THE UNIVERSITY OF MONTANA – MISSOULA



The University of Montana – College of Technology

Respiratory Care Program

Course Syllabus

COURSE NUMBER AND TITLE: RES 265T Clinical Experience II

DATE REVISED: 10/17/11

Syllabus Outline:

B. Student Performance Outcomes (Objectives) for: Adult Critical Care

C. Student Evaluation

D. Affiliate Clinical Instructor's Responsibilities

E. Program Policies: Includes Clinical Attendance Policy

F. Clinical Site Rules and Regulations, Syllabus Agreement

G. Clinical II Forms & Ventilator Patient Case Study

H. Case Study Form and Presentation Grading Criteria

Case Study Presentation Day: Friday, July 16 and Friday, July 23

Clinical paperwork needs to be turned in weekly by Friday at 5pm

SEMESTER CREDITS: 5

CONTACT HOURS PER SEMESTER: 225 Hours

PREREQUISTE: RES 231, RES 232, RES 235, RES 250T, RES 255T

FACULTY:

Shyla Flintom, Director of Clinical Education

243-7806 (Office) 329-8458 (pager)

Office: Health & Business Bldg.

Office hours: Monday – TBA

Clinical Adjunct Faculty

Dora Cardillo, BS, RRT (Billings)

BJ Banister, AAS, RRT ( Missoula)

Lindsey Bow, AAS, RRT (Spokane)

Scott Louis, AAS, RRT (Spokane)

Mike Zwicker, AAS, RRT (Billings)

CLINICAL AFFILIATES:

Kootenai Medical Center, Coure d’Alene, ID

Sacred Heart Medical Center, Spokane, WA

Deaconess Medical Center, Spokane, WA

St. Patrick Hospital, Missoula, MT

St. Vincent Hospital, Billings, MT

Community Medical Center, Missoula, MT

Billings Clinic, Billings, MT

Kalispell Regional Medical Center, Kalispell, MT

St. James Hospital, Butte, MT

RELATIONSHIP TO PROGRAM:

This course provides clinical setting for the student to apply cognitive and psychomotor skills learned in RES 131T, RES 150T, RES 250T, RES 231T and RES 235.

COURSE DESCRIPTION:

Continuation of clinical skills learned in RES 255T, with emphasis on adult critical care. Students utilize skills and knowledge attained in the prerequisite classroom and laboratory courses.

STUDENT ASSESSMENT METHODS AND GRADING PROCEDURES:

The grade will be based on competency-based performance checklists, daily logs, and rotational evaluations according to the following grading scale:

Grading Scale

A = 4.0 95-100% C = 2.00 74-76%

A- = 3.67 90-95% C- = 1.67 70-73%

B+ = 3.33 87-89% D+ = 1.33 67-69%

B = 3.00 84-86% D = 1.00 64-66%

B- = 2.67 80-83% D- = .067 60-63%

C+ = 2.33 77-79% F = 0.00

Students in Health Programs must have a “B-” (80% or better) final grade in order to progress within their programs. Test questions will be based on unit objectives. Unit objectives are to be used as study guides.

METHODS TO IMPROVE COURSE:

Student evaluations and site experience evaluations along with affiliate site visits by the director (s) will be analyzed.

REQUIRED TEXT:

Title: Basic Clinical Lab Competencies for Respiratory Care 4th Edition

Author: White

Publisher: Delmar

COURSE OUTLINE: Adult Critical Care rotations

B. STUDENT PERFORMANCE OUTCOMES (Objectives):

Adult Critical Care Rotaion: RES 265 Clinical II 2011, rev. 04/25/11

Upon completion of the course, the student will be able to under direct supervision, in a hospital setting, perform the following adult critical care tasks:

| |Title |Page |

|1. ** |Elecrocardiograms (ECG) |113 |

|2. ** |End Tidal Monitoring |179 |

|3. ** |Arterial Puncture (if not already done) |139 |

|4. ** |Arterial Line Sampling |141 |

|5. ** |Bronchoscopy Observation (if not already done) |RES 150 Syllabus |

|6. ** |Manual Resuscitation – BLS (if not already done) |409 |

|7. ** |Intubation Assist/Observation |RES 250 Syllabus |

|8. ** |Extubation |413 |

|9.* |Nasotracheal suction (if not already done) |435 |

|10. ** |Endotracheal Suctioning |437 |

|11. ** |Monitoring Cuff Pressures |439 |

|12. ** |Tracheostomy and Stoma Care (if not already done) |441 |

|13 ** |Oral Care |RES 250 Syllabus |

|14. ** |Initiation of Continuous Mechanical Ventilation |575 |

|15. ** |Monitoring Continuous Mechanical Ventilation |447 |

|16 ** |Spontaneous Ventilation Parameters |625 |

|17 ** |Ventilator Waveform, Cl & Raw Interpretations |RES 250 Syllabus |

|18. * |Changing a Ventilator Circuit |RES 250 Syllabus |

|19. ** |Initiation of NPPV |511 |

|20. ** |Monitor Chest Tubes |RES 250 Syllabus |

|21. ** |Puritan Bennett 840 Competency (lab check-off) |RES 250 Syllabus |

|22. ** |Vision BiPAP Competency (lab check-off) |RES 250 Syllabus |

|23. Op |Viasys Avea Competency (lab check-off) |RES 250 Syllabus |

Fifteen must be completed by the end of summer semester in order to matriculate into fall semester. ** ALL 23 of these must be completed prior to graduation.

Additionally, students will complete an adult critical care ventilator patient case study.

C. STUDENT EVALUATION: Clinical evaluations are necessary to confirm your performance on a variety of patients in a facility setting. Each performance evaluation lists discreet steps with evaluation criteria for a given procedure. Because expectations regarding procedure steps, sequence and equipment differ among hospitals, provisions have been made with your instructors to specify which steps and which equipment applies to your evaluation.

Performance assessment is done by direct observation by your instructor as you prepare for, implement, and complete the designated task. Critical steps to successfully complete the task are identified by an asterisk. Completion of the task in a reasonable time frame is necessary.

Ideally, you should 1) observe, 2) practice, and 3) read procedure and references for each procedure before you ask to be assessed. Your instructors will provide demonstrations for you to observe. Pay careful attention to instructions, sequence and explanations.

Repeat and practice the procedure and do a self-assessment or have a peer evaluate you. Prepare yourself for answering basic theory questions by reading and reviewing the references, criteria, and graphs provided on the checklist and in the syllabus. After you have practiced and studied the procedural steps ask your instructor to assess your performance. Once you begin the task, do not ask questions or seek assistance from your evaluator. Instructors will assist you if necessary. Except in unusual circumstances (CPR) do not ask an instructor to evaluate your performance after you have completed it.

Following the proficiency evaluation, you should review the documentation with your evaluator and ensure that all appropriate entries are complete and accurate. The evaluations are competency based - - you must satisfactorily complete all procedures designated for each course. You may repeat the procedure as often as necessary. Keep all procedural evaluations in a notebook and have them accessible at all times while you are in the clinical area.

Competency Based: Students are required to achieve competency in all listed clinical skills and procedures. In consultation with their instructors, students will determine when they are prepared to be evaluated. It is recommended that students practice the procedure/skill on patients often enough, under supervision, to assure passing the performance (checklist) evaluation session. The instructor and student should review the evaluation at the time.

Evaluation Components: Performance (checklist) Evaluations(75 points): These forms evaluate your competency in the task or skill. Performance Evaluations are required per rotation. Each checklist identifies, by asterisk, the critical steps in performing these procedures/skills. These must be demonstrated or the evaluation will be terminated and will need to be repeated. Only by adherence to these criteria can you expect to demonstarate competency in the task. You must complete 15 by the end of the semester, or you will not move on to the fall.

Student Clinical Rotation Performance Review (60 points each): This is a behavioral rating scale and anecdotal record evaluation of performance in the psychomotor, (motor skills) cognitive, (knowledge) and affective (attitudes) learning areas. It is completed and discussed with each student by clinical instructors. The final review should take place in the clinical setting, at the end of the rotation.

Student Daily Log (Daily) 20 pts each week: Students complete this form every day for each clinical day.

Adult Ventilator Patient Case Study 100 points: In-depth information gathering study on one patient receiving mechanical ventilation. See information gathering form in this syllabus.

Clinical Site Evaluations and adjunct evaluations (10 points total): The student is provided an opportunity to evaluate the rotation at each facility as well as the adjunct.

D. AFFILIATE CLINICAL INSTRUCTOR’S RESPONSIBILITIES

I. Definition of an unacceptable performance.

• An unsatisfactory score on any of the checklists.

• Failure to complete all assigned checklists for the semester.

• Less than 36 points on the overall rotational clinical evaluation.

• Overall performance potentially detrimental to the patient.

• Violent, abusive, or disruptive behavior.

II. Definition of minimal acceptable performance. 90% of the total points possible for each Clinical Performance evaluation will be the minimum acceptable score. This includes Daily Logs & Student Rotation Evaluation scores, and completion of all assigned rotations.

III. Assignments: Program emphasis is on the quality of instruction provided during clinical practice, not on the number of procedures performed. You should control the assignment by matching the right patient to meet the students’ objectives. Randomly assigning procedures should not be done. Read the objectives for the clinical practicum to help you make assignments. Estimate how much difficulty the individual student will have completing procedures, then attempt to provide appropriate supervision. Provide leadership and direction and assign the student an appropriate workload.

IV. Supervision: Students are always under the direct supervision of a COT instructor or affiliate clinical instructor (staff respiratory care practitioner). The degree of supervision varies widely and should be applied with the following considerations in mind:

a) departmental policy and procedure.

b) individual student skills and length of clinical exposure.

c) individual instructor or practitioner experience.

In general, students begin under direct supervision and progress to more independence (indirect supervision) as the clinical sequence is completed. Regardless of the degree of supervision, the assigned instructor is responsible for the students’ work and to make a valid assessment of their performance as stated in I-IV above. In all cases, students performing invasive procedures or working in critical care areas are under direct supervision or have immediate access to their assigned instructor. If you are advised to complete the rotational evaluation but have had little contact with the student, please consult your peers who may have had exposure to the student.

V. Performance and Clinical Evaluations: The procedural checklists and weekly evaluation forms are explicit and the explanation concerning completion is given. It is very meaningful to have Facility faculty comment on student progress to incorporate more than one view in the overall evaluation. Affiliate Clinical Instructors are responsible for completing the checklists and the performance evaluations when assigned. There should be a one-on-one discussion with the student.

To avoid unnecessary confusion, if you are involved with student education, read the syllabus for the course and study the objectives. Review the Competency Based Performance Checklists and the Clinical Evaluation/Assessment Guidelines.

VI. Clinical Evaluations: Guidelines for Scoring

The clinical evaluation form has 12 content areas for scoring. The system used will be 1-5 with 1 being the least/worst and 5 being the most/best. The rule of thumb is that a 3 is average or minimum expectations. A 2 would indicate that some improvement is required and a 1 is unacceptable. Above average/expectation is indicated by a score of 4. A 4 would indicate that the standard is always met and sometimes exceeded. A score of 5 would indicate that the standard is always exceeded.

E. PROGRAM POLICIES

1. Dress Code:

• Maroon scrubs with The University of Montana “Griz” patch on one shoulder, or “Griz” embroidered on the scrubs.

• Identification badge mandatory. ID tags issued by local affiliates can be worn at all affiliates.

• Shoes – a good support shoes with closed heels and toes. No sandals. No loud colors.

• Long hair must be pulled back from face.

• No tongue, nose, face studs or rings.

• I have a “zero tolerance” policy on tatoos. Long-sleeved T-shirts may be required.

• No revealing necklines. Ladies may want to wear a T-shirt under scrub tops.

• No perfumes or colognes. Asthmatic patients and professional staff will not appreciate it.

2. Equipment: Same as from Spring semester

.

CLINICAL ATTENDANCE POLICY Part of the student’s clinical grade is attendance based.

Tardiness and absences are recorded. Do not ask adjuncts or preceptors if you can leave early. If your preceptor has stated you can go home early due to low census, YOU MUST CALL THE CLINICAL DIRECTOR!!!

Course credits, program accreditation, and state funding are based on clinical contact hours.

Do not alter your assigned shifts. Rotations are assigned for parallel and equivalent learning.

No rotation schedule changes will be made after the schedules are mailed to affiliates.

All absences will be made up at a time mutually agreeable with the affiliate and the Director of Clinical Education prior to semester’s end. Make up will be on a rotation equivalent basis at the same facility.

Personal Appointments: Students must not make physician, dentist, or attorney, etc. appointments during times scheduled for clinic or classes. Ensure access to reliable transporation and finances for out of town clinical rotations.

EXCUSED ABSENCES: Illness – death in the family – special situations approved by the Director of Clinical Education or adjunct faculty.

Excused absences are made up on an hour for hour ratio.

Double shifts to make up time are not acceptable.

Students must notify departmental staff at the affiliate they are scheduled to attend at least one hour before report time. They must also contact the Director of Clinical Education either by pager, 329-8458, or message at 243-7806.

UNEXCUSED ABSENCES: If student calls one hour before shift, but the reason is not illness, death in the family, or a special situation discussed with the Director of Clinical Education, the absence is considered unexcused.

Unexcused absences are automatically give a grade of zero.

TARDINESS: Late for start of shift = tardy. Three tardies during one rotation = unexcused absence to be given a grade of zero.

More than 30 minutes late, without calling in = unexcused absence for the day. The student will again be given a grade of zero.

PARKING:Follow parking policies of the clinical site.

4. Health:

• Keep in good physical and mental health.

• Eat three meals a day.

• Moderate exercise.

• No smoking in hospitals or affiliate provided housing.

5. Discretion:

• Do not discuss patient status in the immediate patient care areas unless an instructor or physician asks you to.

• Avoid making broad-brusk statements concerning a particular facility, department, or program.

• Avoid discussing opinions concerning competency of instructors, staff, or physicians.

• Allow for individual differences and procedural community.

• Developing discretion early in your career will be one of your best professional assets.

• Do not use facility telephones or copy machines for personal use.

6. Academic Misconduct:

All students must pracatice academic honesty. Academic misconduct is subject to an academic penalty by the course instructor and/or a disciplinary sanction by the University.

All students need to be familiar with the Student Conduct Code. The Code is available for review online at .

7. Disabilities:

Students with disabilities may request reasonable modifications by contacting me. The University of Montana assures equal access to instruction through collaboration between students with disabilities, instructors, and Disability Services for Students (DSS). “Reasonable” means the University permits no fundamental alterations of academic standards or retroactive modifications. (For other options see ).

8. Parking:

9. Follow parking policies and guidelines for the institution.

F. AGREEMENT FORM

The University of Montana - College of Technology Respiratory Care Program

Clinical Site Rules and Regulations

1. It is not acceptable to leave your shift early. You will be counted absent for the whole shift.

2. You have your clinical schedule, so make appropriate arrangements regarding appointments. Missed time will result in being counted absent for the entire shift.

3. If you need to call in sick, please call the affiliate at least an hour before your shift is to start. You must also contact the College of Technology Clinical Director (Beeper number 406/329-8458).

4. It is your responsibility to inform the affiliate and your College of Technology instructor if you are going to be tardy or absent.

5. All of the clinical hours, which are assigned to you, are required hours. You will need these hours to matriculate on to your next clinical semester and to graduate from the respiratory care program.

6. Please do not rearrange your schedule without prior approval from your Clinical Director.

7. The department phone is not for personal phone calls.

8. Enter each clinical site with an open mind. Do not compare sites as each site is different and may do things a little differently.

9. The only reason for leaving a clinical site early is an emergency, and it must be cleared with your instructor first at assigned affiliate and your College of Technology instructor.

10. Arrive at the clinical site 15 minutes early and then be ready for shift report.

11. Clinical times are for clinical opportunities and not to be used as study time.

12. Clinical daily logs and evaluation forms must be signed or a grade of ZERO will be recorded for computing your grade and returned for signatures. All paperwork must be properly completed by the end this semester in order to matriculate into next semester.

13. You must be in uniform at all times while at the affiliate. If you need to go to the affiliate on your own time to complete the case studies, you must be in uniform with your name tag on.

14. It is not acceptable to leave your shift early. You will be counted absent for the whole shift.

15. You have your clinical schedule, so make appropriate arrangements regarding appointments. Missed time will result in being counted absent for the entire shift.

16. If you need to call in sick, please call the affiliate at least an hour before your shift is to start. You must also contact the College of Technology Clinical Director (Beeper number 406/329-8458).

17. It is your responsibility to inform the affiliate and your College of Technology instructor if you are going to be tardy or absent.

18. All of the clinical hours, which are assigned to you, are required hours. You will need these hours to matriculate on to your next clinical semester and to graduate from the respiratory care program.

19. Please do not rearrange your schedule without prior approval from your Clinical Director.

20. Enter each clinical site with an open mind. Do not compare sites as each site is different and may do things a little differently.

21. The only reason for leaving a clinical site early is an emergency, and it must be cleared with your instructor first at assigned affiliate and your College of Technology instructor.

22. Arrive at the clinical site 15 minutes early and then be ready for shift report.

23. Clinical times are for clinical opportunities and not to be used as study time.

24. Clinical daily logs and evaluation forms must be signed or a grade of ZERO will be recorded for computing your grade and returned for signatures. All paperwork must be properly completed by the end this semester in order to matriculate into next semester.

25. You must be in uniform at all times while at the affiliate. If you need to go to the affiliate on your own time to complete the case studies, you must be in uniform with your name tag on.

I have read the course syllabus for RES265T, Clinical Experience II. I am aware of course requirements, rotation objectives, Confidentiality Agreements from RES 255, Clinical Site Rules and Regulations, and the grade scale.

Name: (print)_________________________________, Signature:__________________________________

Date:___________________________

G. Clinical Experience II Forms

1. Student Clinical Check-Off Tracking Log

2. Student Daily Log

3. Clinical Rotation Performance Review (2 pages – Make front to back, single page copies if possible.)

4. Student Clinical Site Evaluation

5. Patient-Ventilator Case Study Form (8 pages)

6. Student Clinical Site Evaluation Form

7. Student Clinical Adjunct Evaluation Form

RES265T

CLINICAL EXPERIENCE II

Student Performance Evaluation Tracking Log, rev. 04/25/11

Name ___________________________________________

| |Title |Page |Date Completed |

|1. ** |Electrocardiograms (ECGs) |113 | |

|2. ** |End Tidal Monitoring |179 | |

|3. ** |Arterial Puncture (if not already done) |139 | |

|4. ** |Arterial Line Sampling |141 | |

|5. ** |Bronchoscopy Observation (if not already done) |RES 150 Syllabus | |

|6. ** |Manual Resuscitation – BLS (if not already done |409 | |

|7. ** |Intubation Assist/Observation |RES 250 Syllabus | |

|8. ** |Extubation |413 | |

|9.* |Nasotracheal suction |435 | |

|10. ** |Endotracheal Suctioning |437 | |

|11. ** |Monitoring Cuff Pressures |439 | |

|12. ** |Tracheostomy and Stoma Care |441 | |

|13 ** |Oral Care |RES 250 Syllabus | |

|14. ** |Initiation of Continuous Mechanical Ventilation |575 | |

|15. ** |Monitoring Continuous Mechanical Ventilation |447 | |

|16. ** |Spontaneous Ventilation Parameters |625 | |

|17. ** |Ventilator Waveform, Cl & Raw Interpretations |RES 250 Syllabus | |

|18. * |Changing a Ventilator Circuit |RES 250 Syllabus | |

|19. ** |NPPV |511 | |

|20. ** |Monitor Chest tubes |RES 250 Syllabus | |

| | | | |

| | | | |

|21. Option|Viasys Avea Competency | |Optional if facility offers this |

| | | |ventilator |

Fifteen must be completed by the end of summer semester inorder to matriculate into fall semester.

** All 20 must be completed prior to graduation.

The University of Montana - College of Technology - Respiratory Care Program

Student Daily Log ** REV. 04/25/11

|Student Name: |Clinical Site & Rotation type: (ex. St. Pat’s/PFT) |

| | |

| |___________________________________ |

|Student Signature: |Date: |

|# of Procedures Performed | Observed |Please circle one and sign. P = Pass F = Fail |

| | |(Every “F” circled requires a comment.) |

|Chest PT | | | |

|FIO2 Analysis | | |1. Motivation/attitude |P |F |

|SVN | | | | | |

|IPPB | | | | | |

|IPV | | | | | |

|Pulse Oximetry | | | | | |

|Incentive Spiro. | | | | | |

|MDI/DPI | | | | | |

|Pep/Acapella | | | | | |

|CPAP | | |2. Response to supervision/interaction |P |F |

|BiPAP | | | | | |

|Low flow O2 | | | | | |

|High flow O2 | | | | | |

|Bronchoscopy | | | | | |

|Conscious sedation | | | | | |

|PFT | | | | | |

|ABG – draw | | | | | |

|ABG – analyze | | | | | |

|Ventilator initiation | | | | | |

|Circuit Change | | |3. Knowledge base (didactic content) |P |F |

|Vent Transport | | | | | |

|Suction | | | | | |

|Intubation | | | | | |

|Extubation | | | | | |

|ECG | | | | | |

|Polysomnogram | | | | | |

|CPR | | | | | |

|Chest drainage/ thoracentesis | | | | | |

|obs. | | | | | |

|Chest X-ray interp. | | | | | |

|TRAUMA assist | | |4. Technical application |P |F |

|Birth or C-section | | | | | |

|Physician Contact Quality Hours: | | | |

|___ In-office assessments | | | |

|___ Bedside rounds | | | |

|___ Formal Class | | | |

|Describe the nature: | | | |

| | | | |

|MOST SIGNIFICANT LEARNING EXPERIENCE |Preceptor’s Name: |

| | |

| |______________________________________________ |

| |NOTE: Dr. Bekemeyer does not need to sign these. |

| | |

The University of Montana - College of Technology - Respiratory Care Program

Student Clinical Rotation Performance Review

Student Name:___________________________ Clinical Institution:_______________________

Date: _______________________ Time Period Covered:______________________

This evaluation form provides a method by which an individual’s clinical performance can be judged with accuracy and uniformity. The evaluator is asked to indicate his/her findings by circling the letter to the corresponding phrase which best describes the student’s work pattern in that area. Ratings of “C” or less require an instructor’s comment in the appropriate section.

EVALUATION CODE: A F

Excellent Failing

Always Seldom

Very much Very little

COGNITIVE: JOB KNOWLEDGE,

PROBLEM-SOLVING 4 3 2 1 0 N/A

1. Learning: Grasps instructions readily. A B C D F N/A

2. Judgment: Makes decisions considering A B C D F N/A

acceptable alternatives.

3. Adaptation of experience: adapts classroom A B C D F N/A

knowledge to clinical situation.

4. Transference of Information: A B C D F N/A

conveys knowledge to staff.

5. Transference of Information: A B C D F N/A

conveys knowledge to patient.

OVERALL PERFORMANCE: COGNITIVE: A B C D F N/A

PSYCHOMOTOR: TASK COMPETENCY

6. Quality of work: Maintains high quality A B C D F N/A

standards.

7. Clinical assignment: Completes work A B C D F N/A

assigned.

8. Use of equipment and supplies: Exercises A B C D F N/A

care in use.

9. Dexterity: Demonstrated proficiency in A B C D F N/A

assembling or setting up equipment.

OVERALL PERFORMANCE: PSYCHOMOTOR A B C D F N/A

AFFECTIVE: ATTITUDE

10. Interest: Motivation A B C D F N/A

11. Tact and courtesy: Tactful and considerate A B C D F N/A

of others.

12. Personal grooming: (only two responses A F N/A

possible) A=Appropriate F=Inappropriate

13. Initiative and responsibility: Supervision not A B C D F N/A

required.

14. Self confidence: Displays confidence to staff. A B C D F N/A

15. Self confidence: Displays confidence to patient. A B C D F N/A

OVERALL PERFORMANCE: AFFECTIVE A B C D F N/A

OVERALL PERFORMANCE A B C D F N/A

(p. 1 of 2)

ATTENDANCE RECORD: MUST BE COMPLETED AT THE END OF EACH ROTATION:

Absent/Tardy Date Time Reason Comment

Called

___________ ____ _____ ___________ ___________________________________________

INSTRUCTOR’S COMMENTS ON OVERALL PERFORMANCE: Include strong points, weak points and suggestions for improvement in clinical performance.

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Signed: ___________________________________________________ Date: _______________________

STUDENT COMMENTS: Include reaction to praise or criticism; include statements which you feel will contribute to more meaningful clinical experience for you. Include areas of improvement.

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Signed: ____________________________________________________ Date: _______________________

Revised: April 2011 (p. 2 of 2)

The University of Montana - College of Technology - Respiratory Care Program

Student Clinical Site Evaluation

Name:______________________________ Clinical Site (be specific) ____________________________

Date: ______________________________ Time Period (at this affiliate) _________________________

This evaluation form provides a method by which clinical sites can be judged with accuracy and uniformity. The student is asked to indicate his/her findings by circling the letter to the corresponding phrase which best describes the rotation. Ratings of “C” or less require comment in the comment section.

EVALUATION CODE: A ------------------------------------------- F

Excellent ---------------------------------- Failing

Always ------------------------------------ Seldom

Very much -------------------------------- Very little

| |A |B |C |D |F |N/A |

|1 |Is shift report orderly, concise, and comprehensive? | | | | | | |

|2 |Are clinical assignments made with student and course objectives in mind? | | | | | | |

|3 |Are assignments clearly made and are you appropriately supervised? | | | | | | |

|4 |Is physician contact helpful and relevant to your learning experience? | | | | | | |

|5 |Is there sufficient time and/or patients to complete performance objectives | | | | | | |

| |during this rotation? | | | | | | |

|6 |Are library resources available in this hospital? | | | | | | |

|7 |Is the clinical evaluation system meaningful and is your clinical competency | | | | | | |

| |periodically discussed with you? | | | | | | |

|8 |Disregarding any personality conflicts, what is your overall (global) | | | | | | |

| |evaluation of your rotation at this clinical site? | | | | | | |

COMMENTS for improvement in areas designated above:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Student Name _________________________________ Date ______________Points ________

(100 possible)

ADULT VENTILATOR CASE STUDY FORM (12 pages) rev. 04/25/11

Case Identifier: ________________, Male ___ Female ___ Age _______ Weight ______ Height _____

Admitting Diagnosis _____________________________ Secondary Diagnosis __________________

I. CLINICAL OBSERVATIONS OF PATIENT (10 pts)

| |First day you care for the patient, or |Current observations or significant changes |

| |admitting data | |

|General Appearance: | | |

| | | |

|Temperature: | | |

|Blood Pressure: | | |

|Breath sounds: | | |

| | | |

|Sputum Characteristics: | | |

| | | |

|Cough: absent, adequate, inadequate | | |

|Breathing Pattern: | | |

| | | |

|Pupils: reactive, non-reactive, unequal | | |

|Skin: pink, pale, mottled, petecia, warm, | | |

|clammy, cool | | |

|Level of Consciousness: | | |

|(Glasgow Coma Scale) | | |

|Other: | | |

II. Baseline ABG (very first) (5 pts): pH ________ PaCO2 _______ PaO2 _______ HCO3 ______

O2 Sat__________FI02 _______ Off Mech. Vent.? _____, On Mech. Vent.? _____ RR = _____

Acid-Base Interpretation: _____________________________________________________________

Oxygenation Interpretation: ________________________________________________________

III. PRIMARY REASON FOR ASSISTED VENTILATION (Your words; based on clinical findings): (5 pts).

_____________________________________________________________________________________

_____________________________________________________________________________________

IV. ASSISTED VENTILATION INFORMATION GATHERING (20 pts.)

Ventilator Brand & Model: ________________________

Type of Airway (ETT, Trach) ______________, size _________, Position at teeth for ETT _____

Initial Ventilator Settings (as apply): Mode: ___________, Volume Control________

Pressure Control _______ Bilevel Pressures: __________, Set breath rate: _______

Set flow if Volume _________, FIO2 _______, PEEP ______, Pressure Support ________

Current Ventilator Settings (as apply): Mode: ___________, Volume Control________

Pressure Control _______ Bilevel Pressures: __________, Set breath rate: _______

Set flow if Volume _________, FIO2 _______, PEEP ______, Pressure Support ________

Current apnea settings: Rate = _______, Volume or Pressure =___________, FIO2 = _______

PEEP = __________, High Press. Limit = ____________

Sigh volumes or pressures = _________________, If sigh breaths are active what frequency? _________

Describe any airway management issues: _________________________________

___________________________________________________________________________

List medications used for sedation or paralysis: ____________________________________

_________________________________________________________________________

What humidification system is being used? _______________________________________

Issues or concerns with the humidification system? ______________________________

If patient requires chest tubes, why? _________________________________________

______________________________________________________________________

Intracranial pressures : ________________________, What, if any, orders are in place for

excessive ICP’s ____________________________________________________________

Other monitors or ventilator settings of interest: ________________________________

Subsequent Ventilator Management Decisions/Setting Changes/Observations ( limit to 5):

|Mode change. |Rate change. |Flow change. |FIO2 change. |PEEP change. |Pressure Support change. |

|Reason & result |Reason & result |Reason & result |Reason & result |Reason & result |Reason & result |

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V. VENTILATOR GRAPHICS (remember, you can adjust scalars to aid your viewing) (8 pts)

Sketch some Pressure-Time waves for this patient:

If peak pressures periodically vary explain why: ______________________________

Explain any adjunstments made based on P-T waves: ________________________

Sketch some Flow-Time waves for this patient:

If flows vary from breath to breath or periodically explain why: __________________

Explain any adjustments made based on F-T waves: ____________________________

Sketch some Volume-Time waves for this patient:

Explain any adjustments made based on V-T waves: _____________________________

________________________________________________________________________

Of the waveforms above (Pressure, Flow, Volume) explain which you would monitor for system leaks:

_____________________________________________________________________________

Sketch some Pressure-Volume loops for this patient (ideally pre & post bronchodilator if possible):

Generally, what do the P-V loops indicate to you about:

Overdistention __________________________________________________

Air trapping ____________________________________________________

Compliance _____________________________________________________

Explain any adjustments or therapies based on the P-V loops: __________________

VI. LUNG/THORAX COMPLIANCE (6 pts)

Briefly describe the lung/thorax compliance of your patient and values if you can get them:_____

_____________________________________________________________________________

If compliance is high what ventilator settings are used to reduced the incidence of air trapping?

________________________________________________________________________________

________________________________________________________________________________

If compliane is low, describe lung protective strategies in use: (ARDS Net protocols, settings, meds):

______________________________________________________________________________

_______________________________________________________________________________

VII. AIRWAY RESISTANCE (4 pts)

Describe airway resistance issues and values if you can get them: ___________________

______________________________________________________________________________

What ventilator settings & therapies are in place to optimize airway resistance?

______________________________________________________________________________

_______________________________________________________________________________

VIII. BRIEF MEDICAL HISTORY & PHYSICAL From Nursing & MD notes or Admission Profile: (4 pts)

Medical History (from nursing or physician or admission profile:

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_____________________________________________________________________________________________

____________________________________________________________________________________________

Physical Exam (from nursing or physician or admission profile):

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_____________________________________________________________________________________________

_____________________________________________________________________________________________

____________________________________________________________________________________________

Space for additional information as desired:

IX. LABORATORY FINDINGS (15 pts)

| |Initial findings |Normal Values/Ranges |Most Recent Findings |

|Sputum cultures | | | |

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|Red Blood Cells | | | |

|Hemoblobin (Hb) | | | |

|Hematocrit (HCT) | | | |

| PTT | | | |

|WBC: Neutrophils | | | |

|WBC: Eosinophils | | | |

|Platelet Count | | | |

|Sodium (Na+) | | | |

|Potassium (K+) | | | |

|Chloride (Cl-) | | | |

|Magnesium | | | |

|Iron | | | |

|Calcium | | | |

|Phosphate | | | |

|Urinalysis | | | |

|Urine Output - or check | | | |

|nursing I & O sheet | | | |

|Blood Urea Nitrogen | | | |

|Createnine or clearance rate | | | |

|Albumin | | | |

|Glucose | | | |

|Basal Energy Expenditure (BEE) | | | |

|Bilirubin | | | |

|Liver Function Tests: | | | |

|MI Indicators: CKI | | | |

|Troponin | | | |

X. ABG Correlation to Ventilation.(Limit to 5 most significant or recent) (15 pts)

|pH |PaCO2 |PaO2 |Vent mode & set |Spontaneous resp.|FIO2 |PEEP/ | Acid Base + Oxygenation |

| | | |rate |rate | |CPAP |Interpretations. |

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XI. DEAD SPACE TO TIDAL VOLUME (Vd/Vt) If ETCO2 monitoring is available and patient is on volume or pressure control (fairly consistent tidal volumes). (6 pts)

Show your calculations & result for the patient’s Vd/Vt: _________________

Normal valaues (%) ____________ vs. Your ventilator patient’s (%) _______________

XII. CHEST X RAYS IN RELATIONSHIP TO PATIENT PROGRESS (10 pts)

(Interpret at least 3, if available: Example: on admission, after placement on vent; most recently)

Film A:

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XIII. CARDIOVASCULAR SYSTEM (15 pts)

| |Current Patient Values |Normal Values/Ranges |Reasons for abnomals |

|EKG: Rate & rhythm, | | | |

|abnormalities | | | |

|Blood Pressure (BP) | | | |

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|Mean Arterial Pressure (MAP) | | | |

|Central Venous Pressure (CVP) | | | |

|Pulmonary Artery Pressure | | | |

|(PAP) | | | |

|Pulmonary CapillaryWedge Pressure | | | |

|(PCWP) | | | |

|Cardiac Index (CI) (accounts for body | | | |

|mass) | | | |

XIV. MEDICATIONS OTHER THAN RESPIRATORY (you’ll do those later), limit to 7 (sedatives, paralytics, pressors, cardiac, antibiotics, peptic ulcer prophylaxis, etc): (10 pts)

|Medication |Indications |Actions |

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XV. Spontaneous Ventilatory Parameters & Weaning Assessment (15 pts).

| |Actual Patient Values |Predicted or Normal Values |

|PaO2/FIO2 Index | | |

|Neg Insp. Pressure (NIP) | | |

|Resp. Rate | | |

|Minute Ventilation | | |

|Tidal Volume (average) | | |

|Vital Capacity (VC) | | |

|Rapid Shallow Breathing Index RSBI | | |

If T-Piece or other method of weaning trial was conducted how did patient tolerate it?

___________________________________________________________________________________

T-piece/weaning trial ABGs (if done): pH = ___________, PaCO2 = ________ PaO2 = _________,

Acid/Base interpretation: _________________________________________________

Oxygenation interpretation: ________________________________________________

Was patient successfully extubated or not? (explain) ____________________________

XVI. RESPIRATORY THERAPY ORDERS: Include all types of respiratory related, i.e. aerosols, chest physio therapy, special suctioning orders, up in chair & T-pieced 30 min QID, etc. (10 pts)

|Therapy Ordered & Frequency |Why was this therapy ordered? (indicators of need) |

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XVII. RESPIRATORY THERAPY MEDICATIONS: (10 pts)

|Medication, dose, & frequency |Indications for this patient. |Any side effects noted?|How is it affecting patient outcome? |

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XVIII. Briefly discuss any surveillance methods that may have been conducted to detect nosocomial pneumonia (VAPS), during your patient’s intubation period. Describe techniques and results:

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

XIX. Describe methods used to reduce the incidence of nosocomial pneumonia (VAPS) on your patient:

_____________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

XX. Describe any methods to reduced the incidence of deep vein thrombosis during your patient’s course on mechanical ventilation.

______________________________________________________________________________________

______________________________________________________________________________________

_______________________________________________________________________________________

XXI.. Synopsis of your patient’s progress in light of ventilator settings in conjunction with ABG’s, vital

signs, lab reports, medications, weaning parameters, etc. What meds or therapies were most & least effective? How did your patient respond to ICU? Include a prognosis or outcome. (10 pts)

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|XXII. Conclusions & Significant Learning (10 pts) |

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The University of Montana- College of Technology

Respiratory Care Program

Student Clinical Adjunct Evaluation Form

Name:______________________________ Adjunct Name:___ ________________________________

Date: ______________________________ Time Period with this adjunct: ________________________

This evaluation form provides a method by which clinical adjuncts can be judged with accuracy and uniformity. The student is asked to indicate their findings by circling a letter grade corresponding phrase which best describes the individual. Ratings of “C” or less require comment in the comment section. Attach additional pages as necessary.

EVALUATION CODE: A ------------------------------------------- F

Excellent ---------------------------------- Failing

Always ------------------------------------ Seldom

Very much -------------------------------- Very little

| |A |B |C |D |F |N/A |

|1 |Do they give clear and concise directions? | | | | | | |

|2 |Is the adjunct enthusiatsic about having students? | | | | | | |

|3 |Is your confidence encouraged by this adjunct? | | | | | | |

|4 |Does this adjunct create an environment condusive to learning? | | | | | | |

|5 |Do you feel the adjunct shares information effectively for the purpose of | | | | | | |

| |learning? | | | | | | |

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|6 |Do they readily provide explanation and clarification? | | | | | | |

|7 |Do they foster foster Bi-directional communication? | | | | | | |

|8 |Disregarding any personality conflicts, what is your overallassessment of | | | | | | |

| |your experience with this adjunct? | | | | | | |

COMMENTS for improvement in areas designated above:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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