Oxygen Plan - Hampton City Schools

Oxygen Plan - Hampton City Schools
Hampton City Schools Oxygen Plan of Care Form
Name:____________________________
504:_____Yes _____No
M
F Birth Date _____________ Grade_____ SY ______
IEP:_____yes _____No Bus rider: ____ yes _____ no
Teacher/Counselor/School:______________________________
Date Implemented in School ___________
Date parent originally notified: ______________
Date
X __________________________
Parent’s Signature
Date
_______
Date
X ____________________________
Physician’s Signature
________
Date
DIAGNOSIS/CONDITION:
BASELINE RESPITORY STATUS:
PROCEDURE: OXYGEN USE (Medication Authorization is Required)
PURPOSE: Oxygen use is indicated for physical conditions in which a child is unable to get enough oxygen into the body, or needs more oxygen,
such as chronic lung conditions like bronchopulmonary dysplasia (BPD), cystic fibrosis, or heart problems.
SUPPLIES:
Mask (appropriate size) or cannula and tubing
Oxygen source
 Cylinder
 Liquid
 Concentrator
Extra tubing and adapters as needed (if supplied)
Humidity source (if supplied)
LOCATION OF SUPPLIES:
ACTION:
1. Gather supplies.
2. Wash hands.
3. Open tank before adjusting flow.
4. Attach appropriate size mask or cannula to tubing and oxygen source. Attach devices when flow control is set at 0.
5. Set oxygen flow on flow meter to the rate prescribed by the doctor:_______________________
Oxygen continuous _______ or PRN _____________. If PRN-Conditions for when to apply the oxygen are:
_____________________________________________________________________________________________________
6. Check that oxygen flow is coming out of the mask/cannula
7. Place mask over nose, mouth or trach cuff or secure the nasal cannula.
8. Wash hands.
9. Document procedure and problems on procedure chart.
10. If the child shows any of the following signs:
•
Increased shortness of breath
•
Agitation
•
Blueness or pallor of lips, nails, or ear lobes
•
Confusion, dizziness, or headache
•
Rapid or pounding pulse
•
Pulling in of muscles of neck or chest
•
Cannot speak in complete sentences
a. Call EMS ((911) immediately
b. Call parent
c. Recheck oxygen flow. Recheck equipment. Make sure mouth and nose are not obstructed by mucous or food. Make sure tank is not empty
or defective. If so, use backup tank.
Hampton City School 05/13
EQUIPMENT PRECAUTIONS:
1. Oxygen is NOT flammable but will cause an existing fire to burn more rapidly. Do not place oxygen near sources of intense heat.
2. Be sure that the oxygen tubing does not become kinked or disconnected.
3. Secure and keep the oxygen canister in an upright position.
4. Keep oxygen away from direct heat or sunlight or open flames.
5. Use water-based lubricants for lips and hands. Do not use petroleum based lubricants (Vaseline) within 10 feet of oxygen.
6. Never touch "frosted" or cold fitting of oxygen canister.
7. Never attempt repairs or adjustments of equipment.
8. Never place foreign objects in equipment openings.
9. Never change oxygen liter flow without physician's permission.
10. Only use outlets with appropriate grounding.
11. Only use approved extension cords.
12. Store in a safe place.
13. Turn off oxygen during fire drills unless essential.
14. Check oxygen level at beginning of school day.
INDIVIDUAL CONSIDERATIONS

Emergency / Fire Drill Response: ________________________________________________

Notify transportation prior to oxygen being transported.

Other: _______________________________________________________________________
CONTACT LIST:









Classroom teacher: _______________________, _____________________, __________________________
PE: _________________________
Transportation: __________________________
Cafeteria: _______________________________
Music/Art (elementary): ____________________
Custodial staff
Office – Administrative support staff:______________________________
Itinerant staff
Other ________________________________
PRECAUTIONS: (POST A SIGN IN DESIGNATED AREAS STATING “OXYGEN IN USE”
• Do not smoke or allow open flames near oxygen. Store oxygen away from heaters, radiators, or hot sun.
• Never allow oil, grease, or highly flammable material to come into contact with oxygen cylinders, liquid oxygen, valves,
regulators, or fittings. Do not lubricate with oil or other flammable substances, and do not handle equipment with greasy
hands or rags.
• Never put anything over oxygen gas tank. Ensure good ventilation.
• Do not use flammable aerosol sprays near oxygen delivery system.
• Have spare oxygen readily accessible, based on the student’s needs. This should be stored safely in a secure place.
• Extra tubing and tank equipment (wrenches, etc.) must be kept in an easily accessible place.
• When using oxygen gas, be sure that the tank is securely placed in its stand and cannot fall or be knocked over.
• Be careful that the oxygen tubing does not become kinked, blocked, or disconnected.
• Use only the flow meter setting prescribed by the student’s doctor.
• When calling EMS 911, be sure to notify dispatcher that student has oxygen on- site.
• Secure the oxygen tank or liquid system for transport in an upright position unless otherwise noted by manufacturer.
• Do not repair damaged devices. Have the supplier repair or replace.
• Do not touch frosted components, as doing so may cause frost bite. Use gloves and face protection.
Adapted from FAIRFAX COUNTY PUBLIC SCHOOLS/FAIRFAX COUNTY HEALTH DEPARTMENT with permission
Hampton City School 05/13
Hampton City School 05/13
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