Clinical Competency Book - School of Allied Health Professions

LOMA LINDA UNIVERSITY School of Allied Health

Professions Department of Cardiopulmonary

Sciences B.S. Respiratory Therapy Program

Clinical Competency Book, 2013

StudentName:__________________________________

Loma Linda University School of Allied Health profession- Cardiopulmonary Department.

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Tableofcontents:Contactinformation……………………………….................................................................Guidelines…………………………………………………………………………………………….GeneralCareCompetencies……………………………………………………………………GeneralCareProcedures………………………………………………………………………..CriticalCareCompetencies……………………………………………………………………


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ThisclinicalcompetencybookisdesignedbasedontheAmericanAssociationofRespiratoryCareOrientationandCompetencyAssuranceManual,2ndEdition2011.

ClinicalCompetencyNotebook:

Notebooksaredoneelectronically.ClinicalInstructorsandtheDirectorofClinicalEducationhaveaccesstoalinktocheckeachstudentdataandcompletionoftheircompetency.Studentwillbeupdatedonwhichcompetencythehavecompletedfrequently.

PATIENTCONFIDENTIALITY

Studentswillseeandhearconfidentialpatientinformation.Thismaybepersonal,clinical,financial,andmaybecomputerized,onpapercopy,ororalinnature.Studentswhohaveaccesstoconfidentialinformationareprohibitedbylawfromdisclosingsuchinformationinanyun-authorizedmanner.

Patientinformationgatheredduringthecourseofthestudent’sclinicalexperiencemustnotleavetheclinicalsitewithoutpriorauthorization.Accessbystudentstothemedicalrecordshouldbelimitedtopertinentareasonly.

Breachesofpatientconfidentialityaresubjecttodisciplinaryaction.Thismayinvolveremovalfromclinicalsite,afailinggradeintheclinicalrotation,orterminationfromtheprogram.Additionally,boththeclinicalsiteandfederalgovernmentmayalsolevymonetarypenaltiesifanylawswereviolated.


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Objective Date Location S or U Comments ( If 1 or is applied).

Orientation Site: LLUMC Site: East Campus Site: VA Hospital Site: Totally Kids Site: Riverside regional Other: (Professionalism, communication, attendance) Arrive clinics on time. Dress professionally Demonstrate Interpersonal communication skills with staff.

Demonstrate proactive practice.

Demonstrate a proper patient introduction and interaction.

Willingness to listen to others opinion and respond in a professional way.

Pre-Patient settings Check the patient chart (History, orders, physical, progress notes).

Gather and collect proper equipment for each procedure.

Demonstrate correct and proper hand washing technique before any patient interaction.

Patient setting: Obtain the following vital signs using proper technique: o Pulse, RR, Temp,

BP.


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Objective Date Location S or U Comments Identify the following during INSPECTION:

a. Increased A-P diameter

b. Use of accessory muscles

c. Cyanosis d. Digital clubbing e. Jugular venous

distension

Identify the following during PALPATION:

a. Decreased tactile fremitus

b. Increased tactile fremitus

c. Altered chest expansion

Normal or abnormal tracheal position.

Identify the following during AUSCULTATION:

a. Normal breath sounds

b. Fine crackle c. Coarse crackles d. Wheezes e. Stridor

Identify the following during PERCUSSION:

a. Hyperresonance b. Decreased/Dull

resonance c. Normal

resonance


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Objective Date Location S or U Comments Demonstrate proper breath sounds technique with locating the following:

a. Right Middle Lobe (RML)

b. Left Upper Lobe (LUL)

c. Right Upper Lobe (RUL)

d. Right Lower Lobe (RLL)

e. Left Lower Lobe (LLL)

Isolation and Infection Control Procedures: Identify different types of Isolation procedures in patient care settings.

Identify the purpose of the Negative pressure room and when is it used.

Identify the purpose of the N-95 respirator, its indication, and proper usage technique.

Identify how/where to dispose blood samples and body fluids after each procedure.

Ensure that respiratory equipment’s are clean/sterile before/after each procedure. (MDI, SVN, Suction catheter).

Patient Assessment: Introduce self, department.

Create good rapport communication with patients.


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Objective Date Location S or U Comments Identify patient by using two methods (wristband

ID, Birthdate)

Perform and demonstrate proper vital signs technique (Pulse, Respiratory Rate, Blood Pressure, Temperature).

Respect patient privacy. Wear gloves before any procedure.

Explain procedure to patient and family.

Observe and coach patient, if applicable, and terminate therapy if adverse reaction occurs.

Obtain vital signs after each procedure.

Evaluate and assure patient stability and safe before leaving the room.

Wash hands after each procedure/patient interaction.

Demonstrate proper charting method.

Floor therapy IPPB treatment, If available.

Demonstrate proper technique setting up and performing the following procedure: Nasal Cannula. Venturi Mask Continues Nebulizer (Mask or Trach mask).

Non-Rebreather mask. Incentive Spirometer. Pulse Oximeter. Chest Physical Therapy (CPT) Manual or pneumatic.


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Objective Date Location S or U Comments High Frequency Chest Wall Oscillator (The Vest).

In-exufillator IPV Oral Suctioning. Nasotracheal Suctioning (NTS).

Endotracheal Suctioning. Inline Suctioning. Medical Gas Therapy Demonstrate the correct procedure for installing a regulator or reducing valve for the following sized cylinders:

a. E cylinder. b. H cylinder.

Demonstrate the proper method to calculate the duration of gas remaining in a cylinder with a specified pressure and flow.

Patient Evaluation Demonstrate a proper SOAP format.

Present an adequate and proper patient report to the next shift.


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SpecialProceduresCompetencySection:

Objective Date Location S or U Comments Airwaycare Demonstrateminimalleaktechnique

Demonstrateminimalocclusivevolume

SuctionpatientviaETTortrachwithcatheter&glove

SuctionpatientviaETTwithinlinesuctioncatheter

Useresuscitationbagtohyperoxygenateandnasallysuctionpatient.

Tapeendotrachealtubeinproperposition.

Identifyendotrachealtubeplacementonchestx-ray.


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- Eachstudenthastocompleteatleasteightcheckoffsforeachprocedure.AfullevaluationfromtheClinicalInstructortakesplaceonthe9thproceduretoensurethatthestudenthasachievedtherequiredlevelforeachcompetency.- Failingthe9thcompetencycheckoffwillresultinremediationofsuchcompetency.Adetailedreportfromtheclinicalinstructorwillbeissuedtothestudentandthedirectorofclinicaleducationtoensurewhichstepshavebeenmissedinsuchcompetency.Areviewsessionwillbeadministeredtothestudenttohelphim/herbecompetentinsuchprocedure.Thereview/remediationprocessisunderthediscretionoftheprogramfacultyandthedirectorofclinicaleducation.


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Date:______________________ ClinicalSite:_______________________MeteredDoseInhaler(MDI)Competency

1 Checkchart.(MDorder,History&Physical,ProgressNote)SorU2 Gatherallappropriateequipmentandmedication SorU3 Washhands.Putongloves.SorU4 Introduceselftopatientandfamily.CheckpatientIDband

andsecondidentifier.Explainprocedure.SorU

5 Positionpatient.Obtainheartrate,respiratoryrate,breathsounds,painassessment,peakflowifapplicable,notepatientappearanceandworkofbreathing.

SorU

6 Demonstrateappropriatetechnique:PutMDIintoaerochamber.ShakeMDI.ActuateMDI.Inhaleslowly.Holdbreath.Exhale.Waitoneminute.Repeatasordered.Rinsemouthifmedicationcontainsasteroid.

SorU

7 ObserveandcoachpatienttechniqueoradministerMDIasappropriate.

SorU

8 Observepatientduringtreatment.Terminatetherapyifadversereactionoccurs.

SorU

9 Encouragethepatienttocoughifable.Instructpatientonsplintingtechniques.Suctionifneeded.

SorU

10 Obtainheartrate,respiratoryrate,breathsounds,painassessment,peakflowifapplicable,notepatientappearanceandworkofbreathing.

SorU

11 Assurepatientisstableandascomfortableaspossible.SorU12 Washhands.SorU13 Charttreatment.SorU

RCPPreceptor/ClinicalInstructorName:____________________________________________Signature:_______________________________________________________________________________Comments:


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Date:______________________ Site:_________________ Timesperformed:________MednebCompetency1 Checkchart.(MDorder,History&Physical,ProgressNote)SorU2 Gatherallappropriateequipmentandmedication SorU3 Washhands.Putongloves.SorU4 Introduceselftopatientandfamily.CheckpatientIDband



SorU

6 Assemblemedneb.Choosemouthpiece,mask,orinlineadaptors.Addmedicationusingaseptictechnique.Instructthepatienttobreathethroughthemouthifable.Adjustflowratetoinsureadequatemedicationaerosolization

SorU

7 Instructpatienttodoaninspiratorybreathholdevery1-2minutesifable.

SorU


SorU


SorU


SorU




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Date:______________________ Site:_________________ Timesperformed:________

OxygenTherapyCompetency1 Checkchart.(MDorder,History&Physical,ProgressNote)SorU2 Gatherallappropriateequipmentandmedication SorU3 Washhands.Putongloves.SorU4 Introduceselftopatientandfamily.CheckpatientIDband



SorU

6 Connectflowmetertowalloutletortank.Connecthumidifier(prn)nasalcannulaormask.Turnflowmetertoappropriateflow.Testforproperfunction.Attachoxygendevicetopatient.

SorU


SorU


SorU




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SuctioningCompetency1 Checkchart.(MDorder,History&Physical,ProgressNote)SorU2 Gatherallappropriateequipmentandmedication SorU3 Washhands.Putongloves.SorU4 Introduceselftopatientandfamily.CheckpatientIDband



SorU

6 Oxygenatepatient.Useaseptictechnique.Lavageairwayifneeded.Lubricatecatheterasneeded.Advancecatheteruntilresistancemet.Withdrawcatheter1cm.Applysuctionfor10-15secondswhilewithdrawingandrotatingcatheter.Discontinueifadversereactionoccurs.

SorU

7 Oxygenatepatient.Assessneedforfurthersuctioning.SorU8 Properlydisposeofequipment.SorU9 Obtainheartrate,respiratoryrate,breathsounds,pain

assessment,peakflowifapplicable,notepatientappearanceandworkofbreathing.

SorU




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DryPowderInhaler(DPI)Competency1 Checkchart.(MDorder,History&Physical,ProgressNote)SorU2 Gatherallappropriateequipmentandmedication SorU3 Washhands.Putongloves.SorU4 Introduceselftopatientandfamily.CheckpatientIDband



SorU

6 Demonstrateappropriatetechnique:Exhale.ActuateDPI.Inhalerapidly.Holdbreath.Exhale.Waitoneminute.Repeatasordered.Rinsemouthifmedicationcontainsasteroid.

SorU

7 Observeandcoachpatienttechnique. SorU8 Observepatientduringtreatment.Terminatetherapyif

adversereactionoccurs.SorU


SorU


SorU




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ChestPhysicalTherapy(CPT)Competency1 Checkchart.(MDorder,History&Physical,ProgressNote)SorU2 Gatherallappropriateequipmentandmedication SorU3 Washhands.Putongloves.SorU4 Introduceselftopatientandfamily.CheckpatientIDband



SorU

6 PerformCPTusinghandclapping,percussorortherapyvestasordered.

SorU


SorU


SorU


SorU




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CriticalCareCompetencySectionThefollowingcompetenciesshouldbecheckedoffstartingthesecondyearoftherespiratorycareprogram.


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HighFlowHumidificationsystem

PreliminaryStepsS,U,orN/A

Acquiresrequisitionorreport.SorU

ObtainsappropriateequipmentandsuppliesaccordingtoClinicalPracticeGuidelines.

SorU

Reviewsmedicalrecordsforprecautions/complications.SorU

Verifiesphysicianorderandassessesforappropriateness.SorU

Ensurespatientprivacy,washeshands,andimplementsstandardprecautions.

SorU

PatientInteractionandEquipmentPreparation

Introducesselfandidentifiesdepartment.SorU

Correctlyidentifiespatientusingtwopatientidentifiers(wristbandandbirthdate).

SorU

Explainsproceduretopatientandprovidespatient/familyeducation.Confirmsunderstanding.

SorU

Properlyassemblesequipmentandtestsequipmentfunctionpriortopatientapplication.

SorU

Addssterilewatertohumidifier,filltoappropriatelevelasmarkedonhumidifierbottle,ifapplicable.

SorU

Explainsthenecessityforcontinuousoxygentherapytopatient.SorU

Attacheshumidifierbottletoflowmeter,concentrator,orcylinderandtightensuntilnoleakwithflow.

SorU

Atraumaticallyappliesthedevicetothepatient,ensuringasnugandcomfortablefit.

SorU

Adjustsdevicetodeliverprescribedhighflowoxygenconcentration(5-60litersperminute).

SorU

Ensurestotalgasflowratemeetsthepatient’speakinspiratoryflowrate,asappropriate.

SorU

Checkspressurereliefpopofftoinsurehighpressurereleaseifoccluded.

SorU

Obtainspulseoximetrymeasurement.AdjustsflowratetomaintainSpO2perfacilitypolicy/protocol.

SorU

Reassuresthepatientandexplainsthefirehazardsofoxygentothepatient.

SorU

Ensuresthat“NoSmoking”signsareposted.SorU

Discouragestheuseofproductscontainingpetroleumonoraroundfacialarea.

SorU

Obtainspulseoximetry/arterialbloodgasfollowingoxygenadministrationifneededperinstitutionpolicy.

SorU

PatientEvaluationandTerminationofProcedure


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Evaluatesoutcomebypatient’sphysiologicresponsetooxygentherapy.

SorU

Modifiestheprocedureinatimelymannerbaseduponpatientresponse.

SorU

Adjustsoxygentherapyperinstitutionalprotocol.SorU

Takesappropriateactionforadversereactionandnotifiesappropriatepersonnel.

SorU

DocumentationandRecords

Appropriatelydocumentsprocedureinmedicalrecordandcompletescharges.

SorU

Effectivelycommunicatesresultsandtreatmenttoothermembersofthehealthcareteam.

SorU

Documentspatient/familyeducation.SorU

RCPPreceptor/ClinicalInstructorName:____________________________________________Date:___________________Unit/Location:_______________________________Signature:_______________________________________________________________________________Comments:


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HighFrequencyChestWallOscillation

PreliminarySteps


Obtainsappropriateequipmentandsupplies.SorU

Reviewsmedicalrecordsforprecautions/complications.SorU

Verifiesandassessesphysicianorderforappropriateness.SorU

PatientInteractionandEquipmentPreparationSorU

Introducesselfanddepartment.

Correctlyidentifiespatientusing2patientidentifiers(wristbandandbirthdate).

SorU

Explainsproceduretopatient/familyandconfirmspatientunderstanding.

SorU

Assessesandprovidesappropriateage-specific/specialneedsmodificationtoprocedure.

SorU

WasheshandsandusesStandardPrecautions.SorU


SorU

Positionspatientinoptimalpositionbaseduponpatientresponse.SorU

Evaluatespatientforbaselinestatus(breathsounds,pulse,sputum).SorU

Selectscorrectsizedvestwrap.SorU

Placesbladderportionofwrapoveranteriorthoraxandinflatableportionunderpatient'sarms.

SorU

Requeststhatpatienttakedeepinspiration,andvestissecuredwithloopclosure.

SorU

Connectsairhosestoinflatablevestairhoseportsandtopulsemachine.

SorU

Plugspowercordintoelectricaloutlet.SorU

Selectsinitialsettings:Pressure:initialbetween1and4SorU

Frequency:Initialbetween10and15.SorU

Instructspatientinuseofpausedevice&activatestreatment.Combineswithaerosoltherapyifordered.

SorU


Monitorspatientresponsetotreatment&requestscoughafter5minutesoftherapyandperiodically.

SorU

Appropriatelyadjustssettingsbaseduponpatientresponse.SorU


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TerminatestherapyandstoresthehosesandSPUinplasticbag.Labelsbagwithpatientname.

SorU


Completesdocumentationinpatientrecordanddocumentspatienteducation.

SorU

Entersappropriatechargeforservices.SorU



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BreathActuatedNebulizerBAN

PreliminarySteps



SorU

Inspectsmedicalrecordsforprecautions/complications.Verifiesorder,assessesforappropriateness.

SorU

Obtainsprescribedmedicationusingapprovedfacilityguidelines(electronicmedicationstoragedevice).

SorU

Ensurespatientprivacy,washeshandsandimplementsstandardprecautions.

SorU


Introducesselfandidentifiesdepartment.SorU


SorU

Interviewspatientandobtainsrelevanthistory(homenebulizeruse).

SorU

Explainsproceduretopatientandprovidespatient/familyeducation,confirmsunderstanding.

SorU

Performsbaselinephysiologicassessment(pulse,breathsounds,peak-flow,dyspnearating).

SorU

Scanspatient'sarmband&medicationbarcodeifusingbedsideidentificationandscanningsystem.

SorU


SorU

Haspatientinhaleandexhaleseveraltimestoveritythemovementofthegreenbutton.

SorU

Ifunabletotriggerthedevice(holdthegreenbuttondownduringinhalation,releaseduringexhalation).

SorU

Accuratelypreparestheprescribedmedicationandasepticallyinjectsmedicationintodeliverydevice.

SorU

Attachoneendofsupplytubingtothebottomofnebulizer&theotherendtoflowmeter/compressor.

SorU

Setflowmeterto8litersperminute.Inhaleslowly&deeply;confirmgreenbuttonindownposition.

SorU

Exhalenormallyconfirmgreenbuttonreturnstotheuppositionindicatingnoaerosolisbeingproduced.

SorU

Instructspatientnottoplacethelipsovertheexhalationvalveonthebottomofthemouthpiece.

SorU


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Encouragespatienttoholdeachbreath3-5sec.continuetreatmentuntilnebulizerbeginstosputter.

SorU

Correctlyidentifiesadverseresponsetomedication.Adjuststherapyperinstitutionalprotocol.

SorU


Monitorsphysiologicparametersbefore,during,andaftertreatment.

SorU

Assessesthetherapeuticresponsetomedicationandoutcomesoftreatment.

SorU

Terminatestreatmentandencouragescough/deepbreathing.SorU

Takesappropriateactionforadverseresponseandnotifiesappropriatepersonnel.

SorU


Documentsprocedureandoutcomesoftherapyinmedicalrecordandcompletescharge.

SorU

Communicatesresultsandtreatmenttoothermembersofthehealthcareteam.

SorU

Documentspatient/familyeducation.SorU



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IntrapulmonaryPercussiveVentilationIPV

PreliminarySteps

Acquiresrequisitionorreport.

Obtainsappropriateequipmentandsupplies.

Inspectsmedicalrecordsforprecautions/complications.

Verifiesphysicianorderorentersorderfromphysician.

Evaluatesorderforappropriatenesswithinstitutionalprotocol/policy.






WasheshandsandusesStandardPrecautions.

Positionspatientinoptimalpositionbaseduponpatientcondition.

Evaluatespatientforbaselinephysiologicstatus(breathsounds,pulse,sputum).

Properlyassemblesthecircuitandconnectsto50psigasoutlet.

Accuratelyverifies,scans,andinjectsappropriatemedicationintonebulizer.

ChecksIPVequipmentfunctionsbeforeusingonapatient.

SelectDrivePressureof20psi(startingpressurefornewpatient);Observemouthpiecefordensemist.

Turnspercussioncontrolknobfullturnsinbothdirections;observeforachangeinpercussive

impactrates.

Releasepercussionthumbbuttonandturnmasterswitchtooffposition.

Connectmouthpieceofin-lineadaptertoPhasitron®tobegintreatment.

Turnmasterswitch“on”andhavepatientstartIPVbybreathingmistfor1minute.

Instructpatienttogettightsealonmouthpiece,holdthumbbuttondownfor10-15seconds,


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duringinspiratoryandexpiratoryphase.

Startpercussiveratearound200bpm,whichishalfwaybetween“easyandhard”.


Adjustpressureswhilevisualizingchestwiggle.Increasespressureuntilchestwiggleisevident.

Correctsleaksaroundmouthpiece;ensuresminimalcheekflappingifusingmouthpiece.

Evaluateseffectivenessoftreatment&appropriatelymodifiestherapybaseduponpatientresponse.


Completesdocumentationandchargesinpatientrecord.

Recordsprocedure,patient/familyeducation,andoutcomesoftreatment.



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AdultCPAP

PreliminarySteps



Reviewsmedicalrecordsforprecautions/complications.

Verifiesphysicianorderandassessesforappropriateness.

Ensurespatientprivacy,washeshands,andimplementsStandardPrecautions.


Introducesselfandidentifiesdepartment.


Interviewspatientandobtainsrelevanthistory,ifapplicable(HomeCPAPuse).

Explainsproceduretopatient/familyandinsuresunderstanding.

Properlyassessespatientforappropriatemasktypeandsize.

Plugsmachineintooutletwithback-uppowerorgeneratorsupplyincaseofpowerfailure.

SetsupCPAPmachineandassurescompliancewithpre-checktestspermanufacturer.

Attacheshumidifierandaddssterilewatertofilllineifapplicabletopatientneed.

AttachescircuittoCPAPmachine,posthumidifierifapplicable.

Connectmasktocircuitandassurecarbondioxideeliminationportisnotobstructed.

TurnsonCPAPmachineandassuresairflowthroughcircuit.

Adjustsinglelevelpressuretoorderedsettings.

Performpressureandleaktestperdepartmentalguidelines.

AdjustFIO2oraddoxygentosystemperorderedsetting.

Placemaskonpatientadjustheadgeartomaintainpropersealandcomfortablefit.

Assessforleaksandre-adjustasneeded.ConfirmstimeofCPAPusewithpatient.

SetandtestCPAPsystemalarms;Disconnect,HighPressure,LowPressureetc.



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Assurepatientcomfortandtolerance.AssessSpO2,heartrate,andbreathsounds.

ExplainandassurepatientunderstandingofCPAPmaskremovalifneeded.



Appropriatelydocumentsprocedureinmedicalrecordsandcompletescharge.


Documentspatient/familyeducation.



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AdultBi-PAP

PreliminarySteps

Acquiresrequisitionorreportandobtainsappropriateequipmentandsupplies.

Obtainsappropriateequipment&supplies.AssessneedforcontinuousSpO2andECGmonitoring.


VerifiesphysicianorderandassessesforappropriatenessaccordingtoClinicalPracticeGuidelines.





Interviewspatientandobtainsrelevanthistory,ifapplicable(HomeBiPAPuse).

Explainsproceduretopatient/familyandinsuresunderstanding.

Properlyassessespatientforappropriatemasktypeandsize.

Plugsmachineintooutletwithback-uppowerorgeneratorsupplyincaseofpowerfailure.

SetsupBiPAPmachineandassurescompliancewithpre-checktestspermanufacturer.

Attacheshumidifierandaddssterilewatertofilllineifapplicabletopatientneed.

AttachescircuittoBiPAPmachine,posthumidifierifapplicable.

Connectmasktocircuitandassurecarbondioxideeliminationportisnotobstructed.

TurnsonBiPAPmachineandassuresairflowthroughcircuit.

AdjustInspiratoryandexpiratorypressurestoorderedsettings.

Setsback-uprespiratoryrate,Insp.Time,RiseTime,andadjustsFiO2asperorderorprotocol.

Placemaskonpatientadjustheadgeartomaintainproperseal&comfortablefit.Assessforleaks.

SetandtestBiPAPsystemalarms;Disconnect,HighPressure,LowPressureetc.

Monitorseffectivenessoftherapyandadjustsettingperinstitutionalprotocol.



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Assurepatientcomfortandtolerance.AssessSPO2,HeartRate,andBreathSounds.

ExplainandassurepatientunderstandingofBiPAPmaskremovalifneeded.


Evaluatetheneedforarterialbloodgasmonitoringperinstitutionprotocol.







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MechanicalVentilatorSystemSet-Up

PreliminarySteps

Washeshands.

Acquiresrequisition/communicationofventilatorsetup.

Ensuresventilatorhasbeencleanedandallequipmentprocessedperinstitutionalprotocol.


EquipmentPreparation

Connectshumidifier/heater&addssterilewatertoappropriatefilllevelpermanufacturerguidelines.

Attachesheaterwiresandtemperatureprobesifapplicableforheaterset-up.

Properlyassemblesbreathingcircuit.

Ifusingheatmoistureexchanger,insteadofhumidifier/heatersystem,placeinlinepermanufacturer.

Correctlyattachesbreathingcircuittoventilatorandhumidity/heatersystemifapplicable.

Inspectsandconnectselectricalcordand/orpneumaticpower.

Ensuresconnectiontogasoutletwithnoleaksnotedinthesystem.

Activatestheventilator.

Adjuststheventilatorcontrolstopreliminarysettingspermanufacturerrecommendations.

PerformsanOperationalVerificationProcedure(OVP)asrecommendedbymanufacturer.

CorrectlyperformsaventilatorOperationalVerificationProcedureperdepartmentalpolicy.

Determinesthebreathingcircuitcompressionfactor.

Checksanddocumentsoperationalfunctionofallaudibleandvisualalarms.

Analyzesthefractionalconcentrationofoxygendelivered.

Ensuressterilityofbreathingcircuitandventilatorperinstitutionalguidelines.

Documentstheventilatorpreparationperdepartmentalpolicy.

Verifiespresenceofequipmentforpatientconnect.


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Ensuresthepresenceofbagmaskresuscitationdevicewithgasconnectionoutlettoflowmeter/regulator.


Ensuresventilatorandcircuitsterilitywhilewaitingforpatientconnect.


DocumentsventilatorsystemsetupandOPVcompetitionasrecommendedbythemanufacturer.

Informshealthcareteamofappropriateventilatorfunctionandsystemreadinessforpatientconnect.



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OralEndotrachealIntubation

PreliminarySteps

Acquiresphysicianorder,orrequisitionforIntubation/RespondstoCardiopulmonarycrisis(CodeBlue).


Obtainsappropriateequipmentandsupplies;suction,bagmaskresuscitator,Intubationsupplies.






Explainsproceduretopatientandprovidespatient/familyeducation.Confirmunderstanding.

Preparesequipment;checkslightonlaryngoscope,cuffonEndotrachealtube,andinsertsstylette.

Positionspatientinsniffingpositionorappropriatepositionbaseduponevaluationforcervicaltrauma.

Manuallyopensairway;headtiltchinlift,ormodifiedjawthrust.Manipulatesairwaytoassurepatency.

Opensmouthandteethwithascissorsmaneuver.Removesalloralappliances(dentures).

Placesoropharyngealairwayinunconscious,sedated,orparalyzedpatientwithnogagreflex.

Ensuresventilationwithabagmaskresuscitator,preoxygenateswith100%FiO2andappropriateflow.

Appliescricoidpressure.Removesoropharyngealairway.

Holdslaryngoscopeinlefthand,insertsbladeonrightsideofpatientsoropharynx,controllingthetongue.

Atraumaticallyexposesglottiswithlaryngoscopeandvisualizesvocalcords.

Atraumaticallyinsertsendotrachealtubethroughvocalcords,intotrachea,andensuresdepthoftube.

Atraumaticallyremoveslaryngoscopeblade,inflatesendotrachealtubecuffinatimelymanner.

Providesmanualventilation/oxygenationbetweenintubationattempts(30secondsforeachattempt).


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Confirmsplacement;bilateralchestmovement,bilateralbreathsounds,andexhaledCO2withdetector.

Stabilizesendotrachealtube/andappliesbiteblockifapplicable.Notesdepthandpositionoftube.

Takesappropriateactionforadverseresponse/complicationstoprocedure.


Confirmsplacement;bilateralchestmovement,bilateralbreathsounds,&exhaledCO2withdetector.

Ensuresendotrachealintubationandpositionbycapnographyandchestradiograph.



Documents;complications,numberofattempts,positionanddepth,verificationmethodsandtime.




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ExtubationofArtificialAirway

PreliminarySteps


Obtainsappropriateequipmentandsupplies;suction,bagmaskresuscitator,Intubationsupplies.







Explainsproceduretopatientandprovidespatient/familyeducation.Confirmunderstanding.

Properlyassemblespostextubationequipmentandensuressuction.

PreparesoxygendeliverysystematappropriateflowandFiO2.

Maintainsheadofthebedinuprightposition,greaterthan45degrees,orperinstitutionalprotocol.

Preoxygenatesandhyperinflatespatient.

Suctionsartificialairway,oropharynx,andsubglotticsecretionsabovetheairwaycuff.

Verifiespresenceofcoughreflexesduringsuctioning.

Deflatesartificialairwaycufftoensureairleak.

Oxygenates&hyperinflatespatientwithmanualbagconnectedto100%oxygen.Ensureadequateflow.

Deflatescuffduringcompressionofmanualbagtopreventsecretionaspiration.

Removesendotrachealtubeatraumaticallyduringpeakinspirationwithmanualbag.

Instructspatienttocoughandclearsecretions,suctionoropharynxasneeded.

Immediatelyadministersoxygen/aerosoltherapy.Maintainsheadofbedintheup-rightposition.

Modifiesprocedureasneededbaseduponpatientresponse.

Takesappropriateandtimelyactionforanadverseresponsetoextubationandinformsappropriate.


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Evaluatesairwaypatencyandventilationbyauscultationimmediatelyfollowingextubation.

Assesspatient'sbreathsounds,heartrateandnon-invasivemonitoring.Re-assurespatient.

Monitorspost-extubationventilatorypatternandensuresabsenceofstridorordistress.







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VentilatorCircuitChange

PreliminarySteps

Acquiresrequisition/orderornotescircuitchangeperinstitutionalprotocol/standardsofcare.


Inspectsmedicalrecordsforprecautions/isolation/complications.

Verifiesorderorcircuitchangeguidelinesandassessforappropriateness.





Explainsproceduretopatientandprovidespatient/familyeducation.Confirmsunderstanding.

Properlyassemblesequipmentwhilemaintainingaseptictechnique.

Turn“off”ventilatoralarms.

Ifusinghumidifier/heaterdisconnectcircuit,by-passhumidifier/heatersystem,andreconnect.

Removesandproperlydisposesofoldheater/humidifiersystem.

Attachheaterwiresandtemperatureprobesifapplicableforheaterset-up.

Fillcleanhumidifier/heatersystemwithsterilewater,toappropriatelevel,permanufacturer'sguidelines.

Ifusingheatmoistureexchangerplacein-line,onnewcircuit,permanufacturer'sguidelines.

Attachesclosedsuctionsystemtocleanventilatorcircuit.

Ensuresbagmaskresuscitatorisreadytoassistwithpatientventilationifextendedtimeisneeded.

Disconnectsusedcircuitfrompatientandventilator.

Correctlyattachescleanbreathingcircuittoventilatorandhumidity/heatersystemifapplicable.

Attachescleanbreathingcircuittopatient.Limitnumberofdisconnects&timepatientisoffventilator.

Ensuresadequateventilationofpatientthroughoutprocedure.

Reassesspatientforcomfortandassuresproperfunctionofcircuit.


38

Returnsalarmstopreviouslevelandfunction.Ensuresorderedventilatorsettingspostprocedure.


Assessventilationbyobservation,auscultationandnoninvasivemonitors.

Monitorpeakpressurebeforeandaftercircuitchange.

Performaleaktestifapplicabletoventilatormanufacturerorinstitutionalguidelines.


Appropriatelydocumentsprocedureinmedicalrecordandcompletescharge.

Effectivelycommunicatesresultsandproceduretomembersofthehealthcareteam.



39

AdultVentilatorMonitoringPatientSystemCheck

PreliminarySteps










Ensuresventilationbyobservation,auscultation,andnon-invasivemonitors.

Assessespatient/ventilatorsynchronyandassuresventilatorcircuitissecurelyconnectedtopatient.

Monitorsinspiredgastemperature,ensuresheatandhumidityoruseofaheatmoistureexchanger.

Documentsoperationalverificationprocedureperdepartmentalprotocol.

Assessendotrachealortracheostomytubesize&position.Measuresartificialairwaycuffpressure.

Verifiesanddocumentsaccuracyofcurrentventilatorsettingsperinstitutionalguidelines:

*ModeofVentilation

*Tidalvolume

*Respiratoryrate

*Oxygenconcentration

Verifiesanddocumentsoperationofallalarms,indicators,andmonitors.

Documentsthatanairwaydisconnectalarmisoperationalandproperlyset.


Ventilationensuredbyauscultation,observation,non-invasivemonitorsanddocumented.


40

Evaluatesbloodgasesornon-invasivemonitors&makesappropriateventilatorychangesperprotocol.

Takesappropriateactionforanadverseresponseandnotifiesappropriatepersonnel.

Recordsrelevantclinicalobservationsofresponsetoventilationinmedicalrecord.


Recordsprocedureanddocumentsoutcomesofventilationinmedicalrecordandcompletescharge.

Documentsdate/timeofpatient/ventilatorsystemcheck.

Effectivelycommunicateresultstoothermembersofthehealthcareteam.



41

ArtificialAirwayCare

PreliminarySteps









Assuresappropriateequipmentatpatientbedside;Replacementairway,Bagmaskdevice,suctionkit.



Ensuresstabilityofartificialairway.Changesairwaystabilizationdeviceperinstitutionalprotocol.

ProvidesadequatehumidityandprescribedFIO2.

Monitorscuffpressureofartificialairwayandassessessizeandposition.

Performstracheobronchialsuctionasneededandlimitstheuseofroutinelavage.

A.Hyper-inflatesandhyper-oxygenatespatient.

B.Setssuctionpressureat-80to-120cmH20,orperinstitutionalprotocol.

C.Maintainssteriletechniqueandadvancessuctioncatheterwithoutapplyingsuction.

D.Appliessuctionandwithdrawscatheterslowly.Donotexceed15secondswithattempt.

E.Reassesspatient,repeatsprocedureifneeded,givingadequaterecoverytimebetweenattempts.

Monitorspatientduringprocedure,assessesheartrate,breathsounds,patientcolor,andSpO2.

Cleansanddressesaroundartificialairwayperinstitutionalpolicy.



42

Auscultateschesttoensuretubepatencyandcheckssize,positionanddepth.

Reviewschestradiographforproperplacement.

Processesequipmentandsupplies.



Recordsprocedure,documentsoutcomesinmedicalrecordandcompletescharge.





43

SpontaneousMechanicsPreliminarySteps



Reviewsmedicalrecordsformedicalhistory,diagnosis,andcurrentpulmonarystatus.

Verifiesphysicianorderforventilatorsettingsandassessforappropriateness.







Properlyassemblesequipmentandverifiesdeliveredoxygenconcentration.

Recognizes&adjustscurrenttherapeuticdevicetoallowfortesting;oxygendevice,NPPV,Ventilator.

Disconnectspatientfromtherapeuticdeviceandusesspirometerfunctionformanualtesting.

Ifpatientisonventilator,allowsystemtestingofpatientparameters,ifapplicabletoventilatorfunction.

Measuresthefollowingtestsperdepartmentalprotocol/policy:

A.TidalVolume(TV)

B.MinuteVolume(VE)

C.VentilatoryRate(f)

Reconnectspatienttotherapeuticapparatus.

Allowsadequaterecoverytimeforpatientbetweenmechanics.


Reassesspatient;heartrate,respiratoryrate,color,andnon-invasivemonitors.



44

Obtainsarterialbloodgassample,afterappropriatetime,refertoinstitutionguidelines.

Comparesactualtopredictedvaluesforpatientandmakesappropriaterecommendations.







45

ArterialLineSet-Up

PreliminarySteps



Reviewsmedicalrecords.

Verifiesandassessesphysicianorderforappropriateness.







AssemblespressuremonitoringkitonIVpole.

Tightensallthreadedcontactpoints,i.e.stopcockattachestotubingconnector.

Closesrollerclamptofluidaccessline.

AsepticallyinsertspressuremonitorlinespikeintoIVbag.

Half-fillsdripchamberwithheparinizedfluidfromIVbag.

Opensrollerclamptofluidaccessline.

Flushespressuremonitorlineandportsbypulling"pig-tail".

Checksforandremovesairbubblesthroughoutpressuremonitorline.

Replaceswhiteventedcapswithyellownon-ventedcapsonstopcocks.

InsertsheparinizedIVfluidbagintopressureinfusionbag.

Pressurizesfluidbagtoapressureof300mmHg.

Attachespressuremonitorlinetopatient'sinvasiveport.

Attachespressuremonitorcabletotransducersite.

Levelstransducerstopcocktodesiredpressuremonitoringsite.

Turnstransducerstopcockofftopatient,andremovesnon-ventcap.


46

Performs"zeroing"maneuveronpatientmonitor.

Returnstransducerstopcocktomonitoringpositionandflushesline.


Ensuresproperwaveformappearsonpatientmonitor.

Ensuresmonitoralarmsare"on"andparametersareapproximatelyset.



Completesdocumentationinpatientrecord.



47

SuctioningofArtificialAirway

PreliminarySteps










Ensuresventilationbyobservation,auscultation,andnon-invasivemonitors.

Assuresappropriateequipmentatpatientbedside;Replacementairway,Bagmaskdevice,suctionkit.

Monitorscuffpressureofartificialairwayandassessessizeandposition.

Properlyassemblesequipmentandselectsappropriatesizedcatheterorclosedsuctionsystem.

Pre-checksfunctionsofcatheterandnegativepressure.Setssuctionpressureperinstitutionpolicy.

A.AssuresappropriateFiO2andhumidity.Hyper-inflatesandhyper-oxygenatespatient.

B.Maintainssteriletechniqueandadvancessuctioncatheterwithoutapplyingsuction.

C.Appliessuctionandwithdrawscatheterslowly.Donotexceed15secondswithattempt.

D.Limitstheuseofroutinelavageperinstitutionguidelines.

E.Maintainssteriletechniqueandcollectssputumspecimeniforderedbyphysician.

F.Reassesspatient,repeatsprocedureifneeded,givingadequaterecoverytimebetweenattempts.

Monitorspatientduringprocedure,assessesheartrate,breathsounds,patientcolor,andSpO2.



48

Auscultateschesttoensuretubepatencyandcheckssize,positionanddepth.

Reviewschestradiographforproperplacement.




Recordsprocedure&documentsoutcomesinmedicalrecord.Completeschargeperinstitutionpolicy.


Documentspatient/familyeducation



49

TracheostomyTubeReplacement

PreliminarySteps










Assessesadequateoxygenation&ventilationbyobservation,auscultation,andnon-invasivemonitors.

Ensuresappropriateequipmentatpatientbedside;Tracheostomytube,Bagmaskdevice,suctionkit.

MaintainsappropriateFiO2andflowviaoxygendeliverydevice.

Suctionstracheostomytubepriortotracheostomychangeperinstitutionpolicy.

Properlyassemblesequipmentwhilemaintainingaseptictechnique.

Ensurescorrectsizeoftracheostomytube.Checkstracheostomytubecuff.

Insertsobturatororguideintotracheostomytube.Lubricatestracheostomytubeperinstitutionpolicy.

Hyper-oxygenatespatientpriortotubeexchangeprocedure.Deflatescuffandremovesexistingtube.

Deflatescuffandatraumaticallyremovestube.Maintainshead,neckpositionandstomapatency.

Insertsnewtracheostomytubethroughstomaopening,removesobturator/guideandinflatescuff.

Ensuresproperpositioning&patencyoftracheostomytube.Placesonpreviousoxygendeliverydevice.

Performsstomacareandappropriatelysecuresthetracheostomytubeafterinsertion.

Allowsrecoverytimepostprocedureandsuctionsasneeded.


50


Checkstubeplacementbyauscultationandverifiespositionbyreviewofchestradiograph.

Observeschestforsymmetricalexcursion.Reassessespatient;Heartrate,color,non-invasivemonitors.








51

ContinuousNebulization

PreliminarySteps


Verifiesphysician’sorder;dosage,strengthofmedicationanddurationofnebulizertherapy.

Inspectsmedicalrecordsforprecautions/complicationsandassessesforappropriateness.


Obtainsprescribedmedicationusingapprovedfacilityguidelines(electronicmedicationstoragedevice).





Interviewspatientandobtainsrelevanthistory(homenebulizeruse).


Performsbaselinephysiologicassessment(pulse,breathsounds,peak-flow,dyspnearating).

ContinuouslymonitorsoximetryandECGthroughoutnebulizertherapyperinstitutionalguidelines.

Assemblesequipmentandtestsequipmentfunctionpriortopatientapplication.

Scanspatient'sarmbandandmedicationbarcodeifusingbedsideidentificationandscanningsystem.

Note:MostcommonlyusedmedicationisAlbuterol.Adultdose(0.5mg/kg/hr)or(5-15mg/hr).

Appropriatelyfollowsmanufacturerguidelines&institutionalprotocolforcontinuousmedicationdelivery.

Accuratelypreparestheprescribedmedication.Dilutesmedicationdosagepermanufacturerguidelines.

Addsorderedmedicationamountandnotesamountofsuspensionsolution.

Addsdilutent(NormalSaline.09%)toensuretotalamountofsolutiontobenebulized.

Asepticallyinjectsmedicationintodeliverydevice.


52

Setsflowmeter,permanufacturerguidelines,todeliverprescribedmedicationinorderedduration.

Usesaerosolmasktodeliverycontinuousnebulizationofmedicationandensurescomfort.



Assesstherapeuticresponsetomedicationandoutcomesoftreatment.








53

VentilatorManagement

PreliminarySteps


Verifiesphysicianorderforventilatorsettingsandassessesforappropriateness.

Reviewshemodynamicstatusofpatient,HR/BP.

Locatesandreviewslabs,chestx-rays.

Reviewscurrentmedicationsrelatedtocardiopulmonarystatus.

Sitesnutritionalstatus,fluidintake/output.



Monitorsandtrendsventilatorchangesandensuresappropriatenessofcurrentsettings.

EnsuresEndotrachealtubeissecure,notesplacement,size,positionanddepth.

Assesspatientforoptimalpositioning;Headofthebedat45degreesorgreaterasconditiontolerates.

Auscultatespatientchestandnotesbreathsounds.

Assesspatientworkofbreathingandventilator/patientsynchrony.

Ensuresadequatehumidityandnotescircuittemperatureortheuseofheatmoistureexchanger.

Suctionsoropharynxandsubglotticsecretions.

Monitorsendotrachealtubecuffpressurestoavoidmicroaspirationofsubglotticsecretions.

Suctionspatientasneededwithclosedsuctionsystem,avoidstheuseofroutinelavage.

Administersinhaledmedicationsperprotocolorasorderedbyphysician.

Notescurrentventilatorsettingsandmonitorsallalarmvaluesforappropriateness.

Assessesrespiratoryrate,heartrate,andnon-invasivemonitors.

Measuresplateaupressures,dynamiccomplianceandautoPEEP,perinstitutionpolicy.


54

Monitorsventilatorwaveformsandgraphicsifapplicable.

AnalyzesFiO2ifapplicable.

Ensuresappropriaterespiratoryequipmentatbedside;bagmaskresuscitator,suctioncatheterkit,HME.


Discussescareplanwithmultidisciplinaryhealthcareteam.

Suggestspossiblerespiratorycareinterventionsandformulatesaplantoweanandextubatepatient.

ReviewsandinterpretsABG’sandpossibletrendsinABGvalues.


Documentsventilatormonitoringandassessmentinmedicalrecordperinstitutionpolicy.

Effectivelycommunicatesresultstoothermembersofthehealthcareteam&documentsplanofcare.



55

LaryngealMaskAirwayInsertion

PreliminarySteps

Acquiresphysicianorder,orrequisitionforLaryngealMaskAirwayinsertion.

Verifiesphysicianorder&assessesforappropriateness;unabletointubate,unabletoobtainBVMseal.

Obtainsappropriateequipment&supplies;suction,bagmaskresuscitator,Laryngealmaskairway.

ObtainsappropriatesizeLMAbasedonweightandmanufacturerguidelines.(Sizes1-5)

Reviewsmedicalrecordsforprecautions/complications;maxillofacial&thoracictrauma,aspirationrisk.




Indentifiesselfanddepartmentandexplainsprocedure.

ChecksfunctionofLMA;ensuresinflationwithnoleak,deflatesLMAtoensureintactvacuum.

Lubricatestipofmaskwithwatersolublelubricant.

Positionspatientwithneckflexedandheadextended.Manuallyopensmouthtovisualizeoralcavity,

GraspsLMA,asclosetomaskaspossible,holdinglikeapen.Placestipagainstsurfaceofupperteeth.

InsertsLMAagainstthehardpalate,&pushesthedeviceinwardsandbackward,usingindexfinger.

Continuestoadvancemask,avoidingthetongue,usingindexfingeruntilresistanceismet.

UsesoppositehandtopressdownontheLMAandthenremovesindexfingerfromoropharynx.

Ensurethattheblackline,markingLMAposition,isorientedanteriorlytowardtheupperlip.

Inflatethemaskwithenoughairtoobtainaseal.Allowdevicetoproperlyseatwithslightmovement.

UsesmanufacturerrecommendedguidelinesforinflationbasedonLMAsizeandpatientanatomy.

Connectsbagvalveventilationdevicewith100%FiO2andventilatespatienttoconfirmplacement.

Observeschestrise&fall,confirmsbilateralbreathsounds,andabsenceofsoundsoverepigastrium.


56

SecuresLMAinthesamemannerasendotrachealtube.Mayusebiteblockifneeded.


NotesLMAisatemporaryairway.EvaluatestheneedforremovalandreplacementofLMAdevice.

Assesspatientsbreathsounds,heartrate,color,andnon-invasivemonitors.







57

HelioxAdministration

PreliminarySteps


Verifiesphysician’sorderandassessesforappropriateness.



Ensurespremixedhelioxgascylinderwithprescribedmixture.Usually70/30or80/20helioxmixture.






Assesspatient;breathsounds,workofbreathing,color,heartrate,andnon-invasivemonitors.

Cracksgascylinder,placeshelioxregulatoronthetankandensuresadequatetankpressure.

Setstheregulatorat50psi.&adjustshelioxflowmetertoensuregasflow.Checkssystemforleaks.

Administerhelioxconcentrationusinginstitutionalpolicyfordevice;non-rebreather,simpleorventurimask.

Attachesnon-rebreathingmaskorapprovedinstitutionaldeliverydevicetotheflowmeter.

Placesdeliverydeviceonpatientandadjustssystemflowtomeetpatientinspiratorydemand.

Ifusingnon-rebreatheradjustsystemflowtopreventreservoirbagcollapseduringpeakinspiration.

Understandspossibilityofhypoxemiaduetotheinadequateoxygenconcentrationinthemixture.

AdministersupplementaloxygenviaanasalcannulatomaintainSpO2atorabovedesiredlevel.

Notespossiblesideeffectofheliumisadistortedhighpitchvocaltone.

Maintainscontinuouspulseoximetryduringhelioxdelivery.

Keepsadditionalhelioxtankswithprescribedmixtureonhandforreplacement.


58











59

VentilatorModeModification

PreliminarySteps




Verifiesphysicianorderforventilatorsettingsandassessesforappropriateness.







Assessadequateoxygenationandventilationbyobservation,auscultation,andnon-invasivemonitors.

Initiatesprescribedventilatormodeandadjustsnecessaryventilatorcontrols.

Appropriatelyadjustsventilatoralarmstoreflectchangestomode.

Readjustspressurelimitifapplicable.

Observes&ensurespatientsynchronywithnewmode;waveforms,chestexcursion,patienttolerance.

Modifiesmodeperorderorinstitutionprotocol.


Evaluatesoutcomepatient’sresponsetomodechange.

Reassesspatient;heartrate,respiratoryrate,color,andnon-invasivemonitors.



Appropriatelydocumentsprocedureinmedicalrecord.


60





61

TransportVentilatorSet-Up

PreliminarySteps

Washeshands.

Acquiresrequisition/communicationofventilatorsetup.

Ensuresventilatorhasbeencleanedandallequipmentprocessedperinstitutionalprotocol.


EquipmentPreparation

Assuresadequatebatterylevelforlengthoftransport.

Checkspressuregaugeonoxygentankandcalculatesflowandtimedurationfortransport.

Inspectsandconnectselectricalcordand/orpneumaticpower.

Properlyassemblesbreathingcircuit.

Correctlyattachesbreathingcircuittoventilatorandhumidity/heatersystemifapplicable.

Connectshumidifier/heater&addssterilewatertoappropriatefilllevelpermanufacturerguidelines.

Attachesheaterwiresandtemperatureprobesifapplicableforheaterset-up.

Ensuresconnectiontogasoutletwithnoleaksnotedinthesystem.Activatestheventilator.

PerformsanOperationalVerificationProcedure(OVP)asrecommendedbymanufacturer.

Checksanddocumentsoperationalfunctionofallaudibleandvisualalarms.

Adjuststheventilatorcontrolstopreliminarysettingspermanufacturerrecommendations.

Ensurestransportwithbagmaskresuscitationdevice.

Transportswithemergencyairwaysuppliesperinstitutionalguidelinesforventilatedpatienttransport.

IfusingHMEsystemforhumidity,disconnectbehindtheHMEtoavoidopencircuittoroomair.

Ensuressterilityofbreathingcircuitandventilatorperinstitutionalguidelines.

Documentstheventilatorpreparationperdepartmentalpolicy.



62

Ensuresventilatorandcircuitsterilitywhilewaitingforpatientconnect.


DocumentsventilatorsystemsetupandOPVcompletionasrecommendedbythemanufacturer.

Informshealthcareteamofappropriateventilatorfunctionandsystemreadinessforpatientconnect.



63

HighFrequencyOscillatory

PreliminarySteps


Reviewsmedicalrecordsandverifiesphysicianorderforappropriateness.


SelectsappropriateHighFrequencyVentilator(3100B>35kg,3100A<35Kg).

Properlyassemblesandcalibratescircuitpriortopatientapplication.





Positionspatientinoptimalposition(headhigherthantubing)baseduponpatientcondition.

Ensuresdeepsedationorparalysisandperformsrecruitmentmaneuver.

Evaluatespatientforbaselinephysiologicstatus(breathsounds,pulse,sputum).

Adjustshighfrequencyventilatorforinitialsettings:

RecommendedRangeAvailable

BiasFlow

MeanAirwayPressure

OscillatoryPressureAmplitude

Frequency5.03.0-6.0

InspiratoryTime%33%33%-50%

Connectsventilatorcircuittopatient'sairway.

Observeschestforadequatechestwiggle,andauscultatesforbilateralbreathssounds.

Obtainsarterialbloodgassampleafter1hourofhighfrequencyoscillatoryventilation.


64

Makesappropriateadjustmentsbaseduponpatientresponse.

Ensurescellphones,cauteryequipment,&hand-heldradiosarenotcloserthan20feettoventilator.


WeanFiO2slowlyto<60%whilemaintainingadequateoxyhemoglobinsaturationlevels.

AfterachievingFiO2to50%,attempttoweanMAPby1-2cm.H2Oevery4hours.

ConsiderchangetoPCV/BilevelventilationwhenFiO2<50%,MAP<24cmH2O,PulseOx>88%.


Monitorsandcompletesdocumentationinpatientrecord.

Entersappropriatechargesforservices.



65

SupplementalOxygenTherapy-OxygenHood

PreliminarySteps




Verifiesphysician'sorder.

EvaluatesorderforcompliancewithAARCClinicalPracticeGuidelines.


Correctlyidentifiespatient.

Ensuresadequateoxygendeliverytopatientduringhoodsetupviamanualbag/tubing.

Explainsproceduretofamilyandprovidesfamilyeducation.

Confirmsfamilyunderstanding.

WasheshandsandimplementsStandardPrecautions.


Ensuresadequategasflowrates,asappropriate.

Adjustsdevicetodeliverprescribedflowrateoroxygenconcentration.

Ensurestotalgasflowratemeetsthepatient'speakinspiratoryflowrate,asapplicable.

AnalyzestheFIO2proximaltotheinfant'sairway.

Obtainsaroom-airpulseoximetrymeasurement.

Explainstothefamilythenecessityforcontinuousoxygentherapy.

Atraumaticallyappliesthedevicetothepatient,ensuringminimalleaks.

Reassuresthepatient'sfamilyandexplainsthefirehazardsofoxygen.

Ensuresthattheenclosuredoesnotcompresstheinfant'shead/neck.

Obtainspulseoximetry/arterialbloodgasmeasurementfollowingoxygenadministration.



66

Evaluatesoutcomebypatient'sphysiologicresponsetooxygentherapy.

Modifiestheprocedureinatimelymannerbaseduponpatientresponse.

Adjustsoxygentherapyperinstitutionalprotocol.



Recordsprocedureandresultsinmedicalchart.

Documentsprocedureindepartmentalrecords.




67

Nasal-ETCPAPSystemSet-Up

PreliminarySteps



Inspectsmedicalrecordsforindications/precautions/complications.



AdherestoStandardPrecautions.


Correctlyidentifiespatient;identifiesselfanddepartment.

Explainsproceduretopatient'sfamily;providesfamilyeducationasneeded.

Properlyassemblesequipment.Testsequipmentfunctionpriortopatientapplication.

Correctlyadjustsprescribedventilatorsettings.

Selectsappropriate-sizednasalprongs,andatraumaticallyinsertsandstabilizesprongs.

Re-adjustsalarms,ifappropriate.

Re-adjustspressurelimit,ifappropriate.

EnsuresadequatetotalgasflowrateandcontinuousanalysisofFIO2.

Analyzesinspiredgasforprescribedoxygenconcentration.

Monitorspatient'sresponsetoinitiationofCPAPmode.

Modifiesprocedureasnecessarybaseduponpatientresponse.

Re-adjustsCPAPpressure/FIO2baseduponpatientresponseanddepartmentalprotocol.

Ensurespresenceofmanualbagandmaskandcorrectsizesuctioncathetersatbedside.

Ensurescontinuousmonitoringofpatient'sheartrate,ECG,andSpO2.

Ensuresavailabilityofgastrictubefordecompressionofstomach,ifneeded.



68

EnsuresadequateventilationfollowinginitiationofCPAPmode.

Obtainsarterialbloodgassampleafterappropriatetime.


Patient/ventilatorsystemchecksperformedQ2-4hoursperdepartmentalprotocol.


Recordsprocedureandoutcomesinmedicalrecord.


Documentsfamilyeducation.



69

CapillaryBloodGasSamplingforNeonatal

PreliminarySteps



Inspectsmedicalrecordsforprecautions/complicationsperClinicalPracticeGuidelines.






Explainsproceduretopatient'sfamily;providesfamilyeducationasneeded.

Washeshandsandputsongloves.

Wrapsheelinwarmerfor5-10minutes.

Properlyassemblesequipment.

Selectsanappropriatepuncturesite.

Atraumaticallystabilizesthepatientpriortopunctureofthesite.

Asepticallypreparesthepuncturesitebythoroughcleaningofsite.

Atraumaticallypuncturesthesiteandverifiesadequatebloodflow.

Obtainsanadequatevolumeofbloodwithout"milking"thesite.

Appliespressuretopuncturesitetoensurecessationofbleeding.

Ensuresbloodsamplecontainsnoairbubblesorclots.

Ensuresbloodsampleissealedandplacedinaniceslushifnotanalyzedwithin10minutes.

Reevaluatespuncturesite.

Deliversbloodsampleforanalysisinatimelymanner(lessthan60minutesat4ºC).


Evaluatespuncturesiteforcessationofbleedingandabsenceofhematoma.


70

Notestime,patientposition,activity,bodytemperature,ventsettings,oxygenflow/FIO2.


Processesanddisposesofallsharps,supplies,andequipmentinappropriatecontainers.



71

SuctioningofNeonatalPediatricArtificialAirway

PreliminarySteps









Explainsproceduretopatientandprovidespatient/familyeducationasneeded.

Determinespropercatheterinsertiondepth.

Washeshandsandwearssterilegloves.

Properlyassemblesequipmentandselectsappropriate-sizedcatheter.

Pre-checksfunctionsofcatheterandnegativepressure.

Hyperoxegenatesandhyperinflatespatientbeforeprocedure,inbetweensuctionevents,andaftertheprocedureusingamanualresuscitationdevice,ifappropriate.

MaintainssteriletechniqueandadherestoUniversalPrecautions.

Suctionspatientfornotmorethan10seconds.

Lavagespatientperinstitutionalprotocol.

Obtainsasputumspecimen,ifneeded.



Evaluatesbreathsoundsbeforeandaftersuctioning.

MonitorsECGorpulseoximeterthroughoutprocedure.

Terminatesprocedurewhennecessaryanddisposesofcatheterandgloves.


72

ProcessesequipmentperStandardPrecautions.


Recordsprocedureandoutcomesinmedicalrecord.





73

SurfactantAdministration

PreliminarySteps






Correctlycalculatesdosagebaseduponmanufacturer'srecommendations.



Identifiesselftofamilyandidentifiesdepartment.

Explainsproceduretopatient'sfamily.

Procuressurfactantdosefrommedicationstorage.

WasheshandsandadherestoUniversalPrecautions.


Ensurespresenceatbedsideofresuscitation,suction,andmonitoringequipment.

Accuratelypreparestheprescribeddoseofsurfactant.

Ensuresthatsurfactantdoseiswarmedforadequatetimetoroomtemperature.

Ensurespresenceandfunctionofsurfactantadministrationdevice.

Performsbaselinepre-treatmentphysiologicassessment.

Asepticallyinjectstheprescribeddoseofsurfactantandpositionspatient.

Assesspatientresponsetotherapyduringtreatment.

Appropriatelymodifiesventilatorsettingsandtherapybaseduponpatient'sresponse.

Correctlyidentifiesadverseresponsetoprocedure.

Adjuststherapeuticprocedureperinstitutionalprotocol.


74




MonitorsSpO2,ECG,surfactantreflux,skincolor,vigor,patientposition,chestmovement,positionofdeliverydevice,pulmonarymechanics,breathsounds,andvitalsigns.



Recordsprocedureanddocumentsoutcomesoftherapyinmedicalchart.





75

SupplementalOxygenTherapy-OxygenTentSystem

PreliminarySteps








Introducesselftopatient/familyandidentifiesdepartment.

Explainsproceduretopatient/familyandprovidespatient/familyeducation.

Confirmspatient'sunderstanding.

WasheshandsandadherestoStandardPrecautions.


Ensuresadequateaerosoloutputasappropriate.

Adjustsdevicetodeliverprescribedflowrateoroxygenconcentrationasappropriate.

Ensurestotalgasflowratemeetsthepatient'speakinspiratoryflowrateasappropriate.

AnalyzestheFIO2(ifappropriate).

Obtainsaroom-airpulseoximetrymeasurement.

Explainsthenecessityforcontinuousoxygentherapytopatient.

Atraumaticallyappliesthedevicetothepatient,ensuringminimalleaks.

Reassuresthepatientandexplainsthefirehazardsofoxygentothepatient.

Ensuresthat"NoSmoking"signsarepostedandspark-producingobjectsareremoved.

Obtainspulseoximetry/arterialbloodgasmeasurementfollowingoxygenadministration.



76

Evaluatesoutcomebypatient'sphysiologicresponsetooxygentherapy.

Modifiestheprocedureinatimelymannerbaseduponpatient'sresponse.

Adjustsoxygentherapyperinstitutionalprotocol.



Recordsprocedureandresultsinmedicalchart.

Documentsprocedureandpatientresponseindepartmentalrecords.




77

AerosolDrugAdministration

PreliminarySteps








Introducesselftopatient/familyandidentifiesdepartment.

Explainsproceduretopatientandprovidespatient/familyeducation.

Confirmspatient'sunderstanding.

WasheshandsandadherestoStandardPrecautions.


Accuratelypreparestheprescribedmedication.

Asepticallyinjectspreparedmedicationintodeliverydevice.

Activatesgasflowandverifiesaerosolgeneration.

Instructspatienttodesiredventilatorypattern.

Performsbaselinephysiologicassessment(pulse,breathsounds,peakflow,dyspnearating).

Appliesdevicetopatient.

Assessespatient'sresponsetotherapyduringtreatment.

Appropriatelymodifiestherapybaseduponpatient'sresponse.

Correctlyidentifiesadverseresponsetomedication.

Adjuststherapeuticprocedureperinstitutionalprotocol.




78


Encouragescough/deepbreathing.

Terminatestreatment,gasdriesnebulizerreservoirandplacesinplasticbag.



Recordsprocedureanddocumentsoutcomesoftherapyinmedicalchart.





79

NitricOxideAdministration

PreliminarySteps


Obtainsappropriateequipment:includingsupplies,connectorsasshownondiagram,andextratank.

Checkstankpressuretoensuregreaterthan200psi.pressure.

Verifiesandassessesphysicianorderforappropriatenessandindicationsfortherapy.

Reviewsrecordsforprecautions/complications(bleedingdiathesis,hemorrhage,metHbreductasedeficiency).







PerformsLowCalibrationofNO,NO2,andO2.

PriortoinitiationofNO,drawbaselineABGwithmetHb.

InitiateNOat20ppm,adjustperphysiciansorderorperprotocol.

Setsalarmsappropriatelyandensuresthatalarmsareactivated.

ObtainABGs30min.afterinitiation.MayrepeatABGPRN,thenQ6hrx24.hrs.Thereafter,anABGdaily.

BeginweaningNOwhenFiO2islessthan50%withadequateoxygenation.

WeanNOinincrementsof50%astolerated.

DiscontinueNOwhenweanedto1ppmorpatientisnotaresponder.

Documentevery2-4hoursNO,NO2,O2,andTankpressures.

AttachmanualresuscitationtoNOequipment,assureproperflow,Leaveflowmeteroff.



80

AssesspatientforimprovedSaO2(measuredbypulseoximetry),increasedPaO2,&decreasedPAP.

Assessforelevated(metHb)levels,IncreasedNitrogenDioxide(NO2).

Physicianisnotifiedtodiscontinuetherapyifpatientsdonotdemonstratepositiveresponse

after1houroftherapy.



EnsuresappropriatechargeenteredanddocumentationcompletedforNOusage.



81

NeopuffT-PieceResuscitationDevice

PreliminarySteps

Acquiresrequisitionorreport.Obtainsappropriateequipmentandsupplies.

Reviewsmedicalrecordsverifiesandassessesphysicianorderforappropriateness.





Explainsproceduretofamilyandconfirmsunderstanding.


Performsbaselinephysiologicassessment(pulse,breathsounds,retractions,noninvasivemonitoring).

Assurepressuremanometerreadszerowithnogasflow.Calibratesmanometertoachievezero.

Connectsgassupplytubingfromoxygenorblendedoxygen/airflowmetertothegasinletport.

Connectsthepatientcircuit,withpatientT-piece,tothegasoutletportonNeopuff.

ConnectsatestlungtothepatientT-piece.Adjustgassupplytothedesiredflow(5to15LPM)

OccludesPEEPcapandturnsPIPcontrolfullyclockwise/counter-clockwisetosetmaximumpressure.

Adjuststhemaximumpressureknobcounter-clockwiseuntilthedesiredpeakinspiratorypressureisset.

AdjuststhePEEPcaptodesiredPEEPlevel.RemovestestlungfrompatientT-piece.

Checksand/oradjuststhegassupplytothedesiredflowrate.

Ensuresproperpatientpositionforadequateventilation.

FitspatientT-piecetoresuscitationmaskandappropriatelyplacesovertheinfant’smouthandnose.

IfpatienthasendotrachealtubesecureT-piecetoendotrachealtube.EnsureETtubeisproperlysecured.


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BeginspositivepressureresuscitationbyplacingandremovingthumboverthePEEPcap.

Deliversappropriatebreathratebasedonneonatalresuscitationguidelines.

Assessespatientandappropriatelymodifiesprocedurebaseduponpatientresponse.


Monitorsphysiologicparametersduringprocedure(pulse,breathsounds,noninvasivemonitoring).

Assessesthetherapeuticresponseandoutcomeofprocedure.








83

Electrocardiogram(ECG)

PreliminarySteps



Reviewsmedicalrecords,inspectshistoryandphysicalexaminationresults.








Ensurespatientprivacy.

Removesallmetalandjewelryfrompatient.

ConnectsECGmachinepowercordtoredelectricaloutlet.Activatespowertomachine.

Properlyconnectschestleadstopatient.

Properlyconnectslimbleadstopatient.

RunsECG12leadrecording.


ExaminesECGpreliminaryrecordingforlifethreateningarrhythmias.

Ensuresrecordingcontainsminimalartifact,correctsartifactiffound.

EnsuresECGrecordingcontainsminimaldrift.

Removeselectrodesfrompatient,disposesofsuppliesandprocessesequipment.



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EnsuresdownloadofECGandprocessesstudyforphysicianinterpretation.

Completesdocumentationinpatientrecord,andenterscorrectchargeforprocedure.

Effectivelycommunicatestestresultstoothermembersofhealthcareteam.



85

BronchoscopyAssisting

PreliminarySteps


Obtainsappropriateequipmentandsupplies.Ensuresbronchoscopeintegrityandsterility.

Reviewsmedicalrecords,inspectshistory&physicalexaminationresults;drug(lidocaine)allergyhistory.

Verifiesandassessesphysicianorderforappropriateness.Verifiespresenceofwritteninformedconsent.







AttachesoximetryprobeandECGelectrodestopatient.

MonitorsanddocumentsbaselinestatusforECGrhythm,heartrate,SpO2,andrespiratoryrate.

Checkspatencyofnaresandadministerstopicalanesthetictonasopharynxandoropharynx.

Repeatstopicalanestheticspraytooropharynxuntilpatientstatesoropharynxisnumb.

Administersoxygentopre-oxygenatepatientandmaintaindesiredSpO2.

Whenbronchoscopistarrives,drapespatient'sheadwithsteriletowels.

Appliesviscouslidocaineintonostrils,andactivateslightsourcetobronchoscope.

Assistsphysicianwithbrushing,washings,biopsyforceps,andlavage.

Asepticallyplacesbiopsytissueintoformalin.


Monitorspatientheartrate,ECG,SpO2,andbloodpressurebefore,during,andafterprocedure.


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Patientcontinuouslymonitoredandtransportedtopost-procedurerecoveryareawhenstable.

Reassurespatient,removeselectrodes,processes,cleans,andsterilizesbronchoscope.

Takesappropriateactionforadverseresponsetoprocedureandnotifiesappropriatepersonnel.


Documentssiteofbiopsy,washings,andspecimens,aswellasserialnumberofbronchoscopeused.

Completesdocumentationinpatientrecord,andenterscorrectchargeforprocedure.

Effectivelycommunicatestestresultstoothermembersofhealthcareteam.



87

PulmonaryFunctionTesting

PreliminarySteps



Reviewsmedicalrecordsforprecautions,complications,relativecontraindications.



Ensuresthatsystemiscorrectlycalibratedandisfunctioningaccurately.




Explainsproceduretopatient.Obtainspatientage,sex,andheighttodeterminepredictedvalues.

Confirmspatient'sunderstanding.Ensuresthatpatienthasnotsmokedoreaten2hourbeforetest.


Properlyassemblesequipmentfortesting.

Enterspatientdataintocomputer.Obtainspulmonaryandsmokinghistory.

Explainsinstructionstopatientforventilatorymaneuvers.

Positionspatientinsittingposition.Documentsotherthansittingposition.

Measuresforcedvitalcapacity(FVC)withaminimumofthreetests.

Measurestotallungcapacity(TLC)orthoracicgasvolume(TGV).

Measuresmaximumvoluntaryventilation(MVV).

Measuresdiffusingcapacityoflung(DLCO).

Measuresfunctionalresidualcapacity.



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Observespatientanddocumentsmaximumeffort.

Determinesvalidityoftestresultsfromproperequipmentfunctionandtestreproducibility.

Takesappropriateactionforadverseresponsetotestingandnotifiesappropriatepersonnel.

Terminatesprocedureanddisposes/sterilizessuppliesindirectcontactwithpatient.


Printsrecordofprocedureandresultsformedicalrecord.




89

ArterialPunctureforBloodGasAnalysis

PreliminarySteps



ReviewsmedicalrecordsforMDorder,bleedingdisorder,anticoagulants,thrombolytics.








Selectsappropriatepuncturesite.

PerformsanAllen'stest(forradialarterypunctureonly).

Asepticallypreparesthepuncturesitebythoroughlycleaningsite.

Stabilizesareaandproperlypositionspuncturesite.(Injectssubcutaneousanesthetic,ifapplicable).

Ensuresthatthesyringeispre-heparinizedandthatthesyringevolumeispre-set(ifapplicable).

Atraumaticallypuncturesartery(usingarounda45degreeangleforradialarterypuncture).

Verifiespulsatilebloodflowandobtainsadequatevolumeofarterialblood.

Atraumaticallyremovesneedlefrompuncturesite&appliespressuretositefor5minutesminimum.

Needleprotectiondeviceisappliedtoneedle,thedeviceisremoved,andthesyringeissealed.

PatientIdentificationlabelisappropriatelyappliedtosampleatbedside(usingbarcodescanner).

Bloodsampleisplacedinice,andinsertedintoBiohazardbagfortransport.


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Re-evaluatespuncturesitetoverifytheabsenceofbleedingandhematomaformation.


Notestime,puncturesite,FIO2,oxygendevice,temperature,andventilatorsettings.


Appropriatelyprocessesallusedsuppliesanddisposesofsharpsincorrectcontainers.


Notifiesappropriatepersonneloftestresultsandcriticalvalues,anddocumentsnotification.

Documentsprocedureinmedicalrecord/computer,andensuresappropriatechargeisentered.



91

Polysomnography

PreliminarySteps



Reviewsmedicalrecordsforsleephistory,physicalexam,medications,andsleepscreeningstudies.



Introducesself&department.Explainsproceduretopatient/family&confirmspatientunderstanding.



AssistspatientinfillingoutPre-Sleepquestionnaire.Measures&documentsbaselinebloodpressure.


Correctlyassemblesequipmentandperformscalibrationsperinstitutionalprotocol.

MeasurespatientheadforelectrodeplacementusingtheInternational10-20system.

Gentlypreparespatientsscalpandappliesrecordingelectrodesusingtheappropriatemontage.

Correctlyappliesrespiratoryeffortbelts,andnasalcannulaforairflowmonitoring.

Appliesoximeterprobeandcorrectlyattacheselectrodestoextremitieswhenappropriate.

CorrectlyattachesEEG,EOG,EMG,andECGelectrodes.

Assistspatienttobed&correctlyattachesheadbox,oximeter,&nasalcannulatoappropriatedevice.

Correctlycheckselectrodeimpedanceofallrecordingelectrodes.

Performsanall-channelandmontagecalibration.Performspatient’sBio-Calspre&postprocedures.

Verifiesthatimpedanceislessthanorequalto10,000ohms.

Reapplieselectrodesthatdonotmeetimpedancerequirement.


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InitiatesvideotapingofprocedureanddigitalcaptureofPSG.Documentsinitiation(lightsout).

Continuouslymonitorspatientanddocumentsapnea/hypopneaeventsperinstitutionalprotocol.

Correctlyidentifiesartifactduringtherecordingandcorrectscauseofartifact.ObtainsaccuratePSG.

Takesappropriateactionforneededclinicalinterventionduringprocedure(Oxygen,CPAP,CPR).


CompletessummarydocumentationinpatientrecordofPSGProcedure/relevantclinicalobservations.

Preparespatientdata/chartforscoring.Completesbackupstoringofstudydata.Cleansallsupplies.

Disconnectspatientfromelectrodes&monitors,assistspatientwithcleanupfromelectrodeadhesive.



93

PolysomnographywithCPAPTitration

PreliminarySteps








Correctlyidentifiespatientusing2patientidentifiers.



Correctlyassemblesequipmentandperformscalibrationsperinstitutionalprotocol.

MeasurespatientheadforelectrodeplacementusingtheInternational10-20system.

Gentlypreparespatientsscalpandappliesrecordingelectrodesusingtheappropriatemontage.

Correctlyappliesrespiratoryeffortbelts,andnasalcannulaforairflowmonitoring.

AppliesoximeterprobeandCorrectlyattacheselectrodestoextremitieswhenappropriate.

CorrectlyattachesEEG,EOG,EMG,andECGelectrodes.

Assistspatienttobed&correctlyattachesheadbox,oximeter,&nasalcannulatoappropriatedevice.

Correctlycheckselectrodeimpedanceofallrecordingelectrodes.

Performsanall-channelandmontagecalibration.Performspatient’sBio-Calspre&postprocedures.

Verifiesthatimpedanceislessthanorequalto10,000ohms.

Reapplieselectrodesthatdonotmeetimpedancerequirement.

EvaluatessubjectsfacialfeaturesandselectsappropriatetypeandsizeofCPAPdeliverydevice.


94

Verifyfitofselectedsystemandadjustsasneeded.

InitiatesPSGrecordingforaminimumof2hours,documentslightsoutandstarttest.

TitratesCPAPpressuretodecreasesnoring,arousals;monitorssubjectresponseduringtherapeutictrial.

Continuouslymonitorspatientanddocumentsapnea/hypopneaeventsperinstitutionalprotocol.

Takesappropriateactionforneededclinicalinterventionduringprocedure(Oxygen,CPAP,CPR).


DocumentsPSG&CPAPpressurewhichdecreasesapnea/hypopneaevents,patientposition;masktype.

Completesdocumentationinpatientrecord.ContactsMDwhenindicatedperinstitutionalprotocol.

Effectivelycommunicatesresultstoothermembersofhealthcareteam.

Entersappropriatecharge.



95

PulmonaryRehabDevelopmentofIndividualizedTreatment

PreliminarySteps





WasheshandsandusesStandardPrecautions






Performsinitialpatientassessmentanddevelopsplanofcare.

Collaborativelysetsgoalswithpatientforselfcareandactivitiesofdailyliving.

Developsmutuallyagreedupontargetsforprogresstowardsgoals.

Performs6minutewalktestandcompletescalculationsforexerciseprescription.

Establishesindividualexerciseplanforgoalaccomplishment.

Preparesandadjustsindividualexerciseplanperprotocol.

Describescommonexerciselimitationsandappropriatelymodifiesexercise.

Demonstratesuseofgradedexercisetechniquesandintervaltraining.

Patientcompletesinitialself-assessmentdocumentation,perimitationalprotocol.

Providespatienteducationonuseofexerciseequipment&warmup,exercise,&cooldownperiods.


Completespatientassessmentbefore,during,andaftersession.


96

Patientsareadvisedtostopsmoking,avoidriskfactors,identifysymptomsearlyand

followupwithphysician;obtainpneumococcalandinfluenzavaccines.


DocumentsActivityofDailyLivinggoalsandexercisetargets.

Documentsplanandgoalsinpatientrecord,andsendscopiesofplantopatient'sphysician.

Effectivelycommunicatesplantoothermembersofhealthcareteam.

EntersappropriatechargeforsessionusingcorrectG-code.



97

PulmonaryRehabIndividualExerciseSession

PreliminarySteps











Completespatientassessmentforindividualizedexerciseneeds.

Collaborativelysetsgoalswithpatientforselfcareandactivitiesofdailyliving.

Developsmutuallyagreedupontargetsforprogresstowardsgoals.

Establishesindividualexerciseplanforgoalaccomplishment.

Providesindividualizedpatienteducationbaseduponidentifiedneeds.

Monitorspatientprogresstowardsgoalsandcoachesasneededbaseduponpatientassessment.

Providesindividualizedpatienteducationonuseofexerciseequipmentandbreathingexercises.

Providesindividualizedpatienteducationonuseofrespiratorymusclestrengthtrainingdevices.

Providesindividualizedpatienteducationonuseofpositiveexpiratorypressuredevices.

Providesindividualizedpatienteducationonuseofairwayclearance&bronchialhygieneequipment.


Completespatientassessmentbefore,during,andaftersession.


98

Evaluateseffectivenessofindividualizededucationbaseduponreturndemonstrationfrompatient.


Documentsprocedurestarttime,stoptime,andtotaltimein15minuteincrements.


Effectivelycommunicatesresultstoothermembersofhealthcareteam.

EntersappropriatechargeforsessionusingcorrectG-code.



99

AsthmaEducation

AssessAsthmaSeverity

Clinicianassessesasthmaseveritybycurrentimpairmentandfuturerisk.

Documentsseverityclassification.

UseWrittenAsthmaActionPlan(AAP)

Reinforcesandeducatespatientonskills&understandingforself-management&utilizationofAAP.

UsesAAPinelectronicmedicalrecord.

InhaledCorticosteroids

Explainslinkbetweenchronicnatureofasthmaandanti-inflammationviainhaledcorticosteroids.

Provideseducationalmaterialsthatareculturallyandlinguisticallyappropriate.

Correctlydemonstratesandexplainseaseofuseanddeliverydevice.

AssessandMonitorAsthmaControl

Assessescurrentimpairmentviapatientpeakflowmonitoring/pulmonaryfunctiontesting.

Encouragepatientdocumentationofpeakflows/triggersnoted/symptoms/medicinesindailyasthmadiary.

ScheduleFollow-upVisits

Implementspatientmonitoringandreferralpolicythatpromotestheincreaseofoutpatientfollow-up.

ControlEnvironmentalExposures

Documentsinstructionsgivenforidentifyingallergens/irritantstowhichpatientissensitive.

Documentsenvironmentalcontrolmeasuresaspatientagreesto.

Providespatient/familyeducationregardingtheavoidanceofsecond-handsmoke(explainstoparents

thattheyshouldneversmokeinacar/enclosedareawithanasthmaticchildpresent).

Educatespatientineventofasthmaattack,tobreatheslowlyandinhalethroughnose,exhaleslowly.

Providesresourcesavailableforsmokingcessation,allergen/irritantexposure.


100



Effectivelycommunicatesresultsoftoothermembersofhealthcareteam.



101

RapidResponseTeam

PreliminarySteps

Receivesnotificationofarapidresponsecall.

Respondsinatimelymanner.


Inspectsmedicalrecordsofpatientandreviewshistoryandphysicalexaminationresults.

Ensurespatientprivacy,washes/disinfectshands,andusesStandardPrecautions.


Introducesselfanddepartment.Receivesreportfromhealthcareteammembers.


Explainsassessmentproceduretopatient/familyandconfirmspatientunderstanding.

Performsinspection,notesactivitylevel,andbreathingposition.

Obtainscurrentvitalsigns(heartrate,respiratoryrate,bloodpressure,temperature).

Interviewspatientforcurrentproblemsanddyspnealevel(1-10scale).

Evaluatesairwaypatency.Manuallyopensairwayandprovidesmanualventilationifindicated.

Auscultateschestandperformsacompletecardiopulmonaryexamination.

Notescoughproductivityandsputumvolume/characteristics.

Obtainssmokinghistory(packsperyear).

Obtainsbaselinepulseoximetryreading&obtainsarterialbloodgassampleperinstitutionalprotocol.

Initiatesortitratesoxygentherapyperinstitutionalprotocol

Reviewsmedicationallergies;initiatessmallvolumenebulizer/MDItreatmentperinstitutionalprotocol.

ReviewscurrentchestradiographresultsandEKGresultsifavailable.

Performs&correctlyinterpretsadditionalbedsidetestingsuchasPFT,FVC,&peakflowifneeded.


102

Reviewsresultsofrelevantclinicaldata(chesttubeplacement,peripherallines,dialysis,etc.).


Identifiesandprioritizesclinicalproblems.

Synthesizesdata&recommends/initiatesappropriateRespiratoryCareplanperinstitutionalprotocol.

Effectivelycommunicates&collaborateswithothermembersofRapidResponseteam&caregivers.

ReportstohealthcareteammembersSituation,Background,Assessment,andRecommendations.


Completesdocumentationofclinicalproblems,careplan,andrecommendationsinpatientrecord.



103

WeaningandSpontaneousBreathingTrial

PreliminarySteps



Reviewsmedicalrecords.








Completesthefollowingventilatorbundleprocedures,perinstitutionalpolicy:

*PreventsVAPbymaintainingheadofbedgreaterthana30degreeangle.

*Completesscreeningcriteriaforreadinesstoweanfromventilator:

FiO2lessthan50%,Peeplessthan8cm.H2O,phgreaterthan7.25,spontaneouslybreathing,

minimalagitation,SpO2>88%,absenceofcardiacarrythmias,minimaldosageofvasopressors.

*Effectivelycommunicates/coordinateswithNursingforsedationvacation.

*Informspatient&performsSpontaneousBreathingTrialperprotocol(CPAPorPressureSupport).

*Identifies&documentssuccessfulSpontaneousBreathingTrial(Resp.Rate/Vt<105)after30mins.

*Performsoralcarewithinstitutionalapprovedoralrinseperpolicy.

*Suctionssub-glotticsecretionserinstitutionalprotocol.



104

FrequentlymonitorspatientduringSpontaneousBreathingtrialforsigns/symptomsofSBTfailure:

(Respiratoryrate>35orlessthan8breaths/min,SpO2satlessthan88%,respiratorydistress,

mentalstatuschanges,acutecardiacarrythmia,RSBI>105.

Ifanysigns/symptomsnotedforSBTfailure,discontinuesSBT,returnstopreviousventilator

settings,reassurespatient,informsMDandNurse,anddocumentsresults.





105