O2 bad if pt already 100% RA?

nurseprnRN, BSN, RN · Jan 2, 2014

Rationale: Billing. Not only because the hospital can bill for the service, the oxygen, the supplies, and the RT (at inflated charges over their costs), but because use of oxygen and associated monitoring will allow an upcharge on the utilization review of the whole ER stay.

As for physiological rationale for supplemental oxygen, if someone comes in with no respiratory symptoms and normal sats on room air, there is absolutely none.

I am far too cynical for my tender years, but I used to do UR, appeal bills, deny billing, and review records for both sides (hospital and insurance), and that's the way the game is played.

classicdame, MSN, EdD · Jan 2, 2014

agreed. Same reason you do not perform a chest x-ray on someone whose chief complaint is a laceration to the arm. HOWEVER, the pulse ox does not take the place of good nursing assesment. So if you can justify the intervention, and document such, then use it.

Altra, BSN, RN · Jan 2, 2014

While the point about CYA/bill for as much as you can ... is a valid one, your question strikes me as somewhat broad. An ER patient whose chief complaint is dyspnea -- what is in the differential?

URI

pneumonia

cardiac issue

PE

anemia

etc.

I'm sure you can see why standing orders/care plans/protocols for a complaint of SOB include application of O2 while diagnostics are completed.

It is also true that "shortness of breath" accounts for a significant percentage of ER visits, and runs the gamut from the mild viral/URI in an otherwise healthy young person, which requires no actual treatment ... to the severe respiratory distress and evolving cardiac events.

What you'll need to know as a nurse is how strictly your department aligns actual practice with these protocols, confidence in your own assessment skills and good working relationships with your department's providers.

classicdame, MSN, EdD · Jan 2, 2014

I agree Altra. Guess I was not clear. What I really meant was that a good nursing assessment supercedes the "general rule". Documentation is vital in this situation.

applewhitern, BSN, RN · Jan 2, 2014

Your question is way too broad, and certainly not a "one size fits all." For chest pain, the sats might be high, but the heart muscle needs the 02; thus the protocol. Aside from chest pain, the patient may have high sats, but is he working hard to maintain the sats? For some people, there is a fine line between "enough oxygen" and "working hard to get there" and they plummet. Your protocols are there for a reason.

nurseprnRN, BSN, RN · Jan 2, 2014

To reiterate: No respiratory symptoms, normal sats, no need for supplemental oxygen.

We're not talking about people who have respiratory symptoms (working hard to maintain sats) or people who desat on movement (abnormal finding). Of course this involves assessment. But it's ridiculous to have a blanket protocol that everyone who walks in the door for any reason gets supplemental oxygen, which is the OP's question. There is no rational reason at all for that protocol.

LearningByMistakes · Jan 2, 2014

Interesting article http://www.ems1.com/columnists/mike-mcevoy/articles/1308955-Can-oxygen-hurt/

Can oxygen hurt?Mike McEvoy

Drug we use most often can cause harm if we give it without good reason

In 2002, a study of 5,549 trauma patients in Texas showed prehospital supplemental oxygen administration nearly doubled mortality.
A Tasmanian study of prehospital difficulty breathing patients published in 2010 compared patients treated with oxygen titrated to saturations of 88 to 92 percent to patients treated with non-rebreather oxygen masks. It showed a reduction in deaths during subsequent hospitalization of 78percent in COPD patients and 58 percent in all patients.
New studies are showing a troubling pattern of worse outcomes associated with hyperoxia post cardiac arrest. Why would oxygen worsen patient outcomes? One mechanism maybe absorption atelectasis.
Gas laws mandate that increases in the concentration of one gas will displace or lower the concentration of others. Room air normally contains 21 percent oxygen, 78 percent nitrogen, and less than 1percent carbon dioxide and other gases.
Nitrogen, the most abundant room air gas, is responsible for secretion of surfactant, the chemical that prevents collapse of the alveoli atend expiration. Premature infants often are not developed sufficiently to produce surfactant and require endotracheal administration of animal surfactant.
“Washout” of nitrogen in adult lungs occurs when high concentration oxygen is administered. Lower concentrations of nitrogen can leadto decreased surfactant production with subsequent atelectasis and collapse of alveoli, significantly impeding oxygen exchange.
Oxygen is also a free radical, meaning that it is a highly reactive species owing to its two unpaired electrons. From a physics perspective, free radicals have potential to do harm in the body.
The sun, chemicals in the atmosphere, radiation, drugs,viruses and bacteria, dietary fats, and stress all produce free radicals. Cells in the body endure thousands of hits from free radicals daily. Normally, the body fends off free radical attacks using antioxidants.
With aging and in cases of trauma, stroke, heart attack or other tissue injury, the balance of free radicals to antioxidants shifts. Cell damage occurs when free radicals outnumber antioxidants, a condition called oxidative stress. Many disease processes including arthritis, cancer, diabetes, Alzheimer’s and Parkinson’s result from oxidative stress.
The concept of free radical damage suggests the old notion that, “high flow oxygen won’t hurt anyone in the initial period of resuscitation” may be dead wrong.
Tissue damage is directly proportionate to the quantity of free radicals present at the site of injury. Supplemental oxygen administration during the initial moments of a stroke, myocardial infarct (MI) or major trauma may well increase tissue injury by flooding the injury site with free radicals
Finally, consider this: five minutes of supplemental oxygen by non-rebreather decreases coronary blood flow by 30 percent, increases coronary resistance by 40 percent due to coronary artery constriction, and blunts the effect of vasodilator medications like nitroglycerine. These effects were demonstrated dramatically in cath lab studies published in 2005.
Wonder why the 2010 ECC Guidelines recommended against supplemental oxygen for chest pain patients without hypoxia? Now you know:supplemental oxygen reduces coronary blood flow and renders the vasodilators used to treat chest pain ineffective.
Where do we go from here? Knowing that both hypoxia and hyperoxia are bad, we must stop giving oxygen routinely. Oxygen saturations should be measured on every patient. Protocols need to be aligned to reflect the 2010 ECC guidelines: administer oxygen to keep saturations between 94 and 96 percent.
No patient needs oxygen saturations above 97 percent and in truth, there is little to no evidence suggesting any clinical benefit of oxygen saturations above 90 percent in any patient.
Bottom line: the drug we use most often can cause harm if we give it without good reason. In the absence of low saturations, oxygen will not help patients with shortness of breath and it may actually hurt them. The same holds true for neonates and virtually any patient with ongoing tissue injury from stroke, MI or trauma. Indeed, oxygen can be bad.

dudette10, MSN, RN · Jan 2, 2014

In the ER, though, part of some of our protocols is O2 on all. Any hard facts with rationale? I would love to learn best practice for this situation

What protocols are you talking about? Chest pain protocol, for one? Any others?

Esme12, ASN, BSN, RN · Jan 2, 2014

essentially everyone is right. Give the 02 as per protocol....for the most part in the ED 02 protocol is a billing money maker. But all with chest pain or SOB are guilty of hypoxia until proven other wise. It also helps calm the patient who initially presents with certain complaints that they are being treated....call it a placebo effect.

Protocols are there to give the nurse options to use critical thinking skills to treat a patient without tracking down the MD which expidites patient care.

Havin' A Party!, ASN, RN · Jan 2, 2014

What GrnTea said.

Emergent, RN · Jan 3, 2014

http://www.ems1.com/columnists/mike-...n-oxygen-hurt/
Can oxygen hurt?Mike McEvoy
Drug we use most often can cause harm if we give it without good reason

In 2002, a study of 5,549 trauma patients in Texas showed prehospital supplemental oxygen administration nearly doubled mortality.
A Tasmanian study of prehospital difficulty breathing patients published in 2010 compared patients treated with oxygen titrated to saturations of 88 to 92 percent to patients treated with non-rebreather oxygen masks. It showed a reduction in deaths during subsequent hospitalization of 78percent in COPD patients and 58 percent in all patients.
New studies are showing a troubling pattern of worse outcomes associated with hyperoxia post cardiac arrest. Why would oxygen worsen patient outcomes? One mechanism maybe absorption atelectasis.
Gas laws mandate that increases in the concentration of one gas will displace or lower the concentration of others. Room air normally contains 21 percent oxygen, 78 percent nitrogen, and less than 1percent carbon dioxide and other gases.
Nitrogen, the most abundant room air gas, is responsible for secretion of surfactant, the chemical that prevents collapse of the alveoli atend expiration. Premature infants often are not developed sufficiently to produce surfactant and require endotracheal administration of animal surfactant.
“Washout” of nitrogen in adult lungs occurs when high concentration oxygen is administered. Lower concentrations of nitrogen can leadto decreased surfactant production with subsequent atelectasis and collapse of alveoli, significantly impeding oxygen exchange.
Oxygen is also a free radical, meaning that it is a highly reactive species owing to its two unpaired electrons. From a physics perspective, free radicals have potential to do harm in the body.
The sun, chemicals in the atmosphere, radiation, drugs,viruses and bacteria, dietary fats, and stress all produce free radicals. Cells in the body endure thousands of hits from free radicals daily. Normally, the body fends off free radical attacks using antioxidants.
With aging and in cases of trauma, stroke, heart attack or other tissue injury, the balance of free radicals to antioxidants shifts. Cell damage occurs when free radicals outnumber antioxidants, a condition called oxidative stress. Many disease processes including arthritis, cancer, diabetes, Alzheimer’s and Parkinson’s result from oxidative stress.
The concept of free radical damage suggests the old notion that, “high flow oxygen won’t hurt anyone in the initial period of resuscitation” may be dead wrong.
Tissue damage is directly proportionate to the quantity of free radicals present at the site of injury. Supplemental oxygen administration during the initial moments of a stroke, myocardial infarct (MI) or major trauma may well increase tissue injury by flooding the injury site with free radicals
Finally, consider this: five minutes of supplemental oxygen by non-rebreather decreases coronary blood flow by 30 percent, increases coronary resistance by 40 percent due to coronary artery constriction, and blunts the effect of vasodilator medications like nitroglycerine. These effects were demonstrated dramatically in cath lab studies published in 2005.
Wonder why the 2010 ECC Guidelines recommended against supplemental oxygen for chest pain patients without hypoxia? Now you know:supplemental oxygen reduces coronary blood flow and renders the vasodilators used to treat chest pain ineffective.
Where do we go from here? Knowing that both hypoxia and hyperoxia are bad, we must stop giving oxygen routinely. Oxygen saturations should be measured on every patient. Protocols need to be aligned to reflect the 2010 ECC guidelines: administer oxygen to keep saturations between 94 and 96 percent.
No patient needs oxygen saturations above 97 percent and in truth, there is little to no evidence suggesting any clinical benefit of oxygen saturations above 90 percent in any patient.
Bottom line: the drug we use most often can cause harm if we give it without good reason. In the absence of low saturations, oxygen will not help patients with shortness of breath and it may actually hurt them. The same holds true for neonates and virtually any patient with ongoing tissue injury from stroke, MI or trauma. Indeed, oxygen can be bad.

Thank you for your very excellent explanation. From now on I will act accordingly, in the best interest of the pt. Thank you!!!!