Handbook of Clinical Skill Training Respiratory System Ver 3 11 2011 PDF

Handbook of Clinical Skill Training
Respiratory System
Undergraduate Program
Faculty of Medicine Universitas Padjadjaran
2011 – 2012
1
Table of contents
GENERAL LEARNING GUIDE ........................................................................................................ i

ANTERIOR NASAL PACKING ....................................................................................................... 1
OXYGEN THERAPY FOR ADULTS ............................................................................................... 10
OXYGEN THERAPY FOR PEDIATRIC .......................................................................................... 22
RESPIRATORY PHYSICAL EXAMINATION IN ADULTS ................................................................ 26
NEEDLE THORACOSTOMY ........................................................................................................ 38
HEIMLICH MANOUVER ............................................................................................................ 41
TUBERCULIN SKIN TESTING (MANTOUX TEST=PPD TEST) ....................................................... 48
HISTORY TAKING OF DIFFICULTY BREATHING IN CHILDREN ................................................... 54
RESPIRATORY HISTORY TAKING IN ADULTS ............................................................................. 59
ACID FAST STAINING PROCEDURE ........................................................................................... 68
1
General Learning Guide
1. Rational / Synopsis
Filled in with the reason or background the importance of learning this system, including
health problem to be dealt with as well as the future impact.
2. Intended Competency
Filled in with intended competency achieved based on FK Unpad competency
3. Number of SCU
4. General learning outcome
5. Specific skills learned
Week Skill Specific learning outcome Department

I Anterior nasal At the end of skill practice, the student will be able to
packing perform anterior nasal packing, which includes:
1. Describe the principle of the procedures.
2. Describe the equipment needs for the procedures.
3. Demonstrate the procedure properly.
II Oxygen therapy At the end of skill practice, the student will be able to
perform the procedure of oxygen therapy, indications for
oxygen therapy, and goal of oxygen therapy.
III Respiratory At the end of skill practice, the student will be able to
physical perform the procedure of respiratory physical examination
examination in systematically including:
adults Systematic physical examination of respiratory system by
performing inspection, palpation, percussion and
auscultation
IV Needle At the end of skill practice, the student will be able to
Thoracostomy perform the procedure of Heimlich’ maneuver indications for
and Hemlich needle thoracotomy, and goal of Heimlich’ manouver.
Maneuver
V Tuberculin Skin At the end of this skill practice, the students will be able to
Testing perform and reading and recording the result of Mantoux
test/PPD test for diagnosis of tuberculosis in children.
VI HT of At the end of this skill practice, the students will be able to
Difficulty understand the systematic information gathering from
Breathing In pediatric history taking about difficulty breathing in children.
Children
VII Respiratory HT At the end of skill practice, the student will be able to
for adults perform the procedure of respiratory History taking
systematically.
i
VIII Acid Fast At the end of skill practice, student could interpret the result
Staining of Ziehl-Neelsen staining
Procedure
6. Learning Method
a. Introduction (20’)
b. Demonstration (10’)
c. Individual training (each student 10’ = 100’)
d. Point nodal evaluation
e. Student self practice
ii
7. Schedule
SCHEDULE OF SKILLS LAB RESPIRATORY SYSTEM

REGULAR PROGRAM
THIRD YEARS PROGRAM
ACADEMIC 2011 - 2012
GROUP
WEEK DAY/DATE TIME TOPIC Back up INITIAL FOR TRAINER
1 2 3 4 RP
Monday 08.00-11.50 LF FD IA NY SSR YY ADP Agung Dinasti Permana,dr.,SpTHT-KL.,M.Kes
7/11/2011 12.30-16.00 LF FD IA NY SSR YY DAW Diah Astri Wulandari,dr.,SpA
Wednesday 08.00-11.50 LF FD IA NY SSR YY DEL Dimas Erlangga Luftimas,dr
I Anterior nasal packing
9/11/2011 12.30-16.00 LF FD IA NY SSR YY GUS Gustiara,dr.,SpRad
Friday 07.00-10.50 LF FD DEL NY SSR YY IA Indah Amelia,dr
11/11/2011 13.00-16.30 LF FD NY NY SSR YY IDK Iceu Dimas Kulsum, dr., SpPD
Monday 08.00-11.50 ADP + ST FD MHB PS/IDK DAW YY LF Lia Faridah,dr.,M.Si
14/11/2011 12.30-16.00 ADP + ST FD MHB PS/IDK DAW YY MHB M.Hasan Bashari,dr.,M.Kes
Wednesday 08.00-11.50 ADP FD MHB PS/IDK DAW ST NY Naomi Yosiati,dr
II Oxygen therapy
16/11/2011 12.30-16.00 ADP FD MHB PS/IDK DAW ST PS Prayudi Santoso, dr., SpPD-KP., M.Kes
Friday 07.00-10.50 ADP FD MHB PS/IDK DAW YY RN Rama Nusyirwan,dr.,spBTKV
18/11/2011 13.00-16.30 ADP FD MHB PS/IDK DAW YY SRS Sri Sudarwati,dr.,SpA(K)
Monday 08.00-11.50 LF FD MHB ST PS/IDK YY SSA Dr Sunarjati Sudigdoadi,dr.,MS,SpMK
21/11/2011 12.30-16.00 LF FD MHB ST PS/IDK YY SSR Sinta Sari Ratunanda,dr.,SpTHT-KL
Wednesday 08.00-11.50 Respiratory physical examination in LF FD MHB ST PS/IDK YY ST Sani Tanzilah, dr
III
23/11/2011 12.30-16.00 adults LF FD MHB ST PS/IDK YY UAH Usep Abdullah Husin,dr.,SpMK.,M.Kes
Friday 07.00-10.50 YY FD MHB ST PS/IDK YM Yanti Mulyana,Dra.,Apt.,MS.,DMM
25/11/2011 13.00-16.30 YY FD MHB ST PS/IDK YY Yovi Yuanita,dr.,M.Kes
Monday 08.00-11.50 YY FD MHB LF PS/IDK
28/11/2011 12.30-16.00 YY FD MHB LF PS/IDK
Wednesday 08.00-11.50 YY FD MHB LF PS/IDK
IV Needle Thoracostomy
30/11/2011 12.30-16.00 YY FD MHB LF PS/IDK
Friday 07.00-10.50 YY FD MHB LF PS/IDK
2/12/2011 13.00-16.30 YY FD MHB LF PS/IDK
iii
GROUP
Back up
WEEK DAY/DATE TIME TOPIC 1 2 3 4 RP
Monday 08.00-11.50 DEL FD NY MHB SRS YY
5/12/2011 12.30-16.00 DEL FD NY MHB SRS YY
Wednesday 08.00-11.50 DEL FD NY MHB SRS YY
V Tuberculin Skin Testing
7/12/2011 12.30-16.00 DEL FD NY MHB SRS YY
Friday 07.00-10.50 DEL FD NY MHB SRS IA
9/12/2011 13.00-16.30 DEL FD NY MHB SRS IA
Monday 08.00-11.50 DEL FD IA LF SRS ST
12/12/2011 12.30-16.00 DEL FD IA LF SRS ST
Wednesday 08.00-11.50 DEL FD IA LF SRS ST
VI HT of Difficulty Breathing In Children
14/12/2011 12.30-16.00 DEL FD IA LF SRS ST
Friday 07.00-10.50 DEL FD ST LF SRS
16/12/2011 13.00-16.30 DEL FD ST LF SRS
Monday 08.00-11.50 LF DEL NY IA PS/IDK ADP
19/12/2011 12.30-16.00 LF DEL NY IA PS/IDK ADP
Wednesday 08.00-11.50 LF DEL NY IA PS/IDK ADP
VII Respiratory HT for adults
21/12/2011 12.30-16.00 LF DEL NY IA PS/IDK ADP
Friday 07.00-10.50 LF DEL NY DEL PS/IDK ADP
23/12/2011 13.00-16.30 LF DEL NY DEL PS/IDK ADP
Monday 08.00-11.50
CHRISTMAS BREAK 2011
26/12/2011 12.30-16.00
Wednesday 08.00-11.50 YM UAH ST SSA FD, GUS
28/12/2011 12.30-16.00 YM UAH ST SSA FD, GUS
VIII Acid Fast Staining Procedure
Thursday 08.00-11.50 YM UAH ST SSA FD, GUS
Friday 07.00-10.50 YM UAH ST SSA FD, GUS
iv
ANTERIOR NASAL PACKING
Sinta Sari Ratunanda, dr., SpTHT-KL
Lina Lasminingrum, dr., SpTHT-KL
I. GENERAL OBJECTIVE
After completing skill practice of anterior nasal packing, the student will be able to
perform anterior nasal packing procedure with appropriate technique.
II. SPECIFIC OBJECTIVE
At the end of skill practice, the student will be able to perform anterior nasal packing,
which includes:
4. Describe the principle of the procedures.

5. Describe the equipment needs for the procedures.
6. Demonstrate the procedure properly.
III. SYLLABUS DESCRIPTION

3.1 Expected Competencies
a. Students describe the principles of the procedures.
b. Students describe the equipment needs for the procedures.
c. Students demonstrate the procedure properly.
3.2 Methods
a. Presentation.
b. Demonstration.
c. Coaching.
d. Self-practice on artificial models.
3.3 Laboratory Facilities

a. Skill Laboratory.
b. Trainers.
c. Students learning guide.
d. Trainer’s guide.
e. References.
3.4 Venue
Skill Laboratory A5.1
1
3.5 Evaluation
a. Skill demonstration.
b. point nodal evaluation.
c. OSCE.
IV. EQUIPMENT
1. Presentation:
Audiovisual: Slides presentations on LCD projector.
2. Demonstration and coaching:
a. Head lamp
b. Nasal speculum
c. Tongue blade
d. Pinset
e. Petrolatum or Vaseline gauze coated with an antibacterial ointment
f. cotton with anesthetic solution ± epinephrine (Lidocaine/ pehacain)
g. gauzes
h. Masker
i. Hand gloves
j. tape
k. kidney basin
l. scissor
m. antiseptic solution
n. Antibiotic ointment
o. antiseptic soap
2
LEARNING GUIDE
ANTERIOR NASAL PACKING PROCEDURE
No. Procedures Performance Scale

0 1 2
A. Client Assessment
1. Greet the patient respect fully and with kindness introduce yourself.
2. The patient should be given adequate explanation about examinations.
3. Explain the goals or the expected result examination.
4. Check the instrument & material
B. Preparation
5. Wash your hands first with antiseptic soap and dry it with paper tissue.
6. Self-protection: put on hand gloves + masker.
7. Put the head lamp.
8. ask the patient to sit ++
C. Procedures
9. Hold the nasal speculum with one hand and then put in on the left or right
nostril.
10. Hold it with the thumb on the joint, the index finger free to steady it on
the patient’s nose and the rest of the fingers on the stem proper to hold
the speculum.
11. Always try to open the stem or times in an upward action and not down
into the floor or the nose. The good view of the nose anteriorly can be
obtained simply by pressing on the tip of the nose. Don’t close the
speculum while its tip is in the nasal cavity
12. Check the source of bleeding in both nostrils and oropharynx. Determine
the location of bleeding.
13. Administered the topical anesthesia. A pledged or cotton swab soaked in
1% Pantocaine or lidocaine solution (with or without containing 1-2 drops
of an epinephrine solution dilutes 1:1,000) is placed in the nose for 3-5
minutes.
14. After 3-5 minutes, remove the cotton and recheck the bleeding from the
nose
15. Next, the traditional anterior pack petrolatum gauze (0.5 x 72 inch) is
firmly packed into the nasal cavity.
The packing is placed in a methodical (layering) fashion toward the
posterior choana, starting at nasal floor and packing up to about the level
middle turbinate. It is possible to put a large amount into each side
16. Great care must be taken that :
- The free-end of the packing should not be visible in the oropharynx
behind the soft palate as this can lead to irritation, an also a danger that
this portion might slip deeper into the aerodigestive tract and cause
complication.
17. a. If the gauze is in the oropharynx  repeat procedures.
b. Fix the nasal packing with gauze and tape in front of nasal cavity.
18. Take all of the instruments to the antiseptic solution. Take off the hand
gloves, masker & head lamp.
17. Once the gauze is firmly packed properly into the nasal cavity :
3
- If needed, the patient should be admitted and kept under careful
observation.
- If needed, give the patient humidifies oxygen
- As the pack will be left in for at least 48 hours, put the patient an broad
spectrum antibiotic.
- If needed, establish an intravenous line, and cross-match the blood.
18. After 48 hour: remove the nasal packing with circular motion and then
check if there is any bleeding from nasal and oropharynx.
Note :
0 = if the students are not doing the task
1 = if the students are doing the task in complete for each step precisely
2 = if the students are doing the task complete for each step precisely
4
SLIDES INTRODUCTION
ANATOMY
 A. Carotis Eksterna
A. Maksilaris
A. Fasialis
LINA LASMININGRUM  A. Carotis Interna

A. Oftalmika  A. Ethmoidales
anterior & posterior
1 4
INTRODUCTION
 EPISTAXIS
Any bleeding from the nose caused by
haemostatic disturbance
 Haemostatic abnormality
• Mucous abnormality
• Vascular pathology
• Coagulation disorders
Adapted from : Netter Atlas
2 5
CLASSIFICATION
 Anterior epistaxis :
 Prevalens: 7% - 14%. Recurrence 4%.  occurs primarily in the Little’s area
 Age : < 10 , > 35 (Kiesselbah’s plexus) and more often venous
 Based on source of bleeding : in origin.
 Anterior epistaxis  esp. child – young  Posterior epistaxis :
adult  primarily in the region of the posterior
 Posterior epistaxis  old age septum,
 Cold climate and low humidity >>   posterior lateral nasal wall (Woodruff’s
DRYNESS nasopharyngeal plexus) & posterior septum
3
 more often arterial in origin 6
5
EVALUATION
 GENERAL APPROACH
 INITIAL : COMPRESSION OF THE NOSTRIL (5-20 MIN)
 PLUGGING WITH GAUZE OR COTTON SOAKED IN
TOPICAL ANESTHETIC – DECONGESTAN
 TILTING HEAD FORWARD  PREVENTS POOLING BLOOD
TO POSTERIOR PHARYNX  AVOIDING NAUSEA &
OBSTRUCTION
 SECURING HEMODYNAMIC STABILITY & AIRWAY
PATENCY  FLUID RESUSCITATION
7 10
EVALUATION
 NO RESPOND LOCATE THE SOURCE

OF BLEEDING : ANTERIOR RHINOSCOPY
/ NASOENDOSCOPY
 WITH PROPER LIGHT SOURCE &
INSTRUMENT
 SELF PROTECTION
 REDUCE THE ANXIETY
 A THROUGH HISTORY SHOULD BE TAKEN
WITH ATTENTION TO DURATION,
FREQUENCY, SEVERITY  FAMILY
HISTORY / BLEEDING DISORDER?
11
INSTRUMENT
ETIOLOGY
LOCAL SYStEMIC
 Trauma: digital,  Hypertension
fractures  Vascular disorders
 Nasal sprays  Blood dyscrasias
 Inflammatory reactions  Hematologic
 Anatomic deformities malignancies
 Foreign bodies  Allergies
 Intranasal tumors  Malnutrition
 Chemical inhalants  Alcohol
 Nasal prong O2, CPAP  Drugs (aspirin, etc)
 Surgery  Liver / renal disease 9 11/3/2011 12
6
PHYSICAL MANAGEMENT
EXAMINATION
• General status  Minor Hemorrhage
• Local status stop spontaneously  pediatric population,
> 64% having experienced epistaxis
Determine :
Anterior nasal
 - Anterior or posterior Antiseptic cream packing Silver nitrat cautery
Barrier agent Removed Electric cautery
 - Other stigmata after 20 men
13 16
 Major Hemorrhage
 Emergency  active epistaxis
Ensure adequate •Blood cloots out of • Anterior

bleeders
his or her nose
Epistaxis anterior.wmv iv access •Explore with speculum ant nasal pack or
& resuscitation or nasal endoscopy cautery
and suction
•Posterior bleeders
post nasal pack
arterial ligation or
embolization
is performed
14 17
MANAGEMENT MANAGEMENT
AIMED
 DIFFUSE / OOZING, MULTIPLE BLEEDING
SITE OR RECURRENT BLLEDING 
INDICATE SYSTEMIC PROCESS
Stop the bleeding
Avoid complication
Avoid recurrence
HEMATOLOGIC EVALUATION
Most anterior epistaxis  self limited
Controlled by pinching ala nasi 5 – 20 min
15 18
7
MANAGEMENT
• TRADITIONAL
• Ribbon gauze with
NASAL vaselin / antibiotic
PACKING oinment
anterior • OTHERS
• Non absorbable
• Absorbable
19 22
MANAGEMENT Balloon Pack
NASAL
PACKING BELLOCQ TAMPON
FOLEY CATHETER
BALLOON PACK
POSTERIOR
20 11/3/2011 23
Posterior Nasal Packing (Bellocq tampon) SURGERY
 LIGATION
 A. ETHMOIDALES ANTERIOR
 A. MAXILLARIS
 A. SPHENOPALATINA
 A. CAROTID EXTERNA
 EMBOLIZATION
 SEPTAL DERMOPLASTY, SEPTOPLASTY
11/3/2011 21 24
8
AVOID COMPLICATION
COMPLICATION AVOIDANCE
 HYPOVOLEMIC SHOCK  IV FLUID
 APNEA, HYPOXIA  MONITOR O2
 SEPTAL PERFORATION  LIMITED CAUTERY, PROPER
PACK SIZE
 ALAR RIM, COLUMELLA  STABILIZATION PACKING
NECROSIS, LASERATION WITHOUT CONTACT WITH
PALATUM MOLLE / LIPS ALAR / COLUMELLA
 ASPIRATION  ADEQUATE PLACEMENT &
SECURING NASAL PACKS
 RECALCITRANT BLEEDING
 PROPHYLACTIC ANTIBIOTICS
 INFECTION
25 27
AVOID RECURRENCE SUMMARY
 Patient education  Avoidance of  GOOD EVALUATION & HISTORY 

digital manipulation,airborne irritants, PREPARATION & PLANNING
dander, smoke  PROPER INSTRUMENTATION
 Keep the nose moist  DON’T PANIC !
 Control of allergies  MANAGEMENT : CONSERVATIVE,
 Tappering amount of nasal spray COMFORTABLE, IF FAILED  SURGERY
 Intranasal surgical technical  AVOID COMPLICATION FROM BLEEDING &
refinements OR MANAGMENT
26 28
9
OXYGEN THERAPY FOR ADULTS
Arto Yuwono, dr.,SpPD-KP,FCCP,FINASIM
Yana Akhmad, dr., SpPD-KP,FINASIM
Prayudi Santoso, dr., SpPD-KP,FCCP,FINASIM,M.Kes
I. General Objective
After completing skill practice, the student will be able to perform oxygen therapy.
II. Specific Objective
At the end of skill practice, the student will be able to perform the procedure of oxygen
therapy, indications for oxygen therapy, and goal of oxygen therapy.
III. Syllabus Description
3.1. Sub Module Objective
After finishing skill practice of oxygen therapy, the student will be able to perform
oxygen therapy
3.2. Expected competencies
Student will be able to demonstrate the procedure of oxygen therapy, indications and
goal of oxygen therapy.
3.3. Method
a. Presentation
b. Demonstration
c. Coaching
d. Self-practice: role – play
3.4. Laboratory facilities
a. Skills laboratory: table, chairs, examination couch, nasal cannula, simple oxygen masks,
partial rebreathing mask, oxygen, venture mask and non-rebreathing mask.
b. Trainers
c. Patient
d. Student learning guide
e. Trainer’s guide.
f. References
10
3.5. Venue
Skills laboratory A5.1
3.6. Evaluation
a. Point Nodal Evaluation
b. OSCE
After finishing skill practice of oxygen therapy, the student will be able to perform
oxygen therapy.
Student will be able to demonstrate the procedure of oxygen therapy, correct

documented or suspected acute hypoxemia, decrease the symptoms associated with
chronic hypoxemia, and decrease the work load hypoxemia imposes on the
cardiopulmonary system.
3.9. Method
a. Presentation
b. Demonstration
c. Coaching
d. Self-practice
a. Skills laboratory
b. Trainers
c. Patient and model
e. Trainer’s guide
f. References
11
Learning Guide
Oxygen therapy in adults
Performance
No Steps/Task Scale
0 1 2
A. CLIENT ASSESSMENT
1. Greet client respectfully and with kindness
2. The patient should be given adequate explanation about oxygen therapy and the
goal or expected result oxygen therapy
B. PROCEDURE FOR OXYGEN THERAPY
B.1. This is basic steps when setting up oxygen equipment:
1 Wash your hands before (and after) initiating oxygen therapy to guard against
transmitting nosocomial
2 If you’re using oxygen cylinder turn on the cylinder. Check the cylinder gauge to
ensure an adequate oxygen supply
3 If you’re providing humidification, fill the humidifier bottle or reservoir until the
water’s level with the sterile distilled water
4 Connect the humidifier bottle to the tubing and the flowmeter. Set the
flowmeter as ordered, making sure the center of the ball is on the line indicating
the prescribed liters per minute.
5 Now begin giving oxygen.
B.2.Setting up with nasal cannula
To start therapy with a nasal cannula, follow these steps:
1 Inspect each nostril using a flashlight. Check for patency, polyps, edema, and
deviated septum or other obstruction. If both nostrils are obstructed, you’ll
need to deliver the oxygen via a mask.
2 Check whether the nasal prongs are straight, smooth, or curved. Place curved
prongs with the curve facing toward the nostrils floor. This position helps
prevent obstruction of the cannula lumen by the nasal mucosa, which can
decrease oxygen flow.
3 Now hook the cannula tubing behind the patient’s ears and under his chin. Then
slide the adjuster upward to hold the cannula in place. When using an elastic
strap to hold the cannula in place, position the strap over the patient’s head
above his ears.
B.3. Setting up with Oxygen Masks
1. Select the size mask that offers the most comfortable fit and best airtight seal
for your patient.
2. Connect the tubing, mask, and humidification device to the flowmeter. Set the
flowmeter to the correct setting to deliver the prescribed oxygen concentration.
3. For a simple face mask, set the flowmeter to supply the prescribed oxygen rate.
4. For a non-rebreathing or partial rebreathing mask, set the flowmeter to the
ordered setting, usually between 6 and 15 liters/minute, depending on the
12
oxygen concentration the patient requires.
5. Observe the reservoir bag for initial inflation. If using a non-rebreathing mask,
ensure that one-way flaps operate properly.
6. As the patient breathes, observe the reservoir bag; it should deflate slightly on
inspiration.
TOTAL
Note:
0 = not doing at all
1 = do the step partially
2 = do the step completely
13
Slide Introduction
Causes of Hypoxia
Pre pulmonary Hypoxia. Hypoxia can be
caused by inadequate delivery of oxygen to
Oxygen Therapy the lung.
• results from inadequate ventilation brought about
by airway obstruction (laryngospasm,
bronchospasm), muscular weakness (disease or
Prayudi Santoso, Arto Y. Soeroto neuromuscular-blocking drugs), or impaired
Pulmonology Division respiratory drive [central nervous system (CNS)
Internal Medicine Department disease, opioids, anesthetics].
Padjadjaran Medical Faculty/Hasan Sadikin
General Hospital -- Bandung
Definition: Causes of Hypoxia

• Oxygen therapy is the administration of Pulmonary Hypoxia - abnormal
oxygen at concentrations greater than ambient pulmonary function can impair
air(21%) oxygenation of the blood.
• With the intent of treating or preventing the • mismatch between ventilation and
perfusion- (e.g., acute respiratory distress
symptoms and manifestations of hypoxia
syndrome, pneumonia, emphysema).
(a deficiency of oxygen reaching the tissues of
• thickened barrier to diffusion and
the body) intrapulmonary shunting of venous blood
(fibrosis, pulmonary edema).
Causes of Hypoxia
Oxygen Deprivation
Post pulmonary Hypoxia
• inadequate delivery of oxygen to tissues
Hypoxia is the term used to may be the result of low cardiac output
denote insufficient oxygenation (shock), mal distribution of cardiac output
(sepsis, vascular occlusion)
of the tissues. • an inadequate concentration of oxygen in
arterial blood (anemia,
hemoglobinopathies, carbon monoxide
poisoning).
14
Oxygen Therapy
 INDICATIONS
• the tissues may be unable to extract or utilize
 Documented hypoxemia
sufficient oxygen. This may result from an  Adults, children, and infants >28 days old: Pao2 <60 mm Hg or Sao2 <90%

unusually high metabolic demand 
Neonates, Pao2 <50 mm Hg, Sao2 <88%, or capillary Po2 <40 mm Hg
Acute care situations in which hypoxemia is suspected
(thyrotoxicosis, hyperpyrexia) or to  Severe trauma
 Acute myocardial infarction
malfunction of cellular enzyme systems  Short-term therapy (e.g., post anesthesia recovery)
(cyanide poisoning).
 CONTRAINDICATIONS
 No specific contra indications to oxygen therapy exist when indications are

present.
Respiratory Physiology Oxygen Therapy

• Oxygenation - blood and the cells become  PRECAUTIONS AND/OR POSSIBLE COMPLICATIONS
saturated with oxygen
 PaO2 >60 mm Hg may depress ventilation in some patients with chronic
• Hypoxia - inadequate oxygen levels in the blood hypercapnia.
• Signs of Hypoxia  FIO2 >0.5 may cause atelectasis, oxygen toxicity, and/or ciliary or
leukocyte depression.
• Increased or decreased heart rate  In premature infants, Pao2 >80 mm Hg can cause retinopathy of
• Altered mental status (early sign) prematurity.
• Agitation  In infants with ductal heart lesions, high Pao2 can close or constrict the
ductus arteriosus.
• Initial elevation of B.P. followed by a decrease  Increased FIO2 can worsen lung injury in patients with paraquat
• Cyanosis (often a late sign) poisoning or those receiving bleomycin. .During laser bronchoscopy,
minimal FIO2 should be used to avoid intratracheal ignition.
 Fire hazard is increased in the presence of high FIO2.
 Bacterial contamination can occur when nebulizers or humidifiers are
used.
Delivery Systems
• Nasal Cannula
• Simple Mask
• Partial Rebreathing Mask
• Non Re breathing Mask
• Venturi Mask
15
Nasal Cannulas
• Can provide 23-45% oxygen to patients with
flowrates up to 6l/ mnt
• The “reservoir” for a nasal cannula is the patients
nose
Once the reservoir is filled between breaths, the oxygen is

directed into the room. During inspiration, the first part of
the patients breath includes the oxygen stored in the nose,
and then is supplemented with the oxygen flowing out of the
cannula.
Nasal Cannulas cont.
• Each liter of flow will increase the FiO2

approximately 2%-4%.
• Flow rates in excess of 6 L/m do not augment the
inspired gas significantly because the extra gas is
directed out to the room and is not available for
inspiration
• High flows can also result in drying of the nasal
mucosa
• Humidification of nasal cannulas with a “bubble
device” is recommended for flow rates > 4 l/mnt
16
Simple Masks
• Can provide 31-61% oxygen to patients at

flowrates between 5-10 L/m
• The reservoir in a simple mask is the space
between the mask and the patients face
• Since this space is larger than the space in the
nose, more oxygen is stored and is available
for the next breath, resulting in higher potential
of FiO2.
Simple Masks cont.
• Less than 5 l/mnt is not recommended

(minimum of 5 l/mnt is needed to flush the exhaled
CO2 from the mask)
• If the PaO2 is too high on 5 l/mnt, a switch to a nasal
cannula would be recommended
Non-rebreathing masks
• Deliver the highest FiO2 of our simple oxygen

devices
• With a perfect fit the FiO2 may approach 1.0
however the FiO2 is usually in the range of
60%-90% depending on the fit of the mask
• The flow rate must be high enough to keep the
bag inflated during inspiration. The flow is set
at 10 l/mnt
17
Nonrebreather Mask
• Preferred method of giving oxygen to prehospital
patients
• Up to 90% oxygen can be delivered
• Bag should be filled before placing on patient
• Flow rate should be adjusted to 15 liters/min.
• Patients who are cyanotic, cool, clammy or short of
breath need oxygen
• Concerns of too much oxygen
• Different size masks
Partial Rebreather Mask

• Similar to nonrebreather except it has a two-
way valve allowing patient to rebreath his
exhaled air.
• Flow rate 6 to 10 liters/min.
• Oxygen concentration between 35 to 60%
Venturi Mask Monitoring the Patient

• Provides precise concentrations of oxygen • Clinical assessment including but not limited
• Entrainment valve to adjust oxygen delivery to cardiac, pulmonary, and neurological status
• Mostly used in the hospital setting for COPD • Assessment of physiologic parameters:
patients measurement of oxygen tensions or saturation
in any patient treated with oxygen
18
Assessing Oxygen Levels
Arterial Blood Gas or ABG

Measures carbon dioxide levels
Oxygen saturation or O2 sat
Oxygen Equipment
• Gas cylinders
• Cylinder pressure gauge
• Flow meter
• Regulator knob
• Nipple adapter
• Humidifier
19
Oxygen: a fire hazard
• NEVER smoke while using supplemental

oxygen
• Severe facial burns can and do happen
Modul Ketrampilan Oksigen Terapi

Precautions of Supplemental
Oxygen I. Tujuan Umum
Setelah melakukan ketrampilan ini para peserta
1. Oxygen toxicity diharapkan dapat melakukan terapi oksigen dengan
2. Depression of ventilation
benar.
3. Retinopathy of Prematurity
4. Absorption atelectasis
5. Bacterial infection with humidifiers II. Tujuan Khusus
Setelah menyelesaikan modul ini diharapkan para
peserta dapat melakukan prosedur oksigen terapi,
indikasi untuk oksigen terapi dan tujuan dari oksigen
terapi.
SIDE EFFECTS OF OXYGEN

III. Perlengkapan
• Nasal drying
• Nasal bleeding • Alat – alat:meja, kursi, tempat pemeriksaan,
• Increase in blood carbon dioxide (CO2) nasal kanul,simple mask oxygen,partial non-
• Atelectasis (collapse) rebreathig, dan true nonrebreathing..
• Airway inflammation • Pelatih
• Lung edema/ inflammation • Pasien
• Damage to retina: infants, high O2 • Panduan belajar
20
IV. Panduan langkah langkah terapi oksigen B.2.Terapi oksigen dengan nasal kanul
pada orang dewasa Inspeksi masing-masing lubang hidung dengan senter.Cek patensi, polip,
edema dan adanya deviasi septum atau adanya obstruksi.Jika ke 2
1 lubang hidung obstruksi, harus menggunakan masker untuk terapi
A . Pendekatan pasien oksigen.
Periksa apakah nasal prong lurus,rata atau terlipat.Tempatkan lekukan

2 nasal prong sesuai dengan anatomi hidung.Posisi ini mencegah
1 Berikan salam pada pasien dengan ramah obstruksi karena mucus nasal yang dapat mengurangi aliran oksigen.
Sekarang kaitkan saluran nasal kanul di belakang telinga pasien dan ke

Berikan penjelasan ke pasien tentang oksigen bawah dagu.
3
2 terapi dan tujuan yang diharapkan setelah
pemberian oksigen terapi tersebut.
B.Prosedur terapi oksigen
B.1. Langkah dasar persiapan alat terapi oksigen.
Cuci tangan sebelum dan sesudah melakukan terapi oksigen.Jika

1 menggunakan oksigen sentral , hubungkan adaptor ke unit tersebut dan
perhatikan apakah ada kebocoran atau tidak.
Hubungkan flow meter dan putar untuk menyakinkan flow meter bekerja
2
dengan baik.Putar silinder pada tabung oksigen .
Periksa ukuran silinder untuk mengecek persediaan oksigen
3
Isi botol pelembab kurang lebih setengahhnya dengan air steril .
4
Hubungkan botol pelembab dengan pasangannya. Set jumlah
5 kebutuhan oksigen pada flowmeter. Yakinkan bahwa pertengahan bola
penunjuk pada garis liter per menit yang diberikan.
Sekarang mulai pemberian oksigen.
6
B.3.Terapi Oksigen dengan masker

Cari ukuran masker yang paling sesuai dengan pasien sehingga
1 mengurangi kebocoran udara.
Hubungkan slang, masker, dan tabung pelembab ke flow meter.Atur
2 konsentrasi oksigen yang diinginkan.
Untuk simple mask atur sesuai dengan kebutuhan oksigen yang

3 diperlukan.For a simple face mask, set the flowmeter to supply the
prescribed oxygen rate.
Untuk non rebreathing atau partial rebreathing mask, atur flowmeter sesuai
4 kebutuhan oksigen , biasanya antara 6 sampai dengan 15 liter per menit.
Amati inflasi dari reservoir bag dari masker.Jika menggunakan non
rebreathing yakinkan bahwa klep aliran satu arah berjalan dengan baik.
5 6.Sewaktu pasien bernafas, perhatikan reservoir akan mengempis
sebagian sewaktu inspirasi.
21
OXYGEN THERAPY FOR PEDIATRIC
Dr. Heda Melinda, dr., SpA(K).,M.Kes
After completing skill practice, the student will be able to perform oxygen therapy.
At the end of skill practice, the student will be able to perform the procedure of oxygen
therapy.
After finishing skill practice of oxygen therapy, the student will be able to perform oxygen
therapy
Student will be able to demonstrate the procedure of oxygen therapy.
3.3. Method
a. Presentation
b. Demonstration
c. Coaching
d. Self-practice: role – play
 Skills laboratory :
a table
b chairs
c examination couch
d Cylinder labeled “OXYGEN”
e Regulator with the gauge
f Humidifier filled up with sterile water
g Oxygen delivery plastic tube
22
h Nasal cannula (one adult nasal cannula and one pediatric cannula, and nasal
prong)
i Hand gloves
j Baby mannequin
 Trainers
 Student learning guide
 Trainer’s guide.
3.5. Venue
3.6. Evaluation
b. OSCE
After finishing skill practice of oxygen therapy, the student will be able to perform oxygen
therapy.
Student will be able to demonstrate the procedure of oxygen therapy, correct documented
or suspected acute hypoxemia, decrease the symptoms associated with chronic hypoxemia,
and decrease the work load hypoxemia imposes on the cardiopulmonary system.
3.9. Method
a. Presentation
b. Demonstration
c. Coaching
d. Self-practice
23
LEARNING GUIDE OXYGEN THERAPY IN PEDIATRIC
Performance Scale
No PROCEDURE (STEP/TASK)
0 1 2
1 Preparations
1. Greet client/parents respectfully and with kindness.
2. Tell client/parents what is going to be done and encourage them to ask
some questions.
3. Provide information about oxygen therapy, indication and its goals.
The indications are central cyanosis, inability to drink, severe chest in
drawing, over 70 breaths/minute, grunting, restlessness
2 The Oxygen Delivery
1. Check the cylinder is written “OXYGEN”.
2. Prepare the equipment for the administration of oxygen
 Oxygen cylinder
 Regulator with the gauge to reduce the high pressure of gas to a
constant lower working pressure (a full oxygen cylinder has a
pressure around 2000 p.s.i / 13,400 kPa / 132 atmospheres or bars,
if less than 120 p.s.i / 800 kPa / 8 atmospheres or bars it means
nearly empty).
 Flow control device must be attached downstream from the
regulator (Flow-meter with a range of 0.5-15 l/min, 0.5-2 l/min for
pediatric patient, sometimes up to 5 l/min if desirable)
 Humidifier filled up with clean water has been boiled and cooled up
to water level (periodically washed and dried)
 A 2-metre length of plastic tube oxygen delivery.
 Prongs or cannula (can be replaced by nasogastric tube).
3 Administration of Oxygen
Using nasal prongs
1. Wash your hand and dry it with dry towel. Put on the gloves.
2. Gently suck all the mucus from the child’s nose and pharynx.
3. Open the flow-meter and check effectiveness of the flow, if the child less
than 2 months old, give 0.5 l/m, if more than 2 months give 1 l/m (will
deliver about 30-35% of oxygen if child’s nose is not blocked and the child
is not breathing through the mouth).
4. Enter the nasal infant or pediatric prongs to the child’s nostrils.
5. Remove the gloves
6. Tape the prongs to the child’s face just inside the nostrils.
4 Warnings on the use of Oxygen

1. Oxygen can cause a fire to spread rapidly.
2. Make sure that no body is smoking.
3. Keep anything that might create a spark or flame.
4. In case of fire, switch off the flow immediately.
Note:
24
25
Indication (cont’)
3. Severe chest indrawing
– Berman et all:
OXYGEN THERAPY Significant relationship between chest indrawing
& hypoxaemia
4. Respiration > 70 x/minute (2 months-5 years)
– Onyango et all:
PEDIATRIC RESPIROLOGY RR>70 x/mt (3-11 month) & RR>60 x/mt (≥ 12

CHILD HEALTH DEPARTEMENT months) best predictor for hypoxaemia by pulse
MEDICINE FAKULTY PADJADJARAN UNIVERSITY oxymetri
DR HASAN SADIKIN HOSPITAL
Introduction
Indication (cont’)
 Oxygen, first isolated: Priestley (1744) 5. Grunting
 First used therapeutically: Beddoes (1798)  Harrison et all:

Grunting is protective mechanism in hypoxaemia
 First used in logical way: JS Haldane
babies with HMD
- Treated soldiers affected by toxic
 Onyango et all:
chlorine gas
<3 months: not significant in hypoxaemia
- Developed equipment delivered oxygen
3-11months: 64% sensitivity & 56% specificity
cheaply and affectively
>12 months: 56% sensitivity & 76% specificity
Indication Indication (cont’)

1. Hypoxemia 6. Restlessness
– PaO2 < 50 or SpO2 < 90% on room air – Morrison:
2. Central cyanosis Restlessness was the best guide to the
– Best clinical sign of hypoxaemia presence of hypoxaemia
– Late sign (PaO2 fetal heme: 32-42;
PaO2 adult heme: 42-53) 7. Inability to drink
– Relatively insensitive sign (ex: anaemia)  Relationship between inability to feed and
– Individual perception & need light mortality from pneumonia
condition
26
Equipment for the Administration of Oxygen
Indication (cont’) Regulator
8. Resuscitation  To reduce the pressure to a constant lower working
– Asphyxia pressure and to allow the flow of gas to be controlled
 Must match with cylinder connector
– Apnea, bradicardia, or hypercarbia
 Should include a high pressure gauge which indicates
amount of oxygen remaining in the cylinder
 The pressure: 120 p.s.i – 2000 p.s.i
Oxygen Sources
• Oxygen Cylinder
Equipment (cont’)
Produced by cooling air until it liquifies Flow meter
And distilling liquid to separate pure oxygen
Flowmeter/flow controller must be
Only be done in large manufactory
attached downstream from the regulator
to allow the flow of oxygen to the patient
precisely set (0,5-2 l/min in pediatric use)
Oxygen Sources (cont’) Equipment (cont’)

• Oxygen Concentrator Humidifier
A portable oxygen concentrator extract
 reduce the dryness of the oxygen
nitrogen and concentrates oxygen.
Deliver 2-4 l/min gas containing > 90% oxygen  if oxygen given by nasopharingeal
Need power supply, more lighter, smaller, and  Water has to be boiled/destilled & add to level
cheaper mark on the jar
 replaced everyday may become colonized
by bacteria
 Periodically washed and dried
27
Equipment (cont’) Methods (cont’)
Plastic oxygen delivery tubing Nasal prong
• Device ending in two

short tapered tubes
• also called nasal cannula
• Not as efficient as
nasopharyngeal catheter
• < 2 month/< 5 kg: 0.5 l/mn;
>2 mt/>5 kg: 1 l/mn
(diliver: 35-40% oxygen)
Methods of Oxygen Administration

Methods (cont’)
Nasopharyngeal catheter Headbox
• The tube passed through the nose until its tip
• Well tolerated by babies, not need
lies in the patient’s throat, just beyond the
soft palate humidification
• Require lowest flow rate (1 l/min deliver 45- • Require much higher flows of oxygen
60% of oxygen to 5 kg child)
• No danger of hyperkarbia • Hypercabia occur if the oxygen tubing kinks,
• Should be humidified disconnects, or oxygen flow rate is too low
• Risk of gastric distension
Methods (cont’)
Methods (cont’)
Nasal Catheter
 Tube passed through the nose and ends with its tip in Facemask
the nasal cavity or just within the nasopharynx. • High flows of oxygen are needed to attain 40-
The tip should not visible when the mouth is open 50% oxygen with mask (4 l/min)
 use 6-8 FG castaheter
 < 2 month/< 5 kg: 0.5 l/mn; >2 mt/>5 kg: 1l/mn
(diliver: 35-40% oxygen)
 require higher flow
 Humidification is not necessary
28
Monitoring
Stop Oxygen Therapy
• Clinical sign Improving clinically
• Blood Gas Analyzed (absence cyanosis or chest indrawing)
• Pulse oxymetri
A trial period without oxygen

Remove nasal prong/disconnect oxygen and closely
observe the child about 10 minutes.
If the child comfortable, oxygen therapy is no
longer needed
29
Respiratory physical examination in adults
After completing skill practice, the student will be able to perform respiratory physical
examination.
At the end of skill practice, the student will be able to perform the procedure of respiratory
physical examination systematically including:
 Systematic physical examination of respiratory system by performing inspection, palpation,

percussion and auscultation
3.1 Sub Module Objective
After finishing skill practice of clinical examination, the student will be able to perform
physical examination of respiratory disorders
3.2 Expected competencies
Student will be able to demonstrate the procedure of respiratory disorders
3.3. Method
a. Presentation
b. Demonstration
c. Coaching
d. Self practice : role-play
3.4 Laboratory facilities
a. Skills laboratory: table, chairs, and examination couch

b. Trainers
c. Patient: real patient and model
30
f. References
3.5 Venue
3.6 Evaluation
a. Point nodal evaluation

b. OSCE
3.7. Sub Model Objective
After finishing skill practice of clinical examination, the student will be able to perform
respiratory system physical examination.
3.8. Expected Competencies
Student will be able to demonstrate the procedure of physical examination of:
 Locating Cervical lymph node

 Tracheal position
 Locating chest abnormalities vertically and circumferentially
 Shape and movement of the chest
 Tactile fremitus
 Chest Percussion
 Normal breath sounds
 Presence and absent of adventitious sounds
 Presence and absent of transmitted voice sounds (bronchophony, egophony and
whispered pectoriloquy)
31
IV. LEARNING GUIDE FOR PHYSICAL EXAMINATION OF ADULT RESPIRATORY PATIENT
Procedure for clinical examination
No Step to be done 0 1 2
I PREPARATION
1 Greet client respectfully and with kindness. Tell the patient what is going to be done
2 Help the patient on to the examination table
3 Wash hands thoroughly with soap and water and dry with a clean dry cloth or air drier
4 The examiner should stand at the patient’s right side
II EXAMINATION TECHNIQUE
A General Physical Examination (described elsewhere)
B Locating Cervical Lymph Nodes

1. Make the patient comfortable and relax
2. Flexed the neck slightly forward and if needed slightly toward the examination
3. Palpate using the pads of your index and middle fingers
4. Move the skin over the underling tissue in each area
5. Describe location, quantity, size (diameter), consistency, movability, presence
specific formation (package).
Findings :
1. Preauricular – in front of the ear
2. Posterior auricular – superficial to mastoid process
3. Occipital – at the base of the skull posteriorly
4. Tonsilar – at the angle of mandible
5. Submandibular – midway between the angle and the tip of the mandible. These
nodes are usually smaller and smoother than lobulated submandibular gland against
which they lie
6. Submental – in the midline a few cm behind the tip of mandible
7. Superficial cervical – superficial to sternomastoid
8. Posterior cervical – along the anterior edge of trapezius
9. Deep cervical chain – deep to the sternomastoid and often inaccessible to
examination. Hook your thumb and fingers around either side of the sternomastoid
muscle to find them
10. Supraclavicular – deep in the angle formed by the clavicle and the sternomastoid
C TRACHEA
1. Inspect trachea for any deviation from its midline position.
2. Place the finger along one side of the trachea and note
the space between trachea and the sternomastoid.
3. Compare it with the other side. Normally the space
should be symmetrical.
D Locating Chest abnormalities To locate vertically Anterior chest
1. Identify the suprasternal notch
2. Move your down about 5 cm
3. Find the horizontal bony ridge that join the manubrium to the body of
sternum.
32
4. Move your finger laterally and find the adjacent 2nd rib and costal cartilage
5. From here you can walk down the interspaces.
6. The first intercostals space below the 2nd rib is the second intercostals space.
Posterior chest
1. Flexed the patients neck forward
2. Find the most prominent process
3. The most prominent is the C7
4. When two process appear equally prominent they are C7 and T1
5. Then you can felt and counted the process below them
6. You can also estimating location from location of inferior angle of scapula is
usually leis at the level of the 7th rib of interspace.
To locate findings around the circumference of the chest

1. midsternal and vertebral are lines drops vertically mid sternal and midvertebral
2. Identify both end of the clavicle and the midclavicular line drops vertically from
the mid point of clavicle.
3. Anterior and posterior axillary lines drop vertically from the anterior and
posterior axillary folds
4. The midaxillary line drops from the apex of the axilla
TECHNIQUES OF CHEST EXAMINATION
Examine the anterior chest

Inspection
1. place the patient in supine position
2. your position is in the midline position in front of the patient
3. inspect the shape of the chest and the way in which it moves
4. findings : deformities or asymmetry, abnormal retraction of interspace during
inspiration, impairment of respiratory movement on one or both side or a unilateral
lag (delay) in the movement.
Palpation
Test respiratory expansion
1. place your thumb about at the level of and parallel to the 10th ribs, your hands
grasping the lateral rib cage.
2. Slide your hand medially a bit in order to raise loose skin folds between your thumb
and the spine.
3. ask the patient to inhale deeply
4. Watch the divergence of your thumbs during inspiration and feel for the range and
symmetry of respiratory as the thorax expands and feel for the extent and
symmetry of respiratory movement.
Tactile fremitus
a. use either the ball (the bony part of the palm at the base of the fingers) or the ulnar
surface of your hand and place it in both side of the chest symmetrically
b. ask the patients to repeat the words “ninety nine” or “one – one – one”
c. repeat this examinations in other areas of the chest symmetrically
33
Percussion
1. hyperextend the middle finger of your left hand (the pleximeter finger)
2. press its distal interphalangeal joint firmly on the surface to be percussed.
3. AVOID contact by any other part of the hand
4. Position your right forearm quite close to the surface with the hand cocked upward.
The right middle finger should be partially flexed, relaxed, and poised to strike
5. Strike the pleximeter finger with the right middle finger (the plexor), with a quick,
sharp but relaxed wrist motion
6. Aim the strike at your distal interphalangeal joint.
7. Learn to identify five percussion notes which can be distinguished by differences in
their basic qualities of sound : intensity, pitch and duration.
Auscultation
1. instruct the patients to breath deeply through an open mouth
2. listen to breath sound with the diaphragm of your stethoscope
3. move your stethoscope from one side to the other and comparing symmetrical areas
of the lung
4. pattern of breath sound identified by their intensity, pitch, and relative duration of
their inspiratory and expiratory phases
5. the normal breath sounds are : vesicular, bronchovesicular and bronchial
6. listen for any added or adventitious sound that are superimposed on the usual
breath sound. Adventitious sounds are crackles (rales), wheezes and rhonchi
7. if you hear crackles, listen for the following characteristics
a. loudness, pitch and duration (summarized as fine or coarse crackles)
b. number (few to many)
c. timing in respiratory cycle
d. location on the chest wall
e. persistence of their pattern from breath to breath
f. any change after a cough or a change in the patients position
8. if you hear wheeze or rhonchi , note their timing and location and do they change
with deep breathing or coughing
9. if you hear abnormally located bronchovesicular or bronchial breath sound, continue
on to asses transmitted voice sound.
10. With stethoscope, listen in symmetrical areas over the chest, as you :
g. ask the patient to say “ninety nine”. Normally the sound transmitted through the
chest wall are muffled and indistinct. Louder and clearer voice sounds are called
bronchophony
h. ask the patient to sal “ee” you will normally hear a muffled long E sound. When
“ee” is heard as “ay”. An E to A change (egophony) is present.
i. Ask the patient to whisper “ninety nine” or “one – two – three “. The whispered
voice is normally heard faintly and indistinctly. Louder, clearer whispered sounds
are called whispered pectoriloquy
Note:
34
Physical Examination on Adult
PRAYUDI SANTOSO
Dept. of Internal Medicine, Pulmonary Division
School of Medicine Padjadjaran University
BANDUNG
35
36
Precautions
• The patient should be comfortable and

treated with respect throughout the
examination. As the examination proceeded,
the examiner should explain what he or she is
doing and share any relevant findings.
37
NEEDLE THORACOSTOMY
After completing skill practice, the student will be able to perform needle thoracostomy.
At the end of skill practice, the student will be able to perform the procedure of needle
thoracostomy, indications for needle thoracostomy, and goal of needle thoracostomy .
After finishing skill practice of needle thoracostomy , the student will be able to perform
needle thoracostomy .
Student will be able to demonstrate the procedure of needle thoracostomy , indications

and goal of needle thoracostomy.
3.3. Method
a. Presentation
b. Demonstration
c. Coaching
d. Self practice: role – play
a. Skills laboratory : table, chairs, examination couch, povidone-iodine solution, a

sterile 16 G or larger needle(vein catheter),syringe 3 cc, cotton swab, measuring
glass with water tube, tape and a sterile glove
b. Trainers
c. Patient
f. References
38
3.5. Venue
3.6. Evaluation

b. OSCE
After finishing skill practice of needle thoracostomy, the student will be able to
perform needle thoracotomy.
Student will be able to demonstrate the procedure of needle thoracostomy, correct

tension pneumothorax for life-threatening until a doctor can insert a chest tube.
3.9. Method
a. Presentation
b. Demonstration
c. Coaching
d. Self practice
b. Trainers
f. References
39
Learning Guide Needle Thoracostomy
No. Steps/Task 1 2
A. Preparation the tools
Needle No. 16(vein catheter), syringe 3 cc, gloves, cotton swab, povidon iodine,
Normal saline, com, kidney basin, measuring glass with water tube, tape
B. CLIENT ASSESSMENT
2. The patient should be given adequate explanation about needle thoracostomy and
the goal or expected result needle thoracotomy (Briefly)
C. PERFORMING NEEDLE THORACOSTOMY
1. Wash your hand and dry it with dry towel. Put on the gloves.
2. Clean the skin around the second intercostals space at the midclavicular line, using
povidone–iodine solution. Use a circular motion, starting at the center and working
outward.
3. Fill the syringe with 2 cc sterile normal saline
4. Change the syringe needle with 16G or larger catheter with needle. Insert the
needle with attached syringe immediately over the superior portion of the rib and
through the tissue covering the pleural cavity while aspirating.
5. When air is aspirated, advance catheter completely and withdraw syringe. Connect
the inserted catheter with tubing immediately and place the other end of tubing in
a measuring glass filled with water.
6. Leave the needle in place until a chest tube can be inserted.
Note:
40
HEIMLICH MANOUVER
Arto S. Yuwono, dr.,SpPD-KP,FCCP,FINASIM
After completing skill practice, the students will be able to perform Heimlich’ manouver.
At the end of skill practice, the student will be able to perform the procedure of Heimlich’
manouver indications for needle thoracotomy , and goal of Heimlich’ manouver.
After finishing skill practice of Heimlich’ manouver, the student will be able to perform
Heimlich’ manouver.
Student will be able to demonstrate the procedure of Heimlich’ manouver, indications and
goal of Heimlich’ manouver.
3.3.Method
a. Presentation
b. Demonstration
c. Coaching
d. Self practice: role – play
a. Skills laboratory: table, chairs, examination couch,

b. Trainers
c. Patient
f. References
41
3.5. Venue
Skills laboratory
3.6. Evaluation

b. OSCE
After finishing skill practice of Heimlich’ manouver, the student will be able to perform
Heimlich’ manouver.
Student will be able to demonstrate the procedure of Heimlich’ manouver,
3.9. Method
a. Presentation
b. Demonstration
c. Coaching
d. Self practice
b. Trainers
f. References
42
Learning Guide Heimlich Manouver
No. STEPS/TASK 1 2
2 The patient should be given adequate explanation about Heimlich manouver and the
goal or expected result Heimlich manouver
B. PERFORMING ABDOMINAL THRUSTS (HEIMLICH’ MANOUVER)
1. Standing behind the patient, wrap both arms around his waist.
2. Place your fist int the center of his abdomen, midway between the umbilicus and the
xiphoid process. Rest the thumb side of your fist aginst his epigastrium and then grasp
your fist with your other hand.
3. Using a quick motion, thrust your fists inward and upward four times
4. Repeat the process until the obstruction is removed.
Note:
43
NEEDLE THORACOSTOMY
TOPIC
HEIMLICH’ MANEUVER
NEEDLE THORACOSTOMY
HEIMLICH’ MANEUVER OBJECTIVE
BE ABLE TO PERFORM PROCEDURE OF

NEEDLE THORACOSTOMY AND HEIMLICH’
SKILL LABORATORY
MANEUVER
RESPIRATORY SYSTEM
YANA AKHMAD
ARTO YUWONO
KNOW INDICATIONS AND GOAL OF THE
PRAYUDI SANTOSO PROCEDURES
INTRODUCTION PNEUMOTHORAX
THE PRESENCE OF AIR WITHIN

• NEEDLE THORACOSTOMY IN THE PLEURAL SPACE
PROCEDURE FOR EMERGENCY

DECOMPRESSION OF THE CHEST UNTIL A CATAGORIES :
CHEST TUBE CAN BE INSERTED
• TRAUMATIC (ACCIDENTAL OR IATROGENIC)
• PATIENT WITH LIFE THREATENING TENSION • SPONTANEOUS (WITHOUT AN OBVIOUS CAUSE)
PNEUMOTHORAX - PRIMARY (NO UNDERLYING LUNG DISEASE)
- SECONDARY (HAS A PREDISPOSING LUNG DISEASE)
MECHANISM CLINICAL MANIFESTATION

• COMMUNICATION BETWEEN THE ALVEOLI • DEPEND ON THE VOLUME OF THE PNEUMOTHORAX
AND THE PLEURAL SPACE (BRONCHOPLEURAL AND PRESENCE OR ABSENCE OF UNDERLYING LUNG
FISTULA) DISEASE
SYMPTOM - DYSPNEA
• COMMUNICATION BETWEEN THE - CHEST PAIN : SHARP AND ABRUPT
ATMOSPHERE AND THE PLEURAL SPACE • SMALL PNEUMOTHORAX :
(PENETRATING CHEST WOUND OR - ASYMPTOMATIC
TRAUMATIC)
44
TENSION PNEUMOTHORAX
• OCCUR WHEN AIR IN THE PLEURAL SPACE EXCEEDS
ATMOSPHERIC PRESSURE
• MEDIASTINAL SHIFT TO CONTRALATERAL SIDE, PLACES
TORSION ON THE INFERIOR VENA CAVA, VENOUS RETURN
DECREASE, CARDIAC OUTPUT DECREASE, AND HIPOTENSION
RESULT
• THE LUNG CONTINOUS TO COMPRESS, INTRA PULMONARY
SHUNTING THROUGH THE COLLAPSED LUNG CAUSED
HYPOXEMIA
LIFE THREATENING
TREATMENT IS EMERGENCY
DECOMPRESI OF THE CHEST
NEEDLE THORACOTOMY
Learning Guide for needle thoracostomy

No. Steps/Task
A.CLIENT ASSESSMENT
2. The patient should be given adequate explanation about needle thoracotomy and the goal or expected
result of needle thoracotomy (Briefly)
B.PERFORMING NEEDLE THORACOSTOMY
1. Clean the skin around the second intercostals space at the midclavicular line, using povidone –iodine
solution. Use a circular motion, starting at the center and working outward.
2. Fill the syringe with 2 cc sterile normal saline
3. Insert a sterile 16G or larger needle with attached syringe immediately over the superior portion of the
rib and through the tissue covering the pleural cavity while aspirating
4. When air is aspirated, advance catheter completely, and withdraw syringe. Withdraw syringe following
connect the inserted needle with tubing immediately and place the other end of tubing in a measuring
glass filled with water
5. Leave the needle in place until a chest tube can be inserted.
45
HEIMLICH’ MANEUVER
(ABDOMINAL THRUSTS)
• COMPLETE OBSTRUCTION : CANNOT TALK, COUGH OR

INTRODUCTION BREATH
 THE PATIENT CLUTCHES AT HIS/HER THROAT
• FOREIGN BODY AIRWAY OBSTRUCTION
(UNIVERSAL DISTRESS SIGNAL OF FOREIGN
- VOMITUS, FOOD BOLUS, OTHER BODY OBSTRUCTION)
 NEED OF EMERGENCY INTERVENTION
• MAY CAUSE EITHER PARTIAL OR COMPLETE  THE PROCEDURE OF CHOICE FOR CLEARING A
OBSTRUCTION FOREIGN BODY FROM AIRWAY OBSTRUCTION :
- ABDOMINAL THRUSTS (HEIMLICH’MANEUVER)
• PARTIAL OBTRUCTION : CONSCIOUS AND COUGHING ADULT, CHILDREN
- BACK BLOWS INFANT,
- CHEST THRUSTS ADVANCED PREGNANCY
46
FORCEFUL THRUSTS APPLIED TO THE EPIGASTRIUM CAN
HEIMLICH’ MANEUVER DISLODGE AN OBSTRUCTION CAUSED BY FOREIGN BODY
• THE PROCEDURE OF CHOICE FOR CLEARING A QUICK THRUSTS TO THE

FOREIGN BODY FROM AIRWAY OBSTRUCTION : ABDOMEN
• THIS PROCEDUR NORMALY ARE FOLLOWED BY A MANUAL

DISPLACE DIAPHRAGM
CHECK AND REMOVAL OF ANY OBSTRUCTING FOREIGN UPWARD
MATERIAL
INCREASING INTRATHORACIC PRESSURE AND CREATING

EXPLUSIVE EXPIRATORY AIRFLOW
EXPEL THE FOREIGN BODY FROM THE AIRWAY
Learning Guide for Heimlich Manuver

No. STEPS/TASK
2 The patient should be given adequate explanation about Heimlich manuver and the goal or expected result
Heimlich maneuver (Briefly)
B. PERFORMING ABDOMINAL THRUSTS (HEIMLICH’ MANUVER)
1. Standing behind the patient, wrap both arms around his waist.
2. Place your fist int the center of his abdomen, midway between the umbilicus and the xiphoid process. Rest
the thumb side of your fist aginst his epigastrium and then grasp your fist with your other hand.
3. Using a quick motion, thrust your fists inward and upward
4. Repeat the process until the obstruction is removed
47
TUBERCULIN SKIN TESTING (MANTOUX
TEST=PPD TEST)
Dr. Heda Melinda, dr., SpA(K).,M.Kes
After finishing this skill practice, the students will be able to perform Mantoux test/PPD
test and reading and recording its result 48-72 hours afterward.
At the end of this skill practice, the students will be able to perform and reading and
recording the result of Mantoux test/PPD test for diagnosis of tuberculosis in children.
a. Methods
a. Presentation
b. Demonstration (by movie)
c. Training
b. Laboratory facilities
i. Skills laboratory:
- Cotton ball
- Alcohol 70% or alcohol swab
- PPD RT 23 – 2 TU solution or PPD-S 5 TU
- Disposable tuberculin syringe
- Medical disposal box
- Non medical disposal box
- Chlorine solution
- Hand soap
- Gloves
- Model
- Transparent millimetre ruler
- Ballpoint/pen
- Examiner guide
 Trainers
 Students learning guide
 Trainers guide
c. Venue
Skills laboratory
d. Evaluation
b. OSCE
48
LEARNING GUIDE
TUBERCULIN SKIN TESTING (MANTOUX TEST or PURIFIED PROTEIN DERIVATIVE=PPD TEST)
No ITEMS 0 1 2
A Preparations
1 Greet client/parents and introduce yourself
Tell client/parents what is going to be done and encourage them to ask
questions.
B The Implementation of procedure
2 Wash hands
3 Aspirate 0.1 ml PPD RT-23 2 TU solution or PPD-S 5 TU into the disposable
tuberculin syringe.
4 Apply antiseptic solution (alcohol 70%) or alcohol swab on the injection area
which is 5-10 cm below elbow joint.
5 Hold the skin of the forearm taut
6 Insert the needle slowly into the skin intracutaneously on the volar surface
of the forearm with the bevel of syringe face up, at an angle 5-150. Needle
bevel should be visible just below skin surface.
7 Checked injection site.
If injected appropriately, a 6-10 mm wheal will be formed. If not, repeat the
injection at a site at least 5 cm away from the original site
8 Remove your syringe
Insert the needles into needle disposal box and cut the needle within the
box, put the used syringe in separate box
9 Wash hands
10 Counseled the parent that the procedure must be evaluated in the 48-72
hours after injection.
C Reading of the result
11 Palpation method.
Palpate the margin of induration by touch and marked the lateral edge by
pen or Ballpoint pen Sokal method by pen and stops at induration.
12 Measure the transversal induration using transparent ruler (in millimeter).
13 Record the result on the patient medical record. If there is no induration,
the record should be written as 0 mm.
TOTAL
49
DEFINITION
Tuberculin skin test

TUBERKULIN SKIN TESTING - Used to determine whether a person has tuberculosis (TB)
(MANTOUX TEST) OR PROTEIN PURIFIED infection. It is not a vaccine
DERIVATIVES
- Tuberculin testing is useful for :
SKILLS LAB a. Examining a person who isn’t sick but may have TB
RESPIRATORY SYSTEM
infection
b. Screening groups of people at risk of TB disease
once infected
c. Examining a person who has symptoms of TB disease
Mantoux Test/PPD Test Types of Skin tests

- The both terms are used interchangeably a. Mantoux skin test (purified protein derivative or PPD)
- Intradermal injection of Purified Protein Derivative 1. Only standarized method available for identifying persons
(PPD) infected with M. tuberculosis
2. Administration
- PPD  highly purified protein fraction  culture - 0,1 ml of PPD tuberculin containing two tuberculin units
filtrates of human type strains of M. Tuberculosis injected intradermally on the volar surface of the forearm
- gloves are not necessary for proper intradermal injections.
- Standar dose  2 tuberculin units ( 2 TU ) However, individual institution or agency policies may
vary
3. Reading
B. Multiple –puncture test
- patient’s arm is inspected 48 to 72 hours after tuberculin
is injected
1. Easy to give and convenient, but not as accurate as
- the reaction is the area of induration, or swelling, around
Mantoux skin test
the injection site. Erythema or redness should be ignored
Amount of tuberculin entering the skin cannot be measured
when assessing induration
2. Positive reactions to multiple-puncture tests should be
* diameter of the indurated area is measured across the
confirmed with a Mantoux skin test
forearm and recorded in millimeters
* erythema, or redness, is not measured. The presence of
erythema does not indicate that a person has TB infection
- a clearly positive reaction may read up to one week (day 7)
after testing
50
DOSAGE & ADMINISTRATION
Positioning The Needle
Mantoux
• PPD solution  plastic walls of syringes •Stretch skin taut between your thumb and
index finger
• Injection intradermally  flexor surface forearm
•Face the bevel of the needle upward and hold the needle
• The site cleansed with alcohol dried with cotton
& syringe almost parallel to the skin
ball
• Inject 0,1 ml PPD solution  ½ inch 26-or 27-
Insert properly
gauge needle
Insert the needle just beneath the skin surface.
• If placed correctly  6-10 mm wheal formed When placed properly, the needle is under the epidermis. A 6-10 mm
• Avoid injecting subcutaneously  no local wheal should appear
reaction develop
The Needle is Too Deep (incorrect)
•Needle placed too deeply under epidermis

 shallow, diffuse bulge instead of a tense
white wheal  difficult to measure
The Needle is Too Shallow (incorrect)
The bevel will barely penetrate the epidermis

Tuberculin → leaking from the injection
→ repeat the test in other arm
51
Method for Reading
-Read the site of the TST in good light with the forearm
supported o a firm surface
-Look for the presence or absence of induration (swelling)
- Using a ballpoint pen, draw a line from the outer edge of
the arm inward toward the induration, and stop when the pen
comes against the border of the induration. Repeat the process
on the other side ( Ballpoint-pen Sokal Method).
- Using a flexible millimeter (mm) ruler , measure across
the induration between the two lines.
- Other method is palpation method
MANTOUX RESULTS
C. Interpretation of Results
A. Readings: TB skin test are measured 48-72 hours 1. Positive Reactions
after injection a. 5 mm
1. A reaction usually consist of both induration and b. 10 mm
erythema. Measure only the induration.
2. Find → margin of induration
3. Diameter of induration → measured transversely 2. Negative Reactions
4. Using a millimeter ruler Any mm reaction < cut-points
B. Recording Results 3. False Negative and Positive Reactions

• All measurements in mm of induration
• No induration 0 mm
D. Counseling Inmates 3. Contraindications

Explain the significance of the (+) or (-) • Those already diagnosed with
reactions culture (+) active TB
• Those with a documented previous
(+) skin test a mm result
52
53
HISTORY TAKING OF
DIFFICULTY BREATHING IN CHILDREN
Sri Sudarwati, dr.,SpA(K)
After finishing skill practice, the students will able to perform history taking of difficulty
breathing in children in order to make a differential and proper diagnosis.
At the end of this skill practice, the students will be able to understand the systematic
information gathering from pediatric history taking about difficulty breathing in children.

3.1 Sub Model Objective
After finishing history taking of difficulty in breathing skill practice, the students will
be able to perform history taking of difficulty breathing in children properly.
3.2 Expected Competencies

Students will be able to demonstrate procedure of pediatric history taking,
especially about difficulty breathing in children.
3.3 Methods
a. Presentation
b. Demonstration
c. Training
d. Self practices
3.4 Laboratory Facilities
 Skills Laboratory:
- Table and Chair
- Oxygen equipment
- Standardized patient
 Trainers
 Standardized patient
 Students Learning guide
 Trainer’s guide
3.5 Venue
Skills Laboratory
3.6 Evaluation
b. OSCE
54
IV.LEARNING GUIDE OF CLINICAL EXAMINATION
Procedure for Clinical Examination
No ITEMS 0 1 2
1 Greets parents and introduces themselves
2 Confirms the identity of the child and the mother
3 Determines the onset and duration of the illness, spontaneously or after some
specific event?
Enquires if this is a first episode or a recurrence?
4 Enquires about associated difficulty in breathing features:
a. Dyspnea on exertion or rest,
b. Medications,
c. Allergies,
d. History of chocking
e. Fever
f. Cough
g. Noisy breathing
h. Wheezing
i. Stridor
j. Cyanosis
k. Environment condition and circumstances
contribute to the symptom develops
(minimal 6 of 11 are asked, give score 2)
5 Previous history
This should include:
 Birth history
 Immunizations
 Medical: Any previous illness or hospital admissions or operations
6 Family history
Any respiratory illness in the family?
7 History of current medication
8 Are there any other significant illnesses?
9 House Environment (ventilation)
TOTAL SCORE
Note:
55
GENERAL PRINCIPLES
HISTORY TAKING OF DIFFICULTY The medical history should be taken in

OF BREATHING IN CHILDREN
• Comfortable seating for all
• A place for clothing and belongings
• Some toys for younger children
• Privacy
SKILLS LABORATORY PROGRAM • Without interruption by phone calls
FACULTY OF MEDICINE – UNIVERSITAS • See one child in at a time
PADJADJARAN
• Questions should be open-ended
STRUCTURE OF THE PEDIATRIC

Data should be recorded include:
HISTORY
• The source of and the reason for referral should
• Name be noted
• The chief complaint should be identified
• Age-date of Birth
• The illness at presentation should be
• Address documented in detail
• Phone numbers - Its onset and duration
- The environment under which it developed
• Name of referring physician
- Its manifestations
• Name of parent - Their treatments and its response
- Its impact on the patient and the family
Symptoms should be defined by:

 The duration of symptom will be classified to
acute, subacute, chronic, recurrent
• Timing, location, aggravating, alleviating factors, • < 3 weeks duration : acute
associated manifestations
• 3 weeks – 3 months : subacute
• Relevant past medical data should be included • > 3 months : chronic
• The onset of disease may have been gradual or
sudden  Symptoms clearly discontinuous with documented
• The age at first presentation (manifest soon after intervals of well being : recurrent
birth to be related to congenital malformation)
 Young normal children may have 6 to 8 respiratory
infectious per year
(particularly during first 2 years)
56
Environmental Factors (seasonal changes) • Diurnal variation (symptom that occur at night)
Should be searched to uncover possible is common in asthma
allergic causes • It is important to know whether other family
• Exposure industrial pollution members are also affected (infection viral)
• Cigarette smoke • Recent travelling to areas where exotic
• Wood burning stove infective organism may have been acquired
• Household pets should be asked (H1N1/Swine Flu)
Exercise in daily activities is a common trigger
factor for cough and wheezing in hypereactive
airways such as asthma
• Drug abuse by parents and high risk life styles

should be asked to consider the possibility of • Feeding history (amount, type, schedule of
HIV infection intake) should be asked. The question of
exercise tolerance in infant is asked by
• Tuberculosis contact should be asked
inquiring how long to finish feeding.
• Birth history should be reviewed (the course
of pregnancy, the duration of pregnancy,
• The reduced caloric intake commonly results
respiratory problems at birth, birth weight,
in a failure to thrive (FTT), older children is
Apgar/Down Score, the neonatal course, signs
loss of appetite.
of neonatal respiratory distress, endotracheal
intubation history
57
• Patients with debilitating neurologic diseases
• Psychosocial development may be affected,
and deficient protective reflexes of upper
limit attendance and performance at school
airways more likely to happen pneumonia
may be found in asthma.
aspiration.
• Family history of respiratory illness should be

• History of the physical development should be
obtained (asthma, tuberculosis pneumonia,
reviewed. In children with chronic respiratory
chronic bronchitis, emphysema, sudden infant
diseases may be retarded.
death).
• Previous medications and their efficacy should be

• A detailed report of immunization should be documented (e.g inhaled bronchodilator).
obtained (BCG, DPT, Polio, measles, Hib,
Pneumococcal vaccine). • Other significant illness should be reported by
review of organ system.
- Cardiovascular findings (palpitation, dysrhytmia)
• Results of prior test e.g tuberculin, chest may be found in hypoxic patients.
radiograph, USG should be documented. - Effect of respiratory disease on the gastrointestinal
tract may appear with cough- induced vomiting and
abdominal pain
• Previous hospital admissions and their
indications should be listed.
58
RESPIRATORY HISTORY TAKING IN ADULTS
After completing skill practice, the student will be able to perform respiratory history
taking.
 At the end of skill practice, the student will be able to perform the procedure of
respiratory History taking systematically.
3.1 Sub Module Objective
After finishing skill practice of clinical examination, the student will be able to
perform history taking of respiratory disorders.
3.2 Expected competencies
Student will be able to demonstrate the procedure of history taking of respiratory

disorders.
3.3. Method
a. Presentation
b. Demonstration
c. Coaching
d. Self practice : role-play
3.4 Laboratory facilities
a. Skills laboratory: table, chairs, and examination couch

b. Trainers
c. Patient : real patient and model
f. References
59
3.5 Venue
Skills laboratory
3.6 Evaluation
a) Point nodal evaluation
b) OSCE
3.7. Sub Model Objective
After finishing skill practice of clinical examination, the student will be able to
perform respiratory History taking.
3.8. Expected Competencies
Student will be able to demonstrate the procedure of History taking of adult

respiratory patient
60
IV. LEARNING GUIDE FOR HISTORY TAKING OF ADULT RESPIRATORY PATIENT
Procedure for clinical examination
No Steps/ Task 0 1 2
2. The patient should be given adequate explanation about history taking and the goal
or expected result of history taking
3. Identifying patient’s data ( described elsewhere)
B. HISTORY TAKING. Take a medical history considering :

1 Chief complaint
- Dyspnea
- Fever
- Cough (expectoration)
- - Chest pain
2. Present illness (depends on the chief complaint)
Chronology of chief complaint
- Location
- Quality
- Severity
- Timing (onset, duration, frequency)
- Setting in which the symptoms occur
- Factors that precipitate, aggravate or alleviate
- Any associated manifestation(s)
3 General medical history

- Past history
- Family history
o (Asthma and other atopic disease Alpha 1 antitrypsin)
- Occupational history
- Tuberculosis contact
- Smoking history
HISTORY TAKING
DYSPNEA
TIMING
 since when ?
 how about the progression. Is it slowly progressive?, acute in onset and
separate with symptoms free period?, sudden onset of dyspnea ?, episodic
and recurrent ?
FACTORS THAT AGGREVATE
61
 is the dyspnea worsen with position (supine, lying down to right/left)
 is the dyspnea worsen with exertion or with rest ?
 is the dyspnea worsen with allergen, irritants, respiratory infection,
emotion.
FACTOR THAT RELIEVE

 is the dyspnea relieve with position (rest, sitting up) ?
 is the dyspnea relieve with expectoration ?
 is the dyspnea relieve with separation from aggravating factors ?
ASSOCIATED SYMPTOMS
 cough, ortopnea, paroxysmal nocturnal dyspnea
 chronic productive cough, recurrent respiratory infection, wheezing
 pleuritic pain, fever
 hemoptysis
 palpitation, chest pain
SETTING
 history of heart disease or its risk factors ?
 history of smoking, air pollutants and recurrent respiratory infection ?
 environmental and emotional condition
 postpartum, postoperative period, prolong bed rest, hip/leg, CHF, COPD
 anxiety
CHEST PAIN
1. Where is it ? Restrosternal, precordial, left or right side of chest wall
Does it radiate? To the neck, back.
2. What is it like? sharp, knife like, pressing
3. How bad is it, severe?
4. When does this complain start? How long? How often does it come?
5. What factor that make is worse? Deep breathings coughing?
6. And what factor make it better, relieve?
Rest, sitting up, lying on the involved side (left/right side)
7. Is there any symptom accompanied it.

Dyspnea, coughing, fever.
COUGH
1. DO YOU HAVE A COUGH?
2. ITS QUALITY DRY OR PRODUCTIVE COUGH
3. ITS QUANTITY OR SEVERITY :
 VOLUME → LARGE IS IT ?
 INTERMITTENT
 PERSISTENT CHRONIC BRONCHITIS
 COLOR
 ODOR
 CONSISTENCY
4. ITS TIMING : NEW SYMPTOM OR MORE CHRONIC
62
5. THE SETTING IS WHICH OCCURS WORSE AT NIGHT ? WORSE IN THE
MORNING
6. FACTORS THAT MAKE A BETTER OR WORSE
7. ASSOCIATED MANIFESTATION : (TABLE 1,2,3)
SYMPTOMS ASSOCIATED WITH THE COUGH LEAD YOU ITS CAUSE
Note:
63
History taking
on Adult
PRAYUDI SANTOSO
Dept. of Internal Medicine, Pulmonary Division
School of Medicine Padjadjaran University
BANDUNG
COUGH COUGH
• A COUGH 1S THE COMMONEST 1. DO YOU HAVE A COUGH ?
2. ITS QUALITY DRY OR PRODUCTIVE COUGH
MANIFESTATION OF LOWER RESPIRATORY
3. ITS QUANTITY OR SEVERITY :
TRACT DISEASE • VOLUME → LARGE IS IT ?
• A PERSON MAY COUGH VOLUNTARILY, BUT »
»
INTERMITTENT
PERSISTENT CHRONIC BRONCHITIS
MORE TYPICALLY COUGH IS A REFLEX • COLOR
RESPONSE TO STIMULLI → IRRITATE • ODOR
RECEPTORS → LARYNX, TRACHEA, LARGE • CONSISTENCY
BRONCHE
Patterns of cough in asthma and chronic

bronchitis
4. ITS TIMING : NEW SYMPTOM OR MORE CHRONIC
5. THE SETTING IS WHICH OCCURS WORSE AT NIGHT ?
WORSE IN THE MORNING Parameter Asthma Chronic bronchitis
6. FACTORS THAT MAKE A BETTER OR WORSE
7. ASSOCIATED MANIFESTATION : (TABLE 1,2,3) Timing Worse at night Worse in the
morning
Chronicity Dry(may be green Productive
SYMPTOMS ASSOCIATED WITH THE COUGH sputum)
LEAD YOU ITS CAUSE Nature Intermittent Persisten
Respon to Associated wheeze is Associated wheeze

treatment reversible is irreversible
64
Types of sputum Common Respiratory Causes Of Cough
Character Cause
Pink/frothy Pulmonary oedema
Cause Nature
Yellow/green Infections/eosinophils in asthma
Asthma Worse at night; dry orproductive
Rusty Pneumococcal pneumonia
Foul-fasting anerobic
COPD Worse in morning; often productive
Viscous,difficult to cough up Asthma/infections Bronchiectasis Related to posture

Large volumes Bronchiectasis Post nasal drip Persistent
Black Cavitating lesions in coal miners Tracheitis Painful
Blood-stained TB,Ca,pneumonia,bronchitis,bronchie Croup Harsh
ctasis,etc
Interstitial fibrosis dry
Cough and Hemoptysis (2

Cough and Hemoptysis (1 Problem Cough and Sputum Associated Symptoms and Setting
Problem Cough and Sputum Associated Symptoms and Chronic Inflammation

Setting Postnatal Drip Chronic cough; sputum mucoid or Repeated attempts to clear the throat.
mucopurulent Postnasal discharge may be sensed by patient
Acute Inflammation
or seen in posterior pharynx. Associated with
Laryngitis Dry cough (without sputum), may An acute, fairly minor illness chronic rhinitis, with or without sinusitis
become productive of variable with hoarseness. Often Chronic Bronchitis Chronic cough; sputum mucoid to Often longstanding cigarette smoking.
amounts of sputum associated with viral purulent, may be blood-streaked or Recurrent superimposed infections. Wheezing
nasopharyngitis even bloody and dyspnea may develop.
Tracheobronchitis Dry cough, may become productive An acute, often viral illness, Bronchiectasis Chronic cough; sputum purulent, often Recurrent bronchopulmonary infections
(as above) with burning retrosternal copious and fouls-smelling; may be common; sinusitis may coexist
discomfort blood-streaked or bloody
Mycoplasma and Viral Dry hacking cough, often becoming An acute febrile illness, often Pulmonary Tuberculosis Cough dry or sputum that is mucoid or Early, no symptoms. Later, anorexia, weight
Pneumonias productive of mucoid sputum with malaise, headache, and purulent; may be blood-streaked or loss, fatigue, fever, and night sweats
possibly dyspnea bloody
Bacterial Pneumonias Pneumococcal: sputum mucoid or An acute illness with chills, Lung Abscess Sputum purulent and foul-smelling; A febrile illness. Often poor dental hygiene
may be bloody and a prior episode of impaired consciousness
purulent; may be blood-streaked, high fever, dyspnea, and chest
diffusely pinkish, or rusty pain. Often is preceded by Asthma Cough, with thick mucoid sputum, Episodic wheezing and dyspnea, but cough
acute upper respiratory especially near end of an attack may occur alone. Often a history of allergy
infection. Gastroesophageal Chronic cough, especially at night or Wheezing, especially at night (often mistaken
Reflux early in the morning for asthma), early morning hoarseness, and
Klebsiella: similar; or sticky, red, Typically occurs in older
repeated attempts to clear the throat. Often a
and jellylike alcoholic men
history of heartburn and regurgitation
Cough and Hemoptysis (3 Chest Pain (1

Problem Cough and Sputum Associated Symptoms and Problem Process Location Quality Severity
Setting
Cardiovascular Temporary Retrosternal or Pressing, Mild to
Angina myocardial ischemia, across the anterior squeezing, tight, moderate,
Neoplasm
Pectoris usually secondary to chest, sometimes heavy, occasionally sometimes
Cancer of the Lung Cough dry to productive; sputum Usually a long history of coronary radiating to the burning perceived as
atherosclerosis shoulders, arms, discomfort
may be blood-streaked or bloody cigarette smoking. Associated
neck, lower jaw, or rather than
manifestations are numerous upper abdomen pain
Cardiovascular Disorders Myocardial Prolonged Same as in angina Same as in angina Often but not
Infarction myocardial ischemia always a
Left Ventricular Often dry, especially on exertion or Dyspnea, orthopnea, resulting in severe pain
Failure or Mitral at night; may progress to the pink paroxysmal nocturnal irreversible muscle
Stenosis frothy sputum of pulmonary edema dyspnea damage or necrosis
or to frank hemoptysis Pericarditis  Irritation

of parietal Predordial, may Sharp, knifelike Often severe
pleura adjacent to radiate to the tip of
Pulmonary Emboli Dry to productive; may be dark, Dyspnea, anxiety, chest pain, pericardium the shoulder and to
bright red, or mixed with blood fever; factors that predispose the neck
to deep venous thrombosis  Mechanism unclear Retrosternal Crushing Severe
Irritating Particles, Variable. There may be a latent Exposure to irritants. Eyes, Dissecting A splitting within the Anterior chest, Ripping, tearing Very severe
period between exposure and nose, and throat may be Aortic layers of the aortic radiating to the
Chemicals, or Aneurysm wall, allowing neck, back, or
symptoms affected
Gases passage of blood to abdomen
dissect a channel
65
Chest Pain (2
Problem Process Location Quality Severity Chest Pain (3
Pulmonary
Problem Timing Factors That Factors That Associated
Tracheobronchitis Inflammation of Upper sternal or on Burning Mild to
trachea and large either side of the moderate Aggravate Relieve Symptoms
bronchi sternum
Cardiovascular Usually 1-3 min but up Exertion, especially in Rest, nitroglycerin Sometimes
Pleural Pain Inflammation of Chest wall overlying Sharp, knifelife Often severe Angina to 10 min. prolonged the cold; meals; dyspnea,
the parietal pleura, the process episodes up to 20 min emotional stress. May nause,
Pectoris
as from pleurisy,
pneumonia, pulmo- occur at rest sweating
nary infarction, or
Myocardial 20 min to several hr Nausea,
neoplasm
Infarction vomiting,
Gastrointestinal and
sweating,
other
weakness
Reflex Esophagitis Inflammation of Retrosternal, may Burning, may be Mild to
the esophageal radiate to the back squeezing severe Pericarditis Persistent Breathing, changing Sitting forward Of the
mucosa by reflux position, coughing, may relieve it underlying
of gastric acid lying down, some- illness
Diffuse Esopha- Motor dysfunction Retrosternal, may Usually squeezing Mild to
times swallowing
geal Spasm of the esophageal radiate to the back, severe
muscle arms, and jaw Dissecting Abrupt onset, early Hypertension Syncope,
Chest Wall Pain Variable, often Often below the left Stabbing, sticking, Variable Aortic peak, persistent for hemiplegia,
unclear breast or along the or dull, aching Aneurysm hours or more paraplegia
costal cartilages;
also elsewhere
Anxiety Unclear Precordial, below the Stabbing, sticking, Variable
left breast, or across or dull, aching
the anterior chest
Chest Pain (4 Dyspnea (1

Problem Timing Factors That Factors That Associated Problem Process Timing Factor that Aggravate
Aggravate Relieve Symptoms
Left-Sided Heart Elevated pressure in Dyspnea may progress Exertion, lying down
Pulmonary Failure (left pulmonary capillary bed slowly, or suddenly as in
Tracheobronchitis Variable Coughing Cough ventricular failure or with transudation of fluid acute pulmonary edema
mitral stenosis) into interstitial spaces and
Pleural Pain Persistent Breathing, coughing, Lying on the Of the alveoli, decreased
movements of the involved side may underlying compliance (increase
trunk relieve it illness stiffness) of the lungs,
increased work of breathing
Gastrointestinal and
Chronic Bronchitis Excessive mucus production Chronic productive cough Exertion, inhaled irritants,
other in bronchi, followed by followed by slowly respiratory infections
Reflex Esophagitis Variable Large meal; bending Antacids, some- Sometimes chronic obstruction of progressive dyspnea
over, lying down times belching regurgitation, airways
dysphagia Chronic Obstrucitve Overdistention of air spaces Slowly progressive Exertion
Diffuse Esopha- Variable Swallowing of food Sometimes nitro- Dysphagia Pulmonary Disease distal to terminal dyspnea; relatively mild
geal Spasm or cold liquid; glycerin (COPD) bronchioles, with cough later
destruction of alveolar
emotional stress
septa and chronic
Chest Wall Pain Fleeting to hours Movement of chest, Often local obstruction of the airways
or day trunk, arms tenderness
Asthma Bronchial hyperresponsive- Acute episodes, separated Variable, including
Anxiety Fleeting to hours May follow effort, Breathlessness, ness involving releasse of by symptom-free period. allergens, irritants,
or day emotional stress palpitations, inflammatory mediators, Nocturnal episodes are respiratory infections,
weakness, increased airway secretion, common exercise, and emotion
and bronchoconstriction
anxiety
66
Dyspnea (2 Dyspnea (3
Problem Process Timing Factor that Aggravate
Diffuse Interstitial Bronchial Acute episodes, separated Variable, including Problem Factors that Relieve Associated Symptoms Setting
Lung Diseases (such hyperresponsiveness by symptom-free period. allergens, irritants,
Left-Sided Heart Rest, sitting up, though Often cough, orthopnea, History of heart disease
as sarcoi-dosis, involving release of Nocturnal episodes are respiratory infections,
widespread neoplas- inflamma-tory mediators, common exercise, and emotion Failure (left dyspnea may become paroxysmal nocturnal or its predisposing
ms, asbestosis, and increased airway secretions, ventricular failure or persistent dyspnea; sometimes factors
idiopathic pulmo- and bronchoconstriction mitral stenosis) wheezing
nary fibrosis)
Pneumonia Inflammation of lung paren- An acute illness, timing Chronic Bronchitis Expectoration; rest, though Chronic productive History of smoking, air
chyma from the respiratory varies with the causative dyspnea may become cough, recurrent pollutants, recurrent
bronchioles to the alveoli agent persistent respiratory infections; respiratory infections
Spontaneous Leakage of air into pleural Sudden onset of dyspnea wheezing may develop
Pneumothorax space through blebs on
visceral pleura, with resulting Chronic Obstrucitve Rest though dyspnea may Cough, with scant History of smoking, air
partial or complete collapse Pulmonary Disease become persistent mucoid sputum pollutants, sometimes a
of the lung (COPD) familial deficiency in
alpha1-antitrypsin
Acute Pulmonary Sudden occlusion of all or Sudden onset of dyspnea
Embolism part of pulmonary arterial Asthma Separation from aggravat- Wheezing, cough, Environmental and
tree by a blood clot that ing factors tightness in chest emotional conditions
usually originates in deep
veins of legs or pelvis
Anxiety with Overbreathing, with resultant Episodic, often recurrent More often occurs at
Hyperventilation respiratory alkalosis and fall rest than after exercise.
in the partial pressure of An upsetting event may
carbon dioxide in the blood not be evident
Dyspnea (4
Problem Factors that Relieve Associated Symptoms Setting
Diffuse Interstitial Rest, though dyspnea may Often weakness, fatigue. Varied. Exposure to one
Lung Diseases become persistent Cough less common than of may substances may
(such as sarcoido- in other lung diseases be causative
sis, widespread
neoplasms, asbes-
tosis, and idiopa-
hic pulmonary
fibrosis)
Pneumonia Pleuritic pain, cough, Varied
sputum, fever, though not
necessarily present
Spontaneous Pleuritic pain, cough Often a previously

Pneumothorax healthy young adult
Acute Pulmonary Often none. Retrosternal Postpartum or post-
Embolism oppressive pain if the operative periods; pro-
occlusion is massive. longed bed rest; conges-
Pleuritic pain, cough, and tive heart failure, chronic
hemoptysis may follow an lung disease, and fractur-
embolism if pulmonary es of hip or leng; deep
infarction ensues. venous thrombosis (often
Symptoms of anxiety not clinically apparent)
Anxiety with Breathing in and out of a paper Sighing, lighteadedness, Other manifestations of
Hyperventilation or plastic bag sometimes helps numbness or tingling of anxiety may be present
tha associated symptoms the hands and feet,
palpitations, chest pain
67
ACID FAST STAINING PROCEDURE
Dr. Sunarjati Sudigdo Adi, dr. MS., SpMK(K)
I. General objective
After finishing skill practice of this session, the student will be able to perform Ziehl-
Neelsen staining procedure from the sputum specimen
II. Specific objective
At the end of skill practice, student could interpret the result of Ziehl-Neelsen staining
III. Methods
o Presentation
o Demonstration
o Coaching
o Self practice
IV. List of equipments, materials, and reagents

Equipments & materials
o Sputum specimen
o Sputum container
o Bunsen burner
o Lighter/ matches
o Cotton soak with 95% alcohol
o Glass slides
o Pencil glass/ marking pen
o Sputum smear preparation positive AFB (not stained)
o Inoculating loop
o Filter/ tissue paper
o Sands with 70% alcohol
o Methanol 96% (spiritus)
o Toothpicks
o Slide holder or box
o Microscope
o Iron stick with cotton
Reagents
 Carbol fuchsin (the Primary Stain)
 Decolorizer HCl 3%+alcohol 95%
 Methylene blue (the Counterstain)
 Water (preferably in a squirt bottle)/ tap water
 Oil emersion
68
I. LEARNING GUIDE
No. S T E P 0 1 2
SMEAR PREPARATION
01. Clean glass slide by wiping it with wet cotton ball 95 % alcohol and/ or flame
directly 2 – 3 times over the fire to make the slide fat free
02. Mark a target oval area about 2x3 cm below the glass slide with a marking pen/
pencil glass
03. Flame a bacteriological loop to get red-hot and the loop become sterile. Let it cool
at room temperature WITHOUT touching anything.
04. Open the sputum container carefully and place the lid face up on the work surface
05. Dip the loop into a sputum sample, select the best portion of sputum, select the
most purulent (the thickest part) of the sputum or bloodstained particles if present
06 Place the loop full of sample in the center of target area.
07 RESEAL the sputum container tightly

08 Dips the loop into the bottle contains sands with 70 % alcohol, moves the loop up
and down, and rotates in the sands. Reflame the loop and let cool and put it in the
rack
69
09. Using a toothpick smear the specimen with coiling methods. Spread the specimen
using a toothpick vertically and horizontally and smear the specimen in small
circular motions to distribute the specimen evenly until about 2x3 cm in size.
Adequate size 2-3 cm

10. DISCARD the applicator stick into a discard container containing sands and suitable
disinfectant (alcohol 70%)
11 ALLOW the smear to air dry completely at room temperature
12. Fixation: Pass bottom part of the slide through the flame of a Bunsen burner 3-4
times but don’t get burned the smear is now ready for staining procedure.
This process kills the bacteria and fixes them to the slide so they won't wash off
during staining or rinsing.
70
Ziehl-Neelsen staining procedure
01 STEP 1: After fixation of the slides, place the fixed slide on the staining rack with
the smeared side facing upwards
02. STEP 2: Flood the entire slide with Carbol Fuchsin Ensure enough stain is added to
keep the slides covered throughout the entire staining step
03. STEP 3: Using a Bunsen burner or iron stick with cotton, heat the slides slowly until
they are steaming. Maintain steaming for 5 minutes by using low or intermittent
heat (i.e. by occasionally passing the flame from the Bunsen burner under the
slides), prevent the stain for boiling.
Allow the slide to cool for 30-60 seconds
Caution: Using too much flame or heat can cause the slide to break.
04. STEP 4: Gently rinse the slide with tap water to remove the excess carbol fuchsin
stain. At this point, the smear on the slide looks red in color.
71
05. STEP 5: Decolorize the slide by dip it into 3% chloric acid-95% alcohol for few
seconds until the slides are clear of stain visible to the naked eye.
To the right are examples of slides insufficiently and sufficiently flooded with acid-
alcohol.
06. STEP 6: Rinse the slide thoroughly with water and then drain any excess from the
slides
07. STEP 7: Flood the slide with the counterstain, Methylene Blue. Keep the
counterstain on the slides for 1 minute.
72
08 STEP 8: Rinse the slide thoroughly with water
09 STEP 9: let it dry at room temperature or dry it by blotting with filter/ tissue paper
(do not rub!!)
A correctly stained smear
10 Interpretation
Morphological Characteristics
- Acid-fast bacilli range from 1 to 10 µm in length and 0.2 to 0.6 µm in
width.
- They typically appear as slender, rod-shaped bacilli, but they may appear
curved or bent.
- Individual bacteria may display heavily stained area referred to as beads
and areas of alternating stain producing a banded appearance.
- Some mycobacteria other than M. tuberculosis may appear pleomorphic,
ranging in appearance from long slender rods to coccoid forms, with more
uniform distribution of staining properties.
73
Method of Examination
Ziehl-Neelsen stained smears should be examined with a 100x oil immersion
objective.
Procedure of microscopy:
Switch the lamp of microscope on
Open diaphragm maximally
Adjust the condenser up maximally
Put the slide on the stage
Put 1 drop of emersion oil
Use 100 x objective lens turn until it touch the slide
Turn coarse adjustment knob until you find the field
Turn fine adjustment knob to set the focus of your eyes
Start to count the bacteria
Reporting Results of Acid-Fast Bacilli Smears

One reporting system recommended by the International Union against
Tuberculosis and Lung Disease (IUATLD) when reporting ZN stained smears
observed at 1000x is:
1. AFB not found in 100 HPF : negative
2. 1 – 9 AFB/ 100 HPF : report the number of bacteria
3. 10 – 99 AFB/ 100 HPF : + or +1
4. 1 – 10 AFB/ 1 HPF: ++ or +2
5. > 10 AFB / 1 HPF: +++ or +3
Note : if 1 – 3 AFB/ 100 HPF, repeat exam using new specimen, if still 1 – 3 report
as neg, if 4 – 9 report as pos.
Note:
74

Handbook of Clinical Skill Training Respiratory System Ver 3 11 2011 PDF

Transféré par

Informations du document

Titre original

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

Handbook of Clinical Skill Training Respiratory System Ver 3 11 2011 PDF

Transféré par

Droits d'auteur :

Formats disponibles

Handbook of Clinical Skill Training

GENERAL LEARNING GUIDE ........................................................................................................ i

Filled in with intended competency achieved based on FK Unpad competency

4. General learning outcome

5. Specific skills learned

Week Skill Specific learning outcome Department

SCHEDULE OF SKILLS LAB RESPIRATORY SYSTEM

II. SPECIFIC OBJECTIVE

4. Describe the principle of the procedures.

III. SYLLABUS DESCRIPTION

3.3 Laboratory Facilities

Skill Laboratory A5.1

Audiovisual: Slides presentations on LCD projector.

2. Demonstration and coaching:

No. Procedures Performance Scale

LINA LASMININGRUM  A. Carotis Interna

 NO RESPOND LOCATE THE SOURCE

Ensure adequate •Blood cloots out of • Anterior

MANAGEMENT Balloon Pack

Posterior Nasal Packing (Bellocq tampon) SURGERY

AVOID RECURRENCE SUMMARY

 Patient education  Avoidance of  GOOD EVALUATION & HISTORY 

II. Specific Objective

III. Syllabus Description

3.1. Sub Module Objective

3.2. Expected competencies

3.4. Laboratory facilities

Skills laboratory A5.1

a. Point Nodal Evaluation

3.7. Sub Module Objective

3.8. Expected competencies

Student will be able to demonstrate the procedure of oxygen therapy, correct

3.10. Laboratory facilities

Oxygen therapy in adults

Definition: Causes of Hypoxia

 No specific contra indications to oxygen therapy exist when indications are

Respiratory Physiology Oxygen Therapy

Once the reservoir is filled between breaths, the oxygen is

Nasal Cannulas cont.

• Each liter of flow will increase the FiO2

• Can provide 31-61% oxygen to patients at

Simple Masks cont.

• Less than 5 l/mnt is not recommended

• Deliver the highest FiO2 of our simple oxygen

Partial Rebreather Mask

Venturi Mask Monitoring the Patient

Arterial Blood Gas or ABG

Oxygen saturation or O2 sat

• NEVER smoke while using supplemental

Modul Ketrampilan Oksigen Terapi

SIDE EFFECTS OF OXYGEN

Periksa apakah nasal prong lurus,rata atau terlipat.Tempatkan lekukan

Sekarang kaitkan saluran nasal kanul di belakang telinga pasien dan ke

B.Prosedur terapi oksigen

B.1. Langkah dasar persiapan alat terapi oksigen.

Cuci tangan sebelum dan sesudah melakukan terapi oksigen.Jika

B.3.Terapi Oksigen dengan masker

Untuk simple mask atur sesuai dengan kebutuhan oksigen yang

II. Specific Objective

III. Syllabus Description

3.1. Sub Module Objective

3.2. Expected competencies

Student will be able to demonstrate the procedure of oxygen therapy.