1. Consult a physician for drug delivery of low-dose heparin for high-risk clients until he ambulation. (Low-dose heparin therapy will result in blood viscosity and thrombosis decreased holding capacity and allows the risk of embolism)
2. Keep track of the signs and symptoms of pulmonary embolism
a. Acute chest pain and clear
b. Dyspnea, fatigue, cyanosis
c. Decrease in oxygen saturation
d. Tachycardia
e. Jugular venous distension
f. Hypotension
g. Acute dilatation of the right venrikel without parenchymal disease (on chest X-ray)
h. Mental disorder
i. Cardiac dysrhythmia
(Pulmonary artery occlusion disrupt blood flow to the lungs resulting in hypoxia distal)
3. If these manifestations occur, perform the protocol on the shock:
a. Keep the IV catheter (for the administration of fluids and drugs)
b. Give the gift of liquids treatment in accordance with the protocol
c. Replace indwelling catheter (Foley) (to monitor the volume of circulation through urine output)
d. Perform EKG monitoring and invasive hemodynamic monitoring (to detect dysrhythmias and treatment guidelines)
e. Give a vasopressor to increase peripheral resistance and increase blood pressure
f. Give sodium bicarbonate as indicated (to correct metabolic acidosis)
g. Give the drugs digitalis, diuretics IV and arrhythmia agents as indicated
h. Give a low dose of morphine IV (lower anxiety and reduce the need for metabolism)
i. Prepare client for procedure angiography and / or perfusion lung Scanning (to confirm the diagnosis and detect the extent of atelectasis)
(Due to massive pulmonary embolism deaths occur within the first 2 hours after awitan, immediate intervention is very important)
4. Give oxygen therapy via nasal catheter and oxygen saturation monitor. (With this action will increase the circulation of oxygen by rapidly)
5. Monitor electrolyte values, GDA, BUN, DL (this laboratory to help determine the status of perfusion and volume)
6. Do thrombolytic treatment, eg urokinase, streptokinase in accordance with the program physician (thrombolysis can cause embolic lysis and increased pulmonary capillary perfusion)
7. After treatment with intravenous thrombolysis, did the provision of treatment with heparin. (IV continuous or intermittent). (Heparin can inhibit or slow down the process of thrombus formation and helps prevent the formation and recurrence of clots.
Sabtu, 28 September 2013
Central Retinal Artery Occlusion
Clinical symptoms:
The disorder is usually about one eye, and particularly the arteries at the entry area in the lamina kribrosa.1, 4.7
Complaints of patients with central retinal occlusion begins with an intermittent blurred vision (amaurosis fugaks), not accompanied by pain and then dark settled.
Or with complaints of vision suddenly dark, where these marks occur when the occlusion is only found in one of the branches in the main stem of a. Central retina but before there is a history of amaurosis fugaks without sighting abnormalities in the outer eye.
Physical examination:
Visual acuity ranged from counting fingers and light perception in 90% of eyes at the time of initial examination. Decrease in visual acuity in the form of repeated attacks can be caused by diseases of vessels spasm or embolism running. Sometimes the visual acuity to be good back when spasmenya disappeared.
Afferent pupillary defect can appear within a few seconds after blockage of retinal artery becomes weak reaction of the pupil with the pupil anisokoria. Pupillary defect is usually precede abnormalities arise fundus for one hour. On funduscopic examination will look all pale in color due to retinal edema and disruption of nutrients to the retina.
There is a picture of a sausage on retinal arteries due to retinal artery filling uneven. 25% of eyes with central retinal artery occlusion have arteries that are silioretina anastomose between a. Central retina and a. siliaris is not about the macula so that the macular region may still see it rather than central visual acuity that can still be maintained.
After several hours of the retina will appear pale, grayish turbid due to edema layer in the retina and ganglion cell layer. In this case the picture will look red cherry (cherry red spots) on the macula lutea. This is due to absence of ganglion layer in the macula, so that the macula retain its original color. Over time the color papil pale and blurred boundaries. Clinically, retinal turbidity disappeared within 4-6 weeks, leaving a pale optic disc as the first ocular findings.
The disorder is usually about one eye, and particularly the arteries at the entry area in the lamina kribrosa.1, 4.7
Complaints of patients with central retinal occlusion begins with an intermittent blurred vision (amaurosis fugaks), not accompanied by pain and then dark settled.
Or with complaints of vision suddenly dark, where these marks occur when the occlusion is only found in one of the branches in the main stem of a. Central retina but before there is a history of amaurosis fugaks without sighting abnormalities in the outer eye.
Physical examination:
Visual acuity ranged from counting fingers and light perception in 90% of eyes at the time of initial examination. Decrease in visual acuity in the form of repeated attacks can be caused by diseases of vessels spasm or embolism running. Sometimes the visual acuity to be good back when spasmenya disappeared.
Afferent pupillary defect can appear within a few seconds after blockage of retinal artery becomes weak reaction of the pupil with the pupil anisokoria. Pupillary defect is usually precede abnormalities arise fundus for one hour. On funduscopic examination will look all pale in color due to retinal edema and disruption of nutrients to the retina.
There is a picture of a sausage on retinal arteries due to retinal artery filling uneven. 25% of eyes with central retinal artery occlusion have arteries that are silioretina anastomose between a. Central retina and a. siliaris is not about the macula so that the macular region may still see it rather than central visual acuity that can still be maintained.
After several hours of the retina will appear pale, grayish turbid due to edema layer in the retina and ganglion cell layer. In this case the picture will look red cherry (cherry red spots) on the macula lutea. This is due to absence of ganglion layer in the macula, so that the macula retain its original color. Over time the color papil pale and blurred boundaries. Clinically, retinal turbidity disappeared within 4-6 weeks, leaving a pale optic disc as the first ocular findings.
ETIOPATOGENESIS OKLUSI ARTERI RETINA SENTRAL
Oklusi arteri retina sentral terjadi akibat dari trombosis pada lamina sklerosis, mungkin berasal dari arteriosklerosis komplikasi, atau dari kejadian emboli. Saat retina menjadi iskemik, retina akan membengkak, dan kehilangan transparan.3
Penyumbatan arteri retina sentral dapat disebabkan oleh:
1. Emboli
Merupakan penyebab penyumbatan arteri retina sentral yang paling sering. Emboli dapat berasal dari perkapuran yang berasal dari penyaklit emboli jantung, nodus-nodus reuma, carotid plaque atau emboli endokarditis.
2. Radang arteri
3. Spasme pembuluh darah
Penyebab spasme pembuluh darah antara lain pada migren, overdosis obat, keracunan alkohol, tembakau, kina atau timah hitam.
4. Akibat terlambatnya pengaliran darah
Perlambatan aliran pembuluh darah retina terjadi pada peninggian tekanan intraokular, stenosis aorta atau arteri karotis.
5. Giant cell arthritis
6. Kelainan hiperkoagulasi
7. Trauma
Hilangnya penglihatan yang tiba-tiba, memberat, dan tanpa nyeri pada salah satu mata merupakan karakteristik dari oklusi arteri retina sentral. Retina akan menjadi opaque dan edema, khususnya dibagian kutub posterior dimana serabut saraf dan sel-sel ganglion menjadi tebal.
Oklusi arteri retina sentralis biasanya terjadi pada usia tua atau usia pertengahan. Kehilangan penglihatan secara tiba-tiba, berat dan tanpa didahului oleh rasa sakit adalah karakteritik oleh oklusi arteri retinal sentralis Merupakan kasus kegawatdaruratan oftalmologi. Keterlambatan penanganan akan mengakibatkan kehilangan penglihatan permanen.
Penyumbatan arteri retina sentral dapat disebabkan oleh:
1. Emboli
Merupakan penyebab penyumbatan arteri retina sentral yang paling sering. Emboli dapat berasal dari perkapuran yang berasal dari penyaklit emboli jantung, nodus-nodus reuma, carotid plaque atau emboli endokarditis.
2. Radang arteri
3. Spasme pembuluh darah
Penyebab spasme pembuluh darah antara lain pada migren, overdosis obat, keracunan alkohol, tembakau, kina atau timah hitam.
4. Akibat terlambatnya pengaliran darah
Perlambatan aliran pembuluh darah retina terjadi pada peninggian tekanan intraokular, stenosis aorta atau arteri karotis.
5. Giant cell arthritis
6. Kelainan hiperkoagulasi
7. Trauma
Hilangnya penglihatan yang tiba-tiba, memberat, dan tanpa nyeri pada salah satu mata merupakan karakteristik dari oklusi arteri retina sentral. Retina akan menjadi opaque dan edema, khususnya dibagian kutub posterior dimana serabut saraf dan sel-sel ganglion menjadi tebal.
Oklusi arteri retina sentralis biasanya terjadi pada usia tua atau usia pertengahan. Kehilangan penglihatan secara tiba-tiba, berat dan tanpa didahului oleh rasa sakit adalah karakteritik oleh oklusi arteri retinal sentralis Merupakan kasus kegawatdaruratan oftalmologi. Keterlambatan penanganan akan mengakibatkan kehilangan penglihatan permanen.
Take Care The Patient With Installation CVP
I. UNDERSTANDING
Central venous pressure (central venous pressure) is the blood pressure in AKA or vena cava. It provides information about the three parameters of blood volume, the effectiveness of the heart as a pump, and vascular tone. Central venous pressure is distinguished from the peripheral venous pressure, which may reflect only local pressure.
II. MONITORING LOCATIONS
a. Right internal jugular vein or the left (more common on the right)
b. Right or left subclavian vein, but lower in the right thoracic duct
c. Brachial vein, which may be bent and develop into phlebitis
d. Proximal lumen of the pulmonary artery catheter in the right atrium or immediately above the superior vena cava
III. INDICATIONS AND USAGE
a. Measurement of central venous pressure (CVP).
b. Blood sample for laboratory examination.
c. Measurement of central venous oxygenation.
d. Parenteral nutrition and administration of hypertonic fluids or fluids that irritate that need immediate dilution in the circulatory system.
e. Vasoactive drug administration by drip (drip) and inotropic drugs.
f. As venous access if all other IV site has been weak.
IV. COMPLICATIONS
The complications of CVP cannulation installation include:
a. Pain and inflammation at the location of the stabbing.
b. Blood clots because tertekuknya catheter.
c. Bleeding: ekimosis or major bleeding when the needle is disconnected.
d. Tromboplebitis (thrombus embolism, air embolism, sepsis).
e. Microshock.
f. Cardiac dysrhythmia
V. ASSESSMENT
Which should be studied in patients who mounted CVP are signs of complications caused by the installation tool.
a. Complaints of pain, shortness of breath, discomfort.
b. Verbal complaints of fatigue or weakness.
c. Respiratory rate, breath sounds
d. Signs redness / pus on the installation location.
e. The presence of blood clots / air bubbles in cateter
f. Suitability infusion set point position
g. Vital signs, perfusion
h. Pressure CVP
i. Intake and output
j. ECG Monitor
VI. Nursing Diagnosis
Activity disorder associated with central venous catheter placement
Assessment criteria focus:
a. Weakness, fatigue.
b. Changes in vital signs, the presence of dysrhythmias.
c. Dyspnea.
d. Pale
e. Sweaty
Central venous pressure (central venous pressure) is the blood pressure in AKA or vena cava. It provides information about the three parameters of blood volume, the effectiveness of the heart as a pump, and vascular tone. Central venous pressure is distinguished from the peripheral venous pressure, which may reflect only local pressure.
II. MONITORING LOCATIONS
a. Right internal jugular vein or the left (more common on the right)
b. Right or left subclavian vein, but lower in the right thoracic duct
c. Brachial vein, which may be bent and develop into phlebitis
d. Proximal lumen of the pulmonary artery catheter in the right atrium or immediately above the superior vena cava
III. INDICATIONS AND USAGE
a. Measurement of central venous pressure (CVP).
b. Blood sample for laboratory examination.
c. Measurement of central venous oxygenation.
d. Parenteral nutrition and administration of hypertonic fluids or fluids that irritate that need immediate dilution in the circulatory system.
e. Vasoactive drug administration by drip (drip) and inotropic drugs.
f. As venous access if all other IV site has been weak.
IV. COMPLICATIONS
The complications of CVP cannulation installation include:
a. Pain and inflammation at the location of the stabbing.
b. Blood clots because tertekuknya catheter.
c. Bleeding: ekimosis or major bleeding when the needle is disconnected.
d. Tromboplebitis (thrombus embolism, air embolism, sepsis).
e. Microshock.
f. Cardiac dysrhythmia
V. ASSESSMENT
Which should be studied in patients who mounted CVP are signs of complications caused by the installation tool.
a. Complaints of pain, shortness of breath, discomfort.
b. Verbal complaints of fatigue or weakness.
c. Respiratory rate, breath sounds
d. Signs redness / pus on the installation location.
e. The presence of blood clots / air bubbles in cateter
f. Suitability infusion set point position
g. Vital signs, perfusion
h. Pressure CVP
i. Intake and output
j. ECG Monitor
VI. Nursing Diagnosis
Activity disorder associated with central venous catheter placement
Assessment criteria focus:
a. Weakness, fatigue.
b. Changes in vital signs, the presence of dysrhythmias.
c. Dyspnea.
d. Pale
e. Sweaty
Anatomi Retina Mata
Retina adalah selembar tipis jaringan saraf yang semitransparan, dan multilapis dan melapisi bagian dalam dua per tiga posterior dinding bola mata. Retina biasa juga disebut selaput jala, merupakan bagian mata yang mengandung reseptor yang menerima rangsangan cahaya.
Retina berbatas dengan koroid dan sel pigmen epitel retina, dan terdiri atas lapisan-lapisan, mulai dari sisi dalamnya, adalah sebagai berikut :
1. Membrana limitans interna
2. Lapisan serabut-serabut saraf
3. Lapisan sel-sel ganglion
4. Lapisan pleksiform dalam
5. Lapisan nuklear dalam
6. Lapisan pleksiform luar
7. Lapisan nuklear luar
8. Membrana limitans interna
9. Lapisan fotoreseptor
10. Lapisan epitel pigmen
Di tengah-tengah retina posterior terdapat makula. Secara klinis dapat didefinisikan sebagai daerah pigmentasi kekuningan yang disebabkan oleh pigmen luteal (xantofil), dan dibatasi oleh arkade-arkade pembuluh darah retina temporal. Di tengah makula, sekitar 3,5 mm di sebelah lateral diskus optikus, terdapat fovea yang secara klinis jelas-jelas merupakan suatu cekungan yang memberikan pantulan khusus bila dilakukan oftalmoskop.
Fovea ditandai dengan menipisnya lapisan inti luar dan dan tidak adanya lapisan-lapisan parenkim karena akson-akson sel fotoreseptor berjalan oblik dan pergeseran secara sentrifugal lapisan retina yang lebih dekat ke permukaan dalam retina. Foveola merupakan bagian paling tengah pada fovea, di sini fotoreseptornya adalah sel kerucut dan merupakan bagian retina yang paling tipis.
Pada funduskopi tempat makula lutea tampak lebih merah dari sekitarnya dan pada tempat fovea sentralis seolah-olah ada cahaya yang disebut refleks fovea, yang disebabkan oleh lekukan pada fovea sentralis. Pada bagian nasal dari makula lutea terdapat papilla nervi optisi, yaitu tempat dimana N.II menembus sklera. Papil ini hanya terdiri dari serabut saraf, tidak mengandung sel batang atau kerucut sama sekali dan disebut titik buta.
Bagian tengahnya ada lekukan yang tampak agak pucat, dari tempat inilah keluar arteri dan vena retina sentralis yang kemudian bercabang-cabang ke temporal dan ke nasal, juga ke atas dan ke bawah. Arteri ini merupakan arteri terminal dan tak ada anastomose. Namun terkadang di dapat anastomose antara a. Siliaris dan a. Retina sentral yang disebut a. Silioretinal yang terletak di makula, sehingga bila terjadi emboli yang masuk ke dalam arteri retina sentralis fungsi dari makula tak terganggu.
Pemasok arteri utama ke orbita dan bagian-bagiannya berasal dari arteri oftalmika, cabang besar pertama dari bagian intrakranial arteri karotis interna. Cabang ini berjalan di bawah nervus optikus dan bersamanya melewati kanalis optikus menuju orbita. Cabang intraorbital pertama adalah arteri retina sentralis, yang memasuki nervus optikus sekitar 8-15 mm di belakang bola mata. Pembuluh darah retina keluar pada papil N.II, membentuk gambaran percabangan yang berbeda-beda pada setiap individu.
Retina menerima darah dari dua sumber. Biasanya bagian dalam retina disuplai oleh a.retina sentral dan cabangnya yang memperdarahi dua per tiga sebelah dalam. Pada bagian luar disuplai oleh koriokapiler yang berada tepat di luar membrana Bruch, yang memperdarahi sepertiga luar retina. Termasuk lapisan pleksiformis luar dan lapisan inti luar, fotoreseptor, dan lapisan epitel pigmen retina.
Retina berbatas dengan koroid dan sel pigmen epitel retina, dan terdiri atas lapisan-lapisan, mulai dari sisi dalamnya, adalah sebagai berikut :
1. Membrana limitans interna
2. Lapisan serabut-serabut saraf
3. Lapisan sel-sel ganglion
4. Lapisan pleksiform dalam
5. Lapisan nuklear dalam
6. Lapisan pleksiform luar
7. Lapisan nuklear luar
8. Membrana limitans interna
9. Lapisan fotoreseptor
10. Lapisan epitel pigmen
Di tengah-tengah retina posterior terdapat makula. Secara klinis dapat didefinisikan sebagai daerah pigmentasi kekuningan yang disebabkan oleh pigmen luteal (xantofil), dan dibatasi oleh arkade-arkade pembuluh darah retina temporal. Di tengah makula, sekitar 3,5 mm di sebelah lateral diskus optikus, terdapat fovea yang secara klinis jelas-jelas merupakan suatu cekungan yang memberikan pantulan khusus bila dilakukan oftalmoskop.
Fovea ditandai dengan menipisnya lapisan inti luar dan dan tidak adanya lapisan-lapisan parenkim karena akson-akson sel fotoreseptor berjalan oblik dan pergeseran secara sentrifugal lapisan retina yang lebih dekat ke permukaan dalam retina. Foveola merupakan bagian paling tengah pada fovea, di sini fotoreseptornya adalah sel kerucut dan merupakan bagian retina yang paling tipis.
Pada funduskopi tempat makula lutea tampak lebih merah dari sekitarnya dan pada tempat fovea sentralis seolah-olah ada cahaya yang disebut refleks fovea, yang disebabkan oleh lekukan pada fovea sentralis. Pada bagian nasal dari makula lutea terdapat papilla nervi optisi, yaitu tempat dimana N.II menembus sklera. Papil ini hanya terdiri dari serabut saraf, tidak mengandung sel batang atau kerucut sama sekali dan disebut titik buta.
Bagian tengahnya ada lekukan yang tampak agak pucat, dari tempat inilah keluar arteri dan vena retina sentralis yang kemudian bercabang-cabang ke temporal dan ke nasal, juga ke atas dan ke bawah. Arteri ini merupakan arteri terminal dan tak ada anastomose. Namun terkadang di dapat anastomose antara a. Siliaris dan a. Retina sentral yang disebut a. Silioretinal yang terletak di makula, sehingga bila terjadi emboli yang masuk ke dalam arteri retina sentralis fungsi dari makula tak terganggu.
Pemasok arteri utama ke orbita dan bagian-bagiannya berasal dari arteri oftalmika, cabang besar pertama dari bagian intrakranial arteri karotis interna. Cabang ini berjalan di bawah nervus optikus dan bersamanya melewati kanalis optikus menuju orbita. Cabang intraorbital pertama adalah arteri retina sentralis, yang memasuki nervus optikus sekitar 8-15 mm di belakang bola mata. Pembuluh darah retina keluar pada papil N.II, membentuk gambaran percabangan yang berbeda-beda pada setiap individu.
Retina menerima darah dari dua sumber. Biasanya bagian dalam retina disuplai oleh a.retina sentral dan cabangnya yang memperdarahi dua per tiga sebelah dalam. Pada bagian luar disuplai oleh koriokapiler yang berada tepat di luar membrana Bruch, yang memperdarahi sepertiga luar retina. Termasuk lapisan pleksiformis luar dan lapisan inti luar, fotoreseptor, dan lapisan epitel pigmen retina.
Fields of hospital management and organizational structure
Management is the process of activities to achieve certain goals through cooperation with others. In this process there are activities of planning, organizing, and supervision.
Management area that need attention are:
1. Planning management
2. Financial management
3. Field of personnel management
4. Biadang hospital information management and medical records
5. Field office management
6. The field of logistics management
7. Bidnag management of pharmaceuticals and generic drugs
8. Field of medical management and care
9. The field of nutrition manajemna
10. Linen management and laundri
11. Field hospital sanitation management and environmental impact
12. Nosocomial infection control management
13. Field of work safety management
14. The field of security management
15. Field marketing management
16. Field monitoring and evaluation management
The division of tasks and organizational structure
In an effort to achieve the target of a hospital must choose an organizational structure that efktif easy to operate and not much bureaucracy. Determination of the organizational structure is intended to be able to divide tasks, provide authority, to supervise and hold accountable.
A successful hospital organizations have cirri:
• organizational structure pyramid-shaped but not flat
• short-tier hierarchy
• organized team oriented malleable and very easy to be dissolved again.
Organizations who served in the hospital are:
• Board of Trustees
• Director of the hospital
• Vice president of medical support
• Deputy director of medical service
• Vice president of promotion and prevention
• Deputy director of general administration and finance
• Head of outpatient
• Head of the emergency room
• Head of hospitalization
• Head of laboratory installation
• Head of radiological installations
• Head of the installation of medical records and information
• Head of administration and staffing
• Head of finance
• Head bookkeeping
• Head of pharmacy
• Head of the hospital facilities maintenance installation
• Head of installation supplies
• Head of the installation of environmental health and occupational health
• Chief operating room and delivery room
• Head UPF diagnostic and physiotherapy
• Committee
Management area that need attention are:
1. Planning management
2. Financial management
3. Field of personnel management
4. Biadang hospital information management and medical records
5. Field office management
6. The field of logistics management
7. Bidnag management of pharmaceuticals and generic drugs
8. Field of medical management and care
9. The field of nutrition manajemna
10. Linen management and laundri
11. Field hospital sanitation management and environmental impact
12. Nosocomial infection control management
13. Field of work safety management
14. The field of security management
15. Field marketing management
16. Field monitoring and evaluation management
The division of tasks and organizational structure
In an effort to achieve the target of a hospital must choose an organizational structure that efktif easy to operate and not much bureaucracy. Determination of the organizational structure is intended to be able to divide tasks, provide authority, to supervise and hold accountable.
A successful hospital organizations have cirri:
• organizational structure pyramid-shaped but not flat
• short-tier hierarchy
• organized team oriented malleable and very easy to be dissolved again.
Organizations who served in the hospital are:
• Board of Trustees
• Director of the hospital
• Vice president of medical support
• Deputy director of medical service
• Vice president of promotion and prevention
• Deputy director of general administration and finance
• Head of outpatient
• Head of the emergency room
• Head of hospitalization
• Head of laboratory installation
• Head of radiological installations
• Head of the installation of medical records and information
• Head of administration and staffing
• Head of finance
• Head bookkeeping
• Head of pharmacy
• Head of the hospital facilities maintenance installation
• Head of installation supplies
• Head of the installation of environmental health and occupational health
• Chief operating room and delivery room
• Head UPF diagnostic and physiotherapy
• Committee
How To Take Care Patient With Ventilator ?
A. Humidifasi and Temperature
Mechanical ventilation through artificial airway negate the body's defense mechanism against sticking and heating.
Two processes must be added moisturizers (humidifier) with temperature control and water filled to the extent specified level (water boiling system) Condensation of water occurs with decreasing temperature to a temperature of 370 C at the end of the mechanical ventilation circuit. In most cases the air temperature of ± equal to body temperature.
In the case hypotermi temperature can be increased more than 370 C - 380 C.
Vigilance is recommended because of the old and the high temperature inhalation burns in the trachea, it is easier secretion of coagulation and consequently airway obstruction can occur. Conversely, if the patient's temperature is less than 360 C makes the opportunity for the growth of germs.
B. Airway Maintenance
Airway maintenance occurs from sticking adequate, changes in position and sucking sucking secretion in doing only when necessary, because this makes the patient uncomfortable and the risk of infection, sterility note!
Furthermore, in addition to sounding the ronkhi (auscultasi) can also be seen from the increasing pressure inspiration (resp. rate) that indicate the presence of adhesions / narrowing of the airway by secretions are an indication to do suction.
Chest physiotherapy is very supportive to reduce atelectasis and to facilitate decision-secretion, can be a way to clapping, fibrasing change position every 2 hours needed to be done to reduce pelengketan secretion.
C. Endotracheal tube care
Endotracheal hose should be installed securely to prevent migration, kinking and terekstubasi, therefore, that adequate fixation should not be ignored. Replacement plesterfiksasi at least 1 day must be done because this is an opportunity for us to see if there are signs of blister / skin irritation on the edge of the lip or endotracheal tube installation location.
In patients who do not cooperate should be installed mayo / Gudel to size, is good for endotracheal tube was not bitten, and could also make it easier for suctioning of secretions.
D. Endotracheal cuff pressure
Cuff pressure should be monitored at least every shift to prevent over inflation and excess pressure on the tracheal wall.
In patients with mechanical ventilation, the best is the lowest pressure without any leakage / decrease in tidal volume.
Cuff kempeskan if possible on a periodic basis to prevent the occurrence of necrosis in the trachea.
E. Nutrition Support
In patients with mechanical ventilation installation of nutritional support must be considered early. If this is overlooked by dozens of side effects that aggravate the condition of the patient, and even can cause pulmonary complications and death.
If there is no disturbance of gastrointestinal tract, Enteral nutrition can be given via Nasogastric tube (NGT), which began with the first feeding test, especially in patients with post laparatomy with bowel resection.
F. Eye Care
In patients with mechanical ventilation installation of eye care is very important in nursing care. Assessments are frequently and giving eye drops / zalf can decrease dry eye cornea. When the blink reflex is lost, the eyelids should be in plaster to prevent corneal abrasion, dry and trauma. edema of the sclera may occur in patients with mechanical ventilation when venous pressure increases.
Mechanical ventilation through artificial airway negate the body's defense mechanism against sticking and heating.
Two processes must be added moisturizers (humidifier) with temperature control and water filled to the extent specified level (water boiling system) Condensation of water occurs with decreasing temperature to a temperature of 370 C at the end of the mechanical ventilation circuit. In most cases the air temperature of ± equal to body temperature.
In the case hypotermi temperature can be increased more than 370 C - 380 C.
Vigilance is recommended because of the old and the high temperature inhalation burns in the trachea, it is easier secretion of coagulation and consequently airway obstruction can occur. Conversely, if the patient's temperature is less than 360 C makes the opportunity for the growth of germs.
B. Airway Maintenance
Airway maintenance occurs from sticking adequate, changes in position and sucking sucking secretion in doing only when necessary, because this makes the patient uncomfortable and the risk of infection, sterility note!
Furthermore, in addition to sounding the ronkhi (auscultasi) can also be seen from the increasing pressure inspiration (resp. rate) that indicate the presence of adhesions / narrowing of the airway by secretions are an indication to do suction.
Chest physiotherapy is very supportive to reduce atelectasis and to facilitate decision-secretion, can be a way to clapping, fibrasing change position every 2 hours needed to be done to reduce pelengketan secretion.
C. Endotracheal tube care
Endotracheal hose should be installed securely to prevent migration, kinking and terekstubasi, therefore, that adequate fixation should not be ignored. Replacement plesterfiksasi at least 1 day must be done because this is an opportunity for us to see if there are signs of blister / skin irritation on the edge of the lip or endotracheal tube installation location.
In patients who do not cooperate should be installed mayo / Gudel to size, is good for endotracheal tube was not bitten, and could also make it easier for suctioning of secretions.
D. Endotracheal cuff pressure
Cuff pressure should be monitored at least every shift to prevent over inflation and excess pressure on the tracheal wall.
In patients with mechanical ventilation, the best is the lowest pressure without any leakage / decrease in tidal volume.
Cuff kempeskan if possible on a periodic basis to prevent the occurrence of necrosis in the trachea.
E. Nutrition Support
In patients with mechanical ventilation installation of nutritional support must be considered early. If this is overlooked by dozens of side effects that aggravate the condition of the patient, and even can cause pulmonary complications and death.
If there is no disturbance of gastrointestinal tract, Enteral nutrition can be given via Nasogastric tube (NGT), which began with the first feeding test, especially in patients with post laparatomy with bowel resection.
F. Eye Care
In patients with mechanical ventilation installation of eye care is very important in nursing care. Assessments are frequently and giving eye drops / zalf can decrease dry eye cornea. When the blink reflex is lost, the eyelids should be in plaster to prevent corneal abrasion, dry and trauma. edema of the sclera may occur in patients with mechanical ventilation when venous pressure increases.
Selasa, 22 Februari 2011
Mechanical Ventilator Settings
Ventilator is a mechanical breathing aid use to help patients with airway disorders, patients with PaCO2> 50 mmHg and PaO2 <50 mmHg requiring help one of them with ventilator breath.
Things to note on the ventilator:
1. Prisoners airway resistance
2. Komplience lung
3. The desired air volume (flow rate)
4. Humidifier
5. Inspired fractional oxygen consentration (FiO2)
6. Sigh
7. Positive End expiratory Pressure
8. The highest expiratory pressure (pressure Peek Limit)
9. Inspiration and expiratory ratio (I / E ratio)
Steps ventilator settings
1. After intubation followed by mechanical pumps
2. See whether elevated asymmetrical chest wall every time inspiration is given and no air leakage sound
3. Select the mode appropriate ventilator patient's condition
4. At the beginning of the use of ventilators provide FiO2 100%, to maintain SatO2> 92%. FiO2 can be derived after the confirmation of the value of oxygen saturation
5. Given tidal volume 8-10 ml / kg, in patients with acute respiratory failure due to neuromuscular disease often membiutuhkan tidal volume of 10-12 ml / kg
6. Determine the rate of breathing and minute ventilation according to clinical state of patients depending on blood pH
7. Use PEEP in diffuse lung damage, PEEP> 15 cmH2O is rarely necessary.
8. High Pressure inspiration PIP> 60 cmH2O, inspiration plateau pressure> 35 cm H2O must be considered
9. If the ventilator requires a flow rate, use the appropriate flow rate to avoid rapid respiration and autoPEEP
10. If there is difficulty in oxygenation, ventilation or excessive high-pressure inspiration, use appropriate medications or change in position
11. Call critical care consultant.
Things to note on the ventilator:
1. Prisoners airway resistance
2. Komplience lung
3. The desired air volume (flow rate)
4. Humidifier
5. Inspired fractional oxygen consentration (FiO2)
6. Sigh
7. Positive End expiratory Pressure
8. The highest expiratory pressure (pressure Peek Limit)
9. Inspiration and expiratory ratio (I / E ratio)
Steps ventilator settings
1. After intubation followed by mechanical pumps
2. See whether elevated asymmetrical chest wall every time inspiration is given and no air leakage sound
3. Select the mode appropriate ventilator patient's condition
4. At the beginning of the use of ventilators provide FiO2 100%, to maintain SatO2> 92%. FiO2 can be derived after the confirmation of the value of oxygen saturation
5. Given tidal volume 8-10 ml / kg, in patients with acute respiratory failure due to neuromuscular disease often membiutuhkan tidal volume of 10-12 ml / kg
6. Determine the rate of breathing and minute ventilation according to clinical state of patients depending on blood pH
7. Use PEEP in diffuse lung damage, PEEP> 15 cmH2O is rarely necessary.
8. High Pressure inspiration PIP> 60 cmH2O, inspiration plateau pressure> 35 cm H2O must be considered
9. If the ventilator requires a flow rate, use the appropriate flow rate to avoid rapid respiration and autoPEEP
10. If there is difficulty in oxygenation, ventilation or excessive high-pressure inspiration, use appropriate medications or change in position
11. Call critical care consultant.
Health Care Information System
The need for evaluation
Health care organizations-long time uses of computers-are considering many new computer based products in the hope of increasing efficiency, reducing costs, and improving patient care. These products include a growing number of medical computer applications in which health care providers interact directly with the computer. These applications are referred to generally as medical or clinical information systems. Medical information systems involved computer-stored database containing patient information to support medical order entry, result reporting, decision support systems, clinical reminders, and other health care applications. In some health care organizations, a comprehensive systems coordinates patient care activities by linking computer terminals in patient care areas to all departments through a central or integrated information system. Other organizations use smaller separate systems tahat link patient care areas to only one department such as the laboratory, radiology, or the pharmacy. These systems provide communication network between departments as well as storage and retrieval of medical information. Other computerized database or expert systems may serve a single department or group of practitioners.
At the same time, the current emphasis on cost-effectiveness in health care is creating new pressures on organizations to justify expenditures through detailed evaluations of the impacts of new informations systems. Although implementation success depends heavily on the integration of the computer systems into a complex organizational setting, professionals who develop, implement, and evaluate health care computer systems have few guidelines for designing effective evaluation strategies and selecting appropriate methods to examine the outcomes of systems use in health care organizations. To ensure that newly adopted systems accomplish their intended purpose, vendors and purchasers alike need to develop detailed plans prior to system implementation for ongoing implementation and post-instalation evaluation to examine the use and long-term impacts ofthese systems.
Evaluating the impact of computer based medical information systems requires not only an understanding of computer technology but also an understanding of the social and behavioral processes that affect and are affected by the introduction of the technology into the practice setting. As technological developments result in the widespread use of computer in health care, the social and behavioral sciences can provide an important perspective to guide the establishment of research agendas and the conduct of policy-relevant investigations.
Health care organizations-long time uses of computers-are considering many new computer based products in the hope of increasing efficiency, reducing costs, and improving patient care. These products include a growing number of medical computer applications in which health care providers interact directly with the computer. These applications are referred to generally as medical or clinical information systems. Medical information systems involved computer-stored database containing patient information to support medical order entry, result reporting, decision support systems, clinical reminders, and other health care applications. In some health care organizations, a comprehensive systems coordinates patient care activities by linking computer terminals in patient care areas to all departments through a central or integrated information system. Other organizations use smaller separate systems tahat link patient care areas to only one department such as the laboratory, radiology, or the pharmacy. These systems provide communication network between departments as well as storage and retrieval of medical information. Other computerized database or expert systems may serve a single department or group of practitioners.
At the same time, the current emphasis on cost-effectiveness in health care is creating new pressures on organizations to justify expenditures through detailed evaluations of the impacts of new informations systems. Although implementation success depends heavily on the integration of the computer systems into a complex organizational setting, professionals who develop, implement, and evaluate health care computer systems have few guidelines for designing effective evaluation strategies and selecting appropriate methods to examine the outcomes of systems use in health care organizations. To ensure that newly adopted systems accomplish their intended purpose, vendors and purchasers alike need to develop detailed plans prior to system implementation for ongoing implementation and post-instalation evaluation to examine the use and long-term impacts ofthese systems.
Evaluating the impact of computer based medical information systems requires not only an understanding of computer technology but also an understanding of the social and behavioral processes that affect and are affected by the introduction of the technology into the practice setting. As technological developments result in the widespread use of computer in health care, the social and behavioral sciences can provide an important perspective to guide the establishment of research agendas and the conduct of policy-relevant investigations.
Anatomy Retina
The retina is a thin sheet of nerve tissue that semitransparan, and multilapis and line the inside of two thirds of the posterior wall of the eyeball. The retina is often called the retina, is part of the eye contains receptors that receive light stimuli.
Bounded by the choroid and retina pigment epithelial cells of the retina, and consists of layers, ranging from the inside, is as follows:
1. Internal limitans membrane
2. Layer of nerve fibers
3. Layer of ganglion cells
4. Pleksiform layer in
5. In the nuclear layer
6. Pleksiform outer layer
7. Outside the nuclear layer
8. Internal limitans membrane
9. Photoreceptor layer
10. Pigment epithelial layer
In the middle there is the posterior retina macula. In clinical can be defined as an area of yellowish pigmentation caused by luteal pigment (xantofil), and bordered by arcades-temporal retinal vascular arcades. In the middle of the macula, approximately 3.5 mm lateral to the optic disc, fovea that clinically there is clearly a reflection of a basin that provides specially when done oftalmoskop.
Fovea is marked with the depletion layer and the outer core and the absence of the layers of parenchyma because of photoreceptor cell axons run in a centrifugal oblique and shifting layers of the retina that is closer to the surface of the retina. Foveola is the most central part of the fovea, here fotoreseptornya are cone cells and is the thinnest part of the retina.
On funduscopic the macula lutea appear redder than its surroundings and on the central fovea as if no light reflex, called the fovea, which is caused by the curvature at the central fovea. In the nasal part of macula lutea contained Nervi optisi papilla, which is a place where N. II through the sclera. Papil is only composed of nerve fibers, did not contain stem cells or cone at all and called the blind spot.
Indentation in the middle there that looked a little pale, from where this is out of central retinal artery and vein which then ramify into the temporal and the nasal, as well as upwards and downwards. The artery is a terminal artery and no anastomose. But sometimes in to anastomose between a. Siliaris and a. Central retina, called a. Silioretinal located in the macula, so that in case of emboli that enter the central retinal artery of macular function undisturbed.
Suppliers main artery to the orbit and their parts derived from arterial oftalmika, the first major branch of the intracranial internal carotid artery. This branch runs below the optic nerve and optic canal with him through to the orbita. The first intraorbital branch is the central retinal artery, which enter the optic nerve about 8-15 mm behind the eyeball. Retinal blood vessels out in papil N. II, forming a picture of the different branches on each individual.
The retina receives blood from two sources. Usually the inside of the retina is supplied by central and branch a.retina memperdarahi inner two thirds. On the outside is supplied by koriokapiler which is right outside the Bruch membrane, which memperdarahi outer third of the retina. Includes outer layer pleksiformis and outer core layer, photoreceptors, and retinal pigment epithelial layer.
Bounded by the choroid and retina pigment epithelial cells of the retina, and consists of layers, ranging from the inside, is as follows:
1. Internal limitans membrane
2. Layer of nerve fibers
3. Layer of ganglion cells
4. Pleksiform layer in
5. In the nuclear layer
6. Pleksiform outer layer
7. Outside the nuclear layer
8. Internal limitans membrane
9. Photoreceptor layer
10. Pigment epithelial layer
In the middle there is the posterior retina macula. In clinical can be defined as an area of yellowish pigmentation caused by luteal pigment (xantofil), and bordered by arcades-temporal retinal vascular arcades. In the middle of the macula, approximately 3.5 mm lateral to the optic disc, fovea that clinically there is clearly a reflection of a basin that provides specially when done oftalmoskop.
Fovea is marked with the depletion layer and the outer core and the absence of the layers of parenchyma because of photoreceptor cell axons run in a centrifugal oblique and shifting layers of the retina that is closer to the surface of the retina. Foveola is the most central part of the fovea, here fotoreseptornya are cone cells and is the thinnest part of the retina.
On funduscopic the macula lutea appear redder than its surroundings and on the central fovea as if no light reflex, called the fovea, which is caused by the curvature at the central fovea. In the nasal part of macula lutea contained Nervi optisi papilla, which is a place where N. II through the sclera. Papil is only composed of nerve fibers, did not contain stem cells or cone at all and called the blind spot.
Indentation in the middle there that looked a little pale, from where this is out of central retinal artery and vein which then ramify into the temporal and the nasal, as well as upwards and downwards. The artery is a terminal artery and no anastomose. But sometimes in to anastomose between a. Siliaris and a. Central retina, called a. Silioretinal located in the macula, so that in case of emboli that enter the central retinal artery of macular function undisturbed.
Suppliers main artery to the orbit and their parts derived from arterial oftalmika, the first major branch of the intracranial internal carotid artery. This branch runs below the optic nerve and optic canal with him through to the orbita. The first intraorbital branch is the central retinal artery, which enter the optic nerve about 8-15 mm behind the eyeball. Retinal blood vessels out in papil N. II, forming a picture of the different branches on each individual.
The retina receives blood from two sources. Usually the inside of the retina is supplied by central and branch a.retina memperdarahi inner two thirds. On the outside is supplied by koriokapiler which is right outside the Bruch membrane, which memperdarahi outer third of the retina. Includes outer layer pleksiformis and outer core layer, photoreceptors, and retinal pigment epithelial layer.
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