Page 85 - MALAYSIAN PATIENT SAFETY GOALS

ROLES AND RESPONSIBILITIES OF NURSES

1. Continuous Nursing Education and Training.

• Continuous Nursing Education at Unit level / Departmental /

Hospital.
• Introduce VAP Care Bundle to all new nurses who report duty
or transfer

in to ICU through Orientation and Mentor - Mentee Program.

2. Standard Precaution And Implementation Of VAP Care Bundle

• Practicing 5 moments of hand hygiene.
• Ensure mouth toilet is done with Chlorohexidine 0.2% every
4 – 6 hours by using tooth brush and tooth paste.
• Suctioning is done in sterile technique and must be performed by

2 nurses.
• Ensure tracheal aspiration for C&S is collected on admission and

weekly basis to identify any growth for further management or to
follow unit policy.
• Ensure patient’s head of bed is elevated to 30 – 45 degrees.
• Ensure the pressure of pilot balloon of endotracheal tube (

ETT ) / Tracheotomy tube is checked every shift (standard:
25 – 30 cmH O)
2
• Aspiration of secretion from ETT and mouth must be
performed before extubation.
• Heat Moisture Exchanger (HME) is changed daily or when
soiled or contaminated.

• Periodically drain and discard any condensate that collects in
the ventilator tubing.

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