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Intensive

care unit
Physical
therapy
by:
Slamet
Sumarno.

Fisioterapi ICU
Intensive Care Unit = Perawatan intensif.
ICU umumnya rawat kond kritis Cardiorespirasi
dan banyak menggunakan alat bantu serta
ditangani secara team.

Siapa yang harus di rawat di ICU.


Gejala gagal nafas (krirtis pernafasan).
Indikasi memerlukan alat bantu pernafasan.
Tidak stabilnya pernafasan .
Kritis trauma capitis.
Kondisi yg memerlukan perawat intensive.

Gagal nafas.
Pengertian.
Gagal nafas diartikan sebagai kegagalan
pertukaran gas dlm paru yg ditandai
dengan turunnya kadar oksigen di arteri
(hipoksimia) atau naiknya kadar
karbondiaksida (hiperkarbia) atau
kombinasi keduanya.

Kriteria diagnosa gagal nafas.


PaO2 <
60mmHg,
PaCO2 > 49
mmHg tanpa
gangguan
alkalosis
metabolik primer
(Muhadi,OE Tampubolon, 1989)

Pemeriksaan lab Gas Darah


Asidosis
acut respiratory
acidosis
a 7.1 metabolik acidosis
r 7.2
chronic respiratory
t 7.3
acidosis
e 7.4
r 7.5
metabolik alkalosis
I 7.6 respiratory alkalosis
7.7
2 4 6 8 10 12
Alkalosis PH= 7,35-7,4 PCO2= 5-6 kpa

Etiologi Gagal nafas.


Penyakit akut atau kronik kembali akut.
Acut dan Acut on chonic respiratory failure
(hipersekresi, spasme bronkus, edema
mukosa).
Spasme bronkus pada: Asma, bronkitis
kronik yg berkembang menjadi emfisema

Lanjutan.
1. Otak: Neoplasma, Epilepsi, Hematoma
2.
3.
4.
5.
6.

subdural, Keracunan morfin dan CVA.


Susunan neuromuskular: Miastenia gravis,
Polyneuritis, Analgesia spinal tinggi,
kelumpuhan otot respirasi.
Dinding thorak, diapragma: Trauma thorak.
Paru: Asma, infeksi paru, Aspirasi, pneumonia,
edema paru.
kardiovaskuler: Gagal jantung, emboli paru.
Pasca bedah: laparatomi dll

Komplikasi rawat ICU.


Peningkatan resiko infeksi nosocomial
atelectasis
Mechanics
ventilasi
pasien
yang
memungkinkan terjadi penurunan FRC dan
CL , V/Q nya tidak sebanding
immobilisasi pada pasien dengan penyakit
kritis yang menderita muscle deconditioning,
peningkatan resiko DVT, pressure sore
FRC=fungsional reserve capacity.
CL = lung capacity
V/Q = volume/ cordiac out put. DVT=penurunan volumr total

Problem

Koknetif

gerak

Manusia
sikap

Physiotherapy Assessment
Cognition, motivation, patients own goals
Previous level of function & independence
Posture, movement, strength, balance, pain
Functional ability; sitting, standing, transferring,
walking, turning, reaching, bed mobility, stairs,
getting up from floor, arm & hand function,
exercise tolerance
Use of Objective measures

Physiotherapy programme
Exercises to address specific problems,
e.g. loss of joint movement, muscle
weakness, balance problem.
Functional activity, in a safe, supervised
environment, to improve performance and
confidence
Provision of and practise using
appropriate mobility aids

Problematik
umum
1. Gangguan pernafasan.
2. Gangguan Jantung dan
sirkulasi.
3. Gangguan Hormonal dan
bufer.
4. Gangguan sistem syaraf.
5. Kecerdasan menangkap
perintah.
6. Ganguan perilaku.

PROBLEM PERNAFASAN.
Oleh karena:
1. Gangguan systen neurologi.
2. Gangguan Sangkar thorak.
3. Gangguan jalan nafas / obtruktif.
4. Gangguan pleurae.
5. Gangguan perfusi / restriktif.
6. Gangguan system sirkulasi pulmonal.
7. Gabungan satu sampai enam

Tujuan Fisioterapi ICU


meningkatkan/mempertahankan
A.fungsi cardiopulmonari:
1. Posisioning.
2. Membuka jalan nafas.
3. Oksigen terapi.
4. Meningkatkan ventilasi.
5. Fasilitasi dan stimulasi breathing.
4 a. mekanik ventilasi
b. Breathing exercises

B. Fungsi Musculoskeletal
1. Joint function / movement
2. Performance kerja otot.
3. Balance, coordination, komunikasi
4. Performance fisik : ambulation / ADL

C. Fungsi Neuromuskular.
1. Sensasi,
2. stimulasi,
3. Inhibisi.

D. Edukasi .
E. Mencapai goul (harapan).
F. Evaluasi .

PROSES FISIOTERAPI

Assessment /reassessment
Mesurment. / remesurment
Analysis of findings

Problems identification

Intervensi/Implementation of
treatment / modifikasi
Planning of treatment

Diagnosa fisioterapi

Evidence Based Practice


Falls strength & Balance training
NSF, NICE, CSP Guidelines
Locally developed guidelines; walking
aids, falls prevention education leaflets,
group exercise, resistance training for
osteoporosis

Evidence Based Medicine (EBM)


Menggunakan segala pertimbangan
bukti ilmiah (evidence) yang sahih yang
diketahui hingga kini untuk menentukan
pengobatan pada penderita yang
sedang kita hadapi.
Merupakan penjabaran bukti ilmiah
lebih lanjut setelah obat dipasarkan dan
seiring dengan pengobatan rasional.

Lima tahap evidence based


Memformulasikan pertanyaan tentang masalah
fisioterapi yang dihadapi
Menelusuri bukti-bukti terbaik yang tersedia
untuk mengatasi masalah tersebut
Mengkaji bukti, validitas dan keseuaiannya
dengan kondisi praktek
Menerapkan hasil kajian
Mengevaluasi penerapannya (kinerjanya)

Assessment FT Kritis Di ICU


Baca status riwayat dan keadaan sekarang.
1. Posisi

pasien:

Sudah memudahkan proses pernafasan.


Sudah membantu
sirkulasi.
Sudah menguntungkan
bila terjadi kekakuan.
Sudah
mencegah dekubitus.
Sudah
memudahkan / memfasilitasi pernafasan dan
gerak fungsional.

2. Kenali alat dan monitor yg ada


a.
b.

c.

d.
e.

Sounde. Tentukan ukuran soude yang masuk


oesophagus.
Thrachea tube : tentukan ukuran panjang yang
masuk thrachea. 18, 19, 20, 21, 22 dst
biasanya dewasa 22 cm.
Tentukan apakah monitor EKG berfungsi
dengan baik ( terutama elektrode yg terpasang
pada dada dan tangan atau kaki biola ada.
Tentukan ventilator berfungsi dengan baik,
menggunakan inhalasi atau tidak,
Monitor Vital sign.

Sistem assesment / mesurment.


1. Fungsi tingkat kesadaran.
2. Vital sign.
3. Fungsi jalan nafas dan paru
4. Fungsi jantung dan sirkulasi.
5. Fungsi sangkar torak : sendi, otot dan tl
6. Fungsi umum: sendi, otot, gerak

Kesadaran.
1.
2.

3.

4.
5.
6.

Kompos mentis : bereaksi sgr dgn orientasi sempurna.


Apatis: terlihat mengantuk tetapi mudah dibangunkan,
reaksi penglihatan, pendengaran dan perabaan
normal.
Somnolen: dapat dibangunkan bila dirangsang, dapat
disuruh dan menjawab pertanyaan bila rangsangan
berhenti penderita tidur lagi.
Sopor: dapat dibangunkan bila dirangsang dengan
keras dan terus menerus.
Soporcoma: reflek motoris terjadi hanya bila
dirangsang dengan rangsangan nyeri.
Coma: tidak ada reflek motoris sekalipun dengan
rangsang nyeri.

PEMERIKSAAN KESADARAN
STEP

PROSEDURE

A. KESADARAN
Tingkat kesadaran.
-Kompos mentis

1.

(GCS=15) E4M6 V5.

2.

-Somnolen
(GCS=12-14)

3.

-Sopor (GCS=8-11)
-Coma (GCS=3-7).
GCS: Glascow
Coma Scala dari 315).

4.
5.
6.

Kompos mentis : bereaksi segera dengan orientasi


sempurna. (15)
Apatis: terlihat mengantuk tetapi mudah
dibangunkan, reaksi penglihatan, pendengaran dan
perabaan normal. (14-15)
Somnolen: dapat dibangunkan bila dirangsang,
dapat disuruh dan menjawab pertanyaan bila
rangsangan berhenti penderita tidur lagi. (12-14)
Sopor: dapat dibangunkan bila dirangsang dengan
keras dan terus menerus.(8-11)
Soporcoma: reflek motoris terjadi hanya bila
dirangsang dengan rangsangan nyeri. 7-8
Coma: tidak ada reflek motoris sekalipun dengan
rangsang nyeri. (3-7)

Glasgow coma scale


M

Best Motor
Response
Terhadap perintah:

Dng Perintah

Menurut perintah

Dng rangsang nyeri

Rangsang nyeri:

no response

Melokalisasi nyeri

flexion-menarik baik

flexion-abnormal

extension

no response

Eye Opening

Spontan

E + M + V = 3 to 15

Best Verbal
Response
orientasi dan
berbicara
disoriented dan
berbicara
Kata-kata tak
sesuai
Suara tak
bermakna
Tidak ada respon

Bila nilai < 12 ICU

V
5
4
3
2
1

MATA (EYE=E=4.
E4= Spontan

E3=
E2=
E1=

membuka

mata.
Terhadap suara
membuka mata.
Terhadap nyeri
membuka mata.
terhadap segala jenis
rangsang Menutup
mata

Tehnik. Baca nama pasien dipapan


nama pasien.
4. Spontan membuka mata.
3. Dipanggil namanya buka mata.
2. Diberi rangsang nyeri buka mata.
1. Rangsang nyeri tidak buka mata.

Respon pupil thd cahaya


Normal = 5
Lambat= 4
Respon tidak sama = 3
Besar tidak sama = 2
Tidak ada respon = 1

Cerebral perfusion presure (CPP)


Tekanan kritis yang adequate blood supply
terhadap otak dan mencegah acidosis, hypoxia
dan kerusakan.
Otak harus diipertahankan kontinusitas tranportsai
oksigennya dan tekanan darahnya secara
otomatis regulasi, range of blood presure over
tidak efektif dan dapat menimbulkan nyeri kepala.
CPP = mean arterial presure (MAP) minus
intracranial presure (ICP).
Normal value > 70mmHg.
Critical value < 50 mmHg.

Intracranial presure.
TIK =Tekanan intra cranial normal berkisar 1-15
mmHg, yg berfluktuasi dng perubahan: BP, RR
pola nafas, batuk, mengejan.
TIK tergantung dari 3 unsur:
1). Jarinagn otak 80-87%.
2). Cairan serebrospinal (CSS)9-10%) dan
3). Darah yg ada dlm pembuluh darah otak
(1-10%).
Bila TIK > 16 mmHg dapat mengancam jiwa
pasien.

Reflek saraf cranial


Semua ada= 5
Bulu mata tidak ada= 4
Kornea tidak ada = 3
Dolls tidak ada =2
Karina (semua) tidak ada= 1

Kejang (skor terbaru).


Kejang tidak ada = 5
Kejang fokal = 4
Umum , intermiten = 3
Umum kontinue = 2
Flaksid = 1

Nafas spontan
Normal = 5
Periodik =4
Hiperventilasi central = 3
Iregular/hipoventilasi = 2
Apnu = 1
Toatal skor = 35 terburuk = 7
Terdiri dari: 1. GSC=15.
2. Pupil= 5
3. Kejang (skor terbaru)=5
4. Reflek saraf cranial=5
5. Nafas spontan=5

Kejang (skor terbaru).


Kejang tidak ada = 5
Kejang fokal = 4
Umum , intermiten = 3
Umum kontinue = 2
Flaksid = 1

Nafas spontan
Normal = 5
Periodik =4
Hiperventilasi central = 3
Iregular/hipoventilasi = 2
Apnu = 1
Toatal skor = 35 terburuk = 7

Pain Stimulus
NAIL BED COMPRESSION

fine pressure with thumb


over pencil on the base
of the cuticle
Test bilaterally
N=(+)Crushing pain
STERNAL RUB

DSP
use knuckle over
sternum as if grinding a
pill for 5 sec.
N=20-30 sec. Posturing
(initial reaction)
Wait for at least 30
seconds

TRAPEZIUS SQUEEZE
using thumb & 2
fingers, grasp 2 inches of
the muscle & then twist
SUPRAORBITAL PRESSURE
use thumb
C/I: Cranial fracture

Oxygenation
Assess respiratory status.
Maintain patent airway & adequate ventilation.
Watch for S/S of hypoxia & hypercapnia

Note for S/S of Hypoxia/


hypoxemia

Oxygenation

(-) Spontaneous respiration


Restlessness/ irritability
Peripheral cyanosis
Use of accessory muscles of
respiration
Ala Nase flaring
Angina
Tachycardia
Tachypnea
GIT/ Renal Dysfunction (Late sx)
Dx/ Lab results:
Pulse Oximetry
Capnography
ABG
Hematology (hct; hgb)

Motor Function
Assess integration of consciousness &
voluntary movement.
Look for purposeful or non-purposeful
response.
Also assess muscle tone, size, strength.
Observe for symmetric, spontaneous
movement of arms & legs

Abn=
tics, tremors
= stress, long term use of
psychotropic drugs,
neurologic disorders
(Parkinsons, MS, or HC)
atrophy, paresis, plegia,
flaccidity, spasticity, rigidity
= motor neuron or muscle
disease
unresponsive clients
hemiplegia - corticospinal
tract damage
decorticate - upper
corticospinal
tract damage
decerebrate brainstem
damage

MUSCLE STRENGTH
GRADING
Grade Description
0
1
2
3
4
5

No contraction
Slight contraction
Full passive ROM
Full ROM
Full ROM against
some resistance
Full ROM against
full resistance

Pupils
Assess for size,
shape & reaction to
light.
Observe for ptosis

Pupillary Size

N= 1.5-6mm (3.5 avg.)


Anisocoria
N=17%;
Abn=Herniation

Controlled by:
CN-III
Brainstem
Midbrain
Pupillary
Assessment
Size
Reaction
Shape

Pupillary Reaction
N=
BRTL
Direct Consensual Light
response

Abn= SRTL
early CN III compression
NRTL/ Fixed
Fixed Dilated= ICP,
Prolonged diffuse hypoxia,
Atropine
Pinpoint pupil = Narcotics
(Morphine, Demerol), Long
Acting analgesia (Fentanyl)

Hippus cannot sustain


- constrict then redilates
with light on
Bilateral Hippus
Abn= Seizure,
Meningitis
Ipsilateral
Abn=(+)lesion/ brain
tumor

Pupillary Shape
N=Round
Abn=oval ICP
(15-20mmHg)
- post frontal
/ anterior
temporal
lesions
- Contusions

Ocular Movement
Assess for deviation to
one side.
Also assess voluntary &
spontaneous
movement
EOM controlled by CN
III, IV, VI

Signs
Assess V/S.
Observe for significant trends.
Look for Cushings reflex:
PR,
RR,
Widened Pulse Pressure

Urinary
Output
Assess for increased output, possible S/S of
impaired water regulation.
Also assess for electrolyte imbalance,
especially hyponatremia
Oliguria ( below 30 cc)

Reflexes
Assess for
pathologic
reflexes,
especially
babinski &
loss of
corneal or gag
reflex

Corneal
Pons
Medulla
Gag/ Cough
Medulla
CN IX
CN X

Emergency
Evaluate assessment findings to determine
whether emergency exists.
If so report findings to doctor STAT

Test for attention, concentration &


calculation.
Ask to count

backward from 100,


subtracting by
seven each time
(100, 93, 86).

N=Can count back

into the 50s within


one minute

Memory
Test for short-term memory

Name 3 unrelated objects

(e.g. car, garbage can, alarm


clock) then ask for these
words again for within a few
minutes

Test for long term memory

Ask clients mothers


maiden name.

Memory Loss abnormal


& signal disease, infection
or temporal lobe trauma

Logic, Judgment, Reasoning &


decision-making ability

Test for

Logic & Judgment

Ask What would you do if you were inside a burning

building?
N=sound judgment.
Abn=Frontal Lobe damage, dementia, psychosis, mental
retardation.

Test for reasoning & decision-making ability


answering questions appropriately

Ask the meaning of a proverb such as A stitch in time


saves nine.
Abn=low intellect, dementia, schizophrenia

Emotional Stability, Speech &


Language
Emotional Stability
Moods, Feeling, Thought process
Speech & Language
Voice quality, Articulation, Content, Comprehension
N=Spontaneous & well paced speech; logical content

Ask to read a sentence form age-& education-appropriate


material; write name or simple sentence.

Abn=Aphasia (speech), dysarthria (articulation & rate),

dysphonia ( voice), apraxia (conversion of thought into motor


sound), agraphia ( writing), alexia (written language
comprehension)

Cerebellar function
Gait
Ask to walk a straight heel-to-toe line.

Abn=staggering, shuffling, tiptoe walking, foot


slap, leg drag.
Uncoordinated gait & loss of balance =
motor, sensory, vestibular or cerebellar
dysfunction.
Cerebellar ataxia unsteady gait with legs
spread wide.
Scissors gait short, stiff steps with thighs
overlapping.
Foot drop - lifts knee high then slaps foot down
Parkinsonian shuffle accompanied by stooped
posture
Spastic paralysis - arms flexed & held to the
body, client throws each leg forward

Cerebellar function Balance


Rombergs test

arms at sides, feet together,


eyes closed for 20 seconds.
Watch for loss of balance.
Stand close enough to prevent falling.

N=slight swaying.
Abn
loss of balance
(+) Romberg
cerebellar ataxia, alcohol intoxication, MS,
impaired visual functioning, or loss of
proprioception.

Test for coordination, muscle strength, & cerebellar function


Ask to stand on 1 foot & do a shallow knee-bend, or hop,.
Abn= Cerebellar dysfunction or lack of physical
fitness

Cerebellar function
(Rapid alternating movements;
Accuracy of movement; Balance; Gait)
Rapid Alternating Movement (RAM) of the hands & fingers assesses coordination & dexterity. Pat knees with the palms, then flip &
do so with the back of the hands, first slowly then faster.
N=smooth & bilateral movement
Abn=slow, awkward movement= cerebellar dysfunction
Ask to touch thumb to each finger from index to 5 th finger & back
again, slowly at first then faster. Repeat on the other hand.
Abn=Dyssenergy (lack of coordinated muscle movement) =upper neuron
weakness, cerebellar disease, EP dysfunction.
Finger-to-nose coordination test
Ask to touch index finger to nose then to the examiners outstretched
vertical finger to different points.
Abn=Dyssnergy, Dysmetria (misjudgment of distance, speed & force
of movement = cerebellar dysfunction

Sensory function
Superficial Pain & Touch Sensation

test distal points on arms & legs


Eyes closed.
Examine Arms, Legs & Abdomen.
Assess sensitivity to light touch with a wisp of cotton (distal to
proximal).
Ask to say now when each sensation is felt.
Sharp object (opened paper clip). Ask whether she feels a sharp or
dull sensation.
Temperature sensitivity
- 2 test tubes (1 filled with hot & 1 with cold water, along the
same routes.
Abn=Peripheral nerve problem: paresthesia &
impairment in touch sensation (Anesthesia, Hypoanesthesia).
Pain sensitivity analgesia, hypalgesia,
hyperalgesia

Proprioception, Vibratory sensation


Proprioception (tested on great toe & hands) sense motion,

position, & vibration

Hands (sides of index finger between thumb & index finger).


Eyes closed. Move finger up or down. Ask client to describe
direction. Repeat on other hand & in both great toes. If (+) abn
proceed to next proximal joint.
Abn=peripheral neuropathy or lesion in the posterior spinal
column, sensory cortex, or thalamus.
Vibratory sensation stem of vibrating tuning fork against clients

distal finger or great toe. Ask to say now if vibration is felt. Proceed
to next proximal joint if abn

Cortical sensation
(stereognosis, graphesthesia, 2-point
discrimination)
Stereognosis recognizing
objects by feel.
Eyes closed. Identify familiar objects (e.g. key). Repeat on other hand
with different object.
Abn=Astereognosis = parietal lobe problems
Graphesthesia identify shapes, numbers, or letters traced on the skin.
Eyes closed. Use blunt object such as closed paper clip to draw shape,
letter or number on the palm. Repeat on the other palm.
Abn=Graphanesthesia = parietal lobe problems.
2-point discrimination touching 2 identical sharp objects (e.g. Opened
paper clips) to the skin in close proximity, while eyes closed.
Ask whether she feels 1 or 2 points, noting distance between 2 points.
Repeat test on arms, legs, face & abdomen, decreasing the actual
distance between the points until client feels 2 points as one.
N=distance-2 to 20 mm.
Abn=parietal lobe problem

Superficial /Cutaneous Reflexes


Abdominal, Plantar
Abdominal Reflex
T8-T10 spinal nerves - controls upper abdominal muscles
T10-T12 lower abdominals
Dorsal Recumbent.
Blunt tipped object (cotton swab).
Scratch each abdominal quadrant lightly (lateral to midline,
high to low)
N=muscle contraction & slight shift of umbilicus
towards the stimulus.

Plantar Reflex (Babinski)


controlled by L4 & L5, S1 & S2
Stroke foot sole with the handle of a reflex hammer. Run
the edge along the outer heel up to the ball of the foot.
Repeat on the other foot.
N=toe flexion (except in infant)
Abn=Dorsiflexion of big Toe, Fanning of Little Toes
(except in infant) Pyramidal Tract / Upper Motor
Neuron Damage

Superficial /Cutaneous Reflexes


Cremasteric, Anal
Cremasteric Reflex
- T12 L2
- For genitourinary complaints only in men.
- Lightly stroke the inner thigh
N=scrotal elevation on the stimulated side
Anal Reflex
- S3-S5
- Gently touching around the anus with a cotton
swab or gloved finger
N=contraction of rectal sphincter

Deep Tendon Reflexes


Biceps, Triceps, Patellar, Achilles,
Brachioradialis
Requires practice & a relaxed client.
Sitting with feet dangling. Easier if
used with distractions.
Pointed hammer small tendons
Flat end larger tendons
Compare bilateral responses
If any of the DTRs are hyperactive =
test for ankle clonus(rhythmic
contraction).
Lift 1 of the clients legs & support
the flexed knee with non-dominant
hand. Grasp the foot & quickly
dorsiflex the toes.
N=(-)Pain & involuntary movement
Abn= Clonus=motor neuron
dysfunction

Deep Tendon Reflexes


(DTR) GRADING
DTR GRADE
0
1+
2+
3+
4+

Response
Absent reflex
Diminished
Normal
Slightly increased
Hyperactive

Jenis intervensi FT ICU


1.
2.
3.
4.
5.
6.
7.
8.

Posisioning.
Oksigen terapi
Stimulasi/ fasilitasi dan inhibisi.
Breathing.
Chest FT.
Inhalasi.
Mobilisasi/ ambulasi
Edukasi.

Chest Fisioterapi
1. P D.
2. Topotement / klepping
3. Breathing
4. Coughing/huffing.
5. assisted coughing hafing.
Chest PT dapat dilakukah pre medikasi dengan:
stimulasi, inhalasi, rileksasi dll
Post chest PT dpt dilakukan: mobilisasi ambulasi
dan tranvers.

Pembersihan Jalan Napas


Inhalasi.
Chest fisioterapi.
Mobilisasi

Ambulasi

Educasi

Retained secretions
Partially occlude

Complete occlude

Uneven distribution of ventilation

Shunting blood

V/Q mismatching

V/Q mismatching
Hypoxemia

Postural drainage position (PD)


Posisi dengan meluruskan segmen
bronchi dengan gravitasi , jadi sekresi
diakumulasi pada segmen
bronchopulmonari bergerak ke arah central
dan dikeluarkan dengan batuk , dan
dengan mudah meludah

Posisi paru atas

Upper lobe
1.
2.
3.
4.
5.
6.
7.
8.

Half supine lying


= Atas depan R/L.
Half prone lying
= Atas belakang R/L
Half supine lying R up = Atas depan R
Half Supine lying L up = Atas depan L
Half prone lying R up = Atas belakang R
Half prone lying L up = Atas belakang L
Half Right side lying = Atas samping kiri
Half Left side lying = Atas samping kanan.

Paru bagian tengah

Paru bagian bawah

Perkusi dan Vibrasi = Manipulasi eksternal dari


area toraks yang berfungsi untuk mobilisasi untuk
membantu proses sekresi.

Perkusi : Tepukan yang cepat, cupping ( dengan


tangan berbentuk mangkok ) dari bagian eksternal
thorax, secara langsung tepat diatas saluran segmen
paru .
Mekanika perkusi : Gelombang mekanik dari energi
yang dihasilkan dipercaya akan ditransmisi sepanjang
dinding paru untuk menghilangkan mukus dari saluran
jalan napas ( Gelombang berkisar 4 5 Hz ).

Percusi

Breathing

Coughing/huffing /fibrasi/ konpresi

Vibrasi : Gerakan
yang
menyebabkan
getaran dilakukan
secara manual dari
gerakan menekan
langsung pada
area ribs dan soft
fissure dada
normal bergerak
selama exhalasi
(pengeluaran
napas)

Bantuan / latihan batuk/ huffing.

Pasien dengan trachea cube


Dilakukan suction

Pada ICU bedside


-Baca status dengan teliti dan perhatikan
a . Vital Sign monitor.

Summary

b. ventilation parameter
c. Alat-alat medis lain : EKG, Infus, Sounde dll
- Mengaplikasikan teknik FT yang tepat
- Closed observation and continuously
monitored selama Rx
- Mengassesment kembali pada akhir Rx
- Sebelum meninggalkan pasien, FT harus
memastikan bahwa semua alarm sudah di
aktifkan, VS stabil, pasien merasa aman dan

Hal-hal yang menjadi pertimbangan untuk FT. pada ICU


Closed observation and continuously monitoring
- patient s ability to tolerate PT Rx
- ventilated patient / penerunan tingkat kesadaran / jeleknya
gag (sumbatan) reflex
aspiration
- perawatan yang tepat

minimize cross-infection

- peningkatan tekanan aliran darah


- tingginya PAP
- arrhythmia
- vital sign
- level of ICP
- tingkat kesadaran , sedation dll.

ICU: Mempunyai masalah komplek.


Dikerjakan secara team.
FT harus ingat perasaan dan rasa takut pasien yang
dapat membuat mereka tidak natural terhadap
lingkungannya
- ketidakmampuan untuk bicara
- loss of perception of time
- suffer from chronic sleep deprivation

Thank
you
For
Your
attention

Any
questions ?

What are the


3 objects
shown a
while ago?

The
END !

GOOD DAY !
and
THANK YOU
FOR
LISTENING !

Kombinasi (penggabungan)
treatment FT
: Postural Drainage dengan perkusi dan vibrasi
memfasilitasi pergerakan sekresi
: Perkusi sendiri dapat menyebabkan :
FEV1
menyebabkan hypoxemia
tetapi efek negatifnya dapat dicegah jika breathing
exercises tergabung ke dalam program Rx

Selama perkusi dan vibrasi FT harus observasi ekspresi


wajah pasien karena nyeri atau tidak nyaman
Konsekuensi nyeri :
- muscle splinting
- meningkatkan kerja pernapasan
- konsumsi O2 meningkat
- bronkospasme

Breathing exercises (BE)


Otot2 ventilasi`terdiri dari otot diaphragma dan otot
intercostal, bertindak sebagai pump muscles yang
berfungsi menggerakan tulang thorax, menyebabkan
intrathoracic pressure, lalu hasilnya aliran udara masuk
ke paru2,
Otot larynx and pharynx bertindak sebagai valves
(katup) yang membantu mengatur dan menjaga aliran
udara

Inspirasi Aktif
Expansi paru-paru pada 3 bagian :
- antero posterior
- transverse
- longitudinal
Pump handle movement terjadi pada upper ribs
Bucket handle movement terjadi pada lower ribs
abdominal berpindah ke downward (ke bawah)

Teknik Pembuangan Sekresi


Batuk
Huffing.

dll.

Suction
(penyedotan)

Pola-pola BE
- Diaphragmatic BE
- Costal BE (thoracic expansion exercise)
- Pursed lips breathing (PLB)
- Sustained maximal inspiration (SMI)
- Deep BE etc.

Collateral ventilation
- Channels of Martin (interbronchiolar channel)
- Channels of Lambert (bronchiole-alveolar channel)
- Pore of Kohn (interalveolar channel)