Professional Practice IV S5 Final 2024-2025 PDF

Zagazig National University Faculty of Medicine Professional Practice IV - S5 2024 - 2025 1 Page  Professional Practice IV [Table of Contents] Table of Contents of Professional Practice IV...

Zagazig National University Faculty of Medicine Professional Practice IV - S5 2024 - 2025 1 Page  Professional Practice IV [Table of Contents] Table of Contents of Professional Practice IV S5 Topic Page Part I: Clinical Skills Nasogastric tube 3 Operating room ergonomics 7 Local Anesthetic Infiltration 15 Intravenous Injections 18 Cannulation 25 Venipuncture and Blood Sample Collection 32 Nebulization and Inhalation Therapy 40 Oxygen Therapy 49 Intensive Care Unit (ICU) 62 Cold and High-Altitude Related Illnesses 72 Part II: Legal and Ethical Issues Ethical concepts 81 Physician- patient relationship 97 Medical liability and malpractice 104 1 Page  Professional Practice IV [Surgery] Surgery Clinical Skills - Surgery ILOS: To learn how to use a nasogastric tube To have some details about operating room ergonomics OBJECTIVES: To get practical experience in the use of nasogastric tube To learn more about operating room safety and hazards 2 Page  Professional Practice IV [Surgery] NASOGASTRIC TUBE A nasogastric (NG) tube is a thin, flexible tube made of plastic or rubber that is inserted through the nose, down the throat, and into the stomach (Fig. 1). INDICATIONS Figure 1: Nasogastric tube To decompress the stomach and gastrointestinal (GI) tract (i.e., to relieve distention due to obstruction, ileus, or atony) 1. To empty the stomach, for example, in patients who are intubated to prevent aspiration or in patients with GI bleeding to remove blood and clots 2. To obtain a sample of gastric contents to assess bleeding, volume, or acid content 3. To remove ingested toxins (rare) 4. To give antidotes such as activated charcoal 5. To give oral radiopaque contrast agents 6. To provide feeding of nutrients into the stomach or feeding directly into the small intestine with a long, thin, flexible enteral feeding tube CONTRAINDICATIONS A. Absolute contraindications 1. Severe maxillofacial trauma 2. Nasopharyngeal or esophageal obstruction 3. Esophageal abnormalities, such as recent caustic ingestions, diverticula, or stricture, because of a high risk of esophageal perforation B. Relative contraindications 1. Uncorrected coagulation abnormalities 2. Very recent esophageal interventions, such as esophageal banding 3 Page  Professional Practice IV [Surgery] COMPLICATIONS 1. Nasopharyngeal trauma with or without hemorrhage. 2. Sinusitis and sore throat 3. Pulmonary aspiration 4. Traumatic esophageal or gastric hemorrhage or perforation 5. Intracranial or mediastinal penetration (very rare). EQUIPMENT Protective gown, gloves, and face shield 1. Nasogastric tube for decompression such as a Levin tube (single lumen) or Salem sump tube (double lumen such that second-lumen vents to atmosphere) (Fig. 2). Figure 2: Equipment for Nasogastric 2. If small intestine feeding is planned, a tube long, thin, intestinal feeding tube (nasoenteric tube) for long-term enteral feeding (use with a stiffening wire or stylet) 3. Topical anesthetic sprays such as benzocaine or lidocaine 4. Vasoconstrictor sprays such as phenylephrine or oxymetazoline 5. Cup of water and straw 6. 60-mL catheter-tipped syringe 7. Lubricant 8. Emesis basin 9. Towel or blue pad 10.Stethoscope 11.Tape and benzoin 12.Suction (wall or mobile device) 4 Page  Professional Practice IV [Surgery] NASOGASTRIC TUBE INSERTION Put on a gown, gloves, and face shield. Check for patency of each nostril by holding one closed and asking the patient to breathe through the other nostril. Ask the patient which provides better airflow. Look inside the nose for any obvious obstructions. Place a towel or blue pad over the patient’s chest to keep it clean. Choose the side for tube insertion and spray topical anesthetic in this nostril and the Figure 3: Insertion of pharynx at least 5 minutes before tube Nasogastric tube insertion. If time permits, give 4 mL of 10% lidocaine via a nebulizer or insert 5 mL of 2% lidocaine gel into the nares. Lubricate the end of the nasogastric tube. Gently insert the tip of the tube into the nose and slide along the floor of the nasal cavity. Aim back down to stay below the nasal turbinate. Expect to feel mild resistance as the tube passes through the posterior nasopharynx. Ask the patient to take sips of water through a straw and advance the tube during the swallows. The patient will swallow the tube, facilitating passage into the esophagus. Continue to advance the tube during swallows to the predetermined depth using the black marks on the tube as guidance. Assess proper tube placement by asking the patient to speak. If the patient is unable to speak, has a hoarse voice, is violently gagging, or is in respiratory distress, the tube is probably in the trachea and should be removed immediately. (Fig. 3). Inject 20 to 30 mL of air and listen with the stethoscope under the left subcostal region. The sound of a rush of air helps confirm the tube’s location in the stomach. Aspirate gastric contents to further confirm placement in the stomach (sometimes no gastric contents can be aspirated even when the tube is properly positioned in the stomach). 5 Page  Professional Practice IV [Surgery] Sometimes a chest x-ray is needed to definitively confirm the location of the tube in the stomach. If the tube will be used for infusing any substances, such as radiopaque contrast agents or liquid feedings, a chest X-ray is highly recommended. Secure the tube to the patient’s nose. Apply benzoin to the skin if available. Use a 4- to 5-inch piece of adhesive tape that is ripped vertically for half of its length and attach the wide half to the patient’s nose. Then wrap the tails of the tape in opposite directions around the tube. (Fig. 4). Figure 4: Secure the Attach the nasogastric tube to suction and set nasogastric tube it to low suction (intermittent suction if possible). 6 Page  Professional Practice IV [Surgery] OPERATING ROOM ERGONOMICS WHAT IS THE OPERATING ROOM? The Operating Room (OR) is a large, sterile room where surgeons operate on patients. It is equipped with surgical tables, monitors, and other equipment necessary for surgery. There are many types of operating rooms depending on the type of surgery. The room is typically cool and quiet, and the air is sterile and clean. The operating complex has several rooms for changing, supplies and equipment. Most of the operating rooms have a separate room for scrubbing and preparing the sterile tables. Most operating rooms have a sluice that connects the operating room to the corridors of the OR complex to optimize the airflow to support infection prevention. The operating room has several other rooms for hand washing, changing, supplies and equipment. For a surgical procedure to be successful, everything is carefully coordinated among the operating room staff from start to finish. OPERATING ROOM STAFF The operating team members usually consist of: Sterile division: it includes the surgeon, assistants to the surgeon, and the scrub team are a part of the sterile division. As a part of the sterile division, you are required to perform surgical handwashing and wear sterile gloves, gowns, and masks. You are only authorized to handle sterile equipment and must remain in the sterile field area of the OR (Fig. 5). Unsterile divisions: it includes the nurse anesthetist, anesthesiologist, circulating nurse, radiology technicians, medical device representative, and additional staff are a part of the non-sterile division. 7 Page  Professional Practice IV [Surgery] OPERATING ROOM DESIGN AND LAYOUT 1) The surgical table is placed centrally in the room, giving the surgical team easy access to the patient on the surgical table. 2) The anesthesia machine is placed at the end of the table where the patient's head is positioned and close to the OR door providing quick access for the anesthetic team in case of an emergency and anesthetic care that is convenient and efficient. 3) The suction device can be used to evacuate blood, body fluids, and smoke during surgery. This makes the suction device a necessary component of surgical procedures and anesthetic care provision. Figure 5: layout of operating room 4) A refrigerator is used to preserve specimens and store medications at desired temperatures. 5) Next, there are the mounted lights and booms that are used to provide lighting during the procedure. These are adjustable and can be moved around to specific locations during the surgical procedure. Mounting the lights provide additional space for operating room staff and additional equipment that may be needed. At least one operating light is installed directly above the surgical table. 6) Back tables are also used during every procedure. These tables are covered in sterile blue cloth and are used to hold the surgical instruments needed for the procedure. 7) All operating rooms consist of an anesthesia cart, oxygen, and additional anesthetic gases. 8) The OR contains additional space and tables for other surgical supplies and emergency equipment that may be needed at any given time. The temperature of the Operating room is usually cold. The patient is kept warm using warmed blankets and/or mattress. Working under an operating 8 Page  Professional Practice IV [Surgery] light with protective gears on might cause the team to sweat, which can, in turn, compromise sterility. One of the advantages of cool temperature in the Operating room is microorganisms grow slower when subjected to lower temperatures OPERATING ROOM ZONES The Operating Room is divided into different zones (sterile, clean, protective, and disposal) to prevent air contamination and regulate materials' transportation (Fig. 6). The sterile zone The sterile zone consists of the Operating rooms and clean preparation areas. In this zone, the highest level of aseptic conditions needs to be maintained. The ventilation system helps maintain air pressure gradient, minimizing airflow from the corridor to the OR. The clean zone The clean zone consists of the store areas, preoperative/holding room, recovery room, or PACU and OR staff rooms. It surrounds the sterile area and connects it to the protective area. Only staff wearing appropriate surgical wear should enter the clean area. The protective zone The protective zone includes dressing rooms, reception, and waiting areas. The zone surrounds the clean zone and forms a protective area between the clean zone of the OR and the rest of the hospital. Figure 6: Operating room zones The disposal zone The disposal zone includes the decontamination rooms and disposal corridors. The soiled instrument uses linen. Operating debris is removed via the disposal zone. 9 Page  Professional Practice IV [Surgery] SURGICAL SCRUBBING HAND WASH To reduce the growth of germs on hands, hand washing must be done for 40–60 s, as shown in the illustration (Fig. 7). Hand washing should be performed: o Before and after examining the patient. Figure 7 :Hand wash o Before minor procedures such as IV cannulation, urinary catheterization, and nasogastric tube insertion. This is done using water, soap, or antiseptic solution such as Chlorhexidine. Wet your hands with clean, running water — either warm or cold. Apply soap and lather well. Rub your hands vigorously for at least 20 seconds. Remember to scrub all surfaces, including the backs of your hands, wrists, between fingers, and under fingernails. Rinse well. Dry your hands with a clean towel or air-dry them. HAND SCRUB Remove jewelry. Use soap, brush, and running water to clean thoroughly around nails. Give special attention to the undersurface of nails and fingers’ webs (Fig. 8). Figure 8 : Hand scrub 10 Page  Professional Practice IV [Surgery] Scrub hands, and arms up to elbows for 3 to 5 minutes. After scrubbing, hold up your arms to allow water to drip off your elbows Turn off the tap with the elbow After scrubbing hands: o Dry with a sterile towel, make sure towel does not become contaminated. o Hold hands, forearms away from body and higher than elbows until putting on a sterile Figure 9: keep hands and gown and gloves (Fig. 9). forearms up GOWNING AND GLOVING A. GOWNING Place arms through sleeves. A nonscrubbed assistant pulls gown over your shoulders so hands go through sleeves. The assistant ties the back of the gown (Fig. 10). B. GLOVING Surgical gloves prevent transmission of HIV and Figure 10: Gowning other infections through contact with blood and other body fluids. Change a glove punctured during surgery, rinse the hand with antiseptic, or re-scrub. 11 Page  Professional Practice IV [Surgery] GLOVING without assistance Open a sealed package of sterile gloves before scrubbing and gowning; place the inner package on the sterile surface (Fig. 11). Once gowned, take the cuff of the left glove with the right hand (1); make sure the thumb in correct position Slide glove onto left hand, wriggle fingers slightly to help. Only touch the inside of the glove, and cuff with bare hands. Figure 11: Gloving without Slide the fingers of the gloved left hand assistance into the cuff of the right glove (2) Pull the glove onto your right hand in a similar fashion to placing left glove (3). Ensure that cuffs cover the ends of both gown sleeves (4) 12 Page  Professional Practice IV [Surgery] PATIENT SKIN PREPARATION Before an operation, wash the surgical site, and surrounding area with soap, and water; particularly washing debris from injuries. Prepare skin with an antiseptic solution; start in the center and move to the periphery (Fig. 12). Chlorhexidine gluconate and iodine are Figure 12 :Skin scrub preferable to alcohol as less irritating to the skin. Solution should remain wet on the skin for at least two minutes. The area should be large enough to include the entire incision and adjacent working area. DRAPING Do not place drapes on the patient until scrubbed, gowned, and gloved. Leave uncovered only the operative field (areas that have been prepped) and areas necessary for anesthesia (Fig 13). Applying Sterile Drapes: Figure 13: draping of the patient Base Drapes: These are placed around the surgical site to cover the patient and the surrounding area. Fenestrated Drapes: These have an opening that exposes the surgical site while keeping the surrounding area covered. Additional Drapes: Depending on the procedure, extra drapes may be used to cover equipment or to create a larger sterile field. Secure drapes with towel clips at each corner. to separate the anesthesiologist from the surgical area. The middle is determined, and the drape is pasted from the middle towards the lateral side. 13 Page  Professional Practice IV [Surgery] OPERATING ROOM HAZARDS Operating room hazards can include everything from surgical tools that can cause injury to personnel to the potential for infections. 1) Sharp objects These objects include scalpels, scissors, and needles. Without proper precautions, these sharp objects can result in a serious injury to the patient or medical personnel. 2) Infections Using contaminated instruments during surgery can cause an infection to spread through the patient's body. These infections are often life-threatening and require immediate attention. To prevent the spread of infection, healthcare providers should only use sterile instruments. Additionally, all instruments that come in contact with the patient's body should be properly disinfected. 3) Strains When a patient is malpositioned on the operating table, this can easily result in muscle strain or compromised nerves. If a patient is undergoing surgery and complains of pain, this might be caused by malpositioning on the operating table. 4) Fire Although rare in modern ORs, a fire outbreak can still occur. ORs are designed considering the correct location of fire extinguishers, installation of fire alarms, and gas shut-off valves. 5) Inadequate ventilation If the air quality within the operating room becomes too poor, it can become toxic and dangerous for patients. 14 Page  Professional Practice IV [Anesthesia] Local anesthetic infiltration Local anesthetics reversibly block nerve conduction near their site of administration, thereby producing temporary loss of sensation in a limited area. Uses for infiltrative anesthetics are as follows: 1- Subcutaneous infiltration (IV placement, superficial biopsy, suturing). 2- Submucosal infiltration (dental procedures, laceration repairs). 3- Wound infiltration (postoperative pain control at incision site). 4- Intraarticular injections (postsurgical pain control, arthritic joint pain control). 5- Infiltrative nerve blocks (ankle block, scalp block, digit block). Most common drugs used in local anesthetic infiltration: Drug Onset Maximum dose Duration Lidocaine rapid 4.5 mg/kg 120 min Bupivacaine slow 2.5 mg/kg 4 hours Steps of wound local infiltration Check the expiry, concentration, and calculate the dose of the suitable local anesthetics. Check your equipment: (gloves, alcohol, anti-septic wash , cotton and fine bore needle). Clean your hands with alcohol and wear sterilized gloves. Clean the wound thoroughly with anti-septic Insert the needle 5 ml lateral and parallel to the wound edge. Local anesthetic is injected slowly while withdrawing the needle. Always aspirate before injection. Wait for 3-5 minutes then test for effectiveness. For prolongation of action, add vasoconstrictor like adrenaline but avoid this in fingers, toes, nose, penis. 15 Page  Professional Practice IV [Anesthesia] Complications associated with local anesthesia: 1- Pain on injection: Pain on injection can be due to aggressive insertion of the needle, damaging soft tissues, blood vessels, nerves. To prevent: use topical anesthetic application and using a smaller-gauge needle. 2- Needle fracture: In most cases, needle fracture happened due to unexpected motion of the patient or assistants. 3- Lack of effect: may be due to anatomical variants, pathological and psychological factors, and poor technique 4- Prolongation of anesthesia and various sensory disorders: paresthesia, or neuralgia N.B: avoiding high concentration of anesthetic agent is recommended. 5- Hematoma: due to venous or arterial laceration To prevent hematoma formation: aspiration before injection, using a short needle and a minimum number of needle penetrations into tissues. N.B: When swelling forms immediately after injection, localized pressure should be applied. 6- Edema: Swelling of tissues can be due to trauma during injection, infection, allergy, hemorrhage, and injection of irritating solutions. N.B: managed as a hematoma. 7- Infection: is rare since the usage of disposable needles. To prevent infection: The area to be penetrated should be cleaned with a topical antiseptic prior to insertion of the needle. The local anesthetic should not be injected through the infected area. N.B: Antibiotics should be prescribed. 16 Page  Professional Practice IV [Internal Medicine] Internal Medicine 17 Page  Professional Practice IV [Internal Medicine] Intravenous Injections 1- Introduction Intravenous (IV) injections are a fundamental skill in medical practice, providing a method for delivering medications and fluids directly into a patient's bloodstream. This handout covers the theoretical knowledge and practical skills necessary for performing IV injections effectively and safely. 2- Theoretical Overview 2.1 Definition and Purpose Intravenous (IV) Injection: A procedure where medication or fluids are administered directly into a vein. This method ensures rapid absorption and distribution of substances, which is essential for immediate therapeutic effects, precise dosage control, and when oral administration is not feasible. Purpose: Immediate Effect: Allows medications to act quickly by entering the bloodstream directly. Controlled Dosage: Provides precise control over the amount and rate of medication administration. Fluid Resuscitation: Essential for managing severe dehydration or blood loss. 2.2 Types of Intravenous Injections Bolus Injection: Definition: A single, rapid injection of medication into a vein. Indications: Used for medications requiring immediate action, such as emergency medications (e.g., epinephrine in anaphylaxis). Procedure: Administered over a short period, often within a few minutes. 18 Page  Professional Practice IV [Internal Medicine] Infusion: Definition: Continuous or intermittent administration of fluids or medications over an extended period. Indications: Suitable for medications requiring slow and sustained delivery (e.g., antibiotics over several hours). Procedure: Involves setting up an infusion drip with a controlled flow rate. Push Dose Medication: Definition: A concentrated dose of medication pushed quickly into the vein. Indications: Emergency situations where rapid effect is needed. Procedure: Administered using a syringe and is often part of advanced resuscitation protocols. 2.3 Common Medications Administered Analgesics: Pain relievers like morphine or fentanyl. Antibiotics: For infections, such as vancomycin or ceftriaxone. Electrolytes: Solutions like potassium chloride or calcium gluconate to correct imbalances. Fluids: Hydration solutions such as normal saline or dextrose solutions. 2.4 Risks and Complications Infection: Phlebitis: Inflammation of the vein, often due to infection. Prevention: Use sterile techniques and proper site care. Extravasation: Definition: Leakage of IV fluids or medications into surrounding tissues. Prevention: Ensure proper placement of the catheter and monitor the infusion site. 19 Page  Professional Practice IV [Internal Medicine] Air Embolism: Definition: Introduction of air into the bloodstream, potentially causing a blockage. Prevention: Remove air from syringes and infusion lines before use. Thrombosis: Definition: Formation of a blood clot in the vein. Prevention: Regularly change infusion sites and use proper techniques to avoid vein irritation. 3- Practical Skills 3.1 Preparation Patient and Medication Verification: Identification: Confirm patient identity using two identifiers (e.g., name and date of birth). Medication Orders: Check the medication order for correct drug, dosage, and administration route. Equipment: IV Catheter: Choose the appropriate size for the patient’s vein and the medication being administered. Syringes and Needles: Ensure they are sterile and the correct size for the procedure. Antiseptic Wipes: For site preparation. Adhesive Dressings: To secure the catheter in place. 20 Page  Professional Practice IV [Internal Medicine] Preparation Steps: 1. Hand Hygiene: Wash hands thoroughly. 2. Prepare Equipment: Assemble IV catheter, syringe, medication, and sterile gloves. 3. Medication Preparation: Draw up medication into the syringe, ensuring no air bubbles are present. 21 Page  Professional Practice IV [Internal Medicine] 3.2 Technique Vein Selection: Choose the Vein: opt for a large, visible vein (e.g., median cubital vein). Avoid veins that are inflamed or hard. 22 Page  Professional Practice IV [Internal Medicine] Aseptic Technique: Site Cleaning: Clean the selected site with antiseptic wipes in a circular motion, starting from the center and moving outward. Gloving: Wear sterile gloves to maintain aseptic conditions. Insertion: 1. Apply Tourniquet: Use a tourniquet to engorge the veins and make them more prominent. 2. Needle Insertion: Insert the needle at a 15–30-degree angle with the bevel up. Once blood is aspirated, advance the catheter into the vein. 3. Confirm Placement: Ensure correct placement by aspirating blood into the catheter. 4. Secure the Catheter: Remove the needle while holding the catheter in place. Secure with adhesive tape and apply a sterile dressing. Medication Administration: Bolus Injection: Push the medication into the vein rapidly as prescribed. Infusion: Connect the IV line to the catheter and set the infusion rate according to the physician’s order. 3.3 Aftercare Site Monitoring: Check for Complications: Look for signs of redness, swelling, or discomfort at the insertion site. Observe Patient: Monitor for any immediate reactions to the medication. Documentation: Record: Document the medication administered, dose, time, and any observations or complications. 23 Page  Professional Practice IV [Internal Medicine] Disposal: Needles and Sharps: Dispose of used needles and sharps in a designated sharps container. Clean-Up: Ensure the area and equipment are properly cleaned and disposed of. 4- Case Studies and Examples Case Study 1: Emergency Bolus Injection Scenario: A patient arrives with severe anaphylaxis. Procedure: 1. Medication: Administer epinephrine IV bolus as prescribed. 2. Technique: Perform a quick venipuncture and inject the medication rapidly. 3. Monitoring: Observe the patient for improvement and any adverse reactions. Case Study 2: Continuous Infusion Scenario: A patient requires a 24-hour infusion of antibiotics. Procedure: 1. Medication: Prepare and set up an IV infusion of the prescribed antibiotic. 2. Technique: Insert a peripheral catheter, connect it to the infusion set, and adjust the flow rate. 3. Monitoring: Regularly check the infusion site and ensure the medication is being delivered as planned. 24 Page  Professional Practice IV [Internal Medicine] Cannulation 1. Introduction Overview Cannulation is a crucial skill for medical professionals, involving the insertion of a cannula (a thin tube) into a vein to provide intravenous access. This procedure is essential for delivering medications, fluids, and blood products, as well as for obtaining blood samples. Importance in Clinical Practice Proper cannulation ensures that patients receive timely and effective treatment, particularly in emergency and intensive care settings. Mastery of this skill minimizes discomfort, reduces the risk of complications, and enhances patient safety. 2. Anatomy and Physiology 2.1 Vascular Anatomy Understanding the anatomy of veins is fundamental for successful cannulation. Key veins include: Peripheral Veins Median Cubital Vein: Located in the antecubital fossa (elbow crease). Often the preferred site due to its size and depth. Cephalic Vein: Found on the lateral side of the forearm and arm. Generally easy to palpate but can be more challenging to cannulate due to its position. Basilic Vein: Located on the medial side of the forearm and arm. It is deeper and less palpable but can be accessed with a more skilled technique. 25 Page  Professional Practice IV [Internal Medicine] Central Veins Internal Jugular Vein: Located in the neck, ideal for long-term access or when large volumes are needed. Subclavian Vein: Found beneath the collarbone, used for central venous catheters and can provide stable access. Femoral Vein: Located in the groin area, often used in emergency situations or when other sites are unavailable. 2.2 Physiology of Veins Veins carry blood back to the heart. They have thinner walls compared to arteries and contain valves that prevent the backflow of blood. Understanding vein physiology helps in selecting appropriate sites and techniques for cannulation. Valves: These structures help prevent backflow and can be a challenge during cannulation if they are in the path of the needle. Vein Wall Composition: Veins are composed of three layers: the intima, media, and adventitia, which influences their flexibility and responsiveness. 3. Indications and Contraindications 3.1 Indications for Cannulation Fluid Resuscitation: Essential in cases of dehydration, shock, or significant fluid loss. Medication Administration: For drugs that require immediate effects or are irritating to the tissues. Blood Transfusion: Necessary for patients with anemia or blood loss. Diagnostic Procedures: Such as blood sampling for various tests. 26 Page  Professional Practice IV [Internal Medicine] 3.2 Contraindications and Precautions Infection: Avoid cannulating areas with signs of infection. Thrombophlebitis: A contraindication due to the risk of exacerbating inflammation. Recent Surgery: Avoid sites near recent surgical procedures to prevent complications. Poor Vein Condition: Veins that are sclerosed or have a history of difficult access may be avoided. 4. Preparation and Equipment 4.1 Patient Preparation 1. Informed Consent: Explain the procedure to the patient and obtain consent. 2. Positioning: Ensure the patient is comfortable, with the limb or site properly supported. 3. Hand Hygiene: Perform thorough hand washing or use an alcohol- based hand sanitizer. 4.2 Equipment Overview Cannula: Select the appropriate gauge (e.g., 18G for large volumes, 22G for smaller veins). Tourniquet: Used to engorge veins and make them more visible. Antiseptic Solution: Commonly iodine-based or alcohol swabs. Needle and Syringe: For administering local anesthetic if needed. Dressing and Tape: To secure the cannula in place after insertion. 4.3 Sterility and Infection Control Sterile Technique: Use sterile gloves, drapes, and a sterile field to prevent infection. Antiseptic Application: Clean the site in a circular motion from the center outward to reduce bacterial load. 27 Page Professional Practice IV [Internal Medicine] 28 Page  Professional Practice IV [Internal Medicine] 5. Cannulation Techniques 5.1 Peripheral Cannulation 1. Apply Tourniquet: Place it above the intended site to distend the vein. 2. Palpate Vein: Identify a suitable vein by palpation or visualization. 3. Clean Site: Use antiseptic solution to clean the area. 4. Insert Cannula: Hold the cannula at a 15-30 degree angle, insert it with a steady motion. 5. Advance Cannula: Once blood returns in the flashback chamber, advance the cannula further. 6. Secure Cannula: Release the tourniquet, secure the cannula with a sterile dressing. 7. Flush Cannula: Use normal saline to ensure patency and correct placement. 5.2 Central Venous Cannulation 1. Preparation: Use sterile drapes, gloves, and consider ultrasound guidance. 2. Identify Site: Based on anatomical landmarks or ultrasound images. 3. Local Anesthesia: Administer local anesthetic if required. 4. Needle Insertion: Insert the needle with sterile technique, confirm placement with blood return. 5. Guidewire and Catheter: Thread a guidewire through the needle, then advance the catheter over the guidewire. 6. Secure and Confirm: Remove the guidewire, secure the catheter, and confirm placement with X-ray if needed. 5.3 Pediatric and Special Considerations Pediatric Cannulation: Use smaller gauge cannulas and consider less traumatic sites such as the scalp or feet. Elderly Patients: May require special techniques due to fragile veins and skin 29 Page  Professional Practice IV [Internal Medicine] 6. Complications and Management 6.1 Common Complications Infection: Signs include redness, swelling, and discharge at the insertion site. Phlebitis: Inflammation of the vein that may present as pain, redness, and swelling. Hematoma: Collection of blood outside the vein causing bruising and swelling. Air Embolism: Rare but serious, can occur if air enters the venous system. 30 Page  Professional Practice IV [Internal Medicine] 6.2 Prevention and Management Infection: Replace the cannula and treat with antibiotics if necessary. Phlebitis: Remove the cannula, apply warm compresses, and monitor for further symptoms. Hematoma: Apply pressure to the site, elevate the limb, and monitor. Air Embolism: Position the patient left lateral decubitus and seek immediate medical attention. 7. Documentation and Follow-Up 7.1 Documentation Practices Date and Time: Record the exact time and date of cannulation. Cannula Details: Note the gauge, type, and site of insertion. Patient Response: Document any immediate patient reactions or complications. 7.2 Follow-Up Care and Monitoring Regular Monitoring: Check the site regularly for signs of infection or complications. Routine Flushing: Flush the cannula with normal saline to maintain patency and prevent clotting. Replacement: Change the cannula every 72-96 hours or as clinically indicated. 8. Summary Cannulation is a critical procedure requiring both theoretical knowledge and practical skills. Understanding vein anatomy, mastering proper techniques, and being aware of potential complications are essential for effective and safe patient care. Proper preparation, execution, and follow-up are key to successful cannulation. 31 Page  Professional Practice IV [Internal Medicine] Venipuncture and Blood Sample Collection 1. Introduction Overview Venipuncture is a fundamental procedure in medical practice, used to obtain blood samples for diagnostic tests, monitoring, and treatment. Mastery of this skill is crucial for accurate diagnosis and effective patient management. This handout provides an in-depth guide on both the theoretical and practical aspects of venipuncture and blood sample collection. Importance in Clinical Practice Blood tests are essential for diagnosing diseases, monitoring health conditions, and guiding treatment plans. Proper venipuncture techniques ensure high-quality samples, minimize patient discomfort, and reduce the risk of complications. 2. Anatomy and Physiology 2.1 Vascular Anatomy Understanding vein anatomy is vital for successful venipuncture. Key veins include: Peripheral Veins Median Cubital Vein: Located in the antecubital fossa (elbow crease). It is the most commonly used site due to its size and accessibility. Cephalic Vein: Situated on the lateral side of the forearm and arm. This vein is more challenging to puncture due to its position but is often used if the median cubital vein is not accessible. 32 Page  Professional Practice IV [Internal Medicine] Basilic Vein: Located on the medial side of the forearm and arm. This vein is deeper and can be more difficult to access but is used in certain situations. Central Veins Internal Jugular Vein: Located in the neck, often used for central venous access in critical situations. Subclavian Vein: Positioned beneath the collarbone, used for central venous catheters and long-term access. Femoral Vein: Located in the groin area, used in emergencies or when other sites are not available. 2.2 Physiology of Blood Flow Veins carry deoxygenated blood back to the heart. Key aspects include: Vein Wall Composition: Composed of three layers (intima, media, and adventitia) that impact flexibility and responsiveness. Valves: Prevent backflow of blood and can affect the ease of blood collection. Venous Pressure: Lower than arterial pressure, which can impact the ease of drawing blood. 3. Indications and Contraindications 3.1 Indications for Venipuncture Diagnostic Testing: For blood tests to diagnose conditions such as infections, anemia, or metabolic disorders. Monitoring: To assess levels of medications, electrolytes, or blood glucose. Therapeutic Purposes: For blood transfusions or therapeutic phlebotomy. 33 Page  Professional Practice IV [Internal Medicine] 3.2 Contraindications and Precautions Infection: Avoid sites with signs of infection to prevent spreading. Thrombophlebitis: Avoid areas with inflammation or clot formation. Recent Surgery: Avoid areas close to recent surgeries to prevent complications. Vein Condition: Avoid veins that are sclerosed, scarred, or difficult to palpate. 4. Preparation and Equipment 4.1 Patient Preparation 1. Informed Consent: Explain the procedure to the patient and obtain consent. 2. Positioning: Ensure the patient is comfortable and the arm is well- supported. 3. Hand Hygiene: Perform thorough hand washing or use an alcohol- based hand sanitizer. 4.2 Equipment Overview Needle and Syringe: Select the appropriate size (e.g., 21G or 23G for most venipunctures). Blood Collection Tubes: Various types depending on the tests required (e.g., EDTA for hematology, serum separator tubes for chemistry). Tourniquet: Used to engorge veins and make them more visible. Antiseptic Solution: Typically iodine-based or alcohol swabs. Dressing and Tape: To secure the puncture site post-collection. 4.3 Sterility and Infection Control Sterile Technique: Use sterile gloves, drapes, and a clean field to avoid contamination. Antiseptic Application: Clean the site in a circular motion from the center outward to minimize the risk of infection. 34 Page Professional Practice IV [Internal Medicine] 35 Page  Professional Practice IV [Internal Medicine] 5. Venipuncture Techniques 5.1 Peripheral Venipuncture 1. Apply Tourniquet: Place it approximately 4-6 inches above the intended site to distend the vein. 2. Palpate Vein: Identify a suitable vein by palpation or visualization. 3. Clean Site: Use antiseptic solution to disinfect the area. 4. Insert Needle: Hold the needle at a 15-30 degree angle. Insert it with a smooth, steady motion. 5. Collect Blood: Attach the collection tube or syringe, and draw the required amount of blood. 6. Remove Needle: Once the sample is collected, remove the needle and apply pressure to the puncture site. 7. Secure Site: Apply a sterile dressing to the puncture site. 5.2 Central Venipuncture 1. Preparation: Use sterile drapes, gloves, and consider using ultrasound guidance. 2. Identify Site: Based on anatomical landmarks or imaging. 3. Local Anesthesia: Administer if needed. 4. Needle Insertion: Insert the needle into the vein with sterile technique and confirm placement with blood return. 5. Blood Collection: Attach the collection device and draw the required blood. 6. Secure and Dress: Secure the site and dress it appropriately. 5.3 Pediatric and Special Considerations Pediatric Venipuncture: Use smaller needles and collection tubes. Consider using scalp veins or veins in the feet for infants. Elderly Patients: Be cautious of fragile veins. Use smaller gauge needles and apply gentle pressure. 36 Page  Professional Practice IV [Internal Medicine] 6. Blood Sample Collection and Handling 6.1 Types of Blood Samples Venous Blood: Collected from peripheral or central veins for most tests. Capillary Blood: Collected via fingerstick or heelstick, often used for glucose monitoring and some screening tests. 6.2 Blood Collection Tubes and Additives EDTA Tubes: For hematology tests, contains anticoagulant EDTA to prevent clotting. Serum Separator Tubes (SST): For chemistry tests, contains a gel that separates serum from blood cells after centrifugation. Sodium Citrate Tubes: For coagulation tests, contains citrate to bind calcium and prevent clotting. 6.3 Sample Handling and Processing Mixing: Gently invert tubes with additives to mix the anticoagulant. Labeling: Clearly label each sample with patient information, date, and time of collection. Transporting: Ensure samples are transported to the laboratory under appropriate conditions (e.g., refrigeration for some tests). 37 Page  Professional Practice IV [Internal Medicine] 7. Complications and Management 7.1 Common Complications Hematoma: A collection of blood outside the vein, causing swelling and bruising. Phlebitis: Inflammation of the vein, leading to pain and redness. Infection: Rare but serious, can occur if sterile techniques are not followed. Nerve Injury: Rare but possible, especially if the needle hits a nerve. 38 Page  Professional Practice IV [Internal Medicine] 7.2 Prevention and Management Hematoma: Apply pressure to the site and monitor for further swelling or pain. Phlebitis: Remove the needle and apply warm compresses to the affected area. Infection: Replace the needle and consider antibiotics if signs of infection develop. Nerve Injury: Avoid repeated punctures at the same site and use appropriate needle techniques. 8. Documentation and Follow-Up 8.1 Documentation Practices Date and Time: Record when the venipuncture was performed. Site and Needle Size: Document the vein used and the needle gauge. Patient Response: Note any reactions or complications experienced by the patient. 8.2 Follow-Up Care and Monitoring Site Care: Monitor the puncture site for signs of complications. Patient Instructions: Advise patients on how to care for the puncture site and when to seek medical attention if complications occur. 9. Summary Venipuncture and blood sample collection are essential skills in clinical practice. Understanding the anatomy of veins and safe sampling. 39 Page  Professional Practice IV [Internal Medicine] Nebulization and Inhalation Therapy 1. Introduction Overview Nebulization and inhalation therapy are crucial techniques for delivering medications directly to the lungs, improving respiratory function in various conditions. These therapies are used to manage acute and chronic respiratory diseases by targeting the medication directly where it is needed. Importance in Clinical Practice Effective management of respiratory diseases often relies on the use of nebulization and inhalation therapies. Mastery of these techniques enhances patient outcomes by providing direct, localized treatment, improving medication efficacy, and minimizing systemic side effects. 2. Anatomy and Physiology of the Respiratory System 2.1 Respiratory Anatomy Understanding the respiratory system's structure is essential for effective inhalation therapy: Upper Respiratory Tract: Includes the nasal cavity, pharynx, and larynx. Lower Respiratory Tract: Includes the trachea, bronchi, and bronchioles. Alveoli: Tiny air sacs where gas exchange occurs. 40 Page  Professional Practice IV [Internal Medicine] 2.2 Mechanisms of Gas Exchange Ventilation: Movement of air in and out of the lungs. Diffusion: Movement of gases (oxygen and carbon dioxide) across the alveolar-capillary membrane. Perfusion: Flow of blood through the pulmonary capillaries, facilitating gas exchange. 3. Indications for Nebulization and Inhalation Therapy 3.1 Common Indications Asthma: To relieve acute bronchospasm and manage chronic symptoms. Chronic Obstructive Pulmonary Disease (COPD): To improve airflow and reduce symptoms. Cystic Fibrosis: To help clear thick mucus from the airways. Acute Respiratory Infections: To reduce inflammation and facilitate mucus clearance. 3.2 Specific Conditions Treated Bronchitis: To reduce airway inflammation and improve breathing. Allergic Rhinitis: To alleviate symptoms by reducing airway inflammation. Pneumonia: To assist in medication delivery for severe cases. 41 Page  Professional Practice IV [Internal Medicine] 4. Types of Inhalation Devices 4.1 Nebulizers Jet Nebulizers: Use compressed air to convert liquid medication into a fine mist. 42 Page  Professional Practice IV [Internal Medicine] Ultrasonic Nebulizers: Use ultrasonic waves to create the aerosol. Mesh Nebulizers: Use a vibrating mesh to produce a fine mist. 43 Page  Professional Practice IV [Internal Medicine] 4.2 Metered-Dose Inhalers (MDIs) Mechanism: Deliver medication as a fine spray of aerosolized drug. Typically require coordination of inhalation and actuation. 4.3 Dry Powder Inhalers (DPIs) Mechanism: Deliver medication in powdered form. Do not require coordination of inhalation and actuation but need a forceful inhalation. 44 Page  Professional Practice IV [Internal Medicine] 5. Nebulization Therapy 5.1 Mechanism of Action Nebulization involves the conversion of liquid medication into a mist that can be inhaled deeply into the lungs. This method allows for direct delivery of medication to the airways and lungs. 5.2 Types of Nebulizers Jet Nebulizers: Utilize compressed air to atomize the medication. Suitable for many types of medications. Ultrasonic Nebulizers: Employ high-frequency sound waves. Useful for medications that are sensitive to heat. Mesh Nebulizers: Use a vibrating mesh to produce a fine aerosol. They are portable and efficient but can be more expensive. 5.3 Procedure and Technique 1. Preparation: Assemble the nebulizer and ensure all parts are clean. 2. Medication: Measure and add the prescribed medication to the nebulizer cup. 3. Positioning: Place the mask or mouthpiece on the patient. 4. Nebulization: Turn on the nebulizer and instruct the patient to breathe normally through the mouthpiece. 5. Completion: Ensure the patient has completed the therapy and clean the equipment. 5.4 Medication Types Used Bronchodilators: Such as albuterol, to relax airway muscles. Corticosteroids: Such as fluticasone, to reduce inflammation. Mucolytics: Such as acetylcysteine, to break down mucus. 45 Page  Professional Practice IV [Internal Medicine] 6. Inhalation Therapy 6.1 MDIs: Mechanism and Technique Mechanism: MDIs deliver medication via a pressurized canister that produces a fine aerosol spray. Technique: 1. Shake the Inhaler: To mix the medication. 2. Prime if Necessary: Follow manufacturer’s instructions. 3. Inhalation: Breathe out fully, place the mouthpiece in the mouth, and press the canister while inhaling deeply and slowly. 4. Hold Breath: For 10 seconds to allow medication to reach the lungs. 5. Rinse Mouth: To prevent side effects like oral thrush. 6.2 DPIs: Mechanism and Technique Mechanism: DPIs deliver medication as a dry powder, which is inhaled directly into the lungs. Technique: 1. Load the Dose: Follow device-specific instructions for loading the medication. 2. Inhalation: Breathe out fully, place the mouthpiece in the mouth, and inhale forcefully and deeply. 3. Hold Breath: For 10 seconds to ensure medication reaches the lungs. 4. Rinse Mouth: To prevent local side effects. 7. Complications and Management 7.1 Common Complications Nebulization Therapy: o Local Irritation: Such as throat dryness or coughing. o Infection: If the nebulizer is not properly cleaned. Inhalation Therapy: o Oral Thrush: Especially with corticosteroids. o Dry Mouth: Common with some inhaled medications. 46 Page  Professional Practice IV [Internal Medicine] 7.2 Prevention and Management Nebulization Therapy: o Clean Equipment: Regularly clean and disinfect the nebulizer. o Hydrate: Encourage fluid intake to minimize throat dryness. Inhalation Therapy: o Rinse Mouth: After using MDIs or DPIs. o Check Technique: Ensure correct inhalation technique to maximize medication delivery. 8. Patient Education and Compliance 8.1 Instructing Patients on Device Use Demonstrate Technique: Provide a step-by-step demonstration of how to use the device. Use Visual Aids: Employ diagrams or videos to aid understanding. Provide Written Instructions: Give patients written instructions for reference. 8.2 Ensuring Compliance and Correct Usage Regular Follow-Up: Schedule follow-up appointments to review technique and medication adherence. Encourage Questions: Allow patients to ask questions about their therapy. Monitor Effectiveness: Track symptoms and adjust therapy as needed. 47 Page  Professional Practice IV [Internal Medicine] 9. Documentation and Follow-Up 9.1 Documentation Practices Medication Details: Record the type, dose, and frequency of medication administered. Patient Response: Document any adverse reactions or side effects. Device Used: Note the type of inhalation device used and any issues encountered. 9.2 Follow-Up Care Monitor Symptoms: Assess patient symptoms and response to therapy during follow-up visits. Adjust Therapy: Modify the treatment plan based on patient feedback and clinical evaluation. Reinforce Education: Continuously reinforce proper use and technique. 10. Summary Nebulization and inhalation therapy are essential techniques for treating respiratory conditions. A thorough understanding of the theoretical and practical aspects of these therapies ensures effective patient management, minimizes complications, and improves therapeutic outcomes. Mastery of inhalation devices, proper technique, and patient education are key to successful treatment. 48 Page  Professional Practice IV [Internal Medicine] Oxygen Therapy 1. Introduction Overview Oxygen therapy is a critical component in the management of various acute and chronic respiratory conditions. It involves the administration of oxygen to maintain adequate tissue oxygenation and alleviate symptoms related to hypoxia. This handout provides a detailed exploration of both theoretical knowledge and practical skills related to oxygen therapy. Importance in Clinical Practice The effective use of oxygen therapy can significantly improve patient outcomes by preventing and treating hypoxia, enhancing tissue oxygenation, and supporting the management of respiratory and cardiac conditions. Mastery of oxygen therapy is essential for optimal patient care and recovery. 2. Anatomy and Physiology of Oxygen Transport 2.1 Respiratory Anatomy Upper Respiratory Tract: Includes the nose, pharynx, and larynx, which filter, warm, and moisten incoming air. Lower Respiratory Tract: Includes the trachea, bronchi, and bronchioles, which conduct air to the alveoli. Alveoli: Tiny air sacs where gas exchange occurs between the air and blood. 49 Page  Professional Practice IV [Internal Medicine] 2.2 Mechanisms of Oxygen Transport Oxygen in Blood: o Dissolved Oxygen: Small amount of oxygen dissolved in plasma. o Oxygen Bound to Hemoglobin: Majority of oxygen transported by hemoglobin in red blood cells. Oxygen-Hemoglobin Dissociation Curve: o Right Shift: Decreased affinity for oxygen (e.g., in conditions like acidosis or high carbon dioxide levels). o Left Shift: Increased affinity for oxygen (e.g., in alkalosis or low carbon dioxide levels). 2.3 Oxygen-Hemoglobin Dissociation Curve Shift to Right: Indicates a decreased affinity of hemoglobin for oxygen, which facilitates oxygen release to tissues. Factors include increased temperature, increased carbon dioxide, and decreased pH. Shift to Left: Indicates an increased affinity for oxygen, making it harder for hemoglobin to release oxygen to tissues. Factors include decreased temperature, decreased carbon dioxide, and increased pH. 50 Page  Professional Practice IV [Internal Medicine] 3. Indications for Oxygen Therapy 3.1 Acute Indications Hypoxemia: Low blood oxygen levels, often measured by pulse oximetry or arterial blood gas analysis. Respiratory Distress: Conditions such as pneumonia, COPD exacerbations, or acute asthma attacks. Cardiac Conditions: Acute myocardial infarction or heart failure, where oxygen delivery is compromised. 3.2 Chronic Indications Chronic Obstructive Pulmonary Disease (COPD): Long-term oxygen therapy to manage chronic hypoxemia. Interstitial Lung Disease: Progressive lung conditions requiring continuous oxygen support. Sleep Apnea: Home oxygen therapy for patients with significant hypoxemia during sleep. 3.3 Special Populations Premature Infants: Often require supplemental oxygen to prevent and manage neonatal hypoxia. Patients with Cystic Fibrosis: May require oxygen therapy to manage chronic lung infections and inflammation. 51 Page  Professional Practice IV [Internal Medicine] 4. Oxygen Delivery Systems 4.1 Low-Flow Systems Nasal Cannula: o Description: A lightweight device with two prongs that sit in the nostrils. o Oxygen Flow Rate: Typically, 1-6 L/min, providing an approximate FiO2 of 24-44%. o Usage: Suitable for patients with mild hypoxemia who require a low to moderate amount of supplemental oxygen. Simple Face Mask: o Description: A mask covering the nose and mouth with side vents to allow exhaled air to escape. o Oxygen Flow Rate: 5-10 L/min, providing an approximate FiO2 of 40-60%. o Usage: Used for patients requiring moderate to high flow rates. 52 Page  Professional Practice IV [Internal Medicine] Partial Rebreather Mask: o Description: Similar to the simple mask but with a reservoir bag to capture exhaled air. o Oxygen Flow Rate: 6-10 L/min, providing an approximate FiO2 of 60-80%. o Usage: Used for short-term therapy in severe hypoxemia. Non-Rebreather Mask: o Description: Includes a reservoir bag and one-way valves to prevent exhaled air from entering the bag. o Oxygen Flow Rate: 10-15 L/min, providing an approximate FiO2 of 80-100%. o Usage: For critical patients needing the highest concentration of oxygen. 53 Page  Professional Practice IV [Internal Medicine] 4.2 High-Flow Systems Venturi Mask: o Description: A mask with a venturi valve that allows for precise control of the FiO2. o Oxygen Flow Rate: Variable, providing a fixed FiO2 of 24- 60%. o Usage: Used when accurate oxygen concentrations are required, such as in COPD patients. 54 Page  Professional Practice IV [Internal Medicine] High-Flow Nasal Cannula: o Description: A specialized cannula that delivers high flow rates of humidified oxygen. o Oxygen Flow Rate: Up to 60 L/min, providing a precise FiO2 of 21-100%. o Usage: Used for patients with severe hypoxemia or respiratory failure. 55 Page  Professional Practice IV [Internal Medicine] CPAP (Continuous Positive Airway Pressure) and BiPAP (Bilevel Positive Airway Pressure): o Description: Devices that provide continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) to maintain open airways. o Usage: CPAP is used for obstructive sleep apnea, while BiPAP is used for patients with respiratory distress or chronic obstructive pulmonary disease (COPD). CPAP: 56 Page  Professional Practice IV [Internal Medicine] 5. Administration Techniques 5.1 Nasal Cannula 1. Positioning: Place the prongs in the nostrils with the tubing positioned around the ears and under the chin. 2. Adjust Flow Rate: Set the flow rate as prescribed, typically between 1-6 L/min. 3. Monitoring: Check for proper fit and comfort, and monitor the patient for adequate oxygenation. 5.2 Face Masks 1. Positioning: Place the mask securely over the nose and mouth. 2. Adjust Flow Rate: Set the flow rate as prescribed to ensure proper oxygen delivery. 3. Monitoring: Ensure a tight seal and comfort. Adjust straps as needed to prevent leaks. 5.3 Venturi Mask 1. Positioning: Attach the correct color-coded adapter for the desired FiO2. 2. Adjust Flow Rate: Set the flow rate according to the manufacturer's guidelines to match the desired FiO2. 3. Monitoring: Ensure a snug fit and check for proper oxygen delivery. 5.4 High-Flow Nasal Cannula 1. Positioning: Place the cannula in the patient's nostrils and adjust the tubing to ensure a secure fit. 2. Adjust Flow Rate: Set the flow rate as prescribed, up to 60 L/min, and adjust the FiO2 accordingly. 3. Monitoring: Check for adequate humidification and comfort. Monitor the patient’s response. 57 Page  Professional Practice IV [Internal Medicine] 5.5 CPAP and BiPAP 1. Fitting: Ensure the mask fits properly and comfortably over the patient’s nose or mouth. 2. Settings: Adjust the pressure settings as prescribed, ensuring the appropriate level of support. 3. Monitoring: Regularly check for mask leaks, comfort, and effectiveness of therapy. 6. Monitoring and Adjusting Therapy 6.1 Monitoring Techniques Pulse Oximetry: Non-invasive method to monitor blood oxygen saturation (SpO2). Arterial Blood Gas (ABG): Provides detailed information about blood gases and pH levels. Clinical Observation: Monitor for signs of respiratory distress, cyanosis, and changes in mental status. 6.2 Adjusting Oxygen Therapy Based on SpO2: Adjust oxygen flow rates or device settings to achieve target SpO2 levels. Based on ABGs: Modify therapy according to changes in arterial blood gas values. Clinical Response: Assess patient symptoms and adjust therapy based on clinical improvement or deterioration. 6.3 Evaluating Effectiveness Symptom Improvement: Evaluate reduction in symptoms such as dyspnea or cyanosis. Oxygen Saturation: Ensure SpO2 levels are within target ranges. Patient Comfort: Assess and address any discomfort or complications related to oxygen therapy. 58 Page  Professional Practice IV [Internal Medicine] 7. Complications and Management 7.1 Oxygen Toxicity Symptoms: Includes chest pain, cough, and visual disturbances. Management: Reduce the FiO2 to the lowest effective level and monitor for symptoms. 7.2 Barotrauma Symptoms: Includes pneumothorax or pneumomediastinum. Management: Adjust pressure settings and monitor for signs of barotrauma. Seek medical intervention if necessary. 7.3 Absorption Atelectasis Symptoms: Collapse of lung tissue leading to reduced gas exchange. Management: Ensure appropriate FiO2 levels and monitor for signs of atelectasis. Use techniques to promote lung expansion. 7.4 Dryness and Discomfort Symptoms: Dry nasal passages or throat irritation. Management: Use a humidifier with oxygen therapy to prevent dryness and provide comfort. 8. Patient Education and Compliance 8.1 Educating Patients on Usage Device Instruction: Demonstrate how to properly use the oxygen delivery device. Safety Precautions: Instruct on safety measures, such as avoiding open flames and ensuring adequate ventilation. Recognizing Complications: Educate on recognizing signs of oxygen-related complications. 59 Page  Professional Practice IV [Internal Medicine] 8.2 Ensuring Compliance Regular Check-Ins: Schedule follow-up visits to assess adherence and effectiveness. Addressing Concerns: Provide support and address any questions or issues patients may have. Home Therapy: Educate patients on managing home oxygen therapy and equipment maintenance. 8.3 Managing Home Oxygen Therapy Equipment: Ensure patients understand how to operate and maintain home oxygen equipment. Emergency Plan: Develop a plan for handling emergencies and equipment failures. Regular Monitoring: Schedule periodic assessments to adjust therapy and equipment as needed. 9. Documentation and Follow-Up 9.1 Documentation Practices Therapy Details: Record the type of oxygen therapy, flow rate, and device used. Patient Response: Document patient’s response to therapy, including symptoms and oxygen saturation levels. Adjustments: Note any changes made to therapy or device settings. 9.2 Follow-Up Care and Adjustments Regular Assessments: Schedule follow-up visits to evaluate the effectiveness of therapy and make adjustments as needed. Monitoring Progress: Track patient’s progress and response to therapy. Education Reinforcement: Reiterate patient education on device use and safety. 60 Page  Professional Practice IV [Internal Medicine] 10. Summary Oxygen therapy is a fundamental treatment for managing respiratory conditions and ensuring adequate oxygenation. This handout covers the theoretical basis of oxygen transport, the various delivery systems, administration techniques, monitoring, and managing complications. Effective patient education and follow-up are essential for optimizing therapy and improving patient outcomes. 61 Page  Professional Practice IV [Internal Medicine] Intensive Care Unit (ICU) 1. Introduction Overview The Intensive Care Unit (ICU) is a specialized hospital unit designed to provide comprehensive and continuous care to patients with severe or life- threatening conditions. This environment is equipped with advanced monitoring and life-support technology and staffed by a multidisciplinary team. The ICU plays a crucial role in managing critical illnesses and supporting patients through complex, high-risk situations. Importance of the ICU The ICU is vital for: Providing Life-Sustaining Treatment: Offering advanced interventions for patients with acute organ failures or critical illnesses. Monitoring and Support: Continuous surveillance of vital signs and immediate response to changes in patient condition. Multidisciplinary Care: Collaborative approach involving various specialties to manage complex medical situations. 2. ICU Environment and Structure 2.1 Types of ICUs General ICU: Provides care for a broad range of critical illnesses and conditions. Cardiac ICU (CCU): Specialized in managing severe cardiovascular conditions such as acute myocardial infarction or heart failure. Neonatal ICU (NICU): Focuses on the care of critically ill newborns and premature infants. 62 Page  Professional Practice IV [Internal Medicine] Pediatric ICU (PICU): Caters to critically ill children and adolescents. Neuro ICU: Specializes in patients with severe neurological conditions like strokes or traumatic brain injuries. 2.2 Equipment and Technology Ventilators: Machines that assist or control breathing. 63 Page  Professional Practice IV [Internal Medicine] Monitors: Devices for continuous measurement of vital signs (e.g., heart rate, blood pressure, SpO2). Infusion Pumps: Used to administer intravenous medications and fluids. 64 Page  Professional Practice IV [Internal Medicine] Dialysis Machines: For renal replacement therapy. 2.3 Staffing and Roles Intensivists: Physicians specialized in critical care medicine. Nurses: Registered nurses with advanced training in critical care. Respiratory Therapists: Specialists in managing ventilatory support. Pharmacists: Provide expertise in medication management. Physical Therapists: Assist with mobilization and rehabilitation. 3. Indications for ICU Admission 3.1 Common Conditions Severe Respiratory Failure: Conditions like ARDS or COPD exacerbations requiring mechanical ventilation. Severe Cardiovascular Conditions: Such as cardiogenic shock or acute myocardial infarction. Multiple Organ Failure: Critical conditions where multiple organ systems are compromised. Severe Trauma: Including significant injuries from accidents or falls. 65 Page  Professional Practice IV [Internal Medicine] 3.2 Assessment Criteria Severity of Illness: Based on clinical parameters and organ system involvement. Need for Continuous Monitoring: Requirements for intensive and frequent monitoring. Requirement for Specialized Interventions: Need for advanced life- support measures or therapies. 3.3 Decision-Making Process Clinical Judgment: Based on the patient’s overall condition, prognosis, and response to initial treatment. Multidisciplinary Input: Collaboration among specialists to determine the best course of action. Patient and Family Preferences: Consideration of patient values and goals of care. 4. Monitoring and Diagnostic Tools 4.1 Vital Signs Monitoring Heart Rate: Monitored continuously to detect arrhythmias or other cardiac issues. Blood Pressure: Measured regularly to assess cardiovascular status. Respiratory Rate and Pattern: Assessed for indications of respiratory distress or failure. Oxygen Saturation (SpO2): Monitored via pulse oximetry to ensure adequate oxygenation. 4.2 Advanced Monitoring Techniques Central Venous Pressure (CVP): Measurement of pressure in the central venous system to assess fluid status and cardiac function. Pulmonary Artery Catheterization: Provides information on cardiac output and pulmonary pressures. Continuous Blood Glucose Monitoring: Important for managing diabetic or critically ill patients. 66 Page  Professional Practice IV [Internal Medicine] 4.3 Diagnostic Imaging Chest X-ray: Commonly used to assess lung and cardiac conditions. CT Scan: Provides detailed imaging for diagnosing trauma, stroke, or other conditions. Ultrasound: Used for bedside assessments of cardiac function, fluid status, and other conditions. 5. ICU Interventions and Therapies 5.1 Ventilatory Support Mechanical Ventilation: Utilizes machines to support or control breathing. o Modes: Assist-control, synchronized intermittent mandatory ventilation, pressure support. o Settings: Tidal volume, respiratory rate, FiO2, PEEP. Non-Invasive Ventilation: Uses CPAP or BiPAP for patients with respiratory distress but without full respiratory failure. 5.2 Cardiovascular Support Vasopressors: Medications like norepinephrine or dopamine to support blood pressure and cardiac output. Inotropes: Drugs that enhance cardiac contractility, such as dobutamine. Mechanical Circulatory Support: Devices like intra-aortic balloon pumps or ventricular assist devices for severe cardiac failure. 5.3 Renal Replacement Therapy Continuous Renal Replacement Therapy (CRRT): Used for patients with acute kidney injury who are hemodynamically unstable. Intermittent Hemodialysis: For patients requiring periodic removal of waste products from the blood. 67 Page  Professional Practice IV [Internal Medicine] 5.4 Infection Control Antibiotics: Administered based on culture results and clinical suspicion of infection. Sterile Techniques: Essential for preventing hospital-acquired infections. Hand Hygiene: Critical for reducing the risk of cross-contamination. 6. ICU Management Protocols 6.1 Fluid and Electrolyte Management Fluid Resuscitation: Administering fluids to manage shock or dehydration. Electrolyte Balance: Monitoring and correcting imbalances of sodium, potassium, calcium, and other electrolytes. 6.2 Nutrition and Metabolism Enteral Nutrition: Preferred method for feeding critically ill patients to maintain gut function. Parenteral Nutrition: Used when enteral feeding is not possible or insufficient. 6.3 Sedation and Analgesia Sedatives: Medications like propofol or midazolam to keep patients comfortable and cooperative. Analgesics: Pain management using opioids or non-opioid medications. 6.4 Pain and Delirium Management Pain Assessment: Regular evaluation and management of pain using scales and patient feedback. Delirium Prevention: Strategies include maintaining sleep patterns, reducing sensory overload, and addressing underlying causes. 68 Page  Professional Practice IV [Internal Medicine] 7. Communication and Team Dynamics 7.1 Interdisciplinary Team Communication Regular Rounds: Structured team discussions to review patient progress and treatment plans. Collaborative Decision-Making: Involves input from various specialists to tailor care plans. 7.2 Family Communication and Support Regular Updates: Providing families with clear and compassionate updates on patient status and treatment. Support Services: Offering emotional support and counseling to families. 7.3 Ethical Considerations and End-of-Life Care Ethical Dilemmas: Navigating issues such as treatment withdrawal, patient autonomy, and best interests. Palliative Care: Focus on comfort and quality of life for patients with terminal conditions. 8. Patient Care and Safety 8.1 Preventing ICU-Associated Complications Ventilator-Associated Pneumonia (VAP): Prevention strategies include elevating the head of the bed and oral care. Deep Vein Thrombosis (DVT): Prophylaxis with anticoagulants and mechanical devices. 8.2 Infection Prevention and Control Aseptic Techniques: Strict adherence to infection control protocols. Regular Cleaning: Disinfection of equipment and surfaces. 69 Page  Professional Practice IV [Internal Medicine] 8.3 Safe Patient Handling and Mobilization Proper Techniques: Use of lifts and support devices to prevent injury. Early Mobilization: Encouraging movement to reduce complications such as muscle weakness and pressure ulcers. 9. Patient Discharge and Follow-Up 9.1 Discharge Planning Assessing Readiness: Determining when a patient is stable enough to be discharged from the ICU. Coordination with Other Services: Ensuring a smooth transition to general care or rehabilitation. 9.2 Transition of Care Handoff Procedures: Detailed transfer of patient information to the receiving unit or facility. Follow-Up Appointments: Scheduling and coordinating post-ICU care and monitoring. 9.3 Post-ICU Follow-Up Long-Term Monitoring: Addressing ongoing health issues and recovery. Rehabilitation Services: Providing support for physical and psychological recovery. 70 Page  Professional Practice IV [Internal Medicine] 10. Summary The ICU is a complex and critical environment requiring specialized knowledge and skills. Understanding the theoretical principles and practical applications of ICU management is essential for providing high-quality care to critically ill patients. This handbook aims to equip medical students with a comprehensive overview of ICU practices, from monitoring and interventions to communication and discharge planning. 71 Page  Professional Practice IV [Internal Medicine] Cold and High-Altitude Related Illnesses 1. Introduction Overview Extreme environmental conditions, such as cold weather and high altitudes, can lead to a range of illnesses that pose serious health risks. Cold- related illnesses include hypothermia and frostbite, while high-altitude illnesses encompass acute mountain sickness (AMS), high-altitude pulmonary edema (HAPE), and high-altitude cerebral edema (HACE). This handout aims to provide a comprehensive understanding of these conditions, focusing on their pathophysiology, clinical manifestations, diagnosis, and management. Importance in Clinical Practice Knowledge of cold and high-altitude related illnesses is essential for several reasons: Prevention: Understanding risk factors and preventive measures helps reduce the incidence of these illnesses. Diagnosis and Management: Early recognition and appropriate management are crucial for improving patient outcomes. Patient Education: Educating patients on how to prevent and recognize these conditions enhances safety and well-being. 72 Page  Professional Practice IV [Internal Medicine] 2. Cold-Related Illnesses 2.1 Pathophysiology Cold-related illnesses occur due to prolonged exposure to low temperatures, leading to physiological and metabolic disruptions. The body's response to cold exposure includes: Thermoregulation: Mechanisms to maintain core body temperature, including vasoconstriction (narrowing of blood vessels), shivering, and behavioral adaptations like seeking warmth or layering clothing. Frostbite: Results from localized freezing of tissues, particularly extremities like fingers, toes, ears, and nose. Ice crystals form within cells, causing cellular damage and reduced blood flow. Hypothermia: Occurs when the body loses heat faster than it can produce it, leading to a core temperature drop below 35°C (95°F). This affects metabolic processes and organ function. 2.2 Clinical Manifestations Frostbite: o Early Symptoms: Numbness, tingling, and redness of the affected areas. o Advanced Symptoms: Skin turns pale or bluish, becomes hard and waxy. Blisters may develop, and severe cases can lead to tissue necrosis and gangrene. Hypothermia: o Mild Hypothermia: Symptoms include shivering, rapid breathing, and confusion. The patient may appear clumsy or have difficulty speaking. o Moderate Hypothermia: Shivering becomes intense, coordination worsens, and the patient may exhibit significant confusion and lethargy. o Severe Hypothermia: Shivering stops, the patient may be unconscious, and signs of cardiovascular or respiratory compromise, such as slow heart rate and shallow breathing, are present. 73 Page  Professional Practice IV [Internal Medicine] 2.3 Diagnosis Frostbite: Diagnosis is based on clinical examination. Early detection involves assessing skin color and texture, and advanced cases may require imaging to evaluate tissue damage. Hypothermia: Diagnosed through clinical history and physical examination. Core temperature measurement is crucial, and laboratory tests may reveal electrolyte imbalances or metabolic abnormalities. 2.4 Management and Treatment Frostbite: o Immediate Care: Rewarm affected areas gradually with body heat or warm (not hot) water. Avoid rubbing or using direct heat sources, which can cause further tissue damage. o Medical Treatment: Administer analgesics for pain management, assess for infection, and consider surgical intervention for severe cases involving tissue necrosis. Hypothermia: o Initial Care: Move the patient to a warm environment, remove wet clothing, and use blankets or warm water baths to gently rewarm the body. Avoid rapid rewarming, which can cause cardiovascular instability. o Medical Treatment: Administer warmed intravenous fluids, monitor vital signs closely, and treat complications such as arrhythmias or electrolyte imbalances. 74 Page  Professional Practice IV [Internal Medicine] 3. High-Altitude Related Illnesses 3.1 Pathophysiology High-altitude illnesses result from reduced atmospheric pressure and lower oxygen levels at elevations above 2,500 meters (8,200 feet). The primary issues include: Hypoxia: Insufficient oxygen in the blood and tissues. Acclimatization: Physiological adaptation to high altitude involves increasing red blood cell production, enhancing oxygen delivery, and adjusting ventilation rates. 3.2 Clinical Manifestations Acute Mountain Sickness (AMS): o Symptoms: Headache, nausea, vomiting, dizziness, and fatigue. Symptoms usually occur within 6-12 hours of ascent. o Severity: Symptoms can range from mild to moderate, with more severe cases potentially progressing to HAPE or HACE. High-Altitude Pulmonary Edema (HAPE): o Symptoms: Shortness of breath, cough (possibly with pink frothy sputum), chest tightness, and cyanosis. Symptoms typically develop after 1-4 days at high altitude. o Severity: Can progress rapidly to respiratory failure if not treated promptly. High-Altitude Cerebral Edema (HACE): o Symptoms: Severe headache, confusion, ataxia (lack of coordination), and loss of consciousness. Neurological deficits may be present. o Severity: HACE is a life-threatening condition that requires immediate descent and medical intervention. 75 Page  Professional Practice IV [Internal Medicine] 3.3 Diagnosis AMS: Diagnosis is clinical, based on symptoms and altitude exposure. Exclusion of other conditions is important. HAPE: Diagnosis involves clinical presentation and physical examination. Chest X-ray may show signs of pulmonary edema. HACE: Diagnosis is based on clinical evaluation of symptoms and neurological examination. CT or MRI may be used to rule out other causes of neurological symptoms. 3.4 Management and Treatment AMS: o Immediate Care: Rest, hydration, and descent to a lower altitude if symptoms persist or worsen. Acetazolamide (Diamox) can be used to facilitate acclimatization. o Medical Treatment: Anti-nausea medications and pain relief may be necessary. 76 Page  Professional Practice IV [Internal Medicine] HAPE: o Immediate Care: Descend to a lower altitude immediately and administer supplemental oxygen. Rest is crucial. o Medical Treatment: Diuretics (e.g., furosemide) and medications like nifedipine can help reduce pulmonary pressure and edema. HACE: o Immediate Care: Rapid descent to a lower altitude and supplemental oxygen. o Medical Treatment: Administer dexamethasone (a corticosteroid) to reduce cerebral edema. Close monitoring and supportive care are necessary. 4. Prevention Strategies 4.1 Cold-Related Illnesses Preventive Measures: o Proper Clothing: Wear layered, moisture-wicking clothing to trap heat and prevent heat loss. Insulated gloves, hats, and footwear are essential. o Avoid Prolonged Exposure: Limit time in extreme cold conditions and take breaks to warm up. o Stay Dry: Wet clothing increases heat loss, so it is important to stay dry by using waterproof outer layers and changing wet clothes promptly. Acclimatization: Gradual exposure to cold environments can enhance tolerance and minimize risk. This includes adapting clothing and adjusting activities based on weather conditions. 77 Page  Professional Practice IV [Internal Medicine] 4.2 High-Altitude Illnesses Preventive Measures: o Gradual Ascent: Ascend slowly to allow the body time to acclimatize. Recommended ascent rates are no more than 300- 500 meters (1,000-1,500 feet) per day above 3,000 meters (10,000 feet). o Hydration and Nutrition: Maintain adequate hydration and a balanced diet to support acclimatization. o Medications: Use prophylactic acetazolamide for individuals at high risk of developing high-altitude illnesses. Acclimatization: Proper acclimatization includes spending time at intermediate altitudes and allowing the body to adjust before further ascent. 5. Case Studies and Practical Applications 5.1 Cold-Related Illnesses Case Study Case Scenario: A skier presents with numbness and tingling in their fingers after a long day on the slopes in sub-zero temperatures. The physical e