Download A Nurse-Directed Model for Nitrous Oxide Use during Labor Pinyan

A Nurse-Directed Model for Nitrous Oxide Use during Labor
Pinyan et al. MCN (May June 2017)
Supplemental Digital Content
Table 2
Nitrous Oxide/Oxygen Policy
1.
2.
3.
4.
Scope:
1.1 Applicable Entities: This policy applies to our facility.
1.2 Applicable Departments: Women’s Services Department.
Purpose: To support the physical and emotional wellbeing of patients in the Women’s Services
Department. Nitrous oxide as analgesia is a complement to the family-centered care
environment.
Policy Statement(s): We offer Nitrous Oxide as a self-administered, minimal analgesia option
for the antepartum, intrapartum and postpartum period. This analgesia option is delivered via
demand flow, at a fixed 50%/50% Nitrous Oxide/Oxygen mixture.
Policy Guidance:
4.1
Candidates for nitrous oxide self-administration are women admitted to the Women’s and
Infants Services department.
4.2
Nitrous Oxide will be ordered by the provider and initiated and managed by the RN who
has demonstrated competency.
4.3
Contraindications for nitrous oxide use are:
4.3.1 Patients with presence of a potential space the gas could fill: Pneumothorax,
intraocular surgery, bowel obstruction or middle ear surgery.
4.3.2 Current Vitamin B12 deficiency.
4.3.3 Acute drug or alcohol intoxication or impaired consciousness.
4.3.4 Hemodynamically unstable.
4.3.5 Impaired oxygenation <94% on room air.
4.4
Precautions for nitrous oxide use are:
4.4.1 Patients receiving epidural/spinal analgesia, unless approved by anesthesia
provider.
4.4.2 Heavy meal within four hours of administration of medication.
4.4.3 Evidence of maternal/fetal compromise.
4.4.4 If the patient has received intravenous, subcutaneous, or intramuscular narcotics
continuous pulse oximetry must be maintained for four hours from narcotic
administration.
4.5
Safety Concerns:
4.5.1 Supportive person and visitor/family abuse: zero tolerance
4.5.2.1 Will be clearly outlined verbally and in writing when
providing education to the patient.
4.5.2.2 Nitrous Oxide will be removed from patient’s
use if there is any suspicion of abuse of use by
persons other than patient.
4.5.2 The demand flow system has a quick connect
attachment and when not in use, will be disconnected and
stored in a secure location.
4.6
`
5.
Documentation
4.6.1 Provider’s orders.
4.6.2 Time of initiation and discontinuation.
4.6.3 Hourly vital signs with spot check of oxygen saturation level.
4.6.4 PRN spot checks of O2 saturation if needed.
4.6.5 Ongoing assessment of pain level with documentation in electronic record.
4.6.6 Hourly patient safety and LOC documented in electronic record.
4.6.7 Monitoring of fetal well-being as ordered by provider.
4.7
Observe for adverse effects: disorientation, lack of cooperation/aggressiveness, or
change in level of consciousness.
4.7.1 Notify ordering provider immediately if adverse effects are observed.
4.7.2 Discontinue use of nitrous and administer supplemental oxygen.
4.8
Consider discontinuing the use of NO/O and administer supplemental oxygen if normal
side effects are not tolerated by the patient or resolved by nursing interventions. Normal
side effects include: nausea, dizziness, dry mouth, drowsiness, and tingling in fingers.
4.9
Patients will be assessed for state of consciousness prior to ambulating:
4.9.1 Patient must have stable vital signs.
4.9.2 Patient must dangle feet at the bedside prior to ambulating.
4.9.3 If no evidence of dizziness or excessive motor weakness, patient may proceed
with assistance with initial attempt to ambulate.
4.9.4 Patient may move freely at her will, once there is no
evidence of dizziness and patient steady on her feet.
4.10
Patient may not receive additional opioids during nitrous oxide administration
(combinations of nitrous oxide and opioids can result in respiratory depression, hypoxia,
and unconsciousness).
4.11
If NO/O is discontinued, ordered opioids can be given immediately without the need for
provider consult.
4.12
If an epidural is in use, OB anesthesia must be consulted if there is a desire for NO/O to
be used in conjunction.
4.13
NO/O may be used in conjunction with hydrotherapy. RN to remain at bedside with
patient under this circumstance.
Definitions:
NO/O is a colorless, odorless and tasteless gas made for inhalation. NO/O’s rapid onset of action
and quick clearance prevents accumulation in maternal or fetal tissues. When NO/O is
administered, without opioids or other central nervous system depressants, it is defined as
minimal analgesia. Responsible Parties: Women’s & Infants Nursing Staff who provide care to
patients.
Table 3
Nitrous Oxide /Oxygen Procedure
1.0
2.0
3.0
3.3.4
Scope:
1.1 Applicable Entities: This procedure applies to our hospital.
1.2 Applicable Departments: Women’s Services Department.
Purpose: To support the physical and emotional wellbeing of patients in the Women’s Services
Department. Nitrous oxide as analgesia is a complement to the family centered care environment.
Procedure:
3.1 Antepartum & Postpartum Administration
3.1.1 Obtain an order from the provider for NO/O for analgesia.
3.1.2 Obtain written consent from patient.
3.1.3 Upon initiation, equipment should be checked for proper
functioning including appropriate readings on all line/tank pressure
gauges, mixture gauges and scavenging system.
3.1.4 May be initiated and discontinued by patient as appropriate.
3.1.5 Must be self-administered by the patient (the patient holds
the mask). Never held by family member, support person or staff.
3.1.6 Explain the importance of the timing of the beginning of
inhalation when being used for labor pain management.
3.1.7 Demonstrate the importance of maintaining seal around
the mask and instruct the patient to inhale and exhale through the mask.
3.1.8 Instruct and supervise the patient’s usage until she is
confident and proficient in the use.
3.2 Intrapartum Administration
3.2.1 Instruct the woman to begin breathing deeply at a normal
rate into the mask at the onset of a contraction and cease only
when the contraction has passed its peak.
3.2.2 Palpate contractions, to assist the woman in recognizing
early onset.
3.2.3 Instruct the woman to remove the mask between
contractions and to breathe normally.
3.2.4 Continuously assess the patient’s pain level and level of
consciousness during use.
3.2.5 Document pain level, O2 spot check and state of
consciousness at least hourly in the EHR.
3.2.6 The RN initiating NO/O use will remain with the patient
until the patient demonstrates competence in use.
3.3
Equipment
3.3.1 A NO/O demand flow delivery system, scavenger tube, 2
oxygen cylinders and 2 nitrous oxide cylinders.
3.3.2 Disposable individual patient mask and bacterial filter.
3.3.3 Quick Connect Key will remain in Pyxsis when not in use
(system not operational without the Quick Connect Key).
Will be maintained by Biomed Department.