JC Respiratory Care Program RES 205 Clinical Practice III · JC Respiratory Care Program RES 205 Clinical Practice III David Zobeck, EdDINSTRUCTOR: , RRT, CPFT OFFICE: JW 221 OFFICE

Winter 2018 RES 205 Syllabus Page 1

JC Respiratory Care Program

RES 205 Clinical Practice III INSTRUCTOR: David Zobeck, EdD, RRT, CPFT

OFFICE: JW 221

OFFICE PHONE: (517) 796-8640

CELL PHONE: (717) 439-3005

EMAIL: [email protected]

Outline of Instruction

Division: Health Sciences Area: Respiratory Care

Course Number: RES 205 Course Name: Clinical Practice III

Prerequisite: RES 120 Respiratory Care Techniques III RES 124 Respiratory Pharmacology RES 125 Clinical Practice II RES 126 Cardiopulmonary Pathophysiology II

Credits: 5

Course Description/Purpose This clinical course allows students to assist in the pulmonary management of adults on mechanical ventilation. An integrated approach to patient care will be stressed through accurate patient assessment and application of various equipment and therapies. Students will also function as members of the health care team.

Major Units o Adult Critical Care: (Introduction) o Adult Critical Care: (Advanced)

Educational/Course Outcomes

The course goals and objectives incorporate specific General Education Outcomes (GEOs) and Essential Competencies (ECs)established by the JC Board of Trustees, administration, and faculty. These goals are in concert with four-year colleges, universities, and reflect input from the professional communities we serve. GEOs and ECs guarantee students achieve goals necessary for graduation credit, transferability, and professional skills needed in many certification programs. The course objectives addressed in this class include the following:

Performance Each student will be expected to: o Perform properly, according to clinical proficiency guidelines, the following procedures in adult ICUs: routine ventilator

checks, ventilator circuit changes and ventilator preparation and application, initiation of weaning protocol, and initiation of

continuous distending pressure therapy. EC 1

Attitudinal Each student will be expected to: o Display acceptable fluency in professional attitudes, professional medical ethics, and concern for patient’s rights as

prescribed in the Respiratory Care program’s Clinical Policies manual. EC 1

o Display acceptable fluency in professional attitudes, professional medical ethics, and concern for patients from diverse backgrounds as prescribed in the Respiratory Care program’s Clinical Policies manual. GEO 7

o Academic Honesty Policy: If there is any suspicion of academic dishonesty, JC's Academic Honesty Policy will be followed and appropriate action will be taken, up to and including assigning a failing grade for the paper, project, report, exam, or the course itself (whichever is deemed necessary). To see the policy, visit: https://www.jccmi.edu/wp-content/uploads/StudentCodeOfConduct.pdf.

o Incompletes Policy: (Excerpt from JC Policy) "A student may request an incomplete from the instructor. The incomplete will be granted only if the student can provide documentation that his or her work up to that point is sufficient in quality, but lacking in quantity, due to circumstances beyond the student's control. Furthermore, a written plan for making up the missing work within one semester must be completed by the student. Final determination of whether an incomplete will be given is the instructor's decision."

https://www.jccmi.edu/wp-content/uploads/StudentCodeOfConduct.pdf


Getting Extra Help: (Besides visiting me during office hours)

It can be very frustrating when you do not understand concepts and are unable to complete homework assignments. However, there are many resources available to help you with your study of respiratory care.

CENTER FOR STUDENT SUCCESS: Tutors (plus additional services for academic success) can be accessed by calling 796-8415 or by stopping by the Center for Student Success Bert Walker Hall, Room 138. Arrange to get regular assistance from a tutor. Students requiring special assistance (including those affected by the Americans with Disabilities Act) should contact the Center for Student Success. This is the first step in acquiring the appropriate accommodations to facilitate your learning.

STUDY GROUP: Find a study partner or a study group. One of your resources this semester will be the other students in your clinic assignment. There will likely be down time on some days that can be used to review for classroom assignments or exams that will lend themselves to a small group study. Sometimes it helps to work through problems with another person.

JETNET: There will be material posted there to help students and allow them to ask questions of the instructor and/or the group.

EMAIL: The best and quickest way to get a touch with an instructor.

Redo problems from tests and homework assignments, particularly ones that you got wrong or have trouble understanding

RES 205 PROFICIENCY EVALUATION LIST MANDATORY - All skills/tasks listed as MANDATORY must be evaluated, in writing (PEF), by the end of the clinical semester. The bolded activities are used to determine the PEF component of the clinical grade (see pages 1.11.3 and 1.14.7-8 of the Clinical Information & Policies Handbook).

A.14 CUFF MANAGEMENT - ARTIFICIAL AIRWAY CARE

B.06 BEDSIDE MONITORING - Parameters

C.01 ROUTINE VENTILATOR CHECK

C.02 VENTILATOR CIRCUITRY CHANGE

C.03 INITIATION OF MECHANICAL VENTILATION

C.04 CONTINUOUS DISTENDING PRESSURE THERAPY (PEEP & CPAP)

C.06 CRITICAL CARE TRANSPORT (ADULT)

C.07 IMV AND VENTILATOR WEANING

C.08 NIPPV

C.10 EXTUBATION


EVALUATION

Points for evaluation are assigned in the following fashion:

a. Pass/Fail Components (ALL must be satisfactory)

1) Completion of patient assessments

2) Satisfactory physician contact time

3) Completion of mandatory proficiencies

4) Satisfactory affective evaluations

5) Satisfactory attendance

6) Completion of daily ICU report sheets for each assigned patient

7) Completion of an approved special project

b. patient assessments = 20 points (4 patient assessments)

c. clinical exams = 20 points (2 exams)

d. physician contact = 20 points e. log sheets = 10 points

f. proficiency evaluations = 20 points

g. special project = 10 points

100 total points possible

h. attendance = +1 if no absences/tardies during the semester, or

0 if only 1 absence/tardy during the semester, or

-1 for each unexcused absence beyond the first during the semester.

Also regarding attendance:

1. Please refer to the JC Clinical Information and Policies Handbook, which states that “Any absence is considered unexcused if

not accompanied by an appropriate notification of absence to the Clinical Instructor”.

2. In addition, students need to contact the Clinical Coordinator in case of absence (text or call).

3. Please be sure you have the correct phone numbers available in advance of your needing to use them.

4. Failure to call in properly will result in the consequences spelled out in the Handbook, and will also result in a 5 point deduction from the

final clinical grade for each occurrence.

5. One 8 hour absence is allowed per this rotation. Absence above 8 hours must be made up to fulfill the required ICU clinical hours.

6. Failure to maintain up to date health records and CPR certification will result in the immediate removal from clinical and/or a

weekly 5 point deduction from the final grade until records are in compliance.


GRADING

To pass RES 205 the final course average score must be ≥ 76%.

Final Course Average Score = (total pts earned/total pts possible) x 100

Grading Scale for All Respiratory Care Courses:

4.0 = 93 - 100 3.5 = 89 - 92 3.0 = 84 - 88

2.5 = 80 - 83 2.0 = 76 - 79 1.5 = 73 - 75

1.0 = 68 - 72 0.5 = 64 - 67 0.0 = Below 64

RES 205 ADULT CRITICAL CARE CLINIC

TENTATIVE GUIDELINES / POLICIES

Students will spend their entire ICU rotation in the same hospital. The clinical topic emphasis will change with each phase.

The first phase is an introduction to ventilator patients in various adult intensive care units. During this introduction there will

be review, practice, and assessment of the students' basic critical care skills such as: airway management (including suctioning and endotracheal tube cuff maintenance), blood gas sampling from the radial artery or arterial line, and ABG analysis, and gathering of weaning parameters (V

• E, VT, VC, IC, and NIF). Treatments and other procedures performed previously in RES 105 and 125 on general floors will now be performed with ICU patients. Students will perform ventilator checks and may be involved in the transport of critically ill cardio-respiratory patients.

The second phase's tasks will continue to build on the knowledge and skills students have acquired in the first half of the rotation and will include: ventilator set up and application, performing ventilator circuit changes, doing compliance studies (as permitted), establishing IMV ventilator therapy, weaning and extubating patients (as ordered by a physician and permitted by the host clinical agency), and initiating and maintaining CPAP therapy (as ordered by a physician). The timetable for a student attempting new tasks will be determined by that student’s performance as evaluated by the clinical instructor. The pace may vary from student to student but all tasks on the list of Mandatory Proficiency Evaluation Forms for RES 205 must be performed and have a documented assessment of performance by the end of the semester.

The overall goal of this semester is to produce and sharpen the students' critical care skills and knowledge to a level where hiring clinical agencies would feel comfortable in assigning these individuals immediately (but within their orientation guidelines) to the adult ICUs to provide basic ventilator care.

Students will be responsible to clock in and clock out in the online tool to document the attendance at the clinical site. In addition, students should complete procedure counts for each clinic day.

Tardiness in turning in clinical documents to the Clinical Coordinator–i.e., past the due dates specified in the class calendar–will result in a loss of points from the log component of the clinical grade as determined by the Coordinator. NOTE: journals, time tracking and physician documentation should be completed within 24 hours of the end of your clinical day. Points will be deducted accordingly.


RES 205 Clinical Objectives The following objectives will be used to construct the mid-term clinical exam: Given appropriate information for the adult patient:

1.1 determine if a patient is indicated for mechanical ventilation.

1.2 suggest ventilator parameters for a patient being placed on mechanical ventilation, including mode, volume, rate, flowrate, oxygen percentage, PEEP, sigh volume/frequency, alarm settings and other settings as available.

1.3 determine which ventilator parameter needs adjustment to correct a patient’s response to mechanical ventilation.

1.4 interpret normal flow, volume, pressure graphs as seen on modern ventilators.

1.5 identify hazards associated with mechanical ventilation and recognize the patient assessment data associated with these hazards.

1.6 determine which ventilator alarm will sound given a variety of patient situations.

1.7 determine the correct action in response to a ventilator/patient interface malfunction or change in patient condition.

1.8 determine if a patient is indicated for weaning from mechanical ventilation.

1.9 perform common calculations associated with the management of mechanically ventilated patients.

2.1 select initial ventilator parameters based upon the specific cardiopulmonary management goals of a variety of diseases and conditions common to the ICU.

2.2 change ventilator parameters based upon the patient’s response to, and in keeping with, the specific cardiopulmonary management goals of a variety of diseases and conditions common to the ICU. Information given to make these changes can include data gathered from the patient’s physical assessment, lab values (ABG, etc.), and monitoring (ventilator graphics, etc.)

2.3 identify the purpose of various drugs used in the management of the above diseases or conditions.

2.4 determine an appropriate weaning technique and suggest initial settings for oxygen and other parameters such as pressure support for patients with the above diseases or conditions.

The final clinical exam will be a modified NBRC Certification exam. It will include all topics covered in the program to date.

PATIENT ASSESSMENTS

Although there may be many unique and interesting patient cases available for assessment during this clinic, the major thrust is in basic adult critical care. As such, the most benefit will come from in-depth familiarization with commonly encountered disease states. With this in mind, the patient assessments are to be selected from the following types of ventilator cases: COPD with a complicating pneumonia, chest trauma, ARDS, coronary artery bypass surgery, neurotrauma, cardiogenic pulmonary edema, or non-cardiogenic pulmonary edema. Although only four patient assessments will be evaluated for points you may complete more, for purposes of interest, and education if you wish.


JACKSON COLLEGE - RESPIRATORY CARE PROGRAM

PATIENT ASSESSMENT SYSTEM© ADULT CRITICAL CARE

STUDENT(S) Susie Paxil

PHASE #1 ASSESSMENT # 1 #2 #3 #4 Date of Admission 12/20/17 EXAM DATE 1/29/18

A. GENERAL PATIENT INFORMATION: 1. PRIMARY DISEASE: CARDIAC SURG PNEUMONIA NEURO (NON-CHI) CHI COPD AND COMPLICATIONS

(limit selection to these) ARDS ACUTE CHF CHEST TRAUMA OTHER

2. AGE 45 3. SEX M/F 4. BODY TYPE: Thin Moderate Obese

5. PERTINENT HISTORY: Patient was admitted on 12/20/17 and intubated for progressive respiratory failure which turned

out to be caused by ARDS. Pt. developed R-sided pneumothorax with chest tube placement on 12/25/17. Patient was trached on 12/29/17.

6. PRESENT CARDIOPULMONARY DIAGNOSES: Pt ARDS gradually resolving and looks about ready to wean from the vent.

7. RESPIRATORY THERAPIES ORDERED (INCLUDE ROUTINE THERAPIES, VENT SETTINGS & MODES, ETC.): Nebulized inline albuterol 2.5 mg with 3mL acetylcysteine Q4hr +prn, Vent: SIMV, f 10 bpm, VT 450 ml, FIO2 0.4, PEEP 5 cm H2O, PSV 8 cm H2O

B. RESPIRATORY PHYSICAL ASSESSMENT (FILL IN BLANK OR CIRCLE APPROPRIATE DESCRIPTORS):

1. AIRWAY TYPE Trach SIZE 8 mmID 9. WOB OK

2. ET TUBE POSITION @ LIP N/A cm 10. BODY TEMP 36.9 C

3. AIRWAY SECURITY foam trach ties 11. CENTRAL CYANOSIS...........Y/N

4. AIRWAY HYGIENE oral suction Q3 hr 12. PERIPHERAL CYANOSIS.....Y/N

5. BREATH SOUNDS diminished LLL and RLL, coarse rhonchi and exp wheezing at bases

6. SECRETIONS moderate amount of thick, white secretions

7. SPUTUM CULTURE (date) N/A

8. CHEST X-RAY(date) Significant consolidation throughout all lung fields 12/25/17. ETT noted 3 cm above carina.

Latest CXR on 1/28/17 shows patchy infiltrates particularly in bases but otherwise clear. Trach tube in correct position.

C. LAB VALUES(date) K+ 4.2 n Na+ 128 n Cl- 109 n RBCs 4.49 n neutrophils 14.6 nBNP 34: n

1/26/18 LA glucose 106 n platelets 223 n PTT 56 n WBCs 11 n lymphocytes 1.42 n

D. THORACIC DRAINAGE (FILL IN BLANK OR CIRCLE APPROPRIATE DESCRIPTORS): 1. TUBE LOCATION removed from R on 1/3/18

FUNCTION: 2. AMOUNT OF DRAINAGE N/A cc 3. COLOR N/A

4. VACUUM APPLIED & BUBBLING VACUUM APPLIED & NO ACTIVITY OPEN TO AIR CLAMPED

E. CARDIOVASCULAR ASSESSMENT (FILL IN BLANK OR CIRCLE APPROPRIATE DESCRIPTORS) if value is not available indicate with N/A:

1. HEART RATE 93 B/min 4. SKIN COLOR pink 7. PER. EDEMA Y/N

2. RHYTHM....................REGULAR/IRREGULAR 5. SKIN TEMP warm 8. PUL. EDEMA Y/N

3. BLOOD PRESSURE...SYS 110 mmHg/DIAS 39 mmHg 6. VENOUS ENGORGEMENT...........….................Y/N ________ 9. RAP/CVP N/A mmHg

_________ 11. PWP N/A mmHg

_________ 13. MAP N/A mmHg 15. SVR N/A mmHg

10. PAP N/A mmHg _________ 12. C.O. N/A L/min

_________ 14. C.I. N/A L/min/m2 16. PVR N/A mmHg

F. RENAL: 1. URINE OUTPUT 108 mL/hr n 2. BUN 6 n 3. CREATININE 0.5 n

G. ABDOMEN (CIRCLE APPROPRIATE DESCRIPTOR): 1. Soft/Firm 2. Distended/Non-distended 3. Circumference is: no change

H. NEUROLOGICAL ASSESSMENT: 1. PUPILS PERRLA 2. ICPs N/A mmHg 3. LEVEL OF CONSCIOUSNESS: Comatose Obtunded Somnolent Lethargic Awake/Alert Sedated 4. DISORIENTED TO: Person Place Time No apparent disorientation Unable to assess due to sedation


I. NUTRITION NOTE: TPN - Adult 2 in 1 lipids 2400 cal continuous @ 100 mL per hr

J. CARDIOPULMONARY DRUG ORDERS:

BRAND NAME GENERIC NAME PHYSICAL ACTION THERAPEUTIC GOAL

Oxygen Increase PAO2 to increase PaO2 Relieve hypoxia, decrease WOB

Lasix furosemide Loop diuretic to reduce fluid Treat increased fluid

Ativan lorazepam Benzodiazepine used to treat anxiety Relieve anxiety and keep pt calm

K. Pulmonary Mechanics: spont. f 22 bpm spont. VT 290 mL RSBI 76 bpm/ml VC 1.8 L MIP -35 cmH2O

(NOTE: Pulmonary Mechanics are spontaneous parameters. They are NOT the values obtained from a ventilator check, even during spontaneous breathing. Those are documented below.)

VENTILATOR MANAGEMENT: Completely fill in the INITIAL PARAMETERS section but record ONLY THE CHANGES made and the subsequent ABG values in the following CHANGE sections. This section may include therapies and/or monitored parameters that do not apply to your patient; mark these "N/A." In the CURRENT PARAMETERS section, record current settings, if they differ. Where possible, correlate ABGs to ventilator settings, to show appropriate relationships.

VENTILATOR PB 840

VENT CHECK Initial Parameters Change #1 Change #2 Current Parameters

DATE/TIME 12/20 1730 12/25 0900 12/25 1100 1/28 1330

MODE

(NOTE ALL

THAT APPLY)

A/C, SIMV or CPAP SIMV AC AC SIMV

Breath Type (PC/VC) VC VC VC VC

BiLevel/BiPAP

VENTILATION

fSET/fPT 14/16 CO2=46 16/20 CO2=54.6 ↑28/28 CO2=57.3 10/14 CO2=41

VT (SET)/VT (SPONT) 450/270 450/N/A 300/N/A 450/300

MINUTE VOLUME 6.8 LPM pH=7.38 9.0 LPM pH=7.31 8.4 LPM pH=7.28 5.7 LPM pH=7.38

SBT (Y/N) N HCO3=23 N HCO3=25 N HCO3=24 Y HCO3=23

PIP/PPlat/MAP 29/24/12 42/39/22 35/30/17 29/24/12

CSTAT/RAW 25 ml/cm H2O 16.7 ml/cm H2O 21.4 ml/cm H2O 25 ml/cm H2O

BiPAP or PCV IPAP

OXYGENATION (NOTE SaO

2 and/or

SaO2, as available)

FIO2 0.50 PaO2=71 0.90 PaO2=51 0.90 PaO2=61 0.40 PaO2=81

PEEP/CPAP 3 SaO2=93 12 SaO2=86 ↑16 SaO2=90 5 SaO2=94

DIST OF FLOW

and WOB

INSP TIME/I:E 1:4.7 1:2.7 1:1.7 1:4.7

Flowrate/Waveform 50 lpm 60 lpm 70 lpm 60 lpm

PSV Y (Value)/N Y (8 cm H2O) N N Y (8 cm H2O)

Trigger Type/Level Flow 1 lpm Flow 1 lpm Flow 1 lpm Flow 1 lpm

Auto PEEP/Tube Comp.

OTHER Pt developed pneumo Pt on norcuron

OTHER Pt 5’4’’; IBW 55 kg 8cc/kg 8cc/kg 5cc/kg 8cc/kg


L. CRITICAL CARE MATH: Calculate the following equations using information gleaned from the chart. (Please use a barometric pressure (PB) of 760 mmHg for appropriate calculations if the correct PB is not known for the day of the assessment). Note the large spaces made available here, and please SHOW YOUR WORK—and the appropriate UNITS. If you do not have an appropriate set of data to complete a calculation (i.e, no venous values for CvO2, A-aDO2 or shunt, or no PECO2 for VD/VT, or no spontaneous parameters for RSBI), please note this and list a set of “made-up” values so that you can perform the calculations. However, ideally you will seek out patients who will have all of the required data available, so that you can see how these values are applied in the real world.

Using ABG/vent settings from 12/25 at 0900 pH=7.31; CO2=54.6; HCO3=25; PaO2=51; SaO2=86%; FIO2 0.90 ; Hgb 11.1; EtCO2 36; PvO2 32; SvO2 61% (Pt. had Swan at that

time); VT 450ml; PIP/PPlat 42/39; PEEP 12 cm H2O; Flow 60 lpm 1. PAO2

= (760-47) x 0.9 – 54.6/0.8

= 713 x0.9 – 68.25

=641.7 – 68.25

= 573.5 mm Hg 2. P(A-a)O2

=573.5 – 51

=522.5 mm Hg (nl: 25-65 mmHg according to RES 120 Unit 4 lecture notes) 3. CaO2

= (1.34 x 11.1x 0.86) + ( 0.003 x 51)

= 12.79 + 0.153

= 12.9 Vol % (nl: 20 vol % according to RES 120 Unit 3 lecture notes) 4. C v O2

= (1.34 x 11.1x 0.61) + ( 0.003 x 32)

= 9.07 + 0.096

= 9.2 Vol % (nl: 15 vol % according to RES 120 Unit 3 lecture notes) 5. C(a- v )O2

=12.9 – 9.2

= 3.7 Vol % (nl: 5 vol % according to RES 120 Unit 3 lecture notes) 6. VD/VT

= 54.6 -36 54.6

= 0.34

= 34% (nl: 20-40% according to RES 120 Unit 4 lecture notes)


7. QS/QT = PA-aO2 x 0.003

Ca-vO2 + (PA-aO2 x 0.003)

= 522.5 x 0.003 3.7 +(522.5 x 0.003)

= 1.56 5.27

= 0.296

= 30% (nl: <10% according to RES 120 Unit 4 lecture notes)

8. P/F ratio

= PaO2 FIO2

= 51

0.9

= 56.7 (nl: 350-400 according to RES 120 Unit 4 lecture notes) 9. RSBI (spontaneous breathing only) values from 1/28/18 SBT (they could not be obtained at the time the rest of

these values were obtained due to severity of pt’s ARDS) = Resp rate

Tidal vol

= 22 0.29L

= 75.6 (nl: 20-40; >100 indicates need for vent according to RES 120 Unit 4 lecture notes) 10. CLT-STATIC and CLT-DYNAMIC

Dyn compliance = exhaled VT = 450 = 450 PIP- PEEP = 42- 12 = 30

= 15 ml/cm H2O (nl: 50 ml/cm H2O according to RES 120 Unit 1 lecture notes)

Static compliance = exhaled VT = 450 = 450

PPlat - PEEP = 39- 12 = 27

= 16.7 ml/cm H2O (nl: 70 ml/cm H2O according to RES 120 Unit 1 lecture notes) 11. ∆P due to RAW and RAW itself

∆P = PPeak- PPlat = 42- 39 = 3 cm H2O

Convert flow of 60 lpm to L/sec by dividing by 60; Flow = 1 L/sec

RAW = PPeak- PPlat = 3 cm H2O flow = 1 L/sec

= 3 cm H2O /L/sec (nl: 0.6-2.4 cm H2O/L/sec according to RES 120 Unit 1 lecture notes)


M. PRESSURE, FLOW, AND VOLUME SCALARS (waveforms)

Vent settings from 1/28 at 1330 (so we can graph a spont breath)

Mode: SIMV / VC

f (set/Tot) : 10/14 bpm

VT (set/spont): 450/300 ml

PEEP: 5 cm H2O

Issues:

Flow: 60 lpm

PIP/PPlat: 29/24 cm H2O

PSV: 8 cm H2O

Diagram curves typical for this pt. Correlate to pt’s settings by describing the settings at the time below. If there are any significant issues apparent in these curves, please describe them.


N. COMPLIANCE (P-V) LOOPS

Mode: SIMV / VC



PIP/PPlat: 29/24 cm H2O

PSV: 8 cm H2O

PEEP: 5 cm H2O

Issues:

Mode: SIMV / VC



PIP/PPlat 29/24 cm H2O

PSV: 8 cm H2O

PEEP: 5 cm H2O

Issues:

Diagram a loop for a typical machine breath. Correlate to patient’s settings by describing the settings at the time below. If there are any significant issues apparent in this loop, please describe them.

Diagram for a typical spontaneous breath (if available). Correlate to patient’s settings by listing the settings at the time below. If there are any significant issues apparent in this loop, please describe them.


O. ABGs Date Time Vent √/∆ pH PaCO2 PETCO2 HCO3- PaO2 SaO2 SPO2 Hgb

a. 12/25 0900 √ 7.31 54.6 36 25 51 86% 88% 11.1

OTHER RELEVANT DATA (i.e., vent settings at the time): AC/ VC VT: 450ML , RR 16(20) BPM, FIO2 90%, PEEP 12 cm H2O

b. 12/25 1100 ∆ 7.28 57.3 35 24 61 90% 92% 11.0

OTHER RELEVANT DATA (i.e., vent settings at the time): AC/ VC VT: 300ML , RR ↑28 (28) BPM, FIO2 90%, PEEP ↑16 cm H2O

c. OTHER RELEVANT DATA (i.e., vent settings at the time):

d. OTHER RELEVANT DATA (i.e., vent settings at the time):

START OF SHIFT ABG interpretation END OF SHIFT ABG interpretation

Which ABG? 12/25 0900 12/25 1100 (after ventilator changes)

Acid-Base: Uncompensated respiratory acidosis Uncompensated respiratory acidosis

Ventilation: Acute hypoventilation Acute hypoventilation (permissive hypercapnia)

Oxygenation: Moderate hypoxia Mild hypoxia

Parts P - R require that you evaluate your collected data and synthesize some of YOUR OWN conclusions as to actual pathologies occurring, effectiveness of present therapy, and what further therapies might be considered reasonable. These sections can be done on outside time. Ask your instructors, doctors, therapists, nurses, or use appropriate textbooks to help gather information to provide a picture of OPTIMAL care. These can be taken home to complete, but remember that these are NOT case presentations. Hit major points, don't get bogged down in the kind of detail that fills up a book. P. DIAGNOSIS: Pulmonary Dx and Functional Pathology (Get from pathology book, or literature research)

RESPIRATORY DISORDER ARDS

IF APPLICABLE, INDICATE WITH √ ATELECTASIS ALVEOLAR CONSOLIDATION X INCREASED ALVEOLAR CAPILLARY MEMBRANE THICKNESS X BRONCHOSPASM EXCESSIVE BRONCHIAL SECRETIONS X DISTAL AIRWAY WEAKENING

Conduct your own research (journal articles and text books) and look for resources that include: Definition, Etiology, Pathology, Clinical manifestations, Complications, Mortality/ Prognosis, Treatment, and Special procedures. You MUST be specific to your

patient when relating researched material to your clinical case. You must have at least 3 resources and only one can be a

textbook. Use your references to support, or not support the therapies ordered and your suggestions. On a separate piece of

paper, create an APA formatted reference page for the references that you used. You must turn in

your reference articles along with your case study and reference page.

Burns, K.E.A., Soliman, I., Adhikari, N.K.J., Zwein, A., Wong, J.T.Y., Gomez-Builes, C., Pellegrini, J.A., Chen, L., Rittayamai, N., Sklar, M., Brochard, L.J., & Friedrich, J.O. (2017). Trials directly comparing alternative spontaneous breathing trial techniques: A systematic review and meta-analysis. Critical Care, 21(1):127.

Perme, C., & Chandrashekar, R. (2008). Managing the patient on mechanical ventilation in ICU: Early mobility and walking program. Acute Care Perspectives, 17(1), 10-15.

Strickland, S. L., Rubin, B. K., Haas, C. F., Volsko, T. A., Drescher, G. S., & O’Malley, C. A. (2015). AARC clinical practice guideline: Effectiveness of pharmacologic airway clearance therapies in hospitalized patients. Respiratory Care, 60(7), 1071-1077. doi:10.4187/respcare.04165


Q. THERAPIES ORDERED AND CONFIRMED INDICATIONS (Correlate with physical assessment and lab data YOU have gathered. Do NOT reiterate indications or goals stated by others in the chart; conclude from your OWN assessment information that is recorded on the previous pages of this form.):

THERAPIES (INCLUDING VENT THERAPIES) INDICATIONS ACTUALLY PRESENTING (NONE MAY BE APPROPRIATE)

SVN albuterol This pt. is experiencing wheezing (bronchospasm)

/acetylcysteine There is no indication for this medication (secretions are moving well)

Mechanical ventilation:

SIMV / VC Pt is able to breathe spontaneously and has good parameters, so this mode is appropriate for status

VT 450ml This gives VT of 8cc/kg, which is current standard for non-ARDS pt.

f 10 bpm Combined with above VT, this is resulting in normal pH and PaCO2 and pt. appears comfortable while taking spont breaths (adequately exercising vent. muscles)

FIO2 40% Given that the SaO2 is < 92% this might be able to be weaned slightly

PEEP 5 cm H2O This is at minimum standard for maintaining physiologic PEEP

PSV 8 cm H2O This is resulting in adequate VTs now; as pt will be getting weaned on f it is possible that this may need to stay at this level to help pt tolerate the next stage of weaning

R. RESPIRATORY CARE PLAN/SPECIAL NOTES (NOT to be a restatement of charted plans. Develop your OWN plans according to OPTIMAL therapy per your research as stated in the pathology and therapy sections of your texts or journals.): Use APA citation when citing your chosen literature.

Dr. Jones. I recommend the following: 1) Continuing albuterol as pt continues to have some wheezing. Recommend changing to MDI 2 puffs QID. Perhaps once vent

is d/c’d then pt can be evaluated for the possibility of switching to LABA (assuming she continues to need a bronchodilator).

2) D/C Mucomyst as pt. no longer has secretions so thick she can’t easily mobilize them herself.

See Strickland et al, 2015, and recommendations to not use Mucomyst routinely to aid in secretion clearance.

3) Given the pt has excellent parameters, RSBI, and ABGs, I recommend placing on spont, with wean to progress as tolerated.

The pt. has not had a lengthy SBT since she has gotten weaned from paralytics and switched to SIMV, so she may need PSV

level left as is while trying this SBT. But I’d recommend weaning PSV to 5 cm H2O as per protocol and as tolerated.

Otherwise I’d recommend FIO2 and PEEP be left as is for now to be altered as tolerated during wean.

See Burns et al, 2017, and recommendations regarding PSV weaning.

4) Evaluating status of airway with an eye toward removing trach as soon as tolerated.

5) The pt. has been receiving PT /ROM exercises in bed, but not really ambulating; recommend ambulation begin ASAP.

See Perme and Chandrashekar, 2008, and recommendations to begin ambulation while in ICU to improve outcomes.

Over the longer term I’d recommend discharge planning begin with:

1) Evaluating pt as she improves to determine if home oxygen is needed with 6-minute oxygen walk;

2) Evaluating pulmonary status with PFT to determine if she needs long term bronchodilators and also extent of long term

damage (if any) to lungs;.

3) Beginning pulmonary rehab if needed;

4) Referring pt to home care company to set up any equipment needed at home;

5) Possible transfer to CareLink to aid in transition to home.

S. CALCULATIONS: Students will be responsible for being able to apply any and all equations to clinical and physiological data as deemed appropriate by the Clinical Instructors. For guidance in this area, please refer to the JC Pulmonary Physiology Math computer program and the RES 120 Respiratory Therapy Equations handout. These are NOT the ONLY equations for which you will be held accountable.

T. ADDITIONAL INSTRUCTIONS/INFORMATION: The purpose of the patient assessments is to encourage integration of classroom knowledge about cardiopulmonary diseases and their respiratory care with the clinical experience you can only get at the patient’s bedside. This is a thorough look at a patient’s cardiopulmonary management while they are in your care (i.e. during an 8 hour shift). Do NOT look far into the past for information, deal with what is at hand.

Parts A - K require information that should be available simply as part of routine data gathering, i.e. extra effort should NOT be required to get this information. If you find it takes a great deal more effort to complete these sections of the patient assessment form than you normally spend on information gathering, then your PREVIOUS information gathering procedure needs to be made more complete on a routine basis. If a patient does not have certain test results in his/her chart which might be needed to complete the patient assessment, just mark that particular blank "N/A" for "not applicable."

"


APA guidelines: Resource: Purdue OWL: APA Formatting and Style In Text Citations: http://owl.english.purdue.edu/owl/resource/560/02/ Reference List: http://owl.english.purdue.edu/owl/resource/560/05/ Reference citations with multiple authors: http://owl.english.purdue.edu/owl/resource/560/06/ Reference list: Articles in Periodicals: http://owl.english.purdue.edu/owl/resource/560/07/ APA sample paper, last page for reference list: http://owl.english.purdue.edu/owl/resource/560/18/ Samples:

Journal: Watts, G. E., & Hammons, J. O. (2002). Leadership development for the next generation. New Directions for Community Colleges, 120(1), 59.

Single report: Weisman, I. M., & Vaughan, G. B. (2002). The community college presidency: 2001. Washington, DC: American Association of Community Colleges.

Website: Wai-Packard, B. (2009). The definition of mentoring. Retrieved on Nov. 23, 2015 from http://ehrweb.aaas.org/sciMentoring/Mentor_Definitions_Packard.pdf.

Textbook: Tesch, R. (1990). Qualitative research: Analysis types and software tools. New York, NY: Falmer.

Ask for help with citations at least a week ahead if possible.

Jackson College

Respiratory Care Program

Adult ICU Competency Guidelines

The goal of JC is to produce respiratory therapists who are ready to competently work in the ICU by graduation.

Please use the following guidelines when assigning ICU patients, and filling out the students’ evaluations in

order to determine competency of our students.

These are bare minimum requirements. Students can be assigned a higher patient load before the time frame

stated below if the student is capable of safely caring for more patients.

I recommend that students NOT be given more than 6 intubated/BiPAP patients during a shift on their

ICU rotation.

Competent= Capable to assume all respiratory care of assigned patients in a timely and proficient manner. The

student should also be knowledgeable of the patient’s current hemodynamic status, pertinent medical history

and make suggestions for the care of their patients.

Weeks 1-2 Students should be competent to care for 2 vented and/or Acute BiPAP pt.s

Weeks 3-6 Students should be competent to care for 3 vented and/or r Acute BiPAP pt.s

Weeks 7-9 Students should be competent to care for 4 vented and/or Acute BiPAP pt.s meaning, student

should be able to care for a reasonable RRT workload at or near employee level

http://owl.english.purdue.edu/owl/resource/560/02/





http://ehrweb.aaas.org/sciMentoring/Mentor_Definitions_Packard.pdf


ICU Schedule (12 hour shifts) Week Monday Tuesday Wed Thursday Friday

1 Jan

JAN 15

16 ICU Clinical Orient. #1:

T/W groups

ICU Clinical Orient. #1:

T/Th group

17 ICU Clin. Orient. #2

18 ICU Clinical Orient. #1:

Th/F groups

ICU Clin. Orient. #2


2

22


ICU Clinical Orient. #3 24 ICU Clin. Orient. #4


ICU Clinical Orient. #4


3 Jan/ Feb

29

30 Clinical Day 1 31 FEB 1 Clinic Day 2 2 Convocation

4

5 4-6PM

RES 205

Mandatory

Meeting

Spec. Proj. Title Due

6 Clinic Day 3

7

8 Clinic Day 4

9

5 12

13 Clinic Day 5

14

15 Clinic Day 6 Formative Eval 1

16

Advisory Committee

6 19 4-6PM

RES 205

Mandatory

Meeting

Pt Assessment 1

20 Clinic Day 7

21

22 Clinic Day 8

23

7

Feb/

Mar

26

27 Clinic Day 9

28

MAR 1 Clinic Day 10

2

8 5

6 Clinic Day 11

7

8 Clinic Day 12 Formative Eval 2

9

Spring

Break 12

SPRING

13

BREAK

14

!!!!!

15

NO

16

CLASS!!!!

9 19 4-6PM

RES 205

Mandatory

Meeting

Pt Assessment 2

Clinic Exam 1

20 Clinic Day 13

21

22 Clinic Day 14

23

10 26 27 Clinic Day 15 28 29 Clinic Day 16 30

11 Apr

APR 2 Pt

Assessment 3

3 Clinic Day 17

4

5 Clinic Day 18 Last Clinical Day,

Summative Eval

6

12

9 Clinical Cardiac

Devices;

ACLS Mock Exercises Research Project Due

Guest Lecture

10 12-3PM

RES 205

Mandatory

Meeting

Spec. Project/

Pt Assessment 4

MOCK CRT Exam

11

MSRC Dearborn

12

MSRC Dearborn

13

MSRC Dearborn

Documents

JC Respiratory Care Program RES 205 Clinical Practice III · JC Respiratory Care Program RES 205 Clinical Practice III David Zobeck, EdDINSTRUCTOR: , RRT, CPFT OFFICE: JW 221 OFFICE