Ansis suction ETT

1. Background and Nursing diagnoses

Ny. H, 33 years old Admitted to X hospital 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 ineffective airway clearance. The diagnosis can be confirmed by the data
that supports among other secretions in the respiratory tract and the sound of
gargling, on auscultation sound ronci wet or cracles in both lung fields.

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

a. Assess for need for suctioning

Identification of these clinical signs will require the nurse to constantly

review the patient (visual inspection with regular chest auscultation to
identify coarse breath sounds and/or changes in air entry) and ventilator (that
is indications of disruption to gas flow such as alteration of flow volume loop
for sawtooth pattern or changes indicating reduction in tidal volume).

Look and listen to RR and pattern of breathing.

Auscultate lung sounds.

Evaluate quality of cough effort.

Drop in SpO2.

Rational: Tracheal suctioning is performed as needed based on assessment

findings. Excess secretions, weak cough ability are indications for the need
for suctioning.

b. Maintain patient tracheal tube

Maintenance patient tracheal tube is of vital importance and whilst there is

evidence to indicate that suctioning should only be done when clinically
indicated there was little quality evidence to identify what the maximum
 time between suction procedures should be. Difficulty passing the suction
catheter through the tracheal tube may be an indication of the build up of
secretions in the lumen of the tube (Cuthbertson and Kelly 2007).

c. Use sterile technique

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.

Rational: Maintaining sterile technique reduces risk for infection.

d. Hyperinflate and hyperoxygenate

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.

Provide before and after each pass.

Set O2 flow meter at 15L/min to provide 100% oxygen.

Give at least 5 deep breaths.

May be done in 3 ways:

Ask conscious patient to deep breathe.

Using a manual bag-valve device.

Using the settings on a ventilator.

Rational: Reduces the risk for hypoxemia, dysrhythmias, and

microatelectasis.

e. Appropriate size of the suction catheter

The size of the suction catheter and the duration of suctioning (i.e.
application of negative pressure) will directly influence the volume of
secretions removed, however, it will also have potential adverse effects on
respiratory function. Thompson (2000) found that there was some evidence
to support limiting the diameter of the suction catheter to less than 50% of the
internal diameter of the tracheal tube.

f. Suction techniques

Set suction at 120-140mm Hg or using a negative pressure setting of between

100-150mmHg. Do not apply suction while inserting the catheter.

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.

Do not suction for more than 10 seconds.

Rational: Prevents tissue trauma and reduces risk for hypoxemia and
dysrhythmias.

g. Frequency of suctioning

Depends on individual need but limit passes to 2-3 times a day.

Rational: reduces risks of suctioning (local trauma, hypoxemia,

dysrhythmias, etc.)

h. Humidification

Humidified air/oxygen per trach collar and keep patient hydrated.

Rational: Prevents drying of trachea and subsequent thick secretions, mucous

plugs.

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.

5. Hazardz and complication

Suctioning may induce hypoxaemia, lead to a loss of lung volume, cause
dysrhythmias, effect cerebral blood flow and introduce pathogens to the lower
airway increasing the risk of nosocomial pneumonia.
Complications of ETT suction:

Decrease in dynamic lung compliance and residual capacity

 Tissue trauma to tracheal and or bronchial mucosa
Hypoxaemia
Atelectasis
Bronchoconstriction/bronchospasm
Cardiac dysrhythmia (bradycardia and tachycardia)
Increased TcCO2
Blood pressure fluctuations (hypertension and hypotension)
Decreased tidal volume
Airway mucosal trauma
ETT dislodgement
Pneumothorax
Pneumomediastinum
Bacteraemia
Pneumonia
Fluctuations in intracranial pressure and cerebral blood flow velocity

6. Result and interpretation

Result of intervention is client airways free or clear from excessive mucus, no
more souns of gargling, ronchi still stand but can be reduced, no complication
after intervention.

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

Doenges, Marilynn E., Moorhouse, Mary F., Murr, Alice C. 2010.

Nursing Care Plans: Guidelines for Individualizing Client care across the
life span. Philadelphia: F. A. Davis Company.
Hess, Dean R. 2012. Respiratory Care: Principle and Practice. Ed. 2.
Ontario: Jones & Bartlett Learning.
Smeltzer, C. Suzanne. 2002. Buku Ajar keperawatan Medikal
Bedah Brunner & Suddarth. Jakarta EGC.

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

5. Hazardz and complication

6. Result and interpretation

7. Other intervention

8. Self evaluation

9. Refference

Baird, Marianne S., Bethel,S. Manual of Critical Care Nursing: Nursing

Interventions and Collaborative Management. Elsevier Mosby
Doenges, Marilynn E., Moorhouse, Mary F., Murr, Alice C. 2010.
Nursing Care Plans: Guidelines for Individualizing Client care across the
life span. Philadelphia: F. A. Davis Company.
Hess, Dean R. 2012. Respiratory Care: Principle and Practice. Ed. 2.
Ontario: Jones & Bartlett Learning.

Ansis Oropharynx

1. Background and Nursing diagnoses

Ineffective airway clearance related to excesse bloody secretion and

inability to perform effective cough. Maintaining airway in this condition is
critically important. First, patient must be placed in the recovery position, clear
his mouth and pharynx, then insert an oropharingeal airway. It is because if his
consciousness is much impaired, the patient has no cough reflex.
2. Intervention

Based on NIC, there are many intervention which can be undertaken to

overcome problem of nursing ineffective airway clearance. One of them is
airway management with oropharyngeal airway. Oropharyngeal airway is
a tube used to provide free passage of air between the mouth and pharynx
of an unconscious person.
Procedure guidelines
a. Take body substance isolation precautions
b. Measure for correct size
The OPA is sized by measuring from the center of the mouth to the angle
of the jaw,or from the corner of the mouth to the earlobe.
c. Open the mouth

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.

a. Pushing the tongue posteriorly, thereby exacerbating the airway

obstruction
 b. Using an incorrectly-sized device: too small a device is ineffective and
can be lost in the oropharynx, possibly causing obstruction; too large a
device can press against the epiglottis and obstruct the larynx
c. Catching the tongue or lips (usually the lower lip) between the airway
and the teeth, thereby traumatizing the soft tissue
d. Using the device in a patient with intact airway reflexes, possibly
inducing vomiting. The OPA must be removed if protective reflexes
are present.

6. Result and interpretation

Result of intervention is

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

Doenges, Marilynn E., Moorhouse, Mary F., Murr, Alice C. 2010.

Nursing Care Plans: Guidelines for Individualizing Client care across the
life span. Philadelphia: F. A. Davis Company.
Hess, Dean R. 2012. Respiratory Care: Principle and Practice. Ed. 2.
Ontario: Jones & Bartlett Learning.
McNett, Molli M., Gianakis, A. 2010. Nursing Interventions for
Critically Ill Trauma Brain Injury. Journal of Neuroscience Nursing. 42
(20) : 71-77.
Tong, J. L., Smith J. E. 2004. Cardiovascular Changes Following
Insertion of Oropharyngeal and Nasopharyngeal Airways. British Journal
of Anesthesia. 93 (3): 339-342.

Ansis gastric lavange

1. Background and Nursing diagnoses

Mrs D, 57 years old

2. Intervention
one of nursing actions which can be undertaken to overcome
Indication for gastric lavage
a. Patients who poisoned food or certain medications

b. Preparation of gastric surgery

c. Preparation of action of gastric examination
d. There is no gag reflex
e. Failed to emesis therapy
f. The patient is conscious
Contraindication
a. Gastric lavage is not performed routinely in the management of
patients with poisoning. Gastric lavage performed when patients
ingest a toxic substance that can be life threatening, and procedures
performed during the 60 minutes after swallowing.
b. Patients seizures
 c. Rinse the stomach can push tablets into the duodenum besides
issuing tablet.
d. Gastric lavage is contraindicated for toxic substances feels sharp
and burning (the risk of esophageal perforation). Gastric lavage is
not allowed for hydrocarbon toxic materials (risk of aspiration), for
example: camphor, hydrocarbons, halogens, aromatic
hydrocarbons, pesticides
e. Gastric lavage is contraindicated for patients who ingest foreign
objects sharp and large
f. Patients without a gag reflex or patients with fainting (unconscious)
requiring intubation before gastric lavage to prevent inspiration.
Tujuan
Membuang racun yang tidak terabsorbsi setelah racun masuk
saluran pencernaan
Mendiagnosa perdarahan lambung
Membersihkan lambung sebelum prosedur endoscopy
Membuang cairan atau partikel dari lambung
g. Prosedur

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.

5. Hazardz and complication

6. Result and interpretation

Result of intervention is

7. Other intervention

8. Self evaluation

9. Refference

Doenges, Marilynn E., Moorhouse, Mary F., Murr, Alice C. 2010.

Nursing Care Plans: Guidelines for Individualizing Client care across the
life span. Philadelphia: F. A. Davis Company.
Hess, Dean R. 2012. Respiratory Care: Principle and Practice. Ed. 2.
Ontario: Jones & Bartlett Learning.