Contoh lembar Observasi Pasien ICU RS Dr. Soetomo. Hak cipta ada pada SMF Anestesiologi dan Reanimasi RSUD. Dr. Soetomo
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University of Lahore Teaching Hospital SOP’s: ICU Admission and Discharge
University of Lahore Teaching Hospital
University of Lahore Teaching Hospital
University of Lahore Teaching Hospital SOP’s: Investigations on Admission in ICU
University of Lahore Teaching Hospital SOP’s: Weaning from Mechanical Ventilation in ICU
University of Lahore Teaching Hospital
University of Lahore Teaching Hospital
University of Lahore Teaching Hospital SOP’s: Initial Assessment and Resscitation on ICU Arrival A! Assign responsibilities to ICU sta "! Start initial assessment and resuscitation C! Take focused history and erform focused physical e!amination D! Send basic investigation #! "iscuss #ith ICU consultant $! Assess response to initial resuscitation %! Assess intensity of support &! Seek Consultations for speci$c problems that might re%uire e!pertise I! Construct a #orking diagnosis and plan for further management '! "iscuss further #ith the ICU consultant (! &rief the relatives
University of Lahore Teaching Hospital SOP’s: Central )ine Placement A! "!
Assess the need for central line placement Check for any contraindications 'Coagulopathy(
Local site infection or burn) C!Choose the appropriate site 'Internal *ugular is preferred( +emoral if lo# latelets and Coagulopathy) D! Choose the appropriate catheter 'Triple lumen or "ouble lumen) #! ,no# the relevant anatomy $! Take informed consent 'ros-Cons-Indications-Complications) %! ,eep all e%uipment ready and Set up the transducing system &! rocedure of Central line placement 'Use C. insertion bundle) i/ ii/ iii/ iv/ v/
vi/
vii/ viii/ i!/
0ear the cap and the mask/ 0ash hands #ith alcohol1based hand rub for 234 min and minimum three applications/ ut on a sterile go#n and gloves 'erformer and Assistant) Clean the skin of the patient #ith 56 chlorhe!idine in alcohol preparation/ 7ive a frictional scrub in a circular manner to at least 89 cm area from the insertion Site( "o not shave if hair is present lace large sterile drapes over the insertion site/ "o not occlude the air supply or $eld of vision #hen draping neck areas of conscious patients Local anesthesia at insertion site Use Seldinger techni%ue for cannulation Aseptic dressing at the end of procedure
University of Lahore Teaching Hospital I! Check C. pressure #ith pressure Transducer : 7et chest ;1ray for C. Line position '
SOP’s: Arterial Catheteri*ation +Radial Arter,A!
Assess the need for intra1arterial pressure
monitoring indications "! Check for any contraindications 'Coagulopathy( Local site infection or &urns) C!Choose the appropriate site '=adial referred) D! Check perfusion of the e!tremity #! Take informed consent 'ros-Cons-Indications-Complications) $! ,eep all e%uipment ready for arterial cannulation and pressure Transducing %! Set up the pressure transducing system &! ositioning '>!tension at #rist #ith a small pillo# I.
beneath #rist) rocedure of =adial arterial cannulation a/ 0ear the cap and the mask/ b/ 0ash hands #ith alcohol1based hand rub for 234 min and minimum three applications/ c/ ut on a sterile go#n and gloves 'erformer and Assistant) d/ Clean the skin of the patient #ith 56 chlorhe!idine in alcohol preparation/ e/ 7ive a frictional scrub in a circular manner to at least 89 cm area from the insertion Site f/ lace large sterile drapes over the insertion site/ "o not occlude the air supply or $eld of vision #hen draping conscious patients
University of Lahore Teaching Hospital g/ Local anesthesia at insertion site h. Use Over-the-Needle Technique or Over-the-Wire Technique for Radial Artery Cannulation i/ Aseptic dressing at the end of procedure
'! Secure the catheter and check perfusion (! Check the arterial #aveform and ?A #ith pressure Transducer
SOP’s: .horacentesis A! "!
Assess the need of thoracentesis Check for any contraindications 'Coagulopathy(
Local site infection or &urns) C!,eep all e%uipment ready for the procedure D! Take informed consent 'ros-Cons-Indications-Complications) #! lace the patient in proper position 'referably sitting) F. rocedure of Thoracentesis a/ 0ear the cap and the mask/ b/ 0ash hands #ith alcohol1based hand rub for 234 min and minimum three applications/ c/ ut on a sterile go#n and gloves 'erformer and Assistant) d/ Clean the skin of the patient #ith 56 chlorhe!idine in alcohol preparation/ e/ 7ive a frictional scrub in a circular manner to at least 89 cm area from the insertion Site f/ lace large sterile drapes over the insertion site/ "o not occlude the air supply or $eld of vision #hen draping conscious patients g/ Local anesthesia at insertion site h. Needle thoracentesis – For Diagnostic Thoracentesis i. Thoracentesis ith intravenous cannula - For Thera!eutic Thoracentesis
University of Lahore Teaching Hospital @/ Aseptic dressing at the end of procedure
%!
Send pleural uid for the laboratory tests
University of Lahore Teaching Hospital SOP’s: Chest ./e Placement A! "!
Assess the need of chest tube insertion Check for any contraindications 'Coagulopathy(
Local site infection or &urns) C! Take informed consent 'ros-Cons-Indications-Complications) D! remedication 'ain meds etc/) : atient position 'lying #ith arm abducted and above head on side of chest tube insertion) #! Selection of site 'Triangle of safety) : Selection of "rain siBe 'Small for pneumothora!( large for empyema) $! ,eep all e%uipment ready for the procedure %! rocedure for Chest tube insertion 'Use Chest Tube Insertion &undle) a/ 0ear the cap and the mask/ b/ 0ash hands #ith alcohol1based hand rub for 234 min and minimum three applications/ c/ ut on a sterile go#n and gloves 'erformer and Assistant) d/ Clean the skin of the patient #ith 56 chlorhe!idine in alcohol preparation/ e/ 7ive a frictional scrub in a circular manner to at least 89 cm area from the insertion Site f/ lace large sterile drapes over the insertion site/ "o not occlude the air supply or $eld of vision #hen draping conscious patients g/ Local anesthesia at insertion site h/ Use #hatever method of insertion is appropriate 7uide#ire tube thoracostomy( Trocar tube thoracostomy( Dperative tube thoracostomy i/ Aseptic dressing at the end of procedure @/ Attach to under#ater seal
University of Lahore Teaching Hospital &!
.eri$cation of chest tube placement 3 7et Chest
;1ray
SOP’s: )m/ar Pnctre A! "!
Assess the need for lumbar puncture erform fundoscopy : Drder CT head before
lumbar puncture C!Check for any contraindications 'Coagulopathy( Local site infection or &urns) D! Take informed consent 'ros-Cons-Indications-Complications) #! ,eep all e%uipment ready for the procedure $! osition the patient 'left lateral preferred) %! ,no# landmarks and anatomy &! rocedure of Lumbar puncture a/ 0ear the cap and the mask/ b/ 0ash hands #ith alcohol1based hand rub for 234 min and minimum three applications/ c/ ut on a sterile go#n and gloves 'erformer and Assistant) d/ Clean the skin of the patient #ith 56 chlorhe!idine in alcohol preparation/ e/ 7ive a frictional scrub in a circular manner to at least 89 cm area from the insertion Site f/ lace large sterile drapes over the insertion site/ "o not occlude the air supply or $eld of vision #hen draping conscious patients g/ Local anesthesia at insertion site h/ Use small L/ needle '+7 55( +7 52( +754)( Insert bet#een L21E( LE14 and collect CS+ in E vials labeled A to " i/ Aseptic dressing at the end of procedure
University of Lahore Teaching Hospital I!
Send samples A( &( C to lab( Store Sample " for future tests