Clinical Monitoring of Patients in the ICU PDF

Clinical monitoring of the patient in the icu introduction The Intensive Care Unit (ICU), also known as the Critical Care Unit is defined by the Task Force of the World Federation of Societies of Intensive and Critical Care Medicine (WF...

Clinical monitoring of the patient in the icu introduction The Intensive Care Unit (ICU), also known as the Critical Care Unit is defined by the Task Force of the World Federation of Societies of Intensive and Critical Care Medicine (WFISCCM) as "an organized system for the provision of care to critically ill patients that provides intensive and specialized medical and nursing care, an enhanced capacity for monitoring, and multiple modalities of physiologic organ support to sustain life during a period of life-threatening organ system insufficiency." Mainly, the ICU's goal is to prevent a progressive deterioration in the physiologic state of a patient as the underlying disease is being managed  Vital Signs The NICE guidelines[ recommends that heart rate (HR), respiratory rate (RR), blood pressure (BP), oxygen saturation (SpO2), level of consciousness and temperature be measured at a minimum but that the additional monitoring of pain, urine output and biochemical analysis also be added. Blood pressure (BP) can be defined as the pressure exerted by the circulatory blood on the arterial walls. It provides an important reflection of the blood flow when the heart is contracting (systole) and relaxing (diastole). Three values are considered when measuring BP: systolic (SBP), diastolic (DBP) and mean (MBP) pressure. SBP indicates the peak pressure attained during the cardiac cycle whereas DBP is the trough. Mean arterial pressure (MAP) is defined as the mean pressure during the cardiac cycle and is an important parameter during resuscitation procedures. The difference between SBP and DBP is known as the pulse pressure (PP) and determines the peripheral palpability of the arterial pressure wave (for example at the radial or femoral site) Parameter Normal range Systolic blood pressure (SBP) 90-140mmHg 90-140 mmHg Diastolic blood pressure (DBP) 60-90Hg 60-90 mmHg Mean arterial pressure (MAP) 70-105Hg 70-105 mmHg [SBP + (2 x DBP)]/3 Normative BP values BP can be measured non-invasively using a sphygmomanometer (BP cuff) but it is often measured invasively using arterial lines which are generally inserted in large blood vessels such as the radial or femoral artery  Respiratory rate Respiratory rate (RR) refers to the number of breaths as calculated over one minute, with a normal RR being 12- 20 breaths per minute. A rise in RR is the most sensitive indicator of clinical deterioration and impending adverse events such as cardiac arrest or death. Tachypnoea refers to a rate of more than 20 breaths per minute and is a sign of respiratory distress. bradypnoea, the RR is less than 10 breaths per minute and is often caused by drugs (e.g. opioids), hypothermia, fatigue or central nervous system depression. A RR of more than 24 breaths per minute is considered a medical emergency as it indicates the possibility of respiratory failure Terminology Definition Tachypnoea Abnormally quick RR (>20 breaths/minute) Bradypnoea Abnormally slow RR ( 100 bpm) and bradycardias (HR < 60 bpm). Oxygen saturation/pulse oximetry Pulse oximetry is the technique used to measure arterial oxygen saturation in the peripheral blood vessels. It can be defined as “the ratio between oxygenated haemoglobin and the total amount of haemoglobin” in the blood and is expressed as SpO2. An SpO2 of 95-100% is considered within normative ranges. An SpO 2 of less than 90% is of grave concern. It is an easy, painless, non-invasive method whereby a probe is placed on the fingertip or earlobe to measure the oxygen saturation indirectly. A fall in SpO2 indicates the development of hypoxaemia long before any visual evidence of cyanosis (SpO2 of 80- 85%) becomes evident  Various factors influence the accuracy of pulse oximetry and these include: Movement of the patient Incorrect positioning of the probe Hypothermia Hypovolaemia Vasoconstriction Nail polish - as it absorbs the light waves used to measure SpO2 temperture Normal body temperature in healthy individuals is considered to be 36.8°C ± 0.4°C [98.2℉ ± 0.7℉] (measured in the oral cavity) with normal circadian variations of 0.5°C (0.9℉). Clinically, temperatures of 33- 36°C (91-96.8℉) are considered as mild hypothermia, 28-32°C (82.4-89.6℉) as moderate hypothermia and below 28°C (82.4℉) as deep hypothermia, whereas any temperature above 38.3°C (100.94℉) is considered a fever/hyperthermia  Level of consciousness Level of consciousness (LOC) is the single most important indicator of cerebral functioning. It can be defined as the “degree of arousal and awareness” of a patient. In the critically ill patient, the LOC is most commonly assessed using the Glasgow Coma Scale (GCS) Alert Responsive to Verbal stimulation Responsive to Painful stimulation Unresponsive The GCS assesses two aspects of consciousness, namely: Arousal/Wakefulness Patient awareness in demonstrating an understanding of what a practitioner said through the ability to complete tasks A GCS score of less than 12 is considered concerning and a patient with a score of less than 9 will probably require airway intervention and intubation. A reduction of 2 points on the GCS is considered significant in indicating clinical deterioration of the patient  A patient’s LOC or mental status can be affected by several factors including side effects of some medications (sedatives or analgesics, e.g. benzodiazepines, anxiolytics, opioids), hypoxia, hypercapnia, hypoglycaemia, hypotension, alcohol, cerebral pathology The goal The goal of monitoring the patient is to detect problems and manage them as early as possible -important parameters should be monitored at regular intervals in a systematic manner - recorded on the monitoring chart  introduction When a new symptom, or sign or a finding appears on routine monitoring ,a search for the possible cause should immediately begin. The following parameters should be monitored Behavior of the patient -Anxiety,fear Response to a new environment/ventilator Treatment ;Reassure, use sedatives decreased PaO₂;check SPO₂,patient- ventilator system  Restlessness , agitation Decreased PaO₂ check Spo₂,patient- ventilator System Pain, check pain medication , Low PIFR Confusion, disorentation , decreased responsiveness , no response to stimuli Use GCS to determine level of alertness. Decreased PaO₂- check spo₂ ,patient- ventilator system  Behaviors of the patient perfusion to brain; evaluate fluid balance, check BP, , examine for any acute event e.g stroke Rising Paco₂ ;obtain ABG analysis Drugs; check medications record -Inadequate sleep Behavior of the patient Twitching ,convulsion, tetany -Decreased level of anticonvulsants Decreased PaCO₂ with rising pH Breathlessness; Anxiety, decreased PaO₂ , decreased ventilation pneumothorax  inspection -Altered chest wall movement Paradoxical movement, flial chest Intercostal muscle recession Lower spinal cord compression Asynchronous movement of thorax and abdomen Splinting after abdominal surgery, COAD , diaphragramatic paralysis, respiratory muscle fatigue with impending respiratory failure inspection Unilateral decrease In chest wall expansion; Intubation of right mainstem bronchus -Splinting secondary to pain -air ,blood or fluid in the pleural cavity -atelectasis -Consolidation , -obstruction of major bronchus  inspection Asynchrony with the ventilator[distressed patient]-monitor every hour Anxiety ,pain;reassure, manage pain -Airway obstruction at the level of ETT, pass suction catheter to exclude airway obstruction Migration of tube either above vocal cords or into the mainstem bronchus inspection In-line continuous nebulization -Secretions -Fluid accumulation in the ventilator circuit -Inappropriate ventilator settings in terms of flow rate, I;E ratio. FIO₂. ,trigger sensitivity ,total minute ventilation -Leaks in the system[commonly at circuit level or around ETT.  Inspection -Pneumothorax -Decreased PaO₂ ,increased PaCO₂ If no obvious cause is found, the first step is disconnection from the ventilator And manual ventilation With 100% O₂ Insp. If patient improves the ventilator or external circuit is the source of the problem If no improvement then the problem is with ETT or the patient find the cause and manage accordingly.  Vital signs Blood pressure ;monitor every 1-4 hours -Hypotension; Decreased intravascular volume High external or internal PEEP,cardiac failure, Drugs-sedatives and vasodilators. Check drainage system Look for inadvertent discontinuation of inotropes or leak from iv site. Vital s. Hypertension; Anxiety, Inadequate sedation, Increased PaCO₂,other causes of sympathetic stimulation, Drugs –vasopressors. disparity between cuff and direct intra-arterial pressure of 5-20mmhg is normal as long as the pressure measurements is higher  Vital.s. Hypotension is a late sign of decreased cardiac output -Early signs of decreased cardiac output include tachycardia , cold peripheries, confused or less responsive patient, and a fall in urine output -A normal blood pressure does not guarantee adequate perfusion. v.s. Heart rate and rhythm[new arrhythmia, tachcycardia , bradycardia ; monitor every 1hour. Anxiety, inadequate sedation ,drugs ,decreased pao2, increased paco2, paco2[check SpO₂, ABG, patient- ventilator system],decreased intravascular volume. -Evaluate other haemodynamic parameters for the Adequacy of perfusion  v.s Urine output; monitor hourly Decreased urine output-inadequate perfusion of kidneys, low intravascular volume and onset of acute renal failure Increased urine out put>50ml/hr. in the absence of diuretic use or diuretic phase of acute renal failure indicate overhydration Normal urine out put is 0.5-1ml/kg/hr in adults and 1ml/kg/hr in children. < 0.5ml/kg/hr is oligurea v.s Temperature ; monitoring/8 hours Fever -overheated humidifier, atelectasis , infection, increased metabolic rate caused by increased inspiratory effort or patient Ventilator asynchrony  v.s. Geriatric patients have a lower body temp. and are easily influenced by environmental Temp as in new born baby. In patient > 90 years body temp of 96- 97f may be normal. v.s. Hypothermia; Decreased environmental Temp., infection especially in newborn -Axillary temp. is 0.5 c lower than oral temp. -Rectal temp. is [more closely related to core body temp] and is approximately 0.5c higher than oral temp.  v.s. Respiratory rate –monitor every 1-4 hours Respiratory rate may be influenced by altered ventilator Setting. -Changes in metabolic needs[ anxiety, stress ,infection ,heart failure ,pulmonary edema]. -Decreased PaO₂ V,s. Hypercapnea [paco2>45mmhg]; Drugs[sedatives, narcotics , anesthetic agents], Unsuccessful weaning[rapid shallow breathing], Increased Intracranial pressure  v.s. Weight gain ,peripheral edema; Monitor daily Heart failure, hypoprotenemia[ oncotic pressure] ,venous or lymphatic obstruction.sepsis, shock, trauma ….etc. [Altered capillary permeability] v.s. Capillary refilling time; It should be 2-3 sec. compress nail bed for 5 sec and releive the compression. >3sec =vasoconstriction or decreased cardiac output with decreased digital perfusion. In cold room it is unreliable.  v.s. O₂ saturation pulse oximetry; monitor continuously -End tidal CO₂ -CVP Physical examination Air leak around ETT-monitor every1- 2 hrs. -Deflated /ruptured cuff -ETT lying above vocal cords.  Airway secretions -Monitor with every suction -Thick secretion; inadequate humidity -Copious secretion, thin; increased humidity, infection, draining of fluid from tubing into trachea[reposition ventilator Tubings. -Observe the colour of secretions. Breath s; Monitor every 1-4 hrs -Unilateral decrease in breath sounds- ;blocked ETT, migration into a mainstem bronchus, air , blood, or other fluids in pleural space, pneumonia -Decreased breath sounds and late inspiratory crackles in the dependent regions; ;atelectasis ,or any condition of lung that causes a loss of lung volume[restrictive Disorders]  Decreased or absent breath sounds with mediastinal shift ; tension pneumothorax Suspected in any patient Who is difficult to ventilate , During CPR or who deteriorate while being ventilated , Especially when high peak pressure and PEEP are being used -Wheeze; asthma, congestive heart failure , bronchitis , high flow rate. -Inspiratory and expiratory Crackles; Bronchitis ,respiratory infections and secretions  - Subcutaneous emphysema ;monitor every 2-4hrs -mechanical vent. Of a patient With fresh tracheostomy ,laceration of lung , or chest wall injury. Secondary to trauma or surgery,tension pneumothorax Air leak via chest tube; Monitor every 1-4 hrs -New pneumothorax. obtain a new chest XR and ABG -Broncho-pleural fistula ; change ventilatory settings if required  Skin temp. Various factors can affect skin temp especially at feet and hands ; perfusion to the extremity ,core temp of body abd environmental temp. -Normally the toe temp. should be at least 2c warmer than the ambient temp. -A difference of