Download - Baromedical Nurses Association

Revised 2007
Guidelines For: Standards of Care For The Patient Receiving Hyperbaric Oxygen Therapy (HBO 2)
Table of Contents
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15.
16.
Anxiety related to knowledge deficit of HBO2 and treatment procedures.
Potential for injury related to transferring patient in/out of chamber, and within hyperbaric facility.
Potential for barotrauma to ears, sinuses, teeth, and lungs or cerebral gas embolism related to changes in atmospheric
pressure inside oxygen chamber.
Potential for oxygen toxicity seizures related to delivery of 100% oxygen at an increased atmospheric pressure.
Potential for inadequate therapeutic gas delivery related to delivery system and patient’s needs/limitations.
Anxiety related to feelings of confinement associated with the hyperbaric oxygen chamber.
Pain related to associated medical problems.
Discomfort related to temperature and humidity changes inside hyperbaric chamber.
Potential for ineffective individual coping related to stresses of illness and/or poor psycho-social support systems.
Potential for dysrhythmia related to disease to disease pathology.
Potential for fluid volume deficit related to dehydration or fluid shifts.
Altered cerebral tissue perfusion related to:
1. carbon monoxide poisoning
2. decompression sickness
3. acute necrotizing infection
4. gas embolism
5. other
Potential for alteration in comfort, fluid and electrolyte balance to nausea and vomiting.
Altered health maintenance related to knowledge deficit for:
1. management of chronic wound
2. restrictions following decompression sickness
3. systems to report after carbon monoxide poisoning.
Potential for pulmonary oxygen toxicity related to 100% oxygen at an increased atmospheric pressure.
Potential for injury related to fire within the hyperbaric chamber.
PROBLEM
1. Anxiety related to knowledge
deficit of hyperbaric oxygen
therapy and treatment
procedures.
GOAL/RATIONALE
1.
Patient and/or family will state:
1.
Definition:
Anxiety is a practical risk with hyperbaric
oxygen treatments. It can occur before,
during or after the treatment.
2.
3.
4.
Rationale for hyperbaric
oxygen therapy.
Goals of therapy.
Procedures involved with
hyperbaric oxygen
therapy.
Potential hazards of
hyperbaric oxygen
therapy.
Identify signs and symptoms of anxiety
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Patient verbal admission of
anxiety
Clenching of fists
Flushed face
Complaint of nausea or diarrhea
Sudden complaint of pain or
discomfort
Feelings of being smothered or
suffocated
ACTIONS
Purpose:
Familiarize the patient with the
procedure, potential beneficial
effects and safety precautions
relating to his/her treatments to
ensure patient’s emotional comfort.
2.
3.
Assess and document patient and/or family’s
understanding of rationale for and goals of
hyperbaric oxygen therapy, procedures
involved with, and potential hazards of
hyperbaric oxygen therapy.
Identify barriers of learning.
Include information on the following when
identified as a learning need:

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

Involve Interpreter if indicated
Apply age-specific teaching
Consider cultural/religious factors
Assess readiness to learn
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Purpose and expected outcomes of hyperbaric
oxygen therapy
Sequence of treatment procedures and what
to expect, (e.g. pressure, temperature, noises,
wound care)
Gas delivery systems; hands-on practice of
applying mask or hood
Ear clearing techniques
Pulmonary barotrauma
Prevention of oxygen toxicity
4.
Provide continued opportunities for
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PROBLEM
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GOAL/RATIONALE
Urgency to empty bladder
Defensive attitude
Hyperventilation
Profuse diaphoresis
Flat Affect
Tachycardia
Restlessness
ACTIONS
discussion and instruction.
5. Provide patient and/or family with
information brochure on hyperbaric oxygen
therapy.
6. Keep patient and/or family informed of all
procedures.
7. Document patient/family instruction, using
the confirmation of instruction form and the
general patient instruction form.
8. Potential for injury related to transferring
patient in/out of chamber and within
hyperbaric facility
1.
Identification:
Equipment located in the hyperbaric
facility should only items necessary to
provide patient care. Excess items like
personal belongings or other medical
equipment unrelated to the function of
HBO treatment contribute to potential
injury hazards and therefore should be
removed.
All necessary equipment in the facility
should be in good working order at all
times.
2.
3.
Patient will not experience any
injury.
4.
Purpose:



The patient has the right to expect
safe care delivery throughout the
admission.

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5.
6.
Only those personnel trained to operate
the equipment should do so.
It is the responsibility of all staff, lead by the
Safely Director to inspect the facility and
identify equipment with the potential of
causing harm to a patient in any state.
Comply with the local Fall Risk Policy;
assess patient’s potential risk for fall and
apply precautions as appropriate.
All equipment with the potential for injury
will be secured to prevent harm.
Assist patient in and out of the chamber
appropriately.
1-2 person assist as necessary
Use of gait belt, as necessary
Use of foot stool and/ or lower gurney to load
patient
Use of slide board, as necessary
Use side rails on stretcher, as appropriate
Communicate transfer plan with patient and
staff involved prior to taking action.
Potential for barotraumas to ears, sinuses,
teeth, and lungs or cerebral gas embolism
related to changes in atmospheric pressure
inside hyperbaric oxygen chamber.
Ear Barotrauma

Administers decongestants, per physician
orders, prior to HBO2

Patient education prior to HBO therapy
should include: methods to equalize pressure
in middle ear during therapy; patient
demonstration of equalization techniques and
importance of notifying chamber operator
immediately when pressure or fullness is felt
in middle ear
Prevention of barotraumas
during HBO2
Nursing interventions include:


Assess tympanic membrane pre and post
HBO treatment, recording level of
barotrauma using TEED scoring system
Assess patient's ability to equalize pressure
PROBLEM
GOAL/RATIONALE
ACTIONS
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
Have HOB elevated during HBO therapy to
assist in equalization of middle ear
Ensure operator of chamber understands
chamber descent should stop when patient is
unable equalize pressure and should return to
the point of no pain/pressure prior to asking
patient to equalize ears.
Pneumothorax
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Identify those patients at greater risk for
development of a pneumothorax
Implement protocols to decrease risk of
pneumothorax in high risk patients
Observe for:
o sudden, sharp chest pain
o difficult, rapid breathing
abnormal chest movements on the affected
side
Nursing interventions include:


Notify physician, follow physician's orders
for patient management
Chamber should not be decompressed until
preparations are made for emergency
decompression of pneumothorax
Document assessments.
1. Report patient assessment outcome to
hyperbaric physician of:
2. Monitor patient during HBO2 and document
signs and symptoms of central nervous
system oxygen toxicity including:
4.
Potential for oxygen toxicity
seizures related to delivery of
100% oxygen at an increased
atmospheric pressure
Signs and symptoms will be
recognized and promptly
addressed. Seizing patients will
suffer no harm.
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elevated body temperature
history of steroid use
history of oxygen seizures
Other high risk factors as appropriate

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Numbness and twitching
Ringing in the ears or other auditory
hallucinations
Vertigo
Blurred vision
Restlessness and irritability
Nausea
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(Note: CNS oxygen toxicity can ultimately result in a
seizure.)
3.
4.
5.
Change 100% oxygen source to air for patient
if signs and symptoms appear and notify the
hyperbaric physician.
Protect patient during seizure.
Potential for inadequate therapeutic gas
PROBLEM
GOAL/RATIONALE
ACTIONS
delivery related to delivery systems and
patient’s needs/limitations.
1.
2.
3.
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Assess the patient’s condition, needs, and
limitations for the best suited gas delivery
systems:
Monitor the patient’s response to the oxygen
delivery system, including their ability to
tolerate chosen system.
Assist the hyperbaric technician with the
delivery system, as appropriate.
head hood for children with facial
deformities, or per patient preference (
customize neck dam when possible for best
fit).
face mask
“T” piece ( Briggs adapter), for patients who
are intubated or with
tracheostomy/laryngectomy.
Ventilator for intubated patients who require
ventilation assistance.
Head Hood
1.
Signs and symptoms of
inadequate oxygen delivery will
be recognized and reported
promptly.
2.
3.
assist patient with application and removal of
hood.
After assembly, check for leaks
Observe patient for signs and symptoms of
CO2 build- up, including restlessness.
Face mask/Mouth Piece
1.
2.
assist patient with mask, application and
removal, and reposition mask/mouth piece as
needed. (i.e. monoplace)
Check form leaks, continuity of seal against
the patient’s face, keep tight fit around mouth
piece.
T-Piece(Briggs adapter)
1.
2.
3.
4.
set-up process
monitor patient’s rate and depth of
respirations, listen to breath sounds.
notify the hyperbaric physician if patient is
experiencing difficulty breathing. Have IV
access for medication administration if
needed.
suction as needed.
Ventilator
1.
2.
3.
document management of ET cuff with NS
prior to descent.
Keep suction equipment nearby and ready to
use. Suction PRN.
Monitor and document patient’s tidal volume,
PROBLEM
6.
GOAL/RATIONALE
Anxiety related to feelings of
confinement associated with
the hyperbaric oxygen
chamber.
Confinement anxiety is a practical risk
Patient will tolerate the
with hyperbaric oxygen treatments. It can hyperbaric oxygen therapy
occur before, during or after the
treatment.
treatment.
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










Patient verbal admission of
anxiety
Clenching of fists
Flushed face
Complaint of nausea or diarrhea
Sudden complaint of pain or
discomfort
Feelings of being smothered or
suffocated
Urgency to empty bladder
Defensive attitude
Hyperventilation
Profuse diaphoresis
Flat Affect
Tachycardia
Restlessness
1.
Patient interaction:



Address patient calmly.
Establish eye contact with the patient.
Reassure patient that he/she is safe.
2.
4.
Assess patient for any history of confinement
anxiety.
Engage patient in problem-solving his/her
feelings of confinement anxiety.
Identify barriers of learning.




Involve Interpreter if indicated
Apply age-specific teaching
Consider cultural/religious factors
Assess readiness to learn
5.
Implement preventative measures as
appropriate:
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Education
Chamber tour
Anti-anxiety medication
Eliminate preconceived notions
Empower patient; he or she is in charge and
may request to end treatment at anytime.
Offer divers ional activities; TV, music,
books on tape, family member chamber side.
Assure patient of nurse presence throughout
treatment.
3.
Definition:
Identify signs and symptoms of anxiety
ACTIONS
respiratory rate and breath sounds prior to
chamber pressurization, after chamber
pressurization, then every 10-15 minutes, or
as ordered.
4. Monitor patient for respiratory distress.
Notify hyperbaric physician if apparent.
5. Manually oxygenate the patient if necessary
(resuscitator bag).
6. Monitor PtcO2 levels, or pulse oximetry or
ABG levels if possible and as ordered.
Notify hyperbaric physician of abnormal
readings.
Purpose:



To prevent confinement
anxiety during treatment.
To assess the degree of
confinement anxiety when
it may occur and manage
it effectively.
Relieving or decreasing
contributing or
precipitating factors may
reduce its incidence.
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6.
7.
8.
9.
Patient will state satisfaction
with pain management
1.
Prior to, during and after the hyperbaric
oxygen therapy treatment, monitor and assess
for signs and symptoms of confinement
anxiety.
Notify hyperbaric physician of patient’s
response to the anti-anxiety measures and
ability to tolerate confinement.
Document results of interventions.
Pain related to associated medical
problems.
Assess patient’s experience of pain and
whether pain is increased during HBO
PROBLEM
GOAL/RATIONALE
Patient will tolerate the internal
climate of the chamber.
ACTIONS
2. Medicate patient for pain before HBO2 as
needed. Document efficacy of analgesic.
3. Have analgesic available during HBO2
4. Reposition patient for comfort.
5. Avoid IM medications immediately prior to
treatment.
6. Discomfort related to temperature and
humidity changes inside hyperbaric
chamber.
1.
Identify barriers of learning:



Involve Interpreter if indicated
Apply age-specific teaching
Assess readiness to learn
2.
Discuss with patient prior to treatment how
the pressure environment effects the
temperature.
Discuss with the patient how their exhalation
contributes to the relative humidity in the
chamber.
Periodically assess patient’s comfort with
humidity and temperature.
Offer the patient comfort measures:
3.
Purpose:
Definition:
According to Charles’ law when gas
volume is kept constant the temperature
of the gas will vary with the absolute
pressure. As pressure increases, so does
temperature; the reverse is true during
decompression.
Slowing the rate of gas flow
through the chamber increases the
relative humidity.
This effect is the result of a greater
accumulation of the patient’s
evaporative moisture loss within
the chamber.
The Increased humidity in a
monoplace chamber decreases the
risk of static electricity.
4.
5.
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
1.
2.
9.
Potential for ineffective
individual coping related to
stresses of illness and/or poor
psych-social support systems.
3.
Patient will be able to comply
with HBO2 treatment procedures
4.
5.
6.
Signs and symptoms of
dysrhythmia will be recognized
1.
If the patient complains of being cold, first
decrease the purge flow of the monoplace
chamber; slowing the flow, increases the
temperature.
If the patient continues to be cold, next offer
a blanket keeping in mind that should a fire
occur within the chamber, more fuel is
available.
If the patient complains of being warm; slow
compression rate and increase the chamber
purge flow; offer a cool moist cotton cloth to
take into the chamber.
Ensure the chamber facility temperature is
maintained according to manufacturer
recommendations; usually 68-72 Degrees F.
Provide support and encouragement without
exceeding treatment outcome expectations.
Discuss with patient ability to cope with other
care givers. Stay informed of progress and
helpful approaches.
Facilitate communication between patient
and/or family and other HBO2 staff members.
Encourage patient, if able, to discuss
concerns and feelings.
Document pertinent discussions and
assessments.
Potential for dysrhythmia related to
disease pathology
As ordered, monitor EKG readings while
patient is inside the chamber, (especially if IP
PROBLEM
GOAL/RATIONALE
and promptly addressed
ACTIONS
on telemetry) .
2. Monitor and document blood pressure as
indicated (by invasive or non-invasive
methods).
3. Assess and document any signs of
hypokalemia in patients with acute
necrotizing infections.
4. Maintain IV infusions as ordered.
5. Maintain invasive pressure monitoring and
record values, as indicated ( make sure
infusion pumps are plugged into D/C).
6. Obtain lab samples as ordered.
7. Notify hyperbaric physician as needed.
8. Potential for fluid deficit related to
dehydration or fluid shifts.
1.
Signs and symptoms of fluid
volume deficit will be recognized
and promptly reported
2.
3.
4.
1.
2.
3.
1.
2.
3.
4.
carbon monoxide poisoning
decompression sickness
gas embolism
other
Signs and symptoms of changing
neurologic functioning will be
recognized and promptly
addressed.
4.
5.
6.
7.
1.
2.
Patient will experience decreased
symptoms of nausea and
vomiting
3.
4.
5.
6.
Patient and/or family will be able
to state/discuss factors
appropriate to the management
of their disease process during
treatment.
1.
2.
3.
Assess fluid and electrolyte balance. Maintain
hydration and/or pressure support as per
physician order.
Monitor patient’s I & O as indicated.
Monitor patient’s vital signs as indicated.
Altered cerebral tissue perfusion to:
Perform baseline neurological assessment
prior to treatment.
Monitor neurological checks per established
protocol.
Use a common language such as Glasgow
Coma Score to facilitate communication and
determination of altered level of
consciousness.
Assess and document patient’s motor and
sensory functioning.
Provide reorientation and emotional support
as needed.
Notify physician of changes as per facility
protocol.
Potential for alteration in comfort, fluid
and electrolyte balance to nausea and
vomiting.
Assess and document patient’s complaints of
nausea.
Maintain airway integrity to prevent
aspiration.
Notify hyperbaric physician of patient’s
nausea and administer medication as ordered.
Place NG tube if ordered.
Monitor and document amount of emesis on
Patient’s I & O record.
Altered health management related to
knowledge deficit.
Assess for knowledge deficits related to
underlying pathology.
Identify patient's expectations of treatment.
Begin discharge planning with patient during
first visit. Supply information in format to
match patient's preferred learning method.
PROBLEM
GOAL/RATIONALE
ACTIONS
4. Document patient/family teaching, their
understanding of instructions and any return
demonstrations.
5. Provide orientation to the hyperbaric
environment to include: chamber orientation;
middle ear equalization, fire hazards; safety
policies and procedures; and risk and benefits
of hyperbaric oxygen therapy.
6. Appropriate information specific to the
patient's disease process should be provided.
7. Upon discharge, written instructions should
be provided to patient and /or family.
8. Potential for pulmonary oxygen toxicity
related to delivery of 100% oxygen at an
increased atmospheric pressure
Monitor the patient during HBO2 and document signs
and symptoms of pulmonary oxygen toxicity
including:
Signs and symptoms of
pulmonary oxygen toxicity will
be recognized and promptly
addressed

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
Add humidity to oxygen as needed to reduce
chest discomfort.
1.
Follow fire prevention procedure per
established policy and procedure.
Hyperbaric oxygen treatment teaching and
consent of the patient will include the risks of
fire in the hyperbaric environment.
Provide the patient and family an educational
pamphlet that discusses the fire risks with
HBO and what materials to be avoided for
treatment.
Staff will conduct a safety inspection prior to
each treatment to ensure fire safety
precautions are met. Prohibited items will not
enter the chamber.
The Safety Director will:
o Screen patients with special
circumstances (prohibited items).
o Collaborate with the Medical
Director to determine medical
necessity.
o Identify ways to reduce fire risk.
o Sign a Prohibited Items release
form, if indicated, to allow certain
materials to enter the chamber.
The chamber and patient will be confirmed as
grounded prior to treatment.
2.
6.
Potential for injury related to
fire within the hyperbaric
chamber.
3.
Patient will not experience any
injury related to fire.
4.
Problem:
Hyperbaric oxygen involves placing a
patient (fuel) in 100% oxygen (oxidizer)
under pressure in a chamber.
To complete the fire triad, an ignition
source is necessary and this can occur
from a spark in the chamber.
Purpose:
substernal irritation or burning
tightness in the chest
dry, hacking cough
difficulty inhaling a full breath
Dyspnea on exertion
Monitor Units of Pulmonary Toxicity Dose
(UTPDs) to max of 1425/ day.
Notify the hyperbaric physician if signs and
symptoms of pulmonary oxygen toxicity
appear.
5.
The patient has the right to expect
safe care delivery throughout the
admission.
6.
PROBLEM
1.
2.
3.
4.
5.
6.
7.
8.
GOAL/RATIONALE
ACTIONS
7. Staff will participate in quarterly unit fire
drills to ensure preparedness.
Norkool, Diane. “Care of the Patient Receiving Hyperbaric Oxygen Therapy” Manual of Patient Care Standards. Reiner,
Ann, Editor. Gaithersburg, Md: Aspen Publishers, Inc., 1988
Kindwall, Eric P. Hyperbaric Medicine Practice. Flagstaff, AZ: Best Publishing Co., 1994
Kindwall, Eric P. and Robert W. Goldman. Hyperbaric Medicine Procedures. Milwaukee, Wn: St. Luke’s Medical center,
1995
Hyperbaric Oxygen Therapy: A Committee Report. Bethesda, Md: Undersea and Hyperbaric Medical Society, 1996
Larson-Lohr V, Garcia J. “Assessing the Critically Ill Hyperbaric Medicine Patient.” In: Hyperbaric Nursing (Larson-Lohr V,
Norvell HC, eds) Best Publishing Company, Flagstaff, AZ, 2002
Norvell HC, Josefsen L, Fabius S, Larson-Lohr V. “Patient Education.” In: Hyperbaric Facility Safety: A Practical Guide
(Workman WT, ed) Best Publishing Company, Flagstaff, AZ, 1999
Larson-Lohr V, Hyperbaric Nursing, (Larson-Lohr V, Norvell HC, eds) Best Publishing Company, Flagstaff, AZ, 2002.
“HBO2”- this algorithm for Hyperbaric Oxygen Therapy, was defined at the 1996 UHMS meeting in Anchorage, AL.,
Approved and endorsed by the UHMS Executive Committee, Neil Hampson, MD, Chair UHMS Hyperbaric Oxygen Therapy
Committee, Undersea & Hyperbaric Medicine 1999:26,4:ProQuest Medical Library, pg. 267.