Summary

ECG

1. The usual shit, the greeting and the explanation

2. Ask pt to remove any jewelry, wrist watches and if they can turn phone
off or put in silent as this will prevent disturbances during the procedure
and prevent alterations of the result
3. Wheel machine to beside and draw the curtains to provide privacy
4. Remove or rise the clients shirt up to only expose chest and arm, but
keeping the abdomen and thighs covered just to make the client
comfortable.
5. Client to be in supine position, and to be instructed to lie still without
talking and crossing legs
6. Wash hands
7. Apply gel in appropriate sites
i. V1- 4th intercostal space (btw 4th and 5th rib) at right sternal angle
ii. V2- 4th intercostal space (btw 4th and 5th rib) at left sternal angle
iii. V3- midway between V2 and V4
iv. V4- 5th ICS (btw 5th and 6th rib) under nipple line
v. V5- Left anterior axillary line
vi. V6- Left midaxillay line

Extremities- one on each extremities

8. Switch on machine and obtain tracing

9. Disconnect leads, wide excess gel, aid in dressing, straighten out bed and
make client comfortable.
10.Label the ECG tracing- Name, NHN, time, date and unit.
11.Terminate procedure, clean ECG leads and return machine at usual place.
12.Informs physian to review result and DOCUMENTTTTT
 Suctioning ETT- to decrease the work of breathing and improve patients comfort

1. Therapeutic interaction
2. Gather all equipment
Suctioning tray
Suction catheter and tubing
Ambu bag
Saline
Sterile golves
Syringe
3. Check oxygen saturation
4. O2 setting must be consistent with the setting the client is currently on
5. Adjust wall suction to minimal pressure for effective suctioning, to avoid
nasopharyngeal nerve spasm
6. Wash hands via aseptic technique
7. Assisting nurse can open the flap of the suction tray and I open from the other cover
of the tray
8. Dry hands thoroughly then son sterile gloves
9. Assisting nurse to open suction catheter, syringe and pour saline into gallipot
10. Attach sterile catheter to suction tubing
11. Assisting nurse to disconnect ventilator and I instill 0.25-0.5 mls of normal saline to
ET tube
12. Hyper oxygenate( bag the client ) for a period of 3 mins if client id O2 dependent
13. Gently pass down the catheter down the ETT only to pre- measured length( DO NOT
SUCTION MORE THAN ONE BREATH CYCLE, 10-15 SECS)
14. Occlude the suction hole and withdraw in a rotating motion maintaining continuous
suction. Allow 10 seconds suctioning time, replace client on ventilator and check
setting including alarm setting
15. Assess clients tolerance during procedure by observing color, heart rate, tone and
activity.
16. Change clients position after suctioning.
17. Check ETT position to ensure no strain or kink is in the tracheal tube
18. Reassess condition, observe vital signs and color
19. Discard used suction catheter and terminate procedure
20. Was hands
21. Record amount of Secretion and color on chart
22. Documentation

 Cycle is same
As for Trac sucking  If more secretions , remove catheter , give O2
and repeat procedure
 Same start but Position client on back
 head slightly raised on pillow
 Rinse suction tubing by dipping end in water and
 Check suction pressure 80-150mmHg apply suction until solution has rinsed the tube
 Hyperoxygentae  Position client comfortably
 Place towel or drape on chest  Was and depose
 Insert suction caterer 1 3rds or client coughs  Document
Tracheostomy dressing- assist client in trac care and removing secretions from
stoma site

1. Greetings, Introduce, Explanation

2. Gather equipment
3. Open dressing tray and pour normal saline into gallipot
4. Wash hands and don gloves
5. Gently clean area by passing a swab beneath the flange of the trac tube.
Dry also like that
6. Note the appearance of stoma – observe for redness, oozing, bleeding
7. Open gauze and cut in middle
8. Gently lift neck plate and slide middle of dressing under neck plate
9. Make client comfortable in bed
10.Discard soiled dressing and discard equipment
11.Record and document

CPR
INTERVENTION RATIONALES

Check for Conscious level (if unconscious)

 Work on the right side of the victim if you are right

hander and left if left hander.
 Tap or shake the shoulders lightly.
 Ask are you OK?
 If the person does not respond and two people are
available, one should call 911 or the local
emergency number and the other should begin
CPR. If you are alone and have immediate access to This will prevent injury from attempted
a telephone, call 911 before beginning CPR – unless resuscitation on a person is conscious.
you think the person has become unresponsive
because of suffocation (such as from drowning). In
this special case
 begin CPR for a minute then call 911 or the local Seek immediate assistance.
emergency number.

CHECK CIRCULATION

 Kneel next to the patient’s neck and shoulders.
 Left hand continues to support the head
 Right hand palpates the carotid pulse, if pulse is not
pulpable start external chest compression.
Position self appropriately.
Cardiac arrest is recognized by
pulselessness in the large arteries of the
unconscious, breathless patient. If there is a
palpable pulse, but no breathing present,
initiate breathing at a rate of 12 breaths
 /minute.

Position arm correctly on the sternum

 Look for xiphoid process.

 Measure 3cm upward on the sternum which is
equivalent to 2-3 cm breadths.
 Heel of the left hand beside the 3cm on sternum.
 Right hand on the left hand and interlace fingers.

PERFORM COMPRESSION:

 Stand on your knees and spread your left feet

behind you.
 Elbow straight, shoulder above the sternum.
 Push straight down to about 4cm and release. To initiate cardiac output.
 Thirty chest compressions followed by two rescue
breaths is considered one cycle. (30:2)

CHECK AIRWAY Head tilt maneuver extends the neck and

 Head tilt, chin lift maneuver – kneeling close to the
patient, place one hand on the patient’s forehead
gently tilt the head back. Then with the other hand
gently lift the chin forward to open the airway.
 Check the airway obstruction by pressing the chin
lightly, look inside the mouth for tongue
obstruction or foreign body.
 Check for head and neck injury.
lifts the tongue away from the back of the
throat, relieving any obstruction of the
airway caused by the tongue.
The jaw thrust technique without the head
tilt is the safest method for opening the
airway in the presence of suspected neck
injury.

CHECK BREATHING (LOOK, LISTEN & FEEL)

Check for normal beathing taking no more than 5 to 10

seconds.

 Place ear over the patient’s mouth and nose while

observing the chest. Keep maintaining an open airway.
 Look – at the chest to rise and fall.
 Listen – for air escaping from mouth during
exhalation and
 Feel - for the flow of the air.
 If no breathing:

GIVE TWO QUICK BREATHS

 Pinch nose with left hand and hand continue to

support neck.
  Seal the mouth completely around victim’s This prevents air escaping from the
mouth. patient’s nose.
 Take a deep breath and blow to fill the lungs,
lasting one second.

Check breathing again (look, listen and feel) To confirm pattern’s breathing.

Continue CPR until patient responds or medical personnel To save the victim’s life.
arrives.