Respiratory System (common complex respiratory conditions) Introduction to Human Factors and Managing risk and Theory of Decision Making and Clinical Judgement.

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Apprenticeship Learning Log

 

Date of Learning: 24/09/25

Time: 9:30 – 16:30

Title of learning activity: Respiratory System (common complex respiratory conditions)

Introduction to Human Factors and Managing risk and Theory of Decision Making and Clinical Judgement.

 

Diary of Learning activity

(itemise learning activity and reflect on the main points of learning from each. You should identify for each entry the relevant KSB)

Reflection on Learning Activity (include model of reflection e.g. Driscoll or Gibbs):

 

On today’s session we were analysing the Respiratory System. The session addressed typical common complex respiratory conditions such as:

  • Asthma
  • COPD
  • Childhood Asthma
  • Pulmonary Fibrosis
  • PE
  • Pneumothorax
  • Pneumonia
  • Cystic Fibrosis

 

The respiratory system in the system in the body responsible for:

  • Gas exchange: Supplies oxygen (O₂) to the bloodstream and removes carbon dioxide (CO₂).
  • Regulation of blood pH: Helps maintain acid–base balance.
  • Sound production: The larynx (voice box) enables speaking.
  • Protection: Filters, warms, and humidifies incoming air.

URT – upper respiratory track.

LRT – lower respiratory track.

Asthma – is a chronic inflammatory disorder of the airways characterised by airflow obstruction, bronchial hyperresponsiveness, and airway inflammation.

It leads to episodic symptoms such as wheezing, shortness of breath (dyspnoea), chest tightness, and cough, often worsening at night or early morning.

 

Diagnosis:

  • History/Symptoms: Recurrent wheeze, breathlessness, cough (triggers: allergens, exercise, cold air, infections).
  • Exam: Expiratory wheeze, prolonged expiration.
  • PFTs (Spirometry)
  • Other tests: Peak flow, methacholine challenge, allergy testing.

Treatment (Stepwise)

  1. Relievers: SABA (e.g., Albuterol) for quick relief.
  2. Controllers: ICS (mainstay), ICS + LABA for moderate/severe cases; LTRA (e.g., montelukast).
  3. Severe cases: Oral steroids (short course), biologics (omalizumab, mepolizumab).
  4. Non-drug: Avoid triggers, vaccines, patient education.

Chronic Obstructive Pulmonary Disease (COPD) is a progressive, inflammatory lung disease characterised by persistent airflow limitation due to chronic bronchitis, emphysema, or a combination, usually caused by long-term exposure to noxious particles or gases (commonly cigarette smoke). Symptoms include dyspnoea (shortness of breath), chronic cough, sputum production, and wheeze.

Diagnosis

  • History/Symptoms: Chronic cough, sputum, progressive breathlessness; risk factors: smoking, occupational exposure, pollution.
  • Exam: Barrel chest, accessory muscle use, decreased breath sounds, wheeze, cyanosis in advanced stages.
  • Spirometry
  • Additional tests: Chest X-ray/CT (emphysema), ABG (hypoxemia/hypercapnia), alpha-1 antitrypsin if early onset or family history.

Treatment:

  1. Non-pharmacologic:
  • Smoking cessation, pulmonary rehab, vaccinations, oxygen therapy for chronic hypoxemia.
  1. Pharmacologic:
  • Bronchodilators: SABA/SAMA (relief), LABA/LAMA (maintenance).
  • ICS: combined with LABA in frequent exacerbators.
  • Combination inhalers: LABA + LAMA ± ICS for moderate/severe COPD.
  • Other drugs: Roflumilast for chronic bronchitis, short oral steroids, antibiotics for infection-triggered exacerbations.
  1. Severe/Advanced Cases:
  • Long-term oxygen therapy, lung volume reduction surgery, or transplantation (rare).

 

Childhood asthma is a chronic inflammatory disorder of the airways in children, characterised by reversible airflow obstruction, bronchial hyperresponsiveness, and airway inflammation. Symptoms are often episodic and may include wheeze, cough (especially at night), chest tightness, and shortness of breath. Triggers include allergens, viral infections, exercise, cold air, and environmental irritants.

Diagnosis

  • History/Symptoms: Recurrent wheeze, cough, breathlessness, often worse at night/morning; family history of asthma.
  • Examination: Wheeze, prolonged expiration, accessory muscle use during attacks; may be normal between episodes.
  • Investigations:
    • Spirometry
    • Peak flow monitoring for younger children.
    • Allergy testing if triggers suspected.
    • Rule out other conditions (e.g., bronchiolitis, airway malformations).

Treatment

  1. Relievers:
  • SABA (e.g., salbutamol) for acute symptoms.
  1. Controllers:
  • ICS first-line for persistent asthma.
  • ICS + LABA for moderate/severe cases.
  • LTRA (e.g., montelukast) as add-on.
  1. Severe/Refractory:
  • Short oral corticosteroids for exacerbations.
  • Biologics (e.g., omalizumab) in severe allergic asthma.
  1. Non-drug measures:
  • Avoid triggers (dust, smoke, pets, pollen).
  • Vaccinations (influenza, pneumococcal).
  • Patient education: inhaler technique, asthma action plan.

Pulmonary fibrosis (PF) is a chronic, progressive interstitial lung disease characterised by scarring (fibrosis) of the lung parenchyma, leading to irreversible loss of alveolar architecture, decreased lung compliance, and impaired gas exchange. Commonly idiopathic (Idiopathic Pulmonary Fibrosis, IPF), but can also result from environmental exposures, autoimmune diseases, medications, or radiation. Leads to progressive dyspnoea, dry cough, and impaired exercise tolerance.

Diagnosis of Pulmonary Fibrosis:

  • History & Exam: Chronic progressive dyspnoea, occupational/environmental exposures, autoimmune symptoms.
  • Pulmonary Function Tests (PFTs): Restrictive pattern (↓TLC), reduced DLCO.
  • Imaging: High-resolution CT (HRCT) is gold standard; shows subpleural/basal reticular opacities, honeycombing, traction bronchiectasis.
  • Lab Tests: Rule out autoimmune disease (ANA, RF, anti-CCP) and infections.
  • Bronchoscopy/Lung Biopsy: Consider if diagnosis unclear; UIP pattern on biopsy is classic for IPF

Treatment:

  • Medications:
    • Antifibrotics: Pirfenidone,
    • Immunosuppressants: Corticosteroids, Azathioprine, Mycophenolate (for autoimmune PF)
  • Supportive Care: Oxygen, pulmonary rehab, vaccinations.
  • Lifestyle: Smoking cessation, avoid lung irritants.
  • Advanced Options: Lung transplant, palliative care for end-stage disease.

Pulmonary embolism (PE) is the obstruction of the pulmonary arteries by a thrombus (blood clot), fat, air, or other material, most commonly a blood clot originating from the deep veins of the legs (DVT). This can impair blood flow to the lungs, cause hypoxemia, and lead to right heart strain or sudden death if massive.

Diagnosis:

  • Clinical Probability: Wells or Geneva score
  • Labs: D-dimer (rule out in low-risk patients)
  • Imaging:
    • CT Pulmonary Angiography (gold standard)
    • V/Q scan (if CT contraindicated)
    • Leg ultrasound for DVT
  • ECG/CXR: Usually nonspecific; may show sinus tachycardia, S1Q3T3, or atelectasis
  • Echocardiography: Assess RV strain in massive PE

Treatment:

  • Anticoagulation: Heparin → Warfarin or DOACs
  • Thrombolysis: For massive PE (e.g., alteplase)
  • Surgical/Interventional: Embolectomy or catheter-directed thrombolysis if needed
  • Supportive Care: Oxygen, careful fluid management
  • Prevention: Early mobilisation, compression stockings, prophylactic anticoagulation in high-risk patients

 

Pneumothorax is the presence of air in the pleural space, which can partially or completely collapse the lung. This disrupts normal negative intrapleural pressure, impairing lung expansion and gas exchange.

Diagnosis:

  • Clinical: Sudden chest pain, dyspnea; absent breath sounds
  • Imaging: CXR (visceral pleural line), CT (small cases), US (no lung sliding)

Treatment:

  • Small/asymptomatic: Observation + oxygen
  • Large/symptomatic: Needle aspiration or chest tube
  • Recurrent/persistent: Surgery (VATS, pleurodesis)
  • Tension: Emergency needle decompression → chest tube

Pneumonia is an acute infection of the lung parenchyma caused by bacteria, viruses, fungi, or other pathogens, leading to inflammation of the alveoli and often consolidation. This impairs gas exchange and can cause systemic symptoms.

Diagnosis:

  • Clinical: History and auscultation
  • Labs: CBC, blood/sputum cultures if severe
  • Imaging: CXR (consolidation), CT if complications

Treatment:

  • Antibiotics:
    • Mild CAP: Amoxicillin, doxycycline, macrolide
    • Moderate/severe CAP: Beta-lactam + macrolide or fluoroquinolone
    • HAP/VAP: Broad-spectrum per local resistance
  • Supportive: Oxygen, fluids, antipyretics, pulmonary hygiene
  • Severe: ICU care, ventilation if needed

Cystic fibrosis (CF) is a genetic, autosomal recessive disorder caused by mutations in the CFTR (cystic fibrosis transmembrane conductance regulator) gene, leading to defective chloride and water transport across epithelial cells. This results in thick, viscous secretions affecting multiple organs, predominantly the lungs and pancreas. Autosomal recessive disorder – defective CFTR – thick, viscous secretions in lungs, pancreas, and other organs.

Key Signs:

  • Chronic cough, recurrent lung infections, bronchiectasis
  • Steatorrhea, malabsorption, failure to thrive
  • Salty-tasting skin, nasal polyps, male infertility

Diagnosis:

  • Newborn screening: IRT test
  • Sweat chloride (>60 mmol/L) – gold standard
  • Genetic testing: CFTR mutations
  • Additional: Pulmonary function tests, sputum cultures

Treatment:

  • Airway clearance: Chest physiotherapy, oscillatory vests, inhaled hypertonic saline
  • Medications: Bronchodilators, mucolytics (dornase alfa), antibiotics, CFTR modulators
  • Nutrition: Pancreatic enzymes, high calorie/fat diet, fat-soluble vitamins
  • Advanced: Lung transplant, management of complications

Prognosis:

  • Life expectancy ~50+ years with modern therapy
  • Pulmonary disease is main cause of morbidity/mortality

Pathophysiology is defined as the study of the functional changes that occur in the body because of a disease or abnormal condition.

Oxygen therapy is the administration of supplemental oxygen to maintain adequate tissue oxygenation, particularly in patients with hypoxemia or conditions that impair oxygen delivery.

Indication:

  • Hypoxemia (PaO₂ < 60 mmHg or SpO₂ < 90%)
  • Respiratory distress or failure
  • Chronic obstructive pulmonary disease (COPD) with exacerbation
  • Acute myocardial infarction, shock, trauma, or post-operative care

Mechanism:

  • Increases the partial pressure of oxygen in alveoli (PAO₂)
  • Enhances diffusion of O₂ across alveolar-capillary membrane
  • Improves arterial oxygen content (PaO₂) and SpO₂
  • Reduces the work of breathing in patients with compromised lungs

Delivery Methods:

  1. Low-Flow Systems
    • Nasal cannula (1–6 L/min, FiO₂ ~24–44%)
    • Simple face mask (5–10 L/min, FiO₂ ~40–60%)
  2. High-Flow Systems
    • Venturi mask (precise FiO₂ 24–60%)
    • Non-rebreather mask (FiO₂ up to 100%)
    • High-flow nasal cannula (HFNC) for severe hypoxemia

Nursing Interventions and Rationales

Intervention Rationale
Assess SpO₂ and vital signs To evaluate the effectiveness of oxygen therapy and detect hypoxemia or hyperoxia
Monitor ABG (arterial blood gases) Provides precise measurement of PaO₂, PaCO₂, and pH, guiding oxygen titration
Choose appropriate delivery device Ensures correct FiO₂ and comfort; high-flow devices for severe hypoxemia, low-flow for mild cases
Humidify oxygen if >4 L/min Prevents mucosal dryness and irritation
Encourage proper positioning (e.g., semi-Fowler) Optimizes lung expansion and ventilation-perfusion matching
Monitor for oxygen toxicity Prolonged high FiO₂ can cause alveolar damage and absorption atelectasis
Educate patient about safety Oxygen is flammable; no smoking or open flames near oxygen sources

 

 

During the afternoon session we established following aspects of Human Factors, managing risk and theory of decision making and clinical judgement.

 

Human Factors – Environmental, organisational, and individual factors that influence healthcare performance and contribute to errors.

Key Elements:

  • Environmental: Lighting, noise, equipment, workflow
  • Organisational: Policies, staffing, communication culture
  • Individual: Fatigue, stress, skill level, cognitive load

Impact: Human error can lead to medication mistakes, procedural errors, miscommunication, and delayed diagnosis.

Managing Risk:

  • System Design: Protocols, checklists, user-friendly equipment
  • Communication & Teamwork: SBAR handovers, open reporting of near misses
  • Training & Simulation: Scenario-based exercises for situational awareness
  • Environmental Adjustments: Reduce noise, improve lighting, minimize distractions
  • Fatigue Management: Adequate staffing, breaks, shift rotation

Rationale: Proactively addressing human factors improves patient safety.

Decision Making and Clinical Judgment

Decision Making: Choosing the best action based on evidence and context.

  • Types: Analytical (stepwise), Intuitive (pattern recognition), Heuristic (shortcuts, risk of bias)

Clinical Judgment: Interpreting patient data and making informed care decisions.

  • Relies on knowledge, assessment skills, critical thinking, and reflection.

Theories:

  • Benner: Expertise develops with experience
  • Tanner: Noticing → Interpreting → Responding → Reflecting
  • Dual-Process: Combines intuitive (System 1) and analytical (System 2) thinking

Applying Clinical Judgment

  • Assessment (Noticing): Collect vital signs, history, labs
  • Interpretation: Identify patterns, deviations, severity
  • Response: Implement interventions (e.g., oxygen therapy, rapid response)
  • Reflection: Evaluate outcomes, adjust future care, document.

 

 

KSBs addressed:

K1: Understand the Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates (NMC, 2018), and how to fulfill all registration requirements

K2: Understand the demands of professional practice and demonstrate how to recognise signs of vulnerability in themselves or their colleagues and the action required to minimise risks to health

K4: Understand the principles of research and how research findings are used to inform evidence-based practice

K6: Understand and apply relevant legal, regulatory and governance requirements, policies, and ethical frameworks, including any mandatory reporting duties, to all areas of practice

K7: Understand the importance of courage and transparency and apply the Duty of Candour

K8: Understand how discriminatory behaviour is exhibited

K12: Understand the importance of early years and childhood experiences and the possible impact on life choices, mental, physical and behavioural health and well-being

K26: Understand where and how to seek guidance and support from others to ensure that the best interests of those receiving care are upheld

K30: Understand the principles of health and safety legislation and regulations and maintain safe work and care environments

K42: Understand and apply the principles of human factors and environmental factors when working in teams

K43: Understand the influence of policy and political drivers that impact health and care provision Skills

S11: Report any situations, behaviours or errors that could result in poor care outcomes

S34: Act in line with local and national organisational frameworks, legislation and regulations to report risks, and implement actions as instructed, following up and escalating as required

S35: Accurately undertake risk assessments, using contemporary assessment tools

S36: Respond to and escalate potential hazards that may affect the safety of people

 

 

 

 

 

 

 

 

 

 

 

 

 

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