Oxygen Therapy

SpokesAndCoffee, ADN · Mar 16, 2021

No need to overcomplicate it. Focus more on the limitations of each device. For example, nasal cannula is the least intrusive, but is limited to 6 L/min at a partial oxygen concentration (not 100%). A simple mask is more intrusive, but can go up to 12 L/min at a partial concentration. A non-rebreather is even more intrusive, but goes at 10-15 L/min at a full 100% oxygen.

So basically, a low need patient will likely do with a nasal cannula. For respiratory distress, you're going straight for that non-rebreather.

Hannahbanana, BSN, MSN · Mar 16, 2021

22 hours ago, LovingLife123 said:

FYI, in the real world you have a standing order to apply oxygen is the spO/2 is less than a certain percent. It’s with every single admission. Nursing school is ridiculous. It’s a standing order with literally ever single admission.

If you do, in fact, have a written standing protocol, then fine. There are, of course, people who should not get supplemental oxygen routinely; one-size-fits-all rarely fits everyone, LOL. But you would question that anyway.

LovingLife123 · Mar 20, 2021

On 3/16/2021 at 7:25 PM, Hannahbanana said:

If you do, in fact, have a written standing protocol, then fine. There are, of course, people who should not get supplemental oxygen routinely; one-size-fits-all rarely fits everyone, LOL. But you would question that anyway.

Right. We then put a new order in for that. I just had a COPD pt the other day. But the standing admission order was then changed. Every, single admission gets a standing order set. To insert IVs, apply O2, HR, and BP. Then say a different BP parameter is needed. A new order is put in for that. My point is, nursing school makes it sound like you will lose your license for putting oxygen on the patient. I hate when they put that fear into students because it won’t happen as you already always have an order for it.

Hannahbanana, BSN, MSN · Mar 20, 2021

Story about that. Community hospital where I was the critical care clinical specialist. One midnight an old bird with long COPD hx is admitted. New grad admits her, sees that physician has written for oxygen 3/4LPM, and thinks that means 3 to 4 LPM. So she starts the old bird on 3L and when she didn’t look so hot in an hour cranked her up to 4L.

At 7:00 am the day charge is making rounds and finds old bird not breathing, but not quite dead yet. She rips the cannula off, draws a stat ABG, and starts bagging furiously. ABG shows PaO2 of 136 (great, huh?) but a CO2 of 96 (lethal territory for anybody), bicarbonate of 49-something (long-standing metabolic compensation for chronic hypercarbia) and a pH of 6.96, IIRC (CO2 is acidic).

This is why they put the fear of god into students about just slapping oxygen on people without a prescription. The old bird had been living c a high PaCO2 for years and so her respiratory drive was based on hypoxia, the back up system when the normal drive of high CO2 is not working anymore. Her system hadn’t seen that much oxygen since the Eisenhower administration so she stopped breathing. This particular new grad misread the O2 prescription but in any case she didn’t know that 3 L (and later 4) would be a bad thing.

Deli · Mar 20, 2021

I find it so funny how you completely understand my situation? . But yeah I personally haven't seen anything on standing orders. The only order I know about so far is the Dr. orders and when I've read I can't recall ever seeing laid out parameters for the patients' vital signs, except for a few special cases, so I didn't really know what to do for those who don't have the parameters, but then again so far I've worked in the medicine and surgical unit so maybe its different for other units.

0.9%NormalSarah, BSN, RN · Mar 21, 2021

Spokesandcoffee wrote exactly what I was going to say. It’s more about how much you need. If I walk in and my patient’s O2 sat is 75% and I’m sure the reading is accurate, I’m getting a non rebreather. No one is going to take your license for getting a non rebreather on them and cranking it to 15L for a couple minutes until you make sure they aren’t super hypoxic. Just don’t put that mask on and walk away and forget about it, like Hannah says, always assess the parameters that are appropriate for your patient. I’d rather have a little extra CO2 on board for a few minutes while I assess my patient’s oxygen needs rather than a profoundly hypoxic person that now needs to be intubated.

amoLucia · Mar 21, 2021

Wow! How scary! I have hypercapnia. And I'd bet very few nurses understand the O2 and CO2 relation. So quick are staff to say "Well, your oxygen sat looks good at 95%". IT'S NOT THE OXYGEN LEVEL!!

Oxygen compensates for carbon dioxide. It's just that there's no easy way to measure CO2 levels, except to draw ABGs. So staff rarely SEE the hypercapneic effects. I get 'fuzzy headed' & increasingly tired. It's hard for me to concentrate. But I know something's wrong. And trying to explain it is soooo difficult, usually futile.

On ‎3‎/‎19‎/‎2021 at 8:33 PM, Hannahbanana said:

... ABG shows PaO2 of 136 (great, huh?) but a CO2 of 96 (lethal territory for anybody), bicarbonate of 49-something (long-standing metabolic compensation for chronic hypercarbia) and a pH of 6.96, IIRC (CO2 is acidic).

This is why they put the fear of god into students about just slapping oxygen on people without a prescription. The old bird had been living c a high PaCO2 for years and so her respiratory drive was based on hypoxia, the back up system when the normal drive of high CO2 is not working anymore. Her system hadn’t seen that much oxygen since the Eisenhower administration so she stopped breathing. This particular new grad misread the O2 prescription but in any case she didn’t know that 3 L (and later 4) would be a bad thing.

At my last hospitalization in May, I had an argument with a covid ER Admission nurse who was insistent that she put an 2L O2 canula on me. As much as I was trying to explain that I was needing bipap & to rest, not a canula, I was imperiously told "that it was NOT my job to explain nsg care to her as SHE was the nurse, and I was the pt". I kid you NOT re this conversation!

I bit my tongue to NOT ask her how many years nsg experience she had, as compared to my 36 yrs practice. I almost reported it on that CMS Medicare satisfaction survey. But it was just the start of the Covid hosp crisis and I felt so devastated for all the staff there doing care. If CMS dinged the hosp, the facility could have easily traced it back to that nurse and I believe she'd have been sacrificed. NOT my intention to persecute anyone!

Oxygen therapy is a critical care practice for staff. As long as one KNOWS what is correct, then do what you believe to be needed. But remember to listen to the pt and not solely depend on equip.

FTR, I use a bipap machine at night with a little O2. No oxygen while awake. And I also use an inhaler.

I just find it so ludicrous when I see a practitioner and the first thing they do is put that little oximeter on me and impressively announce "oh, you're doing well. You're 97%". I want to smack them! IT'S NOT THE OXYGEN LEVEL!!

londonflo · Mar 21, 2021

1 hour ago, amoLucia said:

I just find it so ludicrous when I see a practitioner and the first thing they do is put that little oximeter on me and impressively announce "oh, you're doing well. You're 97%"

Wow, thank God you were able to stand up for yourself. I have pulmonary fibrosis and have low O2 levels. I had a colon resection and was put on 6 liters for a week. Of course every shift checked my pulse ox, smiled and said "good" while I was on O2. When discharge time came they were incredulous that the neccessity for 6 liter flow hadn't been evaluated sooner. I was sent on a walk alone with a 'soon to be dead battery' in a pulse ox machine. When asked about how my oxygen held up I cited I had no way to measure as the pulse ox battery was dead. With a patronizing smile, I was told 'fine" you can go home now.

amoLucia · Mar 21, 2021

Like I said, sometimes I just want to smack 'em. Like why don't they listen?!?!?!

Hannahbanana, BSN, MSN · Mar 22, 2021

A sat of 97% does not equal a PaO2 of 97mmHg, and looking at sats alone will not tell you pH, the reflection of PaCO2, which can be high (see old bird above). It always astonished me how people who have to understand this to provide safe care are oblivious to this basic physiological concept. And as a result.... cases like our old bird and amoLucia.

Get a complete ABG or you miss the point of more than half of respiratory/acid-base function.

amoLucia: suggest you carry little laminated cards c the oxyhemoglobin dissociation curve in your wallet, LOL. Good luck!

londonflo · Mar 22, 2021

On 3/19/2021 at 7:03 PM, LovingLife123 said:

My point is, nursing school makes it sound like you will lose your license for putting oxygen on the patient. I hate when they put that fear into students because it won’t happen as you already always have an order for it.

Having an order and safe adminstration are not the same thing.

amoLucia · Mar 23, 2021

10 hours ago, Hannahbanana said:

Get a complete ABG or you miss the point of more than half of respiratory/acid-base function.

amoLucia: suggest you carry little laminated cards c the oxyhemoglobin dissociation curve in your wallet, LOL. Good luck!

I'd like to be the developer or bioengineer who creates a simple test (like a BG fingerstick or oximetry or an exhalator) that measures carbon dioxide! Or own stock from that IPO! No financial worries ever gain!

Hannah - I have thought about finding some simple explanation that I would carry copies to hand out as FYI for UNinformed practitioners. I know it's not an affliction that's very common, but I would guess that it is more common than most would guess.