Hemodynamic Monitoring and Transcultural Care

Hemodynamic Monitoring

• Hemodynamic monitoring is an adjunct to patient evaluation, it should not replace frequent bedside physical assessments.
• Non-responsive patients should be spoken to as if conscious, with simple explanations of procedures. This is important if family, friends, or other staff are present, or if the patient's sedation level is uncertain.

Transcultural Considerations

• Language or dialect differences may require an interpreter.
• Overcoming ethnocentrism is crucial.
• Intubated patients may need communication boards, pens and paper for communication.
• Prioritize patient's healthcare needs.
• Patients are vulnerable, empathy and excellent care are important.

Cough

• Sputum evaluation:
  • Copious, thick, mucoid, greyish-white, translucent sputum may indicate COPD or smokers.
  • Purulent, foul-smelling, yellow, brown, or green sputum suggests bronchopulmonary bacterial infection (possible bronchiectasis if chronic).
  • Rusty or golden yellow sputum may indicate pneumococcal pneumonia.
  • Clear, white mucoid sputum may indicate asthma or allergies.
  • Eosinophils in sputum may make it appear purulent.
• Hemoptysis:
  • Grossly bloody, streaked, or with small clots suggests possible acute cardiopulmonary edema.
  • Recurrent bloody sputum points to severe pulmonary hypertension.

Tracheoinnominate Fistula

• A potentially fatal tracheostomy complication.
• Positioning the tracheostomy tube against the innominate artery can cause pulsatile movement, leading to tracheal wall erosion.
• Quick repositioning of the tracheostomy tube is necessary.

Dyspnea

• Normal minute ventilation: 4-6 L/min.
• Maximal ventilatory capacity: 200 L/min.
• Causes related to pulmonary disease:
  • Reduced airflow (increased Raw).
  • Reduced airflow (Reduced C₁).
  • Conditions resisting lung expansion (pneumothorax, pleural effusion, inflammation).
  • Increased physiologic VD (pulmonary embolism).
  • Respiratory muscle fatigue (exercise, COPD exacerbation).

Asymmetry of Chest Movement

• Causes:
  • Pleural effusion (unilateral or bilateral).
  • Major bronchus obstruction.
  • Right mainstem intubation.
  • Mucus plugs.
  • Neuromuscular abnormalities.
  • G.B.
  • M.G.
  • Pneumothorax.
  • Hemothorax.
  • Severe atelectasis.

Abnormal Breathing Patterns

• Respiratory muscle fatigue during inspiration or exhalation may result in the abdomen moving abnormally (inward or outward) during breathing.
• These are often rapid, uncoordinated respiratory movements.

Abdominal Paradox

• Inward movement of the abdomen during inspiration (rather than outward).
• This is a non-specific indicator of ineffective breathing patterns or severe respiratory distress.

Cyanosis

• Diffuse bluish discoloration of the skin and mucous membranes (nail beds, lips, nose, earlobes).
• Deoxygenated hemoglobin causes this bluish discoloration.
• Occurs when PaO2 is near 50 mm Hg and SpO2 is 80%.

Central Cyanosis

• Blood leaving the left ventricle is poorly oxygenated.
• Causes include inadequate lung oxygenation or poor perfusion.
• Cyanosis is evident at nail beds, earlobes, nose, under the tongue.
• Skin over the entire body is usually warm.

Peripheral Cyanosis

• Blood leaving the left ventricle is adequately oxygenated.
• Desaturation occurs in the peripheral systemic circulation from blood stagnation in vasoconstricted peripheral arterioles (due to cold environment, anxiety, or circulatory failure).
• Peripheral cyanosis is evident at nail beds, earlobes, nose.
• Mucous membranes under the tongue remain pink.
• Skin is typically cold; cyanosis resolves with warming.

Generalized Edema

• Most commonly observed in feet and ankles.
• Causes:
  • Renal disease.
  • Metabolic disease.
  • Cardiac disease.
  • COPD.
  • Right ventricular failure (due to pulmonary disease or Cor Pulmonale).

Subcutaneous Emphysema

• Air in subcutaneous tissue, an indication of a pulmonary air leak.
• Evidenced by swelling in the chest area, a crackling sensation (like rice crispies or small bubbles).
• Significant subcutaneous emphysema around the throat can compress the airway or blood vessels, posing a serious threat.
• It's a warning sign of an air leak, potentially a pneumothorax.

Posturing

• Patients with respiratory difficulty often prefer sitting/leaning over to lying down.
• They may grasp objects, use their hands as support, or sit in a tripod position with arms resting on their legs.
• This helps activated muscles of inspiration.
• An upright position allows for increased ventilation due to increased diaphragmatic descent.

Diagnostic Percussion

• Used to determine density or consistency of underlying lung tissue by evaluating sounds produced when the chest wall is tapped.

Tracheal Position

• Assessing tracheal deviation helps detect mediastinal shifts.
• Technique includes placing index finger in suprasternal notch, locating trachea and noting any deviation.
• Positional changes (e.g., pressure on one side) shift the trachea to the opposite side.
• Lung volume change shifts the trachea toward the affected side (e.g., atelectasis, consolidation, lobectomy).

Auscultation of Breath Sounds

• Students will need to learn how to perform and interpret auscultation of breath sounds.