Posture involves the relationship of the body parts to each other. A person needs good posture to reduce the risk of injury when lifting patients or heavy equipment. Poor posture may place inappropriate stress on joints and related muscles and tendons. Figure 3-2 illustrates the correct body mechanics for lifting a heavy object. The correct technique calls for a straight spine and use of the leg muscles to lift the object.

Moving the Patient in Bed

Conscious people assume positions that are the most comfortable. Bedridden patients with acute or chronic respiratory dysfunction often assume an upright position, with their arms flexed and their thorax leaning forward. This position helps decrease their work of breathing. In other cases, patients may have to assume certain positions for therapeutic reasons such as when postural drainage is applied.

Figure 3-3 shows the correct technique for lateral movement of a bed-bound patient. Figure 3-4 illustrates the ideal method for moving a conscious patient toward the head of a bed. Figure 3-5 shows the proper technique for assisting a patient to the bedside position for dangling his or her legs or transfer to a chair.

Electrical Safety

The potential for accidental shocks of patients or personnel in the hospital exists because of the frequent use of electrical equipment. The presence of invasive devices, such as internal catheters and pacemakers, may add to the risk of serious harm from electrical shock. Although this risk is present, it has been significantly reduced in recent years through a combination of education and more rigid standards for wiring, especially in patient care areas. RTs must understand the fundamentals of electrical safety because respiratory care often involves the use of electrical devices.

Fundamentals of Electricity

The ability of humans to create and harness electricity is one of the most important developments in modern times. Because controlled electricity is available on a 24-hour-a-day basis, we can depend on it to power the equipment and appliances that make modern life comfortable and productive. Despite the fact that electricity is one of the most popular sources of power, most people who use it have a poor understanding of it. This lack of knowledge is often a major factor in cases of electrocution.

Mini Clini

“Tingling” Equipment

 Problem

An RT is caring for a patient on a mechanical ventilator that requires both electrical and pneumatic power for operation. When the RT touches the metal housing of the ventilator, a shock is felt. How should the RT handle the situation based on this observation?

Discussion

All therapeutic instruments used in patient care, including mechanical ventilators, should be connected to grounded outlets (three-wire). Because the ground wire is a protection device only and not part of the main circuit, equipment may continue to operate without the clinician being aware that a problem exists. Because the RT felt a tingling sensation when touching the ventilator, this could represent an improper ground and possible serious current leakage. In this situation, the RT should immediately take the equipment out of service and get it replaced (while providing backup ventilation). All electrical equipment used in patient care should be routinely checked for appropriate grounding.

Electricity moves from point A to point B owing to differences in voltage. Voltage is the power potential behind the electrical energy. Low-voltage batteries (e.g., 9 V) are sufficient to power a small flashlight but inadequate to power a major appliance such as a microwave oven. Most homes and hospitals are powered with 120-V power sources. Power sources that have high voltage have the potential to generate large amounts of electrical current. The current that moves through an object is directly related to the voltage difference between point A and point B and inversely related to the resistance offered by the makeup of the object. Objects with low resistance (e.g., copper wires) allow maximum current to flow through the object. Objects with high resistance (e.g., rubber tubing) allow minimal or no current to flow through the object despite higher levels of voltage.

The simple analogy of water flowing through a piping system is useful to understand electricity. The water pressure level at the source is equivalent to the voltage. Higher water pressure provides the potential for greater water flow or current. The friction (resistance) offered by the pipe across the length of the pipe influences the flow exiting the other end. Pipes with lots of friction reduce the water flow (current) greatly. If the friction (resistance) is minimal, the water flow (current) is maximal. Similarly, when voltage is high and resistance is low, electrical current flows easily through the object.

The difference in resistance between two people or two objects explains why the same voltage applied to both can seriously damage one and cause no effect to the other. Two people accidentally touching a “hot” wire with 120 V can experience two completely different sensations. A person with wet skin offers little resistance, and the 120 V passes through the person with high current and can cause serious injury or death. A person with dry skin, which offers high resistance, may not even feel a shock and experiences no injury. The degree of resistance offered by the skin varies from person to person based on the chemistry of the person’s skin, the cleanliness of the skin, and the amount of moisture on the surface. For this reason, it is never wise to touch a potentially hot wire even though your skin is dry.

As stated before, voltage is the energy potential from an electrical source, and it is measured with a voltmeter. Current is the flow of electricity from a point of higher voltage to one of lower voltage and is reported in amperes (amps). Current is measured with an ampmeter. The resistance to electrical current is reported in ohms. We can determine the resistance to current for any object by the following equation:

< ?xml:namespace prefix = "mml" />Resistance(ohms[Ω])=Voltage(V)/Current(amps[A])

Current represents the greatest danger to you or your patients when electrical shorts occur. Voltage and resistance are important only because they determine how much current potentially can pass through the body. High voltage provides greater potential for high currents, but if resistance is also very high, current would be minimal or nonexistent. Current represents the potential danger to the patient. The harmful effects of current depend on (1) the amount of current flowing through the body, (2) the path it takes, and (3) the duration the current is applied. Higher currents (>100 milliamps [mA]) that pass through the chest can cause ventricular fibrillation, diaphragm dysfunction (owing to severe, persistent contraction), and death.

Because current is most important, you should be familiar with the equation used to calculate it:

Current(A)=Voltage(V)/Resistance(Ω)

For example, as long as a person is insulated by normal clothing and shoes and is in a dry environment, a 120-V shock may hardly be felt because the resistance is high in this situation (10,000 Ω). Current can be calculated as:

Current(A)=120V/10,000Ω=0.012A or12mA

Currents of 12 mA would cause a tingling sensation but no physical damage.

However, if the same person is standing without shoes on a wet floor, a much higher current occurs because the resistance is much lower (1000 Ω). The current is now calculated as:

Current(A)=120V/1000Ω=0.12A or120mA

Because the heart is susceptible to any current level greater than 100 mA, 120 mA represents a potentially fatal shock; this is in sharp contrast to the first example, where the same voltage caused only a tingling sensation.

A shock hazard exists only if the electrical “circuit” through the body is complete, meaning that two electrical connections to the body are required for a shock to occur. In the previous example, the person standing in water with no shoes has “grounded” himself. The finger touching the hot wire provides the input source while the feet standing in water provide the exit to ground. If the same person is wearing rubber boots, the connection to ground does not exist, and the current cannot flow through the individual.

In electrical devices, these two connections typically consist of a “hot” wire and a “neutral” wire. The neutral wire completes the circuit by taking the electrical current to a ground. A ground is simply a low-resistance pathway to a point of zero voltage, such as the earth (hence the term “ground”).

Figure 3-6 shows how current can flow through the body. In this case, a piece of electrical equipment is connected to AC line power via a standard three-prong plug. However, unknown to the practitioner, the cord has a broken ground wire. Normally, current leakage from the equipment would flow back to the ground through the ground wire. However, this pathway is unavailable. Instead, the leakage current finds a path of low resistance through the practitioner to the damp floor (an ideal ground).

Current can readily flow into the body, causing damage to vital organs when the skin is bypassed via conductors such as pacemaker wires or saline-filled intravascular catheters (Figures 3-7 and 3-8). Even urinary catheters can provide a path for current flow. The heart is particularly sensitive to electrical shock. Ventricular fibrillation can occur when currents of 20 µA (20 microamperes, or 20 millionths of 1 ampere) are applied directly to the heart.

Electrical shocks are classified into two types: macroshock and microshock. A macroshock exists when a high current (usually >1 mA) is applied externally to the skin. A microshock exists when a small, usually imperceptible current (<1 mA) bypasses the skin and follows a direct, low-resistance path into the body. Patients susceptible to microshock hazards are termed electrically sensitive or electrically susceptible. Table 3-1 summarizes the different effects of these two types of electrical shock.

TABLE 3-1

Effects of Electrical Shock*

Amperes (A)	Milliamperes (mA)	Microamperes (µA)	Effects
Applied to Skin (Macroshock)
≥6	>6000	>6,000,000	Sustained myocardial contraction followed by normal rhythm; temporary respiratory paralysis; burns, if small area of contact
0.1-3	100-3000	100,000	Ventricular fibrillation; respiratory center intact
0.050	50	50,000	Pain; fainting; exhaustion; mechanical injury; heart and respiratory function intact
0.016	16	16,000	“Let go” current; muscle contraction
0.001	1	1000	Threshold of perception; tingling
Applied to Myocardium (Microshock)
0.001	0.1	100	Ventricular fibrillation

Duration of exposure and current pathway are major determinants of human response to electrical shock.

^*Physiologic effects of AC shocks applied for 1 second to the trunk or directly to the myocardium.

Fire Hazards

In 1980, approximately 13,000 health care facility fires were officially reported in the United States.³ During the period 2004-2006, the average annual number of fires in health care facilities was 6400.⁴ This significant reduction in health care facility fires is primarily due to education and enforcement of strict fire codes.

About 23% of fires in health care facilities occur in hospitals, and 44% occur in nursing homes; the most common site of origin of the fire is the kitchen.³ About 15% of hospital fires start in patient care rooms and are usually due to patients or visitors smoking or using open flames to light tobacco products. Medical facility fires cause an annual average of five civilian deaths and approximately $34 million in damage.⁴

Hospital fires can be very serious, especially when they occur in patient care areas and when supplemental oxygen is in use. Fires in oxygen-enriched atmospheres (OEAs) are larger, more intense, faster burning, and more difficult to extinguish. In addition, some material that would not burn in room air would burn in OEAs. Hospital fires are also more serious because evacuation of critically ill patients is difficult and slow. For these reasons, hospital fires often cause more injuries and deaths per fire than do residential fires. For a fire to start, three conditions must exist: (1) flammable material must be present, (2) oxygen must be present, and (3) the flammable material must be heated to or above its ignition temperature. When all three conditions are present, a fire starts. Conversely, removing any one of the conditions can stop a fire from starting or extinguish it after it has begun. Fire is a serious hazard around respiratory care patients using supplemental oxygen. Although oxygen is nonflammable, it greatly accelerates the rate of combustion. Burning speed increases with an increase in either the concentration or the partial pressure of oxygen.

Flammable material should be removed from the vicinity of oxygen use to minimize fire hazards. Flammable materials include cotton, wool, polyester fabrics, bed clothing, paper materials, plastics, and certain lotions or salves such as petroleum jelly. Removal of flammable material is particularly important whenever oxygen enclosures, such as oxygen tents or croupettes, are used.

Ignition sources, such as cigarette lighters, should not be allowed in rooms where oxygen is in use. In addition, the use of electrical equipment capable of generating high-energy sparks, such as exposed switches, must be avoided. All appliances that transmit house current should be kept out of oxygen enclosures. Children should not play with toys that may create a spark when oxygen is in use. RTs must be diligent in educating patients and visitors about the dangers associated with spark-producing items, open flames, and burning cigarettes in the hospital environment, especially in OEAs.

A frequent source of concern is the presence of static electrical sparks generated by friction. Even in the presence of high oxygen concentrations, the overall hazard from static sparks with the materials in common use is very low. Solitary static sparks generally do not have sufficient heat energy to raise common materials to their flash points. The minimal risk that may be present can be reduced further by maintaining high relative humidity (>60%).

If you identify a fire in a patient care area, you must know what to do. Each hospital must have a core fire plan that identifies the responsibilities of hospital personnel. The plan should be taught to all hospital personnel and practiced with fire drills to reinforce the education. Requirements may include routinely walking the fire exits and reviewing proper fire extinguisher training. Fire extinguisher training includes following the acronym PASS:

The core fire plan follows the acronym RACE:

RTs are frequently key participants in successful handling of hospital fires. First, they know where the oxygen zone valves are located and how to shut them off. Second, they have the knowledge and skills needed to evacuate patients receiving mechanical ventilation or supplemental oxygen to sustain life. Third, they know how to treat and resuscitate victims of smoke inhalation. For these reasons, RTs should be included in all hospital evacuation planning and practices.

General Safety Concerns

In addition to electrical and fire safety, RTs need to be aware of general safety concerns, including the direct patient environment, disaster preparedness, magnetic resonance imaging (MRI) safety, and medical gas safety. Medical gas safety is discussed in more detail in Chapter 37.

Communication in Health Care

Effective communication is the most important aspect of providing safe patient care. The first two 2010 National Patient Safety Goals of The Joint Commission are to improve accuracy of patient identification and to improve effectiveness of communicating critical test values among caregivers.⁶ All health care personnel must correctly identify patients before initiating care using a two patient identifier system. The patient identifiers can include any two of the following: name, birth date, and medical record number. Effectively communicating critical test values should include a “read back” scenario verifying the reporter and the receiver of the information and accurate reporting and recording of test values. Each institution may have specific values as critical test values; for example, RTs may be expected to report blood gas values of a pH less than 7.2 or a PO₂ less than 50 mm Hg. The process of the “read back” scenario is described in Box 3-1.

As an RT, you will have many opportunities to communicate with patients, other RTs, nurses, physicians, and other members of the health care team. Success as an RT depends on your ability to communicate with these key people. Poor communication skills can limit your ability to treat patients, work well with others, and find satisfaction in your employment.

RTs can communicate empathy to their patients through the use of key words and eye contact and the proper use of touch. Communicating empathy to patients is an effective way of letting them know you care for their well-being and are willing to provide respiratory care to help their breathing. Techniques involve asking the patient about his or her breathing on a regular basis, making good eye contact when the patient is speaking, and using gentle touch on the arm or hand when comforting the patient.

Factors Affecting Communication

Many factors affect communication in the health care setting (Figure 3-10). The uniquely human or “internal” qualities of sender and receiver (including their prior experiences, attitudes, values, cultural backgrounds, and self-concepts and feelings) play a large role in the communication process.

Generally, the verbal and nonverbal components of communication should enhance and reinforce each other. The RT who combines a compassionate-toned verbal message such as, “You’re going to be all right now,” with a confirming touch of the hand is sending a much stronger message to an anxious patient than the message provided by either component alone.

Effective Communication in Health Care

RTs must be effective communicators. Effective communication occurs when the intent or purpose of the interaction is achieved. Several key purposes of communication are summarized in Box 3-2. The RT must consider the roles involved, the message, the channel, and the appropriate feedback to help achieve these purposes when communicating.

Improving Communication Skills

To enhance your ability to communicate effectively, focus on improving sending, receiving, and feedback skills. In addition, identify and overcome common barriers to effective communication.

Sources of Conflict

The first step in conflict management is to identify its potential sources. The four primary sources of conflict in organizations are (1) poor communication, (2) structural problems, (3) personal behavior, and (4) role conflict.

Conflict Resolution

Conflict resolution or management is the process by which people control and channel disagreements within an organization. There are five basic strategies for handling conflict:

Components of a Traditional Medical Record

Each health care facility has its own specification for the medical records it keeps. Although the forms themselves vary among institutions, most acute care medical records share common sections (Box 3-3).

Figure 3-11 provides an example of a desaturation study for home oxygen therapy qualification. Documentation sheets are designed to report data briefly and to decrease time spent in documentation. Entries can include many measurements, and review of a sequence of entries can reveal trends in patient status.

Legal Aspects of Recordkeeping

Legally, documentation of the care given to a patient means that care was given; no documentation means that care was not given. Hospital accreditation agencies critically evaluate the medical records of patients. If the RT does not document care given (i.e., patient assessment data, interventions, and evaluation of care rendered), the practitioner and the hospital may be accused of patient neglect.

Adequate documentation of care is valuable only in reference to standards and criteria of care. Similar to all departments in health care facilities, respiratory care departments must generate their own standards of patient care. For each standard, criteria must be outlined so that the adequacy of patient care can be measured. Documentation must reflect these standards.

Practical Aspects of Recordkeeping

Recordkeeping is one of the most significant duties that a health care professional performs. Documentation is required for each medication, treatment, or procedure. Accounts of the patient’s condition and activities must be charted accurately and in clear terms. Brevity is essential, although a complete account of each patient encounter is needed. The use of standardized terms and abbreviations is acceptable; however, The Joint Commission has published a “Do Not Use” abbreviation list developed to reduce potential errors (Table 3-2).⁷ Documentation of consultations with the attending physician that include the date and time of the conversation is recommended.

Accounts of care and the patient’s condition are generally printed by hand or handwritten. In some institutions, computerized patient information systems facilitate data entry by selection from menus of choices or direct typing. In either case, you must document only what is—not an interpretation or a judgment. Assessments of data must be clearly within one’s professional domain. When a practitioner cannot interpret the data obtained, he or she should state so in the record and contact another health care professional for advice or referral and document the referral in the patient’s medical record. Other general rules for medical recordkeeping are listed in Box 3-4. In addition to these general rules, each institution has its own policies governing medical recordkeeping.

Problem-Oriented Medical Record

The problem-oriented medical record (POMR) is an alternative documentation format used by some health care institutions. The POMR contains four parts: (1) the database, (2) the problem list, (3) the plan, and (4) the progress notes. The precise forms these records take vary among institutions.

The database contains routine information about the patient. A general health history, physical examination results, and results of diagnostic tests are included.

In the POMR, a problem is something that interferes with a patient’s physical or psychologic health or ability to function. The patient’s problems are identified and listed on the basis of the information provided by the database. The list of problems is dynamic; new problems are added as they develop, and problems are removed as they are resolved.

The POMR progress notes contain the findings (subjective and objective data), assessment, plans, and orders of the physicians, nurses, and other practitioners involved in the care of the patient. The format used is often referred to as SOAP (S = subjective information, O = objective information, A = assessment, P = plan of care). Figure 3-12 shows a representative SOAP form for respiratory care progress notes. Box 3-5 provides an example of a SOAP entry. Table 3-3 lists common objective data gathered by RTs and examples of applicable assessments and plans. In many institutions, all caregivers chart on the same form, using the SOAP format.