. ‘In the event of an infection outbreak.03. Patients transferring from specialist areas must be transferred with a prescription for their oxygen therapy utilising target saturation. which should occur as soon as possible. The safe implementation of oxygen therapy with appropriate monitoring is an integral component of the Healthcare Professional’s role. their oxygen should be administered as per the transferring area’s prescription until the patient is reviewed and transferred over to the target saturation scheme. 2008).2010 (Review date: 18/09/2010) Page 4 of 32 19/06/2013 . the Trust recognises that it may not be possible to adhere to all aspects of this document. flu pandemic or major incident. Issue 1. DEFINITIONS PaO2 – Partial pressure of oxygen FiO2 – Fractional concentration of inspired oxygen CO2 – Carbon dioxide BTS – British Thoracic Society EWS – Early Warning Score O2 – Oxygen ABG – arterial blood gases CaO2 – oxygen content of blood COPD – Chronic Obstructive Pulmonary Disease Oxygen prescription and administration in Adults. Thorax. staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’ 4.SCOPE This policy is for use within general wards and departments caring for adult patients . In such circumstances. Oxygen will be prescribed according to a target saturation range. they must be approved via the appropriate clinical governance forum. If a patient transfers from an area not utilising the target saturation system.

Therefore the most common reasons for oxygen therapy to be initiated are: • • Acute hypoxaemia (e. INDICATIONS The rationale for oxygen therapy is prevention of cellular hypoxia.2010 (Review date: 18/09/2010) Page 5 of 32 19/06/2013 . 6.g. NORMAL OXYGEN SATURATIONS • • In adults less than 70 years of age when awake at rest and at sea level: 96% . Aged 70 and above when awake at rest and at sea level: greater than 94%. 11.g. There is some evidence to suggest a decreased incidence of postoperative wound infections with short-term oxygen therapy following bowel surgery.03. myocardial infarction. acute Gastrointestinal blood loss or carbon monoxide poisoning). shock. pulmonary embolus) Ischaemia (e. and thus prevention of potentially irreversible damage to vital organs. NB: Patients of all ages may have transient dips of saturation to 84% during sleep. pneumonia. asthma. Oxygen prescription and administration in Adults.98%. but only if associated with hypoxaemia (abnormally high levels may be harmful to patients with ischaemic heart disease and stroke). Post operative state (general anaesthesia can lead to decrease in functional residual capacity with in the lungs (especially following thoracic or abdominal surgery) resulting in hypoxaemia (Ferguson 1999).PCO2 – carbon dioxide tension PaCO2 – arterial carbon dioxide tension PACO2 – alveolar carbon dioxide tension PaO2 – arterial oxygen tension PACO2 – alveolar oxygen tension PO2 – oxygen tension SaO2 – arterial oxygen saturation SpO2 – arterial oxygen satuation measured by pulse oximetry 5. Issue 1. • Other indications include: • • Pneumothorax – Oxygen may increase the rate of resolution of pneumothorax in patients for whom a chest drain is not indicated. caused by hypoxaemia (low PaO2).g. heart failure. Abnormalities in quality or type of haemoglobin (e.

The goal of oxygen therapy is to achieve adequate tissue oxygenation using the lowest possible FiO2. administering and monitoring oxygen a) Identifying appropriate target saturations • • Guidance on identifying appropriate saturations for patients is provided for the medical staff and other prescribers in Appendices A-E (table 1-4 and figure 1 in the guideline). Issue 1. which lead to the rise in CO2 with oxygen therapy in patients with hypercapnic respiratory failure. Oxygen should be prescribed in the designated section of the hospital prescription card (Appendix F) and the appropriate target saturation should be circled on the chart (or if target saturations are not indicated the relevant box should be ticked to highlight the oxygen is given for palliation). and details are in the BTS guideline available at: http://www. CAUTIONS 8.7. Supplemental Oxygen should be administered with caution in patients suffering from paraquat poisoning and with acid inhalation (seek specialist advice from the UK National Poisons Information Service) or previous bleomycin lung injury. • 8. morbid obesity or musculoskeletal disorders. This may occur in patients with COPD.1 Oxygen administration and carbon dioxide retention In patients with chronic carbon dioxide (CO2) retention. oxygen administration may cause further increases in carbon dioxide and respiratory acidosis.2010 (Review date: 18/09/2010) Page 6 of 32 19/06/2013 .org.03. c) Administering oxygen Oxygen prescription and administration in Adults. There are several factors. b) Prescribing oxygen on the drug chart An oxygen prescription chart has been designed to assist prescription and administration.1 Prescribing.brit-thoracic. CONTRA-INDICATIONS • There are no absolute contraindications to oxygen therapy if indications are judged to be present. In summary oxygen should be prescribed to achieve a target saturation of 94-98% for most acutely unwell patients or 88-92% for those at risk of hypercapnic respiratory failure. neuromuscular disorders.uk/ClinicalInformation/EmergencyOxygen 8.2 Other precautions/ Hazards/ Complications of oxygen therapy • • • • • • Drying of nasal and pharyngeal mucosa Oxygen toxicity Absorption atelectasis Skin irritation Fire hazard Potentially inadequate flow resulting in lower FiO2 than intended due to high inspiratory demand or inappropriate oxygen delivery device or equipment faults 8. as there are air outlets that may be mistaken for oxygen outlets 9. 11.3 Take special care.PROCESS 9.

• • • • • 9. The patient's oxygen saturation and oxygen delivery system should be recorded on Vital PAC or the bedside observation chart (if Vital PAC unavailable) alongside other physiological variables as shown in Appendix K. See Appendix I for more details Any sudden fall in oxygen saturation should be referred to the doctor and lead to clinical evaluation of the patient and in most cases. measurement of blood gases. Critically ill patients should have their oxygen saturations monitored continuously and recorded every few minutes whereas patients with mild breathlessness due to a stable condition will need less frequent monitoring as specified in Appendix M Oxygen therapy should be increased if the saturation is below the desired range and decreased if the saturation is above the desired range (and eventually discontinued as the patient recovers). H.2 Emergency situations • In the emergency situation oxygen prescription is not required. This will be dictated by the Trust’s vital signs escalation protocol. • • Oxygen prescription and administration in Adults. guidance regarding the most appropriate delivery system to reach and maintain the prescribed saturation is provided for those administering oxygen in Appendix G. d) Monitoring and recording oxygen • All patients should have their oxygen saturation observed for at least 5 minutes after starting oxygen therapy. Patients on oxygen should have their saturations recorded at the appropriate frequency for their level of severity of illness. Patients should be monitored accurately for signs of improvement or deterioration. All patients on oxygen therapy should have regular pulse oximetry measurements as decided by the prescriber. 11. All patients who have had a cardiac or respiratory arrest should have 100% oxygen provided along with basic/advanced life support. (See Appendix M). I. Issue 1. The frequency of oximetry measurements will depend on the condition being treated and the stability of the patient. Oxygen should be given to the patient immediately without a formal prescription or drug order but documented later in the patient’s record. This appendix also specifies the codes for oxygen delivery devices to be recorded on the observation chart. Patients should thus be monitored as specified in Appendix M. All peri-arrest and critically ill patients should be given 100% oxygen (15 l/min reservoir mask) whilst awaiting immediate medical review. according to the Early Warning Score (EWS) protocol. noisy or laboured breathing or respiratory rate of less than 8 or more than 25 should be reported immediately to the medical team. with or without oxygen.03.2010 (Review date: 18/09/2010) Page 7 of 32 19/06/2013 . Nurses should also monitor skin colour for peripheral cyanosis and respiratory rate. Personnel who may administer oxygen is shown in Appendix J.Once the target saturation has been identified and prescribed. Oxygen saturations of less than 90%(unless it is with in the prescribed target range for patients at risk of CO2 retention). Patients with COPD and other risk factors for hypercapnia who develop critical illness should have the same initial target saturations as other critically ill patients pending the results of urgent blood gas results after which these patients may need controlled oxygen therapy or supported ventilation if there is severe hypoxaemia and/or hypercapnia with respiratory acidosis.

• • A subsequent written record must be made of what oxygen therapy has been given to every patient alongside the recording of all other emergency treatment. Any qualified nurse/ health professional can commence oxygen therapy in an emergency situation as indicated in the management of the acutely unwell patient.03. 11. Oxygen prescription and administration in Adults. Issue 1.2010 (Review date: 18/09/2010) Page 8 of 32 19/06/2013 .

All patients requiring 35% or greater oxygen therapy should have their nebulised therapy driven by oxygen at a flow rate of greater than 6 litres/minute as prescribed by the doctor. supplementary oxygen should be given concurrently by nasal prongs at 1-4 litres per minute to maintain an oxygen saturation of 88-92% or other specified target range documented on oxygen/nebuliser prescription chart. which should occur as soon as possible.9.2010 (Review date: 18/09/2010) Page 9 of 32 19/06/2013 . TRANSFER AND TRANSPORTATION OF PATIENTS RECEIVING OXYGEN THERAPY Patients who are transferred from one area to another must have clear documentation of their ongoing oxygen requirements and documentation of their oxygen saturation. HUMIDIFICATION Humidification may be required for some patient groups. Peri-operatively and up to 2 hrs post operatively. 14.3 Exclusions • • Patients admitted to specialist areas with a specialised oxygen prescribing policy (see section 3 of this policy document) Patients receiving oxygen as part of palliative care or patients on the end of life care pathway (in which case. If necessary as decided by the doctor. Patients requiring oxygen therapy whilst being transferred from one area to another should be accompanied by a trained member of nursing staff wherever possible. 11. the need for ongoing oxygen therapy should be reviewed as soon as possible. 12. the prescriber should tick the box ‘target saturations not indicated’ on the drug chart).03. it should be driven by compressed air. • • 10. 11. Patients attending Long Term Oxygen Therapy assessment. utilising the target saturation. If oxygen therapy is to be continued. it should be prescribed using the target saturation scheme unless there is an alternative time-limited instruction which is part of the Trust’s PostOperative care policy for selected patients. See Appendix N. If a patient is transferred back to the ward on oxygen therapy and is not on the target saturation system.1). AND THE EFFECTIVENESS OF PROCEDURAL DOCUMENTS Oxygen prescription and administration in Adults. NEBULISED THERAPY AND OXYGEN When nebulised therapy is administered to patients at risk of hypercapnic respiratory failure (see section 8. PERI-OPERATIVE AND IMMEDIATELY POST OPERATIVELY The usual procedure for prescribing oxygen therapy in these areas should be adhered to. If a patient transfers from an area not utilising the target saturation system (see specialist areas above) their oxygen should be administered as per the transferring areas prescription until the patient is reviewed and transferred over to the target saturation scheme by the doctor. If this does not occur. clear instructions must be provided for personnel involved in the transfer of the patient and the oxygen prescription chart must accompany the patient. Issue 1. especially “neck-breathing patients” and those who have difficulty in clearing airway secretions or mucus. (See Appendix L – Example of trust nebuliser prescription chart) 13. TRAINING REQUIREMENTS. MONITORING COMPLIANCE WITH.

63: Supplement VI.org/emergencyoxygen.uk/emergencyoxygen/ • 16. S. nursing assistants and other healthcare professionals involved in prescribing or administrating oxygen should be taught on the oxygen policy. Davison A G. Teaching aides are available on www. Alapati.brit-thoracic. Audits will be performed in all clinical areas. The hospital will participate in the national audits organised by the BTS.org. BTS guideline for emergency oxygen use in adult patients. Issue 1.uk/emergencyoxygen/ Summary of prescription. A record of all those who have been taught will be kept. HEALTH AND SAFETY ISSUES ARE COVERED IN APPENDIX (O). Available on BTS website: www.org. Audit proformas are available on the BTS website.brit-thoracic. Available on BTS website: www. Professor Gary Smith and Chris Fehrenbach are the Oxygen Champions at Portsmouth Hospital NHS Trust. Teaching aids are available on the BTS website. Summary guideline for prescribing oxygen emergency oxygen in hospital.brit-thoracic. REFERENCES AND ASSOCIATED DOCUMENTATION • • O’Driscoll B R. All doctors should be taught about the oxygen policy. APPENDICES (including those reproduced from BTS Oxygen Guidance) Oxygen prescription and administration in Adults. Dr. 11. Howard L S. Thorax 2008.03. administration and discontinuation of oxygen therapy. The BTS has appointed oxygen champions in all Trusts to help introduce the Guideline.2010 (Review date: 18/09/2010) Page 10 of 32 19/06/2013 . 15.All nurses.

Appendix (A) Table 1 Critical illnesses requiring high levels of supplemental oxygen Oxygen prescription and administration in Adults.2010 (Review date: 18/09/2010) Page 11 of 32 19/06/2013 .03. Issue 1. 11.

03.2010 (Review date: 18/09/2010) Page 12 of 32 19/06/2013 . Issue 1. 11.Appendix (B) Table 2 Serious illnesses requiring moderate levels of supplemental oxygen if the patient is hypoxaemic Oxygen prescription and administration in Adults.

Appendix (C) Table 3 COPD and other conditions requiring controlled or low-dose oxygen Oxygen prescription and administration in Adults. Issue 1.03. 11.2010 (Review date: 18/09/2010) Page 13 of 32 19/06/2013 .

Oxygen prescription and administration in Adults. 11. Issue 1.2010 (Review date: 18/09/2010) Page 14 of 32 19/06/2013 .Appendix (D) Table 4 Conditions for which patients should be monitored closely but oxygen therapy is not required unless the patient is hypoxaemic.03.

03. Issue 1.2010 (Review date: 18/09/2010) Page 15 of 32 19/06/2013 .Appendix (E) Chart 1 Oxygen prescription for acutely hypoxaemic patients Oxygen prescription and administration in Adults. 11.

03.Appendix (F) Example of oxygen prescription chart Oxygen prescription and administration in Adults. Issue 1. 11.2010 (Review date: 18/09/2010) Page 16 of 32 19/06/2013 .

Issue 1. Attach oxygen delivery system to patient according to manufacturers instructions. To prevent drying or the oral mucosa. Show and explain the oxygen delivery system to the patient. Ensure patient has either a drink or a mouthwash within reach. 11. To ensure oxygen supply is ready For oxygen to be administered to patient. Most stable patients prefer nasal cannulae to masks. It is the nurses role to assess the patient and use the prescribed system. Inform patient and or relative/ carer of the combustibility of oxygen 6. Ensure oxygen is prescribed on prescription chart. To ensure a complete record is maintained and expedite patient treatment. 3. The type of delivery system used will depend on the needs and comfort of It the patient. Clean oxygen mask as required with general purpose detergent and dry thoroughly needed.Appendix (G) ADMINISTERING ACUTE OXYGEN THERAPY ACTION 1.03. Assemble the oxygen delivery system carefully as shown in Appendix (H). 4. The exception to this action would be during an emergency situation where the resuscitation guideline should be followed. In accordance with the the Policy for prescription and administration of oxygen in adults To ensure oxygen is given as prescribed. 8. To minimise risk of infection (Single patient device) after use. Turn on oxygen flow in accordance with prescription and manufacturers instruction. Ensure that the oxygen dose is clearly If nasal cannula or reservoir masks are being used check that the flow rate is clearly indicated. 12. In emergency situations any trained nurse Can administer oxygen (Madon) . Give the patient the information sheet about oxygen. 7. To obtain consent and cooperation.2010 (Review date: 18/09/2010) Page 17 of 32 19/06/2013 . Attach oxygen delivery system to oxygen source. 5. 9. RATIONALE To promote effective oxygenation To provide accurate oxygen delivery to the patient. To administer correct % of oxygen. In these cases the doctor must review the patients condition within the stated time and prescribe oxygen accordingly. Ensure patency of airway 2. 11. 10. Discard systems Oxygen supports combustion therefore there is always a danger of fire when oxygen is being used. Oxygen prescription and administration in Adults.

DEVICE Nasal Cannulae Uncontrolled oxygen therapy ACTION RATIONALE 1.(see appendix j for advice on use of each device). usually 2-4 l/min but may vary from 1-6 l/min in some circumstances. A) Oxygen source (piped or cylinder) Flow meter Saturation monitor Oxygen Delivery system . Oxygen prescription and administration in Adults.5cm into the nose. Adjust flow rate. 11. They have the advantage of not interfering with feeding and are not as inconvenient as masks during coughing and sneezing. 2. 2.03. To allow optimum comfort for the patient. Sore nasal mucosa can result from pressure or friction of tubing that is too long. 4. each projecting into the nostril and stemming from a tube which passes over the ears and which is thus selfretaining. Nasal cannula DESCRIPTION Nasal cannulae consist of pair of tubes about 2cm long. Place tubing over the ears and under the chin as shown above. Position the tips of the cannula in the patient’s nose so that the tips do not extend more than 1. (When using nasal cannula). Issue 1. 3.2010 (Review date: 18/09/2010) Page 18 of 32 19/06/2013 . Educate patient re prevention of pressure areas on the back of the ear. It is not advisable to assume what percent oxygen (FI02) the patient is receiving according to the Litres delivered but this is not important if the patient is in the correct target range. To prevent pressure sores. Set the flow rate to achieve the desired target oxygen saturation. 3.Appendix (H) EQUIPMENT USED IN THE DELIVERY OF OXYGEN (Choose the appropriate delivery device) 1. which may make the patient reject the procedure. Overlong tubing is uncomfortable. PURPOSE Cannulae are preferred to masks by most patients.

To ensure patient’s safety and that oxygen is being administered as prescribed. Fasten oxygen tubing securely.03. Oxygen is forced out through a small hole causing a Venturi effect which enables air to mix with oxygen. The minimum flow rate is indicated on the mask or packet. Oxygen prescription and administration in Adults. Higher flows are required for patients with rapid respiration and high inspiratory flow rates.2010 (Review date: 18/09/2010) Page 19 of 32 19/06/2013 .B) Fixed performance mask (Venturi mask and valve) DEVICE DESCRIPTION A mask incorporating a device to enable a fixed concentration of oxygen to be delivered independent of patient factors or fit to the face or flow rate. Assess the patient’s condition and functioning of equipment at regular intervals according to care plan. 4. Adjust flow rate. The flow should be doubled if the patient has a respiratory rate above 30 per minute. 3. 11. To ensure that patient receives the correct concentration of oxygen Correctly secured tubing is comfortable and prevents displacement of mask/cannulae. (When using Venturi mask) Connect the mask to the appropriate Venturi barrel attached firmly into the mask inlet. Issue 1. This does not affect the concentration of oxygen but allows the gas flow rate to match the patient’s breathing pattern. Venturi devices come in different colours for % Blue = 24% White = 28% Yellow = 35% Red = 40% Green = 60% Venturi mask ACTION RATIONALE 1. 2. Controlled oxygen therapy PURPOSE This is a high performance oxygen mask designed to deliver a specified oxygen concentration regardless of breathing rate or tidal volume.

the patient’s tidal volume and breathing rate. PURPOSE This is a variable performance device. vent holes are provided to allow air to escape. Flows below 5L/m do not give enough oxygen and may cause increased resistance to breathing and may also cause CO2 rebreathing due to the small mask size. Check that strap is not across ears and if necessary insert padding between the strap and head. Maximum 50%-60% at 15ltrs/minute flow. NOT to be used for CO2 retaining patients. 11.2010 (Review date: 18/09/2010) Page 20 of 32 19/06/2013 . (If using simple face mask) Gently place mask over the patient’s face. Simple face mask Variable Percentage (Delivers unpredictable concentrations that vary with flow rate) Nasal cannulae should be used for most patients who require medium dose oxygen but a simple face mask may be used due to patient preference or if the nose is blocked ACTION Uncontrolled Oxygen therapy b. RATIONALE Ensure a comfortable fit and delivery of prescribed oxygen is maintained. the oxygen flow rate( litres per minute) used.03.C) Simple facemask (variable flow) DEVICE DESCRIPTION Mask has a soft plastic face piece. Must never be below 5L/min To prevent irritation. The oxygen concentration delivered will be influenced by: a. Oxygen prescription and administration in Adults. Issue 1. leakage between the mask and face. Adjust the oxygen flow rate. position the strap behind the head or the loops over the ears then carefully pull both ends through the front of the mask until secure.

2.D) Reservoir mask (non re-breathe mask) DESCRIPTION Mask has a soft plastic face piece with flap-valve exhalation ports which may be removed for emergency air-intake. oxygen flows directly into the mask during inspiration and into the reservoir bag during exhalation. this can be maintained by using 10-15 litres of oxygen per min. DEVICE Reservoir Mask (Non-rebreathe Mask) Uncontrolled oxygen therapy ACTION 1. RATIONALE To ensure the optimal flow of oxygen to the patient.2010 (Review date: 18/09/2010) Page 21 of 32 19/06/2013 . Inadequate flow rates may result in administration of inadequate oxygen concentration to the patient. which prevents re-breathing. Oxygen prescription and administration in Adults.03. All exhaled air is vented through a port in the mask and a oneway valve between the bag and mask. There is also a one-way valve between the face mask and reservoir bag. PURPOSE In non re-breathing systems the oxygen may be stored in the reservoir bag during exhalation by means of a one-way valve. High concentrations of oxygen 80-90% can be achieved at relatively low flow rates. 11. (Non Rebreathe Reservoir Mask) Ensure the reservoir bag is inflated before placing mask on patient. In disposable reservoir. Issue 1. Adjust the oxygen flow to the prescribed rate. NOT to be used for C02 retaining patients except in life-threatening emergencies such as cardiac arrest or major trauma.

Oxygen prescription and administration in Adults.E) Tracheostomy mask for patients with tracheostomy or laryngectomy DEVICE DESCRIPTION Mask designed for “neck breathing patients”. PURPOSE This is a variable performance device for patients with tracheostomy or tracheotomy. b. Tracheostomy mask Variable Percentage (Delivers unpredictable concentrations that vary with flow rate) ACTION Uncontrolled Oxygen therapy Use cautiously at low flow rates in CO2 retaining patients as there may be no alternative. position the strap behind the head then carefully pull both ends through the front of the mask until secure. RATIONALE Gently place mask over the patient’s airway. Adjust the oxygen flow rate to achieve the desired target saturation range. The oxygen concentration delivered will be influenced by: a.03. the patient’s tidal volume and breathing rate. the oxygen flow rate( litres per minute) used. 11. Fits comfortably over tracheostomy or tracheotomy.2010 (Review date: 18/09/2010) Page 22 of 32 19/06/2013 . Exhalation port on front of mask. To ensure that the correct amount of oxygen is given to keep the patient in the target range. Start at 4 l/min and adjust the flow up or down as necessary to achieve the desired oxygen saturation range. Ensure a comfortable fit and delivery of prescribed oxygen is maintained. Issue 1.

Correct Setting for 2 l/min Oxygen flow meter Delivers oxygen to the patient.F) Oxygen Flow Meter DEVICE DESCRIPTION Device to allow the patient to receive an accurate flow of oxygen.2010 (Review date: 18/09/2010) Page 23 of 32 19/06/2013 . ACTION RATIONALE To ensure that the patient receives the correct amount of oxygen. The diagram shows the correct setting to deliver 2 l/min. Issue 1. Attach the oxygen tubing to the nozzle on the flow meter. usually between 2 and 15 litres per minute. Oxygen prescription and administration in Adults. 3 3 2 2 1 1 Take special care as there are air outlets which may be mistaken for oxygen outlets. PURPOSE To ensure that the patient receives the correct amount of oxygen. May be wallmounted or on a cylinder. The CENTRE of the ball shows the correct flow rate. Turn the finger-valve to obtain the desired flow rate.03. 11.

Appendix (I) Flow chart for oxygen administration on general wards in hospitals Oxygen prescription and administration in Adults. 11.03.2010 (Review date: 18/09/2010) Page 24 of 32 19/06/2013 . Issue 1.

11. doctor.Appendix (J) PERSONNEL WHO MAY ADMINISTER OXYGEN Any qualified nurse. Any appropriately registered healthcare professionals in accordance with policy for administration of medicines.03. RSCN. Issue 1. RN or physiotherapist.2010 (Review date: 18/09/2010) Page 25 of 32 19/06/2013 . Oxygen prescription and administration in Adults.

Appendix (K) – Bedside Observation Chart The oxygen delivery device and flow rate should be recorded alongside the saturation on VitalPAC. 11. Issue 1.2010 (Review date: 18/09/2010) Page 26 of 32 19/06/2013 .03. on the bedside observation chart Oxygen prescription and administration in Adults. or if VitalPAC is unavailable.

11.Appendix (L) Example of Nebuliser Prescription Chart Oxygen prescription and administration in Adults.2010 (Review date: 18/09/2010) Page 27 of 32 19/06/2013 . Issue 1.03.

2009) A Recorder’s (e. or c) an EWS of 1 followed by an EWS of 0 after 2200 hrs. the nurse responsible should check that there is a set of observations on VitalPAC or a paper chart. data from a continuous device must be entered each hour).. 11. can be moved to 12 hourly once there have been a) 2 consecutive EWS values of 0. Oxygen prescription and administration in Adults.03. done in the hour before transfer. a full set of vital signs data must be entered into VitalPAC using the “minimum interval” algorithm (e. HDU or ICU care) + DNAR decisions. for a patient with a previous EWS = 4. Where a patient is being continuously monitored using electronic technology. pulse) At all levels of EWS.g.g.. nurse. Issue 1. call ICU (ext 5752) EWS of 3 comes from a single physiological parameter (e. Before transferring a patient. b) two consecutive values of 1.2010 (Review date: 18/09/2010) Page 28 of 32 19/06/2013 . Any patient with EWS >4 should not be transferred until the actions listed in the Trust Transfer [draft] protocol have been followed. it has been explicitly agreed that patient can be transferred and the receiving team + outreach team is aware of the patient.g. HCA) action Nil Nil Inform nurse in charge of patient’s care Registered nurse to inform doctor (FY2 or SHO) Registered nurse to inform doctor (FY2 or SHO) Consider use of continuous patient monitoring Registered nurse to inform doctor (SpR) Consider use of continuous patient monitoring Doctors action Doctor to see patient within 2hrs Doctor to see patient within 30 minutes Dr to discuss patient with SpR + outreach teamC Consider use of continuous patient monitoring B C * This time interval also represents the minimum time between charting observations in VitalPAC.Appendix (M) Monitoring of patients on Oxygen Escalation protocol for VitalPAC Minimum interval between Escalation EWS observation setsA 0 1 2 3 4 6 hourly 6 hourlyB 4 hourly 4 hourly 1 hourly B Doctor to see patient within 15 minutes Dr to discuss patient with Consultant + outreach teamC or >5 30 mins ICU Consider use of continuous patient monitoring Colour coding represents NICE/DoH levels of escalation (see DoH document “Competencies for Recognising and Responding to Acutely Ill Patients in Hospital”. The first vital signs observation set must be undertaken within 15 minutes of arriving in a new clinical area.g. clinical staff should consider the appropriateness of referral for higher care (e.. but particularly at levels of 4 and above.

11. If the flow rate exceeds 4 litres per minute for several days Tracheotomy or tracheostomy patients (“neck-breathing patients)” Cystic Fibrosis patients Bronchiectasis patients Patients with a chest infection retaining secretions Can be given by warm or cold humidifier systems (Warm humidifier systems are mainly used in critical care areas) Oxygen prescription and administration in Adults. 3. 2. 1.Appendix (N) HUMIDIFICATION This should only be used if specifically requested by the doctor or physiotherapist in the following circumstances. 5. Issue 1.2010 (Review date: 18/09/2010) Page 29 of 32 19/06/2013 . 4.03.

Issue 1. there. 11.is always a danger of fire when oxygen is being used. Oxygen prescription and administration in Adults. Oxygen can be potentially dangerous when in contact with sources of ignition and flammable material. Inform patients and carers about the combustibility of oxygen 2. Electrical appliances should be kept at least five feet away from the source of oxygen. 3. Oxygen should be stored in an area designated as no smoking. 4. Avoid grease or oil coming into contact with apparatus. Oxygen supports combustion. Store unused cylinders in a dry well ventilated place.03. 5.2010 (Review date: 18/09/2010) Page 30 of 32 19/06/2013 .Appendix (O) HEALTH AND SAFETY 1.

particularly patients with COPD.Summary Oxygen Administration protocol (and weaning protocol) ACTION All patients requiring oxygen therapy will have a prescription for oxygen therapy recorded on the patient’s oxygen prescription chart. The patient will require weaning down from current oxygen delivery system.03.2010 (Review date: 18/09/2010) Page 31 of 32 19/06/2013 . see Tables 14. Issue 1. or if VitalPAC is unavailable. To identify early signs of clinical deterioration.B exceptions. delivery device and flow rate) The drug chart should be signed at every drug round Once oxygen is in situ the nurse/ trained HCSW will monitor observations in line with trust policy. e. the oxygen therapy will be adjusted accordingly by the nurse looking after the patient The saturation should be monitored continuously for at least 5 minutes after any increase or decrease in oxygen dose to ensure that the patient acheives the desired saturation range.see emergency situations (8. British National Formulary available at www. The oxygen delivery device and oxygen flow rate should be recorded alongside the oxygen saturation on VitalPAC.e. N. To provide the nurses with guidance for the appropriate starting point for the oxygen delivery system and flow rate To ensure that the patient is receiving oxygen if prescribed and to consider weaning and discontinuation To identify if oxygen therapy is maintaining the target saturation or if an increase or decrease in oxygen therapy is required To provide an accurate record and allow trends in oxygen therapy and saturation levels to be identified.org Certain groups of patients require different target ranges for their oxygen saturation. on the bedside observation chart Oxygen saturations must always be interpreted alongside the patient’s clinical status incorporating the Early Warning Score (EWS) If the patient falls outside of the target saturation range. Certain groups of patients are at risk of hyperoxaemia.bnf. See Appendix (I) The patients clinical condition may have improved negating the need for supplementary oxygen Oxygen prescription and administration in Adults.g. If a patient is receiving intermittent therapy they may be monitored at least 8 hourly. BTS National guidelines (2008). elevated respiratory rate To maintain the saturation in the desired range.2) The prescription will incorporate a target saturation that will be identified by the clinician prescribing the oxygen in accordance with the Trust's oxygen guideline The prescription will incorporate an initial starting dose (i. • • Step down oxygen therapy as per guidance for delivery Consider discontinuation of oxygen therapy RATIONALE Oxygen is a drug and should be prescribed. All patients should have their oxygen saturation observed for at least five minutes after starting oxygen therapy. 11.Appendix (P) . Saturation higher than target specified or >98% for an extended period of time.

2010 (Review date: 18/09/2010) Page 32 of 32 19/06/2013 . heart failure etc) Patient safety (The change may be made in stable patients due to patient preference or comfort). and ensure that PaCO2 has not risen to an unacceptable level. once clinical condition allows • A change in delivery device (without an increase in O2 therapy) does not require review by the medical team. Oxygen delivery methods The Trusts recommended delivery devices will be utilised to ensure a standardised approach to oxygen delivery.g. and monitor patient to identify appropriate time for stepping down therapy. or Ph dropped to an unacceptable level and to screen for the cause of deteriorating oxygen level (e.Saturation lower than target specified • Check all elements of oxygen delivery system for faults or errors. 11. • Step up oxygen therapy as per protocols in appendix (I). potentially increasing the risk of adverse incidents Oxygen prescription and administration in Adults.03. Previous audits have demonstrated wide variations in delivery devices across clinical areas. To assess the patients response to oxygen increase. Any sudden fall in oxygen saturation should lead to clinical evaluation and in most cases measurement of blood gases • Monitor Early Warning Score (EWS) and respiratory rate for further clinical signs of deterioration Saturation within target specified • Continue with oxygen therapy. see Appendix (H) In most instances a fall in oxygen saturation is due to deterioration of the patient however equipment faults should be checked for. pneumonia. Issue 1.