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病患抽痰之護理指導

發佈日期:2013-11-11
發佈單位:德仁醫院-行政部
最新更新日期:2013-11-11
1.洗手。
2.評估病人狀況,並向病人解釋。
3.準備患者
 3.1.半坐臥姿勢。
 3.2.平躺仰臥姿勢。
4.執行抽吸
 4.1.打開抽吸器開關,測試抽吸力(成人抽吸壓力約80~120mmHg,小孩抽吸壓力約50~95mmHg)。
 4.2.選擇適當管徑的抽吸管,並拆開封口。抽吸管徑成人:12~18Fr.兒童:8~10Fr.嬰兒:5~8 Fr.
 4.3.右手戴上無菌手套或持鑷子,抽出無菌抽吸管與導管相接。
 4.4.放開控制孔,將抽吸管由病人的氣切造口處、氣管內管或口鼻插入抽吸管,以使用一次為原則,可先抽氣管內管,再抽口、鼻腔。插入深度;(抽口鼻約插入10~15公分)但勿強行插入,且應降低抽吸壓力,以避免造成鼻黏膜破損。抽氣切造口或氣管內管時,可儘量深入,當碰到氣管隆突或支氣管壁時,再回抽1~2公分。
 4.5.按住控制孔,以旋轉間歇性抽吸方式往外抽,抽吸時間每次不超過十五秒,抽吸次數視病人情況而定,二次間隔至少三分鐘,其間並給予病人充分之氧氣。
 4.6.抽吸過程中,患者如有發紺或心律不整的反應,應立即停止抽吸,並立即給予氧氣。
 4.7.抽吸畢,以清水將管內痰液沖洗乾淨,將手套及抽痰管一併丟棄。
 4.8.洗手。
 4.9.觀察病患呼吸情形並記錄痰液性質,如有異常應即告知護理人員。
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