Comprehensive Weekly Narratives

Paige Suroviak

Baptist College of Health Sciences

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Site: Baptist Desoto

Date: Sunday, 02/25/2018
Shift: 0626-1503
Total hours: 8.37

3.Demonstrate knowledge and skills associated with airway management techniques to include;
intubation, extubation, and tracheostomy care for the purpose of maintain airway patency.
4.Assess and critique problematic scenarios involving the patient’s condition on the basis of specific
standards and criteria.

For my initial shift at Baptist Desoto I did not expect to be all over the place, especially on a
Sunday. At 0800 a code blue was called in the Cath lab on the second floor of the hospital and Dr.
Dooley tried to intubate the patient. With a mac 4, he had an unsuccessful intubation, I assisted the
doctor by suctioning the blood and secretions from the patient’s mouth and manually bagging the
patient while he decided what to do next. Shinerica brought a glide scope to help with Dr. Dooley’s next
attempt at intubating the patient. While looking at the glide scope screen, Dr. Dooley was able to
visualize the patient’s swollen vocal cords and was not able to pass the ETT through them due to how
swollen they were. After bagging and suctioning for Dr. Dooley again he decided to put an LMA in until a
CRNA or anesthesiologist was able to arrive to the scene. Finally, out of the Cath lab and at 1115 then
anesthesiologist, Dr. Reed, arrived. She herself had a difficult time intubating the patient, but finally on
her third attempt and with the assistance of Dr. Dooley and a bronchoscope, she placed a size 7.5 ETT in
the patient nasally. On this day knowledge was reinforced on attempting to intubate patients with
minimal neck movement. Dr. Dooley tried to insert the LMA the second time when we arrived to the
floor which is ideal for patients with stiff necks. Due to her swollen airway, both Dr. Dooley and Dr. Reed
were successful by guiding the ETT through the nare with assist from the bronchoscope.
Site: Baptist Desoto
Date: Wednesday 02/28/2018
Shift: 0629-1858
Total hours: 12.29

1.Demonstrate knowledge of diagnostic techniques to include; hemodynamics, arterial line sampling,

and bronchoscopy assisting.
4.Assess and critique problematic scenarios involving the patient’s condition on the basis of specific
standards and criteria.

On Wednesday 02/28/18 my preceptor and I were scheduled to work the shift in the ER.
Throughout, the whole day was fairly busy assessing patient’s work of breathing and administering
aerosol treatments to those in need. While responding to a page from a doctor to obtain an arterial
blood gas on a patient who had just came in, it was clear to see that the patient was using accessory
muscles to breathe and was becoming lethargic. I performed the arterial blood gas on the patient and
ran the results. PH 7.23 cO2 73 paO2 70 HcO3 24.6. The patient had uncompensated respiratory acidosis
with mild hypoxemia. After showing the results to the attending physician in the ER, she recommended
that we placed the patient on BiPAP and allowed us to choose the initial settings. We placed the patient
on an IPAP of 15, EPAP of 10, Rate of 12, and FiO2 of 100%. By assessing the patient, actually looking to
see what she was doing and if he was working to take a breath we were able to tell then that he needed
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more support than just a non-rebreather mask. The ABG proved to assumptions correct and we made
the right decision by putting him on BiPAP.
Site: Baptist Desoto
Date: Thursday 03/01/18
Shift: 0629-1900
Total hours: 12.32
1.Interpret mechanical ventilator parameters for the purpose of assessing the patient’s response to
mechanical ventilation and recommend appropriate changes.
3.Assess and critique problematic scenarios involving the patient’s condition on the basis of specific
standards and criteria.

During this shift there was a particular situation that stood out that really prompted an
educating moment. Around the end of the shift (about 1810) a patient’s ventilator alarm sounded. Upon
entering the room, I quickly looked at the patient and then checked to see which of the alarms were
sounding. The patient’s FiO2 was set to 40% but the “increased O2” alarm was going off and with further
assessment of the ventilator, it showed that the patient was actually receiving 50% O2. We checked the
quick connects to the circuit, both the oxygen and the room air, to make sure they were securely locked
in the wall. Since the oxygen and air lines were both secured, we made an alternative decision to replace
the ventilator to ensure that the patient received the correct amount of oxygen that the physician
ordered. Since this was an alarm that I had not seen before I was able to learn from Latoyia and
Shinerica as they showed me how to navigate to see how much oxygen percentage the patient is
actually getting.
Site: Baptist Desoto
Date: Monday 03/05/18
Shift: Monday 0634-1936
Total hours: 12.32

1.Demonstrate knowledge of diagnostic techniques to include; hemodynamics, arterial line sampling,

and bronchoscopy assisting.
3.Demonstrate knowledge and skills associated with airway management techniques to include;
intubation, extubation, and tracheostomy care for the purpose of maintain airway patency.

The south side of the ICU at Baptist Desoto is considered the CVICU and this is where all of the
post heart surgery patients reside. On this day we had three hearts that were to return to the unit.
Typically, the heart patients (if they have a good/ stable heart) only stay on the ventilator for about 3-4
hours before being extubated. After 30 minutes of the patient being on the ventilator, I was able to
successfully draw an arterial line sample to see if we were able to do a CPAP trial. The arterial blood gas
report was within normal limits for my preceptor and I to put the patient in a spontaneous mode trial.
After another 30 minutes in the spontaneous mode, I was able to perform a maximal inspiratory
pressure and forced vital capacity measurement to see if we could extubate the patient. The patient
performed a NIF of -32 and a FVC of 426 mL, since both these are within limits for extubation I drew one
more arterial line sample to ensure that the patient was in stable condition. Once the results came back
and were within normal limits, I was able to extubate the patient and put him on a nasal cannula at 6
liters per hospital protocol. I was unaware that the heart patients at Baptist Desoto were only
mechanically ventilated for 3-4 hours before they were extubated. On this day knowledge was
reinforced about spontaneous parameters to include the values needed for MIP and FVC for a patient to
be extubated. Though Baptist Desoto does not have all of the equipment to perform a maximal
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inspiratory pressure and a forced vital capacity manually, I learned that these can be done through the
ventilator.

Site: Baptist Desoto

Date: Tuesday, 03/06/18
Shift: 0629- 1649
Total Hours: 12.20

2.Interpret mechanical ventilator parameters for the purpose of assessing the patient’s response to
mechanical ventilation and recommend appropriate changes.
4.Assess and critique problematic scenarios involving the patient’s condition on the basis of specific
standards and criteria.

During this shift, we had a mechanically ventilated patient that was intubated and brought to
the hospital overnight. Usually it is Baptist Desoto’s hospital protocol to wait 24 hours before doing a
spontaneous breathing trail on a patient. Since Dr. Henderson was at the hospital at night when the
patient arrived, and was still at the hospital throughout the day, he opted to do a CPAP trial on the
patient. When I communicated with the nurse, she stated that she had cut the patient’s sedation in half.
The patient did respond to verbal commands but still seemed to be in a lethargic state but my preceptor
for the day suggested to still do the trial. As soon I switched the patient from her VC/AC rate of 14, the
patient did not take a breath and the apneic settings initiated within 20 seconds. I immediately put the
patient back in her regular mechanical ventilator settings and notified my preceptor and the nurse. This
reinforced knowledge of ensuring that the patient is fully awake and alert before performing a
spontaneous breathing trial. An hour afterwards the patient was awake watching television in her bed
so we switched her over to spontaneous mode and she passed her trial.

Site: Baptist Desoto

Date: Wednesday, 03/07/18
Shift: 0630- 1853
Total Hours: 12.23

1.Demonstrate knowledge of diagnostic techniques to include; hemodynamics, arterial line sampling,

and bronchoscopy assisting.
4.Assess and critique problematic scenarios involving the patient’s condition on the basis of specific
standards and criteria.

At the end of first rounds on this shift, we received a phone call from the nurse asking for a
blood gas on a patient in 402. When we arrived to draw the blood, the patient was on a non-rebreather
mask with an SpO2 of 91 and was using accessory muscle to breathe. The patient asked to be put back
on his home CPAP that he uses at night, so my preceptor and I plugged his home CPAP in and placed it
on 6 liters on the flow meter. We drew an arterial blood gas from the patient’s left radial artery and
tested to see the results. The patient’s pH was 7.39, CaO2 was 37, HCO3 was 22.4, and PaO2 was 68. I
made the suggestion to place the patient on a high flow nasal cannula at 15 liters and 100% to give him
extra flow and to increase his oxygen. After putting him on the high flow, the patient’s SpO2 came up to
98 and his work of breathing decreased. During this, my preceptor tested my knowledge by asking me
what I would recommend that would best help this patient.
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Site: Baptist Desoto

Date: Saturday, 03/10/18
Shift: 0634-1847
Total Hours: 12.13

1.Demonstrate knowledge of diagnostic techniques to include; hemodynamics, arterial line sampling,

and bronchoscopy assisting.
2.Interpret mechanical ventilator parameters for the purpose of assessing the patient’s response to
mechanical ventilation and recommend appropriate changes.

Around 10:30 in the morning for this shift, Dr. Sheikh decided that we were going to intubate a
patient that was on Bi-PAP and still had increased work of breathing on the machine. As soon as we got
her intubated and placed her on the mechanical ventilator she started to cough, had increased peak
pressures, and the ventilator started to autocycle several times in a row. To try to decrease the peak
pressures, we suctioned the patient and found a thick glob of dark brown colored secretions come up
the tube. Dr. Sheikh then decided that we perform a bronchoscopy on the patient to obtain a sample of
the specimen and send it to be cultured. While performing the bronch, we found that the patient had
several mucous plugs that had seemed to have dried in airways. We flushed the lungs several times with
saline to try to loosen some of the mucous, and finally (after an hour) were able to relieve most of the
plugs in the airways. During this time with Dr. Sheikh I was able to reiterate knowledge from
bronchoscopy assisting. I assisted him by setting up the bronch cart for him, getting suction ready,
changing my ventilator parameters, and flushing the saline in the scope as well as manually removing
secretions that were plugged in the scope.

Site: Baptist Desoto

Date: Sunday, 03/11/18
Shift: 0631- 1851
Total Hours: 12.20

1.Demonstrate knowledge of diagnostic techniques to include; hemodynamics, arterial line sampling,

and bronchoscopy assisting.
2.Interpret mechanical ventilator parameters for the purpose of assessing the patient’s response to
mechanical ventilation and recommend appropriate changes.
3.Demonstrate knowledge and skills associated with airway management techniques to include;
intubation, extubation, and tracheostomy care for the purpose of maintain airway patency.
4.Assess and critique problematic scenarios involving the patient’s condition on the basis of specific
standards and criteria.

During this shift, all of the objectives were covered while interacting with Dr. Sheikh. One of my
patient’s that was on Bi-PAP, Dr. Sheikh wanted to intubate due to her increased work of breathing and
the severity of sepsis in her body. I assisted him with the intubation by getting the airway kit, setting
everything up for him, bagging the patient, and applying suction before he inserted the ETT. After the
patient was intubated, Dr. Sheikh ordered and ABG that I drew from the patient’s art line and supplied
him with the results. All of the patient’s values were within normal range, but the PaO2 was 208 so we
decreased her O2 from 60% to 40%. Interpreting the results of the ABG, I reiterated knowledge about
hyperoxia and how to correct the problem at hand by decreasing the patient’s set FiO2.
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Site: Baptist Desoto

Date: Wednesday, 03/14/2018
Shift: 0633- 1853
Total Hours: 12.20

1.Demonstrate knowledge of diagnostic techniques to include; hemodynamics, arterial line sampling,

and bronchoscopy assisting.
4.Assess and critique problematic scenarios involving the patient’s condition on the basis of specific
standards and criteria.

At the start of this shift, a patient that I was caring for was on a venturi-mask set at 12 liters and
40 percent FiO2. During first rounds she had a breathing treatment ordered so I assessed her to see how
she looked. Upon assessment she seemed to have been in a lethargic state, she would raise her head
and follow commands if asked to but seemed really fatigued. Dr. Okpor ordered an arterial blood gas for
me to draw to further assess the patient’s condition. pH 7.47, PaCO2 27, PaO2 61, and HCO3 19.7. The
patient was in a respiratory alkalotic state with mild hypoxemia. My preceptor asked what I would
recommend upon showing Dr. Okpor the ABG results, I recommend we place the patient on a high flow
nasal cannula to increase her PaO2 and he agreed. Upon placing the patient on the high flow nasal
cannula, her SpO2 immediately increased. This interaction reiterated knowledge pertaining to oxygen
therapy, as well as knowledge upon obtaining an arterial blood gas and analyzing the results.

Site: Baptist Desoto

Date: Wednesday, 03/15/2018
Shift: 0633- 1509
Total Hours: 8.36

4.Assess and critique problematic scenarios involving the patient’s condition on the basis of specific
standards and criteria.

During the start of this shift we had two patients who received QID DUO-NEB treatments via
small volume nebulizer (SVN). Upon assessing the patients and looking at their chest x-rays, we found
that these two patients would benefit from receiving the Metaneb as compared to a regular SVN
treatment. We found the attending physician, Dr. Okpor, and told him that we would like to implement
this therapy on the patients and he agreed that we could change the order. Upon performing the
Metaneb, my preceptor walked me through how the treatment should be performed on the first patient
and let me set everything up and apply the therapy to the second patient. By her doing this, she helped
walk me through the first therapy, but allowed me to assert the knowledge I gained upon applying the
second therapy. There was a notable difference in the before and after breath sounds of the treatment,
further treatment and x-rays will show the improvement with the Metaneb.
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Site: Baptist Desoto

Date: Tuesday, 03/20/2018
Shift: 0632- 1857
Total Hours: 12. 25

1.Demonstrate knowledge of diagnostic techniques to include; hemodynamics, arterial line sampling,

and bronchoscopy assisting.
2.Interpret mechanical ventilator parameters for the purpose of assessing the patient’s response to
mechanical ventilation and recommend appropriate changes.

On this day at Baptist Desoto, while my preceptor was with me as I just finished my last
breathing treatment for second rounds, another therapist called and asked if I would like to stick an
arterial blood gas. The mechanically ventilated patient had been in a spontaneous breathing trial for a
couple hours and Dr. Wollak ordered an arterial gas on him to see if we could extubate. I was able to
obtain an arterial blood gas sample on the first stick, we immediately ran the sample and the results
came back and all the values were within normal range. We showed Dr. Wollak the results of the blood
gas and he put an order in to extubate the patient. Since this was not my patient and he was another
therapist’s, she asked if I would like to extubate him as well, so I did. Upon extubating the patient, I
placed him on 6 liters nasal cannula per hospital protocol and monitored his oxygen saturations. I
reiterated knowledge of arterial blood gas in relation to performing the Allen’s test and checking for
collateral circulation.

Site: Baptist Desoto

Date: Wednesday, 03/21/2018
Shift: 0641- 1505
Total Hours: 8.24

3.Demonstrate knowledge and skills associated with airway management techniques to include;
intubation, extubation, and tracheostomy care for the purpose of maintain airway patency.
2.Interpret mechanical ventilator parameters for the purpose of assessing the patient’s response to
mechanical ventilation and recommend appropriate changes.

On this day at the hospital, a patient came to the ICU overnight intubated and on the
mechanical ventilator. Since it was the patient’s first day being in the ICU and was intubated for less
than 24 hours, I asked Dr. Wollak if he wanted to perform a spontaneous breathing trial on the patient
since she met all the other criteria. Dr. Wollak did want me to place the patient in the breathing trial so I
did with a pressure support of 8 and PEEP of 5. After an hour of the patient being in the breathing trial, I
found Dr. Wollak and let him know about the patient’s condition. She had tidal volumes in the 500s and
her respiratory rate was steadily around 18. Happy with the results of the patient’s condition, Dr. Wollak
put an order in for me to extubate the patient. After letting my preceptor and the nurse know what the
intensivist had stated, we were able to successfully extubate the patient to 4 liters nasal cannula per
hospital protocol.
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Site: Baptist Desoto

Date: Sunday, 03/25/2018
Shift: 0638- 1440
Total Hours: 8.02

4.Assess and critique problematic scenarios involving the patient’s condition on the basis of specific
standards and criteria.

For this shift, my particular side of the ICU had no mechanically ventilated patients, since the
other therapist’s side had 3 I took one of hers. One of my patient’s, who was not mechanically
ventilated, had myasthenia gravis. Because of his condition, it was ordered the respiratory perform a
negative inspiratory pressure (NIF) test on him every 8 hours. The reason for performing this
spontaneous parameter is to ensure that the patient retains adequate muscle function of his diaphragm
and is able to take in a deep breath (greater than -20 cm H2O). If the patient’s NIF is greater than, or
more positive, than -20 this indicates that the patient is not taking a deep enough breath or his
condition may be worsening and the physician must be informed. I reiterated knowledge on the use of
the Wright’s Respirometer and spontaneous parameters, I asked the patient to take in as deep of a
breath as he could and the respirometer showed -35 cm H2O. Since this is adequate for the patient, I
charted the results and let my preceptor know how the patient did on his performance.

Site: Baptist Desoto

Date: Monday, 03/26/2018
Shift: 0637- 1449
Total Hours: 8. 12

Interpret mechanical ventilator parameters for the purpose of assessing the patient’s response to
mechanical ventilation and recommend appropriate changes.

During this shift, one of my mechanically ventilated patients had aerosolized treatments
ordered every 4 hours, along with a ventilator system check every 4 hours. Upon my first routine check I
noticed that his positive end expiratory pressure was set a 6.0 and his FiO2 was at 65%. I discussed this
with my preceptor and let her know that his oxygen saturation was at 100%. She asked what I
recommend and I told her it would be ideal to wean his FiO2 and, if he had orders, to wean his PEEP.
She agreed so I lowered his positive end expiratory pressure to 5 and his FiO2 down to 50%. By assessing
the patient’s condition and how he was doing with the mechanical ventilation we were able to wean the
patient’s set parameters.
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Site: Baptist Desoto

Date: Thursday, 03/29/2018
Shift: 0639- 1330
Total Hours: 6.51

1.Demonstrate knowledge of diagnostic techniques to include; hemodynamics, arterial line sampling,

and bronchoscopy assisting.
2.Interpret mechanical ventilator parameters for the purpose of assessing the patient’s response to
mechanical ventilation and recommend appropriate changes.

On this day at Baptist Desoto I was stationed on the south side and part of the north side of the
ICU. The south side of the unit is known as the “CVICU” at this hospital so my preceptor and I were
responsible for the heart patients that returned from surgery on this day. At 0954 our first heart patient
came to the unit still intubated so we initiated mechanical ventilation for this patient. It is protocol to
obtain an arterial blood gas on the heart patient’s 30 minutes after they return to the unit so at 1025 I
collected and arterial line blood gas from the patient. The arterial blood gas was all in normal range and
the patient was starting to wake up from her sedation so per protocol we placed the patient in a
spontaneous breathing trial. After the patient was in the trial for 30 minutes we left Dr. Henderson
know about the patient’s condition and how she was performing well in her breathing trial. Dr.
Henderson put in orders to extubate the patient, so we extubated the patient to liters nasal cannula per
hospital protocol.