GENERAL PATIENT CARE

If a patient has asthma refer patient to asthma specialist if the pt has

• multiple hospitalizations for asthma

• one or more life threatening asthma exacerbations

• poor knowledge of their asthma triggers

• poor response to asthma action plan

Smoking cessation programs may include

• instruction

• group counseling and support

• nicotine replacement therapy

• supplemental oxygen ( if indicated )

• pulmonary rehab

• behavioral modification

• stress reduction

Nicotine replacement therapy

• nicotine patch

• nicotine oral

• nicotine nasal spray

• nicotine inhaler

Compliance in a smoking cessation program can be monitored by measuring

• COHb levels in blood

• Exhaled CO levels ( FECO )

• Cotinine levels in blood and urine

Cotinine is a breakdown of nicotine and can be detected in

blood and urine for 2-4 days after smoking

Bupropion hydrochloride ( zyban or wellbutrin )

Antidepressant drugs which work well in combination with group counseling

• have been shown to dramatically reduce nicotine withdrawal symptoms

Varenicline ( chantix )

A prescription medication used to treat nicotine addiction

• reduces cravings for and decreases the pleasurable effects of cigarettes and other tobacco products

• can assist some patients to quit smoking

Disinfection

the process of destroying vegetative pathogenic microorganisms

Sterilization

complete destruction of all microorganisms

Steam under pressure

( steam autoclave )

Pasteurization

disinfection process using moderate temps to kill vegetative organisms

Incineration

the best method of treating contaminated disposable items and supplies

Irradiation

gamma rays are used to sterilize pre-packaged equipment

Ethylene oxide sterilization ( ETO, gas sterilization )

sterilizes equipment by alkylation of enzymes

With ethylene oxide sterilization

biological indicators are necessary to verify that the conditions for sterility have been met

Examples of what can be cleaned with ethylene oxide

• birdmark VII

• flowmeter

• no-disposable resuscitation bag removed from a HIV pt room

Alkaline glutaraldehyde ( cidex )

disinfection or sterilization process

With Alkaline glutaraldehyde

equipment must be rinsed with sterile water after soaking

Alkaline glutaraldehyde is appropriate

method for reusable plastics ( mouthpieces, tubing, nebulizers, humidifiers )

• appropriate method for sterilization a flexible fiberoptic bronchoscope

Acid glutaraldehyde ( sonacide )

disinfection or sterilization process

Alkaline glutaraldehyde equipment

must be rinsed with sterile water after soaking

Alcohol

disinfection process

Soaps and detergents

not antimicrobial agents but used as cleaners

Bleach

disinfection process

Bleach is the most

appropriate for surface disinfection

• used to clean blood spills, equipment surfaces

Nosocomial infections

An infection acquired at least 72 hours after admission to a hospital or other health care facility

Personnel

transmit organisms through inadequate hand washing techniques and nasal discharge

• primary cause of nosocomial infections

Droplet nuclei

these are dispersed via the cough or sneeze, always cover mouth during cough or sneeze

Equipment

transmit organisms as a result of inadequate disinfection or sterilization techniques or contamination

Water containing equipment especially aerosol devices will transmit infectious agents such as

pseudomonas aeruginosa and serratia

• Containers and bottles should be labeled with date and time and used within 24 hours of opening

Any contaminated equipment from an isolation area should be

double bagged and labeled before returning to the cleaning area

items disinfected or sterilized should be labeled

with date and method of processing

Documentation of sterilized equipment is confirmed by a

change in color of heat sensitive tape or heat sensitive chemical indicators

Routes of transmission of infection

• contact ( direct and indirect )

• resp droplets

• airborne droplet nuclei

Hand hygiene should be performed

• before and after all pt contact

• after removing gloves

• after touching blood, body fluids , secretions or excretions

• between procedures on the same pt

• use approved alcohol based product

• use soap and water if hands are visibly soiled

Gloves

• perform hand hygiene before and after removing gloves

• wear clean gloves when touching blood, body fluids, secretions or excretions

• wear sterile gloves for invasive procedures

• don clean gloves before touching mucous membranes and non intact skin

• change gloves between procedures on the same pt

• remove gloves promptly after use

Masks, eyes protection, face shields

Wear to protect mucous membranes of the eyes, nose and mouth during procedures that are likely to generate splashes or sprays of blood, body fluids, secretions or excretions

Gowns

Wear to protect skin and prevent soiling of clothing during procedures and patient care activities likely to generate splashes or sprays of blood, body fluids, secretions or excretions

Don on

• hand hygine

• gown

• face mask

• goggles/ face shield

• gloves

Don off

• gloves

• goggles/ face shield

• gown

• mask

• hand hygiene

Double bag equipment from pts with

HIV/AIDS and hepatitis prior to gas sterilization

Using an MDI is the

most effective way to deliver med to avoid cross contamination

Biohazardous waste includes

• Lab waste such as

• specimen cultures

• research cultures

• vaccines

• culture dishes

• human blood

• other body fluids like

• pleural fluid

• cerebrospinal fluid

Medical waste

Bio-hazardous or sharps waste and waste which generated, produced or researched pertaining to diagnosing, treatment or immunization, testing biologicals and home generated sharps waste

Ventilator- Associated Pneumonia is caused by

aspiration of bacteria that have colonized the upper GI tract or oropharynx

• secretions that pool above airway cuff are aspirated through small folds in the cuff

Prevention protocols for VAP include

• Gentle suction techniques

• use of a closed suction systems

• regular ora hygiene

• post-pyloric feeding

• keeping pts head elevated 30-45 degrees

• not routinely changing vent circuits

• draining and discarding vent tubing condensate appropriately

• use heated wire circuits or HME to prevent tubing condensate

• use MDI instead of SVN for med administration

• stress ulcer prevention

• daily sedation vacation to evaluate readiness to wean and extubate

• tubes designated for continuous aspiration of subglottic secretions

Three settings where pul rehab can be utilized

• hospital

• outpatient rehab clinics

• home care

Objectives to pulmonary rehab

• alleviate or control as many medical symptoms of resp impairment as possible

• teach the pt how to maximize his/her ability to carry out activities of daily living

Long term benefits/ goals of pulmonary rehab

• decrease perception of level of dyspnea

• improved ability to do ADL- walking, climbing stairs

• decreased frequency of hospitalizations

Pulmonary rehab techniques

• pursed lip breathing

• diaphragmatic breathing technique

• cough control techniques

• exercise conditioning

• nutritional balance- increase protein and fat, low carbohydrates

A comprehensive pulmonary rehab program requieres

multidisciplinary approach that utilizes the expertise of many heath care personnel

• each health professional can instruct the pt and family members on important concepts related to chronic illness, home care and rehab

Evaluations that should be performed during the walk test or the pulmonary stress test

• oxygen saturation

• baseline resp rate and rate at which dyspnea occurs

• blood pressure

• baseline heart rate and rate at which dyspnea occurs

• ECG

• presence of joint pain/stiffness

The ultimate goal of any home care program is to allow the pt to

care for themselves at home ( increase functional capacity )

• this means that the pt and his family will need to learn how to do all of the treatments and be able to recognize problems that may arise

Setting up a home care program for a patient involves several steps

• survey the home and make modifications to assure safety and infection control

• instruct the pt in proper use of all equipment

• train the pt and family to recognize problems and emergencies

• infection control

Criteria used to determine if a pt will benefit from oxygen in the home

• PaO2 less than 55 torr on room air

• Exercise limitation that is a responsive to O2 therapy

• Pulse oximetry ( SpO2 ) at rest, excise and sleep is suggested

• polycythemia or cor pulmonale

Reservoir Cannula

Designed to maintain FiO2 at lower flow rates by using a reservoir

• used commonly in the home to reduce costs and increase duration of cylinder flow

Transtracheal Oxygen Catheters

A method of delivering low-flow oxygen therapy directly into the airway by a surgically implanted catheter

• allows the upper airways and trachea to act as a reservoir for oxygen during exhalation

Pulse dose oxygen delivery system

Used in place of a flowmeter with low flow oxygen devices ( nasal cannula, reservoir cannula and transtracheal catheters ) and connected to a 50 psi gas source

• device sense the start of inspiration and delivers oxygen only during inspiration

Cylinders

Indicated for patients who use small amounts of oxygen intermittently

• appropriate for use as a back up system when liquid or a concentrator is used for oxygen delivery in the home

Liquid Bulk oxygen systems

• last longer than cylinders, used often in the home

• non-electrical portable units are easily filled for trips

• liquid systems will vent the oxygen over time if not used, they are NOT to be used as a back up system

Oxygen concentrations

Electrically powered and have limited portability

• utilize a molecular sieve that removes nitrogen and other gases from room air to concentrate the oxygen

• oxygen can be provided at 1-2 L/min continuously

• at higher flows, oxygen concentrations can fall

Safety for oxygen concentrators

• instruct patients to routinely check and change filters

• a properly grounded electrical outlet is required

• a backup system ( cylinder ) must be available in case of a power failure

If no bubbles are seen

• check power source

• check flow setting

• check humidifier for leaks

• check tubing for leaks, disconnections or obstructions