1. VENTILATOR AND SCI TRAINING

2. Payment of Expenses
Please note that to claim for any travel expenses you must:
Please make sure that you sign in. This sheet triggers your certificate and is also verification of your attendance for your payment for today, as well as your intention to claim expenses.
Please list today's training on your time sheet as “Ventilator and SCI Training in the community” and state where this training took place.
Send in with your time sheet a completed expenses sheet (provided here today) with a valid receipt.
Failure to do both of these may result in a delay in your payment or not receiving payment at all.

3. What is mechanical ventilation?
Short term or long term
Invasive (trachy) or non-invasive (face mask)?
Used by those with neuro-muscular diseases, spinal injury (C4), polio, emphysema or chronic bronchitis
Sometimes used just overnight
Often first used in ICU.
Ventilators in the community are often smaller, light weight and portable with an external battery.
A ventilator can take over the act of breathing completely or make breathing easier by assisting weakened respiratory muscles.

4. Daily Checks of Ventilator
Tidal Volume
Rate of breath given per minute
Setting of low pressure alarm
Setting of high pressure alarm
I/E Ratio (Airway Pressure)
Power source

5. Spinal Cord Injury - Causes

6. Spinal column anatomy

7. TRACHEOSTOMY CARE What is a Tracheostomy?
Different types of Trachy tubes
Essential safety Equipment.
Changing the inner tube.
Changing the tape and dressing.
Infection and action.
Changing the whole tracheostomy. 7

8. What is a Tracheostomy?
It is a surgical opening in the windpipe between the 3rd and 4th tracheal rings into which a tube is inserted. 8

9. Different Types of Trachy tubes
1. Plastic tube
2. Metal tube
3. Silicone Tube
4. Fenestrated tube (helps with speech)
5. Cuffed tube, to initially keep in place

10. Essential Safety Equipment
Ambu Bag
2x tracheostomy tubes. 1 same, 1one size smaller.
spare inner (if used)
Dressing
Tube holder
Lubricant gel
Syringe (if cuffed)
Gloves
Hand gel
Suction catheters
Extension lead
Supra pubic catheter and equipment 10

11. Changing the inner tube
One person.
Is the emergency equipment checked and nearby?
Disconnect ventilator, rest on clean gauze.
Wear gloves, hold the flange of the trachy firmly while removing the inner tube.
If clean reinsert, if soiled insert new inner.
Immediately reconnect ventilator.
Clean soiled inner and store in clean dry container.
Dispose of all waste appropriately (is the inner tube to be kept as a spare)

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

13. Changing the holder and dressing
Two people, one person should hold the tube and observe the client.
Prepare all equipment before you start
Is the emergency equipment checked and nearby?
Wear gloves, remove the old dressing and holder.
Change gloves, clean the site, replace dressing and holder.
Dispose of all waste appropriately.

14. SIGNS of INFECTION at the trachy site
Redness
Wet appearance
Odour from site or dressing
Soreness
Skin breakdown
Temperature
Pain 14

15. Tracheostomy Site Infected
ACTION
Swab if available and know how.
Change dressing as/when becomes soiled.
Any other signs?
Document.
Communicate.
If persists – contact GP 15

16. Suctioning – WHY and WHEN?
To keep the airway clear of secretions.
Reduce the risk of airway blockage.
Reduce the risk of infection.
Dependent on need
Client ability to cough.
Amount and consistency of secretions

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

18. Suctioning - How
Open catheter enough to attach to tubing remove some plastic covering
Switch on machine (listen)
Wear gloves
Use one hand to hold suction catheter, do not let it touch anything
Use other hand to access the trachy
Pass the catheter to approx 1/3rd length/ feel resistance. Pull back 1cm.
Apply suction and slowly remove (no more than 15secs) unless client can breathe
Reconnect ventilator (ask client, remove catheter mount and listen)
Watch for signs of respiratory distress
Observe colour/amount/consistency of sputum. (plugs)
Document, report any changes 18

19. Suctioning- Complications
Damage to delicate lining of trachea and lungs. (check for blood)
Lack of oxygen.
Infection.
Bronchial spasm.
Increased secretions.
Consider assisted cough

20. Alternative to Suctioning – Assisted Cough
If your cough is weak you can have an assisted cough:
Place the heel of one hand on your client’s abdomen just above the navel.
Place the second hand on top of the first hand with straight elbows.
The client takes a deep breath.
Push upwards and under the client’s ribs at the same time the client attempts to cough.
Make sure:
If client is in wheelchair, the brakes are on.
Client is not pregnant.
Client has not recently eaten.

21. Humidification Why? How?
Tracheostomy bypasses the nose which warms and moistens air breathed in.
Cold dry air causes lung damage and dries secretions which then become sticky and thick. This can cause tube blockage (plugs).
HME (heat and moisture exchanger) filter in ventilator circuit.
‘Wet’ system, water is warmed by a machine and humidified air fed into the ventilator circuit.
How?

22. ALARMS- know what to do. Alarms are there to warn you of a problem
Do not silence them unless you are doing something to rectify the problem.
By understanding how the ventilator is supporting the client you can take the right action if an alarm sounds.
If there is a continuing problem, report immediately.
Alarm setting should be reviewed by the medical team when the client goes for a review. Check to see if they have been changed.
The humidifier also has alarms it will show where problem is 22

23. Ventilator Alarms Power disconnect.
High pressure- usually means some obstruction. Tube kinked/trapped. Trachy blocked. Check tubing for kinks, check trachy not blocked.
Low pressure. Usually means break in the circuit. Check all tubing for connections. 23

24. Manual Inflation (Bagging)
Used to inflate the lungs temporarily whilst the ventilator is disconnected.
1) If ventilator fails.
2) When changing over the tubing.
3) When it is not safe/practical to use ventilator (eg in the shower).
Used to over inflate the lungs to help to move thick sputum. (imitates cough). 24

25. Problems with Bagging Over inflating lungs can cause damage.
Under inflation causes lower oxygen levels and build up of carbon dioxide.
Too fast and you can remove too much carbon dioxide.
Too slow and you can reduce oxygen levels.
DO NOT force air, there maybe a blockage which needs clearing. 25

26. Tips for Bagging To aid secretion removal Large in breath.
Release quickly to mimic cough.
10 maximum then reconnect ventilator and suction.
Whilst disconnected from ventilator
Match rate with usual ventilator setting [in time with your own breathing rate]
Smooth in breath.
Allow time to breath out.
Keep time bagging to a minimum. 26

27. Safety-Precautions for ventilator
Spare ventilator- battery charged and checked.
Spare battery.
Know your alarms and how to solve problems.
Know the engineer number, check when service is due.
Shift/daily checks.
Always report and document problems. 27

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

29. Four Stages of Pressure Sores
What to Look For
1. Your skin looks lighter than usual. 2. Area of skin looks redder all the time, feels warm, maybe swollen. 3. Blister develops, bluish tinge, blister might open up. 4. Centre of blister turns black/brown, may be discharge.

30. Four Stages of Pressure Sores
What to Do/Other Information
1. Stay off, pressure is stopping your blood supply e.g. if you hold a glass tightly fingertips go lighter.
2. Stay off the area, DO NOT RUB, make sure redness goes after 30 minutes without pressure.
3. Stay off, SEE DOCTOR ASAP, there may be more damage to the skin than you can actually see.
4. Stay off, COVER WITH STERILE DRESSING, see Doctor, eat food with protein, damage has gone very deep, skin infected, discharge means body is losing protein.

31. Spinal Cord Injury Prevention of skin problems Observation/recording
Pressure relief
Equipment
Hygiene
Diet/Nutrition
Clothing [seams on trousers]
checking groin area for men
Emphasis on monitoring – twice daily checks am and pm WILL prevent skin damage.
Show group blanching on hand to describe pink/ darkened skin marks.
Demonstrate participation in leaning forward in chair to evidence removal of pressure from ischium
Equipment – cushions, mattresses and their uses etc 31

32. Spinal Cord Injury Bladder Management
Risks
No sensation
No voluntary void
Risk of kidney problems, stones
Risk of infection
Types of bladder management
Supra Pubic
Intermittent catheters
Urethral Indwelling
Conveen
Draw macro structure of the urinary system and “ normal” function. I usually relate it to pre toilet trained children in terms of the bladder and brain relationship!
Discuss use or not! Of antibiotics for infection 32

33. Changing the suprapubic catheter
two people, (although one in emergency) one removing old catheter the other inserting new one. Firstly both glove up.
Remove water from catheter’s balloon (up to 10 mls) using a syringe.
Remove suprapubic catheter
Replace suprapubic catheter (check date)
Refill balloon with water from a syringe.
Attach leg bag, check draining properly.

34. Spinal cord injury Autonomic dysreflexia
An emergency situation that arises due to an exaggerated sympathetic response to a noxious (painful) stimulus.
This only occurs in injuries above T6
Signs
Pounding headache
Flushed or blotchy skin above level of injury
Nasal congestion
Blurred vision
Anxiety/Panic

35. Spinal Cord Injury Autonomic Dysreflexia Causes PAIN/IRRITATION
Distended bladder
Distended bowel
Infection
Trauma
Ingrowing toe nail

36. Spinal Cord Injury Action Sit upright Identify cause Bladder Bowels
General check
Nifedipine?
999

37. Muscle Spasms
After a SCI, nerve cells below the level of injury become disconnected from the brain.
In an able-bodied person the brain stops most natural reflex actions.
When there is no connection these actions cannot be stopped.
Factors which make spasms worse –
Bladder infection
Kidney infection
Skin breakdown
Drugs used to combat spasms
Baclofen (pump), Valium and Dantrium

38. Wheelchair Safety Checks brakes are on or if electric, power is off
If pushing wheelchair beware of going up slope of 1:12 as wheelchair may overbalance backward
If pushing wheelchair you may find it easier to reverse down curbs (Occupant may slide out of chair)

39. Wheelchair Etiquette treat them as a person
When talking for more than a few moments to someone in a wheelchair try to put yourself at their eye level to avoid stiff necks. Try not to talk over the person in a wheelchair.
if going to a venue check, suitable parking, entrance, toilets, lifts
Scout ahead to see if they can Get to where get get to where they want to go
Do not lean on the wheelchair.
treat them as a person

40. Complications for people with spinal cord injuries
Reduce temperature control
Possible skin conditions
Pressure sores
Blood pressure problems
Diabetes
Phantom pain
Autonomic dysreflexia

41. Ventilator and SCI Training
Bowel Management
What is the bowel and what does it do?
The bowel is the last portion of your digestive tract (the large intestine or colon)
The function is to take food into the body and to get rid of waste.
The bowel is where the waste products of eating are stored until they are emptied from the body in the form of a bowel movement (stool, faeces).
A bowel movement happens when the rectum becomes full and the muscle around the anus opens.

42. Bowel Management What stops normal bowel function?
Spinal Cord Injury Higher Breaks
Brain Injury
Physical Illness (MND, MS)
Immobility
What stops normal bowel function?

43. Bowel Management Methods for emptying the bowel: Manual Removal
Digital Stimulation
Suppository
Mini-Enema

44. Previous bowel history
Bowel Management
Factors that can affect success
Previous bowel history
Timing
Privacy and Comfort
Emotional Stress
Positioning
Fluids
Food

45. Bowel Management What to avoid Using more than one finger
Bending finger
Rushing
More than Four Digital Stimulations at a Time
Long fingernails

46. Manual handling back problems Some Statistics
On any one working day, there are over 90,000 people off work with back problems.
5.5 million working days are lost in Britain ever year as a result of a manual handling back injury.
Absence from work due to back pain costs the UK £365 million per year.
30% of all back injuries in the workplace are caused by, or related to, lifting, handling or load carrying.

47. WEIGHT GUIDANCE FOR LIFTING
Moving and Handling regulations state:
Male = 25kg
Female = 16kg
HOWEVER PERSON HANDLING!!??
No Weight is safe

48. BIOMECHANICS Keep the load close to your body.
Use your leg muscles to lift not your back muscles.
Keep your back straight and your legs/knees bent.
Point your feet in the direction you want to travel.

49. Principles of Safer Handling
COMMUNICATION:
Try to obtain clients consent.
(dependent on clients cognitive ability)
Good communication between carers and client.
Timing of the move, give clear instructions.
The count of should not be used.
Better to use READY STEADY MOVE.
Decide who will be the lift leader,

50. Principles of Safer Handling
DYNAMIC STABLE BASE;
Think Triangle! Can not be pushed over easily.
Weight is evenly distributed.
Will allow you to transfer weight between your feet.
Avoid putting your nose
over your toes!

51. Principles of Safer Handling
KEEPING THE LOAD CLOSE TO YOUR
BODY:
Keep your elbows close to your body as possible.
This helps stabilise your shoulders, which will also help you transfer your weight through your legs
You will use the POWER MUSCLES, this will also reduce twisting movements.
Load is closer to your body giving you more control of the load.
Keep your chin up, good for your neck

52. The LOAD is the person you are moving.
Have they been hoisted before?
Do they know why they need to move?
Have you got consent
Can they weight bear?
What happens when you get them on their feet?
RISK ASSESSMENT
AVOID
ASSESS
REDUCE
REVIEW

53. EXISTING CONTROL MEASURES
Overhead track hoists.
Mobile hoists.
Profiling beds.
Wheelchairs.
Slide sheets.
Transfer boards and turntables.
Using equipment will not save you time but it will save your back!!!!
It is your responsibility not to take on any task that you think may harm you or your client!!!!
SAVE YOUR BACK YOU ONLY GET ONE!!!

54. Administering Medicine Legal Requirement
The Medicines Act (1968)
This was the first comprehensive legislation on medicines in the UK. It provides the legal framework for the manufacture, licensing, prescription, supply and administration of medicines.
The Medicines Act (1998)
“In the United Kingdom, anyone can legally administer prescribed medicine to another person. This includes prescription only medication (POM) and controlled drugs (CD). The administration must only be in accordance with the prescriber’s directions (except in the case of injections)” (The Medicines Act 1998) (UKHCA (2006), Social Care inspection (2005),

55. Providing Support With Medication
Staff should only provide assistance with medication when it is within their competence to do so and they have received any necessary specialist training.
Assistance should only be provided with the informed consent of the client or their relatives if they have a legal standing to do so, or through litigation, friend(s).
If it is clearly requested on the care plan by a named assessor.
It is with the agreement of the carer or support worker’s line manager and is not contrary to the company policy.

56. Side Effects of the Most Commonly Used Medicines
What is a side effect?
A side effect is an unwanted reaction of the body to the toxicity of the medicine.
Some side effects diminish after a period of time
It is important to recognise side-effects in order that your client may receive appropriate intervention/reassurance
Antibiotics:-
Diarrhoea
Constipation
Abdominal Cramps
Rashes
Unusual tastes
Urine colour
Analgesics:-
Constipation
Liver damage for
overdose
Headaches
Dry mouth
Antidepressants:-
Euphoria
Agitation
Abdominal
discomfort
Dry mouth
Nausea
Sedatives:-
Blurred vision
Lethargy
Drowsiness
Tremor
Slower
heart

57. Administration of Medicines Five Rights of Administration
Right - Patient/Client
Right - Time
Right - Route
Right - Medicine
Right - Dose

58. Administration of Medicine
Ensure the five rights are adhered to.
Check medicine not been given.
Ensure client condition is conducive to receiving the medication.
Ensure labels are clear on medicine bottles.
Check medicine is in date
Hygiene
Water
Ensure medicine taken
Sign

59. Do you have any questions?
finish