HYPERBARIC MEDICINE-SPECIFIC NURSING CARE STANDARDS 

The hyperbaric nursing staff utilizes established nursing interventions in the care of hyperbaric patients to achieve desired outcomes. The Baromedical Nurses Association recommends the following guidelines for patients receiving hyperbaric oxygen therapy.  [1]

INTERVENTIONS BY CONDITIONS

Knowledge deficit related to hyperbaric oxygen therapy and treatment procedures 

Goal: Patients and/or family will demonstrate learning using the teach back/return demonstration method

Interventions:

• Assess and document patient and/or family's understanding of purpose and goals of hyperbaric oxygen therapy (HBO), procedures involved and potential hazards of HBO
• Utilize teach back method to confirm patient understanding
• Identify and address barriers to learning:
• Involve interpreter if indicated
• Apply age-specific teaching
• Consider cultural/religious factors
• Assess readiness to learn
• Identify patient's expectations of treatment
• Discuss sequence of treatment procedures and what to expect, e.g. pressure, temperature, noises, wound care
• Provide orientation to the hyperbaric environment, including chamber orientation, middle ear equalization, fire hazards, safety policies and procedures, risks and benefits of HBO
• Document patient/ family teaching, their understanding of instructions and any return demonstrations
• Allow continued opportunities for discussion, questions and instruction
• Provide patient and/or family with written education on HBO
• Discuss post-treatment education
• Assess for knowledge deficits related to underlying pathology and provide appropriate information specific to the patient's disease process
• Provide written discharge instructions appropriate to the patient's age, developmental level and culturel/language

Anxiety related to hyperbaric oxygen treatments or other medical problems

Goal: Patients will tolerate hyperbaric oxygen treatment and other medical procedures with minimal anxiety 

Interventions:

Assess patient for a history of confinement anxiety

Implement preventative measures as appropriate

• Educate the patient during consultation and reinforce with daily HBO treatments
• Reinforce to patient that someone will always be with them, and the staff are well trained for emergency procedures.
• Establish trust letting the patient know that he/she is in charge and may request to end the HBO session at any time.
• Collaborate with the provider regarding treating with anxiolytic medications

Identify signs of symptoms of anxiety before and during HBO treatment

• Patient states they are anxious
• Tense appearing facial/body posturing
• Complaint of nausea or diarrhea
• Feelings of being confined or smothered
• Defensive or argumentative attitude
• Hyperventilation
• Diaphoresis and hyperventilation
• Tachycardia
• Restlessness
• Sudden feeling of being hot

 Interventions to reduce anxiety during HBOT

• Stay in visual contact with patient at all times reminding patient that the chamber operator is present during the entire treament
• Establish eye contact and address the patient calmly
• Reassure patient reminding them they are safe
• Encourage relaxation methods e.g. visualization, television, music, meditation
• Communicate the above assessment and interventions with the provider

Potential for injury within the hyperbaric facility related to transferring the patient in and out of the chamber

Goal: Patient will not experience any injury.

Interventions:

• Integrate and comply with facility's fall risk prevention policy: assess fall risk and safety precautions.
• Communicate and involve patient with the plan of action
• Provide patient education regarding safety precautions
• Provide assistance with transfers as patient needs apply to ensure facility policy is followed. 

• One to two person assist
• Use gait belt as indicated
• Provide a footstool, or lower the cart if possible to assist with transfer
• Utilize a slide board as necessary. Remove prior to initiating HBOT
• Ensure side rails are up

• Use hospital approved mechanical lift equipment per policy and completed competency training. Remove all materials prior to initiating HBOT
• Follow the safety timeout/ pre-treatment safety checklist prior to initiating HBOT
• Ensure all hyperbaric equipment is maintain and inspected per hospital policy

Potential for injury related to fire within the hyperbaric chamber

Goal: Patients will remain safe while undergoing treatment

Intervention:

• Fuel sources in an oxygen enriched environment are an unavoidable circumstance of HBOT and include: linens, equipment, dressings, the patient.
• The fire triangle consists of oxygen, fuel and an ignition source(heat).  In HBOT an ignition source is needed to complete the fire triangle. This may occur due to a spark in the chamber. 
• Follow facility fire prevention steps and NFPA chapter 14 probes for Class A and Class B hyperbaric chambers.

• Follow NFPA guidelines "Oxygen levels shall be continuously monitored in Class A chambers in accordance with NFPA guidelines; ensuring chamber oxygen concentration does not exceed 23.5%"
• HBOT teaching and consent should include the risks of fire in the chamber
• Provide the patient and family with written instructions regarding the risk of prohibited materials during HBOT
• Prior to each hyperbaric treatment, staff should perform and document the pre-treatment safety checklist. Ensure this has been performed and time stamped prior to descent. 
• Prohibited items should undergo risk assessment per the Safety Director in collaboration with the Medical Director to determine if they may enter the chamber on a case by case basis. Safety measures should be initiated if the risk assessment allows for item to enter the chamber as well as completion of a prohbited item's authorization form signed by the Safety and Medical Directors.
• Patient rounding will be checked in all types of chambers per NFPA and faclity guidelines before each treatment.
• Each facility should conduct monthly emergency procedures training with fire drill occurring quarterly. A timed egress worst case scenario drill should be performed atleast annually. All staff should participate in these drills where possible. 
• Casts must be allowed to cure before entering the oxygen enriched hyperbaric chamber

Potential for injury related to changes in atmospheric pressure within the hyperbaric chamber

Goal: Patients and inside tenders will not experience barotrauma during HBOT 

Intervention Ear Barotrauma

• Assess patient's and inside attendant's knowledge of ear clearing techniques and ability to equalize pressure. See "Ear Exam - Barotrauma"
• Collaborate with provider to assess tympanic membrane (TM) for suspected barotrauma prior to and after first HBO treatment and per patient complaint.
• Collaborate with provider to describe and document observations including color and visibility of TM, presence of wax, blood/fluid/air and any hearing deficits or changes. 
• Educate patient prior to HBO therapy

• Methods to equalize pressue in the middle ear during HBO treatment include: yawning, swallowing, jaw thrust, head tilt, valsalva, Toynbee, Roydhouse, Frenzel etc.
• Patient to demonstrate equalization techniques
• Reinforce the importance of notifying the chamber operator immediately when pressure or fullness is felt in the middle ear.
• Chamber operator will stop compression when patient is unable to equalize pressure and should return the pressure to the point of no pain prior to asking the patient to equalize ears.
• Identify nonverbal signs patient may be unable to equalize pressure such as wincing, pulling on or rubbing ear. 
• Consider elevation of head of bed during HBOT to promote equalization of middle ear as appropriate. 
• Identify patients who may benefit from ENT consult for possible tympanostomy procedure. 
• Administer decongestants per provider order before HBOT
• Assess for increased blood pressure with concommitant use of sympathomimetic medications.

Intervention Sinus or Tooth

• Provide patient education regarding sinus and tooth squeeze
• Observe for symptoms of squeeze on compression and decompression
• Sinus squeeze- hold chamber pressure and ask patient to blow nose or drink water
• Tooth squeeze- ask the patient to rub the affected area
• Decompress the patient at 1 psi/min

Intervention Gastrointestinal Barotrauma (GI)

• GI barotrauma may occur on decompression if the patient has a propensity toward production or retention of gas. This situation is rarely dangerous but cause discomfort.
• Symptoms include a feeling of pain, bloating or fullness of the abdomen
• Slow or halt decompression to allow the patient time to expel the gas

Intervention Pneumothorax

• Identify patients at greater risk for development of pneumothorax e.g., recent invasive procedures in the chest, history of spontaneous pneumothorax, Chronic Obstructive Pulmonary Disease (COPD) or other bullous lung disease.
• Monitor for any sudden cardiopulmonary decompensation during decompression as this may indicate tension pneumothorax.
• Specific symptoms of tension pneumothorax include:
• Sudden, sharp chest pain
• Difficult, rapid breathing, shortness of breath
• Rapid heart rate
• Cough
• Tracheal shift
• Abnormal chest movements on the affected side
• Cyanosis
• Notify the provider and follow orders for patient management
• Ensure supplies for emergent needle decompression are immediately available and ready.
• Chamber should not be decompressed until preparations are made for emergency management of pneumothorax and authorized by attending physician or until chest decompression is performed in a multiplace chamber.
• Document according to facility guidelines
• Follow facility emergency procedures

Potential for injury related to central nervous system oxygen toxicity or seizure secondary to 100% oxygen at increased atmospheric pressure

Goal: Signs and symptoms will be recognized and promptly addressed. The seizing patient will suffer no harm.

Interventions:

• Provide patient and family with education about oxygen toxicity risks, and the signs/symptoms of central nervous system oxygen toxicity
• Assess patient prior to HBOT for increased risk factors such as:
• Elevated core temperature
• History of seizures
• History of brain injury/surgery
• Acute carbon monoxide poisoning
• Use of medications that may lower seizure threshold
• Metabolic acidosis
• Dehydration
• Hypoglycemia
• Monitor the patient during HBOT and document signs/symptoms of central nervous system oxygen toxicity including:
• V-E-N-T-ID-C-C or V-E-N-T-I-D-S-H-H
• V-visual changes (acute): tunnel or blurred vision
• E-ears, auditory hallucinations, ringing or roaring in the ears
• N- nausea, numbness
• T- twitching of muscles (usually facial), tingling in the extremities
• I- irritability, personality change or restlessness
• D- dizziness, vertigo
• C- convulsions, seizure activity
• C- change in affect
• S- shortness of breath
• H- hiccups
• H- heart rate increase
• Reinforce to the patient the importance of notifying the chamber operator if they feel different or funny in the chamber.
• If any symptoms occur including a seizure, follow the facility emergency guidelines. 
• Remove BIBS Mask/hood class A (multiplace) chamber 
• Instruct patient to apply air mask immediately class B (monoplace) chamber
• Follow seizure procedure. In class B chamber, do not decompress patient during the seizure. Wait for return of spontaneous respirations then decompress
• In class A chamber, collaborate with the provider to follow established guidelines e.g., the U.S. Navy's for treating CNS oxygen toxicity or the provider's orders for continuation or discontinuation of treatment

Potential for impaired gas exchange related to pulmonary oxygen toxicity

Goal: Signs and symptoms of pulmonary oxygen toxicity will be recognized and promptly addressed 

Interventions:

• Provide patient and family with information about risks, signs and symptoms of pulmonary oxygen toxicty
• Monitor patient for symptoms of pulmonary oxygen toxicity during HBO treatments
• Dry hacky cough
• Air hunger
• Substernal irritation or burning
• History of high FiO2
• Tightness in the chest
• Shortness of breath
• Difficulty inhaling a full breath
• Dyspnea on exertion
• Notify the provider if signs and symptoms of pulmonary oxygen toxicity appear
• Add humidity to oxygen as needed to reduce chest discomfort (multi-place only

Potential for adverse events related to hemodynamic changes secondary to hbo treatment

Goal: Signs and symptoms of physiologic distress will be recognized and promptly addressed

Interventions: 

• Patients with severe congestive heart failure (CHF) and/or a history of CHF exacerbations may be at risk of worsening CHF in the hyperbaric environment due to vasoconstrictive effects of hyperbaric oxygen. The hyperbaric provider should evaluate individual risk, evaluate that risk against the potential benefit of HBO therapy, and reassess the patient throughout the treatment. 
• Nursing assessment of these patients should include evaluation for jugular vein distention, adventitious heart sounds, and signs and symptoms of fluid accumulation in the lungs and lower extremities:
• Assess patient according to facility heart failure guidelines
• Assess fluid and electrolyte balance per provider order
• Assess patient's vital signs as indicated including daily weights

Baseline left ventricular ejection fraction (EJF) is not a predictor of CHF outcomes. The EJF percentage ought not to be used as a criterion for inclusion or exclusion from HBO [2] 

Potential for ineffective breathing gas delivery related to patients' needs or limitations

Goal: Signs and symptoms of inadequate gas delivery will be recognized and corrected promptly

Interventions: 

• Assess the patient's condition, needs and limitations for the best suited gas delivery system.
• 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
• Follow facility guidelines for infection control for all equipment

    Oxygen Treatment Hood

• Assist patient with application and removal of neck seal and hood
• Ensure that oxygen flow is sufficient to ventilate the treatment hood and maximize FiO2 
• After assembly, check for leaks
• Observe patient for signs of inadequate treatment hood ventilation such as fogging, restlessness, anxiety and overt symptoms of CO2 toxicity

Face Mask/ Mouth Piece

• Assist the patient with mask application and removal, and reposition mask/mouth piece as needed (monoplace chamber)
• Check for leaks, continuity of seal against the patient's face, keep tight fit around mouth piece.
• If using a Built-In Breathing System (BIBS) mask, ensure that the straps are adjusted for patient comfort and a tight seal

T Piece Briggs Adapter (Multiplace Chamber)

• Set up equipment
• Monitor patients rate and depth of respirations, listen to breath sounds
• Notify the hyperbaric provider if patient is experiencing difficulty breathing
• Have intravenous (IV) access for medication administration if needed
• Suction as needed

Ventilator

• Ensure that the endotracheal tube (ET) or tracheostomy cuff is inflated with normal saline (NS) prior to pressurization, and replace the saline with air after the treatment
• Keep suction equipment nearby and ready to use
• Monitor and document patient's tidal volume per Wright's spirometer, respiratory rate and breath sounds prior to pressurization, during and after chamber pressurization and then every 10-15 minutes, or as ordered
• Monitor patient for respiratory distress and notify hyperbaric provider if apparent
• Manually ventilate the patient with a bag valve device if necessary during pressurization and depressurization of the chamber and as needed during treatment in a multiplace chamber
• Monitor pulse oximetry or arterial blood gas (ABG) if possible and as ordered for multiplace chamber patients
• Notify hyperbaric provider of abnormal findings

Potential for pain related to hyperbaric oxygen treatment and patient's associated medical problems

Goal: Patients will state satisfaction with pain management

Interventions:

• Assess pain level and document according to facility guidelines
• Address patient's needs related to pain
• Assess patient's experience of pain and whether pain is increased during HBO treatment
• Avoid intramuscular medications (IM) immediately prior to treatment due to vasoconstriction effect from HBO treatments
• Provide non-pharmacological pain-reducing interventions
• Relaxation techniques
• Distraction
• Repositioning
• Family present at chamber side as appropriate

Discomfort related to temperature and humidity changes inside the hyperbaric chamber

Goal: Patients will tolerate the internal climate of the hyperbaric chamber

Interventions:

• Provide patient education related to temperature changes with compression and decompression
• Periodically assess patient's comfort with temperature changes
• Offer patient comfort measures such as extra sheet, increasing ventilation in the chamber or use of environmental control system (multiplace chamber)
• Monitor the room temperatures according to the NFPA guidelines

Potential for ineffective individual coping related to stresses of illness and/or poor psychosocial support systems

Goal: Patients will be able to verbalize and demonstrate effective coping during HBO treatment

Interventions: 

• Assist patient and family to identify coping skills, available support systems, cultural and spiritual values
• Provide emotional support, including active listening and acknowledgement of concerns
• Offer other support systems as needed and as available in the facility 

Altered tissue perfusion related to carbon monoxide poisoning, decompression sickness, gas embolism and other neurological conditions

Goal: Signs and symptoms of inadequate tissue perfusion will be recognized and promptly addressed

Interventions:

• Collaborate with the provider to perform baseline neurological assessment prior to treatment
• Perform neurological checks per established protocol and provider order
• Use a common metric, such as a Glasgow Coma Scale to facilitate communication and determination of altered level of consciousness
• Assess and document patient's motor and sensory functioning as ordered
• Monitor other signs of poor end organ perfusion per provider order:
• Laboratory Values e.g. liver and kidney function
• Shock
• Respiratory failure/Adult Respiratory Distress Syndrome (ARDS)
• Provide reorientation and emotional support as needed
• Notify provider of changes
• Discharge instructions for decompression sickness (DCS), carbon monoxide poisoning (CO), and arterial gas embolism (AGE) should include monitoring for cognitive and neurological sequelae

Impaired physical mobility related to disease pathology and medical ambulation or offloading devices

Goal: Patients will not experience any injury related to ambulation or transfer

Interventions:

• All removable devices will be removed prior to HBO treatments per chamber safety policy
• Prosthetics, diabetic shoes, orthotic boots and total contact casts all impact range of motion and mobility for a population that may already have balance and gait issues
• If this is a new device for them, there may not be sufficient accomodation at home, in their car or with their employment to maintain baseline activities of daily living or independent activities of daily living
• Provider education/re-education regarding safe use of offloading devices
• Observe for statements indicating device non-compliance and/or unsafe use at home
• Advise ordering provider of ineffective treatment, if indicated
• Consider referral to psychosocial community resources as indicated
• Consider referral to occupational therapy/physical therapy as indicated

Imbalanced nutrition/less than body requirements related to intake of nutrients insufficient to meet metabolic needs

Goal: Patient's nutrient intake will be sufficient to meet basal needs and improve healing

Interventions:

• Wounds will not resolve without sufficient metabolic energy and nutrients despite the intervention that is applied
• Assess baseline nutritional status before initiating adjunctive HBO
• Advise hyperbaric provider of nutritional status
• Coordinate nutritional supplementation with primary care physician and/or service referring to HBO
• Provide nutritional education considering patient's needs and dietary preferences
• Consider referral to nutritionist and/or diabetes educator for further education and assistance developing nutritional plan
• Monitor weight and nutrient intake in coordination with interdisciplinary team
• Notify provider of ineffective treatment plan

Potential for vision changes related to hyperbaric oxygen treatments

Goal: Patients will recognize vision changes and report to hyperbaric staff

Interventions:

• Temporary myopic shift may occur during a normal course of hyperbaric oxygen therapy
• Cataract growth is a rare side-effect and is typically after prolonged treatment outside accepted guidelines (<80 consecutive treatments without a break)
• Encourage patients to report any vision changes
• Assess vision pre-treatment using a standard vision measurement tool, e.g. the Snellen eye chart:
• Notify provider if patient has pre-existing acute angle glaucoma, cataracts or optic neuritis as more frequent visual assessments may be necessary
• Reassure patients that myopic shift is usually temporary 
• Reinforce to patients they should not change prescription eye glasses for several weeks following HBO completion
• Patients may need corrective glasses if driving
• If available, offer adjustable eye glasses, e.g. the Aldens Emergensee

Potential for unstable blood glucose level related to hyperbaric oxgyen therapy and disease pathology

Goal: Patients will not experience symptomatic hypoglycemia during hyperbaric oxygen treatments

Interventions:

• Literature notes hyperbaric oxygen therapy carries its own mechanism for increased glucose usage through oxygen-mediated transport of glucose into muscle cells and may also increase insulin sensitivity
• Assess patient's knowledge level, recent hypoglycemic events and patient specific symptoms of hypoglycemia prior to HBO treatments
• Adequate glucose control < 200mg/dL is vital for wound healing
• Consider timing of short and long acting glycemic control medications when scheduling HBO to avoid peak action time while at depth in the chamber 
• Prevention of acute hypoglycemia in the hyperbaric chamber is vital for patient safety
• Follow facility policy and procedure guidelines for pre and post treatment glucose control
• Assess HgbA1c
• Assess peripheral blood glucose prior to HBO treatment to ensure level is > 100 mg/dL or within facility guidelines 
• Recommend patients eat one hour prior to HBO treatment assuring complex carbohydrates have been eaten, e.g, multigrains, &vegetables 
• Consider sending complex carbohydrate source, fruit juice, glucose tabs or gel into chamber with patient in the event of a symptomatic hypoglycemia during treatment
• Assist patient to use glucose tabs, gel or juice prior to HBO treatment 

Potential for dysrhythmia related to disease pathology

GOAL: Signs and symptoms of dysrhythmia will be recognized and promptly addressed

Interventions:

• As ordered, monitor EKG readings while the patient is inside the chamber, (especially if Inpatient or Telemetry).

• Monitor and document Blood Pressure as indicated (by invasive or non-invasive methods).

• Assess and document any signs of hypokalemia in patients with acute necrotizing infections.

• Maintain IV infusions as ordered.

• Maintain invasive pressure monitoring and record values, as indicated (make sure infusion pumps are plugged into D/C).

• Obtain lab samples as ordered.

• Notify hyperbaric physician as needed.