question about scope of practice and the use of high flow O2

  1. I was wondering why nurses aren't allowed to give high flow O2 without a doctors order (at least in CA). The reason I ask is that I am currently working as an EMT (until I start nursing school) and I regularly respond to calls at SNFs where a patient is in respiratory distress and the nurse only has them on a cannula a 2-3 liters (and the machine only goes up to 5). I've heard this is because they need a doctors order to put them on high flow. Is there something I don't know about O2? Thanks.
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  2. 15 Comments

  3. by   CoffeeRTC
    In LTC you need an order for O2 low or high flow. However..I will apply O2 then call md for an order etc. Generally, we use low flow (2-3lmp) because of the oxegen drive rational, but in an emergent contition...its gets bumped up.
    I took EMT classes (passes but never practiced) and things are done differently. An EMT can do more skills than CNAs in LTC for the most part.
  4. by   bruinlaura
    I guess it just baffles me that an RN with much more medical education and training than me, an EMT, needs a doctors order to give O2 when I can give it anytime I think the patient needs it. Maybe someone is afraid in LTC that it will be administered too gratuitosly?

    this questioning all started with a call the other day i walked into a room and the pt was sucking air, only mouth breathing, reps 48/min, o2 sat 75 and she had a nasal cannula on at 5L (presumably because of this doctors order nonsense). it would have done her more good if they had put the cannula by her mouth, (wouldn't that be something to see:chuckle )
  5. by   CapeCodMermaid
    It has nothing to do with the staff education and everything to do with REGULATIONS...I never wait for the doctor to OK something IF I know the patient , but I am pushier than most and have been doing this a long time..
  6. by   UM Review RN
    Quote from bruinlaura
    this questioning all started with a call the other day i walked into a room and the pt was sucking air, only mouth breathing, reps 48/min, o2 sat 75 and she had a nasal cannula on at 5L (presumably because of this doctors order nonsense). it would have done her more good if they had put the cannula by her mouth, (wouldn't that be something to see )
    If someone's satting that badly, I would put a Venti mask on, jack up the O2 and take the heat later--if indeed any came down. The Nurse Practice Act is all about what a prudent nurse would do in any given situation, considering the standard of care, and the patient you describe obviously needed more O2 than was available via NC @ lower flows.
  7. by   begalli
    The regulations surrounding this question relates to the fact that oxygen is a DRUG. You need a doctor's order to administer a drug. It doesn't have anything to do with the hypoxic drive (but of course you have to take that into considersation when administering 02).

    I would do, and have done too many times to count, the exact same thing that Angie O Plasty stated. The other RN's I work with as well as my NM would ream me if I didn't treat low sats with 02 while waiting for more difinitive treatment. BUT, I work in an ICU, not LTC, but I think I would still do the same thing.

    bruinlaura - I would think that you have standing orders or a protocol signed by your EMS director, an MD, to be able to administer 02 and that's why you can do it. Frequently nurses don't have these things to work with and must call the doc to be in compliance with their nurse practice act. Also - I frequently blow the 02 into a patients mouth via their nc if they are mouth breathing and asleep. If it doesn't work with up to 6 liters nc, I'll put a mask or face tent on them.
    Last edit by begalli on Feb 3, '05
  8. by   CoffeeRTC
    yep. No standing orders in LTC against regs.

    Now this should be on an other thread, but how about the O2 addicts. I know that O2 is a wonder drug for some, but some of our residents refuse to be weaned from it because "I had it in the hospital...the doc ordered it for me.." I agree....a little O2 via nc does help releive anxiety, sob, etc, but when the medical condition warranting it is resolved and the resident is sating 98% on room air....bome on.
    Oh by the way...yep oxygen is a billable service.
  9. by   Antikigirl
    The reason for the ties on nurses for setting O2 come from the many lawsuits around the country against nurses that gave O2 too high and put their patients at risk of hypoxic drive into that condition. If you don't know about hypoxic drive..you better look it up for reference. Most patients with respiratory conditions can be at risk..even though it is rare.

    Now, an EMT has the equipment and skills to treat this immediately if it is to occur...as we really don't in most cases. That is why EMT/Paramedics have protocols for this condition and other respiratory conditions.

    Also...can anyone tell me the highest O2 that can go via a Nasal Cannula? Most nurses I talk to don't...and just for the record it is 6L/min (no not 8 as some think..that is old school!). Even at 6 is it not very efficient...too fast, and acts more like a hose on high than anything. If I have to go above 5 I like to have a mask...which my facility really do not have (we have a few in an oxygen room far away that even if I dared to go get it the EMT/Paramedics would already have been in the patients room!).

    Oxygen is a medicine, it can cause side effects (like the hypoxic drive), and needs to be watched carefully. If you see that your patient is not doing well on their prescribed O2 and route (ie the nasal cannula not cutting it for a mouth breather), you need to be notifying the MD stat anyway to get orders for a change in condition and orders.

    I have also found that putting the nasal cannula in the residents mouth is very irritating and even barely responsive patients will yank that out...or cause serious harm to the soft pallate by drying it causing gagging (which sometimes leads to bleeding and then you have the old case of aspiration on blood!). If I feel a change to mouth breathing is an issue I get orders for a mask (I like non rebreathers myself), and hope the patient keeps it on...(but I can sympathize...masks are uncomfortable, but so is not getting O2!!!).

    Working with EMT/Paramedics I see orders for O2 for comfort as a nurse and just giggle...because I know that you may as well stand there with a fan and get the same results...so I try to really help my patients by speaking with their physicians or hospice nurse to get the correct route and O2 rate that will best help the patient. Takes practice...but worth it!
  10. by   bruinlaura
    Thanks everyone for your responses. Since I haven't even started nursing classes it helps to understand why the nurses do what they do. We did learn about hypoxic drive in EMT class but I guess since we only have the patient for a few minutes I'm usually not that concerned about it. especially since most of my pts are getting too little O2. we were even taught that if a copd pt is in major distress to put them on high flow for a few minutes to stabilize them and then back down to 2-3l.

    again thanks for taking the time to respond. i really appreciate the info.
  11. by   CoffeeRTC
    Isn't it no more than 4 LPM via NC?
  12. by   southern_rn_brat
    Quote from TriageRN_34
    The reason for the ties on nurses for setting O2 come from the many lawsuits around the country against nurses that gave O2 too high and put their patients at risk of hypoxic drive into that condition. If you don't know about hypoxic drive..you better look it up for reference. Most patients with respiratory conditions can be at risk..even though it is rare.

    Now, an EMT has the equipment and skills to treat this immediately if it is to occur...as we really don't in most cases. That is why EMT/Paramedics have protocols for this condition and other respiratory conditions.

    Also...can anyone tell me the highest O2 that can go via a Nasal Cannula? Most nurses I talk to don't...and just for the record it is 6L/min (no not 8 as some think..that is old school!). Even at 6 is it not very efficient...too fast, and acts more like a hose on high than anything. If I have to go above 5 I like to have a mask...which my facility really do not have (we have a few in an oxygen room far away that even if I dared to go get it the EMT/Paramedics would already have been in the patients room!).

    Oxygen is a medicine, it can cause side effects (like the hypoxic drive), and needs to be watched carefully. If you see that your patient is not doing well on their prescribed O2 and route (ie the nasal cannula not cutting it for a mouth breather), you need to be notifying the MD stat anyway to get orders for a change in condition and orders.

    I have also found that putting the nasal cannula in the residents mouth is very irritating and even barely responsive patients will yank that out...or cause serious harm to the soft pallate by drying it causing gagging (which sometimes leads to bleeding and then you have the old case of aspiration on blood!). If I feel a change to mouth breathing is an issue I get orders for a mask (I like non rebreathers myself), and hope the patient keeps it on...(but I can sympathize...masks are uncomfortable, but so is not getting O2!!!).

    Working with EMT/Paramedics I see orders for O2 for comfort as a nurse and just giggle...because I know that you may as well stand there with a fan and get the same results...so I try to really help my patients by speaking with their physicians or hospice nurse to get the correct route and O2 rate that will best help the patient. Takes practice...but worth it!
    A non rebreather does not work on 5L. It is to deliver high oxygen concentration of at least 80% and must be used with AT LEAST 12 LPM.
  13. by   DelightRN
    Exactly. Generally I crank the flowmeter up with a NRB.

    Its also important to remember that if you're using a simple face mask you need to be up to at least 6L or the pt will be rebreathing their CO2.
  14. by   Antikigirl
    YOu can go 6 per nc, but I find it isn't effective...stick with 4...need more get better equipment is my motto...and for me that is 9-11 LOL!!!!!

    Yep, you are so right about hypoxic drive in EMT/PARAMEDICS, and I count on it! Since I can't bump up O2 (mainly because I have nasal cannulas), I trust them to get those O's going...and they do! Bump it up..we can fix the rare hypoxic drive if we must...is my hubbys moto (paramedic).

    But the old legality scares that run nursing have nurses having to check with a doc all the friggen time putting patients at risk of hypoxia anyway! OH well...that is when my EMT/PARAMEDIC friends come in..they come quicker than getting through a receptionist, nurse, and maybe the doc on the phone...especially on weekends or Lord forbid it happens between 1200 and 1300! LOL!

    I am more with the paramedics, always have been...nursing protocols hold me back much of the time...O2 is a perfect example.

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