(adapted from clinical reflective journal)
Patient (Assessment • Diagnosis • Medical History):
This reflection is on my experience in a hyperbaric chamber. S.R. Is a 39-year-old female who was prescribed hyperbaric oxygen therapy (HBOT) to treat the effects of radiation for cancer in her left sinus cavity. She had received several radiation treatments and began to lose her teeth and vision on her left sid. The damage is likely permanent, but she decided to have her teeth extracted and to be fitted for dentures. Before she could be cleared for the fitting she is required to complete 30 two-hour sessions of HBOT. This includes ten minutes of pressurization and ten minutes of depressurization with 100 minutes of pressurized oxygen therapy at 100% O2. This stimulates the pressure of scuba diving at a certain depth, so it is sometimes called “diving” and the patients may be referred to as “divers”.
Medical History: Upon physical assessment, she appeared to be alert and oriented x 4 and in good health aside from the effects of radiation. Her left eye did not accommodate appropriately – it actually moved more quickly than her right with some nystagmus noted. She denied being in any pain but expressed heightened agitation with her current situation, although she was still quite pleasant to interact with. She explained that repeated diving had affected her hearing in her left ear and was also being fitted for hearing aids upon completion of HBOT. Her medical history listed her cancer treatment and a full hysterectomy. Her medication list also alluded to some unlisted psychoses. This will be discussed later under the Clinical Experience.
Nursing Process • Critical Thinking • Clinical Judgment • Policies • EBP
While HBOT was originally developed to treat scuba diving injuries, this form of therapy has also been proven as an evidence-based approach to wound healing, including those associated with radiation treatment. During my assessment, I noticed the effects of radiation not only on the patient’s face but also on her mental well-being. In my opinion, the current priority nursing diagnosis for this patient is anxiety related to radiation therapy as evidenced by the patient’s demeanor and verbal expressions of frustration; and, albeit less forthright, her medication list. My interventions would be centered around S.R.’s mental well-being and effective coping, as would be evaluated by the interview and a review of long-term antipsychotic medication use.
Today I applied my nursing knowledge when I was talking with the respiratory therapists (RT’s) in the chamber. My critical thinking was applied more to the theoretical aspects of HBOT, such how oxygen toxicity is monitored or how an emergency is handled while a patient is “diving” and can’t be immediately “brought back up” except in the most critical life-threatening situations.
Here I would like to explain a little bit more about scuba diving and its relation to HBOT. When you go scuba diving, you can go down at whatever rate you are able to equalize your ears. You are either breathing normal air (roughly 21% oxygen and 78% nitrogen) or a specialized blend of increased oxygen (“nitrox”). The diver is breathing this air or nitrox blend under increasing pressure. The increasing pressure can cause mild discomfort to outright pain as you go down in the water column. There are several techniques that divers use to equalize the pressure in their ears, such as the Valsalva maneuver or swallowing. These same techniques can be used in the chamber. This is what is meant by “pressurizing” in both scuba diving and HBOT. After maximum bottom time is reached, which generally means the scuba diver’s tank has hit about 500 psi (with a start of 3000 psi), the decompression process begins as the diver slowly ascends to the surface. You can’t just go right back up as quickly as you may have gone down. You need to go up slowly enough to allow the nitrogen that has built up in your tissues to off-gas during your ascent. If you go up too quickly, the nitrogen gets trapped and forms bubbles in the body, termed “decompression sickness”, causing serious damage including paralysis or death if these bubbles get trapped in the brain. Clinical judgment lead me to ask S.R. if she had experienced any ear-related injuried due to her repeated HBOT, which she stated she had.
Long story short, you need to ascend slowly to avoid seriously hurting yourself. Aside from ear barotrauma, decompression sickness is the most common scuba diving injury and is significantly more serious than barotrauma. It’s a big deal if you “shoot to the surface”, so unless the patient is literally about to die otherwise, they need to go through the depressurization process. The RT’s told me that the policy is that even if the patient is having a seizure in the chamber, they may not bring them up unless the airway is compromised. Sometimes they just watch the patient closely and let the seizure pass. The risk of bringing them up too quickly often outweighs the risk of letting them seize in the chamber.
HBOT includes a variety of interdisciplinary fields and areas of practice, including nursing, wound care, and respiratory therapy. Skills and procedures performed included therapeutic communication and a head-to-toe assessment. Assessments were focused on the patient’s mental status, wound healing, and oxygen saturation. S.R.’s lab values were within normal limits and no diagnostic tests were scheduled at the time of assessment.
Medications: S.R. is prescribed clindamycin HCL (Atarax), a prophylactic anti-infective because of her radiation therapy. She is also prescribed the antiemetic Ondansetron (Zofran) to counter the nauseating effects of radiation. While no psychoses were recorded on her medical history, S.R. is prescribed Vortioxetine (Trintellix), an SSRI prescribed to treat major depressive disorder, and Chlordiazepoxide (Librium), a benzodiazepine to manage anxiety. She is also prescribed Olanzapine (ZyPrexa), a thienobenzodiazepine. This drug is not only used as an antipsychotic and mood stabilizer, but, interestingly it is also used as an antiemetic during radiation therapy.
Communication and Diversity
Therapeutic communication was important in this situation because the patient was quite obviously very upset about her situation. In early adulthood, she was diagnosed with cancer in her sinuses, which means she had radiation aimed at her face, which essentially lead to the destruction and eventual removal of all of her teeth, blindness in one eye, and so far only a mild paresis of the left side of her face with progressive worsening. As previously mentioned, she was prescribed HBOT for 30 two-hour sessions. By her original 28th session, S.R.’s insurance changed and denied her final two treatments. The orthodontist who was handling her extractions and fitting for dentures required that she begin the 30 day treatment from the start once the insurance issue was resolved. These were understandably touchy topics for the patient, and discussing them with her took some amount of sensitivity.
No significant cultural or nursing considerations were evident.
In Summary: HBOT can be used to treat decompression sickness, to encourage wound healing, and to treat the effects of radiation treatment. It treats decompression sickness by forcing high levels of oxygen into the tissues under pressure and pushing the nitrogen out. It’s effective in wound and radiation treatment because the intense oxygen load forces new blood vessels to form, causing the body to heal more quickly. HBOT is also used to treat carbon monoxide poisoning.