daily monitoring of the patient in intensive care unit

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Raj Kumar Mehta, MSN (Critical Care), RN
Associate Professor,
CON, CMC, Bharatpur
Monitoring the patient in
Intensive Care Unit

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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.

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 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…

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Behaviors of the patient
 Anxiety, fear
 Response to new environment / ventilator:
Reassure, use sedatives
 ↓Pao2 : Check Spo2, patient – ventilator
system

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 Restlessness, agitation
 ↓Pao2: Check Spo2, patient-ventilator
system
 Pain : check pain medication
 Low PIFR
Behaviors of the patient…

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 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…

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 ↓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…

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 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…

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 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

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 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 …

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 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…

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 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…

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 Pneumothorax
 ↓PaO2, ↑PaCO2
 If no obvious cause is found, the first
step is disconnection from the
ventilator and manual ventilation with
100% oxygen
Inspection…

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 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…

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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

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 Hypertension
 Anxiety
 Inadequate sedation,
 ↑ed PaCO2, other causes of sympathetic
stimulation,
 Drugs - vasopressors
Vital signs…

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 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…

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 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…

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 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…

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 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…

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 Temperature : monitor every 8 hours.
 Fever – overheated humidifier,
atelectasis, infection, ↑ed metamolic
rate caused by ↑ed inspiratory effort
or patient ventilator asynchrony.
Vital signs…

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 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…

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 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…

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 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…

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 ↑ed PaCO2
 Drugs (sedatives, narcotics, anesthetic
agents)
 Unsuccessful weaning (rapid shallow
breathing)
 ↑ed intracranial pressure
Vital signs…

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 Weight gain, peripheral edema :
monitor daily
 Heart failure, hypoproteinemia (↓oncotic
pressure), venous or lymphatic
obstruction, sepsis, shock, trauma etc.
(altered capillary permeability)
Vital signs…

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 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…

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 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…

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 Oxygen saturation with pulse oxymeter
– monitor continuously
 End tidal CO2
 Central venous pressure.
Vital signs…

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Physical Examination
 Air leak around ETT-monitor
every 1-2 hours
 Deflated / ruptured cuff
 ETT lying above vocal cords

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 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…

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 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…

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 ↓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…

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 ↓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…

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 Presence of wheeze : asthma,
congestive heart failure, bronchitis, high
flow rate
 Inspiratory and expiratory crackles
present: bronchitis, respiratory
infections, and secretions.
Physical Examination…

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 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…

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 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…

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 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…

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 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…

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 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…

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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

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 Blood urea, serum creatinine
 Twice a week or daily
 Liver function tests
 Weekly or twice a week
 X-ray chest
 Daily
Lab. Investigations…

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 Cultures from various sites
 As the condition demands
 Twice a week or less often
Lab. Investigations…

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The Problem

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Conversation between important organs

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TIME IS A KEY FACTOR
CRITICAL CARE

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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

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The one who works with
his hand is a laborer
And
The one who works with
his head and hands
Is a craftsman

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