Care of a Ventilated Patient

Background

Background

Case Summary

Robert Caron is a 57-year-old male admitted to the medical unit this morning with shortness of breath, mild chest pain which increases with deep breaths, and mild fever.  Symptoms increased in severity requiring intubation.  His last set of vitals post-intubation were: T 38.2, HR 120, BP 110/60, and SPO2 95% FiO2 50%.  The RT will provide the vent settings.  He’s currently sedated with fentanyl and midazolam.  He also received rocuronium during induction.  He had a nasopharyngeal swab for COVID-19, results pending.  He is a full code.  His past medical history includes HTN, BPH, and type 2 diabetes.  His wife is at home and the physical is calling her right now to update her on the patient’s condition and transfer to the ICU.  

Target Learner
: Senior Nursing Students and New Graduate Nurses

Keywords: Critical Care, Ventilator, Prone, Suctioning
Learning Outcomes

 

Learning Outcomes

 
  1. Understand infectious disease transmission factors and required modifications to practice that should be considered when selecting appropriate PPE equipment to adhere to principles of infection control and prevention.

  2. Identifies the need for and performs endotracheal suctioning for the intubated patient to maintain a patent airway.

  3. Adheres to practise interventions for a patient in a prone position to prevent deterioration of the patient status.

  4. Conducts a nursing assessment for an intubated patient to determine the next steps in care.

  5. Communicates essential information to the healthcare team in a critical care situation to determine the most appropriate plan of care.

  6. Evaluates potential causes of ventilator alarms for the intubated patient to prevent adverse outcomes.
Self Assessment Rubric

 

Learning Outcomes Self-Assessment Rubric

The use of this customized learning outcomes rubric, based on self-regulated learning (SRL) theory, allows student self-assessment of the game content and targeted learning outcomes.  Each rubric also describes competency indicators which levelled from the novice to competent learner. Below each learning outcome, users can provide additional comments/reflections/rationale to support scoring. The self-assessments rubric can be used to:
  1. Assess success on preparation for the simulation
  2. Assess performance during the simulation
  3. Guide the post-simulation debriefing in order to identification remedial learning requirements.
Further, the rubric can be used by the simulation facilitator for evaluation purposes or by examining the difference between instructor assessment scores and students’ self-assessment of the understanding of course criteria.
For the Airway Management/Ventilation Learning Outcomes Assessment Rubric Learning Outcome Assessment Rubric (word document) – click here

For the Airway Management/Ventilation Learning Outcomes Assessment Rubric (pdf) – click here
Game Link


English Game LinkClick here  
  1. The game works best using Google Chrome or Firefox.  The game does not have full functionality when using your cell phone.

  2. You will be shown a video of an interaction between a nurse and a patient, their family and/or other medical staff.

  3. Following each video, you will be asked to select the most appropriate response.

  4. Please note that sound is required to fully understand the interactions within the video.

  5. It is preferred you use Google Chrome or Firefox to maintain optimal audio/visual output.

  6. The game will take approximately 20-30 minutes to complete.

  7. You may complete the virtual simulation game as many times as you like.
   
Virtual Debrief

The Can-Sim Virtual Simulation Games are an online resource that can be used as either presimulation preparation, stand-alone games, or as a teaching resource in or outside of the classroom.  According to The International Nursing Association for Clinical Simulation and Learning (INACSL) Standards of Best Simulation Practice (2016), debriefing is a critical aspect of the simulation experience. Debriefing after simulation provides the opportunity for self-assessment and peer evaluation by giving feedback to others. Therefore, it is important that after any simulation, a debriefing should take place. Options for debriefing a virtual simulation game debriefing include:

  1. Embedded feedback debrief: CAN-Sim Virtual Simulation Games (VSG) are designed to provide the player with immediate feedback to selected responses in the form of an Embedded Debrief.  Aligned with the game’s learning outcomes, the player is required to answer a series of multiple-choice clinical decisions key points during the game.  Upon selecting a response, the player will be shown a video clip portraying the outcome of their chosen response with a written rationale on why their decision was either correct or incorrect. Correct responses will advance the game to the next video and corresponding decision point.

  2. Self-debrief: Use the provided game-specific Learning Outcomes Assessment Rubric to reflect on perceived self-competence specific to game learning outcomes. It is recommended that completion of the Learning Outcomes Assessment Rubric should be done before and after playing the virtual simulation game.  Using the Learning Outcomes Assessment Rubric, reflect on areas of perceived competence and areas needing further improvement.  We have provided suggested reading resources to support further learning.

  3. In-person debrief: This form of debriefing involves a traditional face-to-face debrief with a facilitator. This debrief can be performed in the classroom or lab setting.

  4. Synchronous online debrief: This involves an online debrief immediately following gameplay guided by a simulation facilitator using a video-conference software (ie. Zoom, Adobe Connect). Similar to an In-person Debrief, the synchronous online debrief uses an online platform.

  5. Asynchronous online debrief – This asynchronous involves a debrief using a discussion board platform where participants post responses to reflective debriefing questions. Other participants and facilitators then respond to reflective postings.
 
Reflective Questions

Reflective Questions

 
  1. What are the key considerations for the prevention of ventilator-associated pneumonia?

  2. What would be key considerations when caring for a patient in a prone position?

  3. What are some challenges you anticipate when caring for an intubated patient in a prone position?  How will you modify care to address these challenges?

  4. How will you determine the appropriate care to delegate to other healthcare providers?  Specifically, consider what you would delegate to the unlicensed assistive personnel or the practical nurse.

  5. What safety considerations should be observed when caring for a ventilated patient?

  6. Do you believe family should be permitted visitation for intubated patients during COVID?

  7. How will you assess pain in the intubated patient?

  8. Do you believe it is important to communicate with intubated and unresponsive patients?  Why?

  9. The nurse in the Emergency Department (ED) does not routinely provide care to the ventilated patient.  Do you think ED nurses should maintain competency in ventilator care?  How can the nurse maintain this competency?

  10. When contacting the patient’s family to give an update on the patient’s condition, there is a significant language barrier.  How should the nurse ensure information is understood by the family?

 

Resources

 

Resources

 
Brewster, D. J., Chrimes, N. C., Do, T. B., Fraser, K., Groombridge, C. J., Higgs, A., … & Nickson, C. P. (2020). Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group. Med J Aust16.

Gattinoni, L., Chiumello, D., & Rossi, S. (2020). COVID-19 pneumonia: ARDS or not? Critical Care, 24(154) doi: 10.1186/s13054-020-02880

Kapp, C. M., Zaeh, S., Niedermeyer, S., Punjabi, N. M., Siddharthan, T., & Damarla, M. (2020). The use of analgesia and sedation in mechanically ventilated patients with COVID-19 ARDS. Anesthesia and analgesia. Access document here

Luo, M., Cao, S., Wei, L., Tang, R., Hong, S., Liu, R., & Wang, Y. (2020). Precautions for intubating patients with COVID-19. Anesthesiology: The Journal of the American Society of Anesthesiologists132(6), 1616-1618.

Murthy, S., Gomersall, C. D., & Fowler, R. A. (2020). Care for critically ill patients with COVID-19. Jama323(15), 1499-1500.    

 

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