TREATMENT OF HYPOXEMIA REGISTERED NURSE INITIATED DECISION SUPPORT TOOL
REGISTERED NURSE (RN) INITIATED ACTIVITY Decision support tools are evidence–based documents used to guide the assessment, diagnosis and treatment of client-specific clinical problems or conditions. When practice support tools are used to direct practice, they are used in conjunction with clinical judgment, available evidence, and following discussion with colleagues. Nurses also consider client needs and preferences when using decision support tools to make clinical decisions. This Decision Support Tool is meant to serve as a guide for nursing practice.
Adapted from the PHSA DST (2008); Author: Erin McGarvey, BScN, MSN
The Nurses Section 6(1) (l) (i): Registered Nurses may dispense or administer oxygen or (Registered) and humidified air by inhalation. Nurse Practitioners Regulation:
For use by: Registered Nurses in perinatal practice settings Indications: The initial assessment and treatment of hypoxemia. Does not reflect ongoing management of oxygen therapy.
Initiation of oxygen in perinatal women to treat hypoxemia as measured by: . SpO2 less than 94% (pulse oximeter reading) . An acute situation in hypoxemia is suspected (e.g. hemorrhage, pulmonary embolism) . Severe trauma . Short-term therapy or surgical intervention
If left untreated, hypoxemia can lead to hypoxia. Hypoxia can be life threatening for both mother and fetus.
Some fetal conditions may indicate need for oxygen therapy. Refer to specific BCPHP Decision Support Tools for identified condition:
#2 – Fetal Health Surveillance #9 – Postpartum Hemorrhage #10 – Obstetrical Emergencies
Related Policies: Related Standards: CRNBC Standards of Practice: “Acting without an Order” Definitions: Hypoxemia: a decreased blood oxygen level Hypoxia: a condition in which there is insufficient oxygen to meet the metabolic demands of the tissues and cells. SpO2 : Oxygen saturation in blood, as measured by pulse oximeter PaO2 : Partial pressure of oxygen in arterial blood SaO2 : Arterial oxygen saturation, as measured by an arterial puncture ABGs: Arterial blood gases
Assessment:
Oxygen therapy is indicated when assessment of the woman and/or fetus identifies inadequate oxygen tensions and/or saturations identified through invasive or non-invasive methods (e.g. pulse-oximetry, ABGs, co-oximetry, pulse co-oximetry, electronic fetal monitoring tracing).
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TREATMENT OF HYPOXEMIA REGISTERED NURSE INITIATED DECISION SUPPORT TOOL
It is recommended that, whenever possible, measure the woman’s SpO2/ SaO2/ PO2 at rest, in order to correctly determine the presence of hypoxemia. Reassessment must occur by monitoring these parameters to determine responsiveness to oxygen therapy.
Contributing Factors or Causes for Maternal Hypoxemia Amniotic fluid embolism Pregnancy-Specific Conditions Tocolytic-induced pulmonary edema Pre-eclampsia Placental abruption Peripartum cardiomyopathy Trophoblastic embolism Fetal surgery
Obstetrical sepsis Related to Pregnancy Secondary to obstetric hemorrhage Gastric aspiration Pulmonary edema secondary to pre-existing heart disease Increased infection risk . Listeria . Pylonephritis . Varicella . Blastomycosis
Asthma Not Specific to Pregnancy Trauma Drug overdose Other infections Bariatric or Morbid Obesity
Signs and Symptoms
The existing subjective and objective assessment criteria are signs and symptoms of cardiopulmonary and neuromuscular failure and are not specific to hypoxemia.
System Subjective Objective Signs and Symptoms Signs and Symptoms Neurological . restlessness / agitation . decreased level of consciousness . anxiety / apprehension . behavioral changes . inability to concentrate . fatigue / difficulty sleeping . dizziness Respiratory . dyspnea . SpO2 less than 94% . tightness in chest . shortness of breath . chest pain . use of accessory muscles to breath . decreased or adventitious lung sounds Cardiovascular . change in baseline vital signs . cardiac dysrhythmias Integumentary . diaphoresis . pallor . cyanosis WW.03.17B Fetal Maternal Newborn and Family Health Policy & Procedure Manual Effective Date: 14-MAY-2012 Page 2 of 4 Refer to online version – Print copy may not be current – Discard after use
TREATMENT OF HYPOXEMIA REGISTERED NURSE INITIATED DECISION SUPPORT TOOL
The following may assist to inform treatment decisions: . Lab results - ABGs (PaO2 less than 55 – 60 mmHg or SaO2 less than 90%) - Hgb . History of chronic, acute or terminal disease (e.g. asthma, cancer) or smoking . Medications
Diagnosis: Hypoxemia (as measured by blood oxygen levels)
Precautions / Special Considerations: Pregnancy is a dynamic physiologic state resulting in dramatic mechanical and bio-chemical changes in maternal cardiovascular and pulmonary systems affecting respiratory function and gas exchange.
Maternal hypoxemia can have detrimental affects to the fetus. Fetal well-being is dependent on the effectiveness of the maternal cardiopulmonary system’s ability to deliver oxygen to the fetus while compensating to meet her own oxygenation/perfusion needs.
There are limitations to SpO2 monitoring via pulse monitor. Factors such as motion, abnormal Hgb, poor tissue perfusion, skin pigment, nail polish or nail coverings. Technical limitations of pulse oximeters may vary leading to inaccuracy in reporting.
Complications may result from administration of oxygen. Although some of these complications are specific to ongoing or long-term oxygen therapy, it is important to consult with a physician or appropriate health care provider once the initial administration of oxygen has taken place.
Dyspnea is not always indicative of hypoxemia therefore measurement of SpO2/SaO2/PO2 is recommended.
Interventions: 1. Correct any obvious causes of hypoxemia which might immediately reverse the condition (airway, breathing, circulation), suctioning may be required. 2. Initiate the minimal amount of oxygen necessary to reverse the signs and symptoms of hypoxemia or correct fetal distress; SpO2 greater than or equal to 94%. Administer oxygen via mask (8-10 L/ minute) or nasal prongs (1 - 6L/ min). 3. Increase frequency of fetal health surveillance for all pregnant women receiving oxygen therapy. 4. Notify physician or appropriate health care provider once oxygen therapy is initiated to establish ongoing oxygen therapy and management. 5. Call Adult Code Blue (Dial 33) for assistance if required, as per woman’s situation.
Intended Outcomes: With the safe and effective administration of oxygen, signs and symptoms of hypoxemia will be reduced or eliminated.
An improvement in SpO2 equal or greater than 94%.
Unintended Outcomes: Despite oxygen therapy, hypoxemia may not improve.
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TREATMENT OF HYPOXEMIA REGISTERED NURSE INITIATED DECISION SUPPORT TOOL
Oxygen therapy may improve symptoms but does not treat the underlying cause of hypoxemia therefore the client may not improve or may further deteriorate despite oxygen administration.
Education: When appropriate, explain purpose and procedure, and inform of safety hazards with oxygen.
DOCUMENTATION Record: . Initial and ongoing assessment data . Diagnosis of hypoxemia . Date and time oxygen administration was initiated . Method of administration . Oxygen concentration and flow . Woman’s response to treatment . Teaching provided for woman . Consultation with physician or appropriate health care professional for any related orders or ongoing oxygen therapy and management
Documents: Interprofessional Progress Notes
WW.03.17B Fetal Maternal Newborn and Family Health Policy & Procedure Manual Effective Date: 14-MAY-2012 Page 4 of 4 Refer to online version – Print copy may not be current – Discard after use