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Ansis Suction ETT
Ansis Suction ETT
2. Intervention
one of nursing actions which can be undertaken to overcome problem of nursing
ineffective airway clearance is airway suctioning. The intervention aims to clear
the airway of obstruction or excessive mucus secretion.
Procedure guidelines
3. Principle
Drop in SpO2.
Keep dominant hand sterile. Use nondominant hand to open & pour solution,
to connect & manipulate the suction catheter.The pulmonary system is sterile
past the oropharynx.
Patient respons before during and after suctioning must be evaluated and this
should include reversal of pre-suction clinical signs, examination of suction
yield and possible adverse effects of the suction procedure such as patient
distress, hypertension, hypoxia and intracranial hypertension.
f. Suction techniques
Insert catheter just past end of trach tube or to a depth that stimulates a
cough, then apply suction.
If catheter reaches the carina, withdraw 1 cm before applying suction.
Rational: Prevents tissue trauma and reduces risk for hypoxemia and
dysrhythmias.
g. Frequency of suctioning
h. Humidification
4. Analysis
Endotracheal intubation prevents the cough reflex and interferes with normal
muco-ciliary function, therefore increasing airway secretion production and
decreasing the ability to clear secretions. Endotracheal tube (ETT) suction is
necessary to clear secretions and to maintain airway patency, and to optimise
oxygenation and ventilation in a ventilated patient. The goal of ETT suction
should be to maximise the amount of secretions removed with minimal adverse
effects associated with the procedure.
Tracheal suction through a endotracheal tube bypasses the normal protective
mechanisms such as the cough reflex that the upper airways provide. Critically ill
patients often have an increase in the production of mucous and a weakened
ability to clear secretions. If secretions are not cleared then the patient may be at
risk of infection, atelectasis and alveolar collapse (Day et al, 2002).
Appropriate management of the patient with an artificial airway can have an
impact on reducing complications, length of stay and mortality and
morbidity.Correct technique and preparation by the clinician can assist in
reducing the risks of adverse events and reduce the level of discomfort for the
patient.
7. Other intervention
Beside airway suctioning there is artificial airway management as another
intervention that can be done to overcome ineffective airways clearance.
Independent action of airway management are assess airway patency, evaluate ET
tube placement,
8. Self evaluation
Implementation of the suction needs precision and caution, especially this time of
suction action is done through ETT with the condition of patients who
experienced spontaneous breathing disorders. Although suction the ETT is the
first experience for me, but I can do calmly, without difficulty, and still maintain
the principle sterile.
9. Refference
Ansis CVP
1. Background and Nursing diagnoses
Ny. H, 33 years old Admitted to hospital Tugurejo Decreased Because her
condition after necrotomy and debridement surgery. The assessment found there
is secretions in the respiratory tract and the sound of gargling. Patients have
installed ET and using mechanical ventilators on 28 November 2013 due to
respiratory failure. Ventilator with PCV mode, the frequency rate of 12, I: E ratio
1:2, FiO2 50%. Breathing in regular, sound ronci wet or cracles in both lung
fields. Respiratory rate of 30 rpm, BP 106/66, MAP 75, 140 bpm heart rate, SpO2
98%, and temperature of 36.5.
In the circumstances of the client, the nursing diagnoses that may appear one of
them is decreased of cardiac output.
2. Intervention
one of nursing actions which can be undertaken to overcome
3. Principle
4. Analysis
7. Other intervention
8. Self evaluation
9. Refference
Ansis Oropharynx
The mouth is opened using the crossed finger technique. Always use
Standard Precautions. To open the patients mouth using this technique:
1. Using your dominant hand, cross your index finger under your thumb.
2. Place your thumb and index finger against the patients upper and
lower teeth.
(Be careful not to insert either finger between the patients teeth.)
3. Spread your thumb and finger apart to open the patients mouth.
d. Insert the OPA without pushing the tongue back
The OPA is inserted in the patients mouth upside down so the tip of the
OPA is facing the roof of the patients mouth. As the airway is inserted it
is rotated 180 degrees until the flange comes to rest on the patients lips
and/or teeth. The OPA may be inserted with the pharyngeal curvature if a
tongue blade is used to depress the tongue.
3. Principle
4. Analysis
An oropharyngeal airway is an ideal way to restore airway patency which become
obsructed by tounge in an unconcious patient. This device very easily inserted,
can be used to support suctioning ini unconcious or half concious patient, and
also prevent patient from bitting tounge.
Implementation oropharyngeal airway instalation in the ICU Tugurejo is an
appropriate in accordance with the procedure nursing actions both from the
hospital and also based on reference books and journals evidence based practice.
5. Hazardz and complication
In semicomatose or alert patients, Oropharyngeal airway may gag or
induce vomiting and increase the risk of aspiration. Other complication
may be laryngospasm, coughing, and dental damage.
7. Other intervention
Independent
Assess the patency of airway.
Keep the unconscious patient in a position that facilitates drainage of the
secretions with the head of the bed elevated to about 30 degrees to
decrease intracranial venous pressure.
Establish effective suctioning procedures to facilitate drainage of the
secretions.
Encourage deep breathing and coughing exercises
Guard against aspiration and respiratory insufficiency
Monitor arterial blood gas values to determine adequate cerebral blood
flow
Monitor patient condition and needs to receiving mechanical ventilation
Collaborative
a. USE OF MANNITOL
Mannitol is effective for control of raised ICP after severe TBI.
Effective doses range from 0.25 to 1 g/kg/body weight.
b. USE OF BARBITURATES IN THE CONTROL OF
INTRACRANIAL HYPERTENSION
High-dose barbiturate therapy is efficacious in lowering ICP and
decreasing mortality in the setting of uncontrollable ICP refractory to
all other conventional medical and surgical ICP-lowering treatments,
in salvageable TBI patients. Utilization of barbiturates for the
prophylactic treatment of ICP is not indicated. The potential
complications attendant on this form of therapy mandate that its use
be limited to critical care providers and that appropriate systemic
a;monitoring be undertaken to avoid or treat any hemodynamic
instability. When barbiturate coma is utilized, consideration should
also be given to monitoring arteriovenous oxygen saturation as some
patients treated in this fashion may develop oligemic cerebral
hypoxia.
c. NUTRITION
Replace 140% of resting metabolism expenditure in nonparalyzed
patients and 100% in paralyzed patients using enteral or parenteral
formulas containing at least 15% of calories as protein by day 7 after
injury.
8. Self evaluation
Knowing how to properly insert an oropharyngeal airway is the best way to
ensure an optimal and injury free outcome.
9. Refference
2. Intervention
one of nursing actions which can be undertaken to overcome
Indication for gastric lavage
a. Patients who poisoned food or certain medications
Mencuci tangan
Perawat memakai skort
Perlak dan alas dipasang disamping pasien
NGT di ukur dari epigastrium sampai pertengahan dahi
kemudian diberi tanda
Ujung atas NGT diolesi jelly,bagian ujung bawah diklem
NGT dimasukkan perlahan-lahan melalui hidung pasien sambil
disuruh menelannya ( bila pasien sadar
Periksa apakah NGT betul-betul masuk lambung dengan cara ;
- Masukan ujung NGT kedalambaskom yang berisi
air,jika tidak ada gelembung Maka NGT sudah masuk
kedalam lambung.
- Masukan Udara dengan spuit 10cc dan didengarkan
pada daerah lambung dengan menggunakan
stetoskop.setelah yakin pasang plester pada hidung
untuk memfiksasi NGT.
Setelah NGT masuk pasien diatur dengan posisi miring tanpa
bantal atau kepala lebih rendah selanjutnya klem dibuka.
Corong dipasang diujung bawah NGT,air/susu dituangkan
kedalam corong jumlah cairan sesuai kebutuhan.cairan yang
masuk tadi dikeluarkan dan ditampung dalam baskom.
Pembilasan lambung dilakukan berulang kali sampai air yang
keluar dari lambung sudah jernih.
Jika air yang keluar sudah jernih Selang NGT dicabut secara
pelan-pelan dan diletakan dalam baki.
Setelah selesai pasien dirapikan,mulut dan sekitarnya
dibersihkan dengan tissue jelaskan pada pasien bahwa prosedur
yang dilakukan telah selesai.
Alat-alat dikemas dan dibersihkan
Perawat mencuci tangan
Mencatat semua tidakan yang telah dilakukan pada status
pasien
3. Principle
4. Analysis
Endotracheal intubation prevents the cough reflex and interferes with normal
muco-ciliary function, therefore increasing airway secretion production and
decreasing the ability to clear secretions. Endotracheal tube (ETT) suction is
necessary to clear secretions and to maintain airway patency, and to optimise
oxygenation and ventilation in a ventilated patient. The goal of ETT suction
should be to maximise the amount of secretions removed with minimal adverse
effects associated with the procedure.
Tracheal suction through a endotracheal tube bypasses the normal protective
mechanisms such as the cough reflex that the upper airways provide. Critically ill
patients often have an increase in the production of mucous and a weakened
ability to clear secretions. If secretions are not cleared then the patient may be at
risk of infection, atelectasis and alveolar collapse (Day et al, 2002).
Appropriate management of the patient with an artificial airway can have an
impact on reducing complications, length of stay and mortality and
morbidity.Correct technique and preparation by the clinician can assist in
reducing the risks of adverse events and reduce the level of discomfort for the
patient.
7. Other intervention
8. Self evaluation
9. Refference