Ecg

A.
PREPARATION (crackles, rhonchi, low spo2, tachypnic

1. Introduce self and verify patient’s name
2. Informs patient abt the procedure and its importance
 Maintain patency of the artificial airway
 Improve gas exchange
 Decrease airway resistance
 Reduce infection risk by removing secretions from trachea & main stem bronchi
3. Handwashing
4. Assembles articles & equipment to bedside
5. Position patient in a comfortable position & lay towel over patient’s chest
 Semi fowler’s position if conscious
 Side lying is unconscious
6. Turn suction on and set appropriate pressure
 50-100mmHg: small children;
 100-120mmHg: older children and adults
7. Hyper oxygenates patients
 Ambu bag3-5 breaths
 C (index & thumb letter c- press)
 Remaining fingers hyper extend
Breath in breath out 1,2,3
8. Provides privacy
B. PROCEDURE
Dominant hand hawak ay suction catheter ipulupot sa hand mo
Non dominant
1. Connect suction tubing to the machine
2. Opens sterile suction kit and prepares materials
 Pour saline to container
 Takip turn up
3. Attaches suction catheter to suction tubing (state nalang)
4. Puts on sterile gloves
5. Holds catheter in dominant hand and the connector in non dominant hand. Attach catheter
to the Y-connector
6. Using the sterile gloved hand, puts the catheter tip in the sterile saline solution and suction
a small amount of sterile solution through the catheter.
7. Hyper oxygenates the patient
8. Remove oxygen delivery device with non-sterile hand
9. With non-dominant thumb turns off the suction port, quickly but gently insert the catheter
into the trachea thru the tracheostomy tube. Insert the catheter about 10 to 12.5 cm (4 to 5
in) or until the patients cough.
10. Apply suction for 5-10 secs. By occluding the thumb port with the non-dominant thumb.
Allows 20-30 secs rest between suction.
11. Rotates catheter by rolling it between thumb and forefinger while slowly withdrawing it.
12. Withdraws the catheter completely & release the suction
13. If secretions are thick, flushes the tracheostomy tube with approximately one ml sterile
saline, then suction
14. Encourage patient to breath deeply and cough. Repeat the suction until the air passage is
clear and the breathing is relatively effortless and quite.
15. Assesses patient’s cardio-pulmonary status between each suctioning (breaths ni patient)
16. Turn off suction machine
C. PROCEDURE FOR TRACHEOSTOMY CARE
1. Opens tracheostomy set, hydrogen Peroxide and sterile saline
2. Dons sterile gloves keeping dominant hand sterile
3. Pours Hydrogen Peroxide into one tray and sterile NaCl into other tray using non dominant
hand
4. Puts sterile brush & pipe cleaners into H2O2 tray using sterile gloves
5. Puts 4X4s and 1 cotton swab into H2O2 tray and Na Cl tray, keeping two 4x4s dry
6. Instructs re: deep breathing then removes oxygen source if present, with non-dominant
hand
7. Removes inner cannula; If disposable, dispose
8. If not disposable, puts in hydrogen peroxide with brush
9. Washes inner cannula with brush
10. Holds cannula (sterile) over basin and pours NaCl over cannula to rinse
11. Shakes off excess saline
12. Using 4x4s and cotton swab from H2Os tray, cleans outer cannula and stoma in circular
motion 4-8 cm from stoma
13. Uses 4x4s and swab from saline tray to rinse area and pat dry
D. CHANGING TRACHEOSTOMY TIES

1. Ties ends securely in double square knot allowing space for only one finger in tie or
attaches Velcro strips
2. Inserts fresh tracheostomy dressing under clean ties and faceplate
E. AFTER CARE
1. Positions client comfortably
2. Performs hand hygiene
3. Performs after care of all articles and equipment used
F. DOCUMENTATION
Documents the procedure and all nursing assessment
• Time tracheostomy care was done
• Condition of tracheostomy
• If cannula was changed
• Effect of tracheostomy care to patient
ECG LEAD PLACEMENT
A. PREPARATION
1. Checks the doctor’s order
2. Introduces self to patient and verifies patient’s name
3. Informs patient of the procedure and its importance (XPOSING YOUR CHEST
AREA FOR PLACING ELECTRODES IN THE BODY WOULD THAT BE
OKAY?
 Know heart rate & rhythm
 test irregularities in how the heart functions
 determine / diagnose M.I
 screen patients for possible cardiac ischemia
4. Performs handwashing
5. Assembles articles and equipment's needed at the bedside
6. Provides privacy
7. Places patient in supine position, with head slightly elevated
8. Prepares client’s skin should there be a need for:
a. Hair needs to be shaved
b. Greasy skin to be washed and dried
c. Remove all metals, pins, coins
d. Turn on the machine to check if functioning and check for tracing paper
e. Wipe area using alcohol swab / water (lahat ng lalagyan ng leads)
 wait until alcohol is dry
B. PROCEDURE
9. Applies the 4 limb leads properly on correct placement
 RA (below clavicle)
 RL
 LA (below clavicle)
 LL
10. Applies the 6 precordial leads
V1- 4TH ICS Right Sternal margin
V2- 4th I CS Left Sternal margin
V3- midway bet V2 and V4 Left
V4- 5th ICS Mid Clavicular Line (MCL) Left
V5- 5th ICS Anterior Axillary line Left (middle of v4 and v6)
V6- 5th ICS Mid Axillary Line (MAL) Left
11. Instructs client to relax and standstill
12.Turns on the machine and set according to the doctor’s order/need
14. Places/ Encode name of the patient, time, age, date of ECG
 After maprint ang result ng ecg
 State encode (NTAD)
14. Turns off the ECG machine
15. Tell the client that you are going to remove the leads gently, starting with the chest
leads followed by limb leads
 Use cotton ball w alcohol
 We are going to put back the clothes of the patient
16. Places client in comfortable position
AFTER CARE
1. Positions client comfortably
2. Performs hand hygiene
3. Performs care of all articles and equipment's used
DOCUMENTATION
1. Documents the procedure and all nursing assessment
a. Date and time of ECG procedure
b. Record the ECG strips for interpretation
c. Patients' reaction to ECG procedure

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A.

PREPARATION (crackles, rhonchi, low spo2, tachypnic

D. CHANGING TRACHEOSTOMY TIES

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