ICU monitoring

what are guidelines for exercise and progression: at rest, determine in progression or termination, and use for rest w/ exercise

Guidelines at rest: do not proceed with exercise without clearance

Guidelines to determine progression or termination: provide rest, then initiate exercise again and potentially modify variables to reduce abnormal exercise responses

Guidelines to use for rest and with exercise: rest to see if symptoms reduce, if they reduce initiate exercise again and modify variables to reduce abnormal exercise responses

where can ECG be seen? if an alarm goes off what does it indicate?

can be seen above bed & potentially at a central monitoring console with other pts

- Alarm will indicate change in rate (outside of presets) or rhythmic; may also indicate poor pad placement or movement due to a cough or movement

- Must identify cause of alarm before silencing it

what should the spO2 be at

what are the limitations to taking spO2 with pulse ox?

Connected to monitor at bedside and is continuously displayed- Sp02 should above 88% Sat

- Limitations: dark nail polish, jaundice, abnormal hemoglobin, anemia, intravascular dyes, dark skin pigmentation, states of lowperfusion (hypothermia, vasoconstriction, low cardiac output)

what are some indications to determine of declining cardiac status

ST change

onset, inc, or change of premature ventricular contractions

onset of ventricular tachycardia

progression of heart block

loss of pacemaker spike

Capnography

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

Sidestream Capnography

Attached to airway of intubated patient

Mainstream Capnography

Attached to airway of intubated patient

Capnography Output

Can be shown as a number or waveform: height is amount of CO2 depleted, length is duration of exhalation

Normative Value for ETCO2

35-45 mm Hg

Hypoventilation in Capnography

Length of plateau is longer and very high

Hyperventilation in Capnography

Length of plateau is shorter and not as high (excessive blowing off of CO2)

Blood Pressure Monitoring

Monitored by the oscillometric technique and displayed on the bedside monitor.

Cuff Placement

Placed proximal to the antecubital space in the upper extremity to assess the pressures in the brachial artery.

Alternative Cuff Locations

If not accessible, cuff may be placed in other locations in either upper or lower extremity.

Arterial Line Placement

May be able to postpone arterial line placement.

ICU Monitor Settings

ICU monitor may be set to assess the pressures at preset times for updates or can be assessed as needed with the push of the appropriate button.

what are some causes of altered respiratory rate

such as in tachypnea vs bradypnea

tachy: atelectasis, fever, hypoxemia, anxiety, asthma, pneumonia, heart failure, shock, PE

brady: head injuries, sedation, drug overuse, inc ICP,sleep apnea, etc

Loss of Consciousness used to determine

Outcomes measures used to determine confusion and agitation

Richmond Agitation Sedation Scale (RASS) is

A scale used to assess agitation and sedation levels

Confusion Assessment Method in the ICU scale

A scale used to assess confusion in ICU patients

Bispectral index (BSI) used to assess

Used to assess sedation levels in ICU; measures muscular and cortical activity with a flexible sensor on the forehead (0 no activity - 100 fully awake)

Sedation titration parameters

Sedatives can be titrated to be within parameters (usually 60-70 for mild to moderate sedation)

Invasive arterial line monitors what

Intraarterial blood pressure monitoring

Indications for invasive arterial line

Pts who are hemodynamically unstable or at risk for instability; low stroke volume or excessive peripheral vasoconstriction may render arterial pulsations impossible to hear

Insertion sites for arterial line

Inserted in radial, femoral, brachial, axillary, ulnar or dorsalis pedis

Catheter placement observation

Observe placement of catheter before, during and after intervention for bleeding and making sure it is secure

Weight bearing precautions with arterial line

Avoid weight bearing on upper extremity with arterial line

Effect of transducer height on BP readings

Arterial line transducer will be based on position; lower transducer higher BP, higher transducer lower BP (idea is height of right atrium)

what are the indications for placement of an arterial line

Continuous blood pressure measurement

•Frequent analysis of ABGs

•Frequent sampling of blood for analysis of critical laboratory values

•Drug administration

•Use of an intraaortic balloon pump (IABP)

•Advanced hemodynamic monitoring for measurement of cardiac parameters and fluid status

Venous Line is

Central (jugular or subclavian vein) or peripheral access used for various medical purposes.

Central Venous Pressure (CVP)

Measurement used to assess fluid status and cardiac function.

Increased CVP indicates

Indicates fluid overload, tricuspid insufficiency, or ventricular failure.

Reduced CVP indicates

Indicates hypovolemia and dehydration.

Central Venous Catheter is

A port used for medication, fluid administration, blood sampling, and emergency placement of temporary pacemaker.

PICC Line (peripheral access)

Peripheral access inserted into cephalic vein, basilic vein, or brachial vein, advanced into the distal superior vena cava.

what is Pulmonary Artery Catheter (Swan-Ganz catheter):

inserted into central vein and inserted into pulmonary artery; balloon at the tip of the catheter can be inflated for a measure of pulmonary capillary wedge pressure or left sidedfilling pressures

what is the pulmonary artery catheter used to assess

Assess severity of left ventricular failure•

Assess mitral and aortic valve dysfunction

•Assess and treat pulmonary edema (pulmonary capillary wedge pressure >20 mm Hg)

•Assess pulmonary hypertension• Assess and treat hypovolemic states

what is temperature monitoring used

multi organ dysfunction can have metabolic and system issues

What are methods for temperature monitoring in comatose or intubated patients?

Brain probe, urinary catheters, esophagus probe, nasopharyngeal probe, rectal probe (significant temperature lag), and Swan-Ganz Catheter (gold standard but not recommended for routine use).

what is Intracranial pressure monitoring (ICP):

intracranial HT from Neurologic insults such as traumatic head injury, hypoxic brain damage, aneurysm, hemorrhage, cerebral tumor, meningitis or brain surgery

why do we care for ICP monitoring

many of our interventions will inc ICP

Elevated ICP may cause

May extend brain damage; quick return to baseline minimizes risk.

Normal ICP range for adults

Less than 10 mm Hg, may reach up to 50 mm Hg naturally.

Normal ICP range for patients younger than 6 years

0 to 5 mm Hg.

Target Cerebral Perfusion Pressure (CPP)

50 to 70 mm Hg; less than 50 mm Hg should be avoided.

Effect of high ICP on CPP after brain injury

High ICP results in low CPP.

Hyperventilation effect on ICP

Reduces ICP by decreasing PaCO2, leading to arterial vasoconstriction.

Manual resuscitator bag use

Can be used to mechanically apply hyperventilation to reduce ICP.

what are some activities that can increase ICP

isometrics, valsalva, extreme hip extension, lateral neck flexion, coughing, prone position,head position below 15 degrees horizontal, occulsion of tube, pain

Non-Invasive Positive Pressure Ventilation (NPPV) is

provides ventilatory support for adults and children withacute and chronic ventilatory failure and neuromuscular disease

What is CPAP used for?

It is the gold standard in obstructive sleep apnea (OSA) and provides pressure throughout the entire respiratory cycle.

What are the common complications of CPAP?

Tightly fitting mask may cause local skin damage, eye irritation, sinus pain or congestion, and gastric distention.

What is BiPAP?

BiPAP delivers two levels of pressure: a high amount during inspiration and a low amount during exhalation.

Who can benefit from BiPAP?

Patients who cannot handle a CPAP.

What is a potential use of CPAP besides treating OSA?

It can also be a bridge to extubation for patients who still need positive pressure ventilation.

Which patients may need CPAP as a bridge to extubation?

Patients who have heart failure or are obese with obstructive sleep apnea (OSA).

Nasal Cannulae

Used for low and medium dose O2 flow (between 1-6L/min for adults and as low as 1/16L/min in neonates)

When do u start experiencing Dryness with Nasal Cannulae

Can experience dryness with greater than 4L/min so recommend using a humidifier

High Flow Nasal Cannulae (HFNC) flow is and always used with?

Flow above 6L/min, always used with heat and humidification

Benefits of HFNC

Reduce CO2 in upper airways and reduce work of breathing; highest flow the patient can comfortably use reduces the most CO2

HFNC for O2 Therapy

May be superior for O2 therapy before intubation

what are some reasons for high flow O2

hypoxemic respiratory failure, postexubation, preoxygenation before intubation, attempt to avoid intubation, acute PE, transport to critically ill,

Simple Mask is benefit for which patients

what is the flow rate

Benefits patients who are breathing through their mouth or may have nasal restriction. Will fit over nose and mouth and may have a diluter to add room air. Flow rate is 5-10L/min for adults and may use a humidifier.

Aerosol Mask is used for

what is the flow rate

Used for aerosolized medications or at controlled % of 02 greater than that for a simple mask (10-12L/min). Used with nebulizer to humidifier air.

Reservoir Mask is

Mask attached to reservoir bag and may allow some or no rebreathing of gases; need to be tightly sealed on face which can be uncomfortable for patient.

Partial Mask is

Mask with holes; 2/3 of mask is filled prior to inspiration with supplemental O2 and air flowing in from exhalation ports.

Partial Mask Exhalation Process

During exhalation, first 1/3 is exhaled into reservoir bag (which has high O2 & is inhaled during next breath) and last 2/3 vented out into the room via the exhalation ports.

Non-rebreathing Mask is used for pts

Looks the same as partial but does not allow for rebreathing of exhaled air.

Oxygen Flow Rate for Non-rebreathing Mask

8-15L/min.

Oxygen Flow Rate Consideration

O2 flow rate should not exceed patient's minute flow rate, particularly important for patients with COPD - they may initiate breathing with a hypoxic drive.

Venturi device mechanism

O2 entering larger tubing creates negative pressure, pulling in room air from entrainment ports. Entrainment ports may be color-coded for different FiO2 values.

Tracheostomy collar use

Placed over the open stoma of a tracheostomy for supplemental O2 delivery. Can be used when a patient is weaning from a ventilator for spontaneous breathing trials.

Long term tracheostomy purpose

To maintain airway clearance or to bypass the larynx.

what are the 4 purposes of artificial airways

Bypass upper airway obstruction

Assist or control respirations over prolonged periods

Facilitate the care of chronic respiratory tract infections

Prevent aspiration of oral and gastric secretions

what are the indications for artificial airways

Restlessness

Tachycardia

Confusion

Motor dysfunction

Decreased O2 sat

Cardinal signs of dangerous airway obstruction:

stridor and chest wall retractions

What are commonly used methods for cuff inhalation?

Minimal air leak and minimal occlusive volume.

How often should cuff pressure be checked?

Every 4-8 hours.

What is the recommended cuff pressure?

15-25 mmHg.