Week 11: PFTs & Monitoring and Life Support - MLML

Gemini help w generation

Primary purpose of monitoring/life support

To interpret settings, displays, and data to make informed clinical decisions.

Clinical Shift

Equipment is migrating from ICU to long-term care, inpatient rehab, and home health as acute stays decrease.

ECG Lead Configuration

Uses 10 electrodes to provide 12 lead signals (4 limb leads for 6 limb signals; 6 V leads for 6 chest signals).

Standard Clinical Monitor Display

Typically shows heart rate, SpO2 waveform, and respiration waves.

Asystole (flatline) on monitor

Often caused by a detached lead during movement rather than actual cardiac arrest.

PT Wave Monitoring

Look for ST-segment changes, multiple PVCs/change in foci, onset of V-Tach/V-Fib, or worsening heart block during activity.

Continuously Measured Vitals

O2 saturation, Respiratory Rate, Heart Rate, and EKG.

Non-Continuous Vital

Blood Pressure (automated machines are set to specific 5–15 minute intervals).

Pulse Oximetry (SpO2)

Measures arterial oxygen saturation as a percentage of oxygen bound to hemoglobin.

SpO2 Threshold

Maintain levels above 90%; PTs may have orders to titrate O2 during activity to meet this.

Pulse Ox Limitation (Low Perfusion)

Anemia or low circulation prevents an accurate pulsatile signal.

Pulse Ox Limitation (Interference)

Nail polish, fluorescent lights, and jaundice (bilirubin) interfere with light absorption.

Pulse Ox Limitation (Skin Pigmentation)

Darker skin contains more melanin, which absorbs light and can affect accuracy.

Pulse Ox Limitation (Arrhythmias)

Irregular pulsatile signals make consistent calculation difficult.

Critical Safety Rule (Pulse Ox)

Always take pulse manually during the first assessment to ensure the device is reading HR correctly.

Which of the following does not affect the pulse ox readings?

arrhythmia

jaundice or darker skin

nail polish

time of day

anemia

time of day

Manual BP Cuff/Stethoscope

Essential for PTs to bring when mobilizing because automated machines do not move with the patient.

Normal Adult HR (Rest)

50 to 100 beats per minute.

Normal Adult Systolic BP (Rest)

85 to 140 mm Hg.

Normal Adult Diastolic BP (Rest)

40 to 90 mm Hg.

Normal Adult RR (Rest)

12 to 20 breaths per minute.

Normal Adult SpO2 (Rest)

95% on FiO2.

Arterial Lines (A-Lines)

Used for unstable patients needing continuous BP management or frequent arterial blood gas (ABG) sampling.

Mean Arterial Pressure (MAP) Normal Range

70–110 mm Hg.

MAP < 60

Indicates poor organ perfusion.

A-Line Transduction Positioning

Sensor must be at the level of the right atrium; too high reads low, too low reads high.

Radial A-Line Precaution

Limit or avoid weight-bearing on that wrist.

Femoral A-Line Precaution

Monitor closely and avoid dislodging.

A-Line Dislodgement Action

Apply firm direct pressure immediately to stop massive "spurting" blood loss.

Central Line

Measures Central Venous Pressure (CVP) or right atrial pressure via subclavian or internal jugular veins.

PICC Line

Peripherally Inserted Central Catheter inserted in cephalic/basilic/brachial veins ending at the Superior Vena Cava.

PICC Line Precautions

Must remain sterile. Usually well covered near skin insertion

Secure ends before mobilizing

Avoid compression and dislodging

Use precautions when femoral PICC is used

Swan-Ganz (Pulmonary Artery Catheter)

Threaded through the right heart into the pulmonary artery to locate/monitor heart failure/pressures.

Pulmonary Capillary Wedge Pressure (PCWP)

Indirectly estimates left side heart filling pressure and left ventricular function.

Uses of Pulmonary Capillary Wedge Pressure (PCWP)

Monitoring heart function (post-sx)

Diagnosing chronic heart failure

Differentiating causes of pulmonary edema

Guiding diuretic dosing to manage fluid overload

Elevated PCWP

Indicates Pulmonary HTN or resistance to flow into the left ventricle.

Swan-Ganz Complications of dislodgement

Serious arrhythmia, pulmonary artery rupture, valve damage, or heart infection if dislodged.

Temperature can be measured via

Swan Ganz, urinary catheters, NG tube, Rectal probe

Only when is a rectal probe used to measure temperature

When the patient is comotose, intubated, or confused

Intracranial Pressure (ICP) Usage

Brain surgery, head injury, hemorrhage, tumors, or meningitis.

High ICP Effect

Decreases brain perfusion.

What can help control increased/high ICP

Low CO2

A drain or shunt may be placed

PT Role (ICP)

Assessing tolerance/response to position changes and early mobilization.

Nasal Cannula

Most common system; flow rates of 1–6 L/min.

Rule of Fours (Nasal Cannula)

Every 1 L/min of O2 increases FiO2 by ~4% (e.g., 2 L/min = 28%).

Nasal Cannula Humidification

Required if flow is >4 L/min to prevent drying membranes.

Face Mask

5–10 L/min delivering 35–56% FiO2; involves air loss through sides.

Humidification is common

Trach Mask/Collar

Must be humidified because it bypasses the upper airways' natural functions.

Venturi Mask

Provides precise FiO2 delivery using color-coded adapters and specific orifice sizes.

Based on doctor’s orders of FiO2

Non-Rebreather Mask

Provides up to 100% O2 via one-way valve and reservoir bag; must be fully inflated.

Due to high flow rate, need to start with full tank and bring a spare

High Flow Nasal Cannula (HFNC)

25–60 L/min; creates Positive Expiratory Pressure (PEP) to splint airways open.

Rank from lower to higher O2 support

Nasal canula, venturi mask, rebreather mask, high flow nasal cannula

CPAP

Constant positive pressure during both inhalation and exhalation.

Common in sleep apnea

BiPAP

Two pressure levels (IPAP/EPAP); often used to wean patients off ventilators.

Invasive Mechanical Ventilator Indications

Failure to oxygenate, failure to ventilate, or airway protection.

2 types of mechanical ventilations

Endotracheal tube

Tracheostomy tube

Endotracheal tube indications

Nasal or orla

short-term

Tracheostomy tube indications

Longer term issues

Tidal Volume (TV)

Amount of air delivered per breath.

PEEP

Positive expiratory end pressure

Pressure that keeps alveoli from collapsing to increase gas exchange time.

Ventilator FiO2 Safety Limit

Aim to keep under 50% long-term to avoid oxygen toxicity and atelectasis.

Control Mode Ventilation

Machine has complete control; no patient-initiated breaths.

Assist Control (AC-VC)

Set RR

Every breath has a set volume

Patient can initiate extra breaths, which the machine assists to the full preset volume.

Synchronized Intermittent Mandatory Ventilhation (SIMV-VC)

Set RR and volume provided

Extra patient breaths are NOT volume controlled.

Spontaneous/Pressure Support

Set pressure, PEEP and FiO2

Patient initiates/dictates volume; machine provides pressure to overcome resistance.

Median Sternotomy

Skin incision midline of sternum; used almost exclusively for cardiac procedures.

Posterolateral Thoracotomy

Incision from T4 to anterior axilla; divides trapezius, serratus anterior, and latissimus dorsi.

Anterolateral Thoracotomy

Sternal edge to mid-axillary line; used for lung surgeries or mitral valve repair.

Axillary (Lateral) Thoracotomy

Shorter, muscle-sparing incision for minimally invasive cardiac procedures/pacemakers.

Subxiphoid Incision

Single incision below xiphoid for pericardium or epicardium access.

Thoracoabdominal Incision

Combination used for diaphragmatic procedures; makes mobilization very difficult.

PT Thoracotomy Assist

Give as much assist as needed from supine to sit; focus is upright tolerance.

VATS/RATS Advantages

Shorter LOS, less pain (ribs not spread), and reduced inflammatory response.

Splinted Cough Technique

Essential early PT intervention for pain management and airway clearance.

Chest Tube Purpose

Remove air/fluid from pleural space and re-establish intrapleural pressures.

Chest Tube Placement

Top (apex) for air; lower for fluid/blood.

Chest Tube Rule

Collection system must stay below chest level; device must not be tipped over.

Leadless Pacemakers

Mini-battery devices implanted directly into the heart using a coiled spring.

Intra-aortic Balloon Pump (IABP)

Balloon inflates in diastole (preloading) and deflates in systole (increasing output).

ECMO

Management for total failure; blood leaves femoral vein, is oxygenated, and returns to femoral artery.

Hemodialysis

Similar to ECMO but filters blood and corrects electrolytes without a pump.

Cerebral Edema

Impaired cognition and delirium.

Myocardial Edema

Conduction disturbance and diastolic dysfunction.

Pulmonary Edema

Impaired gas exchange and increased work of breathing.

Hepatic Congestion

Impaired synthetic function and cholestasis.

Renal Interstitial Edema

Reduced GFR and salt/water retention.

Gut Edema

Malabsorption and ileus.

Tissue Edema

Poor wound healing and pressure ulceration

Key Pulmonary Diagnostic Tests

Arterial Blood Gases (ABGs), Spirometry, DLCO, and Imaging (CXR, CT, MRI, V/Q scans).

Arterial Blood Gas (ABG) Analysis

Snapshot of a patient's current metabolic and respiratory status.

pH Normal Range

7.35–7.45 (Human average = 7.4).

PaCO2 Definition

Partial pressure of dissolved CO2 in plasma.

PaCO2 Normal Range

35–45 mmHg.

HCO3- Normal Range

22–28 mEq/L.

PaO2 Normal Range

80–100 mmHg.

SaO2 Normal Range

≥95%.

Base Excess (BE) Normal Range

+/- 2 mEq x L-1.

Indicator of Ventilation Adequacy

PaCO2 levels.

Hyperventilation Definition

PaCO2 < 40 mmHg.

Hypoventilation Definition

PaCO2 > 40 mmHg.