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VENTILATOR AND SCI

TRAINING

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Payment of ExpensesPlease note that to claim for any travel expenses you must: • Please make sure that you sign in. This sheet triggers your

certificate and is also verification of your attendance for your payment for today, as well as your intention to claim expenses.

• Please list today's training on your time sheet as “Ventilator and SCI Training in the community” and state where this training took place.

• Send in with your time sheet a completed expenses sheet (provided here today) with a valid receipt.

• Failure to do both of these may result in a delay in your payment or not receiving payment at all.

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What is mechanical ventilation?• Short term or long term • Invasive (trachy) or non-invasive (face mask)?• Used by those with neuro-muscular diseases, spinal

injury (C4), polio, emphysema or chronic bronchitis• Sometimes used just overnight• Often first used in ICU.• Ventilators in the community are often smaller, light

weight and portable with an external battery.• A ventilator can take over the act of breathing

completely or make breathing easier by assisting weakened respiratory muscles.

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Daily Checks of Ventilator

• Check :

• Tidal Volume

• Rate of breath given per minute

• Setting of low pressure alarm

• Setting of high pressure alarm

• I/E Ratio (Airway Pressure)

• Power source

Spinal Cord Injury - Causes

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Spinalcolumn

anatomy

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TRACHEOSTOMY CARE1. What is a Tracheostomy?2. Different types of Trachy tubes3. Essential safety Equipment.4. Changing the inner tube.5. Changing the tape and dressing.6. Infection and action.7. Changing the whole

tracheostomy.

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What is a Tracheostomy?

It is a surgical opening in the windpipe between the 3rd and 4th tracheal rings into which a tube is inserted.

Different Types of Trachy tubes1. Plastic tube

2. Metal tube

3.Silicone Tube

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4. Fenestrated tube (helps with speech)

5. Cuffed tube, to initially keep in place

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Essential Safety Equipment

• Ambu Bag• 2x tracheostomy tubes. 1 same,

1one size smaller.• spare inner (if used)• Dressing• Tube holder• Lubricant gel• Syringe (if cuffed)• Gloves• Hand gel• Suction catheters• Extension lead• Supra pubic catheter and equipment

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Changing the inner tube• One person.• Is the emergency equipment checked and

nearby?• Disconnect ventilator, rest on clean gauze.• Wear gloves, hold the flange of the trachy

firmly while removing the inner tube.• If clean reinsert, if soiled insert new inner.• Immediately reconnect ventilator.• Clean soiled inner and store in clean dry

container.• Dispose of all waste appropriately (is the

inner tube to be kept as a spare)

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Changing the whole tracheostomy

• Prepare equipment, clean site• One clean, one dirty nurse• Take client off the ventilator• Dirty nurse removes old trachy • Clean nurse inserts new trachy• Clean nurse removes guiding tube • Clean nurse inserts inner tube• Put client back on ventilator• Redo collar

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Changing the holder and dressing

• Two people, one person should hold the tube and observe the client.

• Prepare all equipment before you start• Is the emergency equipment checked and nearby?• Wear gloves, remove the old dressing and holder.• Change gloves, clean the site, replace dressing and

holder.• Dispose of all waste appropriately.

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SIGNS of INFECTIONat the trachy site

• Redness• Wet appearance• Odour from site or

dressing• Soreness• Skin breakdown• Temperature• Pain

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Tracheostomy Site Infected

ACTION• Swab if available and

know how.• Change dressing

as/when becomes soiled.

• Any other signs?• Document.• Communicate.• If persists – contact

GP

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Suctioning – WHY and WHEN?

• To keep the airway clear of secretions.

• Reduce the risk of airway blockage.• Reduce the risk of infection.• Dependent on need• Client ability to cough.• Amount and consistency of

secretions

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Suctioning – How

Equipment• Suction unit- set at 120-150mmHg• Correct size catheters (-2x2)• Gloves• Water to rinse tubing.• Yankeur.• Closed-circuit

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Suctioning - How• Open catheter enough to attach to tubing remove some plastic covering• Switch on machine (listen)• Wear gloves• Use one hand to hold suction catheter, do not let it touch anything• Use other hand to access the trachy• Pass the catheter to approx 1/3rd length/ feel resistance. Pull back 1cm.• Apply suction and slowly remove (no more than 15secs) unless client can

breathe• Reconnect ventilator (ask client, remove catheter mount and listen)• Watch for signs of respiratory distress• Observe colour/amount/consistency of sputum. (plugs)• Document, report any changes

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Suctioning- Complications

• Damage to delicate lining of trachea and lungs. (check for blood)

• Lack of oxygen.

• Infection.

• Bronchial spasm.

• Increased secretions.

• Consider assisted cough

Alternative to Suctioning – Assisted Cough

If your cough is weak you can have an assisted cough:• Place the heel of one hand on your client’s abdomen just above the navel.• Place the second hand on top of the first hand with straight elbows.• The client takes a deep breath.• Push upwards and under the client’s ribs at the same time the client attempts to cough.

Make sure:

1.If client is in wheelchair, the brakes are on.

2.Client is not pregnant.

3.Client has not recently eaten.

Day 1 Finish 20

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Humidification

• Tracheostomy bypasses the nose which warms and moistens air breathed in.

• Cold dry air causes lung damage and dries secretions which then become sticky and thick. This can cause tube blockage (plugs).

• HME (heat and moisture exchanger) filter in ventilator circuit.

• ‘Wet’ system, water is warmed by a machine and humidified air fed into the ventilator circuit.

Why?

How?

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ALARMS- know what to do.

• Alarms are there to warn you of a problem• Do not silence them unless you are doing something to

rectify the problem.• By understanding how the ventilator is supporting the

client you can take the right action if an alarm sounds.• If there is a continuing problem, report immediately.• Alarm setting should be reviewed by the medical team

when the client goes for a review. Check to see if they have been changed.

• The humidifier also has alarms it will show where problem is

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Ventilator Alarms

• Power disconnect.• High pressure- usually

means some obstruction. Tube kinked/trapped. Trachy blocked. Check tubing for kinks, check trachy not blocked.

• Low pressure. Usually means break in the circuit. Check all tubing for connections.

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Manual Inflation (Bagging)

• Used to inflate the lungs temporarily whilst the ventilator is disconnected.

1) If ventilator fails.

2) When changing over the tubing.

3) When it is not safe/practical to use ventilator (eg in the shower).

• Used to over inflate the lungs to help to move thick sputum. (imitates cough).

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Problems with Bagging

• Over inflating lungs can cause damage.

• Under inflation causes lower oxygen levels and build up of carbon dioxide.

• Too fast and you can remove too much carbon dioxide.

• Too slow and you can reduce oxygen levels.

• DO NOT force air, there maybe a blockage which needs clearing.

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Tips for Bagging

To aid secretion removal

• Large in breath.• Release quickly to

mimic cough.• 10 maximum then

reconnect ventilator and suction.

Whilst disconnected from ventilator

• Match rate with usual ventilator setting [in time with your own breathing rate]

• Smooth in breath.• Allow time to breath out.• Keep time bagging to a

minimum.

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Safety-Precautions for ventilator

• Spare ventilator- battery charged and checked.

• Spare battery.• Know your alarms and

how to solve problems.• Know the engineer

number, check when service is due.

• Shift/daily checks.• Always report and

document problems.

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Spinal Cord Injury• Skin Management• Causes of Skin breakdown;• Lack of movement• Loss of sensation (poor blood circulation)• Psychological well being• Poor handling • Clothing too tight• Incorrect cushion or mattress

Four Stages of Pressure Sores

Stage What to Look For

1. Your skin looks lighter than usual.

2. Area of skin looks redder all the time, feels warm, maybe swollen.

3. Blister develops, bluish tinge, blister might open up.

4. Centre of blister turns black/brown, may be discharge.

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Four Stages of Pressure SoresStage What to Do/Other Information

1. Stay off, pressure is stopping your blood supply e.g. if you hold a glass tightly fingertips go lighter.

2. Stay off the area, DO NOT RUB, make sure redness goes after 30 minutes without pressure.

3. Stay off, SEE DOCTOR ASAP, there may be more damage to the skin than you can actually see.

4. Stay off, COVER WITH STERILE DRESSING, see Doctor, eat food with protein, damage has gone very deep, skin infected, discharge means body is losing protein.

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Spinal Cord Injury

• Prevention of skin problems• Observation/recording• Pressure relief• Equipment• Hygiene• Diet/Nutrition• Clothing [seams on trousers]• checking groin area for men

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Spinal Cord InjuryBladder Management

• No sensation• No voluntary void• Risk of kidney problems, stones• Risk of infection• Types of bladder management• Supra Pubic• Intermittent catheters• Urethral Indwelling• Conveen

Risks

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Changing the suprapubic catheter

• two people, (although one in emergency) one removing old catheter the other inserting new one. Firstly both glove up.

• Remove water from catheter’s balloon (up to 10 mls) using a syringe.

• Remove suprapubic catheter• Replace suprapubic catheter (check date)• Refill balloon with water from a syringe.• Attach leg bag, check draining properly.

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Spinal cord injury• Autonomic dysreflexia• An emergency situation that arises due to an

exaggerated sympathetic response to a noxious (painful) stimulus.

• This only occurs in injuries above T6• Signs• Pounding headache• Flushed or blotchy skin above level of injury• Nasal congestion• Blurred vision• Anxiety/Panic

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Spinal Cord Injury

• Autonomic Dysreflexia• Causes• PAIN/IRRITATION• Distended bladder• Distended bowel• Infection• Trauma• Ingrowing toe nail

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Spinal Cord Injury

• Action• Sit upright• Identify cause• Bladder• Bowels• General check• Nifedipine?• 999

Muscle Spasms• After a SCI, nerve cells below the level

of injury become disconnected from the brain.

• In an able-bodied person the brain stops most natural reflex actions.

• When there is no connection these actions cannot be stopped.

• Factors which make spasms worse –• Bladder infection• Kidney infection• Skin breakdown• Drugs used to combat spasms• Baclofen (pump), Valium and Dantrium

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Wheelchair Safety

• Checks brakes are on or if electric, power is off• If pushing wheelchair beware of going up slope of

1:12 as wheelchair may overbalance backward• If pushing wheelchair you may find it easier to

reverse down curbs (Occupant may slide out of chair)

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Wheelchair Etiquette• When talking for more than a few moments to

someone in a wheelchair try to put yourself at their eye level to avoid stiff necks. Try not to talk over the person in a wheelchair.

• if going to a venue check, suitable parking, entrance, toilets, lifts

• Scout ahead to see if they can Get to where get get to where they want to go

Do not lean on the wheelchair.

treat them as a person

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Complications for people with spinal cord injuries

• Reduce temperature control

• Possible skin conditions

• Pressure sores

• Blood pressure problems

• Diabetes

• Phantom pain

• Autonomic dysreflexia

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Ventilator and SCI Training

• Bowel Management• What is the bowel and what does it do?• The bowel is the last portion of your digestive tract (the

large intestine or colon)• The function is to take food into the body and to get rid of

waste.• The bowel is where the waste products of eating are

stored until they are emptied from the body in the form of a bowel movement (stool, faeces).

• A bowel movement happens when the rectum becomes full and the muscle around the anus opens.

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Bowel Management

• What stops normal bowel function?

Spinal Cord Injury Higher Breaks

Brain Injury

Physical Illness (MND, MS)

Immobility

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Bowel Management• Methods for emptying the bowel:

• Manual Removal

• Digital Stimulation

• Suppository

• Mini-Enema

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Bowel Management

• Factors that can affect success

Previous bowel history

Timing

Privacy and Comfort

Emotional Stress

Positioning

Fluids

Food

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Bowel Management

What to avoidUsing more than one finger

Bending finger

Rushing

More than Four Digital Stimulations at a Time

Long fingernails

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Manual handling back problems Some Statistics

• On any one working day, there are over 90,000 people off work with back problems.

• 5.5 million working days are lost in Britain ever year as a result of a manual handling back injury.

• Absence from work due to back pain costs the UK £365 million per year.

• 30% of all back injuries in the workplace are caused by, or related to, lifting, handling or load carrying.

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WEIGHT GUIDANCE FOR LIFTING

• Moving and Handling regulations state:

• Male = 25kg

• Female = 16kg

• HOWEVER PERSON HANDLING!!??

• No Weight is safe

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BIOMECHANICS

• Keep the load close to your body.

• Use your leg muscles to lift not your back muscles.

• Keep your back straight and your legs/knees bent.

• Point your feet in the direction you want to travel.

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Principles of Safer Handling

COMMUNICATION:Try to obtain clients consent. (dependent on clients cognitive ability)

Good communication between carers and client.

Timing of the move, give clear instructions. The count of 1---2--- 3 should not be used.

Better to use READY STEADY MOVE.

Decide who will be the lift leader,

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Principles of Safer Handling

DYNAMIC STABLE BASE;• Think Triangle! Can not be pushed over easily.

• Weight is evenly distributed.

• Will allow you to transfer weight between your feet.

• Avoid putting your nose

over your toes!

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Principles of Safer Handling

KEEPING THE LOAD CLOSE TO YOURBODY:• Keep your elbows close to your body as possible.

• This helps stabilise your shoulders, which will also help you transfer your weight through your legs

• You will use the POWER MUSCLES, this will also reduce twisting movements.

• Load is closer to your body giving you more control of the load.

• Keep your chin up, good for your neck

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The LOAD is the person you are moving.• Have they been hoisted before?

• Do they know why they need to move?

• Have you got consent

• Can they weight bear?

• What happens when you get them on their feet?

• RISK ASSESSMENT

• AVOID

• ASSESS

• REDUCE

• REVIEW

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EXISTING CONTROLMEASURES

• Overhead track hoists.

• Mobile hoists.

• Profiling beds.

• Wheelchairs.

• Slide sheets.

• Transfer boards and turntables.• Using equipment will not save you time but it will save your

back!!!!

• It is your responsibility not to take on any task that you think may harm you or your client!!!!

• SAVE YOUR BACK YOU ONLY GET ONE!!!

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Administering Medicine Legal Requirement

The Medicines Act (1968)

• This was the first comprehensive legislation on medicines in the UK. It provides the legal framework for the manufacture, licensing, prescription, supply and administration of medicines.

The Medicines Act (1998)

• “In the United Kingdom, anyone can legally administer prescribed medicine to another person. This includes prescription only medication (POM) and controlled drugs (CD). The administration must only be in accordance with the prescriber’s directions (except in the case of injections)” (The Medicines Act 1998) (UKHCA (2006), Social Care inspection (2005),

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Providing Support With Medication

• Staff should only provide assistance with medication when it is within their competence to do so and they have received any necessary specialist training.

• Assistance should only be provided with the informed consent of the client or their relatives if they have a legal standing to do so, or through litigation, friend(s).

• If it is clearly requested on the care plan by a named assessor.

• It is with the agreement of the carer or support worker’s line manager and is not contrary to the company policy.

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Side Effects of the MostCommonly Used Medicines

What is a side effect?• A side effect is an unwanted reaction of the body to the

toxicity of the medicine.

• Some side effects diminish after a period of time

• It is important to recognise side-effects in order that your client may receive appropriate intervention/reassurance

Antibiotics:-Diarrhoea ConstipationAbdominal CrampsRashesUnusual tastesUrine colour

Analgesics:-ConstipationLiver damage foroverdoseHeadachesDry mouth

Antidepressants:-EuphoriaAgitationAbdominaldiscomfortDry mouthNausea

Sedatives:-Blurred visionLethargyDrowsinessTremorSlower heart

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Administration of MedicinesFive Rights of Administration

• Right - Patient/Client

• Right - Time

• Right - Route

• Right - Medicine

• Right - Dose

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Administration of Medicine

• Ensure the five rights are adhered to.

• Check medicine not been given.

• Ensure client condition is conducive to receiving the medication.

• Ensure labels are clear on medicine bottles.

• Check medicine is in date

• Hygiene

• Water

• Ensure medicine taken

• Sign

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Do you have any questions?

• finish