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St John Ambulance Australia WA Ambulance Service Inc The College of Pre-hospital Care Critical Care Paramedic Internship CCPI Name NO Preceptor Name Date © St John Ambulance Australia WA Ambulance Service Inc. Andy Symons March 2010 Institution 1 SCGH ACKNOWLEDGEMENTS Revised & Updated by: David Read (CSP) St John Ambulance (WA) June 2011 Andy Symons St John Ambulance (WA) March 2010 Kerry Reid (CN) Intensive Care Unit Sir Charles Gairdner Hospital July, 2007 Originally Compiled by: Avril Patterson (ASDN) and Rosemary Spenneit (CN) Royal Perth Hospital May 2000 St John Ambulance would also like to thank Sir Charles Gardiner Hospital for the information provided in the appendix and the Criteria for Clinical Evaluation Rating Scale. © St John Ambulance Australia WA Ambulance Service Inc. Andy Symons March 2010 2 TABLE OF CONTENTS HOW DO I USE THIS BOOK?.................................................................................................................4 INTENSIVE CARE UNIT - PARAMEDIC ICU CLINICAL PLACEMENT OUTLINE ...............................6 LOGBOOK ...............................................................................................................................................8 Criteria for Clinical Evaluation ...........................................................................................................9 Standard Procedure ............................................................................................................................9 Quality of Performance .......................................................................................................................9 Assistance ............................................................................................................................................9 RESPIRATORY COMPETENCIES....................................................................................................... 10 ABGs, O2 Therapy & Airway Management .................................................................................... 10 Tracheostomy ................................................................................................................................... 10 Mechanical Ventilation ..................................................................................................................... 11 Intercostal Catheters ........................................................................................................................ 12 CARDIOVASCULAR COMPETENCIES .............................................................................................. 13 ECG .................................................................................................................................................... 13 PRESSURE MONITORING ................................................................................................................ 13 INTRAVENOUS ACCESS .................................................................................................................. 13 CENTRAL VENOUS PRESSURE MONITORING ............................................................................. 14 ARTERIAL PRESSSURE MONITORING .......................................................................................... 14 EXTERNAL PACING.......................................................................................................................... 15 CARDIOVASCULAR DRUGS ............................................................................................................ 16 RENAL COMPETENCIES .................................................................................................................... 17 NEUROLOGICAL COMPETENCIES ................................................................................................... 17 GASTROINTESTINAL COMPETENCIES ............................................................................................ 17 PAIN AND SEDATION COMPETENCIES ........................................................................................... 18 TRANSPORT OF THE CRITICALLY ILL PATIENT COMPETENCIES .............................................. 18 WORKSHEETS ..................................................................................................................................... 19 BLOOD AND BLOOD PRODUCTS WORKSHEET ............................................................................. 20 RESPIRATORY & OXYGEN THERAPY WORKSHEET ..................................................................... 22 MECHANISMS OF BREATHING ....................................................................................................... 24 AIRWAY MANAGEMENT .................................................................................................................. 26 RESPIRATORY FAILURE ................................................................................................................. 28 OXYGEN THERAPY .......................................................................................................................... 30 CARDIAC WORKSHEET ..................................................................................................................... 32 CARDIAC ANATOMY AND PHYSIOLOGY ...................................................................................... 33 ELECTROPHYSIOLOGY ................................................................................................................... 38 HAEMODYNAMIC MONITORING ..................................................................................................... 40 GASTROINTESTINAL WORKSHEET ................................................................................................. 42 ACID-BASE BALANCE AND ABG INTERPRETATION WORKSHEET ............................................. 44 NEUROLOGICAL WORKSHEET ......................................................................................................... 50 PHARMACOLOGY – INOTROPES WORKSHEET ............................................................................. 54 SHOCK WORKSHEET ......................................................................................................................... 58 APPENDIX ............................................................................................................................................ 61 INFORMATION FOR NEW STAFF .................................................................................................... 61 Contents ............................................................................................................................................ 62 EMERGENCIES ........................................................................................................................... 63 RESOURCES ............................................................................................................................... 64 Level 1 .................................................................................................................................................. 65 © St John Ambulance Australia WA Ambulance Service Inc. Andy Symons March 2010 3 PATIENT MANAGEMENT ............................................................................................................ 71 Intensive Care Unit Placement Goals: By the end of the placement students should be able to complete a structured, comprehensive assessment of the critical care patient for flight retrieval. Identify the extent and severity of injury and illness and manage appropriately to enable transportation. Display the correct usage of critical care equipment. Objectives: 1. Effectively recognise and institute management of critically ill patients. 2. Is aware of potential problems for the patient. 3. Observes the environment of the patient: infusions, ventilator settings and monitored parameters. 4. Assess level of consciousness of patient 5. Expose patient and assess lines, drains, tubes etc. 6. Assess each system: CVS/RENAL, RESP, ABDO/GIT, CNS · Cardio Vascular System/Renal: Heart rate, rhythm, peripheral perfusion, examine urine output, inotrope requirements, central pressures, DVT prophylaxis, fluid regimen · Respiratory: Ventilator settings, oxygen saturation, examine chest, review chest xray, chest tube activity, and arterial blood gas results · Abdomen: examine abdomen, nasogastric tube losses, bowel activity, nasogastric feeds, need for stress ulcer prophylaxis · Central Nervous System: Glasgow coma score if relevant, focal neurology, sedative requirements 7. Review observations/investigations including microbiology 8. Document findings 9. Apply treatment in accordance with Critical Care Paramedic CPG’s to stabilise patient for transport. 10. Prepare patient for aero medical transport. © St John Ambulance Australia WA Ambulance Service Inc. Andy Symons March 2010 4 HOW DO I USE THIS BOOK? This is a competency based learning manual. Each listed competency is a composite of knowledge, behaviour and skills, which can be demonstrated verbally and by specific performance in the practice situation. The outcome is that each Paramedic will achieve a safe and effective level of practice, which is in keeping with hospital procedures, policies and standards. The competencies range from basic ICU nursing skills to more complex, less frequently used skills. To aid you, specific objectives have been outlined to guide your progression through the competency book. The aim of this competency book is to aid the Paramedic in being self-directed in achieving the necessary theory and skills required to work effectively in the ICU environment. This is achieved by supervised practice and utilising the resource files available. You will be allocated a preceptor who will help to guide you in the competencies which are most relevant at various stages of learning. The rating scale used to monitor your progress —Criteria For Clinical Evaluation— has been included in the booklet (see table of contents for page number). © St John Ambulance Australia WA Ambulance Service Inc. Andy Symons March 2010 5 INTENSIVE CARE UNIT - PARAMEDIC ICU CLINICAL PLACEMENT OUTLINE The following is designed as a guide for your progression through your stay in the unit. Obviously, people will vary in their study requirements, the level of support needed and the rate at which they progress. GENERAL ICU OBJECTIVES Will be able to: Complete bedside and emergency checks Complete daily ICU patient care. Care for a stable ventilated patient with SDN support.. Demonstrate the basic operations of the bedside monitor. Demonstrate the basic modes and alarms for ICU ventilators Care for patient with basic haemodynamic monitoring. Pt ALLOCATION Demonstrate trouble-shooting skills with the bedside monitor. Demonstrate trouble-shooting skills with ICU ventilators. Independently cares for a stable ventilated patient with an ETT and/or tracheostomy tube. State the normal values for ABGs, Na, K, Mg, PO4, Creat, Urea, Hb, WCC, Plts, INR, APTT. Analyse ABG and state significance of finding. State the vasoactive drugs commonly used in intensive care, including the associated implications. Will be able to: Care for a stable acute head injured patient, including those with EVDs and Codman catheters insitu. Understand the physiology and anatomy relating to raised ICP and CPP © St John Ambulance Australia WA Ambulance Service Inc. Requiring mechanical ventilation. Facial CPAP Monitoring of arterial lines and CVC’s. Patient receiving CPAP/BiPAP. Stable ventilated patients. Monitored patients. Overdose patients. Stable head injured patients with EVD/Codman catheter. PLAN WORKSHEETS TO BE COMPLETED IV Medications COMPETENCIES TO BE COMPLETED Respiratory management Cardiac A&P ABG Acid Base Balance Gastro-intestinal Arrhythmia Neuro Haemodynamic Monitoring Respiratory; 1:2 – 1:3, 1:5 – 1:11. Cardiovascular; 1:1, 2:3, 2:4, 4:4. Pain and Sedation 1:1 1:2. Respiratory; 1:1, 1:4, 2:5, 3:1 – 3:7, 4:1, 4:3 – 4:6. Cardiovascular; 2:1 – 2:2, 3:1 – 3:12, 4:1 – 4:8. Gastrointestinal; 1:1 – 1:4. Cardiovascular: 5:1 -5:8, 6:1 – 6:6, 7:1 – 7:6 Neurological: 1:1 – 1:5. 6 25-Aug-03 D:\565330561.doc PLAN OBJECTIVES Identify the following arrhythmias; Atrioventricular Blocks, SVT, Junctional Rhythms, Atrial Ectopic Beats and Ventricular Ectopic Beats. State the significance of ST Segment elevation and depression. Describe cardiac arrest priorities and the drugs commonly used in an arrest situation. Competently transport a stable ventilated/non-ventilated patient out of the ICU. © St John Ambulance Australia WA Ambulance Service Inc. Pt ALLOCATION Overdose patient. Stable patient requiring transport outside of ICU. WORKSHEETS TO BE COMPLETED COMPETENCIES TO BE COMPLETED Renal: 1:1 Transport of Critically Ill: 1:1 – 1:7 7 25-Aug-03 D:\565330561.doc LOGBOOK © St John Ambulance Australia WA Ambulance Service Inc. Criteria for Clinical Evaluation Performance Score Standard Procedure Safe 5 Accurate Procedurally correct Outcome is therapeutic Safe 4 Accurate Procedurally correct Outcome is therapeutic Safe 3 Accurate Procedurally correct Outcome is therapeutic 2 } } Without supporting prompts but may consult with peers Efficient and coordinated Occasional supporting prompts Each time Each time Each time Limited confidence or competence Variable Skill level Most times Time Management still required Occasional physical directive prompts Continuous verbal prompts But not alone Inefficient Performs } With uncertainty Uncoordinated Outcome is therapeutic Unsafe } Frequent verbal prompts Supervision still required } Accurate Assistance Proficient, confident and competent. Within accepted time frame Safe Procedurally correct 1 } } Quality of Performance Supervisory intervention required Occasionally Frequent physical directive prompts Works outside accepted time frame Unable to meet standard required Continuous physical and verbal prompts References Bondy, K. (1983). Criterion-referenced definitions for rating scales in clinical evaluation… clinical competencies of nursing students. Journal of Nursing Education, 22 (9), 376-82 Confederation of Australian critical care Nurses Inc. (1999). Competency standards for specialist Critical Care Nurses: Sydney: Author. © St John Ambulance Australia WA Ambulance Service Inc. 9 25-Aug-03 D:\565330561.doc RESPIRATORY COMPETENCIES ABGs, O2 Therapy & Airway Management Minimum expected Level of achievement No. COMPETENCY 1:1 State the normal ranges for: pH PaO2 PaCO2 O2 saturations Base excess Bicarbonate Lactate And interpret the ABG of a patient, identifying any abnormalities. 1:2 Maintain an effective airway by: Positioning the patient Use of nasopharyngeal airway 1:3 Demonstrate checking the position of endotracheal tube as per ICU procedure. 1:4 Perform correct use of cuff monometer and recognition of cuff leak. 1:5 Demonstrate correct suctioning technique of artificial airway as per ICU procedure. 1:6 Describe potential complications of artificial airway suctioning and how they may be minimised. 1:7 Demonstrate sampling of an arterial blood gas via an arterial line as per ICU procedure. 1:8 State the indications for taking an arterial blood gas. 3 4 4 3 3 3 3 3 Assessment Score Date & assessor Initials Tracheostomy Minimum Expected Level of achievement No. COMPETENCY 2:1 Care of a tracheostomy as per ICU procedure manual. 3 © St John Ambulance Australia WA Ambulance Service Inc. Assessment Score Date & assessor Initials 10 25-Aug-03 D:\565330561.doc Mechanical Ventilation Minimum Expected Level of achievement No. COMPETENCY 3:1 Define the following terms: Minute volume Tidal volume Functional residual capacity I:E ratio PEEP & Auto PEEP Peak Airway Pressure 3:2 Define the following basic modes of ventilation and indications for each: SIMV PS CPAP 3:3 Perform correct checking procedure of a ventilator prior to connecting a patient as per ICU guidelines. 3.4 State the potential complications of IPPV and how they may be minimised. 3:5 State the actions to be taken in the following situations: 1. an inappropriately high airway pressure 2. a low expired minute volume. 3:6 State indications for the use of CPAP. 3:7 State the complications of CPAP and how to minimise these. 3:8 Explain the difference between BIPAP and CPAP 3:9 Demonstrate the use of BIPAP on basic BIPAP machine and Vision BIPAP machine as per ICU procedure. 3:10 Demonstrate the correct set up procedure for BIPAP machine as per procedure manual. 3 3 4 4 4 Assessment Score Date & assessor Initials 3 3 3 4 4 © St John Ambulance Australia WA Ambulance Service Inc. 11 25-Aug-03 D:\565330561.doc Intercostal Catheters Minimum Expected Level of achievement No. COMPETENCY 4:1 State the indications for an intercostal catheter (ICC). 4:2 State the physiology behind the use of ICCs. 4:3 State the potential complications associated with insertion of an ICC. 4:4 Assist with insertion of an ICC. 4:5 Care of an ICC while in situ. 4:6 Remove ICC as per ICU procedure manual. 3 Assessment Score Date & assessor Initials 3 3 3 3 3 © St John Ambulance Australia WA Ambulance Service Inc. 12 25-Aug-03 D:\565330561.doc CARDIOVASCULAR COMPETENCIES ECG Minimum Expected Level of achievement No. COMPETENCY 1:1 Attach patient to bedside monitor: Correct electrode placement Select appropriate leads for monitoring Set alarm limits for rate, ST segment and life threatening arrhythmias as per ICU guidelines. 4 Assessment Score Date & assessor Initials PRESSURE MONITORING Minimum Expected Level of achievement No. COMPETENCY 2:1 Describe how pressures are transmitted from cannula, to transducer, to monitor. 2:2 Prepare an intraflow for continuous pressure monitoring. 2:3 Perform correct levelling procedure and rezeroing. 2:4 State the actions, which should be taken in the following situations: A dampened waveform No pressure waveform reading is displayed. 3 3 3 3 Assessment Score Date & assessor Initials INTRAVENOUS ACCESS Minimum Expected Level of achievement No. COMPETENCY 3:1 State the potential complications of jugular/femoral venous catheter insertion. 3:2 Describe how the potential complications of jugular/femoral venous catheter insertion may be minimised. 3:3 Insertion of jugular/femoral venous catheter. 3:4 Remove a jugular/femoral venous catheter as per ICU procedure. 3 3 Assessment Score Date & assessor Initials 3 3 © St John Ambulance Australia WA Ambulance Service Inc. 13 25-Aug-03 D:\565330561.doc CENTRAL VENOUS PRESSURE MONITORING Minimum Expected Level of achievement No. COMPETENCY 4:1 State the potential complications of central venous catheter insertion. 4:2 Describe how the potential complications of central venous catheter insertion may be minimised. 4:3 Assist in the insertion of a central venous catheter. 4:4 State the normal central venous pressure range in mmHg. 4:5 Remove a central venous catheter as per ICU procedure. 3 3 3 3 3 Assessment Score Date & assessor Initials ARTERIAL PRESSSURE MONITORING Minimum Expected Level of achievement No. COMPETENCY 5.1 Assist with arterial cannula insertion. 5:2 Perform correct re-zeroing procedure. 5:3 Obtain an arterial pressure trace on the monitor. 5:4 Set alarm limits on the monitor as per guidelines. 5:5 State the potential complications of arterial cannulation. 5:6 Describe how the potential complications of arterial cannulation may be minimised. 5:7 Remove an arterial cannula and state responsibilities following removal. 5:8 Change an intraflow system for arterial pressure monitoring and replace arterial cannula dressing. Assessment Score Date & assessor Initials 3 3 3 3 3 3 3 3 © St John Ambulance Australia WA Ambulance Service Inc. 14 25-Aug-03 D:\565330561.doc EXTERNAL PACING Minimum Expected Level of achievement No. COMPETENCY 3 6:1 State indications for the use of the External Cardiac Pacemaker. 3 6:2 Describe placement of the posterior and anterior electrodes for external pacing. 3 6:3 Describe the waveform on the monitor you can expect to see when the patient is paced. 3 6:4 State the complications associated with the external pacemaker. 6:5 Distinguish between epicardial / transthoracic and transvenous pacing. 6:6 Discuss these pacing terms: Output Sensitivity Pulse width AV interval Rate 6:7 Discuss the different pacing modes. 6:8 Define potential pacemaker problems and ways to rectify problems: Failure to capture Failure to pace Failure to sense. 3 3 3 3 © St John Ambulance Australia WA Ambulance Service Inc. Assessment Score Date & assessor Initials 15 25-Aug-03 D:\565330561.doc CARDIOVASCULAR DRUGS Minimum Expected Level of achievement No. COMPETENCY 3 8:1 Describe the terms: Inotrope Chronotrope 3 8:2 State responsibilities during the administration of an inotropic drug. 3 8:4 Set up and deliver an inotropic drug using a syringe infusion pump and change syringes as per ICU procedure. 3 8:5 State the routine dilution and effects on the cardiovascular system of the following inotropic drugs: Assessment Score Date & assessor Initials Adrenaline Aramine Atropine Dopamine Dobutamine Isoprenaline Noradrenaline 3 8:6 State the indications for, actions and side effects and usual dose of the following medications: GTN Protamine Captopril Amiodarone DDAVP - Desmopressin 3 8:7 Administer electrolyte replacements according to unit policy: Potassium Magnesium Potassium dihydrogen phosphate Sodium acid phosphate © St John Ambulance Australia WA Ambulance Service Inc. 16 25-Aug-03 D:\565330561.doc RENAL COMPETENCIES Minimum Expected Level of achievement No. 1:1 3 COMPETENCY Assessment Score Date & assessor Initials Perform urinary catheterisation in accordance with hospital procedure: Male Female. (Desirable) NEUROLOGICAL COMPETENCIES Minimum Expected Level of achievement No. COMPETENCY 3 1:1 Discuss methods of prevention of intracranial hypertension. 3 1:2 Care for a patient with intracranial pressure monitoring device insitu as per ICU guidelines. 3 1:3 State the potential complications of intracranial pressure catheterisation and how these may be minimised. 3 1:4 Perform re-zeroing of Codman catheter as per ICU procedure manual. 3 1:5 Care for a patient with an Externalising Ventricular Drain (EVD) insitu including correct re-zeroing procedure and placement of transducer. 3 1:6 Assessment Score Date & assessor Initials (Desirable) Discuss methods used to reduce raised intracranial pressures. GASTROINTESTINAL COMPETENCIES Minimum Expected Level of achievement No. COMPETENCY 3 1:1 Demonstrate auscultation for the presence of bowel sounds. 3 1:2 Demonstrate aspiration of nasogastric tube as per ICU procedure. 3 1:3 Care of nasogastric tube as per ICU procedure. 3 1:4 Perform insertion of nasogastric tube as per ICU procedure. 3 1:5 State the indications for, actions and side effects and usual dose of the following medications: Maxalon Phenergan © St John Ambulance Australia WA Ambulance Service Inc. Assessment Score Date & assessor Initials 17 25-Aug-03 D:\565330561.doc PAIN AND SEDATION COMPETENCIES Minimum Expected Level of achievement No. COMPETENCY 3 1:1 Discuss the signs and symptoms of pain in an intubated and sedated patient. 3 1:2 State indications for, actions of, and usual doses for the following drugs / infusions Assessment Score Date & assessor Initials - Morphine - Midazolam - Fentanyl - Pethidine - Propofol - Thiopentone - Ketamine - Haloperidol TRANSPORT OF THE CRITICALLY ILL PATIENT COMPETENCIES Minimum Expected Level of achievement No. COMPETENCY 4 1:1 Demonstrate the use of the oxylog ventilator. 4 1:3 Transfer patient monitoring to the transport monitor and set alarms. 4 1:4 Prepare patient and patient attachments for safe transport. 3 1:6 Discuss contents and use of transport resuscitation box. 3 1:7 Demonstrate the transfer of a patient. Assessment Score Date & assessor Initials CARE OF ICU PATIENTS REQUIRING SPINAL PRECAUTIONS Minimum Expected Level of achievement No. COMPETENCY 3 1:1 Demonstrate Appropriate Lifting Techniques . 3 1:2 Demonstrate spinal precautions appropriate to injury 3 1:3 Care of the spinally injured patient © St John Ambulance Australia WA Ambulance Service Inc. Assessment Score Date & assessor Initials 18 25-Aug-03 D:\565330561.doc WORKSHEETS © St John Ambulance Australia WA Ambulance Service Inc. 19 25-Aug-03 D:\565330561.doc BLOOD AND BLOOD PRODUCTS WORKSHEET 1. What do you flush the IV line with before commencing blood? 2. What is the maximum length of time blood can be hung for? 3. What is the maximum length of time the blood can be removed from the fridge before it is hung? 4. How do you administer the following? a) b) c) d) e) Phenytoin: Lasix Digoxin Vitamin K Folate ______ ______ ______ ______ 5. Using the following formula complete the following calculations below. mcg/kg/min = st(mcg) Vol (ml) x mls/hr = wt x mcg/kg/min x 60 st(mcg) Vol 1 wt x mls/hr 60 a) Calculate the amount of Dopamine given to patient in micrograms per kilogram per minute (mcg/kg/min) i. Solution strength – Dopamine 200mg diluted in 500ml 5% dextrose Patient’s weight – 70kg Rate of infusion ordered – 20ml/hour ii. Solution strength – Dopamine 400mg diluted in 500ml 5% dextrose Patient’s weight – 70kg Rate of infusion ordered – 30ml/hour iii. Solution strength – Dopamine 200mg diluted in 500ml 5% dextrose Patient’s weight – 90kg Rate of infusion ordered – 40ml/hour iv. Solution strength – Dopamine 800mg diluted in 500ml 5% dextrose Patient’s weight – 90kg Rate of infusion ordered – 40ml/hour v. Solution strength – Dopamine 200mg diluted in 500ml 5% dextrose Patient’s weight – 85kg Rate of infusion ordered – 30ml/hour b) Calculate the amount of dobutamine given to patient in micrograms per kilogram per minute (mcg/kg/min) i. Solution strength – DOBUTAMINE 250mg diluted in 50ml 5% dextrose Patient’s weight – 65kg Rate of infusion ordered – 5ml/hour __________________ ii. Solution strength – DOBUTAMINE 250mg diluted in 100ml 5% dextrose Patient’s weight – 70kg Rate of infusion ordered – 10ml/hour __________________ © St John Ambulance Australia WA Ambulance Service Inc. 20 25-Aug-03 D:\565330561.doc c) Calculate the amount of glycerol trinitrate (gtn) given to patient in micrograms per minute i. Solution strength – GTN 50mg diluted in 50ml 5% dextrose Rate of infusion ordered – 10ml/hour __________________ ii. Solution strength – GTN 50mg diluted in 100ml 5% dextrose Rate of infusion ordered – 35ml/hour __________________ iii. Solution strength – GTN 50mg diluted in 50ml 5% dextrose Rate of infusion ordered – 1.5ml/hour __________________ © St John Ambulance Australia WA Ambulance Service Inc. 21 25-Aug-03 D:\565330561.doc RESPIRATORY & OXYGEN THERAPY WORKSHEET 1. Which of the two main bronchi branches from the trachea is at more of an acute angle? Why is this so? What significance does this have for clinical practice? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________ ___________________________________________________________________________ 2. Surfactant is found in the fluid lining the inner surface of the alveolar walls. What is surfactant and what are its functions? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________ ___________________________________________________________________________ 3. Outline the meaning of the following terms: Ventilation _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ Respiration _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 4. State the partial pressures of oxygen and carbon dioxide in: Arterial blood ___________________________________________________________________________ Venous blood ___________________________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 22 25-Aug-03 D:\565330561.doc 5. Define the following terms: Anatomical dead space _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________ ___________________________________________________________________________ Physiological dead space _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________ ___________________________________________________________________________ Compliance _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________ ___________________________________________________________________________ Resistance _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________ ___________________________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 23 25-Aug-03 D:\565330561.doc MECHANISMS OF BREATHING 1. Outline the muscles used to maintain ventilation during: Inspiration (quiet breathing) _______________________________________________________________________________ _______________________________________________________________________ Inspiration (forceful) _______________________________________________________________________________ _______________________________________________________________________ 2. Outline the mechanism of a cough _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 3. Define the following terms and state the normal adult volumes. a) Tidal Volume _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ b) Inspiratory Reserve Volume _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ c) Expiratory Reserve Volume _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 24 25-Aug-03 D:\565330561.doc d) Residual Volume _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ e) Vital Capacity _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ f) Functional Residual Capacity _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ g) Total Lung Capacity _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ h) Minute Volume _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 25 25-Aug-03 D:\565330561.doc AIRWAY MANAGEMENT 1. List four indications for intubation. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________ 2. What is the function of the cuff on an endotracheal or tracheostomy tube? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________ 3. Describe the procedure you would use to produce a cuff seal. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________ 4. Why are cuffed tubes NOT required for infants and younger children? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________ 5. What will happen if an endotracheal tube is introduced too far? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________ 6. You are the general ICU and notice your intubated patient’s airway pressure has risen with the patient becoming tachycardic and hypertensive. The Doctor has recently inserted a central venous line for drug therapy. What is a likely cause for these haemodynamic changes and how should you respond to this situation? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 26 25-Aug-03 D:\565330561.doc 7. List the complications that may occur during oral / nasal intubation and Briefly state how these may be avoided. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 8. List the complications which may occur due to prolonged intubation and state how these may be prevented or minimise in the critical care setting. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 27 25-Aug-03 D:\565330561.doc RESPIRATORY FAILURE 1. Define respiratory failure. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 2. Using the following headings, list common causes of respiratory failure. a) CNS _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________ b) Peripheral Nerves _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________ c) Neuro-Muscular Junction _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________ d) Pleura _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________ e) Airways _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 28 25-Aug-03 D:\565330561.doc f) Lung _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________ g) Chest Wall _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________ 3. List the clinical features associated with hypercarbia. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 4. List the clinical features associated with hypoxia. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ __________________________________________________________________________________ _____________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 29 25-Aug-03 D:\565330561.doc OXYGEN THERAPY 1. What percentage of oxygen do you achieve with delivery via a Hudson mask? ___________________________________________________________________________ 2. What percentage of oxygen do you achieve with delivery via nasal prongs? ___________________________________________________________________________ 3. What percentage of oxygen can be delivered via a non rebreathing mask? ___________________________________________________________________________ 4. Approximately what percentage of oxygen is delivered via a partial rebreathing mask? ___________________________________________________________________________ 5. Describe the Bernoulli Principle _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ __________________________________________________________________________________ _____________________________________________________________ 6. Discuss the differences between a low flow and high flow oxygen system _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ __________________________________________________________________________________ _____________________________________________________________ 7. Why should the reservoir bag on a non or partial rebreathing mask never be totally collapsed during inspiration? _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ __________________________________________________________________________________ _____________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 30 25-Aug-03 D:\565330561.doc 8. The patient in your care is post open heart surgery, they have oxygen running at 10 litres per minute via a hudson mask. An ABG reveals a pO2 of 56 mmHg and an oxygen saturation of 86%. What are your actions (provide rationales for your answer). _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 9. What are some of the potential problems associated with oxygen toxicity? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 31 25-Aug-03 D:\565330561.doc CARDIAC WORKSHEET Label the following diagram of the heart. 1. __________________ 2. __________________ 3. __________________ 4. __________________ 5. __________________ 6. __________________ 7. __________________ 8. __________________ 9. __________________ © St John Ambulance Australia WA Ambulance Service Inc. 32 25-Aug-03 D:\565330561.doc CARDIAC ANATOMY AND PHYSIOLOGY 1. How does cardiac muscle differ from skeletal muscle? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 2. The heart may be described as having an ‘all or none’ response to a stimulus. Why does this occur? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 3. Atrial contraction is responsible for what approximate percentage of ventricular filling? ___________________________________________________________________________ 4. What mechanism produces closure of the atrio-ventricular valves? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 5. 6. The thickest layer of the heart is the? a. Myocardium b. Endocardium c. Epicardium d. Pericardium The right atrium does all of the below, EXCEPT: a. Receive venous blood through three openings. b. Contain the sino-atrial node within the posterior wall. c. When contracting, empties across the tricuspid valve into the right ventricle. d. Pump oxygenated blood. © St John Ambulance Australia WA Ambulance Service Inc. 33 25-Aug-03 D:\565330561.doc 7. 8. 9. 10. 11. Which of the following statements is FALSE concerning the right ventricle? a. It contains papillary muscles. b. It pumps only deoxygenated blood. c. Blood enters the cavity through the tricuspid valve and exits through the pulmonary valve. d. It has a smaller volume capacity than does the left ventricle. e. It is lined with trabeculae carneae of the enocardium. Which of the following are involved in pulmonary circulation? a. Right ventricle, pulmonary trunk and left atrium. b. Superior vena cava, right atrium and right ventricle. c. Left ventricle, aorta and inferior vena cava. d. Right atrium, right ventricle and left atrium. Which statement is TRUE in comparing the atria to the ventricles? a. The atria receive only oxygenated blood. b. The volume capacity is less in the atria than in the ventricles. c. The walls of the atria are thinner. d. Travelulae carneae reinforce the walls of the atria and the ventricles. e. Both b and c are true. The cardiac centre in the medulla of the brain stem consists of two areas. Name the areas and briefly state what happens when each is stimulated. a. ______________________________________________________ b. ______________________________________________________ Which nerve supplies parasympathetic fibres to the heart? What is the effect on the heart if this nerve is stimulated? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 34 25-Aug-03 D:\565330561.doc 12. Beta receptors in the heart respond to sympathetic stimulation. What is the effect on the heart if these receptors are stimulated? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 13. The diagrams below are a representation of pre-load and after-load. Describe these terms. a) Preload _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ b) Afterload _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 35 25-Aug-03 D:\565330561.doc 14. What is the significance of Frank Starling’s Law of the Heart? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 16. What is an ‘Inotropic’ effect on the heart? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 17. What is a ‘Chronotropic’ effect on the heart? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 18. What are the factors that affect venous return? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 19. What are the factors that affect blood pressure? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 36 25-Aug-03 D:\565330561.doc 20. Barorecptors and chemoreceptors are located in the carotid sinus and the arch of the aorta. What is the function of these receptors? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 37 25-Aug-03 D:\565330561.doc ELECTROPHYSIOLOGY 21. Briefly explain the four properties of cardiac muscle. a. ______________________________________________________ ______________________________________________________ b. ______________________________________________________ ______________________________________________________ c. ______________________________________________________ ______________________________________________________ d. ______________________________________________________ ______________________________________________________ 22. 23. 24. 25. During systole: a. The atrioventricular valves are open b. The Purkinje fibres are being stimulated c. The semilunar valves are open d. The SA node is depolarising e. Both b and c The ECG deflection produced during atrial depolarisation is the: a. P wave b. T wave c. QRS wave d. U wave Which part of the ECG recording occurs at the beginning of diastole? a. P wave b. T wave c. QRS wave d. The flat line immediately following the T wave The portion of the conducting system of the heart that conducts impulses at the slowest rate is the: a. Purkinje fibres b. Bundle of His c. AV node d. SA node © St John Ambulance Australia WA Ambulance Service Inc. 38 25-Aug-03 D:\565330561.doc 26. 27. The correct sequence of electrical impulses through the conduction system of the heart is the: a. AV node, SA node, bundle of His and Purkinje fibres b. SA node, bundle of His, SA node and Purkinje fibres c. SA node, AV node, bundle of His and Purkinje fibres d. None of the above Which of the following statements about action potentials in the SA node are true? a. They are produced autonomically b. They result from a spontaneous depolarisation that occurs during diastole c. They are accompanied by a diffusion of Ca++ into the cells d. All of the above are true © St John Ambulance Australia WA Ambulance Service Inc. 39 25-Aug-03 D:\565330561.doc HAEMODYNAMIC MONITORING 28. Define central venous pressure (CVP). _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 29. What is the normal range of CVP in mmHg and cmH2O? ____________________________________________________________ 30. 31. What four factors influence CVP? a. ______________________________________________________ b. ______________________________________________________ c. ______________________________________________________ d. ______________________________________________________ To negate the effect of hydrostatic pressure the level of the CVP transducer must correspond with the level of the right atrium. What anatomical landmark corresponds with the right atrium? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 32. Why should an ‘Allens’ test be performed prior to insertion of an arterial line? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 33. How do calculate mean arterial pressure? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 34. List five causes of dampening of any invasive pressure line. © St John Ambulance Australia WA Ambulance Service Inc. 40 25-Aug-03 D:\565330561.doc 35. a. ______________________________________________________ b. ______________________________________________________ c. ______________________________________________________ d. ______________________________________________________ e. ______________________________________________________ List the functions of the four lumens on the swan ganz catheter. Proximal_______________________________________________________ Distal port _____________________________________________________ Thermistor _____________________________________________________ Balloon _______________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 41 25-Aug-03 D:\565330561.doc GASTROINTESTINAL WORKSHEET 1. The oesophagus is a collapsible muscular tube approximately 25cm long originating at the larynx and located ____________________________ to the trachea. 2. The oesophagus passes through the diaphragm via an opening called the _______________________ . 3. Define Achalasia. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 4. Describe the location of the stomach in relation to the abdomen. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 5. Arterial blood supply to the stomach comes mainly from the ___________________________________________________________________________ 6. The liver is located in the ______________________ quadrant of the abdomen. 7. Blood supply to the liver is via the ___________________________ artery and ________________________ veins. 8. Explain four functions of the liver: a)_____________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________________ b)_____________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 42 25-Aug-03 D:\565330561.doc c)_____________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________________ d)_____________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 43 25-Aug-03 D:\565330561.doc ACID-BASE BALANCE AND ABG INTERPRETATION WORKSHEET 1. Describe how the respiratory system can act as a feedback regulatory mechanisms for controlling pH. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 2. Briefly describe how the kidneys can regulate the pH of the body. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 3. Define the term ‘Respiratory Acidosis’. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 4. List four possible causes of respiratory acidosis. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ __________________________________________________________________________________ _____________________________________________________________ 5. Define the ‘Respiratory Alkalosis’. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 44 25-Aug-03 D:\565330561.doc 6. List four possible causes of respiratory alkalosis. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 7. Define the term ‘Metabolic Acidosis’. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 8. List four possible causes of metabolic acidosis. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 9. Define the term ‘Metabolic Alkalosis’. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 10. List four possible causes of metabolic alkalosis. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 45 25-Aug-03 D:\565330561.doc 15. State the normal value of: paO2 ______________________________________________________ paCO2 ______________________________________________________ HCO3 ______________________________________________________ Base excess ___________________________________________________ 16. Interpret the following blood gas results. Indicate if compensation has occurred and if it is partial or complete. Comment on the possible diagnosis and cause. CASE 1 pH 7.10 PaCO2 30mm Hg PaO2 73mm Hg HCO3 14mmol/L Bx -6 SaO2 94% Lactate 7 BSL 5mmol/L _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ CASE 2 pH 7.54 PaCO2 17mm Hg PaO2 116mm Hg HCO3 22mmol/L Bx 2 SaO2 99% _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 46 25-Aug-03 D:\565330561.doc 17. Interpret the following blood gas results. Include reference to FIO2 and PaO2. Identify the primary acid base disorder if compensation has occurred and your action. CASE 1 The patient has fractured ribs and is spontaneously ventilating on 8L Hudson mask. pH 7.30 PaCO2 48mm Hg PaO2 44mm Hg HCO3 23.9mmol/L Bx -4 SaO2 86% Analysis _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________ ___________________________________________________________________________ Management _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________ ___________________________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 47 25-Aug-03 D:\565330561.doc CASE 2 The patient is an acute renal failure and is spontaneously ventilating on 8L Hudson mask. pH 7.40 PaCO2 29.7mm Hg PaO2 83mm Hg HCO3 18.8mmol/L Bx 0 SaO2 94% Analysis _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________ Management _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 48 25-Aug-03 D:\565330561.doc CASE 3 The patent is experiencing an episode of acute pulmonary oedema and has received 15mg IV morphine. They are spontaneously ventilating on CPAP 5cm, FIO2 0.7. pH 7.28 PaCO2 49mm Hg PaO2 49mm Hg HCO3 22mmol/L Bx -7 SaO2 85% Analysis _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________ Management _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 49 25-Aug-03 D:\565330561.doc NEUROLOGICAL WORKSHEET 1. List three reasons for pinpoint pupils and three reasons for dilated pupils. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ __________________________________________________________________________________ _____________________________________________________________ 2. List the classic signs of raised intracranial pressure. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ __________________________________________________________________________________ _____________________________________________________________ 3. Provide a definition of Cerebral Perfusion Pressure (CPP) and state the desired range of this pressure. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ __________________________________________________________________________________ _____________________________________________________________ 4. Describe the Monroe-Kellie Hypothesis. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ __________________________________________________________________________________ _____________________________________________________________ 5. Discuss Autoregulation of cerebral blood flow. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ __________________________________________________________________________________ _____________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 50 25-Aug-03 D:\565330561.doc 6. An increase in cerebral blood volume can cause a rise in intra-cranial pressure (ICP). List four causes of increased cerebral blood flow. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ __________________________________________________________________________________ _____________________________________________________________ 7. An increase in CSF volume can cause a rise in ICP. List four causes of increased CSF volume. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ __________________________________________________________________________________ _____________________________________________________________ 8. List the advantages and disadvantages of intraventricular monitoring devices (fluid coupled v’s solid state). _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 9. List potential complications of sub-arachnoid haemorrhage. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ___________________________________________________________ 10. Why is Nimodipine used on patients following sub-arachnoid haemorrhage? _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ __________________________________________________________________________________ _____________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 51 25-Aug-03 D:\565330561.doc 11. Discuss collaborative management of the head injured patient under the following headings: a) Respiratory ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________ b) Haemodynamics _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ __________________________________________________________________________________ _____________________________________________________________ c) Maintenance of CPP >75mmHg _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ __________________________________________________________________________________ _____________________________________________________________ d) Positioning _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ____________________________________________________________________________________ ________________________________________________________________ e) Sedation _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ________________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 52 25-Aug-03 D:\565330561.doc f) Neurological observations _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ________________________________________________________________ g) Pharmacological agents _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ________________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 53 25-Aug-03 D:\565330561.doc PHARMACOLOGY – INOTROPES WORKSHEET 1. Define the following terms: a) Inotrope _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ________________________________________________________________________________ _______________________________________________________________ b) Chronotrope _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ________________________________________________________________________________ _______________________________________________________________ c) Dromotrope _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ________________________________________________________________________________ _______________________________________________________________ d) Lusotrope _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ________________________________________________________________________________ _______________________________________________________________ 2. List four functions of the Sympathetic and Parasympathetic nervous systems. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ________________________________________________________________________________ _______________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 54 25-Aug-03 D:\565330561.doc 3. Complete the following table: Effects of Adrenergic Stimulation Receptor Dopaminergic Location Action Alpha 1 Beta 1 Beta 2 4. Complete the following table; (use +/++/-) Adrenergic Receptor Specificity of Inotropes Drug Alpha Beta 1 Beta 2 Adrenaline Noradrenaline Dobutamine Isoprenaline 5. What role does digoxin and milrinone play in the management of heart failure? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ________________________________________________________________________________ _______________________________________________________________ 6. Discuss the use of adrenaline in the treatment of asthma. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ________________________________________________________________________________ _______________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 55 25-Aug-03 D:\565330561.doc 7. 8. Circle True or False to the questions listed below: a) A side effect of Noradrenaline is angina T b) Digoxin toxicity can cause a prolonged PR interval T F c) Adrenaline can cause an increase in serum lactate T F d) Dobutamine may cause bronchospasm T F e) Isoprenaline has no effect on Beta 2 receptors T F f) Noradrenaline is the inotrope of choice for sepsis T F F Complete the following table; (+/++/+++/-) Cardiovascular Effects of Inotropes Drug CO Cardiac Contractility Heart Rate SVRI PVRI Blood Pressure Adrenaline NorAdrenaline Dopamine Dobutamine Isoprenaline Digoxin CO = cardiac output SVRI = systemic vascular resistance index PVRI = pulmonary vascular resistance index © St John Ambulance Australia WA Ambulance Service Inc. 56 25-Aug-03 D:\565330561.doc 9. Discuss the following cases in relation to treatment management options, with regard to inotrope therapy. a) Patient with cardiogenic shock, afebrile, peripherally cold and shutdown. MAP 55mmHg PAWP 23mmHg CI 1.7l/min/m2 SVRI 4976 dynes/cm5/m2 _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ________________________________________________________________ ________________________________________________________________________________ b) Patient with haemorrhagic pancreatitis, febrile, bounding pulses. MAP 67 mmHg PAWP 12mmHg CI 9.2l/min/m2 SVRI 976 dynes/cm5/m2 _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ________________________________________________________________ ________________________________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 57 25-Aug-03 D:\565330561.doc SHOCK WORKSHEET 1. Define ‘Shock’. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ________________________________________________________________________________ _______________________________________________________________ 2. Define ‘Cardiogenic Shock’. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ________________________________________________________________________________ _______________________________________________________________ 3. List five clinical features of cardiogenic shock. a) ___________________________________________________________ b) ___________________________________________________________ c) ___________________________________________________________ d) ___________________________________________________________ e) ___________________________________________________________ 4. 5. What will happen to the following parameters in cardiogenic shock ( or ). CO _______________________________________________________ SVRI _______________________________________________________ PCWP _______________________________________________________ CVP _______________________________________________________ What inotropic agents may be chosen to treat cardiogenic shock? Why? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ________________________________________________________________________________ _______________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 58 25-Aug-03 D:\565330561.doc 6. List seven possible causes of hypovolaemic shock. a) ___________________________________________________________ b) ___________________________________________________________ c) ___________________________________________________________ d) ___________________________________________________________ e) ___________________________________________________________ f) ___________________________________________________________ g) ___________________________________________________________ 7. List five clinical features of hypovolaemic shock. a) ___________________________________________________________ b) ___________________________________________________________ c) ___________________________________________________________ d) ___________________________________________________________ e) ___________________________________________________________ 8. 9. What will happen to the following parameters in hypovolaemic shock ( or )? CO _______________________________________________________ SVRI _______________________________________________________ PCWP _______________________________________________________ CVP _______________________________________________________ List five possible causes of septic shock. a) ___________________________________________________________ b) ___________________________________________________________ c) ___________________________________________________________ d) ___________________________________________________________ e) ___________________________________________________________ 10. List five clinical features of septic shock. a) ___________________________________________________________ b) ___________________________________________________________ c) ___________________________________________________________ d) ___________________________________________________________ e) ___________________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 59 25-Aug-03 D:\565330561.doc 11. What will happen to the following parameters in septic shock ( or )? CO _______________________________________________________ SVRI _______________________________________________________ PCWP _______________________________________________________ CVP _______________________________________________________ © St John Ambulance Australia WA Ambulance Service Inc. 60 25-Aug-03 D:\565330561.doc APPENDIX INFORMATION FOR NEW STAFF "No such thing as a dumb question, just a question you wished you asked!" © St John Ambulance Australia WA Ambulance Service Inc. 61 25-Aug-03 D:\565330561.doc In order to maintain patient care and safety and to give you a working knowledge of the unit and its environment, we have compiled this information booklet for your reference. Contents Emergencies Patient related (cardiac arrest, respiratory arrest) emergencies Non-patient related emergencies Resources a) b) Human Resources: Medical Nursing Physiotherapy Pharmacy HSAs PSAs Ward Clerks Secretary Social Worker Material Resources: Information Files Intranet Telephone system Unit map © St John Ambulance Australia WA Ambulance Service Inc Nursing Matters Requests Meal Breaks Change Rooms Communication Education Patient Management Handover/Patient Notes Observations Investigations CXR Medications Routines Universal Precautions Hygiene Care Patient Property Visitors Enquiries Relatives Rooms Transfer 62 25-Aug-03 D:\565330561.doc EMERGENCIES Patient related (cardiac arrest, respiratory arrest) emergencies Call for help and then commence Cardio-Pulmonary Resuscitation (CPR), notify immediately the staff next to you, who will call for medical assistance and will then assist you with resuscitation measures. Should the emergency occur next to you and medical assistance is required, lift up the phone’s handset, press the intercom "PAGE" button and speak into the handset “Doctor required urgently to (Specify which side – 'north' or 'south' - do not mention the patient name!) . Non-patient related emergencies The emergency telephone number is ‘55’. Connected to each phone is a flip sheet of emergency procedures: Code Red Code Blue Code Purple Code Yellow Code Black Code Brown Code Orange Fire / Smoke Medical Emergency (Emergency Sternotomy in ICU) Bomb Threat Internal Emergency Personal Threat External Emergency Evacuation In the event of a fire (Code Red) the shift coordinator is the section warden and will provide you with the necessary instructions for evacuation if required. The SDN will discuss the location of fire fighting apparatus and preferred evacuation routes during Day One orientation. © St John Ambulance Australia WA Ambulance Service Inc 63 25-Aug-03 D:\565330561.doc RESOURCES a) Human Resources Medical Staff: The SCGH Department of Intensive Care has seven Intensive Care Consultants: 1. Dr Paul Woods. ( Head of the Department ). 2. Dr Vernon van Heerden 3. Dr. Peter Cameron. 4. Dr Mary Pinder. 5. Dr Brad Power. 6. Dr Wally Thompson. 7. Dr David Moxon 8. Dr Stuart Baker 9. Dr John Blott In addition to the Intensive Care Consultant on during the day, there is always at least one ICU Registrar, a senior Registrar and a Resident present in ICU at all times. Allocation of medical staff to patients is written on the white board at the nurses’ station on either side of the unit. Refer to the shift coordinator or your resource nurse with patient problems/issues as well as referring patient problems to the medical officer caring for your patient(s). If medical staff visiting the department requests treatment, ICU medical staff MUST sanction it! Medical Handover: A bed-to-bed medical round commences at 0800 and 1900 daily. Exceptions to this is on Wednesday (when the 0800 medical round is held in the ICU conference room), and on Friday when the bed-to-bed medical round commences at 0830 following the anaesthetic meeting. Identification of Medical Staff: Generally they wear maroon scrubs. © St John Ambulance Australia WA Ambulance Service Inc 64 25-Aug-03 D:\565330561.doc Nursing: Level 4 Nursing Co-Director Central CSU Andrew Marshall Level 3 Level 3 Clinical Nurse Manager Peter McEwen Acting Clinical Nurse Consultant Karen Laurie Level 2 Level 2 Level 2 Acting Area Manager Kath Whitington Clinical Nurses Staff Development Nurses Marlene Maxwell Caroline Hill Jenny Andrews Level 1 Registered Nurses Identification of Nursing Staff: Clinical Nurse Consultant. Red trim on collar. Staff Development Nurse. Navy trim on collar. Clinical Nurses. Red eppillettes or "CN" on Name Badge. Shift Coordinator (Clinical Nurse or Acting Clinical Nurse). Red sash around neck. © St John Ambulance Australia WA Ambulance Service Inc 65 25-Aug-03 D:\565330561.doc Physiotherapy: There is at least one physiotherapist present in the unit from 0730 to 2400, seven days per week. They are an excellent resource for assistance with extubation, suctioning and problems with airway management. They are responsible for all physiotherapy that is carried out in the department. You will be asked to hand ventilate the patient on 100% oxygen during the patient's physiotherapy chest treatment using the laerdel bag. In consultation with medical staff, you will also liase with the physiotherapist and assist, when it is appropriate, in getting your patient(s) out of bed and/or mobilising the patient. Identification of Physiotherapists: They wear a green top over blue trousers. Pharmacy: The unit has a dedicated pharmacist Monday to Friday, 0800 - 1700. The pharmacist reviews all patient medications daily and organises the preparation of prescribed IV infusion orders and antibiotics (if appropriate) for patients. These are stored in the North and South drug room fridges - please ensure you check both fridges for these BEFORE you make up any IV infusions/antibiotics. HSA’s (Hospital Service Assistants): The HSA’s in ICU assist with: Patient re-positioning (approximately every 2 hours, with rounds commencing on the even hour, beginning on the South Side). Patient positioning for X-rays. Weighing of patients. Transferring patients from bed to chair (& vice versa). Transferring patients between departments. Transferring discharged patients to ward with nurse. NB When repositioning or transferring, ensure that you support the patient’s head and maintain a patent airway. Safely position and hold all tubing attached to the patient to prevent any accidental dislodgment. PLEASE - as a well organised team member - be READY to wash/turn/transfer your patients when the HSA's arrive. DO NOT UNNECESSARILY CALL THE HSA's TO YOUR BEDSIDE BECAUSE YOU ARE READY. Should you require the HSA’s assistance out of sequence (eg: if the RMOs' require a patient in a particular position for a procedure, if there is an emergency with your patient or if your patient is soiled), please ask your resource nurse or the shift coordinator to call them. © St John Ambulance Australia WA Ambulance Service Inc 66 25-Aug-03 D:\565330561.doc PSA's (Patient Support Assistants): The PSA's in ICU assist with the unit based cleaning, and with meal distribution to patients that are able to eat. Ward Clerks: Located on the south side of the unit only. Coverage is: 0730-2100, Monday to Friday. 0730-1330 and 1600-2000, Saturday and Sunday. When the telephone is ringing in between these times, please answer the call! Secretary: Located at reception desk from 0800 - 1600 Monday to Friday. Social Workers Often relatives require support services. Social Work can provide assistance with accommodation, financial arrangements and psychological support for the patient and relatives. Please don't wait to be asked - check whether the Social Worker is required and contact them. We have a Welfare Officer for accommodation issues, a Neuro Social Worker for neuro patients and a Social Worker for all other patients. © St John Ambulance Australia WA Ambulance Service Inc 67 25-Aug-03 D:\565330561.doc b) Material Resources: Information Folders Green Resource File: Located in each bedspace. This is a listing of the unit specific Nurse Practice Guidelines not covered in the Hospital Policy Manual. Hospital Policy Manual: Located in the Tutorial Room. Infection Control Guidelines: Located in the Tutorial Room. MIMS: Available on-line using all computer terminals located on either side of the unit. Self-Directed Learning Packages: Located in the Tutorial Room. See SDNs' for availability. Unit Library: You are welcome to guidelines: 1. 2. 3. 4. borrow books, provided you adhere to the following Access key from north side drug keys. Complete library card. No more than two books borrowed at one time. Borrowing period is no longer than two weeks. Articles: Located in labelled folders in the Tutorial Room. Equipment Ask the Shift Coordinator, Resource Nurse or Staff Development Nurse how to use any piece of equipment that you are unfamiliar with. It is your responsibility to ensure that you understand how each piece of equipment operates and to use them according to the Hospital and Unit policy and standards - based on manufacturers' recommendations. Please ensure that all infusion pumps (whether in operation or not) are plugged into main power at all times to guarantee maximum battery charge - essential for safe transfer of patients. Telephone System A commander telephone system operates throughout the unit. Please ask for assistance on how to use it if you are unsure. Please become familiar with the paging procedure, especially for Emergencies, CXR, ECG and ICU SDN's Unit Layout See following map for unit layout. Unit Map © St John Ambulance Australia WA Ambulance Service Inc 68 25-Aug-03 D:\565330561.doc Sluice Room S7 S6 N7 N6 Equipment Room S5 S8 S4 N5 N8 Respiratory Room N4 IV Room S3 S9 S2 Ward Clerk y c a m r a hP s ci s y h p o i B m o o R s ci n o rt c e l E N9 m o o R Linen Room N3 N2 y c a m r a h P N1 S1 m g o e o RR Sto re Ro o m re o t S m o o R n o i U pt e Cc I e R Office CNS,CNE,SDN Tutorial Room y a R -X m s o e Ro R Tea Room Mens Visitors Waiting Rooms Womens Lifts © St John Ambulance Australia WA Ambulance Service Inc 69 25-Aug-03 D:\565330561.doc s re g e a ci n ff a O M NURSING MATTERS Education: Daily Inservice in the ICU Tutorial Room @ 1415, Monday - Friday. Guidelines: The SDN's will canvass RN's, SRN's, CN's, medical and other allied health staff to present topics to staff on these days, and on occasions present to night staff. Staff Meal Breaks: Morning Tea Lunch Afternoon Tea Dinner Night Duty 0900 - 1030 hrs 15mins 1230 - 1345 hrs 30mins 1500 - 1515 hrs 15mins 1700 - 1830 hrs 30mins 45 minute meal break between 2400-0400 hrs 6, 7 and 8-hour shift workers are allowed one 30-minute break and a 15-minute tea break. 12 hr shift workers are allowed two 30-minute meal breaks, and two 10-minute tea breaks. Meals can be obtained from the 8th floor cafeteria (week days only) between 0630 and 1830, or the coffee shop in E Block, ground floor seven days a week, from 0800 and 1900. Vending machines with food are also located in the Watling St and the entrance to the 8th floor cafeteria. There are facilities in the staff-room for light meals and drinks, including: Refrigerator. Microwave ovens. Toaster. Toasted sandwich maker. Mini oven/grill. Tea , coffee, milk and hot water. Cold water fountain. It is your responsibility to clean up after you!! The tea-room is a venue we hope you will relax in during your breaks - enjoy the television, tropical fish tank, chit chat or read the social bulletin board. Staff Change Rooms: Staff change rooms include lockers, toilets and facilities for showering. They have a security lock code number. Ask the shift coordinator or resource person for current code number. Relatives are NOT to be given the security code under any circumtances. Public Toilets are located near the Green Lifts. © St John Ambulance Australia WA Ambulance Service Inc 70 25-Aug-03 D:\565330561.doc PATIENT MANAGEMENT Universal Precautions: All staff must wash their hands prior to and after patient contact. Should you come into contact with body fluids follow universal precautions and wear gloves and a plastic apron. Inform the shift coordinator and the Nurse Manager if you have a needle stick injury or body substance contact, during office hours. After hours ring switch and ask them to call the Immunology Registrar on call and ask for advice. Handover and Integrated Patient Notes: A brief 10-minute nursing handover occurs in the Tutorial Room at 0700, 1300 and 2100 hrs. There is also an additional handover at 1900 hrs for those staff who work a 12-hour shift. After the 'general' handover, the nurse caring for your patient(s) gives a detailed report at the bedside. You will be expected to give a handover at the end of your shift to the oncoming nurse. A written report is also required for your shift. Medico-legal requirements include documenting the date and time of the report, no blank spaces or lines, legible writing, with signature, printed name and designation. You also need to sign the 24-hour flow chart. This is a mandatory requirement of the hospital. Observations: At the start of your shift, carry out a baseline general physical assessment and bedside check of your patient(s), documenting assessment findings and checks on ICU 24-hour flow chart. A) AIRWAY: Check emergency airway management tray and suction apparatus on console. Check size, position and security of ETT/NTT. Check cuff pressure. If patient has trach insitu, ensure tracheal dilator & spare trach tubes present and correct sizes (ie. one same size and the other one size smaller). B) BREATHING: Check Air-viva (ensure attached to O2 supply at all times), ventilation prescription (including FiO2), mode settings, measured values and alarm settings. If patient not ventilated, check O2 flow rate. Auscultate chest. Assess SaO2, EtCO2 and ABG's. C) CIRCULATION: Check bedside emergency drugs, IV fluid orders and medication chart(s). Position and zero all pressure transducers, check monitor alarm settings, check ECG rhythm, perform manual blood pressure (check value against arterial line reading at the beginning of each shift and if patient is hypo / hypertensive) and assess peripheral perfusion (ie. Pulses/CWMS/capillary refill). © St John Ambulance Australia WA Ambulance Service Inc 71 25-Aug-03 D:\565330561.doc NB: 1. 2. 3. 4. 5. D) Neurological Observations: Full GCS assessment, pupillary reaction, Ramsay sedation score. Check reference value for Codmans and zero unit. Zero EVD and check drainage system is at correct height above tragus of ear. Check if daily CSF sample has been sent off to microbiology (Daily @ 0800) E) Renal Assessment: Check last few hours urine output - if less than 1/2 ml/Kg per hour, notify the shift coordinator / resource nurse / medical staff). Assess urine for colour, turbidity and ensure daily urinalysis is performed. Check fluid balance and fluid status of patient, assess for oedema. Check U & E results. F) Abdominal Assessment: Auscultate bowel sounds, check NGT is in correct position, check patient is receiving prescribed NGT feed as per Total Calorie Requirement (TCR) guidelines, check bowel care, inspect abdomen and lightly palpate. G) Integument Assessment: Assess for pressure areas, review wound care, TEDs on and document Braden Score. Cardiovascular and Respiratory observations are performed hourly unless otherwise stated - please document any acute changes on flow chart when in between observations. Temperature is taken orally with Ivac digital thermometer, 4-hrly & PRN. When measuring CV, PAWP or performing C.O.s', ensure patient is positioned supine or head up 30 degrees. Nasogastric feeds are managed according to Nursing Practice Guidelines in green bedside file. Dextrostix performed according to unit protocol. Investigations: Blood Investigations are ordered by the medical staff and collected by the nurse, routinely at 0600 and 1800 hrs. All blood samples are taken via the arterial line. If you are unfamiliar with arterial bloodline sampling, please ask the Staff Development Nurse / Resource Nurse/ Shift Coordinator to perform this procedure. If an arterial line is not in situ, then ask ICU nursing/medical staff to perform a venipuncture or arterial stab to obtain the necessary samples for you. Once the specimens are collected, they are placed in the “Bio-Hazard” plastic bag (with the specimen in the sealable portion and the request form in the unsealed portion) and sent via the chute located on the south side of the unit (SDN's will show you how to correctly use this). Other Specimens: © St John Ambulance Australia WA Ambulance Service Inc 72 25-Aug-03 D:\565330561.doc Cerebral Spinal Fluid (CSF) is collected daily at 0800hrs if a ventricular drain is insitu. Please ask your Staff Development Nurse / Shift-Coordinator / Resource nurse to assist you with this. Chest X-Rays: Chest X-Rays are carried out each morning at 0800 hrs commencing on the south side. HSA's assist with positioning of the patient. Where patients have a head injury, ensure bed remains elevated at 30 degrees; where patients have a spinal injury, ensure bed remains flat and tilted; and patients who are hypotensive remain supine for their CXR. All other Chest XRays should be performed with the patient sitting up at 90 degrees unless other contraindications. Medications: Patient ID must be confirmed, and all intravenous, intramuscular, subcutaneous and oral medication(s) must be checked by two RNs, one of who must be ICU nursing staff member. Medication that is not at the bedspace can be obtained from the drug room on the north and south side nurses’ station. If you are unfamiliar with a drug that has been prescribed for your patient refer to the ICU Doctors / ICU Pharmacist (during weekdays) / Shift Coordinator / resource nurse, or access MIMS on-line at any computer terminal in ICU. Daily Changes: The frequency of invasive line/catheter changes are documented in the “Daily Nursing Care Plan” located in the patient’s nursing notes. Check what is scheduled to be changed during your shift and ask for assistance from the Staff Development Nurse / Shift Coordinator / Resource Nurse. It will be necessary to check individual tags on IV lines for the change due by date. Nasogastric bags and various drain fluids are emptied at 2400 hrs and added into the daily fluid output total before the daily fluid balance is calculated. © St John Ambulance Australia WA Ambulance Service Inc 73 25-Aug-03 D:\565330561.doc Record of signatures Name Print Job Title © St John Ambulance Australia WA Ambulance Service Inc Initials Signature Contact Phone 74 25-Aug-03 D:\565330561.doc Preceptors Additional Comments Comments/Recommendation: please attach further comments if space is insufficient. Name of preceptor: _______________________________ Signature: _______________________________ Date: _______________________________ Interns Comments Comments: please attach further comments if space is insufficient. Name of Intern : ____________________________ Signature: _______________________________ Number_______________________________ Date: _______________________________ Date report received: _______________________________ © St John Ambulance Australia WA Ambulance Service Inc 75 25-Aug-03 D:\565330561.doc Confidential Student Critique Student Name _________________________ No _________________________ As an RTO we are obliged to ensure all of our training and clinical practicum’s are evaluated by those who participate. This enables us to continually assess whether CPHC is meeting your training needs. Please answer these questions objectively and in as much detail as possible to supply the college with information that will aid us in our training development. Your answers will remain confidential. . 1. Pre-Placement Information made me feel adequately prepared for this clinical placement Disagree 1 2 3 4 5 Agree Could anything else have been included? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _________________________________________________________ 2. Their was adequate exposure to procedures and patients to ensure I was able to meet the objectives of this clinical rotation Disagree 1 2 3 4 5 Agree 4 5 Agree 3 4 5 Agree 3 4 5 Agree 3. The patient load: a. Match my level of expertise b. Disagree 1 2 3 c. Provide hands on experience Disagree 1 2 d. Provided enough variety Disagree 1 © St John Ambulance Australia WA Ambulance Service Inc 2 76 25-Aug-03 D:\565330561.doc e. Allowed me enough time Disagree 1 2 3 4 5 Agree 4. Staff were supportive and contributed positively to my learning experience Disagree 1 2 3 4 5 Agree 5.I was provided with constructive feedback during your clinical placement Disagree 1 2 3 4 5 Agree 6. My Preceptor was effective as an educator? Disagree 1 2 3 4 5 Agree 7. I now feel more confident and competent with my clinical skills as a result of this clinical Placement Disagree 1 2 3 4 5 Agree 8. In general the College gave me enough support during this period? Disagree 1 2 3 4 5 Agree Where do you feel that it could have been improved? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _____________________________________________ Student’s Evaluation of Clinical Placement Experience © St John Ambulance Australia WA Ambulance Service Inc 77 25-Aug-03 D:\565330561.doc
