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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.

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 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

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.

Intervention

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



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.

     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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