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Intubated patients are spending far longer in our emergency
Here is a quick bullet-point refresher on some of the important points in providing quality care for them
There are more ways to tie a tube than there are nurses who attempt it. There is little evidence for a best practice standard for this, so follow your departments policy.
Make sure any ties are firm but not so tight as to obstruct venous return through the neck (this can raise intracrainial and intraoccular pressures).
* ETT Placement.
Auscultate. Listen under both auxilla for air entry.
Fogging of tube.
Capnograph (end-tidal CO2).
* ETT patency.
* Length mark at teeth.
* Cuff pressure (lowest pressure that prevents a leak). The easiest way to check for correct cuff pressure is to use a cuff manometer. You can also auscultate over the patients trachea to check for air leak.
* Auscultate for adventitious breath sounds.
* Assess for symmetrical chest excursion/ TML (trachea mid line).
* Assess SaO2, ETCO2, ABG.
* Check tubing for integrity, kinks, snag risks.
* Ensure tubing is secure and supported.
* Confirm ventilator settings. Document vent obs
* Note any spontaneous resps.
Is patient fighting the ventilator? Does the ventilation mode need to be changed?
* Check ventilator is on correct O2 supply and power supply.
Remember to swap your patient back from cylinder to wall oxygen when returning from a trip to CT or Xray.
* Assess need for closed circuit suctioning.
* Assess pulse pressure/ blood pressure /urine output.
* Observe MAP
MAP is defined as the average arterial blood pressure during a single cardiac cycle.
The reason that it is so important is that it reflects the haemodynamic perfusion pressure of the vital organs.
* Peripheral Cannula security.
Cannot stress the importance of proper taping of all peripheral cannulas. A few extra seconds of attention will save a whole lot of grief later on.
* Assess central catheters.
* At the proximal end of the catheter 3 separate extension tubes are marked with the gauge size and position of the exit part of the lumen – proximal 18G, middle 18G, distal 16G.
Proximal 18G (white) – blood sampling or general access
Middle 18G (blue) – TPN or general access
Distal 16G (brown) – CVP monitor, blood products, general access.
* Check for active external bleeding.
* Check IV fluids.
* Document Glasgow Coma Score.
* Monitor pt temperature
(Remember the lethal triad: hypothermia, acidosis, coagulopathy)
* Consider rectal/oesophageal probe.
* Consider need for active warming (eg hypothermic trauma patients) or active cooling (eg post VF arrest).
Paralysis and sedation.
* Assess requirements.
* Pay attention! But go to the patient not the monitor.
* Check power supplies.
* Zero transducers. Arterial/Central Venous Pressure.
* Monitor integrity.
We had just taken delivery of a brand new Oxylog ventilator, which I dropped on the floor and broke because I had not taken time to secure it to the bed properly. Lesson.
* Cable safety.
I almost extubated a paediatric near drowning when my belt pouch caught up on the ETCO2 cable that was attached to her Endotrachal Tube. Lesson.
* ANTICIPATE & PLAN
Know your way around the advanced life support trolley.
If in doubt hit the BIG RED BUTTON early.
* BVM- bag valve mask + PEEP valve.
Even when your patient is intubated, dont for get to have a correctly fitting mask handy…worst case scenario.
* Full O2 cylinders.
* Suction available.
* Take away drugs (when transporting to CT, ICU etc).
* Suctioning prn
* 2nd hourly oral hygiene.
* Vaseline to lips.
* Check for FB (teeth etc)
* Risk of complications from conjunctivitis to corneal injury/ulceration.
* Sedation and muscle relaxants ? inadequate closure of eyes.
positive pressure ventilation, ETT tapes too tight ? raised IOP ? conjunctival oedema (chemosis).
* Consider taping of eyes.
* Inspect regularly.
* 2nd hourly eye care.
* Care during suctioning (bacterial Keratitis).
* NG tube confirmation. Best practice: test pH of aspirate. If less than 5.5-6.0 you are good.
* NG tube security.
* Regular Penile/perineum catheter care.
* Hourly FBC (fluid balance chart).
Pressure area care/positioning.
* Regular repositioning (2nd hourly):
Assists with clearance of secretions.
Prevents pressure areas
It has been estimated that the management of pressure ulcers, costs the Australian health system $285 million per annum.
Pressure ulcers develop when excessive friction, prolonged pressure or a sheering force results in damage to skin and tissue. It commonly occurs in areas where forces are applied to an area where a thin covering of tissue overlies a bony prominence. When areas such as the heels, buttocks, hips, scapula and even the back of the head are placed under continuous compression, the resulting impedance of the lymphatic and circulatory system quickly leads to cellular damage and death.
In high risk patients such as intubated patients it can take as little as one hour of unrelieved compression for serious damage to occur.
* Consider head up 30 deg for head injured patients.
* Watch for ETT and NG pressure area problems.
* Change hard collar to Aspen ASAP.
جــــ .. الله كل خير ..ــــزاك ..*_*
موضوع مفصل وراقي جدا ..*_*
سلمــــ ..أناملك ..ــــت ..*_*
|مواقع النشر (المفضلة)|
|الكلمات الدليلية (Tags)|
|care, department., emergency, patient, the, ventilated|
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