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Monitoring of patient in intensive care unit (ICU)
1. 1
Raj Kumar Mehta, MSN (Critical Care), RN
Associate Professor,
CON, CMC, Bharatpur
Monitoring the patient in
Intensive Care Unit
2. 2
Introduction
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.
3. 3
When a new symptom, sign, or a finding
appears on routine monitoring , a search
for the possible cause should immediately
begin.
The following parameters should be
monitored.
Introduction…
5. 5
Behaviors of the patient
Anxiety, fear
Response to new environment / ventilator:
Reassure, use sedatives
↓Pao2 : Check Spo2, patient – ventilator
system
6. 6
Restlessness, agitation
↓Pao2: Check Spo2, patient-ventilator
system
Pain : check pain medication
Low PIFR
Behaviors of the patient…
7. 7
Confusion, disorientation, decreased
responsiveness, no response to
stimuli
Use GCS scale to determine patient’s level
of alertness
↓Pao2 : Check Spo2, patient - ventilator
system
Behaviors of the patient…
8. 8
↓Perfusion to brain : Evaluate fluid balance,
check BP, examine for any acute event (e.g.
stroke)
Rising PaCo2: Obtain ABG.
Drugs : Check medication record
Inadequate sleep
Behaviors of the patient…
9. 9
Twitching / convulsions / tetany
↓ed serum levels of anticonvulsants in a
patient with known convulsive disorder
↓PaCo2 with rising pH.
Breathlessness
Anxiety, ↓ PaO2, ↓ed ventilation,
pneumothorax.
Behaviors of the patient…
10. 10
Altered chest wall movements
Paradoxical movement - flial chest
Inward movement of thorax during inspiration
– Lower cervical cord transection
Asynchronous movement of the thorax and
abdomen – Splinting after abdominal surgery,
COPD, diaphragmatic paralysis, respiratory
muscle fatigue with impending respiratory
failure
Inspection
11. 11
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 …
12. 12
Asynchrony with the ventilator
(distressed patient) – Monitor every
hour.
Anxiety, pain : Reassure, manage pain
Airway obstruction at the level of ETT : pass
a suction catheter to exclude airway
obstruction
Migration of tube, either above vocal cords or
into the mainstem bronchus.
Inspection…
13. 13
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…
14. 14
Pneumothorax
↓PaO2, ↑PaCO2
If no obvious cause is found, the first
step is disconnection from the
ventilator and manual ventilation with
100% oxygen
Inspection…
15. 15
If patient improves promptly, the
ventilator or external circuit is the
source of problem
If patient does not improve, then
problem is with the ETT or the patient.
Find out the cause and manage
accordingly.
Inspection…
16. 16
Vital signs
Blood pressure – monitor every 1-4 hours
Hypotension
Decreased intravascular volume,
High external or internal PEEP,
Cardiac failure and
Drugs – sedatives and vasodilators
Check drainage system,
Look for inadvertent discontinuation of inotropes or
leak from IV site
18. 18
Disparity between cuff and direct (intra-
arterial) pressure measurements of 5-20
mmHg may be considered normal as long as
the pressure measurement is higher
When cuff pressure is high, check
monitoring system for - leaks, bubbles, or
other causes of damped pressure.
Vital signs…
19. 19
Hypotension is late sign of decreasing
cardiac output
Early signs of a decrease in cardiac output
include tachycardia, cold peripheral
extremities, confused or less responsive
patient and a fall in the urine output.
A normal blood pressure does not guarantee
adequate perfusion.
Vital signs…
20. 20
Heart rate and rhythm (new arrhythmias,
tachycardia, bradycardia) – monitor every
1 hour.
Anxiety, inadequate sedation, drugs, ↓PaO2,
↓PaCO2, ↑PaCO2 (check SpO2, ABG,
patient-ventilator system), ↓ed intravascular
volume.
Evaluate other haemodynamic parameters
for the adequacy of perfusion
Vital signs…
21. 21
Urinary output – monitor hourly
↓ed urine output : inadequate perfusion of
kidneys, low intravascular volume, and onset
of acute renal failure.
↑ed urine output :(>50 ml/hr) in the absence
of diuretics or diuretic phase of renal failure
(overhydration)
Normal urine output : 0.5-1.0mL/kg/hr in
adults, 1mL /kg/hr in children.
Vital signs…
22. 22
Temperature : monitor every 8 hours.
Fever – overheated humidifier,
atelectasis, infection, ↑ed metamolic
rate caused by ↑ed inspiratory effort
or patient ventilator asynchrony.
Vital signs…
23. 23
Geriatric patients have a lower body
temperature, and are more easily
influenced by environmental
temperature (as in new born and
infants).
In patients over 90 years of age, body
temperature of 960
F-970
F may be
normal.
Vital signs…
24. 24
Hypothermia : ↓ed environmental
temperature, infection (especially in new
born)
Axillary temperature is approximately 0.50
C
lower than oral temperature,
Rectal temperature (related more closely to
core body temp.) is approximately 0.50
C
higher than the oral temperature.
Vital signs…
25. 25
Respiratory rate : monitor every 1-4 hours
RR may be influenced by altered ventilator
settings
Changes in metabolic needs (anxiety, stress,
infection, infection, heart failure, pulmonary
edema,)
↓ed PaO2
Vital signs…
27. 27
Weight gain, peripheral edema :
monitor daily
Heart failure, hypoproteinemia (↓oncotic
pressure), venous or lymphatic
obstruction, sepsis, shock, trauma etc.
(altered capillary permeability)
Vital signs…
28. 28
Increasing weight does not
necessarily mean an adequate
intravascular volume.
The patient could be hypovolemic,
because of shifting of fluid to the
tissues or to “third space”.
Vital signs…
29. 29
Capillary refill time
Normally, after a 5 second compression of
the nail bed, the pink colour should return to
the blanched area within 3 seconds.
If it takes longer, it indicates vasoconstriction
or reduced cardiac output with decreased
digital perfusion
This may not be reliable when the room
temperature is low.
Vital signs…
30. 30
Oxygen saturation with pulse oxymeter
– monitor continuously
End tidal CO2
Central venous pressure.
Vital signs…
32. 32
Physical Examination
Air leak around ETT-monitor
every 1-2 hours
Deflated / ruptured cuff
ETT lying above vocal cords
33. 33
Airway secretions-monitor with every
suction
Secretions thick : inadequate humidity
Secretions copious, thin : ↑ed humidity,
infection, draining of fluid from tubing
into trachea (reposition ventilator
tubings)
Observe the colour of secretions
Physical Examination…
34. 34
Breath sounds-monitor every 1-4
hours
Unilateral ↓ed breath sounds: blocked
ETT, ETT migration into a mainstem
bronchus, air, blood, or other fluid in the
pleural space, pneumonia
Physical Examination…
35. 35
↓ed breath sounds and late
inspiratory crackles in the dependent
region : atelectasis or any condition
of lung that causes a loss of volume
(restrictive disorder)
Physical Examination…
36. 36
↓ed (or absent) breath sounds along
with mediastinal shift : tension
pneumothorax (suspect in any patient
who is difficult to ventilate during CPR
or who deteriorates while being
ventilated, especially when high peak
pressures and PEEP are being used)
Physical Examination…
37. 37
Presence of wheeze : asthma,
congestive heart failure, bronchitis, high
flow rate
Inspiratory and expiratory crackles
present: bronchitis, respiratory
infections, and secretions.
Physical Examination…
38. 38
Subcutaneous emphysema-monitor
every 2-4 hours
Mechanical ventilation of a patient with
fresh tracheostomy, laceration of lung or
chest wall secondary to trauma or
surgery, tension pneumothorax
Physical Examination…
39. 39
Air leak via chest tube – monitor
every 1-4 hours
New pneumothorax : Obtain and
evaluate X-ray chest and ABG
Broncho-pleural fistulae : change
ventilatory settings if required
Physical Examination…
40. 40
Skin temperature
Various factors which influence the
temperature of skin (especially of feet and
hands) are perfusion to the extremity, core
temperature of body and environmental
temperature.
Normally the toe temperature should be at
least 20
C warmer than the ambient
temperature.
Physical Examination…
41. 41
A difference of <20
C indicates hypoperfusion
and a difference of <0.50
C indicates a life-
threatening situation resulting from reduced
perfusion.
Cold and clammy skin occurs as a result of
sympathetic stimulation, and is a
compensatory mechanism for a decrease in
cardiac output- indicates impending shock
Physical Examination…
42. 42
Gastric distension - monitor every 1-
4 hours
Malpositioning of ETT,
Air swallowing,
Excessive inspiratory effort by the
patient,
Nutritional intolerance,
Blocked nasogastric tube.
Physical Examination…
44. 44
Lab. investigations
Arterial blood gas (ABG) analysis
Evaluate with every change in ventilator
setting or with any unexplained change
in patient’s condition
Serum electrolytes
Daily or twice weekly
45. 45
Blood urea, serum creatinine
Twice a week or daily
Liver function tests
Weekly or twice a week
X-ray chest
Daily
Lab. Investigations…
46. 46
Cultures from various sites
As the condition demands
Twice a week or less often
Lab. Investigations…
51. 51
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Providing necessary services
within the fastest possible
time
“Time is a key factor”
Sooner we can provide the
services, the greater are the
chances of recovery
52. 52
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