Out-of Hospital Ventilation: An Interdisciplinary Perspective on Landscape and Health

Description:

Safe handling of patient and device in home ventilation!
This book offers all relevant contents of the further training “Basic qualification extra-clinical artificial respiration” and addresses itself to maintaining and responsible persons, who supply ventilated humans at home or in the nursing home.  Learn comprehensive basics about anatomy, pathology and the different ventilation modes and benefit from the authors’ wealth of experience. Here you can read in an easily understandable and concise manner how to provide your patients or residents with all-round competent care and how to handle the ventilation situation with confidence. Ideal for all employees and nursing services to train and qualify for the challenging care of ventilated patients!

Preface

Nonclinical ventilation claims to be a companion book for colleagues who attend the training course “Basic qualification in nonclinical ventilation” DIGAB-accredited providers. Since 2011 (2012), the German Interdisciplinary Society for Out-ofHospital Ventilation (Deutsche Interdisziplinäre Gesellschaft für Außerklinische Beatmung e. V.) has been developing a curriculum in which the contents of the training course are developed. Participants in this training course are to acquire extensive knowledge for the care of ventilator-dependent people. The book is therefore aimed at all professional nursing colleagues who attend this advanced training course and also at those who feel insecure in the care of these people, patients, and residents.

The aim of my co-authors and myself is to provide a comprehensible orientation on the topic of artificial respiration in the context of out-of-hospital care.

Out-of-hospital ventilation is didactically divided into six parts and is based on the requirements of the DIGAB curriculum:

Part I: Basics of breathing and respiratory failure

Part II: Ventilation options

Part III: Ventilation modes and patterns

Part IV: Further treatment measures

Part V: Monitoring and nursing care of the patient and ventilation

Part VI: Legal bases for out-of-hospital ventilation

Part I deals with the anatomical and physiological basics of respiration, explains respiratory failure, and describes diseases that can lead to the need to ventilate.

Part II gives an overview of the different ventilation options, either noninvasive ventilation or invasive ventilation with tracheal cannula.

Part III explains the different ventilation modes, their nomenclature, settings, and functions of the individual settings. The purpose of the different ventilation modes is illustrated using case studies.

Part IV gives an overview of other treatment measures that are additionally given to people who are ventilated outside the hospital, including various drugs and often oxygen therapy. The people affected suffer from swallowing disorders, have to be artificially fed, and require psychosocial care, which must also include their relatives.

Part V represents the comprehensive care and supervision of people. It gives an overview of terms used in ventilation and describes the alarm and measurement values of ventilation. In addition, there are respiratory therapeutic measures that are of great importance in the ongoing care, such as respiratory gas conditioning, secretion management, and weaning.

Part VI summarizes the legal basis of out-of-hospital ventilation. An orderly discharge management ensures the transition to domestic care. Liability and the Medical Devices Act are immediate issues for professional caregivers. Important for all people are topics concerning care or the patient’s will.

Out-of-hospital ventilated patients pose high challenges for all professional caregivers. Understanding the reasons for ventilation, understanding the types of airway access, differentiating between the different ventilation modes, and providing comprehensive patient care are very extensive and complex aspects. This is the aim of our book, and we would like to be measured by your, the readers’, experience.

I wish all readers an exciting read in an area that is not always easy to understand and that all those who work on and with respiratory patients find a common working basis and working language in which the technical and factual uncertainties are removed.

Hartmut Lang

Hamburg

January 2017

Table of contents :

Preface
Acknowledgments
Contents
Contributors
I: Basics of Breathing and Respiratory Failure
1: Anatomy and Physiology of Respiration
1.1 Upper Airways
1.1.1 Tasks of the Upper Airways
1.1.2 Reference to Artificial Respiration
1.1.3 Nose
1.1.4 Larynx and Vocal Cords
1.2 Lower Airways
1.2.1 Trachea (Windpipe)
1.2.2 Carina
1.2.3 Bronchial tree (Bronchial System)
1.2.4 Mucociliary Clearance
1.2.5 The Position of the Lungs in the Body
1.2.6 The Lobes, Lobes and Segments of the Lungs
1.2.7 Alveoli and Surfactant
1.2.8 Pulmonary Vessels
1.3 Respiratory Support Musculature
1.3.1 Inspiration
1.3.2 Expiration
1.4 Physiology
1.4.1 Breathing Air
1.4.2 Diffusion Time: Diffusion Distance
1.4.3 Breathing Regulation
1.4.4 Physiological Shunt Volume
1.4.5 Breathing Mechanics
1.5 Central and Peripheral Nervous System
1.5.1 Anatomy of the Brain
1.5.2 Brain Structure
1.5.3 The Lobes and Regions of the Brain
1.5.4 Pyramidal and Extrapyramidal System
1.5.5 Blood Supply to the Brain
1.6 Spinal Cord
1.6.1 Structure of the Spinal Cord
1.6.2 The Internal Structure of the Spinal Cord
1.6.3 Structure of a Nerve Cell
1.7 Phrenic Nerve
1.8 Interconnection of the Nerve Tracts
References
2: Indications and Goals of Ventilation
2.1 Respiratory Insufficiency
2.1.1 Failure of the Respiratory Pump
2.1.2 Failure of Pulmonary Gas Exchange
2.1.3 Disturbance of Pulmonary Gas Exchange
2.1.4 Interaction Between the Lungs and the Respiratory Pump
2.2 Ventilation Goals
References
3: Diseaseology
3.1 Basics and Diagnostics of Respiratory Disorders
3.1.1 Types and Frequency of Home Ventilation
3.1.2 Central Respiratory Regulation
3.1.3 Airways
3.1.4 Breathing Mechanics
3.1.5 Lungs
3.1.6 Gas Exchange
3.2 Illnesses and Treatment
3.2.1 Hypoxic Brain Damage
Anoxia or Asphyxia
Persistent Vegetative State: Rehabilitation Phase Model
Clinic
Ventilation for Hypoxic Brain Damage
3.2.2 Stroke: Ischemic Insult
Causes
Clinic and Symptoms
Ventilation for Stroke
3.2.3 Paraplegia
Causes and Frequency
Clinic and Symptoms
Tetra- and Paraplegia
Ventilation for Severe Paraplegia
3.2.4 Neuromuscular Diseases (NMD)
Definition
Overview
Occurrence and Frequency
General Symptoms
Description of Different Diseases
Therapy
Ventilation
3.2.5 COPD
Indicator of COPD
Pathophysiology of COPD
Clinical Symptoms of COPD
Staging
Ventilation for COPD
3.2.6 Obesity Hypoventilation Syndrome (OHS)
Clinic and Symptoms
Further Pathophysiological Mechanisms
Ventilation with OHS
Criteria
3.2.7 Thoracic Restrictive Disorders
Problems of Thoracic Restrictive Diseases
Indications for NIV
Targets of Ventilation in Thoracic Restrictive Diseases
Ventilation for Thoracic Restrictive Diseases
Criteria for Ventilation
References
II: Ventilation Options
4: Tracheotomy
4.1 Terminology
4.1.1 Indication for Tracheotomy
4.1.2 Advantages and Disadvantages of Tracheotomy
4.1.3 Places of Tracheotomy
4.2 Tracheotomy Procedure
4.2.1 Implementation of PDT (According to Caglia)
4.2.2 Plastic Tracheostoma
4.2.3 Changes Caused by a Tracheostoma
4.3 Various Tracheal Cannulas
4.3.1 Tracheal Cannula with Cuff
4.3.2 Construction of a Tracheal Cannula
Subglottic Suctioning
4.3.3 Speech Valve: Inhalation Valve
4.3.4 Tracheal Cannula Without Cuff
4.3.5 Core or Inner Cannula
4.3.6 Fenestrated Cannulas
4.4 Dressing Changes for Tracheal Cannulas
4.5 Changing the Tracheal Cannula
4.5.1 Preparation
4.5.2 Implementation
4.6 Closure of the Tracheotoma
4.6.1 Cuff Leak Test
4.6.2 Placeholders
References
5: NIV (Non-invasive Ventilation)
5.1 Indications and Contraindications
5.1.1 Indications
Possibilities of NIV
Risks in the Application of NIV
5.1.2 Contraindications of NIV
5.2 Characteristics of the NIV
5.3 Different Mask Systems
5.3.1 Nasal Mask
5.3.2 Full-Face Mask (Oronasal Mask)
5.3.3 Total Face Mask
5.3.4 Special Models
5.4 Modern NIV Masks
5.5 Typical Applications
5.5.1 COPD
5.5.2 Thoracic Restrictive Disorders
5.5.3 Obesity Hypoventilation Syndrome
5.5.4 Neuromuscular Diseases (NME)
5.6 Assessment of an Adjusted Ventilation Setting
5.7 Ventilation Setting of the NIV
References
III: Ventilation Modes and Patterns
6: Respirator Models
6.1 Air or Piston Pump Model
6.2 Model Ambu Bag (Respiratory Bag)
6.3 Model of Open/Semi-Open Systems
6.4 Model of a Surge Tank
6.5 Respirator Model of an Intensive Care Ventilator
6.6 Intensive Care and Turbine-Controlled Ventilators
6.6.1 Intensive Care Ventilators
6.6.2 Turbine Controlled Ventilators
6.7 Ventilation Hose Systems
6.7.1 Leakage System
6.7.2 Single Hose System with Integrated Exhalation Valve
6.7.3 Two-Hose System
6.7.4 Grommet and Function Check
6.8 Breathing Gas Conditioning: Breathing Gas Humidification
6.8.1 Passive Humidifiers
6.8.2 Active Humidifiers
Reference
7: Spontaneous and Positive Pressure Ventilation
7.1 Respiratory Pattern on the Respirator
7.1.1 Other Characteristics of Spontaneous Rest Breathing
7.2 Positive Pressure Ventilation
References
8: Ventilation Modes
8.1 Distinguishing Features of Ventilation Modes
8.2 Ventilation Curves
8.2.1 Pressure Curve
8.2.2 Flow Curve
8.2.3 Volume Curve
8.2.4 CO2 Curve
References
9: Pressure-Controlled Ventilation (PCV/A-PCV)
9.1 Nomenclature
9.2 Parameter Setting
9.2.1 Oxygen
9.2.2 PEEP and EPAP
Advantages of PEEP
Adverse Effects of PEEP
9.2.3 Inspiration
Example
Example
Example
9.2.4 Frequency
9.2.5 Inspiration Time
Example
9.2.6 Breathing Time Ratio I:E
9.2.7 Ramp or Rise Time
Example
9.2.8 Trigger
Flow Trigger
Pressure Trigger
Purpose of the Trigger Functions
9.2.9 Maximum Air Pressure Limit
9.3 Procedure for Pressure-Controlled Ventilation
9.4 Application of PCV Ventilation
9.5 Case Study: PB 560 (Covidien)
References
10: Volume Controlled Ventilation (VCV)
10.1 Nomenclature
10.2 Parameter Setting
10.2.1 Breathing Volume
10.2.2 Flow
Example
10.3 Procedure for Volume-Controlled Ventilation
10.3.1 Why Does the Air Pressure Drop Again?
10.3.2 Plateau Phase
10.3.3 Expiration
10.4 Problems of Volume-Controlled Ventilation
10.4.1 Risk of Unknown Air Pressures
10.4.2 Pendulum Air
10.4.3 Shearing Forces
10.4.4 Atelectasis and Emphysema
10.5 Application of VCV Ventilation
10.6 Case Study: Astral 150 (ResMed Company)
References
11: Pressure-Regulated- Volume-Controlled Ventilation
11.1 Nomenclature
11.2 Parameter Setting
11.3 Independent Ventilation Pressure Level Adjustment
11.3.1 Lung Extensibility (Compliance)
11.3.2 Resistance
11.4 Application of Pressure-Regulated-Volume-Controlled Ventilation
11.5 Case Study: PB 560 (Covidien Company)
Reference
12: Pressure Support Ventilation (PSV)
12.1 Nomenclature
12.2 Parameter Setting
12.3 Pressure Support for Breathing
12.3.1 Optimum Level of Pressure Support
12.3.2 Trigger
Flow Trigger
Pressure Trigger
Example
12.3.3 Back-Up
12.4 Case Study: PSV Breathing
12.5 Exhalation Trigger
12.6 Advantages and Disadvantages
12.6.1 Benefits of PSV Breathing
12.6.2 Disadvantages of PSV:
12.7 ST Mode
12.7.1 Description of the ST Ventilation Mode
References
13: SIMV (Synchronized Intermittent Mechanical Ventilation)
13.1 Volume-Controlled SIMV (VC-SIMV)
13.1.1 Parameter Setting
13.2 Pressure Controlled SIMV (PC SIMV)
13.2.1 Parameter Setting
13.3 Advantages and Disadvantages of SIMV
13.3.1 Advantages of SIMV
13.3.2 Disadvantages of SIMV
13.4 Application in Out-of-Hospital Ventilation
References
14: AVAPS (Average Volume Assured Pressure Support)
14.1 Pressure Controlled Ventilation and AVAPS
14.2 Parameter Setting
14.3 Case Study: Trilogy 100 (Phillips Respironics)
14.4 Using AVAPS
References
15: Emergency Management
15.1 What Is an Emergency?
15.2 Who Is Responsible and When?
15.2.1 If the Family Doctor Is Not Available …
15.2.2 Weaning Centre
15.2.3 Rescue Service
15.2.4 Qualification of Rescue Service Personnel
15.2.5 Making an Emergency Call
15.2.6 Transport Management
15.3 Patient Assessment
15.4 Red Thread of Emergency Care
15.5 Ventilation Problems
15.5.1 Tracheal Cannula Relocation
15.5.2 Accidental Decannulation
15.5.3 Torn Cuff Tube
15.6 Cerebral Seizure
15.6.1 Symptoms
15.6.2 Hazards
15.6.3 First aid
15.6.4 Extended Measures
15.6.5 Causes
15.6.6 Epidemiology
15.7 Resuscitation
15.7.1 Procedure
15.7.2 Advanced Resuscitation Measures
15.7.3 The Resuscitation Result (Outcome)
15.8 Child Resuscitation
15.8.1 Procedure
References
IV: Further Treatment Measures
16: Pharmacology
16.1 Introduction to Pharmacology
16.1.1 The Action of a Medicinal Product in the Body
16.1.2 Application Types
16.1.3 Pharmaceutical Forms
Oral Use
Bronchopulmonary Use
16.2 Groups of Medicines
16.2.1 Cardiacs
Antihypertensives (High Blood Pressure, Hypertension)
Heart Failure
Antiarrhythmics (Cardiac Arrhythmia)
16.2.2 Bronchodilatatives/Bonchospasmolytics
Beta-2 Receptor Agonists
Theophylline
Anticholinergics/Beta-2 Sympathomimetics
PDE-4 Inhibitors
16.2.3 Secretolytics/Expectorants
Ambroxol
Acetylcysteine (ACC)
Saline Solutions
16.2.4 Sedatives
Benzodiazepines
Zolpidem and Zopiclon
Neuroleptics
16.2.5 Antidepressants
SSRI (Selective Serotonin Reuptake Inhibitors)
SSNRI (Selective Serotonin/Noradrenaline Reuptake Inhibitor)
NaSSA (Norepinephrine and Specifically Serotonergic Antidepressants)
MAO inhibitors (Tranylcypromine, Moclobemide)
16.2.6 Anticoagulants
Antiplatelet Aggregation Inhibitor
Direct and Indirect Anticoagulants
Further Reading
17: Oxygen Therapy
17.1 Respiratory Tasks
17.1.1 Absorption of Oxygen and Release of Carbon Dioxide
17.1.2 Oxygen and Carbon Dioxide
Oxygen (O2)
Carbon Dioxide (CO2)
17.2 Symptoms of Oxygen Deficiency
17.3 Measuring Methods for Oxygen Measurement
17.3.1 Transcutaneous Oxygen Saturation
17.3.2 Pulse Oximetry
17.4 Indications for Oxygen Administration
17.4.1 Long-Term Oxygen Therapy (LTOT)
17.4.2 Intermittent Oxygen Administration
17.4.3 Basic Diagnostics
17.5 Devices for Oxygen Supply
17.5.1 Oxygen Concentrator
17.5.2 Oxygen Cylinders
Bottle Sizes
Humidification
Filling Quantities and Consumption
Demand Systems or Trigger Systems
17.5.3 Liquid Oxygen
17.5.4 Selection of an Appropriate Mobile System
17.6 Application Systems
17.7 Safety Against Fire
References
18: Dysphagia
18.1 Physiological Swallowing
18.2 Impaired Swallowing
18.2.1 Symptoms of Dysphagia
18.3 Causes of Dysphagia
18.4 Diagnosis of Dysphagia
18.4.1 Medical History
18.4.2 Own/Foreign Anamnesis
18.4.3 Clinical Diagnostics
General Assessment
Examination of Motor and Sensitive Functions
Screenings to Assess the Risk of Aspiration
Severity Classification
Instrumental Diagnostics
Video Copy of Swallowing (FEES)
Videofluoroscopy of Swallowing
Further Instrumental Diagnostic Procedures
18.5 Therapy of Dysphagia
18.5.1 Therapy Preparation
18.5.2 Restitutive Therapy Procedures
18.5.3 Compensatory Therapy Procedures
18.5.4 Adaptive Therapy Methods
18.6 Tracheal Cannula Management
18.6.1 Cooperation
18.6.2 Patient Examples
References
19: Communication in Care Relationships
19.1 Communication Partners
19.2 Theory of Cognitive Control
Conclusion
19.3 Transmitter–Receiver Model
19.3.1 Iceberg Model
Conclusion
19.3.2 Distorted Perceptions
19.4 Theories of Communication Science
19.4.1 5 Axioms by Paul Watzlawick
19.4.2 Four-Sided Model
19.4.3 Small Talk, High Talk, Move Talk
19.5 Communication Model of Transaction Analysis
19.5.1 Communication as a Transaction
19.5.2 Other Concepts of Transactional Analysis
O.K. Position
Covert Transactions
Healthy and Unhealthy Symbiosis
Discount Stamp Model
Contracts
Conclusion
References
V: Monitoring and Nursing Care of the Patient and Ventilation
20: Hygiene
20.1 Introduction to Hygiene
20.2 Service Life
20.2.1 General
20.2.2 Aqua
20.2.3 Hose Systems
20.2.4 Disinfection
20.3 Dry Breathing Systems
20.3.1 Reusable Breathing Tube
20.3.2 Disposable Hose Systems
20.3.3 Standing Times
20.3.4 System Change
20.3.5 Reusable Systems
20.4 Tubes with Humidifier
20.4.1 Hose Systems
20.4.2 Changing the Heatable Hose Systems
20.4.3 Humidifying Liquids
20.5 HME Filters and Goose Gargle
20.6 Ventilation Masks
20.7 Tracheal Cannula Management
20.7.1 Lay Days
20.7.2 Cleaning of Cannulae
20.8 Equipment Maintenance
20.8.1 Ventilators
20.8.2 Cough Assist
20.8.3 Oxygen Equipment
20.8.4 Suction Devices
20.9 Washing Hands
Conclusion
References
21: Resistance and Compliance
21.1 Resistance
21.1.1 Standard Values
21.1.2 Effect of the Resistance
Pressure Controlled Ventilation
Volume-controlled Ventilation
Pressure-supported Ventilation
Volume-controlled-pressure-regulated Ventilation
PEEP
Conclusion
21.2 Compliance
21.2.1 Standard Values
21.2.2 Impact of Compliance
Pressure Controlled Ventilation
Volume-controlled Ventilation
Pressure-supported Ventilation
Volume-controlled-pressure-regulated Ventilation
PEEP
Conclusion
21.3 Resistance and Compliance
References
22: Control Mechanisms and Types of Control
22.1 Ventilation Control Mechanisms
22.2 Ventilation Control Modes
22.3 Ventilation Modes of Practical Relevance
Reference
23: Flow and Flow Curves
23.1 Sinus Flow, Constant Flow, Decelerating Flow
23.1.1 Statements of Flow Curves
23.1.2 Advantages of the Decelerating Flow
23.2 Flow During Volume-controlled Ventilation
23.3 Flow During Pressure-controlled Ventilation
23.3.1 Flow Behaviour with Different Steep Ramps
23.3.2 Flow Behaviour at Different Pinsp
23.3.3 Flow Curve for Too Short Expiratory Time
23.3.4 Flow Curve with Too Short Inspiration Time
23.3.5 Flow Trigger
23.3.6 Pressure Trigger
23.3.7 Flow Trigger Versus Pressure Trigger
Conclusion
23.4 Flow Curve in PSV
23.4.1 Flow Trigger
23.4.2 Rise or Ramp
23.4.3 Expiratory Trigger
Reference
24: Alarms and Alarm Settings
24.1 Alarm Message Levels
24.2 Special Alarms
24.2.1 Airway Pressure/Pmax
24.2.2 Minute Volume
24.2.3 Breathing Volume
24.2.4 Respiratory Rate
24.2.5 Apnea Time/Apnea Ventilation/Back-up Setting
Reference
25: Ventilation Measured Values
25.1 Measured Values
25.1.1 Pressure Values
25.1.2 Volumes
25.1.3 Frequency Values
25.1.4 Further Measurement Parameters
25.2 Ventilation Protocol
Conclusion
References
26: Monitoring
26.1 Clinical View/Clinical Monitoring
26.2 Pulse Oximetry
26.3 Capnometry
26.4 Circulation, Pulse and Blood Pressure
References
27: Blood Gas Analysis (BGA)
27.1 Assessment of a BGA
27.2 Oxygen and Carbon Dioxide
27.2.1 Oxygen (O2)
27.2.2 Carbon Dioxide (CO2)
27.2.3 Partial Pressure of Oxygen and Carbon Dioxide (pO2 and pCO2)
27.2.4 Oxygen Saturation
27.2.5 Oxygen Fixation Curve
Right Shift
Left Shift
27.2.6 Central Venous Oxygen Saturation (ScvO2)
27.2.7 Horowitz Quotient
27.3 Acid–Base Balance
27.3.1 pH Value
27.3.2 Buffers and Buffer Systems
27.3.3 Regulation of the Acid–Base Balance
Carbon Dioxide Bicarbonate Buffer System
Regulation Via the Kidney
Regulation via the Lungs and Respiration
27.3.4 Disturbances of the Acid–Base Balance
27.3.5 Base Excess (BE)
Respiratory Acidosis
Respiratory Acalosis
Metabolic Acidosis
Metabolic Alkalosis
27.4 Effects of Acidosis and Alkalosis
27.5 Reading a BGA
References
28: Breathing Gas Conditioning
28.1 Tasks of the Airways
28.2 Absolute and Relative Humidity
28.3 Active Respiratory Gas Humidification
28.3.1 Pass-over Evaporator
28.3.2 Countercurrent Method
28.4 Ventilation Filter
28.4.1 Mechanical Filters
28.4.2 Electrostatic Filters
28.5 Passive respiratory Gas Humidification
28.5.1 General Operation
28.5.2 Physical and Chemical HME Elements
28.5.3 HMEF
28.6 Active Versus Passive Humidification
Further Reading
29: Secretary Management
29.1 Ability to Cough
29.1.1 Coughing Procedure
29.1.2 Problems with Reduced Cough
29.2 Support for Coughing
29.2.1 Measures to Increase the Intrathoracic Volume
Mechanical Support Measures
29.2.2 Measures for Intensified Expiratory Air Flow
Manual Cough Support
Mechanical Cough Support
29.3 Endobronchial/Endotracheal Suction
29.3.1 Closed Versus Open Suction
29.3.2 Subglottic Suction
29.4 Inhalation Therapy
29.4.1 Deposition
29.4.2 Types of Deposition
29.4.3 Metered Dose Inhalers
29.4.4 Nebuliser Systems
References
30: Weaning
30.1 Weaning Process
30.2 Weaning Classification
30.3 Conditions for Successful Weaning
30.4 Nursing Measures to Strengthen the Respiratory Musculature
30.5 Weaning Strategies
30.5.1 Discontinuous Weaning
30.5.2 Continuous Weaning
30.6 Weaning Index (RSB Index)
30.7 Weaning of Long-Term Ventilated Patients
30.7.1 Conditions
30.7.2 Weaning Process
30.7.3 Carrying Out the Spontaneous Breathing Test
30.7.4 Weaning
30.7.5 Closure of the Tracheotomy
Further Reading
VI: Legal Bases for Out-of-Hospital Ventilation
31: Discharge Management in Nursing
31.1 Legal Requirements
31.1.1 Supply Contract According to Sections 132, 132a Para. 2 SGB V
31.1.2 Care Contract for Outpatient Care According to Section 72 SGB XI
31.1.3 Requirement of the Medical Service of the Health Insurance Fund (MDK)
31.1.4 Recommendations of the Robert Koch Institute (RKI)
31.1.5 Staff Requirements
31.2 Discharge Management
31.2.1 Request for Patient Admission
31.2.2 Initial Interview
31.2.3 Contacting the Cost Unit
31.2.4 Regulation of Home Care
31.2.5 Maintenance Contract
31.2.6 Domestic visit
31.2.7 Contacting the Providers
31.2.8 Contact with the Family Doctor and Management of Medicines
31.2.9 Documentation
31.2.10 Personnel Planning
31.3 Outlook
References
32: Criminal and Liability Aspects
32.1 The Sources of Law
32.2 Verification Scheme for Liability
32.3 Justification for the Exclusion of Fault
32.3.1 Legal Relationships
32.3.2 Contract Liability
32.4 Intent and Negligence
32.5 Personal Injury
32.6 Injunctive Relief
References
33: Implementation of MPG/Operator Regulation
33.1 Reasons for a Medical Devices Act (Medizinproduktegesetz, MPG)
33.2 Sense and Purpose of the Medical Devices Act
33.3 Application of Medical Devices
33.4 Medical Devices Operator Ordinance
References
34: Care, Power of Attorney and Living Will
34.1 General Information on Care
34.2 Provisional and General Power of Attorney
34.3 General Information on the Patient Decree
References
Appendix