Respiratory Monitoring Protocols

Patient Monitoring in ICU

• Monitoring in medicine involves observing a disease, condition, or medical parameters over time.
• Monitoring can be continuous (e.g., vital signs using a bedside monitor) or repeated (e.g., blood glucose monitoring).
• Monitoring aims to detect problems early and manage them.
• Important parameters are monitored regularly and recorded.

Introduction

• Monitoring initiates when a new symptom or finding arises.
• Crucial parameters for ICU monitoring include cardiac and hemodynamic function, respiratory status, blood glucose, body temperature, renal function, and nutritional status.

Patient Behaviors

• Monitor for anxiety, fear, restlessness, and agitation, also patient's response to the environment and medical devices.
• Assess comfort and use sedatives when needed.
• Check Pao2 and Spo2, and evaluate the patient-ventilator system.
• Check for and manage pain.
• Use the Glasgow Coma Scale (GCS) to assess alertness/consciousness levels.
• Evaluate perfusion to the brain by checking blood pressure and looking for acute events like strokes.
• Monitor ABGs if PaCO2 increases.
• Note and manage medication use.
• Track sleep adequacy.

Patient Behaviors (continued)

• Monitor for twitching, convulsions, and tetany, especially if anticonvulsant levels are low in patients with known seizures.
• Check for PaCO2 changes with rising pH.
• Observe for breathlessness, anxiety, decreased oxygen (↓PaO2), decreased ventilation, and pneumothorax.

Inspection

• Evaluate chest wall movements and look for paradoxical chest movement, inward chest movement during inspiration, or asynchronous chest and abdominal movement.
• Observe for unilateral decrease in chest wall expansion. This could be due to bronchus intubation, pain, air, blood, or fluid in the pleural cavity, atelectasis, or consolidation.
• Look for airway obstruction at the endotracheal tube (ETT) level.
• Assess for in-line continuous nebulization and monitor for secretions.
• Check for fluid accumulation in the ventilator circuit.
• Inspect for inappropriate ventilator settings (flow rate, I:E ratio, FiO2). Watch out for leaks in the system at ETT levels or the circuit itself.
• Observe for pneumothorax by looking for decreased oxygen levels (↓PaO2) and increased carbon dioxide levels (↑PaCO2). If no cause is found, disconnect from the ventilator and use manual ventilation with 100% oxygen.

Vital Signs

• Blood Pressure: Monitor hourly. Hypotension may indicate decreased intravascular volume, high external/internal PEEP, cardiac failure, or certain medications (sedatives and vasodilators). Check drainage systems and for IV site leaks. Hypertension may be due to anxiety, inadequate sedation, high carbon dioxide (↑PaCO2), or medications like vasopressors
• Heart Rate and Rhythm: Monitor frequently (hourly) for new arrhythmias or changes (tachycardia or bradycardia). Evaluate for anxiety, sedation, drug use, low oxygen/high carbon dioxide levels, and low intravascular volume. Check other hemodynamic parameters to evaluate perfusion.
• Urinary Output: Monitor and calculate hourly. Decreased output points to low kidney perfusion, low intravascular volume, and acute renal failure. Increased output (over 100 mL/hr) indicates possible overhydration. Normal ranges exist for adults and children
• Temperature: Monitor every 4-8 hours. Fever could be due to overheating humidifiers, atelectasis, infection, and high metabolic rates. Lower temperatures might be seen in the elderly. Observe if the axillary temperature is lower, or if the rectal temperature is higher than the oral temperature.
• Respiratory Rate: Monitor every 1-4 hours for changes related to ventilator settings, metabolic needs (anxiety, stress, infection, edema), low oxygen (↓PaO2), and high carbon dioxide (↑PaCO2) levels. Note use/potential effect of medications (sedatives, narcotics, anesthetics). Watch out for weaning complications and raised intracranial pressure

Physical Examination

• Breath Sounds: Monitor hourly or every 1-4 hours. Listen for unilateral decreased sounds, suggesting ETT blockage or fluid in the pleural space, blocked ETT, or issues like pneumonia. Look for late inspiratory crackles, which point to atelectasis or restrictive lung issues. Also check for decreased or absent breath sounds accompanied by mediastinal shift, which is a possible sign of tension pneumothorax. This is especially important in patients who are difficult to ventilate during CPR or those who worsen during ventilation.
• Air Leaks: Consistently inspect ETT and its cuff for leaks (hourly or every 1–2 hours) as this can lead to deflated/ruptured cuffs or ETT positioning above the vocal chords.
• Airway Secretions: Regularly check and evaluate airway secretions (with each suction). Thick secretions may indicate low humidity levels, while copious, thin secretions could suggest infection or fluid drainage into the trachea.

Lab Investigations

• Arterial Blood Gas (ABG): Evaluate with changes in ventilator settings or unexplained changes in the patient's condition.
• Serum Electrolytes: Daily or every other day.
• Blood Urea and Serum Creatinine: Twice weekly or Daily if needed.
• Cultures: As needed based on the patient's condition.

This quiz explores the protocols for monitoring new symptoms during routine health checks, particularly in respiratory care. Questions cover the importance of addressing new signs, potential causes for changes in the patient’s condition, and appropriate responses to asynchrony with the ventilator. Test your knowledge on critical monitoring practices and interventions in respiratory management.