Week 1 Narrative

Targeted Learning Outcomes

1. Demonstrate clinical information gathering and assessment skillsets as applicable to

specific patient scenarios and pathology.
2. Collaborate with patients, patients families, and other disciplines of the health care
team to educate the patient/family on disease management via the used of
therapeutic modalities related to the patient.
January 18, 20170645-190011.75

During this shift, I performed basic assessment gathering that include patient-ventilator

assessment, and CBG/arterial line sampling and analyzing, as well as witnessing intubation on a

pediatric patient. Performing and observing these tasks allowed me to improve techniques

related to blood gas sampling. Being allowed to analyze samples forced the internist to reinforce

the concepts of acid-base balance and recognize the appropriate values as it relates to pediatric

patients. After analyzing the samples as uncompensated respiratory acidosis, I collaborated with

the clinical preceptor and fellow physician to make changes to the patients ventilator settings as

needed. To correct the problem, I suggested increasing the patients mandatory respiratory rate to

allow the patient to excrete the excess CO2 retained. Both physician and therapist agreed. The

physical also suggested, increasing the patients tidal volume to allow more CO2 to be excrete

with each breath.

Targeted Learning Outcomes

1. Demonstrate clinical information gathering and assessment skillsets as applicable to

specific patient scenarios and pathology.
2. Collaborate with patients, patients families, and other disciplines of the health care
team to educate the patient/family on disease management via the used of
therapeutic modalities related to the patient.
3. Perform basic and advance therapeutics related to airway and drug management
and ventilator management as applicable to the pediatric patient care setting.
 Week 1 Narrative

January 19, 20170645-1900-11.75 hours

During this shift, I continued to perform basic assessment gathering along with using

advanced modes of ventilation to increase patient oxygen saturation. This shift allowed me to

see APRV used as a ventilator mode in conjunction with nitric oxide. Seeing and making these

changes reinforced previous knowledge about the ventilator modeusing both a high and low

pressure for different durations to allow the patient to receive the pressure they need to sustain

oxygenation while spontaneously breathing. APRV uses an inverse ratio method by delivering a

high pressure for a longer time during inhalation, and a low pressure for a shorter time to act as a

rate on exhalation. At the high pressure, the patient is allowed to spontaneously breath, while

maintaining FRC. The advantage with this mode of ventilation is that although the patient is on

an inversed ration, sedation and paralysis isnt necessary. With the same patient, I observed a

pediatric bronchoscopy that was indicated as a result of oxygen desaturation and abnormal CXR

that indicated mucus plugging. I also educated patient families on the modality used to ventilate

the patient by explaining the information listed above related to APRV.

Targeted Learning Outcomes

1. Demonstrate clinical information gathering and assessment skillsets as applicable to

specific patient scenarios and pathology.
2. Collaborate with patients, patients families, and other disciplines of the health care
team to educate the patient/family on disease management via the used of
therapeutic modalities related to the patient.
3. Perform basic and advance therapeutics related to airway and drug management
and ventilator management as applicable to the pediatric patient care setting.
January 21, 20170645-12456 hours
 Week 1 Narrative

During this shift, I continued to perform basic assessment gathering such as CBG

sampling and analysis and patient-ventilator assessment. I also performed changes in oxygen

therapy to better serve the patient such as switching from a high flow nasal cannula to a basic

binasal cannula. This change in oxygen delivery device was indicated because the patient no

long displayed clinical presentation that indicated the need for increase flow such as retracting

and increased work of breathing as evidenced by tripoding. I also engaged in family teaching

that was related to ventilator changes and drug management. During this interaction, I informed

family members about the need for decreasing the amount of pressure being deliver to the lungs

due to over-distension. When looking at the patient pressure-volume loop, I recognized the

partridge shape that correlated to alveolar over-distension. Performing these tasks reinforced

knowledge previously gained and validated key concepts related to ventilation and oxygenation,

such recognizing changes in ventilator graphics and changing setting accordingly to resolve

those problems.