RESPIRATORY CARE 322
Clinical Practice VI
Summer, 2006
I.
Instructor: Aaron K. Koseki
Office: Kauila 122A
Phone: 734-9224
Health Sciences phone: 723-9270
Email: akoseki@hawaii.edu
Office hours: Mondays, 1-3
II.
Text: Clinical Notebook (student created and maintained)
III.
Objectives (outcomes)
After completing RESP 322, the student will be able to:
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Perform routine physical assessment on the critically ill patient in the intensive
care unit.
Interpret and evaluate diagnostic tests such as ABG’s, electrolytes, and chest xrays.
Calculate shunt, deadspace, static compliance and airway resistance.
Evaluate hemodynamic parameters such as CVP, SVR, PVR, MAP, PCWP, CO,
and CI.
Identify basic abnormal and life-threatening EKG patterns.
Document results of the patient’s assessment and diagnostic tests in the patient’s
record.
Communicate the patient’s respiratory care plan, response to therapy, and
progress to other members of the health care team.
Perform suctioning through tracheostomy and endotracheal tubes (ETT).
Perform tracheostomy care.
Perform manual ventilation with self-inflating bag.
Select and insert oral and nasal airways to maintain airway patency.
Inflate and measure endotracheal and tracheostomy tube cuff pressures.
Secure the ETT with cloth tape or other appropriate devices.
Perform bedside ventilatory assessment such as NIF, TV, VC, and minute
volume.
Set-up and test for function the mechanical ventilator prior to patient use.
Initiate and manage a new ventilator patient in the intensive care unit (ICU).
Manage at least (3) ventilator patients in the ICU.
Adjust ventilator settings per ABG’s.
Make clinical recommendations based on various patient data.
Identify and troubleshoot common ventilator problems.
Wean patient off the ventilator following weaning protocols.
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Perform ABG stick and draw arterial blood from an arterial line.
Check and document ventilator-patient interface.
Administer respiratory care medications to mechanically ventilated patients.
Monitor and evaluate the patient’s response to respiratory therapy.
Identify the actions of common medications used in the ICU: antimicrobial
agents, paralyzing agents, respiratory stimulants/depressants, and
analgesics/anesthetics.
Communicate with mechanically ventilated patient and relay his or her needs to
other members of the health care team.
Discuss the role of the respiratory care practitioner as part of the health care team
in the ICU
Apply universal precaution in the patient care setting.
Attend ICU rounds and physician and respiratory care departmental inservices.
IV.
Evaluation: All of the following items must be completed in order to
receive a grade and credit for the course:
1. Internship interview (Finals week, Spring 2006)
2. Completion of clinical hours, minimum 144 hours, May 22 – June 30,
2006
3. Complete six (6) evaluations of clinical work with site preceptors and
the Director of Clinical Education (print evaluation sheet for
preceptors each week).
V.
Grading:
1. Internship interview:
VI.
100-92%= A
91%-83% =B
82%-75%=C
<75% no pass
2. Clinical internship: total of 27 points on rubric (6 evaluation)
Weekly evaluations:
27-25 = A
24-22 = B
21-20 = C
Final Evaluation: total of 162 points cummulative (6 evaluations)
162- 149= A
147- 134 = B
132 – 122 = C
Grading rubrics (see attached sheets)
Schedule
I.
Week of May 15
II.
Week of May 22
III.
Week of June 5
IV.
Week of June 19
V.
Week of June 26-30
Contact clinical site, establish first day clinical
Complete corporate orientation materials
Sign clinical contract forms
Begin Clinical VI
Weekly evaluations faxed to DCE (734-9126)
Set-up midterm evaluation date with preceptor(s)
& DCE
Midterm evaluations with student, DCE, preceptor(s)
Set-up midterm evaluation date with preceptors(s)
and DCE
Final evaluations with student, DCE, preceptor(s)
Poster presentations due
Grading rubric for clinical practice
Student’s Name
Date
Clinical Instructor’s Name
A. Professionalism
(dependability)
1. Attendance (clinical,
rounds, evaluations and
conferences)
2. Punctuality
3. Appearance (clinical dress
policy, neatness, grooming,
personal hygiene)
4. Interpersonal
Relations/Communications
(integrity, attitude,
cooperative)
Circle: Weekly Midterm Final
1
One of more “nonnotified” absences or 2
or more “notified”
absences this rotation
Tardy 2 or more times
during this rotation
Occasionally follows
guidelines for
appearance,
inconsistent
Occasionally fails to
maintain
confidentiality;
antagonistic,
frequently displays
inappropriate
emotions, inflexible
(know-it-all)
B. Quality of Care
1. Skills
1
Limited, takes more
than the usual amount
of time to absorb
direction, behavior
slow to change, low
efficiency
2. Supervision/guidance:
progression toward mastery
of skills
Needs unusual
amount of
supervision, full-time
monitoring, constant
cuing required, low
efficiency
2
3
One “notified”
absence during this
rotation
Never absent
Tardy one time
during this rotation
Follows guidelines
for appearance with
reminders from
clinical instructor
Rarely violates
confidentiality by
referring to patient
name, attitude
indifferent,
willingness to remain
flexible and
cooperative is
inconsistent
2
High, learns with
minimum amount of
coaching, follows
instructions, and
changes behavior, low
efficiency
Never late
Needs normal amount
of direct supervision
& occasional direct
supervision with
complex patients &
environments,
minimal cuing, high
efficiency
Always follows
guidelines for
appearance
Ensures
confidentiality,
enthusiastic, never
displays disruptive
emotions, always
flexible in
performance of
activities
3
High, consistently
follows directions
well, always able to
demonstrate clinical
skills without
coaching, high
efficiency
Independent
performance with
minimum amount of
direct supervision,
high efficiency with
complex patients &
environments
B. Quality of Care
3. Consistency of
performance—
meeting patient
outcomes, evaluation of
appropriateness of
therapy, quality of care
1
Problem solving needs
improvement, even for
non-complex patients;
fails to maximize
therapy to patient’s
needs; often fails to
evaluate therapy;
provides high quality
patient care with
clinical instructor’s
assistance
2
Consistently able to
solve problems;
evaluates therapy to
maximize patient
outcomes, aware and
attentive to patient
needs; frequently
provides high quality
patient care without
clinical instructor’s
assistance
4. Complexity of
task/environment
Does not always
recognize limits of
skills, occasionally fails
to recognize limitations
and/or to stay within
role/scope of practice;
often nervous, which
may interfere with
complex patient care;
clinical instructor must
always control patients
and environment to
protect student and
patient
5. Efficiency of
performance-clinical time used
appropriately in planning
and organizing activities
Occasionally fails to
complete patient care
activities on time;
requires high
expenditure of time for
routine patient care
procedures, very high
expenditure of time for
complex patients
Recognizes limitations,
recognizes standards
and boundaries of
role/scope of practice;
seeks assistance when
necessary; rarely
nervous, consistently
handles pressure
situations and complex
patients; clinical
instructor occasionally
must control patients
and environment to
protect student and
patient
Seldom fails to
complete patient care
activities on time;
requires little
expenditure of time for
non-complex patients
& moderate
expenditure of time for
complex patients
Director of Clinical Education Signature
3
Routinely able to solve
problems despite
complexities of patient
and environment,
provides alternative
solutions; always
evaluates therapy to
maximize patient
outcomes, routinely
provides high quality
patient care without
clinical instructor’s
assistance
Self-confident &
recognizes limitations
and seeks assistance
when necessary; calm,
handles complex
patients and pressure
confidently and
appropriately; clinical
instructor rarely must
control patients and
environment to protect
student and patient
Completes patient care
activities on time;
highly efficient
expenditure of time for
complex patients
Date
Clinical Psychomotor Skills (completed through didactic, laboratory, and clinical courses with grade of C
or higher)
Medical Floor or Emergency Department
Oxygen Rx
 Low flow (NC, 02 mask, NRB)
 Titrate per protocol, ABG, pulse oximetry
 Transport with 02
Aerosol/Humidity Rx (mask, trach collar, T-P, USN)
SVN Rx, including PEFR
MDI Rx or instruct
DPI Rx or instruct
Hyperinflation Rx
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IS, IS instruct
 IPPB (normal saline, medication)
Secretion management/Bronchial Hygiene
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Chest percussion and postural drainage
Flutter
PEP Rx
Trach bag and suction per sterile procedure
Nasotrachel suctioning
ABG: radical, brachial, femoral sampling (safety, Allen’s Test)
 Analysis (including QA)
 DAR
Respiratory Care Protocols: assess and treat
Patient Data
Vital signs
Chest auscultation (normal,
adventitious)
Chest X-ray
prominent landmarks
soft tissue, ribs, carina,
trachea, cardiac silhouette,
costophrenic angles, aortic
knob, spine, clavicle, 1st rib
ETTplacement position,lines,
chest tubes
Abnormalities
hyperinflation,
atelectasis,
consolidation,
infiltrates,
pneumothorax
12-Lead ECG (electrode
placement, error free)
Pulmonary Function Testing
bedside spirometry, PEFR
CPR
ventilation,chest
compression,bag-mask
ventilation,
ventilation via ETT
Medications
β2agonists,
anticholinergics,
steroids, inhaled antiinflammatories,
mucolytics, ACLS
medications,
Antimicrobials,
paralytics
Critical Care (ICU)
Ventilator Care
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Ventilator set up
Ventilator circuit change
Mechanical Ventilation (AC, SIMV, Bilevel, APRV)
 Ventilator-patient interface check
 Adjust ventilator parameters as ordered or per ABG protocol
 Obtain spontaneous ventilatory data (NIF, VC, Vt, VE, RVR, RR)
 Ventilator weaning per protocol
 Taping/retaping ETT
 ETT placement via CXR
 ETT cuff management
 ETT suctioning (inline, ventilation via ETT & suction)
 ETT extubation (post-extubation care)
 Patient Transport (transport with self-inflating bag,transport ventilator set-up)
 Inline Rx with MDI or SVN
 Humidity (or Heat/moisture exchanger)
 Ventilator graphics analysis
 Capnography
 Tracheostomy care (clean and secure tube, trach button, Passy-Muir valve)
Arterial Blood Gases
 ABG puncture and analysis
 Arterial line sampling
 Capillary blood sampling
Noninvasive Positive Pressure Ventilation
 NIPPV set up (mask CPAP/BiPAP set up, fitting)
 NIPPV check
Assist with bedside bronchoscopy
Assist with SLP swallow exam
Calculations
Shunt, deadspace, static compliance and airway resistance
ECG
 Identify abnormal and life-threatening ECG patterns
Hemodynamics
 Evaluate parameters (CVP, SVR, PVR, MAP, PCWP, CO, CI)
Grading rubric for interview (see course link)