Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [198], C).
2. 2.Show
   Assess the patient's consciousness level.
   To obtain a baseline and be able to assess the patient for changes in condition (see Chapter c14: Observations). E

   A reduction in level of consciousness or altered mental status may indicate hypoxaemia. E
3. 3.Show
   Observe and record the following:

   1. respiratory function
   2. respiratory rate
   3. work of breathing
   4. colour, skin and mental status
   5. oxygen saturation (SpO₂).
   To obtain a baseline of respiratory function. E

   To observe for any change in respiratory function. E
4. 4.Show
   Explain the principles of CPAP to the patient and their family and demonstrate the system to them.
   To minimize anxiety, increase knowledge and aid in patient compliance. E
5. 5.Show
   Decide whether it is appropriate to insert an arterial cannula for ongoing assessment of arterial blood gases (ABGs).
   In order to monitor the partial pressures of serum oxygen and carbon dioxide and the acid/base balance, to evaluate the effectiveness of the intervention. E
6. 6.Show
   Observe and record the patient's cardiovascular function, including:

   1. heart rate
   2. blood pressure
   3. temperature
   4. central venous pressure (if patient has a central venous access device).
   To obtain a baseline in order to assess any change in conditions (see Chapter c14: Observations). E
7. 7.Show
   Assess and record the patient's fluid balance:

   1. input
   2. output
   3. accumulative balance
   4. overall fluid balance
   5. daily weight.
   To obtain a baseline of fluid balance (see Chapter c08: Nutrition and fluid balance). E

   To enable an assessment of dehydration, fluid overload and renal function (Beitler et al. [20], E).
8. 8.Show
   Assess the patient's level of anxiety and compliance with treatment (the patient's ability to cope with the treatment).
   To enable an assessment to be made and an evaluation of the suitability of CPAP therapy (Dres and Demoule [68], E).

Procedure

1. 9.Show
   Set up the CPAP circuit as per the manufacturer's instructions.
   To prepare the equipment for use. E
2. 10.Show
   Ensure the patient is comfortable, sitting in a semi‐recumbent position, ideally with their head elevated to a 30–45° angle (or sitting in a supportive chair).
   To promote comfort and aid lung expansion and breathing (Brill [30], E).
3. 11.Show
   Explain to the patient how the mask or helmet is to be applied.
   To relieve anxiety and to reassure the patient. E

   To aid the patient's compliance with CPAP. E

If using a mask

1. 12.Show
   Ensure the correct size is selected for the patient by using the manufacturer's guide or measurement device.
   To relieve anxiety and to reassure the patient. E

   To aid the patient's compliance with CPAP. E
2. 13.Show
   Connect the mask to the circuit and ensure the settings are correct. Commence the flow of gases.
   To ensure the correct set‐up of the circuit and to check gases are flowing through the circuit prior to initiation of treatment. E
3. 14.Show
   Place the mask over the patient's nose and mouth; applying a little pressure, hold the mask in place, ensuring there are no leaks. Allow the patient a short time to get used to the pressure and mask.
   To allow the patient time to adapt to the change in pressure and the feeling of the tight‐fitting mask. E
4. 15.Show
   Once the patient is comfortable and settled, apply the straps.
   To retain the mask in place and aid patient comfort (Vargas et al. [278], E).
5. 16.Show
   Apply tissue protective dressings around vulnerable pressure points as required, e.g. nose, ears, back of head and neck.
   To alleviate pressure and prevent tissue breakdown (Scott [246], E).

If using a helmet

1. 17.Show
   Using a two‐person technique, stretch the seal around the bottom of the helmet and lower the helmet over the patient's head.
   Two people are usually required to stretch the seal enough to lower the helmet over the patient's head comfortably. E
2. 18.Show
   Attach the straps, ensuring patient comfort.
   The helmet will begin to lift once pressure is applied. E
3. 19.Show
   Close the safety valve or outlet and allow the pressure to build up within the helmet until the valve remains closed.
   The helmet requires time to fill and expand. Once the helmet is full, the pressure within it will keep the valve closed. E
4. 20.Show
   Ensure a good seal and that no leaks are present. Inflate the inner neck cuff if applicable.
   To ensure a tight seal in order for the system to function optimally (Vargas et al. [278], E).

Post‐procedure

1. 21.Show
   Give further explanation to the family or next of kin of how CPAP works and the importance of their presence and participation in communication.
   To relieve anxiety and support and reassure the family and patient. E
2. 22.Show
   Reassure the patient constantly.
   To relieve patient anxiety and promote co‐operation. E
3. 23.Show
   Discuss with the medical team the use of medication that might aid patient compliance with CPAP therapy and administer it as necessary.
   Prophylactic administration of small doses of anxiolytic can aid compliance with CPAP therapy (Hilbert et al. [109], E).
4. 24.Show
   Continue observation of vital signs and work of breathing. If patient is tiring, notify the doctor.
   To prevent acute respiratory deterioration and to inform the doctor in a timely manner in order to intubate the patient to avoid a respiratory arrest (Davison et al. [57], C).