Nursing 221 Oxygen Delivery Lab Lecture PDF

Greetings everyone and welcome to Nursing 221, lab lecture on oxygen delivery devices and titration. So today's lab is a big one and we will continue on our lab lecture. This is the last major lab lecture until we get to the critical judgment, critical thinking and clinical judgment labs lectures th...

Greetings everyone and welcome to Nursing 221, lab lecture on oxygen delivery devices and titration. So today's lab is a big one and we will continue on our lab lecture. This is the last major lab lecture until we get to the critical judgment, critical thinking and clinical judgment labs lectures that will be the last two. And so in those labs, I will put together opportunities to pull it all to put up put everything together and review some areas. So one of the things that I wanted to also mention about these lab lectures is it's highly important that you only you don't only use these lab lectures as your study tool. You need to make sure that you have a good solid knowledge base, so you need to do the readings because this is a way to very dive deeper into the content and I won't be providing all of the detail that you need in order to be a safe practitioner. So you, this is a supplement for sure, and will include some aspects that might be not in your readings, but certainly this is just a part of it. So our learning outcomes today discuss indications for oxygen therapy modalities, clinical reasoning and judgment related to oxygen therapy. discuss complications of oxygen administration and safety considerations, and discuss complications, discuss comfort and hygiene measures related to oxygen therapy. Review interventions to promote airway clearance and oxygenation, and identify a patient experiencing respiratory challenges distress, what we call respiratory distress, and determine appropriate nursing actions. The last one isn't in your lap guide, but I thought very important to add and always important to practice and to review. So one of the things that I have created here is a match the term to correct information so if you could pause the video and then look at the terms and find out which one matches with which and then I will give you the answer so if you could pause it now. Okay so I'm going to go ahead and give you the correct answers but FiO2 aligns with B, fraction of inspired oxygen and so it's also important to know what is room air and fraction of inspired oxygen and that is 21% and so what we are doing when we are providing oxygen therapy is that we are increasing that FiO2. Incentive spirometry is F which is used to promote deep breathing and prevent or treat atelectasis. Hypoxemia is number D, decrease in oxygen tension in the blood. So that is at the perfusion level. And hypoxia is C, inadequate tissue oxygenation at the cellular level. Orthopnea is A, a condition in which two plus pillows are required during sleep and this is often required for persons who are having problems with their oxygenation and breathing, their work of breathing. So nebulization is a treatment and it is number E or letter E, sorry, process of adding moisture or medications to inspired air. So, we'll talk further about that. So oxygen therapy, I'm not going to read all of this, but this is what the main points used to prevent or relieve tissue hypoxemia, is often used in conjunction with other interventions. So we also are involved with providing other interventions, and it requires a prescriber's order. But I want to know you to note that there is a program or a protocol that where and it is on one of the documents it's a professional practice notice and it's initiating oxygen therapy and when you can do this without an order, and it is on AHS website and it's dated 2023, and administering oxygen may, healthcare professional may initiate oxygen without a prescriber's order under the following conditions. When pulse oximetry is less than or equal to 90%, when no pulse oximetry is available and patients have signs and symptoms of hypoxia. So once that is initiated, you then the RN or other healthcare professional would not a student, I might add, is then to contact the most responsible healthcare practitioner involved in the care to obtain an order and a plan. time. So this is something that you need to know. So as you, you know, I say it requires the prescribers ordering and you might see in situations where it may indeed be started and then an order obtained after. It is treated like medication. And so all rights and checks apply. So you need to make sure that the equipment is labeled as well for the patients so that, And for example, nasal cannula equipment is not accidentally used by another. And that when you start it or you're using it that you know who the order is for when you're titrating it. Often initiated when once initiated, the patient needs to be continuously assessed. And by patient, I means the patient, but also the whole, the tubing and the monitor or the flow meter. So you need to make sure that you're constantly looking to make sure it's at the right flow meter level. We also need to know that complications can arise and safety measures must follow. So when in oxygen therapy, there are a lot of complications and we're gonna talk a little bit about oxygen toxicity, but also safety measures related to the use of oxygen itself. Jan Heigard, so I have a scenario for you, is a 72-year-old male who is a resident on your unit. He has COPD, and his secretions are tenacious, and he sometimes has difficulty clearing his throat and back of his mouth. Now, what I mean by tenacious is that's the word we use when we're talking about thick and sticky. So they're not easy to clear. So what we are having here is a problem with his airway. He coughs periodically, but his cough is weak. He is underweight and has a poor appetite. His vital signs are temp, 37.5, pulse, 92, respirations, 22, SPO2 is 86 and his BP is 136 over 84. You note he is using his accessory muscles when breathing at times and he is presently on room air. So what are you noticing about this situation and what comes to mind? So there are a lot of things going on. So if you could stop the video and write down your concerns or your what we would call your red flags that would be ideal. So one of the things that we have a big red flag here is if we go to the SPO2 and it is 86. So even for a person who has COPD this might not be within the patient and so this is a concern. It appears too that if he's using his accessory muscles when breathing he might be having difficulty maintaining that saturation and so his work of breathing is being used. He's using a lot of work for breathing and if he is already underweight and with a poor appetite we're talking about he's using a lot of calories to maintain this. His temperature is high, his pulse is high, and his BP might be his normal BP. We'd have to find out from his chart to find out what's going on. The concern as well is his airway and his clearance of his secretions. of his secretions. So they are tenacious and he has sometimes difficulty clearing his throat in we assist him with clearing the secretions because what we know is that when they start to pool, and if they're pooling in his chest, this is a good place for bacteria to grow. And I'm concerned because of his temp that we already may be having seen something like an exacerbation of an infection. So could something be going on? on? So we have orders here for him, and this is one way orders could be occurring for oxygen. So we would have, just like when we are doing medication orders, we would have his name, state of birth, Alberta health care number, or unique identifier, the date, we didn't indicate the time, but we should have the time, and we have the order for the amount. So two liters per minute and we have the way to deliver it. So per nasal cannula. So this is the flow amount per per minute and it is signed by Dr. Kelty. So the other way could be and it is more often used because what it's trying to do is target. It is a target range. So what we would like to see is more specific information. So oxygen per nasal cannula to keep SPO2 between 88 and 90 percent. So in this format, what the nurse has to do is titrate the oxygen to the amount to get to this range here and then keep it at that range. So this might be where they start at one, see how he responds and then increase it to two and see how he responds. If he's not responsive on that, we'd continue. However, we do know that he is a CO2 retainer so we also are keeping in mind his oxygen as CO2 drive and so we would if we are concerned regarding having to increase it all his healthcare provider. So there is the way so we are have the two ways and as I said you're more often to see it with the range with out there. So what you need to know is how is it supplies and how do you apply it. So we will be talking more about that in your labs this week and it's going to be an opportunity to actually work wall flow meters and the devices so that you can get the hang of it, but just know that it's piped into the wall from tanks in the basement so they have huge supply coming from the basement and lines in the hospital. The other ways that it can be provided is through compressed gas cylinders. So these ones are maybe oxygen tanks. So this would be a way we would, and a liquid gas system. These two might be ways that you will see, for example, a tank might be used in a patient being transferred, and so a special tank has to be ordered and brought up to the unit, and then it is then transferred from the wall to the tank. And there is a protocol in place or a policy in place called transfer. And so there is a transfer ticket that has to be completed for transfers. And so this is something done to be safe. And one of the things that's very concerning, whenever a patient is being transferred on oxygen, that they have to have the right device and also the right amount so that they don't inadvertently run out of oxygen midway or partially way through their transfer. So that is something that you might want to read up on because there is a document on Albury Health Services. So the oxygen concentrator, this is an interesting device. It is one that's used out in the community more often and it is used on electricity or a battery. A battery is when a patient is traveling somewhere, they're using it as a portable device and it's usually a little pack that they carry and their tubing is applied, their oxygen tubing is applied to it. It has a few more things to take care of than the other systems, such as having to change a filter, making sure that their battery is charged, and also that they are plugged in. So when there's periods of long power outages, this can be a concern. The other I just wanted to mention is the cylinders can be very bulky and very heavy and when they drop or crash these are the ones that actually you'd never want a spark to occur and they need to be recharged or refueled or on the unit, they'd have to go back down to be refilled. So there's modalities that the patient might be ordered for them. And it's important to know the difference between high flow and low flow modalities. So a low flow device is one where the room air is contributing to the patient's airflow. And so, we don't know for sure exactly how much they're getting, but they are getting low from the oxygen that is being provided. And so, it also depends on the patient's inspiration and expiration. So they're, in terms of how well it's been, how efficiently they're breathing. So there's some, we'll go into looking at more at the specific masks that provide that. The other is a low, high flow. And this is where it's more confined in terms of the, We are more defined in terms of how much the patient is getting. For example, in this Venturi mask, which is an example of a high-flow device, the dial goes to the FiO2 that has been required for the patient. And so they are getting the specific amount. So this would be more concise. The other ones that are out there, there are quite a number of other ones that are high flow such as the trach collar, face tents, and the other ones that might be mechanical. So we're not going to go into any of the trach supplies or the CPAPs or BiPAP machines or the ventilators in this as it's beyond the So, these are the nature of those two. So an example of a low flow is a nasal cannula. And you can see, and I'm taking this from a chart that is in your Gregory text, one to six liters per minute can be provided this way. Easy to use because patients can talk and eat without removal and drink, which is important. And so they are better at not desaturating, especially if the patient is one who gets quite breathless. So what I mean by desaturating is when they are off their oxygen or doing something like such as moving around or you know walking, their saturation levels decrease. The one thing that we have to be very careful when we're using this device is that it is use correctly so that the nasal prongs are in place and that they don't rub, especially on the ears or in the nares, because this can cause ulcerations. And also if it's coming in at four liters or greater, it is difficult because it can be very drying and so very drying to the nasal passages. So the patient might need some humidification, a bottle of humidifier sterile water attached to the flow meter and the air goes through the humidified air. The air flows through the water to provide humidified air. Now the other thing that can be used for some patients if they require it is water-based nasal ointment and that can be relieving for that. Then it can still be used, this nasal prongs can still be used by mouth breezers if they are doing, if they end up doing, being more mouth breather. But it's important to see if they can breathe through their nose. So simple face mask is another one and this is used periodically. This is 6 to 10 liters and it has to be at least 6 liters flow from the flow meter because if it's not, what happens is the CO2, it entraps the CO2 that the patient has breathed out and so what we need is to not have that occurring. It's easy to apply and requires for you know a good fit. Poor compliance often because it's uncomfortable and must be removed when eating and drinking and sometimes too when the patient is talking they find it difficult to talk with it on so they might feel that they need to do this. Now if you'll notice on this there's the oxygen tubing and also often there is air hole ports on the sides and this is where exhalation usually occurs through those ports however some they may draw in some air from the outside as well as air from the tubing. Too tight a fit as well can cause irritation and we also need to be aware of the type of elastic band if it's too tight on the face. So the next type is the partial or non-rebreathing mask with reservoir bags. And so this is one that provides also a higher amount of oxygen concentration. And it actually delivers the highest percentage of O2 without intubation or mechanical ventilation. It should be without in that word. And the valves must be secure and functioning if it is a non- rebreathing mask. And like simple masks, they can't eat or drink with mask in place. And the reservoir bag must be kept inflated. So when they're breathing in and out, which it shouldn't deflate fully. They need to keep it inflated. So that is the flow rate that will do that. So when the patient inhales, there is a valve right at the entry of the mask from the bag, the reservoir, we call this the reservoir bag, which is filled with oxygen. And the valve will open and then the patient can draw in the oxygen. When they exhale, the valve will close, so the O2 will not go into the bag. CO2 will not go into the bag. That is for a non- rebreathing mask. If it's a partial rebreathing mask, they don't have that valve there. So it means that part of their breath going, their exhalation will go back into that reservoir bag. So you can see that the non-rebreathing bag has a higher concentration of oxygen available. The other thing to notice is that you will have valves on the side of the mask. And if you can see here, I've got my pointer on that. And it is a little flesh colored, beige colored valve here. It will allow the patient to exhale and when the patient breathes in it will close so that they're not drawing in air from the outside. So room air. So this is the type of mask that you will see in lab this week. The other high flow device I briefly mentioned was the Venturi mask and it is 4 to 10 liters per minute. Flow rate needs to be set using the barrel on the meter barrel. So this is where we are going to be identifying the liters and the percentage of FiO2. So here's the percentage of FiO2 if it's that way. Allows for concise amounts and is, again, they have usually a little device on the side. this is sorry not this picture does not indicate a venturi mask this one does this device here again like the other rebreathing mask non-rebreathing mask allows the patient to exhale and then when they inhale they are only taking in from the from the device the oxygen from the device so I'm just pointing out this chart that is in your textbook. It also indicates a lot of the information that I've just talked about for each of the devices so that you can review it. And it is on page 938 in your Gregory 3. text, table 3 And so you can see where you're at in terms of the FIO2 and that the patient is receiving with each of these devices and whether or not you're using it correctly, for example. Okay, the important piece that we also need to talk about is safety in oxygen therapy. We know that oxygen therapy is highly combustible. No open flames or products that are combustible should be used, such as oils of petroleum jelly. You need to inform everyone in the environment that oxygen is in use. So there is often verbal reminders as well as signage. So signage would be at the bedside, outside the room, etc. So no smoking. Now this can be difficult for some of the patients who are smokers and so they need to talk to their team about this really important part and they also need to not hide the fact that they're smoking. So there was an incident in on a unit at the University Hospital a number of years ago where there was a fire on a unit and it was a patient on oxygen and he had light lit up a cigarette, I believe. I believe that's what happened. You ensure all electrical equipment is functioning and grounded. So this is an important procedure so when the patient's items come, if they're admitted, they have to be checked out by engineering. You are up to date on your fire safety and procedures. Patients and families need really good education on O2 safety and if they're going home on oxygen, there will be a lot of discussion and planning related to that. So some patients are very fearful of going home on oxygen They're not sure what to expect or how to take care of the equipment So this is really important and oftentimes a home care referral to a home care team An RT in the home and an oxygen supply company would be important so So make sure when the patient leaves the unit, and I talked about that, there is a transfer policy. So when a patient leaves the unit, you need to refer to the transfer policy to make sure that you're following the steps correctly, and the transfer ticket is filled out, and that the assessment has been completed before they leave, and you have assessed that they have enough oxygen before they go. So toxicity is a real concern for patients. And I've noticed that in the Alberta Health Services Literature, they've talked, there is more information about the toxicity and about the concerns about wasting. One, and why is that? Well, too high of a concentration for patients is they can have oxygen toxicity and it can be damaging to the cells of their lungs, which can then create a real problem with their respiratory status. So we need to be really mindful of what the signs and symptoms of oxygen toxicity are and they include sub-sternal pain, parasthesia, which is numbness and tingling, dyspnea, so shortness of breath, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxia, so that means hypoxia that is not responding to treatment, and atelectasis and infiltrates. So these are really quite significant and can be quite deadly. So the best treatment approach is less is more. And so making sure that the patient isn't oversubscribed with the amount. So how do we prevent this? And of course, I just mentioned that the lowest amount of oxygen is used to obtain the necessary PA O2 levels. If possible, decrease or monitor the amount of time on higher oxygen levels. So as mentioned, a patient who is more at risk is one who might be receiving 50 to 60 percent or greater for a period of a longer period of time. So even 24 hours, that's a long period of time. Treat the underlying cause or why the O2 is needed. So this is an important part of their care provider. And so if the patient is anemic, the treatment plan or might be instead to supplement with blood transfusion or something to get them so that the oxygen carrying capacity of their blood is improved. Monitor for those signs and symptoms and report immediately. So one of the things that's concerning about those signs and symptoms is that we might discard them thinking that there oxygen is that they're not getting enough oxygen and so you and you might write it off as that and then start to increase it but you have to keep an eye on the PSPO2 and their PAO2 and that might be a better indicator. So one of the posters that they have is out there is oh sorry I should also mention another poster or another notice, and it's called Prudent Use of Oxygen in Acute Care, and there it is a notice to make sure that we're not wasting oxygen, that we're using the right amount for the right patient situation, and that if we're keeping a patient up too high for too long, that can be very detrimental. The other is regarding weaning. So weaning means reducing the amount of oxygen over a period of time so that the patient is gradually weaned off the oxygen. So this poster is one that I came across and it is check the flow before you go. So this is an important one. Confirm clinically necessary oxygen with an order that includes a target SPO2. So it also is interesting because they're also saying make a plan for weaning as soon as oxygen therapy is started. So that would be an important discussion to have with the most responsible health care provider. Titrate oxygen diligently to keep near lowest SP target. Check the oxygen flow and all its connections routinely. So interestingly what can happen is if you have a long set of, a long tubing, you could have oxygen flow that is inefficient because of maybe there's a connection that's loose or it's not getting to the patient. Wean to the weaning plan or oxygen titration quick reference tool. The other is turn off oxygen when not in use. So this is an important one that we have to keep in mind because it be quite wasteful. So here's Mr. Heigert again. He is 72 year old male and he has difficulty clearing his throat because of tenacious secretions. And he has an order now for two 89% bionesocannula. So he's in the target range. His order was for between 88% and 90%, as we talked about the orders before. And you can see that his temp hasn't changed. His pulse has gone down slightly. His respirations remain the same. And his BP is slightly down, but it may not be significant. You note he is still using his accessory muscles when breathing at times. So what we also know is that we need to, in addition to oxygen, and while he's on oxygen, we need to incorporate other interventions that will be important for his care. So can you think of other interventions that we should be including in his care? So if you could stop the video now and then identify those interventions, write some down and we can then discuss them. So the interventions that you might have written down are patient and family teaching related to safety and oxygen therapy and breathing techniques. So I'm going to talk a little bit more about breathing techniques such as personal breathing in a little bit, assessing and monitoring to ensure adequate oxygenation. So we are really keeping an eye on his oxygenation saturations as he's new to oxygen and see how he tolerates it. Respiratory assessments included in his assessment, in his vital signs, but we want to know because if he's having issues with clearing his secretions, they might be building up, he might be having more challenges with that, and he might even be presenting with pneumonia. Increase his fluids, monitor intake and output. One of the ways we can ensure his secretions are more clear and easier to clear and more fluid are by increasing his fluids. So we want to do that. Also we should do a nutritional assessment with a nutritious diet, an adequate caloric intake. So his work of breathing is quite significant. So what do we need to increase his calories, have enough nutrition, nutrients? Maybe he has to have supplementation with certain types of supplemental formulas. He needs good oral hygiene care often because of those secretions, but also if he aspirates any of that fluid, that can create really another pooling area for his oral health. If he has poor oral health, it can go into his lungs and create another area for bacteria. He may need assistance with airway clearance, such as oropharyngeal suctioning. He, we would include deep breathing and coughing exercises. Chest physio may be ordered and a physiotherapy might be involved. And also he might have nebulization. So nebulizer is oxygen or air driven. And you can see there's a little picture here. It disperses a medication which is inhaled, creates a small mist when it's attached to the flow meter so oxygen or air goes through the mist and creates the mist through the liquid and creates the mist with this mask and it's often done before other interventions so if it's a bronchodilator that the patient is ordered and receiving through this method it would be ideal to do it before he has other interventions such as chest the physio so that we can open up the airways. So deep breathing and coughing is an important one for Mr. Heibert because of his clearance he needs to maintain his clearing of his airways. So you know getting him to do diaphragmatic breathing if he can tolerate that. Now that is where he's using his diaphragm and using his abdomen to help with his breathing so he can get in those good deep breaths. The other one might be pursed lip breathing, so to prolong exhalation and increase airway pressure during expiration, thus reducing the amount of trapped air and the amount of airway resistance. so if you can see on your in your textbook on page 932 they have the method for doing so and basically you're taking a small slow deep breath through your nostrils into your chest so taking it an account of four and then using your lips piercing your lips together and using it like a straw and slowly breathing out so you're controlling that breath out. This can be helpful too when you have for example patients who are breathing really fast and they need to slow down this might be a method to help them with that. Cough coughing is another measure and what the patient does is lean forward as they exhale they make a sharp cough sound and then they huff again and it's a way of coughing and so they just basically force the cough out twice. Incentive spirometry, and this is often used for post-operative patients, and so it may be used for other patients. I'm not sure if it'd be used for Mr. Hargard because of his situation. It encourages patients to increase their intake of air, so deep breathing. And so what they're basically doing is they might have a ball in here, and they're sucking in the air just to ensure that the ball rises. So their title volume is measure. And so gradually, especially after surgery, this type of patient, it's important for them to get in those big *******, expand their lungs, and work exercise, and take in those big ******* to get the air all the way down to their basis and avoid atelectasis. So the other measure might be chest physio. And so it includes postural jainage, chest percussion, and vibration. And so basically what happens in this, and it might be ordered for several times a day, and the patient might be positioned so that the segment of the lung that needs to be drained is it assists with the drainage through gravity and so these are the positions that are in your textbook that show you so you can see the upper lungs the right and left if you're having to drain them they would be you'd be sitting up for that. If it is the lower lungs basis they need to be in a head tilt position or head lowered position so that they can have the gravity for that. So this is helping those secretions that are in the bronchioles and in the lung airways to come forward or move forward, to move from the smaller to the larger bronchioles. With this comes chest percussion, And what we call percussion is when you're tapping or you're clapping on the patient's chest area and you're using a cup like hand and you're going on that segment of lung with the towel over it, the chest area, and then you're clapping like this so that you're causing this vibration and helps the secretions detach from the lung tissue to be more easily moved through the airway. So you can see too, you'll practice that in lab this week, how it looks and how you can practice that. The other type of technique that might be used is vibration, and that would usually be in where we are vibrating the area with our hands over the chest wall and it's just creating small little movements. You may see more often now they might be using a vibration tool over that area and or a device that can help with that. So you need to know the contraindications for chest physio as well. And usually it requires an order. And so any patient, for example, who has a head injury, or who has any kind of trauma to their chest, or surgery to the chest, this would be very, this might be contraindicated for them, but it depends on their situation. So you'd find out so and it does outline that in your textbook. So the other A thing that we might have to help Mr. Heigert with is his oral pharyngeal suctioning. And I also bring up nasopharyngeal suctioning as well. This is a Yankar suction device. This is for oral suctioning, and you saw that in your oral hygiene and feeding lab. And the suction device below is softer and thinner, and that would be the type of device used for the nasal area. So if you had to put it into the nose, you'd have to be very careful. This one would be too wide and too stiff in order to do this. This one is softer, but you can also see narrower. So when you're suctioning, what you do is you make sure that the patient is feeling relaxed and taking in good breaths. And if they can, they can keep on their oxygen if they have a nasal cannula. And what you're going to do is just get them to deep breathe and cough and then gather the secretions at the back of their throat, gently gather the secretions at the back of their throat or the front of their mouth wherever they can bring it to and You should never do it for longer than 10 to 15 seconds You need to do clean technique and you have to care for the catheter and you may need you will not wear PPE So you might wear a face guard as well as definitely gloves Now, one of the things too is the catheter is only used for this patient and it kept in a clean area and you saw that in your video how they've kept it clean. Complications can occur and so we need to make sure that we are watching for desaturation. So if the patient, for example, when we're suctioning the patient's mouth, we also are suctioning maybe the air around them and the oxygen that they're receiving. so that's why we can't do it for very long. Also we have to make sure we're not injuring any of the oral area or the nasal area and especially we have to be careful if you have a patient for example who's easily bruised or has any problems in these areas so be mindful of that. So we're getting near the end of and leaning over his bedside table trying to catch his breath. He is having a difficult time talking. His nasal cannula is lying on his bed. When he says he just got budged, he just went to the washer. So what is your priority and what would you do? So I'm just going to get you to take a moment and write it down and then restart the video. So your priority is to increase his oxygenation status. It seems like he may be having difficulties with that so we would get on his, get him into bed, get him in a chair and apply his nasal cannula and we will see how well he does and let him rest there and take some breaths. You don't need to increase his oxygen flow meter for the first little while just try and with the amount he has unless he's running into complications. You might want to take his vital signs when he's rested and see how he does after a short period of time. So he should be catching his breath within a few minutes and if he's still having difficulties you need to alert others. So this patient might be having difficulties and running into problems because he was without oxygen for a period of time, which is a real indication now of his status and he shouldn't be going away and mobilizing without his oxygen. So you either need to get him a longer tube oxygen tubing or you need to get a portable oxygen device so that he can, when he gets up he needs help, he'll call the nurses and they will help them to the washer. The worry though when you have too long of a tubing is that especially if he's a person who's not very good on his feet and he's hanging on to things is he might trip over his tubing so keep in mind keep an eye out for that. So what we need to know is the signs of hypoxia and hypoxemia. So dyspnea so he was showing signs of dyspnea. Tachypnea we didn't know we didn't take his respiratory status or his respiratory rate. He didn't seem to have a decreased level of consciousness, but he did have increased work of breathing. He was at, we didn't see, we didn't notice agitation or confusion and disorientation, but also that is we didn't hear him talking, so as soon as we he gets he's able to begin talking to us. We'd find out how he's doing. We would find out if he's having any issues with tachycardia or bradycardia and we'd also notice his skin colour. Psygnosis is a late stage though of hypoxemia and so hopefully we have not begun to see that yet or won't see that. So this is the end of our lecture this week but I do have a few questions and so here they begin. So of the following which of the which oh goodness I've got a printing error there of the following which is considered a high-flow device. So if you can identify of the four which is a high-flow device So, if you've identified it as the venturi mask, you are correct. So C, if your patient is breathing room air, the FiO2 that they are breathing is which is the following. It would be B, 21%, which is true about the use of nasal cannula. So I'm going to let you read through these and identify which one applies. select all that apply. So D is the only one that does not apply and that is because it can in fact be used by air mouth breathers as well they are still getting air through their nose into their nasal cavity down into their airway so just so you're aware. Okay thank you very much for your time this week and I I hope you have a great lab. Goodbye now.