· Web viewDiscuss the controversy of correcting metabolic acidosis with alkaline agents Discuss blood gas results from mixed venous sites (PAC) and central venous sites (central lines)

CLINICAL OBJECTIVES2012 GRADS

Index of rotations**For a quick link to the desired rotation objectives, place curser over rotation name and follow instructions.

Adult ICU

Asthma Education

Community Care

Emergency

Hyperbaric Oxygen Therapy

Neonatal ICU

Operating Room

Pediatric Wards

Pediatric ICU

Pulmonary Functions

Sleep

Wards

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SCHOOL OF HEALTH SCIENCES RESPIRATORY THERAPY

AICU I and II

Rotation overview:

In the AICU clinical rotation students will practice skills and demonstrate knowledge required to conduct care of critically ill adult patients in the ICU setting. Students are expected to work with their preceptors to gain experience with the outlined clinical objectives, as well as practice and achieve competency with related CBO’s. Clinical experience may vary somewhat based on the type of ICU, and volume of patients, therefore two 4 week rotations are scheduled at different clinical sites to optimize exposure to the complete list of clinical objectives and related CBOs. Although the same list of clinical objectives applies to rotation 1 and 2, students will be expected to perform in the 2nd rotation with more independance, and assume responsibility for a larger volume of patients and skill sets.

Schedule 12 hour shifts which may include nights and weekends. See Site Schedules

Pre Rotation Clinical Simulation Week prior to 1st AICU rotation only Pre rotational exam prior to 1st AICU rotation only (80% to pass). The

break down for the exam is under AICU Clinical Simulation. See schedule in Clinical Simulation

Site orientation Orientation will be provided by the NAIT clinical instructor except for Red Deer which will be provided by that sites RTs/preceptpors.

Workbook/Assignment

Workbook 1 must be done in time for review on AICU 1 common day Workbook 2 must be done in time for review on AICU 2 common day Some questions may require presentation on common day Workbooks will not be marked but are meant as a self study tool and

guide for review on common dayCommon Day Common class day will be scheduled in the 3rd week of each AICU

rotation See Common Day Schedule for date, time and location of common day

Exam Post rotation exam 1 will be written at the end of AICU 1 (60% to pass) Post rotation exam 2 will be written at the end of AICU 2 (60% to pass) Exams will be graded and count towards the final RET602 mark Exam dates will be scheduled by NAIT clinical site faculty

Clinical Performance Evaluation

One mid rotation evaluation required for each rotation One end point evaluation required for each rotation

Clinical Objectives

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Upon completion of the AICU Clinical Rotation, the student will be able to:

Professionalism Adhere to dress code, and maintain professional appearance Report to shifts on time Demonstrate respect towards patients, health care staff and preceptors Maintain patient privacy and confidentiality Advocate patient care and safety Demonstrate compassionate care Practice within ethical guidelines Adhere to scope of practice limitations Integrate with an interdisciplinary approach to patient care Demonstrate flexibility and adaptability when working with others Manage and resolve conflicts constructively Demonstrate accountability for actions

Communication Clearly and concisely discuss procedures and care with patients and families, Use medical terminology in the appropriate context Demonstrate appropriate nonverbal communication skills Provide effective patient reports (shift end, interdisciplinary rounds etc…) Effectively engage in consultation and collaboration with other disciplines Report pertinent data to staff in a timely and accurate manner Maintain detailed and accurate documentation (hard copy, electronic records) Effectively access medical records and information systems

Knowledge Recall relevant information from previously taught subject matter Acquire and recall information from past clinical experience with preceptors and/or faculty Demonstrate an understanding of relevant basic concepts Effectively apply learned concepts to practice

Critical Thinking Demonstrate sound decision making skills Demonstrate problem solving skills Provide rationale for procedures and changes in therapy Analyze and correlate clinical information Integrate input from other health disciplines with own critical judgment Develop effective patient care plans Demonstrate effective critical evaluation skills of patients, care plans and equipment Adapt therapy to changes in patient status Use self evaluation effectively to improved performance

Efficiency Follow direction appropriately from preceptors Complete tasks and assigned workload in a timely manner without prompting Apply a systematic approach to completing tasks and workload Prioritize tasks and patient care effectively Demonstrate effective workload planning skills Complete tasks in a reliable and safe manner Performs manual skills safely and according to skills guidelines and hospital protocols

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Recognize own limitations and need to ask for help

Initiative Clearly outline relevant past experience, abilities, limitations and/or previous clinical

responsibilities Discuss goals for improved clinical performance Seek, and react positively to, constructive feedback Take responsibility for errors and establish strategies to improve Attempt to complete tasks and assigned workload in a timely manner without prompting Assist others (RTs and other health disciplines) with random tasks Seek new clinical experiences and challenges Seek repeated clinical experience for improved performance Ask questions frequently Use “down time” constructively for learning

Health, Safety and Infection Control Demonstrate effective coping skills with stressful situations Use personal protective equipment appropriately Comply with all infection control standards Adhere to policy and guidelines on biohazard waste management Use patient care equipment and supplies appropriately and safely Discuss isolation protocols for significant organism precautions Evaluate technique of gown/glove/mask Clean and disinfect equipment List methods of transmission for different common pathogens

Patient Care

1. Patient Assessment Outline information that should be obtained from patient’s chart Describe factors affecting patient care plan through a body systems review Apply patient assessment results to available RT protocols Identify basic structures and ETT placement on CXR Associate abnormal CXR findings with patient’s past medical history, current status,

and with previous films Analyze patient plan through the evaluation of patient results in diagnostic imaging

databases Discuss the indications, function, and troubleshooting of chest tube drainage

2. Blood Sampling Establish need for obtaining analysis of arterial blood Interpret ABG based on PMHX and current condition Suggest corrective action, and discuss issues around the corrections of ABGs Calculate the correct minute ventilation for a target PaCO2 based on ABG results Evaluate/suggest arterial gas orders Discuss implications of acidosis or alkalosis on patient’s condition and

pharmacological therapy Discuss the controversy of correcting metabolic acidosis with alkaline agents

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Discuss blood gas results from mixed venous sites (PAC) and central venous sites (central lines) and implications for mechanical ventilation and cardiovascular pharmacological management

3. Pulmonary Diagnostics Outline indications for ETCO2 use Discuss theory of operation of ETCO2 Discuss indications for therapeutic and diagnostic bronchoscopy in the AICU Evaluate success of bronchoscopy post procedure Apply ETCO2 readings to an evaluation of patient deadspace Discuss use of ETCO2 when determining optimal PEEP Describe theoretic course of action with deteriorating patient status during

bronchoscopy

4. Cardiac Monitoring Evaluate patient dysrhythmias and suggest course of action Discuss the clinical relevance of pulmonary artery catheter readings (i.e. (CVP, PAP,

PAOP, PVR, SVR, Cardiac Output) Describe how disease processes, PPV, and patient condition influence pulmonary

artery catheter (PAC) readings Evaluate PAC values and correlate with patient’s current condition and past medical

history Discuss patient specific PAC values and implications for mechanical ventilation and

cardiovascular pharmacological management

5. Basic Respiratory Care and Medical Gas Therapy Discuss oxygen therapy post-extubation, based on requirements when mechanically

ventilated Discuss theory of operation of High Flow Cold Nebulizer to provide humidified

oxygen therapy Describe oxygen toxicity in terms of etiology, pathophysiology, effects, prevention

and treatment Discuss complications of tracheal suctioning Outline indications for sputum collection Discuss how contamination may affect results of sputum analysis Describe how sputum collection results may affect patient care plan Describe indications for xylocaine (and/or short acting boluses of sedative) pre-

suctioning Discuss controversies regarding use of instillations

6. Airway Management Describe indications for use of an oropharyngeal airway (OPA) List indications for intubation Discuss how the position of the ETT is assessed post intubation Describe complications of intubation and corrective action for these Describe extubation parameters measured prior to extubation Evaluate patients for extubation

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Describe complications of extubation and corrective action for these Discuss theory of cuff pressure monitoring Discuss complications of cuff management Discuss indications for tracheostomy Describe the function and maintenance of Evac tubes Describe the function of various tracheostomy tube adjuncts including: flange, cuff,

fenestration, inner cannulae, obturator and plug Describe how to utilize various devices used for difficult intubations Discuss implications of re-taping an ETT on the development of Ventilator

Associated Pneumonia (VAP) Describe a comprehensive plan to prevent ventilator associated pneumonia (VAP) Discuss complications of tracheostomy including the procedure and surgical

technique Discuss theory behind trach weaning Evaluate patients for trach downsizing Evaluate patients for plugging trials Discuss complications of a trach change and course of action for these

7. Mechanical Ventilation Describe the effects of positive pressure ventilation on the various body systems

including: CNS, CVS, Respiratory, GI, GU, and MSK Describe the concepts of barotrauma (including volutrauma, atelectrauma, shearing

forces) including etiology, pathophysiology, effects, prevention and treatment Describe the concept of permissive hypercapnea, Describe the components of the ventilator circuit and their function Discuss how resistance and compliance is measured, evaluated and the implications

for mechanical ventilation Discuss theory behind initial ventilatory parameters selected for particular patients Evaluate ventilatory monitoring for precision, accuracy and completeness Describe how to optimally set the following parameters based on your particular

patient’s disease/condition, ventilator parameter analysis, ventilator waveform analysis, and patient assessment/diagnostic results:

- Vt in VC- Pressure Limit in PC- Peak Inspiratory Flow in VC with a set insp flow and set flow waveform- Ti in a PC or Volume Targeted Mode- Inspiratory Rise Time or Slope- Trigger- Cycling Mechanism (I.E. ESENS)- PEEP- Mode

Evaluate the following ventilator mechanics: CSTAT, AutoPEEP, PPLAT, RAW; and suggest course of action

Evaluate the following calculations and describe possible course of action- Alveolar to arterial oxygen gradient- Deadspace- A-V Difference

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- Oxygen Exchange Ratio- P/F Ratio- Classic Shunt Equation- Oxygen Consumption- Oxygen Delivery

Contrast and discuss a patient readiness to wean with patient readiness for extubation - Discuss the use of various weaning and extubation tests including; RSBI, NIF,

Leak around the ETT, VC, P 0.1, and other indices- Discuss the concepts of “off loading” a patient’s work of breathing, and

strength/endurance training as applied to weaning ventilation - Evaluate weaning trials

Discuss indications for Non-Invasive Mechanical Ventilation (NIMV) Describe the following modes; A/C , SIMV, PS, Volume Targeted, VS, MMV, TC,

APRV, PAV, ILV, HFO, in terms of the following:- indications- theory of operation- parameter interfacing- differences with each ventilator (including the Drager Evita, PB 840, Servo I)

Describe how all adjuncts (e.g. ATC, etc) function on the ventilators listed above Discuss alternative weaning strategies, used at different sites, when patients are

difficult to wean Discuss complications for NIMV Describe how to utilize patient assessment results and diagnostics to optimize NIMV Comprehensively describe how to utilize ventilator (and other airway pressure/flow

analysis devices as they become more mainstream) waveforms (scalars and loops) to analyze and optimize mechanical ventilation

Discuss the theory behind the use of airway recruitment maneuvers (ARMS), indications, and effects

8. Cardiopulmonary Resuscitation Describe the RT’s role in a code situation Evaluate the effectiveness of chest compressions in a code situation Discuss the use of manual ventilations in a code situation

9. Pharmaceuticals Compare MDI versus SVN administration to a mechanically ventilated patient in

terms of: technique, efficacy, and infection control Evaluate MDI and SVN technique for efficacy, and for infection control Describe the classification, indications, mode of action, routes of administration,

therapeutic effects, side effects, and dosages of the following medications:Respiratory

- acetylcysteine (Mucomyst and *Parvolex)- epoprostenol (Flolan / Prostacyclin)- fluticasone (Flovent), budesonide (Pulmicort) and other inhaled corticosteroids- heliox- ipatropium bromide (Atrovent)- isoflourane

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- methylprednisolone (Solu-medrol)- nitric oxide- prednisone- racemic epinephrine (Vaponefrin)- salbutamol (Ventolin) and other short acting beta agonists- sodium bicarbonate- tobramycin (inhaled)

Describe the classification, indications, therapeutic effects, and side effects of the following medications:

CNS- diazepam (Valium)- fentanyl (Sublimaze)- haloperidol (Haldol)- ketamine (Ketalar)- lorazepam (Ativan)- meperidine (Demerol)- methadone- methylphenidate (Ritalin)- morphine- naloxone (Narcan)

- neostigmine (Prostigmin)- nitroglycerin- oxycodone (Oxycontin)- pancuronium (Pavulon)- phenobarbital- phenytoin (Dilantin)- propofol (Diprivan)- rocuronium (Zemuron)- succinylcholine (Anectine)

GU- acetazolamide (Diamox)- furosemide (Lasix)

- spironalactone (Aldactone)- mannitol

CVS - amiodarone (Cordarone)- amlodipine (Norvasc)- atropine- captopril (Capoten)- digoxin (Lanoxin)- diltiazem (Cardizem)- dopamine- drotrecogin (Xigris)- enalapril (Vasotec)- epinephrine

- heparin- hydralazine (Apresoline)- labetalol (Trandate)- lidocaine- milrinone (Primacor)- metoprolol- norepinephrine- vasopressin (adh)- warfarin (Coumadin)

Systemic calcium caspofungin cefazolen (Ancef) ciprofloxacin (Cipro) clindamycin (Dalacin) fluconazole

linezolid magnesium sulfate metronidazole (Flagyl) piperacillin / tazobactam polystyrene (Kayexalate) potassium chloride

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vancomycin (Vancocin)10. Patient Transport

Provide estimated cylinder duration for patient transports. Describe internal transport preparation based on individual patient and destination Outline possible complications and describe course of action during patient

transport

11. Diseases / Conditions For the following urgent ventilator/patient conditions, describe how they could be

diagnosed, urgently treated, and prevented:- secretions in the airway- acute pulmonary edema- atelectasis- bronchospasm- artificial airway (ETT or trach) plugged with secretions (dried or copious

amount) or blood clot- water in the circuit- circuit leak- cuff leak (hole) or leak around the cuff- kinked tubing / biting the tube- tension pneumothorax- pneumothorax recurring with chest tube present

For the following diseases/conditions: barotrauma, oxygen toxicity, COPD (emphysema and chronic bronchitis) exacerbation, Status Asthmaticus, CHF, myocardial infarction, cardiogenic shock, pneumonia, VAP, ARDS, post-operative situations, head injury, Sepsis, BOOP, Wegener's Granulomatosis, Goodpasture's Syndrome, SARS, SIRS, Pancreatitis, Neuromuscular Diseases (e.g. Guillian Barre, ALS, etc), Rhabdomyolysis, DIC, BP Fistula;

- Discuss pathophysiology (including shunt and deadspace, as well as lung compliance and resistance), etiology, presentation, assessment, diagnostics, and treatment

- Discuss implications for mechanical ventilation including: goals, modes, adjuncts/parameters, maintenance, weaning and extubation, and protocols (such as the ARDSNet Protocol)

Compare and contrast Hemodialysis; Peritoneal dialysis; Renal replacement therapy

Describe the basic function of PRISMA

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ASTHMA EDUCATION CLINIC

Rotation overview:

In this clinical rotation students will be exposed to pediatric and adult patients in a clinic, where education is provided to the patient on managing their chronic disease.

Schedule 1 to 2 days in an asthma education clinic 1 to 2 days in a COPD education clinic These dates will be scheduled in the same week as HBO See Site Schedules

Pre Rotation N/A

Site orientation No clinical site orientation will be provided by NAIT faculty

Workbook/Assignment

Clinical assignment must be submitted into Moodle by Sunday midnight following the rotation.

Assignment will be reviewed for completion by clinical faculty and full marks will be given if complete. This assignment mark will count towards the RET602 final mark.

Common Day N/A

Exam There is no post rotation exam


There is no formal evaluation required

CLINICAL OBJECTIVESASTHMA EDUCATION CLINIC

Upon completion of the Asthma Education clinical rotation, the student will be able to:

1. Objectively measure obstructive airway disease (using most recent Canadian Consensus Guidelines) by

a. PEFRb. Pediatric spirometry

2. discuss the following components of asthma educationa. Definition, pathogenesis and diagnosis of asthma b. Environmental controls and triggers and strategies to managec. Self assessment and monitoring

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i. Symptom reviewii. PF monitoring

d. Developing action plane. Medication type and delivery

3. Understand the use ofa. Inhaled

i. Steroids (hi and low dose) Flovent Pulmicort QVAR Alvesco

ii. Bronchodilators Short acting (rescue)– Ventolin– Aeromir– Bricanyl Long Acting (preventative)– Oxeze– Serevent

iii. Combihalers Advair Symbicort

iv. Low flow inhalersv. CFC free inhalers

b. Oral systemici. leukotriene antagonists

Singulair

c. Injection Xolair

d. Delivery devicesii. MDI

iii. DPIiv. Aerochambers

4. Discuss the guidelines to asthma management outlined in the Canadian Consensus Guidelines on Asthma. Ref. link: http://www.asthmaguidelines.com/home.html

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http://www.asthmaguidelines.com/home.html

COMMUNITY CARE

Rotation overview:

The Community Care clinical rotation will provide the student with experience in comprehensive health care outside of hospitals and the acute care setting. Preceptors will introduce the student to the clinical environment and students are expected to work with their preceptors to gain experience with the outlined clinical objectives, as well as practice and achieve competency with related CBO’s.

Each student will be placed in one of 6 Community Care Options as per their preferences. Below are broad descriptions of each of the 6 elective options:

Private Home Care

Private Home Care companies are the providers of assessment and equipment. They are responsible for the delivery, set up and teaching of all respiratory therapy equipment required in a home setting. The companies are privately owned and operated, and are funded partially by the AADL program as well other agencies such as; department of veterans affairs, support for independence, etc.. All clients will be screened for funding as the equipment is costly to rent or purchase. The role of the RT is diverse, assessment, education of the equipment as well as the client’s condition is important. RT’s are also involved in public relations and sometimes equipment sales.

Main program location: The student will be paired with one home care company within Edmonton

RRT roles and responsibilities: Patient assessment and vital signs Comprehend and select appropriate oxygen and related equipment Apply AADL knowledge Patient Education Oximetry and oxygen titration Multidisciplinary Communication Smoking cessation Travel to hospitals/clinics and patients’ homes

Student Expectations: The student will travel to the Homecare Companies main office for this rotation

Pulmonary Rehabilitation

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Pulmonary Rehabilitation (PR) has proven to be the standard of care in the management of Chronic Obstructive Pulmonary Disease (COPD) and has been shown to be more effective than pharmacologic management of the disease alone. It improves health status and functional exercise capacity while reducing exacerbations and ER/hospital admissions. PR is a program for patients with a confirmed diagnosis of chronic lung disease. It follows a multidisciplinary approach with three major components: exercise, education and support. It is aimed at improving each participant’s ability to manage their disease, improve exercise tolerance, reduce shortness of breath, maintain independence, and improve overall quality of life.

RT Duties: Cardiopulmonary Stress Testing Exercise prescription (flexibility, aerobic exercise, strength training) Monitoring of exercise: oximetry, blood pressure, ECG Oxygen titration Patient education: group, one-on-one, Telehealth (video conferencing to reach

patients in rural locations)o Breathing techniques, medication review, exercise action plan , smoking

cessation awareness Communication with physicians, homecare providers, etc. AADL Oxygen Walk Tests

Student Expectations: The student will travel to the General Hospital for this rotation Students will work under the supervision of Respiratory Therapists as well as

Respiratory Aides Students will participate in all RT responsibilities Monday – Friday 8:00 – 16:00 (students may be required to complete some

evening shifts 13:00-20:00 )

Main program location: General Hospital, Edmonton - The Centre For Lung Health “Breath Easy Program” 3C-16, 11111 Jasper Ave 780 342-8951

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Allied Health and Chronic Disease Management

RRT’s within this program have a wide scope of practice and generally work independently; they are considered experts in their field and are consulted by other Health Care Providers for a diverse number of community and client needs. Many programs have been developed by this dynamic group and their role is ever changing to fit the needs of the public. Main program location/s:

Fort Saskatchewan Hospital Leduc Hospital Plaza downtown, Edmonton Mira Health Centre, Edmonton NE Family Care Clinic, Edmonton

Main Programs: Pulmonary Rehabilitation Supportive Living Quite Core Family Care clinic Outpatient Clinics

RRT roles and responsibilities: ABG and Spirometry Patient Education and Education for other Health disciplines (IPE) Smoking cessation Full Respiratory Assessment Quality of life Questionnaires Oxygen assessments and titration AADL criteria Use multiple types of Medical record programs CPR Instructor CRE (Certified Respiratory Educator)

Student Expectations:

The student will be required to travel to and from multiple sites for a rich and diverse experience

AHS Home Living

The AHS home living program provides care for clients within a home setting. The approach to care is interprofessional, which means that many different healthcare professionals may

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be involved with a client and their care. The team consists of Registered nurses, Physical therapists, Occupational therapists, Social workers, Rehab assistants, LPN’s, SLP’s, Rec therapists, Registered Dieticians, Physicians, Pharmacists and Respiratory Therapists. The role of the RT is very diverse and challenging, starting with a comprehensive assessment not only of the client, but as well their ability to manage their disease process independently or with the aid of caregivers. The key aspect of this rotation is working within a team, but autonomously in a client’s home. Education is paramount, as it is necessary that clients understand their disease, treatment and care. The client populations range from infants and pediatrics to geriatrics and palliative care. The program is also divided into different zones within the city and surrounding areas. Our aging populating, people suffering from COPD, and the increased acuity level of patients being sent home has created a greater need for the skill and expertise provided by RTs in the home setting.

Main program locations: North East – NE/North Palliative/Regional – Kingsway Professional Building South East – SE and South Palliative – St. Margerite Health Services Centre South West – Mother Rosalie Health Services Centre North – Sturgeon Health Services Centre, St Albert Strathcona – Strathcona Health Centre, Sherwood Park Leduc – Leduc Health Centre Children’s – East Edmonton Health Center * Possible Sub-rotation see below

RRT roles and responsibilities: Patient, family and caregiver education Airway management including trach changes, suctioning and bagging Case management/Interprofessional communication Proper medication review and delivery techniques Smoking cessation Thorough assessment and history including psychosocial Quality of life and activities of daily living questionnaires Ventilator and Bi-level management (more so in children’s) Students may also go on joint visits with other disciplines during their rotation

Student Expectations: The student may be expected to travel to and from patients homes and the

program office. ** The student may choose AHS home living and request Children’s as the preferred

patient population, keeping the following in mind: The student must have completed their child health block previous to entering

this sub-rotation The student must have a strong desire to work with the infant and pediatric

population The student must be prepared for complex/high acuity cases within children’s Additional driving as children’s covers the entire city and surrounding areas

Chronic Ventilator Management

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The goal of a chronic ventilation program is to provide a safe, home like environment for residents requiring ongoing ventilator-assisted respiration. Patients are stable and have been ventilated for many months and/or years, and an important goal is to ensure the environment provides as much freedom as possible by giving physical, emotional, mental and spiritual care to the resident, family and friends. RRTs work with LPNs, RN, Doctors, and nursing aids as they aim for this holistic approach to patient care. This rotation is diverse in that the student will spend the first 3 days at the UofA hospital on the ward where chronic ventilator patients are managed until they are ready to be discharged. The student will then spend one day with the Respiratory Outreach program who manages ventilated patients in their own homes, as well as a few hours with an AADL consultant for an overview of guidelines and clinical assessment of patients from that perspective. The last four days will be at the Norwood long term care center where ventilator dependent patients are managed in a facility setting.

Main program locations: UofA (Chronic Ventilator Unit) Norwood General Hospital (AHS/ AADL / Respiratory Outreach program)

RRT Roles and Responsibilities (Site dependent): Suction Ventilator set-up/check out/circuit changing Trach tube changes and overall management Oxiflow and Bipap management Patient and caregiver education on Ventilator and related equipment Management of the BIPAP patient Rounds Interdisciplinary communication Medication delivery

Student Expectations: The student is expected to travel to the main program locations.

COPD Self Initiative Program “CSI”

This unique program allows RT’s work within the hospital continuum recognizing and supporting clients with COPD or suspected COPD using the guiding principles of the Canadian Thoracic Society. Multiple visits with the patient while they are in the hospital

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allow Therapists to educate, reinforce disease management and proper medical delivery device use. Interprofessional relationships and ongoing communication with other allied health colleagues ensure optimum patient care. Thorough pt assessment and history taking is a foundation for disease management keeping in mind the psychosocial aspect of the patient’s life.

Main program location: Royal Alexandra Hospital

RRT roles and responsibilities: ABG Spirometry Patient Education Proper Medication review and delivery techniques Smoking cessation and nicotine replacement therapy Classify COPD severity as per Canadian Thoracic Guidelines Full Respiratory Assessment and History Quality of life Questionnaires Walk Tests Arrange home oxygen Identify and refer appropriate community resources for hospital discharge ex.

Pulmonary rehabilitation Outpatient clinics for disease follow-up and diagnosis

Student Expectations: The student will travel to the RAH for this rotation

Schedule 8 hour weekdays only and statutory holidays will be days off. The Center for Lung Health for Pulmonary Rehabilitation may

require some evening shifts 1300-2000 See Site Schedules

Pre Rotation Check for Pre-reading documents for your specified area in moodle Site orientation Orientation will be provided by the site preceptorsWorkbook/Assignment

Each student will be required to do a class presentation on the final day of their rotation. (see presentation instructions)

The presentation will be graded by faculty, and count towards the RET602 final mark

Common Day Common class days will be held the 1st and last day of the rotation See Common Day Schedule information

Exam No exam for this rotationClinical Performance Evaluation

One end point evaluation required

CLINICAL OBJECTIVESASTHMA EDUCATION CLINIC

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Upon completion of the Asthma Education clinical rotation, the student will be able to:

1. Objectively measure obstructive airway disease (using most recent Canadian Consensus Guidelines) by

a. PEFRb. Pediatric spirometry

2. discuss the following components of asthma educationa. Definition, pathogenesis and diagnosis of asthma b. Environmental controls and triggers and strategies to managec. Self assessment and monitoring

i. Symptom reviewii. PF monitoring

d. Developing action plane. Medication type and delivery

3. Understand the use ofa. Inhaled

i. Steroids (hi and low dose) Flovent Pulmicort QVAR Alvesco

ii. Bronchodilators Short acting (rescue)– Ventolin– Aeromir– Bricanyl Long Acting (preventative)– Oxeze– Serevent

iii. Combihalers Advair Symbicort

iv. Low flow inhalersv. CFC free inhalers

b. Oral systemici. leukotriene antagonists

Singulair

c. Injection Xolair

d. Delivery devicesii. MDI

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iii. DPIiv. Aerochambers

4. Discuss the guidelines to asthma management outlined in the Canadian Consensus Guidelines on Asthma. Ref. link: http://www.asthmaguidelines.com/home.html

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http://www.asthmaguidelines.com/home.html

EMERGENCY

Rotation overview:

In the ER clinical rotation students will practice skills and demonstrate knowledge required to conduct acute and critical respiratory care of mostly adult patients, and some pediatrics in the emergency room. Students are expected to work with their preceptors to gain experience with the outlined clinical objectives, as well as practice and achieve competency with related CBO’s.

Schedule 12 hour shift schedule which may involve weekends and nights See Site Schedules

Pre Rotation N/ASite orientation Clinical site orientation will be provided by NAIT facultyWorkbook/Assignment

Clinical assignment on which a quiz will be based Marks will be given for the assignment and count towards the RET602

final markCommon Day N/AExam There will be a short quiz in Moodle. (60% required to pass)

The ER quiz will be graded and count towards the RET602 final markClinical Performance Evaluation

1 end point clinical performance evaluation is required

CLINICAL OBJECTIVESEMERGENCY

Upon Completion of the Emergency Room clinical rotation, the student will be able to:

1. Patient assessment

a. Discuss information obtained from a patient history.

b. Conduct a complete physical assessment and describe the purpose and procedure of IPPA.

c. Interpret vital signs


d. Discuss and interpret information from the patient’s chart including lab data, radiology reports, ABG’s, consultative summaries and interdisciplinary assessment records (nursing, pharmacy, physiotherapy etc…)

e. Develop therapeutic objectives based on comprehensive assessment.

2. Oxygen therapy

a. Describe the indications for oxygen therapy

b. Discuss the physiology of oxygen transport

c. Discuss the pathophysiologic processes behind tissue hypoxia

d. Discuss the toxic effects of oxygen

e. Describe oxygen delivery devices (low and high flow).

f. Describe oxygen storage systems (liquid O2, cylinders).

g. Evaluate the effectiveness of oxygen therapy.

h. Indicate the hazards of oxygen therapy

3. aerosol therapy

a. Provide rationale for the appropriate aerosol delivery device for inhaled medications

b. Discuss the indications for high flow cold neb (HFCN) therapy

4. pulse oximetry

a. Indicate the need for pulse oximetry

b. Identify factors contributing to erroneous pulse oximetry results

c. Discuss the principles of pulse oximetry

5. Spirometry and peak flow measurement

a. Contrast the range of parameters available by spirometry vs. peak flow meter

b. Rationalize the use of spirometry vs peak flow meter

c. Interpret spirometry results

6. Airway management

a. Describe interventions to support an unprotected airway

b. Describe indications for use of an oropharyngeal airway (OPA)

c. List indications for intubation

d. Discuss how the position of the ETT is assessed post intubation

e. Describe complications of intubation and corrective action for these

f. Describe various adjuncts used to manage the difficult to intubate patient

g. Discuss the indications for emergency cricothyrotomy

7. blood sampling

a. Discuss reasons for obtaining arterial blood

b. Discuss appropriate technique for radial artery procurement

c. Discuss appropriate transportation and analysis methodsd. Contrast normal values between arterial and venous blood gasses

e. Describe all parameters analyzed or calculated on the blood gas analyzer

f. Interpret ABG results

g. Identify the need for corrective action based on ABG results, and discuss the reevaluation of your corrective action

8. Discuss and develop strategies for organizing workloads

9. Professionalism

a. Understand and discuss the benefits to team approach in the ER department

b. Discuss the benefits of effective communication with staff, patients and family

c. Discuss cultural influences on verbal and non verbal communication

d. Identify appropriate terminology in terms of verbal and written communication

10. Infection control

a. Describe routine precautions

b. Describe the differences between airborne, droplet and contact isolation

11. CPR

a. Describe the correct procedure in adult or pediatric CPR

b. Discuss the RT’s role in CPR

c. Evaluate the effectiveness of CPR

12. Patient transportation

a. Describe internal transport preparation based on individual patient, destination and available equipment

b. Outline possible complications and describe course of action during patient transport

13. pharmaceuticals

Describe the classification, indications, therapeutic effects, and side effects of the following medications:

Respiratory acetylcysteine (Mucomyst and *Parvolex) flovent, budesonide (Pulmicort) and other inhaled corticosteroids heliox ipatropium bromide (Atrovent) methylprednisolone (Solu-medrol) prednisone racemic epinephrine (Vaponefrin) (epinephrine for same treatment indications) salbutamol (Ventolin) Combivent

CNS diazepam (Valium) fentanyl (Sublimaze) ketamine (Ketalar) lorazepam (Ativan) meperidine (Demerol) morphine naloxone (Narcan)

oxycodone (Oxycontin) phenobarbital phenytoin (Dilantin) propofol (Diprivan) succinylcholine (Anec

GU acetazolamide (Diamox) furosemide (Lasix)

mannitol

CVS (circulatory)

amiodarone (Cordarone) amlodipine (Norvasc) atropine captopril (Capoten) coumadin digoxin (Lanoxin) diltiazem (Cardizem) dopamine drotrecogin (Xigris) enalapril (Vasotec) epinephrine heparin hydralazine (Apresoline) labetalol (Trandate) lidocaine milrinone (Primacor) metoprolol Nitroglycerin Norepinephrine Tissue Plasminogin Activator vasopressin (adh)

HYPERBARIC OXYGEN THERAPY (HBO)

Rotation overview:

In the HBO clinical rotation students will observe and assist Respiratory Therapists with the care of patients undergoing hyperbaric oxygen therapy.

Schedule 1 day shift See Site Schedules

Pre Rotation Pre reading material must be reviewed prior to attending this rotationSite orientation No clinical site orientation will be provided by NAIT facultyWorkbook/Assignment

Clinical assignment must be submitted into Moodle by Sunday midnight following the rotation.


Assignment will be reviewed for completion by clinical faculty and full marks will be given if complete. This assignment mark will count towards the RET602 final mark.

Common Day N/AExam There is no post rotation examClinical Performance Evaluation

No evaluation is required for this rotation

CLINICAL OBJECTIVESHYPERBARIC OXYGEN THERAPY (HBO)

Upon completion of the HBO clinical rotation the student will be able to:

1. Describe the history of HBO. (discovery of oxygen, pressurized air and oxygen under pressure)

2. Discuss the physiological effects of hyperbarism and hperbaric oxygen

3. Explain the toxic effects of oxygen

4. Explain the physiological mechanisms which lead to decompression sickness (“the bends”)

5. Describe the following in relation to HBO therapy:- Atmospheric pressure- Absolute pressure- Gauge pressure

6. Relate the following gas laws to the application of HBO therapy:- Boyle’s Law- Henry’s Law- Charles’s Law

7. List the approved standard and adjunctive indications for HBO therapy

8. Describe the absolute and relative contraindications for HBO therapy

9. List and explain side effects of HBO therapy

10. Explain the safety precautions that must be considered in providing HBO therapy

11. Explain the basic operation of the Sechrist ventilator in a monoplace chamber

12. Discuss the complication of administering HBO regarding:- IV access

- Ventilator management- Patient communication

13. Identify the uses of TcPO2 monitoring in terms of wound management

14. Discuss the experimental and future application of HBO therapy

15. Differentiate the indications and safety issues of multiplace HBO chambers

NEONATAL INTENSIVE CARE

Rotation overview:

In the NICU clinical rotations students will practice skills and demonstrate knowledge required to conduct acute and critical respiratory care of term and preterm infants with a broad range of medical disorders and surgical needs.The neonatal portion of the Child Health rotation will include 2 different clinical environments:

1 week NICU (Grey Nuns), gives the student experience with stabilization and resuscitation of the newborn in the labor and delivery suite.

3 weeks NICU (Royal Alexandra), gives the student experience with term and pre term infants requiring respiratory care, including mechanical ventilation for a variety of disorders, as well as attend and participate in high risk deliveries.

1 week NICU (University/Stollery), gives the student experience with mostly term infants that require surgical interventions for a variety of disorders, many of which are associated with the airway and congenital heart repairs. Students will work with ventilated and nonventilated infants.

Students are expected to work with their preceptors to gain experience with the outlined clinical objectives, as well as practice and achieve competency with related CBO’s.


Pre Rotation Clinical Simulation Week Pre rotational exam written in clinical simulation week (80% to pass).

The break down for the exam is under Child Health Clinical Simulation. See schedule in Clinical Simulation

Site orientation Formal orientation will be provided by the NAIT clinical instructor for the NICU (RAH) and NICU (UAH)

Workbook/Assignment

Neonatal part of Child Health workbook must be done for Child Health Common day

Workbooks will not be marked but are meant as a self study tool and guide for review on common day

Some questions may require presentation on common dayCommon Day See Common Day Schedule for date, time and location of Child Health

common day which will include review of the pediatric and neonatal workbook questions and concepts.

Exam The Child Health Exam will incorporate the neonatal test questions,


and will occur in the last week of the Child Health block. (60% to pass) Test questions will be based on clinical experience and objectives from

all 3 neonatal rotations within the Child Health block. Exam will be graded and count towards the final RET602 mark Exam date and time will be scheduled by NAIT clinical site faculty


One mid and end point evaluation required for NICU (RAH) and PICU (UAH)

One end point evaluation required for NICU (GNH), and NICU (UAH).

CLINICAL OBJECTIVESNEONATAL INTENSIVE CARE

Upon Completion of the NICU clinical rotations, the student will be able to:

A. Patient Assessment

1. Assess relevant patient informationi. Access patient and maternal history from the patient chart, and respiratory

therapy information card indexing system/binderii. Use information obtained from report and rounds to develop a care plan

iii. Modify existing care plan based on patient assessment

2. Assess patient for relevant clinical signs.i. Spontaneous breathing rate and apneas

ii. Signs of respiratory distressiii. Vital signsiv. Auscultation

3. Blood gas analysis.i. Determine need for sample

ii. Analyze sample and correlate clinicallyiii. Recommend appropriate action

4. CXRi. Promote neutral position of endotracheal tube during the process of

repositioning patient for CXR and utilize neck brace if applicableii. Assess position of endotracheal tube and advance or retract ETT if indicated

iii. Identify specific abnormalitiesiv. Compare with previous films

B. Communication

1. Documentationi. Clearly and concisely document patient assessment and patient progress

ii. Document patient proceduresiii. Chart with reference to established guidelines

2. Verbal Communicationi. Communicate effectively with patient’s caregivers and health care team

ii. Provide accurate and relevant patient reportiii. Present information on patient roundsiv. Suggest respiratory care plan

C. General Therapeutics

1. Oxygen therapyi. Assess need

ii. Select appropriate delivery deviceiii. Administer oxygen via appropriate delivery device.iv. Assess clinical effectiveness and titratev. Record data

vi. Discuss various methods of applying oxygen via CPAP devices including high flow nasal cannula, nasal prongs, nasal masks and nasopharyngeal tube.

2. Humidity Therapyi. Demonstrate ability to maintain appropriate humidity and temperature control

with all medical gasesii. Evaluate effectiveness of therapy and modify if needed

3. Aerosol Therapyi. Assess need for aerosol/inhaled medication

ii. Select appropriate device or method for the application of aerosol/inhaled medication

iii. Evaluate effectiveness of therapy and record appropriate dataiv. Identify the specific drug names, indications, relative contraindications,

effects, side effects, routes, and dosages of the following inhaled drug classifications

1. beta two agonists/alpha one agonists2. corticosteroids

4. Airway Managementi. Intubation and tracheostomy

1. prepare equipment2. assist with procedure3. secure tube and evaluate placement4. perform tracheostomy care5. record appropriate data

ii. Extubation and decannulation1. assess patient for extubation readiness2. perform extubation3. provide post extubation care

4. assess patient as per patient assessment and site policy5. record appropriate data

iii. Suction Therapy (oral, nasal, and into artificial airway via inline or glove and catheter)

1. assess need for suctioning and instillation (instillation as per site policy)

2. assemble required equipment3. initiate procedure4. monitor effects of therapy

iv. Manual Ventilation1. assemble equipment and ensure function2. perform ventilation with self inflating, flow inflating units and t-piece

resuscitators3. assess effectiveness of therapy and modify as needed

5. Mechanical Ventilationi. Discuss the available modes and particulars of the following ventilators; Servo

300 & Servo i, Drager Evita 2, 4 & XL, Drager Babylog, Arabella Blender, Viasys SiPAP Unit, Sensormedics 3100A

ii. Perform initial checkout of standby ventilatoriii. Select appropriate ventilator parameters as per protocol, modifying for patient

clinical presentation and/or manual ventilation resultsiv. Initiate therapyv. Assess initial patient response and modify accordingly

vi. Select appropriate alarm and apnea settingsvii. Measure and assess patient respiratory mechanics

viii. Optimize ventilationix. Determine suitability for weaningx. Develop weaning plan based on rounds

xi. Perform weaning based on ABG results, ETC02 and clinical presentation

D. Diagnostics

1. Pulse Oximetry/ ETCO2/Transcutaneous Monitoringi. Assess need

ii. Gather equipment (for all of the available units) and follow set-up procedureiii. Apply monitor/probe correctlyiv. Establish reliability of measurementv. Troubleshoot as required

vi. Correlate readings with ABG resultsvii. Modify therapy based on readings

viii. Record appropriate data

E. Transport

1. Discuss use of isolette and transport isolette to maintain a neutral thermal environment for the neonate.

2. Identify equipment needed for in and out of hospital transports3. Discuss implications to therapy from high altitude environments during transport4. Discuss function of transport ventilator.

F. Medications

1. Discuss the indications, effects, (and dosages and side effects where applicable) of the following medications: caffeine indomethacin (Indocid) HCO3/Tham Acetate surfactant (BLES) epinephrine dobutamine dopamine atropine magnesium sulfate dexa / betamethasone cortisone Vitamin K succinylcholine Pavulon / Rocuronium neostigmine fentanyl/sufentanil ventolin (salbutamol)

morphine Narcan (naloxone) chloral hydrate phenobarbital midazolam (Versed) valium (Diazepam) digoxin nitric oxide sildenafil (Viagra) Lasix (furosemide) Aldactazide racemic epinephrine

(Vaponefrin) prostaglandin E1,/ alprostadil

(Prostin)

G. Disease / Condition

1. Discuss the presentation, pathophysiology, and treatment for the following diseases/conditions:

RDS & CLD PPHN CDH CHD MAS Hydrops TTN Apnea of Prematurity PDA IVH ROP Chromosomal Abnormalities Air leak syndromes Pneumonia Pulmonary hypoplasia/agenesis Hyperbilirubinemia Pierre Robin Placenta Previa Placenta Abruptio Omphalocele Gastroschesis

Other1.Discuss indications, theory, procedure and use of the equipment/attachments for the

following items: High Frequency Ventilation / Oscillation Nitric Oxide Transillumination Hyperoxygen, Hyperventilation Test Responding to Brads / Apneas Bronchoscopies

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OPERATING ROOM

Rotation overview:

In the OR clinical rotation students will practice skills and demonstrate knowledge required to prepare and manage equipment and patients pre operatively, intra operatively and post operatively. Preceptors will introduce the student to the clinical environment and students are expected to work with their preceptors to gain experience with the outlined clinical objectives, as well as practice and achieve competency with related CBO’s.

Schedule Monday to Friday 8 hour day shifts Statutory holidays will be a day off for the student

Pre Rotation Strongly recommended to review Anesthesia course notes and related text material

Site orientation Informal orientation will be provided by site RT/preceptorWorkbook/Assignment

N/A

Common Day N/AExam There will be a post rotation exam on the final day of the rotation

(60% required to pass) The OR exam will be graded and count towards the RET602 final mark



CLINICAL OBJECTIVESOPERATING ROOM

Upon completion of this rotation the student will be able to:

1. Describe component parts and principles of operation of the anaesthetic gas machine (AGM)a. vaporizers b. circuits

i. circleii. Jackson

c. scavenging systemsi. active vs passive

d. Modes of ventilatione. safety mechanisms

i. color codingii. o2 flushiii. pressure limit

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iv. o2 alarm v. one way valve mechanismvi. electro-mechanical system to prevent hypoxic mixture

f. alarmsi. anaesthetic gas analyzerii. pressure and volumeiii. O2 analyzer

2. Discuss what quality assurance relates to the maintenance of an AGMa. initial check out b. Preventative maintenance

3. Explain and contrast the terms a. Anesthesiab. Analgesiac. hypnosisd. amnesia

4. Describe how each of the following influence risk to the patient during anaesthesiaa. ageb. weightc. substance abused. pregnancye. pathophysiology of the

i. cardiovascular systemii. central nervous and neuromuscular systemiii. respiratory systemiv. renal system

5. Distinguish between the following methods of anaesthesiaa. regional

i. spinal, epidural, nerve blockb. local

i. freezingc. general

i. volatile agentii. IV sedation (propofol, versed, fentanyl, remi fentanil)

6. Explain what is meant by “induction” as well as the following associated methodologya. inhalationb. intramuscularc. intravenous d. rapid sequence

i. indicationsii. contraindications

7. Discuss the physiologic principles of uptake and elimination of volatile anaesthetic agents, taking into consideration

a. alveolar ventilationb. blood flow

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c. anaesthetic agent stability

8. Discuss the meaning and application of a. MAC valuesb. the second gas effect

9. Describe the equipment and/or skills used, and importance of, monitoring the following intraoperatively:

a. cardiovascular systemb. central nervous systemc. fluids and electrolytesd. body temperaturee. respiratory status

i. ABGii. SpO2iii. EtCO2

f. nerve stimulator, and implications fori. drive to breathii. abdominal muscle effort

10. Differentiate in general terms the following drug classifications and explain indications therapeutic effects/mechanism of action, contraindications and adverse effects of the listed specific agents.

a. barbituratesi. sodium thiopental (pentathol)

b. narcoticsi. fentanyl, morphine, remi fentanil

c. benzodiazepinesi. vallium, ativan

d. ketaminee. propofolf. inhaled volatile anaesthetic agents

i. sevofluraneii. isofluraneiii. desflurane

g. nitrous oxideh. Neuromuscular blockers

i. depolarizing succinylcholine

ii. non-depolarizing rocuronium pancuronium

i. reversal agentsi. narcan ii. neostigmine

j. anticholinergicsi. atropine

k. Antiemeticsi.

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11. Explain precipitating factors as well as treatment of the following anesthesia related complications:

a. allergic reactionsb. aspiration c. barotrauma d. hyper/hypotensione. hypothermiaf. malignant hyperthermiag. nerve injuryh. air embolismi. CNS depressionj. diffusion hypoxia

12. Discuss fluid management and indications for:a. colloidsb. crystalloidsc. blood productsd. Fluid warminge. Cell saver

13. Discuss tracheal intubation in terms of a. indicationsb. evaluating ease / difficulty of procedure

i. mallampati scoreii. Cormack

c. preferred route (oral vs. nasal)d. conventional supplies needed for proceduree. techniques

i. BURPii. Sellick

f. adjunctive devices used to manage a difficult airwayi. bougieii. glidescopeiii. bullardiv. bronchoscopev. intubating LMAvi. light wands

g. complications during procedure

14. Discuss cricothyrotomy in terms ofa. indicationsb. equipment c. procedured. risks

15. Discuss the management of an laryngeal mask airway (LMA) in terms of:a. indicationsb. equipment

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c. procedured. riskse. ability to ventilate

16. Understand techniques in manual ventilation with a flow inflating bagger, by mask on a non intubated patient (via AGM)

17. Discuss techniques and strategies in maintaining a patent airway usinga. proper patient positioningb. oral pharyngeal tubes (OPA)c. Jaw thrustd. Head tilt, chin lift

18. Explain the post-operative management ofa. emergenceb. atelectasisc. hypotensiond. hypoventilatione. hypoxiaf. laryngospasm, laryngeal edema and stridorg. painh. vomiting and aspirationi. pulmonary edema

i. negative pressureii. fluid overload

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PEDIATRIC S (PICU and Peds Wards)

Rotation overview:

In the PICU and PW clinical rotations students will practice skills and demonstrate knowledge required to conduct acute and critical respiratory care of pediatric patients with a broad range of medical disorders and surgical needs. The pediatrics rotation makes up 4 weeks of the Child Health block and consists of two different experiences.

Pediatric wards is a one week rotation where you will be exposed to pediatric tracheostomy care, chronic ventilator management, pediatric Bipap, oxygen therapy and sleep studies.

The other three weeks of this rotation are spent in PICU, which is divided into a medical and cardiac PICU. In the medical PICU you will be exposed to ventilator and Bipap management of children with a wide variety of acute and chronic medical conditions. In the cardiac PICU you will be exposed to a variety of congenital heart defects at various stages of surgical correction.

Students are expected to work with their preceptors to gain experience with the outlined clinical objectives, as well as practice and achieve competency with related CBO’s.


Pre Rotation Clinical Simulation Week Pre rotational exam written in clinical simulation week (80% to pass).

The break down for the exam is under Child Health Clinical Simulation. See schedule in Clinical Simulation

Site orientation Formal orientation will be provided by the NAIT clinical instructor for the PICU.

Workbook/Assignment

Pediatric part of Child Health workbook must be done for Child Health Common day

Workbooks will not be marked but are meant as a self study tool and guide for review on common day

Some questions may require presentation on common dayCommon Day See Common Day Schedule for date, time and location of Child Health

common day which will include review of the pediatric and neonatal workbook questions and concepts.

Exam The Child Health Exam will incorporate the Pediatric test questions, and will occur in the last week of the Child Health block. (60% to pass)

Exam will be graded and count towards the final RET602 mark Exam date and time will be scheduled by NAIT clinical site faculty


One mid and end point evaluation required for PICU One end point evaluation required for PW

CLINICAL OBJECTIVES PEDIATRIC WARDS

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Upon completion of the Pediatric Wards Clinical Rotation the student will be able to:

Professionalism Utilize self analysis and preceptor feedback to plan specific daily and rotation goals and

objectives Describe appropriate responses to patient and family members when: inquiries are made

regarding patient condition, and when providing patient and family education

Infection Control Discuss isolation protocols for significant organism precautions Evaluate technique of gown/glove/mask Evaluate method of disinfecting equipment

Patient Assessment Outline information that should be obtained from patient’s chart Apply patient assessment results to develop a care plan appropriate for patient condition

Consultation and Communication Evaluate patient shift reports, and medical rounds reports, for essential and non-essential

information Provide accurate and relevant patient shift report Evaluate documentation for clarity, accuracy, and completeness

Blood Sampling Establish need for obtaining analysis of capillary or venous blood Interpret results based on PMHX and current condition

Basic Respiratory Care and Medical Gas Therapy Discuss indications for oxygen therapy Discuss appropriate oxygen therapy delivery devices

Airway Management Discuss indications for tracheostomy Discuss complications of tracheal suctioning Discuss complications of a tracheotomy tube change Discuss indications for a cough assist device

Mechanical Ventilation Describe the components of the ventilator circuit and their function Evaluate weaning trials Discuss indications for Non-Invasive Mechanical Ventilation

Cardiopulmonary Resuscitation Describe the RT’s role in a code situation Evaluate the effectiveness of chest compressions in a code situation Discuss the use of manual ventilations in a code situation

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Pharmaceuticals Describe the classification, indications, mode of action, routes of administration,

therapeutic effects, side effects, and dosages of the following medications: Acetylcistine Fluticasone, budesonide and other inhaled corticosteroids Levo epinephrine Pentamidine Salbutamol and other short acting beta agonists Tobramycin

Diseases / Conditions Discuss the following diseases /conditions

Brain injury Bronchiolitis Bronchopulmonary dysplasia Central Hypoventilation Syndrome Cerebral palsy Croup Epiglottitis Laryngomalacia Neuromuscular diseases affecting ventilation Pierre-Robin Syndrome Tracheomalacia Treacher Collins Syndrome

CLINICAL OBJECTIVESPEDIATRIC INTENSIVE CARE

41


Upon completion of the PICU Clinical Rotation(s), the student will be able to:

A. Patient Assessment

Assess relevant past medical history and gather pertinent data- summarize pertinent medical history from patient chart- use information obtained from Respiratory Therapy report and team rounds to develop a care plan

consistent with patient condition

- explain rationale and implications for Respiratory care plan

Assess patient for relevant clinical signs- respiratory status/pattern- thoracic dimensions/deformity- bilateral chest excursion- tracheal position- auscultation: assess presence of breath sounds and intensity, and describe the

presence, location, quality, and phase of adventitious sounds

Blood Analysis- determine the need for sampling- obtain capillary blood gas sample- analyze sample and assess the reliability of results- interpret results and evaluate in accordance with patient clinical status- correlate with monitoring devices- recommend appropriate action for clinical situation

CXR- assess position of endotracheal tube- identify specific abnormalities- compare current CXR with previous films

a. Cardiovascular Assessment- evaluate heart rate, blood pressure, and mean arterial pressure- evaluate pulmonary artery pressure and pulmonary artery occlusion pressure- measure Qs/Qt- interpret data/correlate with ventilator management

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Communication

Documentation- clearly and concisely document patient assessment and patient progress- document patient procedures- chart with reference to established guidelines

Verbal Communication- communicate effectively with patient, family, and other members of the health care

team- provide accurate and relevant patient report- present information at patient rounds - suggest respiratory care plan and alternatives

C. General Therapeutics

1. Oxygen Therapy- assess the need for oxygen therapy- select appropriate device - administer oxygen therapy via nasal cannula, oxygen mask, and high flow nebulizer- assess clinical effectiveness of oxygen therapy- titrate oxygen therapy appropriately

2. Humidity/Aerosol Therapy- administer appropriate humidity and temperature control with all medical gas

administration- list the indications, contraindications, routes of administration, dosage, desired

effect, and side effects of the following:- salbutomol and other Beta Agonists- racemic epinephrine- inhaled corticosteroids- inhaled antibiotics- assess need for inhaled medications- select appropriate delivery device and administer medication using proper

technique; ventilated and non ventilated patient- monitor patient for beneficial effects and side effects of medication- evaluate treatment plan; recommend changes to therapy as necessary

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D. Airway Management

1. Intubation and Tracheostomy- perform checks of emergency intubation equipment and crash carts- select and prepare equipment for intubation - assist with intubation- assess proper tube placement- secure endotracheal tube/tracheostomy tube- perform cuff management- perform repositioning of endotracheal tube- perform extubation- perform tracheostomy care- perform insertion of oropharyngeal airway/nasopharyngeal airway- manage accidental extubation/decannulation

2. Suction Therapy- assess the need for suctioning/instillation- select and assemble appropriate equipment- perform oral and tracheal suctioning- collect sputum sample- assess patient response to therapy

A. Manual Ventilation

- select and assemble appropriate equipment- ensure function of equipment- perform manual ventilation via artificial airway- assess effectiveness of manual ventilation and modify therapy as necessary

B. Mechanical Ventilation

1. Initiation- set up standby ventilator and verify function- select appropriate ventilator and initial parameters according to clinical indications- initiate ventilation- monitor initial patient response and adjust parameters as necessary- select appropriate alarm/apnea backup settings

2. Management- evaluate patient–ventilator interaction- verify and monitor ventilator settings- measure/assess respiratory mechanics- static and dynamic compliance- plateau pressures- auto-PEEP- airway resistance- waveforms- measure and assess oxygenation status- PaO2, SpO2, SaO2, PaO2/FiO2, DO2, CaO2, C(a-v)O2, oxygen index- measure/assess ventilation status

44

- PaCO2, PetCO2, VD/VT- adjust ventilator settings to obtain optimal patient/ventilator synchrony and

minimize the adverse effects of positive pressure ventilation- adjust ventilator settings to meet therapeutic goals- perform ventilator circuit/component changes as necessary

3. Weaning- assess patient’s condition to determine readiness for weaning- obtain weaning indices when appropriate and assess validity of results- VC, VT, NIF, P.01, rapid/shallow breathing index- select appropriate weaning method consistent with weaning protocol and patient

condition- assess patient response to weaning- monitor and evaluate weaning process- adjust or discontinue weaning method as necessary

C. Pathophysiology

- describe the following diseases/conditions - describe common respiratory therapy goals and methods of treatment

1. Pulmonary- ARDS- pulmonary edema- chest wall abnormality- COPD/BPD- asthma- pneumonia- chest trauma- neuromuscular diseases affecting ventilation- pulmonary embolus

2. Cardiac- HLHS- PDA- VSD and ASD- AVSD- Coarctation of the aorta- Transposition of the great vessels- TAPVD- Tetrology of Fallot- Valvular atresia- Aortic stenosis- Truncus arterioisis

3. Other Body Systems - Shock- Sepsis- Head injury- Renal failure

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- Depressed ventilatory drive (O.D., post anesthesia)

D. Infection Control

- follow standard and universal precautions- use appropriate hand washing technique- identify and use appropriate isolation procedure as required- use sterile or aseptic technique where indicated- follow procedures for biological and ‘sharp’ disposals- carry out equipment exchanges

46

PULMONARY FUNCTION

Rotation overview:

In the PFT clinical rotation students will practice skills and demonstrate knowledge required to obtain pulmonary diagnostics on adult patients. Preceptors will introduce the student to the clinical environment and students are expected to work with their preceptors to gain experience with the outlined clinical objectives, as well as practice and achieve competency with related CBO’s.

Schedule Monday to Friday 8 hour day shifts Statutory holidays will be a day off for the student

Pre Rotation Workbook 1 must be complete before the rotation startsSite orientation Informal clinical site orientation will be provided by RT/preceptorWorkbook/Assignment

Workbooks for this rotation are intended to help students understand the concepts related to PFT and are excellent study tools for the post rotation exam.

Workbook 1 must be complete before the rotation starts Workbook 2 must be complete during the rotation The workbooks will not be graded but may be verified for completion

by clinical faculty and/or site RT/preceptorCommon Day N/AExam There will be a post rotation exam on the final day of the rotation

(60% required to pass) The PF exam will be graded and count towards the RET602 final mark



CLINICAL OBJECTIVESPULMONARY FUNCTION

Upon completion of the Pulmonary Function rotation, the student is expected to be able to:

1. List the indications and contraindications for pulmonary function testing.

medical urgical disability evaluation research

2. Explain the significance of the following:47


VT, f, VE, Vp, VA, VD/VT

IRV, ERV, RV, IC, FRC, SVC, TLC, RV/TLC, CV, CC FVC, FEV1%, FEV1, FEF25-75%, PEFR, FEF 200-1200 V, VMAX 75%, 50%, 25%, FEF 25%, 50%, 75%, MVV VTG, RAW, GAW, CL DLcoSB, DLcoSS VO2, VCO2, respiratory exchange ratio MIP, MEP PIF, PEF

3. Explain the significance of the following on predicted values:

age sex height rate the use of +/-20% and standard deviation weight when applicable

4. Describe the factors affecting validity of test results according to American Thoracic Society Standardization of Spirometry.

equipment recommendations equipment validation equipment quality control maneuver performance recommendations measurement procedures acceptability and reproducibility reference values and interpretation standardization

5. Explain the indications for termination of a test.

6. Explain the principles of the following tests:

lung volumes and capacities ventilation/perfusion pulmonary mechanics diffusion

7. Explain the rationale for pre and post bronchodilator testing.

8. Compare the principles of operation, advantages and disadvantages of the following types of equipment:

volume displacement spirometers

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- water seal- dry rolling seal- bellows

flow measuring spirometers- turbines- differential pressure pneumotachometers- thermal anemometers- ultrasonic sensors

plethysmographs- variable pressure type- flow or variable volume type

gas analyzers- infrared absorption- thermal conductivity- emission spectroscopy (Giesler tube)

9. List the advantages and disadvantages of computerized system.

10. Describe quality control measures.

quality assurance program- equipment- tests (ex. patient sitting or standing)- calibration procedures for volume, flow and time

11. Describe the differences between:

Morris Knudson Kory Polgar

12. Derive the predicted pulmonary function values from a nomogram.

13. Identify the pattern of abnormality of pulmonary function results using the following criteria:

Select the best test according to the standards Interpret the test results Assess the effectiveness of bronchodilators

14. Perform routine and Advanced Pulmonary Function maneuvers.

FVC, Flow Volume Loop (assessment of bronchodilator therapy) Spirometry MVV NWm (FRC/RV) Body Plethysmography

- Airway resistance

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Diffusion Capacity BTPS correction factors

15. Differentiate between function test results in terms of: Interpret pulmonary function test results in terms of:

normal pattern obstruction patterns upper airways fixed variable intra-thoracic variable extra-thoracic lower airway restrictive patterns pulmonary parenchyma non-pulmonary parenchyma pulmonary extra pulmonary diffusion defects combination patterns

16. Know infection control procedures utilized in the pulmonary function lab.

17. Document pertinent information and observations.

18. Describe the purpose of exercise testing.

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CLINICAL OBJECTIVESSLEEP

Rotation overview:

In the Sleep Diagnostics clinical rotation students will observe and assist in Level I sleep diagnostics and a CPAP clinic. Students will have exposure to patients with sleep disordered breathing, diagnostic results, as well as diagnostic and therapeutic technology used in level I and level III clinical environments.

Schedule Provincial Sleep Lab at the Edmonton General hospital Monday 0700-1830 Tuesday 1945 - 0720 (night shift) Friday - 1 day at a CPAP clinic reviewing test data, fitting patients with

appropriate masks and CPAP devices, and educating the patient and family See Site Schedules for CPAP Clinic rotation

Or

Avant Sleep Lab All of the clinical rotation including CPAP will be at the Avant Lab Monday 0900-1700 Tuesday 0900-1700 Wednesday 0900-1700 Thursday 2030-0700 (night shift)

In the event of a statutory holiday falling in the week of your rotation, see below:

If the Stat Falls on a Monday at the General Sleep Lab the schedule will be: Tuesday, 0700-1830 at the Edmonton General Hospital Wednesday, 1945-0720 at the Edmonton General Hospital Friday day shift at a CPAP clinic, refer to:

o CPAP Clinic Schedule for the clinical site you are scheduled at and Clinical Site Information for site details and shift hours

If the Stat Falls on a Friday your CPAP clinic day will be on Thursday instead (if the CPAP clinic schedule does not reflect this please contact your clinical instructor)

If the Stat falls on a Monday at Avant Sleep Lab your shifts will be :

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Tuesday 0900-1700 Wednesday 0900-1700 Thursday 2030-0700

Pre Rotation Pre reading material must be reviewed prior to attending this rotationSite orientation Informal clinical site orientation will be provided by RT/preceptorWorkbook/Assignment

Complete the Sleep Diagnostics clinical assignment in Moodle. You will need to refer to the Polysomnography file to answer one of the questions in the assignment.

Due on the Sunday at midnight following the end of the rotation. Assignment will be reviewed for completion by clinical faculty and full

marks will be given if complete. This assignment mark will count towards the RET602 final mark.

Common Day N/AExam There is no post rotation examClinical Performance Evaluation

One evaluation is required for the Level 1 Sleep Lab experience after completion of night shift.

CLINICAL OBJECTIVESSLEEP

Upon completion of the Sleep clinical rotation, the student will be able to:

1.Discuss the scope of practice in modern sleep diagnostics

2.Understand the impact of undiagnosed sleep disorders

3.Define OSA and OSAS as well as related pathophysiology

4.Describe risk factors associated with Obstructive Sleep Apnea (OSA)

5.List symptoms associated with Obstructive Sleep Apnea Sysndrome (OSAS)

6.Describe the relationship between OSA and the following conditions:a. Hypertensionb. Cardiovascular diseasec. Cerebral vascular diseased. Cardiac arrhythmias

7.Describe the apnea-hypopnea index (AHI) and diagnostic criteria for OSAS

8. Define central sleep apnea (CSA) as well as related pathophysiology

9. Define hypoventilation syndromes

10. Define Cheyne-Stokes breathing pattern

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11. Describe equipment used, and parameters measured during PSG testing in a level 1 sleep study.

12. Contrast level 1 PSG studies versus sleep screening.

13. Define the term “Epoch” as it relates to sleep studies.

14. Recognize and interpret sleep study results for the following conditions:a. Obstructive apneab. Central apneac. Mixed apnead. CPAP titratione. Cheyne Stokes respirations

15. Discuss the significance in correlating chart review, patient assessment, and sleep study interpretation in the diagnoses of OSA.

16. Compare and contrast surgical versus non surgical management of OSAS

17. Discuss the titration of:a. Oxygenb. CPAPc. Bi-Level

18. Contrast the effectiveness of positive airway pressure (PAP) on:a. OSAb. CSAc. Hypoventilation syndromes

19. Describe components to positive airway pressure (PAP) devices used in treatment of OSAS.

20. Understand the differences between and indications for CPAP, bilevel, APAP, and ASV.

21. Recognize the differences and appropriate use of different types of PAP interfaces (masks, pillows etc…)

22. Describe how oxygen is integrated into CPAP and Bilevel devices

23. Discuss considerations in patient comfort when initiating PAP therapy for sleep disordered breathing

24. Describe and recognize adverse conditions that can develop from PAP therapy in treatment of sleep disordered breathing

25. Discuss possible modifications in therapy to improve patient comfort and compliance.

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26. Explain the importance of, and assist with patient education regarding testing and diagnoses as well as equipment related to treatment.

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WARDS

Rotation overview:

In the Wards clinical rotation students will practice skills and demonstrate knowledge required to conduct respiratory care of adult patients with acute and chronic respiratory disease/disorder. Students are expected to work with their preceptors to gain experience with the outlined clinical objectives, as well as practice and achieve competency with related CBO’s.


Pre Rotation N/ASite orientation Formal orientation will be provided by the NAIT clinical instructor

except for Red Deer which will be provided by that sites RTs/preceptors.

Workbook/Assignment

Workbook must be done in time for review on Wards common day Some questions may require presentation on common day Workbooks will not be marked but are meant as a self study tool and

guide for review on common dayCommon Day Common class day will be scheduled in the 3rd week of the rotation

See Common Day Schedule for date, time and location of common dayExam Post rotation exam will be written at the end of rotation (60% to pass)

Exams will be graded and count towards the final RET602 mark Exam date and time will be scheduled by NAIT clinical site faculty


One mid rotation evaluation required One end point evaluation required

CLINICAL OBJECTIVESWARDS

Upon completion of the Wards Rotations, the student will be able to:

Patient Assessment

1. Take a patient history.

2. Conduct a complete physical assessment and describe the purpose and procedure of IPPA.

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3. Review and interpret significant information from the patient’s chart including lab data, radiography reports, ABG’s, medications, and past medical history.

4. Develop therapeutic objectives based on assessment.

5. Document patient assessment.

Oxygen Therapy

1. Describe the indications, hazards and complications of oxygen therapy.

2. Assess the patient’s need for oxygen therapy utilizing total body system review.

3. Describe oxygen delivery devices (low and high flow).

4. Describe oxygen storage systems (OCD’s, liquid O2, cylinders).

5. Assess the clinical effectiveness of oxygen therapy.

6. Calculate the duration of various oxygen storage systems.

7. Describe the calibration and troubleshooting of an oxygen analyzer.

Arterial Blood Gases

1. List the various sample sites.

2. List the indications and contraindications for taking ABG’s.

3. Interpret results.

4. Record appropriate data.

Pulse Oximetry

1. Describe the indications for pulse oximetry.

2. List the sites that may be used for obtaining SpO2 measurements.

3. Describe the factors that affect the accuracy of results.

Bedside Spirometry

1. List the indications for performing spirometry.

2. Record appropriate data.

3. Discuss the use of bedside spirometry versus peak expiratory flowrates for assessment of obstructive lung disease.

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Sputum Induction

1. List the indications.

2. Determine appropriate agent.

3. List the indications for sputum induction.

4. Describe the sputum induction procedure.

5. Discuss the side effects of agents.

6. Describe the various methods of obtaining a sputum sample.

7. State the various devices used to promote deep breathing and coughing.

8. Identify the various sputum tests and their indications (C+S, AFB, cytology).

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Humidity and Aerosol Therapy

1. List the indications for humidity and aerosol therapy.

2. Discuss humidity and aerosol delivery devices.

3. Describe the proper administration of each type of aerosol generating device.

4. List the indications, contraindications, routes of administration, dosage, desired effect and side effect of the following:a. Salbutamol and other Beta agentsb. Ipatropium Bromidec. Racemic Epinephrined.N-Acetylcysteinee. Inhale Corticosteroidsf. Long acting Beta 2 agonistsg.Anti Leukotrienes

5. Perform a MDI start with appropriate patient instruction.

6. Instruct the patient in the use of a spacer device.

7. Assess the effectiveness of the bronchodilator therapy and adjust treatment plan accordingly.

8. Discuss the rationale for changes to an appropriate delivery for medication administration.

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Documents

· Web viewDiscuss the controversy of correcting metabolic acidosis with alkaline agents Discuss blood gas results from mixed venous sites (PAC) and central venous sites (central lines)