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Nursing Interventions

HYPERBARIC MEDICINE-SPECIFIC NURSING CARE STANDARDS 

The hyperbaric nursing staff utilizes established nursing interventions in the care of hyperbaric patients to achieve desired outcomes.

INTERVENTIONS BY CONDITIONS

Anxiety related to insufficient or erroneous knowledge on HBO 

Patient/family has an understanding of the treatment rationale, goals, procedure, benefits, risks, and side effects of hyperbaric oxygen therapy.

  1. Identify barriers to learning and ability/readiness to learn, utilizing the Comprehensive
    Nursing Assessment.
  2. Complete or review patient’s history for potential contraindications to, or risks of, treatment.
  3. Complete hyperbaric medicine orientation with patient and family.
  4. Ensure patient/family has a Hyperbaric Patient Brochure.
  5. Provide time for questions and discussion.

Risk of Injury

  1. Patient does not experience any injury related to transferring patient in/out-of-chamber, explosion of equipment, fire and/or medical support equipment.
  2. Assess patient as fall risk on comprehensive nursing assessment
  3. Assist patient in and out of the chamber appropriately
  4. Utilize lift devices correctly, as needed
  5. Follow Administration of HBO policy and procedure.
  6. Follow fire prevention procedures per established policy and procedure
  7. Follow all unit and hospital safety policies and procedures as appropriate

Ear, sinus and tooth barotrauma

  1. Screen patient for history of sinus, tooth, and ear problems, especially with situations involving pressure changes.
  2. If patient has history of dental caries, explain that problems may occur. Compress slowly, observing patient for signs of tooth pain. Notify hyperbaric physician if dental pain occurs. Document on patient record.
  3. Hyperbaric staff to examine patient’s ears prior to and following first treatment, then PRN/part-time to decrease possibility of pressure discomfort during treatment.
  4. Instruct patients in the use of techniques to equalize pressure in the ears. The methods include jaw movement, Toynbee maneuver, modified Valsalva maneuver, and yawn.
  5. If indicated, hyperbaric physician will consult with ENT service to evaluate Eustachian tube function and determine possible need for myringotomy or pressure equalization tube.
  6. Administer prophylactic agents (decongestant nasal spray or oral antihistamines) per physician order.
  7. Compress patients at a rate (1-2 psi) that is comfortable for ear equalization. Remind patient to equilibrate ears during compression. Maintain direct visual contact with patient during all changes in pressures.
  8. Staff may hold or decrease pressure if patient is having mild to moderate pain in ears, resume pressurization when pain subsides.
  9. If ear pain or discomfort becomes severe and pain does not subside when pressurization is held or decreased, interrupt treatment, decompress chamber. At surface pressure, hyperbaric physician to examine patient’s ears for evidence of barotrauma. Document findings and any management.

 Ear/ sinus equalization during compression

  1. Immediately halt compression--by adjusting set pressure gauge to read present chamber pressure.
  2. Instruct the patient not to attempt further equalization unless instructed.
  3. Inform the patient that you plan to reduce the chamber pressure slightly.
  4. Reduce pressure 1 psi below existing chamber pressure. Rate can be increased as indicated.
  5. At reduced pressure, ask the patient to reattempt equalization, with light pressure.
  6. If equalization occurs, resume normal compression procedure. Note difficulty on patient record.
  7. If equalization does not occur after 2-3 attempts, advise patient of further pressure reduction.
  8. If equalization is still incomplete, inform patient they will be returned to surface pressure.
  9. Reduce pressure to zero, set rate at 1 psi/min. 
  10. At the surface, remove patient from chamber, have ears examined. Consult with hyperbaric physician as necessary. Nasal decongestants may be indicated if barotrauma is not severe. Myringotomy may be necessary in acute patients.

 Ear/ sinus equalization during Decompression

  1. Immediately halt decompression by adjusting set pressure gauge to read present chamber pressure.
  2. Instruct the patient not to attempt equalization by Valsalva maneuver.
  3. Inform the patient that you plan to increase the chamber pressure slightly, to balance the pressure differential.
  4. Increase pressure 1-2 psi greater than existing chamber pressure.
  5. Confirm relief/improvement has occurred.
  6. If equalization occurs, resume normal decompression procedure and note difficulty on patient record.
  7. If equalization does not occur, compress 1-2 psi further and re-check.
  8. Once pressure balance is restored, restart decompression.
  9. Reduce pressure to zero, set rate at 1 psi/min. 
  10. At the surface remove patient from chamber, have ears examined. Consult with hyperbaric physician as necessary. Myringotomy tubes may be indicated if barotrauma is severe.

Oxygen Delivery

  1. Signs and symptoms of inadequate oxygen delivery related to delivery system and patient’s needs and/or limitations are recognized and reported promptly.
  2. Assess patient’s condition, needs and limitations for the best suited air break delivery system.
  3. Assess patient’s ability to properly trigger and use air break assembly prior to treating.
  4. Confirm mask fitting
  5. Suction patient as needed
  6. Follow the ventilator policy if applicable
  7. Follow Loss of Oxygen Supply procedure in operations manual as applicable.

Confinement anxiety/ claustrophobia

Confinement anxiety or claustrophobia is a practical risk with hyperbaric oxygen treatments. It can occur before, during, or after the treatment. Relieving or decreasing contributing or precipitating factors may reduce its incidence.

  1. If patient history indicated previous feelings of confinement anxiety, obtain specific causes of fear (i.e., association with darkness or death). Document patient’s fears.
  2. Orient patient to hyperbaric facility and chamber. Emphasize that the patient does have control of the situation, and that he/she can refuse or terminate the treatment if desired or necessary.
    1. Familiarize patient with chamber, procedure, side effects, and risks.
    2. Encourage “trial” treatment if necessary (have patient lie on stretcher, push halfway in, then fully in if patient is able to tolerate).
  3. Provide psychological support. Allow the patient to see how the chamber works from the outside. Ask the patient if he feels he/she is ready.
  4. Per hyperbaric physician order, medicate patient with anti-anxiety medication prior to treatment. Commonly, this may be Diazepam, Versed or Ativan.
  5. Provide diversionary activities during treatment:
    1. Encourage creative thinking.
    2. TV, VCR.
    3. Reading materials must be on the outside of the chamber.
    4. Significant other, if care of other patients permits.
  6. Intervene if sudden extreme confinement anxiety by initiating decompression as quickly as tolerated and offering support, such as:
    1. Coaching patient to breathe more slowly using abdominal muscles.
    2. Stay with patient continuously.
    3. Direct patient to perform distracting tasks (counting, reciting information, etc.).
    4. Inform patient of progress in decompression.
    5. Take patient out of chamber as soon as door is opened.
  7. After patient is removed from chamber, discuss feelings and ask for suggestions of things that may help make the treatment more comfortable.
  8. Confer with hyperbaric physician and patient’s referring physician if patient is unable to tolerate hyperbaric oxygen treatments.

 Altered neurological status

Identify signs and symptoms of decreasing neurological function related to: Carbon Monoxide Poisoning, Decompression Sickness, Acute Necrotizing Infection, Cerebral Arterial Gas Embolism or other conditions that may result in decreased neurological function.

  1. Perform baseline neurological assessment prior to treatment.
  2. Monitor and document neurological function checks.
  3. Compare ongoing neurological assessment with baseline assessment.
  4. Assess and document patient’s sensory and motor function.
  5. Provide psychometric testing as ordered.
  6. Provide reorientation and emotional support as needed.
  7. Notify the hyperbaric physician of any changes as indicated.

Coping measures

Aid individuals who may not possess effective coping skills related to the stresses of illness and or an inadequate psychosocial support system. This may improve the patient’s ability to comply with hyperbaric oxygen therapy and treatment procedures.

  1. Provide support and encouragement without exceeding treatment outcome expectations.
  2. Discuss with the patient, the ability to cope with other caregivers. The hyperbaric staff members should stay informed of progress and helpful approaches.
  3. Facilitate communication between the patient, family and the hyperbaric staff.
  4. Encourage the patient, if able, to discuss any concerns and feelings.
  5. Document pertinent discussions and assessments.

Discomfort related to temperature and humidity

Improve the patient’s ability to tolerate the internal climate of the hyperbaric chamber

  1. Periodically assess the patient’s comfort, related to temperature and humidity.
  2. Adjust the chamber flow rate and directional air vents on the chamber door.
  3. Offer the patient comfort measures, i.e. ice filled glove, additional linen, etc.
    1. Additional items given to the patient, for comfort measures, may require authorization by the Safety Officer.


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