637 Ch15 ICU Monitoring

What are 5 indications of declining cardiac status?

• ST changes

• Onset, increase, or change of foci of PVCs

• Onset of Vtach or Vfib

• HB progression

• Loss of pacemaker spike

What are 5 examples of noninvasive ICU monitoring equipment?

1. ECG

2. Pulse Ox for sPO2

3. Capnography for ETCO2 (PaCO2 at end of exhaled breath)

4. Blood pressure cuff oscillometric technique

5. RR through movement of ECG electrode waveforms

6. LOC outcome measures, sensors, questions etc.

What are examples of invasive ICU monitoring equipment?

1. Arterial line

2. Venous line

3. Pulmonary artery catheter/Swan-Ganz catheter

4. Temperature monitoring (brain probe, urinary catheter, esophagus probe, nasopharyngeal probe, rectal)

5. ICP

If the ECG alarm goes off what does this mean and what should you do?

• Alarm indicates change in rate or rhythmic/poor pad placement or movement

• Must identify cause of alarm before silencing it w/ CI approval

Where can SpO2 be monitored? What should the SpO2 be in the ICU? What are limitations to an accurate read?

• Finger, ear, toe (finger probe best)

• Above 88%

• Dark nail polish, jaudnice, abnormal Hgb, anemia, intravascular dyes, dark skin pigmentation, states of low perfusion (hypothermia, vasoconstriction, low CO)

*What does capnography measure? How is the waveform measured? What is a normative value? What indicates that there is hypoventilation vs hyperventilation?

• Measures end tidal CO2 (ETCO2) which is PaCO2 at end of exhaled breath

• Waveform height = CO2 depleted, length = duration of exhalation

• 35-45 mmHg

• *Hypoventilation = Long length of plateau, very high height (holding onto CO2)

• *Hyperventilation = Short length of plateau, not as high height (excessive blowing off of CO2)

How is noninvasive BP measured?

• Monitored by the oscillometric technique, cuff proximal to antecubital space or LE, postpones need for arterial line

How is noninvasive respiratory rate measured? What is a normal RR for an adult?

• Monitored as a waveform from movement of ECG electrodes

• 12-18 breaths/min for adult

*What are causes of altered RR, tachypnea vs bradypnea?

• Tachypnea

  • Exercise

    • Atelectasis

    • Fever

    • Hypoxemia

    • Anxiety/emotional distress

    • Pain

  • Asthma

  • PULMONARY EMBOLISM

  • Pneumonia

  • ARDS

  • Anaphylaxis

  • HF

  • Shock

  • DKA

    • Neuromuscular disorders

    • COPD

• Bradypnea

  • Head injuries

    • Sedation

    • Drug overdose

  • Increased ICP

  • Diabetic coma

  • Exhaustion caused by severe airway obstruction

  • Sleep apnea

  • Obesity hypoventilation syndrome

*How does DKA and diabetic coma affect RR?

• DKA - tachypnea

• Diabetic coma - bradypnea

If you are suspicious of a PE, how would the patient’s RR be altered?

Tachypnea

*What are 3 ways to measure LOC?

• Richmond Agitation Sedation Scale (RASS)

• Confusion assessment method in the ICU scale

• Bispectral index (BSI) - sedation levels in ICU

*Describe the scoring on the RAAS scale.

*What does an arterial line do? Who typically gets one? Where is it inserted and how often do you monitor it? What do you do if it gets dislodged? What activities do you want to avoid? Ideal positioning of transducer?

• Intraarterial BP monitoring

• Hemodynamically unstable, risk for instability, low SV, excessive peripheral vasconstriction

• Radial, femoral, brachial, axillary, ulnar, or dorsalis pedis; monitor before, during, and after for bleeding

• Dislodged → apply pressure, notify nursing ASAP

• Avoid w/b on UE w/ arterial line

• *Lower transducer = higher BP, higher transduer = lower BP; ideal @ RA

If the arterial line gets dislodged, what do you do?

• Apply pressure

• Immediately notify nursing staff

What are 6 indications for an arterial line?

• Continuous BP measurement

• Frequent analysis of ABGs

• Frequent sampling of blood for critical lab values

• Drug admin

• Use of an intraaortic balloon pump (IABP)

• Hemodynamic monitoring for cardiac parameters and fluid status

Why would you want an arterial line for a pt w/ COPD?

If fluctuating pH, want to monitor ABGs

What are signs for carpal tunnel after insertion of arterial line?

Persistent pain and paresthesia

Where is a venous line inserted? What does it measure and what happens when it is increased/reduced? What else can it be used for? Where is a PICC line inserted?

• Central (jugular/subclavian to superior vena cava) or peripheral

• Measures central venous pressure (CVP) or right atrial pressure (RAP) for fluid status & cardiac fx

  • Increased CVP - hypervolemia/fluid overload, tricuspid insufficiency, ventricular failure

  • Reduced CVP - hypovolemia/low blood volume, dehydration

• Also for meds, fluids, blood sampling, temporary pacemaker, port = central venous catheter

• PICC peripheral access - cephalic, basilic, brachial to superior vena cava

What happens with increased vs reduced CVP?

• Increased CVP - hypervolemia/fluid overload, tricuspid insufficiency, ventricular failure

• Reduced CVP - hypovolemia/low blood volume, dehydration

What is a pulmonary artery catheter/Swan-Ganz catheter? What is it used for? Where does the transducer need to be? What does a high/low SvO2 mean?

• Inserted into central v & pulmonary a; ballon at tip of catheter inflated for pulmonary capillary wedge pressure or left sided filling pressures

• Used for:

  • LVF

  • Mitral/aortic valve dysfunction

  • Pulm edema

  • pHTN

  • Hypovolemic states

• Transducer @ RA, midaxilla

• High SvO2 = bad perfusion, low SvO2 = high O2 consumption, low CO

Why do you want to measure temperature invasively? For what type of patients? Examples? Gold standard?

• Multiorgan dysfunction → met & sys issues

• Comatose pts

• Brain temp w brain probe urinary catheters, esophagus probe, nasopharangeal probe, rectal

• Gold standard - Swan-Ganz Catheter, not for routine use

Is a pulmonary a. catheter/Swan-Ganz Catheter good for routine use?

No, but is the gold standard for temp monitoring

*Why would you want to measure intracranial pressure invasively? What is a normal ICP range for adults and children under 6 y/o? What is the target cerebral perfusion pressure (CPP)? What kind of ICP & CPP will you see after a brain injury? What helps reduce ICP?

• Intracranial hypertension from neurologic insults i.e. TBI, hypoxic brain damage, aneurysm, hemorrhage, cerebral tumor, meningitis, brain surgery

• *ICP <10 mmHg adults, 0-5 mmHg children under 6 y/o

• CPP 50-70 mmhg

• Brain injury → High ICP causes low CPP

• Hyperventilation reduces ICP

What kind of activities increase ICP? How can we reduce ICP?

• Isometric exercise

• Valsalva maneuver

• Extreme hip flexion

• Lateral neck flexion

• Coughing

• Prone

• Head position below 15 degrees horizontal

• Occlusion of the tube

• Pain

• Manually influence ventilation b/c hyperventilation reduces ICP

What is the ideal position for venous drainage for patients w/ high ICP?

HOB >30deg

What does non-invasive positive pressure ventilation (NPPV) do? Two examples/gold standard?

• Provides vent support for those w/ acute/chronic vent failure and NM disease

• 1. CPAP - gold standard for OSA, pressure THROUGHOUT, less intense

• 2. BiPAP - two levels of pressure, high during inspiration, low during exhalation, more intense, can be used if pt cannot handle CPAP

What is a nasal cannulae (NC) used for? Complications? What kind of flow is a high flow nasal cannulae (HFNC)? How does it differ?

• NC - Low and medium dose O2 flow 1-6L/min

• Dryness if >4L/min → humidifier

• HFNC - high dose O2 flow >6L/min, ALWAYS used w/ heat & humidification

  • Reduce CO2 in upper airways and work of breathing

What are reasons for using high flow O2?

• Hypoxemic respiratory failure

• Postextubation

• Preoxygenation before intubation

• Attempt to avoid intubation

• Acute pulmonary edema

• Transport of the critically ill

• Pts who have DNR/DNI orders

What are the 5 masks for O2 delivery? Describe them.

1. Simple mask

   1. pts who mouth breathe/have nasal restriction; 5-10L/min

2. Aerosol mask

   1. for aerosolized meds (i.e. bronchospasm), + nebuillizer, 10-12L/min

3. Reservoir mask

   1. attached to reservoir bag, some/no rebreathing of gases, tightly sealed & uncomfy

      1. Partial - first 1/3 exhaled into bag, 2/3 vented out

      2. Non-rebreather - no rebreathing of exhaled air

4. Venturi mask

   1. Mixed O2 w/ room air with a side port/holes

5. Tracheostomy

   1. Collar placed over open stoma, pt weaning from vent

What are four purposes of artificial airways? Indications? Cardinal signs of dangerous airway obstruction?

1. Bypass upper airway obstruction

2. Assist/control respirations over prolonged period of time

3. Facilitate care of chronic RTIs

4. Prevent aspiration of oral & gastric secretions

• Indications

  • Restlessness

  • Tachycardia

  • Confusion

  • Motor dysfunction

  • Decreased O2sat

• Obstruction if: stridor & full chest wall retractions

• Cyanosis: late and ominous sign

What is a passy muir valve?

speaking valve/button for tracheostomy

If a pt with a trach is gasping what do you do? If the trach is shifting up and down what do you do?

1. Call a code

2. Call nursing