Advanced Critical Care Nursing by Wafaa Ahmed

College of Nursing Critical Care Nursing

2021-2022

Critical Care Skills Laboratory

OBJECTIVES

STUDENT CODE OF CONDUCT

SCHEDULES

LIST OF PROCEDURES

DOCUMENTS

WORKSHOPS AND TRAINING 6. 7. 8. 9.

CHECKLISTS SIMULATION INVENTORIES

Critical Care skills Laboratory Objectives The critical care laboratory in the college of nursing is a fully equipped laboratory designed to recreate the atmosphere of the critical care unit, the latest in laboratory and simulation technology such as high fidelity human patient simulators, and electronic supply and static mannequins are all included within the lab. The lab also provides a space for debriefing and reflective thinking exercises that allow the students time to review their decisions and actions with the instructor and their classmates.

Mission: 6

Preparing graduate nurses qualified for caring for critically ill patients according to the universal standards of nursing practice.

Objectives: 

Enhance learning using simulation technology and related resources.



Provide educational materials for students, faculty, and staff.



Provide hands-on learning experiences specific to critical care nursing course objectives as directed by the nursing curriculum.



Provide a safe environment for students to practice critical care nursing skills



Bridge the gap between theoretical learning and clinical training



Encourage independent student learning opportunities



Integrate Clinical Simulation into critical care Nursing curriculum



Increase preparedness of nursing students before introduction to hospital training



Introduce physiology/ pharmacology/health assessment, etc. into cases critical care students



Increase preparedness for dealing with high acuity and critical cases



Enhance communication skills



Demonstrate the value of team-work and collaboration

RESPONSIBILITIES AND CONDUCT OF STUDENTS IN CLINICAL SIMULATION LAB  Review the skills to be practiced and/or demonstrated as well as having read the assigned chapters by your instructor prior to lab attendance.  Gather and return the equipment used for skill performance.  Inform instructor when unable to locate equipment, supplies or resources 8

 Handle simulators and equipment with care and respect  Follow safety measures at all times  Maintain cleanliness of the area  Dispose of sharps appropriately  Demonstrate respect and consideration for self and others.  All students should display professional conduct.  Allow others the opportunity to practice  Inform instructor if supplies are running low.  Any damage or malfunction of mannequins or equipment should be reported to the lab faculty immediately.  Inform the instructor of any particular learning needs.

‫رقم‬

‫أسم الموضوع‬

‫رقم‬

‫الصفحة‬

‫المسلسل‬ ‫كلمه رئيس القسم‬

‫المقدمة‬

‫الرؤيه‬

‫الرساله‬

‫تشكيل مجلس القسم‬

‫مهام اعضاء مجلس القسم‬

‫قواعد التدريب بالمعامل‬

‫مراحل التدريب وشروط التدريب والفئة المستهدفة‬

‫والية التدريب‬ ‫أساليب التعليم والتعلم بالمعامل واستراتيجيات التقويم‬

‫احتياطات األمن والسالمة وأجهزة ومعدات األمن‬

‫قاعدة بيانات أعضاء هيئة التدريس بالمعامل‬

‫ الخطة الدراسية لبرنامج التمريض‬Advanced

Critical Care Nursing (NUR 405E)

Preface This book provides an easy to follow guide to the most commonly performed procedures in the Intensive Care Unit. It is has been written with the newcomer looking for step by step guidance as well as the seasoned practitioner looking to push their memory in mind. “Bedside Procedures” is not intended to replace more voluminous intensive care textbooks. I hope that by discussing 10 procedures all the 10

way from indication to the management of possible complications this book will be useful in clinical practice, preparing for examinations and as a teaching tool. I would like to thank all those who helped preparing the manuscript. My special thanks go to the authors who contributed their expertise by writing the chapters for this book.

‫نبذة عن القسم‬ ‫ وهي عبارة عن فن وعلم ينتهجه الممرض لتق<<ديم الخ<<دمات العالجي<<ة‬, ‫تتصف مهنة التمريض بأنها مهنة إنسانية‬ ‫ كما يهدف التمريض إلي مراقب<<ة الحال<<ة الص<<حية للم<<ريض خالل‬,ّ‫للمجتمع للحفاظ علي صحة الفرد وبقائه سليما‬ ‫ وتتخ<<ذ مهن<<ة التم<<ريض ج<<انبين أح<<دهما‬.‫رقوده علي سرير الشفاء والحد من المضاعفات التي قد ترافق< المرض‬ <.‫مهاري واألخر معنوي‬

‫وفي ضوء ذلك صدر القرار الجمهوري< رقم ( ‪ 411‬لسنة ‪ 2020‬م ) والذي يقضي بفص<<ل قس<<م التم<<ريض بكلي<<ة‬ ‫العلوم الطبية التطبيقية وإنشاء كلية تمريض مستقلة إبت<<داءاّ من الع<<ام األك<<اديمي< ‪. 2021-2020‬ومن ثم تم إنش<<اء‬ ‫قسم تمريض العناية الحرجة والطوارئ ضمن أقسام< الكلية الثمانية بن<<اءاّعلي ق<<رار مجلس الكلي<<ة رقم (‪ )6‬للع<<ام‬ ‫األكاديمي ‪)2021-2020‬‬ ‫ويضمن تخصص تمريض الرعاية المركزة وتمريض< الطوارئ واألسعافات األولية‪.‬‬ ‫يعتبر القسم إمتداداّ طبيعيا ّ من الناحية الهيكلية واإلداري<ة حيث ي<درس كأح<د التخصص<ات< بقس<م التم<ريض بكلي<ة‬ ‫العلوم الطبية التطبيقية ويمد الطالب بالمعرفة والمهارات التخصصية التي تمكنه من التعامل مع الحاالت الحرجة‬ ‫والطارئة داخل وخارج المؤسسات< الطبية المتنوعة‪.‬‬

‫تنبثق تلك المهارات التخصصية من رؤية ورسالة القس<<م في إع<<داد ك<<وادر تمريض<<ية مؤهل<<ة وق<<ادرة علي القي<<ام‬ ‫بواجباتها علي الوجه األكمل في ضوء رؤية ورسالة الكلية وتكامل ت<<ام م<<ع رؤي<<ة ورس<<الة جامع<<ة مص<ر< للعل<<وم‬ ‫والتكنولوجيا‪,‬كما< يتواجد بالقسم أعضاء هيئة تدريسية وهيئة معاونة علي مس<<توي متم<<يز وتحم<<ل خ<<برات عملي<<ة‬ ‫متنوعة تساهم في تنمية قدرات الطالب وتقديم المحتوي< العلمي بشكل سلس وفعال‪ <,‬كما يحتوي القسم علي معم<<ل‬ ‫المهارات اإلكلينيكية مجهز علي أعلي مستوي يلبي كافة اإلحتياجات التدريبية والتفاعلية والطالب ‪.‬‬

‫رؤية قسم تمريض العناية الحرجة والطوارئ‬ ‫يسعي قسم تمريض العناية الحرجة والطوارئ ‪ -‬كلية التمريض ‪ -‬جامعة مصر للعلوم‬ ‫والتكنولوجيا إلي االرتقاء بالرعاية الصحية وأعداد كوادر تمريضية متميزة تعمل بوحدات‬ ‫الرعاية الحرجة والطوارئ قادرة علي التنافس محليا واقليميا‪.‬‬ ‫‪12‬‬

The vision of the critical care and Emergency department The critical care and emergency department - faculty of nursing - Misr University for Science and Technology- strive to enhance the health care and prepare nursing personnel to work in the critical care and emergency units and can compete .nationally and regionally

‫ العناية الحرجة والطوارئ‬W‫رسالة قسم تمريض‬ ‫ جامع<<ة مص<<ر للعل<<وم والتكنولوجي<<ا إلي‬- ‫ كلي<<ة التم<<ريض‬- <‫يهدف قسم تمريض العناية الحرجة والط<<وارئ‬ ‫إعداد كوادر مؤهلة بقدرات ذات جودة ومهارة عالية لتقديم رعاية تمريضية متخصصة في مج<<ال تم<<ريض‬ <.‫الحاالت الحرجة والطوارئ‬

The Mission of the critical care and Emergency department The critical care and emergency department - faculty of nursing - Misr University for Science and Technology - aim to prepare competent and highly qualified nursing personnel with excellent skills to provide specialized nursing care in the critical care and emergency field.

:‫ العناية الحرجة والطوارئ‬W‫أهداف قسم تمريض‬ ‫ جامعة مصر للعلوم‬- ‫ كلية التمريض‬- ‫في ضوء رؤية و رسالة قسم تمريض العناية الحرجة والطوارئ‬ :‫والتكنولوجيا وفي ضوء األهداف األستراتيجية للكلية تم وضع أهداف القسم‬

.‫إعداد كوادر تمريضية ذات قدرات متميزة في مجال تمريض الحاالت الحرجة والطوارئ‬

-1

.‫إعداد كوادر تمريضية ذات قدرات متميزة تتناسب مع إحتياجات سوق العمل في الداخل والخارج‬

-2

‫‪-3‬‬

‫إعداد دورات تدريبية لإلسعافات االولية والطوارئ والحاالت الحرجة‪.‬‬

‫‪-4‬‬

‫المشاركة في األنشطة المجتمعية لرفع الوعي الصحي لدي المجتمع‪.‬‬

‫‪-5‬‬

‫تنمية القدرات لهيئة التدريس والهيئة المعاونة بالقسم من خالل عقد يوم علمي دوري‪.‬‬

‫‪-6‬‬

‫تحفيز وتدعيم النشر العلمي الدولي ألعضاء هيئة التدريس والهئية المعاونة‪.‬‬

‫‪-7‬‬

‫توعية مستمرة للعاملين في تخصص تمريض العناية الحرجة والطوارئ‪.‬‬

‫‪-8‬‬

‫تط وير كف اءة األداء المع رفي والمه اري للطالب لموكب ة التط ورات المس تحدثة في تخص ص تم ريض العناي ة الحرج ة‬ ‫والطوارئ‪.‬‬

‫‪-9‬‬ ‫‪-10‬‬

‫تطوير البرامج والمقررات التعليمية بالقسم بما يحقق المعايير األكاديمية القومية واألقليمية‪.‬‬ ‫رفع كفاءة مهارات التعليم الذاتي والمستمر لدي الطالب بالمراحل التعليمية المختلفة‪.‬‬

‫‪:Objectives of the Critical and Emergency Nursing Department‬‬ ‫‪In the light of the vision and mission of the Department of Critical care and‬‬ ‫‪Emergency Nursing - Faculty of Nursing - Misr University for Science and‬‬ ‫‪Technology, the strategic goals of the faculty have been set:‬‬ ‫‪1- Preparing nursing staff with distinct capabilities in critical and emergency‬‬ ‫‪nursing.‬‬

‫‪14‬‬

2- Preparing nursing staff with distinct capabilities that suit the needs of the labor market at home and abroad. 3- Preparing free courses for first aid, emergency and critical. 4- Participating in activities to raise health awareness in the community. 5- Developing the capabilities of the teaching staff in the department by holding a periodic scientific day. 6- Motivate and support international scientific publishing for faculty members. 7-

Continuous awareness for workers in the specialty of critical care and emergency nursing.

8- Developing the efficiency of cognitive and skill performance of students to keep pace with the recent developments in the specialty of critical care and emergency nursing. 9- Developing educational programs and courses in the department to achieve national and regional academic standards. 10- Raising the efficiency of self- and continuous education skills among students in the different educational stages.

LIST OF PROCEDURES PROCEDURE

ACLS

Continuous Positive Airway Pressure ((CPAP

Eye Care for Critical ill Patient.

Mouth Care for Critical ill Patient

Incentive Spirometer

Scoring Systems in the Intensive Care Unit 18

LIST OF PROCEDURES

STUDENT EVALUATION OF SIMULATED CLINICAL EXPERIENCE Student name: ………………………... Student ID…………….………………… Program:………………………………. Year……………….. Semester ……………… Simulated clinical experience:……………..……………………………………………. Instructor:………………………………........................Date:…………………………... Strongly Agree 5

Serial

1. 2. 3.

4. 5.

The instructor prompts guided me I thinking critically I feel more confident in my ability to deal with real patients I developed better understandings of drugs used in the simulated clinical experience I feel more prepared for decision making My physical examination and assessment skills have improved

Agree 4

Uncertain 3

Disagree 2

Strongly Disagree 1

6. 7. 8. 9. 10. 11.

I feel more able to predict what pathophysiological changes may occur in a real patient The simulated clinical experience has reinforced my theoretical knowledge The simulated clinical experience has challenged me to think and make decisions I have learned a great deal from observing my colleagues I have learned ways to improve my communication skills with patients and colleagues Debriefing sessions and discussions were valuable

Comments : ………………………………………………………………………..………………… ………………………………………………................................................................... ...........................................................................................................................................

Simulated Clinical Experience Evaluation Sheet Simulation: ………………………………………………… Instructor: ……………... Student Name: …………….……… Student ID: …………..……………………. Date : ……………………………..…Group: ………………………………………..….. Serial

Theme

Done 2

Incomplete 1

Not done 0

ASSESSMENT : (TOTAL 12 grades) 1. 2. 3. 4. 5. 6.

     

Proper equipment used Systematic approach Appropriate techniques Identifies significance of findings Refers to appropriate personnel Evaluates after intervention

COMMUNICATION : ( TOTAL 8 grades) 1.  Communicates effectively with members of healthcare team 2.  Uses appropriate verbal and non- verbal communication 3.  Communicates effectively with patient and family members 4.  Uses terms appropriate to patient’s level of education NURSING MANAGEMENT : (TOTAL 14 GRADES) 1. 2. 3.

  



5. 6.

 



Uses best practices Prioritizes interventions Uses appropriate protocols / procedures/ treatments /interventions Uses Critical thinking / problem solving Delegates appropriately Proper Fluid/ blood /drug administration Coordinates appropriately with interdisciplinary team

KNOWLEDGE AND COGNITIVE SKILLS (TOTAL 6 GRADES) 1.



Post SCE written exam

PSYCHOMOTOR SKILLS (TOTAL 10 GRADES) 1.



Procedure checklist

TOTAL GRADE (50) Instructor’s signature:

Training Evaluation Form 22

Date:

Comments

Please provide feedback regarding the training session that you attended. Your opinion is valuable to us and will guide us in planning future training workshops. Workshop: ……………………………………………………………………………………………… Instructor(s): ……………………………………………………………………………………… ……… Please check the box corresponding to the degree to which you believe the training workshop achieved its goals: SN

Strongly Agree 5

Agree 4

Uncertain 3

Disagree 2

Strongly Disagree 1

Objectives for the workshop were met

Questions were answered to my satisfaction 3. I better understand the components of the simulator 4. I better understand how to operate the simulator 5. I better understand how to run a simulation scenario 6. I received guidance on how to use simulation in my course 7. I better understand how I can integrate simulation into my curriculum 8. I am better prepared to assume the role of facilitator in a simulation setting 9. I am better prepared to make the simulator and its environment more realistic 10. I better understand the importance of debriefing 11. I feel confident in my ability to use the simulator with my student 12. Overall I am satisfied with the workshop/ training Comments:

……………………………………………………………………………… ……………………………………………………………………………… ………………………………………………………………………………

Training Attendance Sheet Training Session:………………………………………………. 23

Instructor:………………………………………………………………….. Date:………………………………………………………………………… Attendance Serial

Name

Signature

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Lab manager s:……………………………………………………….. Lab coordinator: Dr.

ACLS Overview Definition: ACLS indicates advanced cardiovascular life support; BLS, basic life support; CPR, cardiopulmonary resuscitation; ET, endotracheal; IV, intravenous; and ROSC, return of spontaneous circulation. Indications for ACLS 26

 ACLS Cases Respiratory Arrest.  Arrhythmia-Ventricular Fibrillation and Pulseless Ventricular Tachycardia.  Pulseless Electrical Activity (PEA) & Asystole.  Adult Cardiac Arrest Management Algorithm.  Cardiac Arrest Management.  Adult Immediate Post Cardiac Arrest Management Algorithm.  Symptomatic Bradycardia-Slow Heart Rate. Adult Chain of Survival ■ Immediate recognition of cardiac or respiratory arrest with early access to the emergency medical response team ■ Early CPR ■ Early defi brillation ■ Early access to advanced medical care ■ Effective post-resuscitation care Pediatric Chain of Survival ■ Prevention of cardiac or respiratory arrest ■ Early CPR ■ Early access to the emergency medical response team ■ Early access to advanced medical care ■ Effective post-resuscitation care CPR Quality     

Push hard (2-2.4″ (5-6 cm)) and fast (100-120 bpm) and allow chest recoil Minimize interruptions Do not over ventilate If no advanced airway, 30:2 compression to ventilation ratio Quantitative waveform capnography 

If ETCO2 <10 mmHg, attempt to improve CPR quality

Shock Energy 

Biphasic: Biphasic delivery of energy during defibrillation has been shown to be more effective than older monophasic waveforms. Follow manufacturer recommendation (e.g., initial dose of 120 to 200 J); if



unknown, use maximum available. Second and subsequent doses should be equivalent and higher doses should be considered. Monophasic: 360 J Reversible Causes (5 H and 5 T)

          

Hypovolemia Hypoxia H+(acidosis) Hypothermia Hypo-/hyperkalemia Hypoglycemia Tamponade, cardiac Toxins Tension pneumothorax Thrombosis, pulmonary or coronary Trauma

Procedures steps 1. Scans check for movement

Rationale - To check responsiveness.

(5-10 seconds). 2. Shout near Tap or shake the patient’s shoulder gently. Ear “are you OK”. 1. Tells someone to activate the

- To call for help.

emergency response system and get an AED or 2. Activates the emergency response system and gets the AED Or Directs second rescuer to activate the emergency response system and get the AED 3. Check carotid pulse (5-10

seconds). Note that pulse is present 4. Does not initiate check compressions or attach AED 5. Delivers first cycle of compressions at correct rate (acceptable: 18 seconds or less for 30 compressions) 6. Place hand nearest patient’s forehead and apply backward 31

- To open air way.

pressure to tilt head back (Head-tilt/ chin –lift position). 7. inserts oropharyngeal or

To open air way.

nasopharyngeal airway 8. Administer oxygen Performs correct bag-mask ventilation for 1 minute 9. Gives proper ventilation - rate and volume. 10.Performs ventilations at the correct

To avoid pressure over air way

rate of 1 breath every 5-6 seconds (10-12 breaths per minute). 11.If you suspect a neck injury, use jaw thrust method. (Do not move

- To avoid cervical injury complications.

victim’s head or neck, Try lifting chin without tilting head back). 12.Delivers second cycle of compressions at correct hand position (acceptable: greater than 23 of 30 compressions) 13.Perform the initial assessment a. Perform high-quality CPR

- To be sure that victim breathes or not.

b. Establish an airway and provide oxygen to keep oxygen saturation > 94% c. Monitor the victim’s heart rhythm and blood pressure. 14.If the patient is in asystole or PEA,

this is NOT a shockable rhythm. 15.Continue high-quality CPR for 2

- To keep air way open.

minutes (while others are attempting - To enter enough amount of air. to establish IV or IO access). Watching chest rise to see if your 32

breath go in. 16.give epinephrine 1 mg as soon as

possible and every 3-5 minutes 17.Check for pulse (Carotid pulse in child and adult and brachial pulse in infant) take 5-10 second. 18.After 2 minutes of CPR, check

- Carotid artery is used because it

leis close to the heart and is accessible. - In infant carotid pulse is very difficult to reach.

rhythm 19.If the monitor and assessment show VTach or VFib, move

- - To make sure there is pulse.

to VTach/VFib algorithm 20.Evaluate and treat reversible causes - To avoid recurrent arrested 21.if the patient attains Return of Spontaneous Circulation (ROSC), provide Post Cardiac Arrest Care

CHECKLIST FOR ACLS Done

Skills

Needs more practice

1. Scans check for movement 2. Tells someone to activate the emergency response system and get an AED 3. Check carotid pulse 4. Delivers first cycle 5. inserts oropharyngeal or

nasopharyngeal

airway 6. Perform the initial assessment 7. give epinephrine 1 mg as soon as possible and every 3-5 minutes 8. Check for pulse 9. Evaluate and treat reversible causes 10.if the patient attains Return of Spontaneous Circulation (ROSC), provide Post Cardiac Arrest Care

Capnography 34

Not done

Capnography General objective At the end of this procedure, the student will acquire knowledge and skill about Continuous End Tidal Carbon Dioxide Monitoring by using capnography.

Definition Capnograph is a noninvasive continuous measurement of the end-tidal partial pressure of carbon dioxide, referred to as PetCO2. A capnograph is a graphic depiction of a waveform tracing each respiratory cycle. The partial pressure of end-tidal CO2 is representative of alveolar CO2 (Pa CO2), which under normal ventilation/perfusion matching in the lungs closely parallels arterial levels of CO2 (Pa CO2)

Purposes The purpose of the Capnograph is to 1. Determine baseline data about PetCO2 value. 2. Continuously monitor the patency of the airway and presence of breathing and Assessment of ventilator, breathing circuit and gas sampling integrity 3. Provide a mechanism for early detection of change in PetCO2 value. 4. Evaluate the patient’s response to activities that may affect ventilation (i.e. suctioning, nutritional supplement). 5. Verification of proper endotracheal tube placement

Indications of PetCO2 Capnograph is needed for the patients at risk for: 1. Acute airway obstruction or apnea. 36

2. Dead space ventilation i.e. air embolism. 3. Incomplete alveolar empty i.e. COPD

Normal arterial and end-tidal CO2value Arterial CO2 (PaCO2) from arterial blood gas sample (ABG ) - Normal PaCO2values: 35 to 45 mmHg End-tidal CO2 (EtCO2) from capnography - Normal EtCO2values: 30 to 43 mmhg

The characters of normal capnographic waveform 1. Zero base line (A - B) represents the beginning of exhalation of CO2 free gas from anatomic dead space. 2. Rapid, sharp rise (B – C) containing a mixture of fresh gas and CO2 begins to be exhaled from the lung. 3. A nearly flat alveolar plateau (C – D) that occurs as exhaled flow velocity. 4. A distance end tidal value (D) that reflects the maximum concentration of exhaled CO2 and the end of exhalation. 5. A rapid down stroke (E) as the patient begins the inspiration of gas that is essentially devoid of CO2.

Zero base line (A-B) Rapid, sharp rise(B-C) Alveolar plateau(C-D)

End tidal value(D) Rapid sharp Down stroke (E)

Capnograph normal wave 37

Equipment • • •

Personal protective equipment Capnometer Airway adapter or Petco2 nasal cannula

Patient assessment and preparation Patient Assessment and Preparation

 Verify the correct patient with two identifiers  Assess for indications for Petco2 monitoring  Assess vital signs. 38

 Auscultate breathing sound

Nursing Procedure and Rational Steps

Rational

1. Hand hygiene

The order provides a guideline for

2.Prepare Equipment

duration of monitoring, acceptable

Obtain order or follow

parameters

institutional protocol for continuous

appropriate

Petco2 monitoring with capnography.

abnormal results.

4. Assess for the proper functioning of

Ensures reliability of Petco2 values

capnograph, including electronic

and waveforms obtained.

for

results,

and

interventions

for

equipment, self-start, auto-calibration, airway adapter, sensor, and display monitor; and secure connections. 5. Connect capnograph into a grounded

Decreases incidence of electrical interference.

wall outlet, connect the appropriate patient cable into display monitor, and

Accurate measurement for devices

turn on the instrument.

depends on proper calibration.

Perform calibration routine.

Calibration procedure should occur daily

Improper calibration may lead to erroneous Petco2 values.

or more often when instrument is in clinical use. 7.

If the patient is not intubated,

apply Petco2 nasal cannula and connect to capnograph. 8.

Decreases incidence of improper gas sampling.

For intubated patients, assemble

airway adapter, sensor, and display monitor; connect to the patient’s circuit as close as possible to the patient’s ventilation connection. 40

Decreases

condensation

and

secretion accumulation on CO2

port where gas is drawn for 9. Ensure that the light source is on top

sampling.

of the circuit so that condensation and secretions do not pool and obstruct the light transmission in the mainstream sensor. 10.

Set appropriate alarms. Alarm

limits should include respiratory rate, apnea default, high and low Petco2, and minimal levels of inspiratory CO2. 11.

Discard supplies

12.

Hand hygiene

13.

Documentation should include the

following: •

Medications that may affect the respiratory system (e.g., neuromuscular blockers, sedatives)

• • •

Mechanical ventilator settings Petco2 value Paco2 (partial pressure of arterial carbon dioxide)

•

Respiratory assessment (e.g., respiratory rate, Petco2 gradient

•

Unexpected outcomes

•

Arterial blood gases

•

Times of calibration

Alerts the nurse to potentially life-threatening problems.

Checklist for CAPNOGRAPHY STUDENT’S NAME:…………………………….. Procedure

No 1 2

Hand hygiene Prepare Equipment

Obtain order or follow institutional protocol

STUDENT’S ID: … … … … … … … … … .

Assess for proper functioning of capnograph, including electronic equipment, self-start, autocalibration, airway adapter, sensor, and display monitor; and secure connections. 5 Connect capnograph into grounded wall outlet, connect the appropriate patient cable into display monitor, and turn on instrument. 6 Perform calibration routine. Calibration procedure should occur daily or more often when instrument is in clinical use. 7 If the patient is not intubated, apply Petco2 nasal cannula and connect to capnograph. 8 For intubated patients, assemble airway adapter, sensor, and display monitor; connect to the patient’s circuit as close as possible to the patient’s ventilation connection. 9 Ensure that the light source is on top of the circuit so that condensation and secretions do not pool and obstruct the light transmission in mainstream sensor. 10 Set appropriate alarms. Alarm limits should include respiratory rate, apnea default, high and low Petco2, and minimal levels of inspiratory CO2. 11 Discard supplies - Hand hygiene 12 Documentation Total 42

Done (2)

Need more Not done practice(1) (0)

Student Evaluation Sheet Procedure

No 1 2

Hand hygiene Prepare Equipment

1 1

Obtain order or follow institutional protocol

Assess for proper functioning of capnograph, including electronic equipment, self-start, auto-calibration, airway adapter, sensor, and display monitor; and secure connections. 5 Connect capnograph into grounded wall outlet, connect the appropriate patient cable into display monitor, and turn on instrument. 6 Perform calibration routine. Calibration procedure should occur daily or more often when instrument is in clinical use. 7 If the patient is not intubated, apply Petco2 nasal cannula and connect to capnograph. 8 For intubated patients, assemble airway adapter, sensor, and display monitor; connect to the patient’s circuit as close as possible to the patient’s ventilation connection. 9 Ensure that the light source is on top of the circuit so that condensation and secretions do not pool and obstruct the light transmission in mainstream sensor. 10 Set appropriate alarms. Alarm limits should include respiratory rate, apnea default, high and low Petco2, and minimal levels of inspiratory CO2. 11 Discard supplies - Hand hygiene 12 Documentation Total

Grade

2 1 1

1 1 15

St Grade

Continuous Positive Airway Pressure (CPAP)

General Objectives: At the end of this procedure the student will be able to provide nursing care for the patient on CPAP therapy.

Definition: CPAP is a type of positive airway pressure that is used to deliver a set pressure to the airways that is maintained throughout the respiratory cycle. It is measured in centimeters of water pressure (cm H2O). The difference between CPAP and PEEP is simple: CPAP stands for “continuous positive airway pressure,” and PEEP stands for “positive end expiratory pressure.” Note the word “continuous” in CPAP means that air is always being delivered. With PEEP, air is only delivered at a specific time — namely, the end of an “expiration,” or breath.

Purpose: 45

 Decrease atelectasis  Increases the surface area of the alveolus  Improves V/Q matching  Improves oxygenation.

Indications:  Airway collapse (such as obstructive sleep apnea (OSA). 

Hypoxia and decrease the work of breathing in infants with acute infectious processes such as bronchiolitis and pneumonia.

 Hypoxic respiratory failure associated with congestive heart failure in which it augments the cardiac output and improves V/Q matching.  Successfully patients `s extubation that might still benefit from positive pressure but who may not need invasive ventilation.  In the neonatal intensive care unit (NICU) to treat preterm infants whose lungs have not yet fully developed and who may have respiratory distress syndrome from surfactant deficiency.

Types of CPAP: A- Invasive CPAP: No additional pressure above the set level is provided, and patients are required to initiate all their breaths.

Invasive CPAP B- Noninvasive CPAP can be administered in several ways based on the mask interface used: 

Nasal CPAP: Nasal prongs that fit directly into the nostrils or a small mask that fits over the nose



Nasopharyngeal (NP) CPAP: Administered via a nasopharyngeal tubean airway placed through the nose whose tip terminates in the nasopharynx. This has the advantage of bypassing the nasal cavity, and CPAP is delivered more distally.



CPAP via face mask: A full face mask is placed over the nose and mouth with a good seal. It can be used for those that are mouth breathers, or for pre-oxygenation in spontaneously breathing patients prior to intubation.

Noninvasive CPAP Contraindications Noninvasive CPAP:

The following are relative contraindications for CPAP:  Uncooperative or extremely anxious patient  Reduced consciousness and inability to protect their airway  Unstable cardiorespiratory status or respiratory arrest  Trauma or burns involving the face  Facial, esophageal, or gastric surgery  Air leak syndrome (pneumothorax with bronchopleural fistula)  Copious respiratory secretions  Severe nausea with vomiting  Severe air trapping diseases with hypercarbia asthma or chronic obstructive pulmonary disease (COPD).

Complications:  Congestion, runny nose, dry mouth, or nosebleeds.  Irritation or redness of the skin,  Abdominal distension or a sensation of bloating might occur which rarely can lead to nausea, vomiting and subsequently aspiration. 48

CPAP Procedure Assessment:  Assess patient need for CPAP therapy.  Assess amount of pressure of CPAP mask ordered by the physician.  Assess bilateral breath.  Assess pulse oximetry.  Assess patient`s ability to cough.  Assess patient`s tolerance to treatment.  Assess ABG analysis.

Equipment’s:  Appropriately sized CPAP (small, medium and large)  Head strip  Oxygen tubing, humidifier, and oxygen source  Prescribed pressure adapter  Suctioning equipment’s

Nursing Procedure and Rational No.

Steps

Rational

Hand washing

To prevent transmission of infection

Explain and give rational for the use of To CPAP

3. 4.

reduce anxiety and maintain

cooperation

Apply appropriate size face mask, and To make an adequate seal and head strip

minimize pressure sores on the face

Adjust oxygen concentration

To provide optimal oxygenation to the patient

Monitor patient for nausea and vomiting To avoid air entry to the stomach

Provide communication devices as To enable patient to communicate his/

(writing board or cool light)

her needs

Evaluation and follow up:

To establish need for alternative

 Assess bilateral breath

interventions

 Evaluate pulse oximetry  Evaluate patient`s ability to cough  Evaluate

patient`s

tolerance

treatment  Evaluate ABG analysis.

Documentation:  Skin color, capillary refill, and oxygenation saturation before and after procedure.  Fio2 concentration used.  Color, consistency, and color of secretions.  Vital signs alterations before and after therapy.  Associated nausea or vomiting.  Amount of pressure of CPAP mask ordered by the physician.  Episodes of hypotension

Checklist for CPAP Therapy STUDENT’S NAME:……………………………………

STUDENT’S NUMBER: …………………………………………

Procedure

No 1.

Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy.

Explain the procedure to the patient even if he is comatose.

Prepare the required equipment’s and maintain privacy.

Perform hand hygiene and apply clean gloves and other PPE as patient condition dictates. Assessment:  Assess patient need for CPAP therapy.

 Assess amount of pressure of CPAP mask ordered by the physician.  Assess bilateral breath.  Assess pulse oximetry.  Assess patient`s ability to cough.  Assess patient`s tolerance to treatment.  Assess ABG analysis. 6.

Apply appropriate size face mask, and head strip

Adjust oxygen concentration

Monitor patient for nausea and vomiting

Provide communication devices as (writing board or cool light)

Done Need more Not done practice

Procedure

No 10.

Evaluation and follow up:  Assess bilateral breath  Evaluate pulse oximetry  Evaluate patient`s ability to cough  Evaluate patient`s tolerance to treatment  Evaluate ABG analysis

11.

Remove and properly dispose of gloves and other PPE, if used. Perform hand hygiene.

12.

Done

Need more Not done practice

Student Evaluation Sheet No

Steps

Grade

Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy.

Explain the procedure to the patient even if he is comatose.

Prepare the required equipment’s and maintain privacy.

Perform hand hygiene and apply clean gloves and other PPE as patient condition dictates. Assessment:  Assess patient need for CPAP therapy.

Apply appropriate size face mask, and head strip

Adjust oxygen concentration

Monitor patient for nausea and vomiting

Provide communication devices as (writing board or cool light) Total

St' grade

Eye Care for Critical ill Patient.

GENERAL OBJECTIVE At the end of this procedure, the student will be able to perform eye care for critically ill patients effectively.

Definition: A basic nursing care procedure essential for critically ill patients to prevent complications, such as eye infection or injury.

It is one of the most

important, yet simple to perform, nursing interventions required when caring for ventilated patients.

Eye assessment Eyes should be assessed as part of a holistic patient assessment and as part of personal care. It is important to discuss any long-term eye problems the patient has and document how these are managed; for example, glaucoma requires regular eye drops, or blepharitis (inflammation of eye lid margin) may require a personalized plan of care. Patients should be asked whether they have any new problems with their vision. These should be reported immediately, as acute eye problems such as acute glaucoma, orbital cellulitis or retinal detachment may result in serious eye complications if treatment is delayed. It is important to record any sight aids the patient uses such as glasses, contact lenses and a prosthetic eye. If necessary, patients should be given support to use these aids, such as ensuring that patient’s glasses are clean; nurses should seek expert help if they lack skills to meet a patient’s needs.

Purposes  To clean the eye of discharge and crusts  To decrease eye irritation, pain and discomfort  To prevent corneal damage/abrasion in unconscious/sedated patients.  After eye surgery to prevent complications  Prior to eye drop installation

Potential eye complications for ICU patients 1. Superficial keratopathy: is a non-inflammatory disease of the cornea. 57

2. Superficial corneal abrasions: is a more common result of eye exposure. 3. Keratitis: is any inflammation of the cornea. 4. Conjunctivitis: is inflammation of the conjunctiva. It is caused by bacterial or viral infection. 5. Conjunctival chemosis (ventilator eye): is edema of the conjunctiva. It is due to the adverse effect of ventilatory support, the drugs used to facilitate artificial respiratory support, and securing endotracheal tube tape too tightly. This can compromise venous return from the head, leading to venous congestion, and can potentially increase intraocular pressure.

The underpinning principles of eye cleansing

 The eye should be carefully assessed before eye care is provided  Patients should be encouraged to carry out their own eye care if they are assessed and found able to do so  Each eye should be treated as a separate procedure and a separate dressing pack should be used for each eye to prevent crosscontamination  Infected eyes should be treated last to reduce the risk of crossinfection.  A clean technique can be used for eye cleansing unless there are specific concerns about infection risk such as in postoperative patients – in which case an aseptic procedure should be used

 Low-lint or lint-free swabs should be used to cleanse eyes as lint fibers can scratch the cornea. Cotton wool should be avoided as the cotton wool threads can catch on the eyelashes  Recommend sterile water for eye cleansing and suggest sterile sodium chloride 0.9% may cause stinging and irritation. However, other authors suggest using sodium chloride 0.9%.  A light source should be positioned behind the nurse so it illuminates the eye, but it should not shine directly into the eye as this will be uncomfortable for the patient Equipment 

Sterile dressing pack;



Sterile low-lint swabs;



Sterile water or saline Sterile lubricant or eye preparation as ordered by physician.

Nursing Procedure and Rational Steps

Rational

1. Confirm the patient’s identity. 2. Decontaminate hands following the five moments for hand hygiene. 3. Explain procedure to the patient.

To gain his cooperation

4. Discuss the procedure with the patient; ask about their usual eye care routine and any problems they have with their eyes. 5. Ensure the patient’s privacy by screening the bed or ensuring their room door is closed. 6. Assemble your equipment and ensure the bed is at the correct working height. 7. Position the patient sitting comfortably

with the head tilted back with the face

To prevent obstruction of

upward (Fig 2).

lacrimal duct

8. Assess the external appearance of the eye. 9. Ask the patient to close their eyes if conscious. 10.Check for any discharge, bruising or inflammation (Fig 3).

If the eyelids fail to close completely, report this to medical staff as it may be a sign that a lump or cyst is present or there may be problems with eyelid muscles.

11.Ask the patient to open their eyes and check for signs of redness in the conjunctiva and for evidence of discharge (Fig 4).

These signs may indicate the presence of infection or inflammation.

12.Take a sterile swab in your hand and

A very wet swab can be

moisten it slightly with sterile water or saline.

13.Swab the lower eye lid from the medial canthus outwards (Fig 5).

14.Repeat, using a clean swab each time to reduce the risk of infection, until the eyelid is clean. 15.Moisten a swab and gently clean the upper eyelid from the medial canthus outwards (Fig 6b).

uncomfortable for the patient and increase the risk of contamination of the opposite eye. Swabbing in this direction reduces the risk of introducing infection into the lacrimal punctum. Do not allow the swab to go above the lid, to ensure that contact between the swab and cornea is avoided – this is uncomfortable and may cause damage to the cornea.

16.Repeat with a new moistened swab until the lid is clean. Dab off any excess

to ensure patient is dry and comfortable

water/saline around the eye. 17.Repeat the procedure on the second eye Instillation of eye ointment

 Hold a swab in the non -dominant hand under the lower lid margin.  Hold the tube of ointment in the dominant hand 2.5 cm above the lower lid.  Squeeze the tube to allow a ribbon of ointment into the lower conjunctival sac a. Close the eye

Place an eye pad over the eyes and tape in position 18.Record the care in the patient’s records. Record and report any abnormal findings.

To keep the eye moist.

Checklist for eye care STUDENT’S NAME:……………………………………

Procedure

No 1

STUDENT’S NUMBER: …………………………………………

I. Assessment 1. Note the appearance of the eye for symmetry and clarity. 2. Observe for edema or swelling of tissue around the eyeball. 3. Observe for irritation, redness, crusts or unusual exudates.

Done (2)

Need more practice(1)

Not done (0)

II. Preparation A. Environment 1. Prepare equipment. B. Nurse 1. Wash hands 2. Wear gloves C. Patient 1. Explain procedure to the patient. 2. Position the client on back with the face upward. III. Implementation 1. Cleansing of the eye  Wipe the two eyes from the inner to outer canthus. 2. Instillation of eye medication a. Instillation of eye drops  Hold a swab in the non-dominant hand under the lower lid margin.

Procedure

 Hold the dropper in the dominant hand, and allow one drop to fall into the lower conjunctival sac  Close the patient’s eyes. b. Instillation of eye ointment  Hold a swab in the non-dominant hand under the lower lid margin.  Hold the tube of ointment in the dominant hand.

 Hold the tube 2.5 cm above the lower lid; squeeze the tube to allow a ribbon of ointment into the lower conjunctival sac. c. Close the eye.  Place an eye pad over the eyes, and tape in position. IV. Post care A. Patient 1. Return the patient to comfortable position B. Environment 1. Clean and return equipment. C. Nurse 1. Remove gloves. 2. Wash hands V. Documentation 1. Recording  Date & time.  Type of eye medication. 2. Reporting Any abnormal findings.

Total

Done

Need more practice

Not done

Student Evaluation Sheet Steps I. Assessment 4. Note the appearance of the eye for symmetry and clarity. 5. Observe for edema or swelling of tissue around the eyeball. 6. Observe for irritation, redness, crusts or unusual exudates. II. Preparation A. Environment 1. Prepare equipment. B. Nurse 3. Wash hands 4. Wear gloves C. Patient 3. Explain procedure to the patient. 4. Position the client on back with the face upward. III. Implementation 1. Cleansing of the eye  Wipe the two eyes from the inner to outer canthus. 2. Instillation of eye medication a. Instillation of eye drops  Hold a swab in the non-dominant hand under the lower lid margin.

Grade 1 1 1

St' grade

Steps

Grade

 Hold the dropper in the dominant hand, and allow one drop to fall into the lower conjunctival sac

 Close the patient’s eyes.

b. Instillation of eye ointment  Hold a swab in the non-dominant hand under the lower lid margin.  Hold the tube of ointment in the dominant hand.  Hold the tube 2.5 cm above the lower lid; squeeze the tube to allow a ribbon of ointment into the lower conjunctival sac. c. Close the eye.  Place an eye pad over the eyes, and tape in position. IV. Post care A. Patient 1. Return the patient to comfortable position B. Environment 1. Clean and return equipment. C. Nurse 1. Remove gloves. 2. Wash hands V. Documentation 1. Recording  Date & time.  Type of eye medication. 2. Reporting Any abnormal findings.

Total

1 1 1 2

1 1 1

St' grade

Mouth Care for Critically Ill Patient

General Objective: At the end of this procedure, the student will be able to perform oral care for critically ill patients effectively.

Definition: Mouth care is defined as the scientific care of the teeth and mouth by using antiseptic solutions or other mouth-cleaning preparation.

Purposes: 1. To keep mucosa clean, soft, moist, and intact. 2. To keep the lips, clean, soft, moist, and intact. 3. To prevent oral infections. 4. To remove the food debris as well as dental plaque without damaging the gum. 5. To alleviate pain, discomfort and enhance oral intake with appetite.

Indications: 1. Patients with high fever or hyper-pyrexia. 2. Very ill or unconscious patients. 3. Patients have a liquid diet or cannot take anything by mouth or swallow. 4. Patients with nasal tubing. 5. Post-operative patients. 6. Patients with oral sores. 7. Patients with dehydration. 8. Patients are breathing through the mouth.

Mouth Care Procedure Assessment: 73

1. Assess risk factors for oral hygiene 2. Presence of nasogastric or tracheal tube 3. Presence of mouth bleeding & clotting factors 4. Radiation therapy for head or neck 5. Assess the condition of the oral cavity

Equipment: A clear tray containing: Sterile dressing tray.

Suction unit.

Mackintosh and towel.

Sponge cloth.

Toothbrush and paste.

A tongue depressor

Mouth wash solution.

A pair of gloves

Cup of water.

Gauze pieces. Kidney tray. A bowl with clean water.

Nursing Procedure and Rational N o.

Steps

Rational

Hand washing

To reduce transmission of microorganisms.

Explain and give a rationale for mouth care even if the patient is unconscious

To reduce anxiety and maintain cooperation

Gather all equipment near the patient side.

To promote efficiency.

Discuss the procedure with the patient.

To discover hygiene preferences.

Wear clean gloves.

To prevent contact with microorganisms or body fluids.

Assess oral mucosa, teeth, and throat.

To determine status of oral cavity and patient’s need for care and teaching.

Take the patient to the edge of the bed in semi-fowler o laterally if the patient is unconscious

For no difficulty of doing the procedure and to prevent the aspiration.

Put a small mackintosh with a face towel on the patient’s chest and tuck it under the chin.

to prevent the soil and make the patient comfortable.

Place the kidney tray against the cheek and directly under the mouth.

To dispose the used gauze.

10. Raise the head end of the bed to 45 degrees.

To avoid the aspiration.

11. If the patient is unconscious; with help of a tongue depressor, gently

To Prevent injury and bleeding.

open the jaw. 12. Examine the patient’s oral cavity completely with the help of a torch, tongue depressor or spatula and gauze.

To identify any changes in moistures, cleanliness, infection or bleeding, ulcers in the oral cavity.

13. Pour antiseptic gauze into a cup soaked with solution, and squeeze with help of artery forceps.

To prevent infections and easy to do the procedure.

14. Clean oral cavity from proximal to distal using one gauze or use the suction machine if patient is unconscious

To avoid crosscontamination.

15. Discard used gauze into the basin.

To help for proper disposal and make the patient comfortable.

16. Provide a tumbler of water and instruct the patient to gargle mouth.

Rinsing takes away loosened debris and make the mouth taste and fresher.

17. lean tongue from inner to outer aspect To prevent injury and remove folding rag piece in such a way that the bad taste in the mouth. the tip. 18. Lubricate lips using a swab stick.

To prevent dry lips and lips crack.

19. Rinse used articles and replaced equipment, returning the patient to a comfortable position.

To Promote a safe and comfortable environment to the patient.

20. Remove and properly dispose of gloves and other PPE, if used. Perform hand hygiene. 21. Documentation (observation, bleeding, presence of mucosa or ulceration

To reduce the transmission of microorganisms.

To establish a database and the need for alternative interventions and report abnormal findings.

Checklist for Mouth care STUDENT’S NAME:……………………………………

STUDENT’S NUMBER: …………………………………………

Procedure

Identify the patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy.

Explain the procedure to the patient even if he is comatose.

Prepare the required maintain privacy.

Perform hand hygiene and apply clean gloves and other PPE as patient condition dictates.

Assess oral mucosa, teeth, and throat.

Take the patient to the edge of the bed and if possible, in semi-fowler if it is not contraindicated.

Put a small mackintosh with a face towel

Done (2)

equipment

and

Need more practice(1)

Not done (0)

on the patient’s chest and tuck it under the chin. 8. 9.

Place the kidney tray against the cheek and directly under the mouth. Raise the head end of the bed to 45 degrees.

10. Clean oral cavity from proximal to distal using one gauze for each stroke with wet gauze or suction as needed. 11. lean tongue from inner to outer aspect folding rag piece in such a way that the tip. 12. Rinse used articles and replaced equipment and returns the patient to comfortable position. 13. Remove and properly dispose of gloves and other PPE, if used. Perform hand hygiene. 14. Documentation 15.

Total

Student Evaluation Sheet No Steps 1) Identify the patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy. 2) Explain the procedure to the patient even if he

Grade 1

is comatose. 3)

Prepare the required equipment and maintain privacy.

Perform hand hygiene and apply clean gloves and other PPE as patient condition dictates.

Assess oral mucosa, teeth, and throat.

Take the patient to the edge of the bed and if possible, in semi-fowler if it is not contraindicated.

Put a small mackintosh with a face towel on

St' grade

the patient’s chest and tuck it under the chin. 8)

Place the kidney tray against the cheek and directly under the mouth. Raise the head end of the bed to 45 degrees.

10) Clean oral cavity from proximal to distal using

one gauze for each stroke with wet gauze or suction as needed. 11) lean tongue from inner to outer aspect folding

rag piece in such a way that the tip. 12) Rinse used articles and replaced equipment

and returns the patient to comfortable position. 13) Remove and properly dispose of gloves and

other PPE, if used. Perform hand hygiene. 14) Documentation 15)

1 Total

Incentive Spirometer

Incentive Spirometer General objective: At the end of the session, the students will be able to acquire skills and knowledge about the incentive spirometer.

Definition: It is a handheld medical device that measures the volume of breath. It is designed to mimic natural sighing by encouraging patients to take slow, deep breaths.

Purpose: 82



Improving lung function.



Reducing mucus buildup.



Strengthening lungs during extended rest.



Lowering the chance of developing lung infections.

Indications: 

Pre-operative screening of patients at risk of postoperative complications to obtain a baseline of their inspiratory flow and volume.



Presence of pulmonary atelectasis.



Conditions predisposing to atelectasis such as: 1. Abdominal or thoracic surgery 2. Prolonged bed rest 3. Surgery in patients with COPD 4. Presence of thoracic or abdominal binders 5. Lack of pain control



Restrictive lung disease associated with a dysfunctional diaphragm.



Patients with an inspiratory capacity less than 2.5 liters.



Patients with neuromuscular disease or spinal cord injury.

Contraindications of Incentive Spirometer. 

Patients who cannot use the device appropriately or require supervision at all times.



Patients who do not understand or demonstrate proper use of the device.



Very young patients or pediatrics with developmental delay.



Hyperventilation.



Hypoxemia secondary to interruption of oxygen therapy.



Fatigue.



Patients who unable to take a deep breath effectively due to pain, diaphragmatic dysfunction, or opiate analgesia.



Patients who are heavily sedated or comatose.



The device is not suitable for people with severe dyspnea.

Precautions of Incentive Spirometer. 

The technique is inappropriate as the sole treatment for major lung collapse or consolidation.



Hyperventilation may result from improper technique.



There is potential for barotrauma in emphysematous lungs.



Development of bronchospasm may occur in susceptible patients.



Close monitoring of patients with hyper-reactive airways should be maintained.

Incentive spirometer components:

Equipment:  Incentive Spirometer.  Stethoscope.  Pulse oximeter.  Personal Protective Equipment (facemask, gloves, etc.).  Dressing/ gauze.

Nursing Procedure and Rational 85

Steps

Rational

Assessment: 1-

Assess the respiratory system for:  Tachypnea  Decreased or diminished breath sound  Dyspnea  Chest pain  Anxiety 

Restlessness

Preparations 2-

Prepare all necessary equipment and supplies

Hand washing

Explain the procedure to the patient

- To facilitate the quick and efficient procedure - - To reduce transmission of microorganism - To gain patient cooperation and to sure that the patient knows all information about the procedure

Position patient in a sitting position or a semi- Fowler’s position,

Perform respiratory assessment and auscultate lung sounds

- To helps lungs fully expanded and help the patient to expel secretions - To obtain any abnormalities before the procedure

Instruct the patient to set the pointer at - To help the patient to see the level of ball the appropriate level on the incentive 86

movement and know lung volume during

spirometer. 8-

Have the patient position the mouthpiece in his or her mouth,

the procedure. - To prevent leak of air during inhalation and for accurate measurement.

closing the lips tightly around the device 9-

Ask the patient to exhale slowly, emptying lungs as much as possible.

10-

- To avoid fainting and headedness this may occur.

Instruct the patient to keep inhaling - To achieve an accurate measurement for until the indicator reaches the target

the incentive spirometer.

goal position. Inhalation should take at least 3 seconds 11-

Monitor vital signs and pulse oximeter - To document the baseline of the vital sign according hospital policy

12-

Auscultate lungs post spirometry and document findings

13-

Document and report the volume the

before the procedure - To compare lung sounds before and after spirometry procedure. - To reflect proper monitoring technique.

patient reached. 14-

15-

Remove the mouthpiece and wash it in - To prevent cross-infection between warm water, then dry it. Place the patients mouthpiece in a plastic storage bag between exercises and label it and the spirometer with the patient name. Remove PPE and perform hand - To reduce transmission of microorganism hygiene

16-

Document procedure, assessments and - To reflect proper monitoring technique. how patient tolerated.

Checklist for Incentive Spirometry STUDENT’S NAME:……………………………………

Procedure

No 1. i.

STUDENT’S NUMBER: …………………………………………

Review the assessment of respiratory system. Obtain necessary equipment.

Verify orders, identify patient, introduce yourself, and explain the procedure.

Perform hand hygiene and apply any needed PPE.

Position patient in a sitting position or a semi- Fowler’s position, perform respiratory assessment and auscultate lung sounds

Have the patient position the mouthpiece in his or her mouth, closing the lips tightly around the device.

Have the patient take a slow, deep breath, using the diaphragm.

Instruct the patient to keep inhaling until the indicator reaches the target goal position. Inhalation should take at least 3 seconds

Provide mouthwash to rinse the mouth.

Monitor vital signs and pulse oximeter according to hospital policy.

10. Auscultate lungs post spirometry and document findings. 11. Document and report the volume the patient reached.

Done (2)

Need more practice(1)

Not done (0)

12. Remove the mouthpiece and wash in warm water, Place the mouthpiece in a plastic storage bag and label it with patient's name. 13. Remove PPE and perform hand hygiene 14. Document procedure. Record abnormal findings and report it to the physician.

15.

Total

/15

Student Evaluation Sheet No

Steps

■ Review the assessment of respiratory system. i.

Obtain necessary equipment.

Grade 1 1

■ Verify orders, identify patient, introduce yourself, and explain the procedure.

■ Perform hand hygiene and apply any needed PPE.

■ Position patient in a sitting position or a semiFowler’s position, perform respiratory assessment and auscultate lung sounds

■ Have the patient position the mouthpiece in his or her mouth, closing the lips tightly around the device.

■ Have the patient take a slow, deep breath, using the diaphragm.

■ Instruct the patient to keep inhaling until the indicator reaches the target goal position. Inhalation should take at least 3 seconds

■ Provide mouthwash to rinse the mouth.

■ Monitor vital signs and pulse oximeter according to hospital policy.

■ Auscultate lungs post spirometry and document

St' grade

findings.

■ Document and report the volume the patient reached.

■ Remove the mouthpiece and wash in warm water, Place the mouthpiece in a plastic storage bag and label it with patient's name.

■ Remove PPE and perform hand hygiene

Patients with life threatening illness Supporting failing organ systems procedure. Record abnormal findings and ■ Document it to thespecialized physician. environment ICU reportHighly ■

Total /15 Organ support equipment Intravenous lines, feeding, suction, drains, catheter Constant monitoring of bodily functions

Scoring Systems in the Intensive Care Unit

Equipment

Monitoring

Observing vital signs Key to improve patients survival Generates data like waveforms

■Document vital parameters sampled by monitors ■Demands on PDMS have increased immensely ■PDMS are currently expected to assist 90

clinicians at every level of intensive care, e.g. □ Strategic level of physician orders and prescriptions □ Operational level □ Administrative level ■Scoring system as clinical decision support ■Severity scales important to predict □ Patient outcome, □ Comparing quality-of-care, and □ Stratification for clinical trials. ■Essential part of improvement in clinical decisions and in identifying patients with unexpected outcomes ■Using logistic regression models ■ Scoring system usually comprises of two parts □ a score (a number assigned to disease severity) and □ a probability model (equation giving the probability of hospital death of the patients). ■First-day scoring systems □ Acute Physiology and Chronic Health Evaluation (APACHE) □ Simplified Acute Physiology Score (SAPS) □ Mortality Prediction Model (MPM) ■Repetitive scoring systems □ Organ System Failure (OSF) □ Sequential Organ Failure Assessment (SOFA) □ Organ Dysfunction and Infection System (ODIN) □ Multiple Organ Dysfunction Score (MODS) 91

□ Logistic Organ Dysfunction (LOD)

Glasgow Coma Score (GCS) Let’s Take a Closer Look at One Score ■Neurological scale ■Give a reliable and objective way of recording the conscious ■Initially used to assess a person's level of consciousness after a head injury ■Now used by first responders, EMS, nurses, and doctors ■Part of several ICU scoring systems, including APACHE II, SAPS II, and SOFA Behavior

Response

https://gunnar.com/

Eye Opening Response 4 Spontaneously 3 To speech 2 To pain 1 No response

Verbal Response 5 Oriented to time, person and place 4 Confused 3 Inappropriate words 2 Incomprehensible sounds 92 1 No response

Motor Response 6 Obeys command 5 Moves to localized pain 4 Flex to withdraw from pain 3 Abnormal flexion 2 Abnormal extension

1 No response

■Infant, moves spontaneously towards objects and follows them, smiling and orienting towards interesting sounds. The infant opens the eyes spontaneously.

■ Adult, moves hand towards head when applying pressure above the

eye socket. The patient is disoriented but able to form sentences. The patient opens the eyes in response to speech

APACHE 11 Acute Physiology and Chronic Health Evaluation

Clinical Pulmonary Infection Score (CPIS) For Ventilator-Associated Pneumonia (VAP) OBJECTIVE: To assess the diagnostic accuracy of the clinical pulmonary infection score in the diagnosis of ventilator-associated pneumonia in mechanically ventilated patients. Purpose: The CPIS assists the diagnosis of ventilator associated pneumonia by stratifying risk of positive diagnosis in patients presenting with fever, increased WBCs or tracheal secretions. It is best used in patient evaluation before following other diagnostic methods as its considerable inter observer variability makes it impossible to use in randomized clinical trials.



Clinical Pulmonary Infection Score (CPIS)

Patient temperature ≥36.5 degrees C and ≤38.4 degrees C (0 points) ≥38.5 degrees C and ≤38.9 degrees C (1 point) ≥39 degrees C (2 points) 96

≤36 degrees C (2 points)

WBC ≥4,000/mm (0 points)

-3

<4,000/mm (1 point)

-3

and ≤11,000/mm or >11,000/mm

-3

-3 -3 <4,000/mm or >11,000/mm with ≥500 bands (2 points)

Tracheal secretions (0-4+ quantifications summed over 24 hours) <14+ (0 points)

Absence of tracheal secretions ≥14+ (1 point) Presence of non-purulent tracheal secretions ≥14+ and purulent (2 points) Presence of purulent tracheal secretions

PaO2(mmHg)/FIO2 >240 or ARDS present (0 points) 97

≤240 or no ARDS present (2 points) Chest X-Ray (Pulmonary radiography) No infiltrate (0 points) Patchy or diffuse infiltrate (1 point) Localized infiltrate (2 points) Quantitative pathogenic bacterial culture growth from tracheal aspirate ≤1+ or no growth (0 points) >1+ (1 point)

Moderate or heavy quantity

>1+ and same bacteria seen on gram stain (2 points)

Total Criteria Point Count:

CPIS Interpretation 0 to 6 points:

Pneumonia less likely

7 to 12 points:

Pneumonia more likely

Notes The CPIS is used in the diagnosis of ventilator associated pneumonia Key point: The CPIS ranges between 0 and 12, where the highest the score, the greater the likelihood of positive diagnosis of VAP. The original study introduces a cut-off for diagnosis at 6 points. This means that scores of 6 and above present a high risk of pulmonary infection. CPIS items

Answer choices (points)

Description

Temperature (°C)

36.1 - 38.4 (0) 38.5 - 38.9 (1) ≤36.0 or ≥39.0 (2)

Checks for fever presence (as sign of infection).

Blood leukocytes /mm3

4,000 - 11,000 (0) <4,000 or >11,000 (1) Band forms ≥50% (2)

White blood cell number as another sign of infection.

■ Absence of tracheal

Tracheal secretions

Oxygenation, PaO2/FiO2 (mmHg)

Pulmonary radiography 99

secretions (0) ■ Presence of nonPresence of secretions is considered risk factor for purulent tracheal positive diagnosis. secretions (1) ■ Presence of purulent tracheal secretions (2)

■ >240 or ARDS (0) ■ <240 and no ARDS (2)

■ No infiltrate (0)

Oriented around the 240 cut off point with or without ARDS (Acute respiratory distress syndrome). ARDS defined as PaO2/FiO2 <200, PCWP <18, and acute bilateral infiltrates. Evaluates the presence or

■ Diffuse (or patchy) infiltrate (1) ■ Localized infiltrate (2)

absence of infiltrates and their aspect.

■ Pathogenic bacteria cultured

Culture of tracheal aspirate

100

in rare or light quantity or no growth (0) ■ Pathogenic bacteria cultured Assesses the possible type of in moderate or heavy quantity pathogenic bacteria. (1) ■ Same pathogenic bacteria seen on gram stain (2)