INTELLECTUAL DISABILITY CLIENTS REQUIRING INTERMITTENT OXYGEN THERAPY: A PRACTICAL GUIDE

by Evelyn Mc Elwain, Lecturer in Nursing, Dublin City University.

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Introduction

Oxygen is defined as a colourless, odourless, tasteless gas (Mallett and Dougherty 2000), however it is also considered a drug (BMA 2000). When administrating any drug/medication, there are regulations that the practitioner must be guided by in relation to potential benefits and side effects (Bateman and Leach 1998). Registered nurses must also take cognisance of the guidelines set down by their professional body. Both the Code of professional conduct (An Bord Altranais 1988) and the Guidance to nurses and midwives on medication management (An Board Altranais 2003) provide the registered nurse/midwife with clear and direct guidelines when administrating any medication preparation.

Providing an education session: My experience

I have recently been involved with providing educational sessions for services that care for intellectual disability clients. Due to the complicated nature of a small number of these clients’ medical conditions, they require intermittent oxygen therapy. While the carers for these clients come from a number of professional and non-professional backgrounds, they all need to be educated on the use of oxygen therapy.

Each of the educational sessions provided has involved training for the needs of a specific client. The carers have ranged from registered nurses (a number from both the general branch and intellectual disability branch), healthcare attendants, teacher (two clients were aged eight and fourteen years old), and parents of the clients. Looking at the ‘varied’ carers, it would be right to assume a ‘varied’ level of knowledge in relation to oxygen therapy, although this was not necessarily the case. As a number of the registered nurses had worked in the community setting for a long period of time with intellectual disabled clients, they were keen to point out that their skills in relation to ‘the use of oxygen therapy’ was well forgotten. For some of the other carers, in particular teachers and parents, they had carried out some Internet work on the topic of ‘oxygen therapy’, therefore their knowledge level was quite high. However, in relation to application of knowledge to practice, registered nurses were more capable of articulating this.

Overall, in relation to educational needs in relation to these clients, I found some carers had very specific concerns in relation to oxygen therapy, but overall, the majority of them had common concerns. In each of the educational sessions, I concentrated on three areas:

  1. General guidelines in relation to the use of oxygen therapy
  2. Specific concerns each carer had
  3. Individual needs for specific clients
The education session

Researching the use of oxygen therapy highlighted that information required to administer it does not appear to be founded in any particular statutory regulations—only general guidelines on its use are available. With this in mind, the need to have a clear policy on the administration of oxygen therapy is vitally important for the service involved.

Structure of the educational session

The information in the educational session included the theory of oxygen therapy and its application to practice:

  • Brief overview of oxygen therapy
  • The need for oxygen therapy
  • Equipment to administer oxygen
  • Setting up oxygen therapy
  • Carrying out observations when a client is receiving oxygen
  • Health and safety points to consider when putting a policy together for the administration of oxygen therapy
Brief overview of oxygen therapy

Oxygen is a colourless, odourless, tasteless gas (Mallett and Dougherty 2000). Oxygen supports combustion; therefore, care should be taken to avoid contact with naked flames when oxygen is being used (Nursing Standard 2001). As oxygen is a drug, it needs to be carefully prescribed and administered (Jones 1997).

The need for oxygen therapy

Oxygen therapy is required when there is insufficient oxygen in the blood, resulting in inadequate oxygen uptake into the tissues/organs (Nursing Standard 2001). There may be a number of reasons/conditions for this lack of oxygen. For the patient who has a respiratory condition, e.g. asthmas, this may result in impaired gaseous exchange in the lungs (Sheppard 2000). Cardiac problems, e.g. myocardial infarction, can also impair oxygen delivery to the tissues necessitating oxygen therapy. A client who has an intellectual disability may also have medical conditions. Deterioration in these conditions will sometimes necessitate the client requiring supplementary oxygen therapy.

Equipment to administer oxygen
  • Oxygen supply—a portable cylinder that is universally coloured black with a white top and marked ‘oxygen’. The size of the oxygen cylinder will depend on the client’s needs (Jones 1997).
  • Oxygen gauge—a visible indicator stating the volume of oxygen in litres remaining in the cylinder.
  • Flow meter—controls the flow of oxygen coming out of the cylinder in litres per minute.
  • Oxygen tubing—this delivers the oxygen to the client, usually green.
  • Delivery device—oxygen mask or nasal prongs, oxygen is delivered to the client via the nose with nasal prongs, or via the nose/mouth with the use of an oxygen mask.
Setting up oxygen therapy

This is the practical part of the educational session, where I demonstrate the use of the equipment required for the administration of oxygen therapy. All the equipment is set up; each of the carers is given the opportunity to handle and set up the equipment. The equipment was new to some of the carers, in particular the school teacher and the parent, but for others like the registered general nurses, this served more as ‘revision’. During this session, carers can discuss specific concerns they have. Also they have the opportunity to discuss the individual needs of their specific client.

Carrying out observations when a client is receiving oxygen
  • Skin colour—the skin will appear pale. The client may have peripheral cyanosis (bluish colour), although this may be difficult to assess in some clients who already have congenital heart disease or chronic respiratory problems. Observe the lips, the ear lobes and the nail beds; when there is a reduced uptake of oxygen into the tissues, these specific areas will be observed as being a more bluish colour.
  • Temperature of skin—does the skin feel cool/cold to touch? This may be the case when insufficient oxygen is getting to the peripheries.
  • Work of breathing—observe the client’s breathing, is the respiratory rate faster/slower than normal, is the rhythm irregular, are the respirations shallow, are the respirations noisy?
  • Use of accessory muscles­­—does the client appear to be using the diaphragm, stomach or shoulders when they are breathing?
  • Mental status—is the client more restless, confused or agitated, drowsy or confused than usual.
Health and safety points to consider when putting a policy together for the administration of oxygen therapy
Prescription

• Oxygen is a drug – to be prescribed by a registered medical doctor.
• Amount of oxygen to be administered in litres per minute to be prescribed.
• Ensure a ‘sliding’ scale is prescribed, to allow the carer increase/decrease oxygen.
• Mode of delivery—face mask/nasal prongs.

Supply of oxygen (and other equipment)

• Name and phone number of supplier.
• Name of contact person in company.
• Details of all equipment needed.
• Arrangements for re-filling/ordering oxygen.
• Out-of-hours emergency arrangements.
• Designated person(s), whose responsibility it is to re-order oxygen/equipment.

Transporting oxygen

• No smoking in any vehicle carrying oxygen.
• Check for obvious signs of leaks in cylinder prior to commencing journey.
• Not recommended that more than two cylinders of oxygen be carried at any one time.
• Cylinders to be stored out of direct sunlight.
• Cylinders should not be able to move about freely as this could lead to cylinder damage, or act as a hazard to occupants of the car.
• The vehicle windows should be partially open.
• Inform your insurance company.
• A sign displayed in the vehicle to highlight carrying of oxygen with advice on what to do in an emergency situation.

Storage

• Don’t store in the same area as flammable liquids (e.g. paint, petrol, turpentine).
• Store in a clearly defined no-smoking area.
• Ensure cylinder valve is closed when not in use.
• Prevent a concentration of oxygen build up in confined spaces; ensure good ventilation.
• Don’t use the cylinder as a ‘clothes hanger’.
• Cylinders should be kept under cover, preferably inside and protected from extremes of heat or cold.
• Don’t remove any labels or repaint the cylinder.
• Handle with care, don’t allow to fall over, keep in a secure stand.

Care of oxygen

• Follow manufacturer’s instructions in relation to care of oxygen and equipment supplied with it, e.g.:
• all equipment must be checked regularly, e.g., monthly, and a record of this kept.
• all equipment must be replaced regularly, e.g. on a yearly basis.

Staff training

• Staff involved in administration of oxygen must undergo approved training specific to this area.
• All carers involved should be fully aware of the policy in relation to the administration of the oxygen—an identified person should coordinate this.

Using oxygen

• Cylinders should be opened gently to avoid a ‘rush of pressure’.
• Security for the oxygen cylinder—in a stand with wheels to bring it safely to the client or, if using a small cylinder, in a bag which is easy to carry.

Fire hazard

• The use of water-based lubricants on lips or nostrils—don’t use oil-based products like petroleum jelly.
• No smoking.
• Don’t have oxygen in the same room as naked flakes.

Infection control

• Follow services instructions in relation to care of disposable equipment, e.g.:
• Replacement for mask and tubing–after a cold or after a specific period of time (e.g. monthly).
• Cleaning of oxygen and tubing, e.g. with soap and water after every use, and dry properly.

Documentation

• The need to document details in relation to oxygen administered, e.g.:
• Time started / time finished
• Amount received (litres)
• Observations made of the client while receiving the oxygen therapy (skin colour and temperature, work of breathing, use of accessory muscles and mental status).

Conclusion

Services caring for clients requiring oxygen therapy must ensure that a clear policy is in place on the administration of the oxygen. All staff involved in the care of the client receiving the oxygen must have the opportunity to receive appropriate training / education to ensure they can safely care for the needs of the client receiving oxygen. While oxygen therapy can be a life-saving therapy, it can also be dangerous if not handled correctly.

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