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Patient Label
OXYGEN PRESCRIPTION
& PATIENT CONSENT
Refer to Protocol ‘CPM 02.7
OXYGEN THERAPY — COMMUNITY SUPPLY
Refer to Respiratory Nurse for education and
equipment supply
I have had explained to me and understand and consent to:
•
•
•
DIAGNOSIS ...................................................................
EQUIPMENT REQUIRED
Product
Code
Description Number
M11003 Adult oxygen Concentrator - High Flow
M11003 Paediatric oxygen Concentrator - Low Flow
That I am aware if I smoke the oxygen will be
removed immediately.
M11007 Adult Regulator 0.15 LPM - High Flow
That oxygen is a prescribed medication. My oxygen
must be used as prescribed to me and the oxygen
suppliers legally cannot supply more than is
prescribed.
G17003 400L Oxygen Cylinder (Small)
That I am responsible for the care of the equipment.
If lost, stolen or damaged I will be responsible for
payment of all costs.
7ft Nasal Cannula
(x1 for cylinder, x1 for concentrator)
If phone number and delivery address is different
from above please document here
Number
Required
M11006 Paediatric Regulator 0.3 LPM - Low Flow
G17004 1600L Oxygen Cylinder (Medium)
(ONLY if oxygen saturation on room air is below 88%)
35ft Tubing + Connector (for concentrator)
OXYGEN CONCENTRATOR
_____ litres per minute
PRN use over 2 hours OR
Use over 16 hours
OXYGEN CYLINDERS with regulator _____ litres per minute
For Ambulatory Oxygen OR
Short Burst Oxygen
Health professional signature:
Date:
Print Name:
DATE:
pH
pCO2
pO2
HCO2
O2 saturation
Referral and prescription sent to
District Nursing.
List hospital equipment given at
discharge over leaf.
FAX Tauranga 07 571 6046
Whakatane 07 306 0992
Note any home hazards for staff visiting
For Level 5 patients send this form
directly to the rest home.
Discharge date:
Prescriber Name:
Designation:
Prescribers Number:
Signature:
Date:
Ensure referral to Respiratory
Physician Completed
Criteria
for
oxygen
overleaf
Time:
Delivery date:
Inpatient
COMMENTS
Patient signature:
Date:
ARTERIAL BLOOD GASES
Outpatient
ASSESSMENT FOR LONG TERM OXYGEN THERAPY (LTOT)
Does the patient smoke?
•
•
If patient has clinically proven
pulmonary hypertension and or
polycythaemia and p02 7.3-8 kPa LTOT
(discuss with Respiratory Physician)
No
Yes
Refer to Respiratory Nurse.
Does not qualify for
LTOT.
Offer smoking cessation
advice
LTOT is not prescribed for symptom
relief
Cylinder will last on 2 Litres per
minute with a regulator for:
x1 small - 3.20 hours
x2 small - 6.40 hours
x1 medium - 13.20 hours
x2 medium - 26.40 hours
EQUIPMENT GIVEN TO PATIENT
(please record equipment numbers)
Concentrator #
Regulator #
BM2
BMR
Cylinder batch # _________________
No
Patient is clinically stable, receiving
optimum medical management and
preparing for discharge.
Yes
Measure SpO2 on air (patient resting 10
mins) - Is SpO2 less than 90%
greater than 90%
less than 90%
Perform ABG analysis on air.
Is PaO2 less than 7.3 kPa?
greater than 7.3
less than 7.3
Is PaCO2?
less than 6
For LTOT:
If PaO2 less than 7.3 kPa
order LTOT @ 2L/min for
16+ hrs / day*
greater than 6
Discuss with Respiratory
Physician, may prescribe
LTOT at 1 L/min for
16+ hours / day
Arrange Respiratory Specialist
reassessment in three months.
Laboratory form for mandatory carbooxyhaemoglobin blood test to be given
to patient and completed prior
to appointment.
Delay assessment until clinically stable,
receiving optimum medical management
and preparing for discharge.
Prepare for discharge without LTOT.
Wean off oxygen, monitor SpO2 on air
hourly for 4 hours, then 4 times daily
for 24 hours, ensure optimum medical
management and prepare for discharge.
Not for LTOT, consider if SBOT or
Ambulatory oxygen if appropriate.