Reflection:
Using the Gibb's Reflective Model, i will be reflecting on the
practical session we had on the 21st of March, 2016.
Description:
This week we
practiced assisting ventilations of an apneic patient using a BVM, as well as
the use of a non-rebreather mask. I started by checking for a response of the
patient. The patient was unresponsive and was not breathing. At this point I
asked for further EMS help. I continued assessing the patient by checking
his pulse. The patient did have a pulse. This showed me that I must start
ventilating the patient, and that there was no need for chest compressions. I
opened the patient’s airway using the head tilt-chin lift. When I looked into
the patient’s mouth, my teacher told me that I could see secretions in the
mouth. Using the Yankeur catheter, I suctioned the buccal cavity. I suctioned
while going into the mouth and my teacher corrected me, by telling me we only
suction while removing the catheter from the mouth. I absorbed this and fixed
my mistake by suctioning as I was withdrawing the catheter from the patient’s
mouth. Then my teacher informed me that the secretions have been cleared out. I
then checked for breathing and the patient was still not breathing. Therefore,
I inserted an OPA, after measuring it, grabbed the BVM and started giving
ventilations immediately. I squeezed only half the bag and ventilated at a rate
of 1 breath every 5-6 seconds. At first, I could not see a chest rise. However,
when I adjusted my hands to tighten the seal around the face mask, there was
chest rise. I maintained this position to ensure sufficient chest rise with
each breath. After a few breaths I attached the BVM to the oxygen cylinder and
set the rate to 15L/min. After 2 minutes, I rechecked for breathing and a
pulse. Following this, we practiced using a non-rebreather (NRB) mask. To start
this I checked the regulator was attached properly. Then I cracked the valve
and checked for any leaks. Also, I checked the tank pressure. I, then, attached
the NRB mask to the port on the regulator. I adjusted the flow rate to 12L/min.
After this, I placed the mask on the patient’s face and adjusted it to fit
properly. My teacher asked me if I would like to add anything and I remembered
that I forgot to prefill the mask’s reservoir. I then retraced my steps and
removed the mas off the patient’s face. I filled the reservoir then replaced
the mask on the patient’s face.
Feelings:
At first I was confident and sure of what I had to do.
However, I felt oblivious while suctioning the patient’s mouth when my teacher
corrected me. This is because I already knew that I should only suction while
withdrawing the catheter from the patient’s mouth, but I don’t know what
happened at the moment. This shook my confidence a little. Nonetheless, I
corrected my mistake and continued managing the patient. After this I got
confused and checked the patient’s breathing again. My teacher corrected me and
I began to feel unsure of what I was doing. However, I kept going and inserted
the OPA and began ventilations, both skills I learned last year. In this part
of the scenario I was sure and confident in what I was doing, where I even
corrected myself when I couldn’t see a chest rise. This made me feel
self-assured and knowledgeable. When performing oxygen administration via an
NRB mask I was confident. I followed the correct steps and it felt great.
However, when my teacher asked me if I forgot something I instantly remembered
that I forgot to refill the reservoir. I felt relieved that I remembered what I
did wrong and got to fix my mistake.
Evaluation:
Analysis:
The beginning was good
because I followed the correct steps according to the BVM ventilation of an
apneic adult patient. It was bad for me to start suctioning as I advanced the
suction catheter into the patient’s mouth because the catheter will keep
attaching on the inside of the mouth. This can cause damage to the tissues and
will make suctioning of the patient’s mouth much more difficult. Also, it was
really bad to check for breathing again after suctioning because this delayed
ventilations, and I had only 30 seconds to start ventilations. Furthermore, it
was really good that I corrected the face mask seal because there was no chest
rise. This lack of chest rise means that the ventilations are ineffective.
Therefore, it is crucial to ensure right face seal for good ventilations. It
was good that I only squeezed half the bag in order to avoid causing
barotrauma. I used the NRB mask well because I did all the checks I needed to
do to make sure the oxygen cylinder is functional. This is to ensure good
oxygen delivery. Also, I chose 12 L/min which is within the range needed for an
NRB mask, which is 10-15 L/min. Finally, not filling the reservoir was a bad
mistake. This is because the mask will not deliver oxygen if the reservoir is
not pre-filled. Therefore, this point is very important to remember. In
addition, it is important to ensure good seal of the face mask to avoid the
leaking of oxygen outside the mask, reducing the effectivity of the oxygen
delivery.
Conclusion: In this lab session, there are a few things I would do
differently. I would only suction as I withdraw the suction catheter from the
patient’s mouth. Moreover, I will start providing ventilation immediately after
I suction the patient’s mouth, rather than check for breathing again. This is
to minimize the time to ventilation delivery as much as possible. Also, I will
ensure tight face mask seal in order to deliver effective ventilations and
obtain chest rise. Furthermore, it is very important to check the oxygen
cylinder before attempting to administer oxygen to patients. It is also
important when using an NRB mask to set the flow rate at 10-15 L/min and not
anything less. Moreover, it is crucial to remember to fill the reservoir bag of
the mask before applying the mask to the patient’s face. Finally, tight seal is
important to ensure effective oxygenation and to prevent leaking of the oxygen.
Action Plan: I plan to remember my mistakes from this lab session and
avoid them in my future practice. I plan to suction only as I withdraw from the
patient’s mouth, provide ventilations immediately after suctioning and ensure
correct face seal. Moreover, I intend to continue doing everything I did
correctly in this session. I plan to continuously practice the steps to
providing effective ventilations for an apneic patient, until I master this
skill. I plan to perform oxygen administration using the NRB mask just as I did
this lesson, however, I must remember to fill the reservoir. I plan to learn
from my mistake and to always keep this point in mind.
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1: Me checking for patient's response.
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2: Me checking for patient's pulse and breathing.
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3: Inserting OPA into patient's mouth.
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4: Providing assisted ventilation using BVM.
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Learned Concepts:
This week we did not have an
allocated lecture. However, we covered the lecture for week 9. These are the
concepts i learned from this lecture:
Symptoms of motor-neurone disease
include stumbling, difficulty holding, slurring of speech, swallowing
difficulties, muscle twitching, cramps, fatigue, and weight loss. Death from
MND is caused by respiratory failure. The causes of MND are unknown.
Parkinson's disease is a
progressively degenerative neurological disorder which affects the control of
body movements. This happens when Substantia Nigra die. These cells produce
dopamine. Dopamine allows for smooth, coordinated function of the body's
muscles and movement.
Symptoms of Parkinson's are tremor,
rigidity, and bradykinesia.
There is a high incidence of chest
infections in patients with Parkinson's disease. Respiratory complications,
particularly aspiration pneumonia, are the most common cause of death.
Aspiration pneumonia attributed to the impairment of the epiglottis, laryngeal
musculature, pharyngeal musculature, swallowing, and cough reflex.
Respiratory complications of this
disease include:
- Respiratory muscle weakness
- Chronic or recurrent airflow obstruction
- Upper airway muscle dysfunction
- May have inspiratory muscles of rib cage and neck involved
Symptoms of Post polio
syndrome include slowly progressive muscle weakness, fatigue, and muscle
atrophy. This disease is rarely life-threatening, however, can be if there is
untreated respiratory muscle weakness, weakness in swallowing which can result
in breathing difficulties and aspiration pneumonia.
Symptoms of late effects of polio
include:
- Unaccustomed fatigue unrelated to activity
- Decreased strength and endurance
- Inability to stay alert
- Pain in muscles and joints
- Muscle spasms
- Respiratory and sleep problems
- Swallowing and speaking difficulties
- Cold/ heat intolerance
Myasthenia gravis is an autoimmune
disease where the body produces antibodies that attack the acetylcholine
receptors on skeletal muscles.
Factors that can trigger episodes of
weakness in MG are viral respiratory infections, drugs that affect the
neuromuscular junction, hot weather, pregnancy, and emotional upset.
Usually weakness of the eye muscle
is the first noticeable symptom of MG. Other symptoms include difficulties in
swallowing, chewing, speaking, and breathing. This can lead to aspiration.
MG also affects respiration where
30% had oral, pharyngeal, or laryngeal complaints and 15% of the 30% had
swallowing difficulties.
Therapy for MG includes
Anticholinesterase inhibitors, immunomodulating agents, intravenous immune
globulin, plasmapheresis, and thymectomy.
Multiple sclerosis is the most
common chronic disease of the CNS among the young. This disease is progressive
and unpredictable. This disease occurs when the myelin sheath around the nerve
fibers in the brain and spinal cord becomes damaged.
Symptoms of MS are muscular spasms,
problems with weakness, coordination, balance, problems with the functioning of
arms and legs, vertigo, neuralgia, continence problems, memory loss,
depression, cognitive difficulties and fatigue. Uncommon in MS to have respiratory
problems through loss of autonomic system control. However, can occur due to
loss of muscle strength and endurance. Can also result from aspiration
pneumonia from swallowing difficulties.
Symptoms of hypothyroidism include
fatigue, depression, bradycardia, unexplained weight gain, intolerance to cold
temperatures, fatigued and aching muscles, dry and coarse skin, puffy face,
hair loss, constipation, problems with concentration, and goitre.
Newborns with hypothyroidism have
problems with frequent choking and a large, protruding tongue.
Medical complications associated
with spinal cord injury include respiratory complications. Death after
traumatic SCI most commonly caused by respiratory problems.
Cervical and high thoracic SCI
affect respiratory muscles. Severity of ventilatory failure and requirement for
assisted ventilation depends on the level and severity of the SCI. Lesser
degrees of ventilatory failure may cause dyspnea and exercise intolerance.
Moreover, due to impaired cough
reflex and difficulty mobilizing lung secretions, patients with SCI have an
increased risk for pneumonia. DVT and PE are also common complications of SCI.
Sleep apnea is a serious sleep
disorder that occurs when a person's breathing is interrupted during sleep.
Patients with untreated sleep apnea stop breathing repeatedly in their sleep.
This reduces oxygen supply to the brain and the rest of the body. Sleep apnea
can be obstructive or central. Obstructive sleep apnea is when the airway is
blocked usually when soft tissue in the back of the throat collapses dutring
sleep. On the other hand, in central sleep apnea the airway is not
blocked. It happens when the brain fails to signal the muscles to breathe due
to instability in the respiratory control center.
Risk factors of sleep apnea include:
- Male
- Overweight
- Age over 40
- Large neck size
- Large nostrils, large tongue, or small jaw bone
- GERD
- Nasal obstruction
Skeletal dysfunction is common in
patients with COPD. Signs and symptoms are muscles strength and endurance are
decreased, muscle fatigability is increased, muscle atrophy, and a reduction in
fibers' cross-sectional area.
Oxidative enzyme activity is
decreased and aerobic capacity reduced.
Spinal muscular atrophies are a
spectrum of genetically inherited disorders. They all result in progressive
lower motor neurone weakness.
SMA with respiratory distress type
I's predominant symptom is severe respiratory distress due to involvement of
the diaphragm muscles. Respiratory problems are generally the first symptoms.
Additional Readings
I read the recommended
readings and highlighted the most important notes in my opinion.
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5: Highlighted notes about post-polio syndrome and its pathophysiology.
Adopted from (Halbritter, 2001).
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6: Highlighted notes about post-polio syndrome and its pathophysiology.
Adopted from (Halbritter, 2001).
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This article helped me understand
post-polio syndrome and its pathophysiology better. This was great because the
pathophysiology of this disease was not discussed in the lecture.
Reference
Halbritter, T. (2001). Management of a
patient with Post-polio syndrome. Journal of the American Academy of Nurse
Practitioners, 13(12), 555-559. doi: 10.1111/j.1745-7599.2001.tb00325.x
Biggest Impression
Learning how to provide assisted
ventilations to an apneic patient and how to administer oxygen via a NRB mask
made an impression on me as a paramedic. These two skills are very important
and are critical to know when dealing with respiratory patients. This is
because an NRB mask is used to treat hypoxia and BVM ventialtions to manage
apnea, oth possible scenarios for respiratory patients.
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