2. outline
Definition of monitoring
Classification of monitoring
Standards' of monitoring
Techniques of monitoring
Patient monitoring
Infusion monitoring
Drug/equipment monitoring
2
3. Definition
The ward monitor originates from the Latin
word “monere”, which means “to remind,
advise, or warn”.
monitoring is the observation of a disease,
condition or one or several medical parameters
over time.
It can be performed by continuously measuring
certain parameters, example, by continuously
measuring vital signs), and/or by repeatedly
performing medical tests (such as blood
glucose monitoring with a glucose meter in
people with diabetes mellitus).
3
4. General Guidelines
Monitoring ensures rapid detection of changes in
the clinical status
Allows for accurate assessment of progress and
response to therapy
When clinical signs and monitored parameters
disagree, assume that clinical assessment is
correct
Trends are generally more important than a
single reading
Use non-invasive techniques when possible
Alarms are crucial for patient safety
4
5. The aim of monitoring patients is to
detect organ dysfunction and guide the
restoration and maintenance of tissue
oxygen delivery.
Monitoring is a crucial part of the care of
the critically ill patient in the emergency
department as the physiological
response to critical illness is linked
strongly to outcome.
5
6. Having a basic knowledge of the principles of
monitoring equipment and being able to
interpret data correctly is therefore important.
No amount of monitoring, however, can replace
the close observation of clinical signs by the
nurse in ER or ICU.
Monitoring is not the same as treatment, nor is
it a substitute for treatment.
Instituting even the most invasive of
monitoring techniques cannot alone alter a
patient’s outcome without modification of
treatment.
6
7. Importance of monitoring the
critically ill patient
The ultimate aim of monitoring in the
critically ill is to assist in the prevention
or treatment of organ dysfunction and
cellular injury by optimizing the supply
of oxygen to the tissues.
7
8. Again Oxygen delivery is the product of
cardiac output and blood oxygen content;
thus, several commonly monitored
variables contribute to the monitoring of
oxygen delivery.
i.e. Cardiac output is the product of stroke
volume and heart rate (easily measured
and monitored), whilst blood oxygen
content is related to haemoglobin content
and oxygen saturation, which are both
easily measured and monitored.
8
9. Early goal‐directed therapy applied in
the emergency department to critically
ill patients reduces mortality.
This strategy is dependent on specialized
monitoring in order to improve oxygen
delivery to the tissues.
Organ dysfunction may be monitored by
several methods depending on the
organ, for example, urine output as a
monitor of renal organ function
9
10. Standard of monitoring
As a minimum standard of care , the
following physiological observations should
be recorded at the initial assessment and
as part of routine monitoring:
heart rate
respiratory rate
systolic blood pressure
level of consciousness
oxygen saturation
temperature.
10
11. In specific clinical circumstances,
additional monitoring should be
considered; like:
hourly urine output
biochemical analysis, such as lactate,
blood glucose, base deficit, arterial pH
pain assessment.
11
12. Concerning frequencies of follow
up
Frequency of observations is highly
variable; it depends upon individuals
patient condition, disease type and
progresses of the disease
Physiological observations should be
monitored at least every 12 hours, unless a
decision has been made at a senior level to
increase or decrease this frequency for an
individual patient.
The frequency of monitoring should
increase if abnormal physiology is detected
12
13. Patient Monitoring
Repeated or continuous observations
or measurements of the patient, his
or her physiological function, and
the function of life support
equipment, for the purpose of
guiding management decisions,
including when to make therapeutic
interventions, and assessment of
those interventions” [Hudson, 1985,
p. 630].
13
14. Patient Monitoring in ICUs
Categories of patients who need physiologic
monitoring:
1. Patients with unstable physiologic regulatory
systems;
Example: a patient whose respiratory system is
suppressed by a drug overdose or anesthesia.
2. Patients with a suspected life-threatening
condition;
Example: a patient who has findings indicating
an acute myocardial infarction (heart attack).
3. Patients at high risk of developing a life-
threatening condition;
Example: patients immediately post open-heart
surgery, or a premature infant whose heart and
lungs are not fully developed.
4. Patients in a critical physiological state;
Example: patients with multiple trauma or
septic shock.
14
16. Classification
Monitoring can be classified by the
target of interest, including:
Cardiac monitoring
Hemodynamic monitoring
Respiratory monitoring
Neurological monitoring
Blood glucose monitoring
16
17. Cardiac monitoring
WHAT TO MONITOR??
ECG
ABP
Invasive or noninvasive
CVP [central vanes presser]
HR
PAC:[pulmonary arterial catheter] high risk-to-
return ratio, so only used on most complicated
patients
Allows monitoring of
CO[cardiac out put]/cardiac index
Pulmonary arterial pressure
Pulmonary capillary wedge pressure
Pulmonary vascular resistance
Systemic vascular resistance
17
18. ECG detects the voltage difference at the body
surface and amplifies and displays the signal.
Provides useful information about ischemia,
arrhythmias, electrolyte imbalance and drug
toxicity.
Electrocardiogram (ECG)
18
24. ABP = CO X SVR
Arterial pressure is affected by changes in
the volume status of the patient, vasomotor
tone and cardiac output.
BP is maintained by physiological
compensation in the face of changes in blood
volume and CO
Arterial Blood Pressure
24
25. If BP is inadequate then tissue perfusion will
be inadequate.
Furthermore, in critical illness autoregulatory
mechanisms in vascular beds such as the
brain and kidney may become impaired and
perfusion to these organs will be pressure
dependent.
Flow to tissues is crucially dependent on mean
blood pressure.
BP contd
25
26. Indirect methods of measuring blood pressure
include palpation, auscultation and
oscillotonometry.
Direct arterial pressures can be recorded by
inserting a cannula in the radial, femoral or
dorsalis paedis artery and connecting it to a
zeroed and alibratedc transducer which
converts pressure energy into electrical
signals.
BP cnt
26
27. BP should be taken in an hourly basis in ICU
patients but can be taken more frequently or
less frequently depending on patient
conditions
27
28. include the assessment of a patient’s heart
rate, pulse quality, CRT[catode ray tube], skin
color and temperature
Hemodynamic Monitoring
28
29. Monitoring of all the fluid given and its
adequacy
. Blood transfusion monitoring
. RBC transfusion monitoring
. UOP[urine out put] monitoring
. Tissue perfusion monitoring
Infusion monitoring
29
30. Blood volume
Neonate- 85-90ml/kg
Children and adolescents-70-80ml/kg
Adult- 60-70ml/kg
30
31. Blood loss estimation
Clinical findings- V/S, CRT[capilary refilig test],
mental state, urine out put, response to IV fluids,
level of Hct …
Amount and speed of blood loss- socked towels
and swabs, contents of suction machine, inspection
of the surgical area
31
32. Monitoring the transfused pt
….
● Skin: tem, capillary refill
● Renal system: increased urinary output
● Vital signs: PR, BP , RR, Temp.
● CNS: improved level of consciousness
● Equipments functionality monitoring
32
33. Kidney functions
Filtering and excretion of wastes
Regulates fluid and electrolyte composition
Renal failure is noted by
BUN increases of 10 to 15 mg/dl/day
Creatinine increases of 1 to 2.5 mg/dl/day
Urine volume reflects renal perfusion
Oliguria <400 ml/day in average-sized adult
Anuria occurs with <50 ml/day
Monitoring Renal Function
33
34. UOP is a very useful guide to the adequacy of
cardiac output, splanchnic perfusion and renal
function.
Patients on transfusion, cardiac patients,
patients on diuretics therapy need closer and
frequent UOP monitoring
Urine Output
34
35. Patients should be catheterized and their
hourly urine out put should be documented
Normally UOP
1- 1.5ml/kg/hr For child
0.5-1ml/kg/hr For Adult
35
36. liver performs the important functions of
synthesis, storage, metabolism and excretion of
toxic products.
Damage to the liver may not obviously affect its
activity because of a considerable functional
reserve.
Consequently, tests of liver function alone are
insensitive indicators of the degree of liver
disease and indicators of cell damage are
frequently used instead , for example
measurement of hepatic enzymes.
HEPATIC SYSTEM
36
37. Respiratory Monitoring
- is all about monitoring of ventilation and
oxygenation.( i.e removal of C2O and tissue
oxygenation or delivery of oxygen.)
37
38. Respiratory monitoring con’d
It can be monitored through
P/E
Laboratory (ABG analysis)
Pulse oximetry
Capnography,
Transcutaneous blood gas monitoring
38
39. Physical Exam
Observation:
Rate of breathing
Effort of breathing (accessory muscle usage)
Depth of breathing
Rhythm of breathing
Auscultation:
wheeze;
stridor;
air entry;
crackles;
39
40. Pulse Oximetry
Pulse oximetry is a noninvasive monitoring technique used to
estimate the measurement of arterial oxygen saturation
(Sao2) of hemoglobin (also measures pulse rate).
Oxygen saturation is an indicator of the percentage of
hemoglobin saturated with oxygen at the time of the
measurement .
The reading, obtained through pulse oximetry, uses a light
sensor containing two sources of light (red and infrared ) that
are absorbed by hemoglobin and transmitted through tissues
to a photodetector.
40
41. Pulse Oximetry - Mechanics
Light source is applied to an area of the body
that is narrow enough to allow light to traverse
a pulsating capillary bed and sensed by a
photo detector
Each heartbeat results in an influx of oxygen
saturated blood which results in increased
absorption of light
Microprocessor calculates the amounts of
HgbO2 and reduced Hgb to give the saturation
41
42. Typical pulse oximeter sensing
configuration on a finger
Probes for fingers and ear lobes are commonly used
42
43. Functional vs Fractional
Pulse ox yields functional saturation
Ratio of HgbO2 to the sum of all functional
hemoglobins (not CO-Hgb)
Sites filled/sites available for O2 to stick
Fractional saturation measured by co-
oximetry by blood gas analysis
Ratio of HgbO2 to the sum of all
hemoglobins[hgbo2 and hgb co2]
43
44. Saturation (SpO2) and PaO2
Saturation PaO2
100 100+
95 75
90 60
75 40 (mixed venous blood in pulm.
artery) 60 30
50 27 (Hb P50 point)
Very rough rule – PaO2: 40,50,60 for Sat.:
70,80,90
44
46. Pitfalls and Limitations
Margin of error is +/- 4% at Sao2 95%
Margin of error is upto 15% at SaO2 <70%
Does not measure arterial oxygen (PaO2)
46
47. Is not a substitute for arterial blood gas
Spo2= O2Hb+COHb
SPO2>90%even with COHb 70%
Low perfusion e.g. low cardiac output
Extreme anemia
47
48. A pulse oximeter gives no information on any of
these other variables:
•The oxygen content of the blood
•The amount of oxygen dissolved in the blood
•The respiratory rate or tidal volume i.e.
ventilation
•The cardiac output or blood pressure
48
49. Capnography
Used to monitor ventilation by measuring
amount of expired c2o in the expired gas
Two form or type of analyser
49
50. Capnography – Sidestream or
Mainstream
The monitor may be placed directly in line with
the patient's breathing system or a constant
sample of gas can be diverted to the
capnometer (this is known as a sidestream
analyser).
Sidestream devices are lighter and more
flexible, but have a slower response time of 1–
2 s, and some gas mixing occurs so that the
measured values of CO2 may be slightly less
than in mainstream monitors.
50
51. While capnography is a direct measurement of
ventilation in the lungs, it also indirectly measures
metabolism and circulation.
For example, an increased metabolism will increase
the production of carbon dioxide increasing the ETCO2.
A decrease in cardiac output will lower the delivery of
carbon dioxide to the lungs decreasing the ETCO2.
51
52. Normal Values
ETCO2 30-45 mm Hg is the normal value for capnography.
The normal wave form appears as straight boxes on the
monitor screen:
52
53. Waveform Explained
A to B is post inspiration/dead space exhalation,
B is the start of alveolar exhalation
B-C is the exhalation upstroke where dead space gas mixes with lung
gas
C-D is the continuation of exhalation, or the plateau(all the gas in
alveolar now, rich in C02)
D is the end-tidal value – the peak concentration, D-E is the inspiration
washout
53
54. Abnormal Values
ETCO2 Less Than 35 mmHg =
"Hyperventilation/Hypocapnia"
Ph Increases (Alkalosis)
ETC02 Greater Than 45 mmHg =
“Hypoventilation/Hypercapnia"
PH Decreases (Acidosis)
Simply put, A number less than 35 means the patient is
being ventilated too fast, and a number higher than 45
means the patient is ventilated too slow and is becoming
acidotic.
54
55. Common indications
INTUBATED APPLICATIONS:
• Verification of ETT placement
• ETT surveillance during transport
• CPR: compression efficacy, early sign of ROSC (retun
of spontaneous circulation), survival predictor
NON-INTUBATED APPLICATIONS:
• Bronchospasm: asthma, COPD, anaphylaxis
• Hypoventilation: drugs, stroke, CHF, post-ictal
• Shock & circulatory compromise
• Hyperventilation syndrome: biofeedback monitor
55
56. Verifying Tube Placement
Continuous end-tidal CO2 monitoring can confirm a
tracheal intubation. A good wave form indicating the
presence of CO2 ensures the ET tube is in the trachea.
You're out (missed the chords).
You have proper placement!
56
57. Extra Tips
ETCO2 can be the first sign of return of spontaneous
circulation (ROSC). During a cardiac arrest, if you see
the CO2 number shoot up, stop CPR and check for
pulses.
End-tidal CO2 will often overshoot baseline values when
circulation is restored due to carbon dioxide washout
from the tissues.
In a resuscitated patient, if you see the stabilized
ETCO2 number significantly drop in a person with
ROSC, immediately check pulses. You may have to
restart CPR.
57
58. Normal Values
ETCO2 30-45 mm Hg is the normal value for capnography.
The normal wave form appears as straight boxes on the
monitor screen:
58
59. DISLODGED ETT: Loss of
waveform, Loss of ETCO2
reading
CPR: “Square box” waveform;
baseline CO2 = 0; ETCO2 = 10-
15 mm Hg (possibly higher) with
adequate CPR
Management: Change rescuers if
ETCO2 drops < 10
ROSC: As in CPR, but ETCO2
rises above 10-15 mm Hg
Management: Check for pulse
59
60. “ SHARKFIN” (Slanting and prolonged phase 2 and
increased slope of phase 3 ) with/without prolonged
expiration = Bronchospasm (asthma, COPD, allergic
rxn)
Esophageal intubation:
Small CO2 spikes
Hypoventilation: low RR, gradually increases ETCO2
values > 45 mmHg with normal base line
RISING BASELINE = Patient is rebreathing CO2:
Rebreathing producing gradual elevation of base line and
ETCO2 values
Management: Check equipment for adequate oxygen inflow, allow
intubated patient more time to exhale
60
61. Sustained hyperventilation: high RR; shortened
waveform; baseline ETCO2 = 0; ETCO2 < 35 mm
Hg
PATIENT BREATHING AROUND ET TUBE:
angled, sloping downstroke on waveform
Adult: Broken cuff or tube is too small
Pediatric: tube is too small
Onset of hyperventilation: results in gradual
lowering of ETCO2 values.
61
62. Transcutaneous monitoring
Mainly used in infants (NICU,
PICU)
Measures O2 and CO2 diffusing
through the skin
Relies on the oxygen content of
capillary blood
agrees well with arterial blood
pO2 when tissue perfusion is
adequate, but not in states of
hypoperfusion
measured by heating skin
locally to dilate capillaries
The heat emitted by the
electrode may cause areas of
redness on the skin. Hence, the
site of placement of the sensor
needs to be changed regularly.
62
64. What is an ABG
Arterial Blood Gas
Drawn from artery- radial, brachial, femoral
It is an invasive procedure.
Caution must be taken with patient on
anticoagulants.
Arterial blood gas analysis is an essential part
of diagnosing and managing the patient’s
oxygenation status, ventilation failure and acid
base balance.
64
65. COMPONENTS OF THE ABG
pH: Measurement of acidity or alkalinity, based on the hydrogen (H+)
7.35 – 7.45
Pao2 The partial pressure oxygen that is dissolved in arterial blood.
80-100 mm Hg.
PCO2: The amount of carbon dioxide dissolved in arterial blood.
35– 45 mmHg
HCO3
: The calculated value of the amount of bicarbonate in the blood
22 – 26 mmol/L
N B.
The base excess indicates the amount of excess or insufficient
level of bicarbonate. -2 to +2mEq/L
(A negative base excess indicates a base deficit in blood)
SaO2:The arterial oxygen saturation.
>95%
65
66. Neurological monitoring
Can be monitored thought
Checking mentation of the patient (check PPT)
Calculating GCS or APVU
And invasively using
EEG
Transcranial Doppler
Cerebral Oximetry
ETC
66
67. GLASGOW COMA SCALE
Eye opening 4 eyes open spontaneously
3 open to speech
2 open to pain
1 no opening
Verbal response 5 orientated
4 confused
3 inappropriate words
2 incomprehensible sounds
1 no speech
Motor response 6 obeys commands
5 localizes to pain
4 flexion
3 decerbrate/abnormal flexion
2 decorticate/ abnormal
extension
67
68. References
Recommendations for standards of monitoring
during anesthesia and recovery 4th edition
Halstead, D., Progress in pulse oximetry—
a powerful tool for EMS providers. JEMS,
2001: 55-66.
WWW. GOOGLE.COM
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