Physiologic Monitoring
what is the protocol for CPT (chest/cardiac PT) including tendelemberg position?
- 15 minutes as long as the ICP os <25mmHg an the CPP is >50mmHg (if patient has stable and continual ICP's- maybe eligible for CPT) -always check w MD first
what are the two types of tracheal tubes
- Endotracheal tubes (ET-T): oral/nasal - Tracheostomy tube (trach): Cuffed, cuffless/ fenestrated, nonfenestrated/ metal and plastic
ICU monitor:
- Green: ECG (78b/min). Normal is 60-90b/min - Red: A-line with the MAP, (BP-129/58 and MAP is 79). Normal blood pressure is 120/80 mmHg and MAP is between 60-110 with normal being 92 - CVP: central Venus Pressure- (9). Normal is 2-8 ccmH2) or 2-6mmHg - Blue: Intracranial Pressure (19mmHg). normal is 0-10mmHg for adults and 0-5mmHg for children - Purple: Sp02 (100) Normal being between 97-98
some alarms to be considered with ventilator are: (2)
- High pressure: airway blocked, tension pneumothorax, or more likely coughing - Low pressure: disconnected from vent, air leak
what are some activities that may increase ICP
- Isometric exercise - Valsalva maneuver - Extreme hip flexion - coughing - prone lying - head positions below 15 degrees - horizontal or HOB<30 deg - Occlusion of the tube - Pain
what are some concerning findings which may lead to intubation:
- RR > 30/min - inability to maintain arterial O2 saturation >90% with O2(FiO2)>0.60 -PacO2>50mmHg (aveolar ventilation) with pH<7.25. - 50/50 rule: MV is indicated if a patient's PaO2 falls below 50mmHg and the PaCO2 raises above 50mmHg
ventilators are set to deliver:
- a constant value (volume cycled) - a constant pressure (pressure cycled) - a combination of both with each breath ----- you will also see pressure regulated or volume regulated -----
what are pulse oximeters
- a sensitive detector of early hypoxemia
in a fenestrated trach, what should be done prior to suctioning?
- an inner cannula without an opening in the posterior wall should be inserted and the cuff inflated prior to suctioning
what are the most commonly modes of mechanical ventilation are:
- assisst-control or continuous mandatory ventilation (A/C, CMV) - synchronized intermittent mandatory ventilation (SIMV) - pressure support ventilation (PSV)
Where are chest tubes inserted?
- between the fourth and fifth intercostal space at the midaxillary line for fluid - they are interested in the second intercostal space at the midclavicular line for a pneumothorax - ideally the placement should be lateral to avoid discomfort when lying supine and sitting
how does ECMO work?
- blood is removed and the CO2 is removed from the blood - RBC's are oxygenated
(CVP catheters) are used to gain information about:
- cardiac function - vascular volume
temporary placemaker implications for PT (3)
- clarify all orders for therapy with MD who place the pacemaker - traction on lead by flexion of UE could pull lead out of position - coughing may cause lead displacement
what are some triple lumen catheter (TLC) PT implications?
- defer PT until STAT CXR conforms correct line placement and rules out pneumothorax - continue to defer therapies pending further orders if pneumothorax is ruled in
a hemo cath allows for dialysis in ESRD patients when: (2)
- fistula/ graft heals - if permanent access is clotted
(CVP catheters) what are some ways in which the waveform can be affected?
- fluctuates with respiration - decreased with spontaneous inspiration - increased with positive pressure respiration
what is a risk for oral ET-T
- if secured with tape to avoid expulsion it can cause wounds
when are chest tubes indicated?
- indicated following thoracic trauma, cardiothoracic surgery, or injury and disease when excess fluid or air is present - indicated for hemothorax, pneumothorax, bronchopleural fistula, empyema, and mediastinal fluid
what are the risks of a temporary pacemaker?
- infection (systemic or at insertion site) - arrhythmias - myocardial perforation - cardiac tamponade (fluid between heart and pericardium) - pneumothorax (collapsed lung) - pulmonary emboli (blood clot stock in lung artery) - pacing wire displacement - bleeding/hematoma at insertion site - displacement
what is the purpose of a triple lumen catheter (TLC)
- it provides 3 separate catheters contained in one sheath for infusion of meds, nutrition, and blood products - allows blood withdrawal
what do CVP catheters reflect?
- it reflects changes in the cardiovascular system - directly reflects right atrial pressure - indirectly right ventricular end diastolic pressure
why is the radial artery the most common site for A-line
- least discomfort - allows freedom of motion - does not require joint immobilization - associated with low risk of ischemic injury to the heart
what are some PICC risks
- mechanical phlebitis (Venus wall inflammation) - infection - Venus thrombosis - catheter embolus (free piece of catheter)
other functions of pulmonary artery catheters are: (5)
- meds are administered -pulmonary artery pressures are measured - mixed Venus blood samples are drawn - CVP is measured - Q is measured
the basics of ventilator support include: (3)
- modes - settings - alarms
the specificity of pulse oximeters is limited by:
- motion artifact - ambient light - skin pigmentation - nail polish - low tissue perfusion - vasoconstriction - anemia: false/high readings occur - improper probe placement - dysrhythmias including A-fib
what is the placement for a temporary pacemaker?
- pacing wire is inserted transvenously through subclavian or internal jugular vein into right atrium or right ventricle
what is the implantable port placement?
- percutaneous placement into superior vena cava or right atrium via subclavian or internal jugular vein -portal is placed over 3rd or 4th ribs
where us a hemo cath inserted?
- percutaneously into subclavian internal jugular, or femoral vein - catheter is sutured in place
where are chest tubes placed
- placed in the pleural or mediasinal cavity to remove excess fluid or air
what are some hemo cath risks?
- pneumothorax - hemothorax - air ebolism (air enter artery) - bleeding --- retroperitoneal hemmorrhage at femoral insertion site
what are implantable port risks
- pneumothorax - infection -venus thrombosis - catheter migration - hemothorax (blood between chest Wall and lung) -cardiac dysrhythmias
what are some triple lumen Cather risks
- pneumothorax (collapsed lung) - embolization - vessel and tissue damage - hemorrhage - infection - catheter displacement by patient or staff during movement, turning or raising/lowering bed rails
all breaths are mandatory and delivered by the vent at a:
- present volume or pressure - breath rate - inspiratory time
what may a femoral sheath be used for? any contraindications?
- sheath may be used for procedures such as cardiac cath or angiogram - strict immobilization of hip contraindication for PT
how is a triple lumen catheter inserted?
- the placement is performed at bedside - catheter (TLC) is inserted percutaneously into the superior vena cava through the subclavian, external jugular, or internal jugular vein or into the femoral vein of the lower extremity
what are A-lines used for
- they are used to draw blood samples - to monitor arterial blood pressure to maximize drug therapy - used when vasopressor therapy is anticipated (blood vessel constriction)
what are the purposes of tracheal tubes
- to access the upper airway in those with upper airway obstruction - to permit easier, safer suctioning - enables mechanical ventilation - airway protection
what are some complications that might present with tracheal tubes
- ulceration - erosion/scarring - fistula - laryngeal/ vocal chord damage - infection - airway obstruction - dislodgment or extubation of the trach
descrive endotracheal tubes (ET-T)
- used for short term management of the airway -generally no longer than 7-10 days - if inserted into the oral cavity, the patient cannot eat solid food
fenestrated trach are used to:
- used to assess a patient's readiness for extubation and permit speech as gases pass through the fenestration and vocal chords
ECMO has two basic configurations which are:
- ventroarterial: provides cardiac or cardiopulm support - vevo-venous: provides respiratory support only
what are the two main types of ICP monitors?
-EVD (external ventricular drain), also drains CSF -Bolt
what are indications for neurologic monitoring devices?
-Glasgow Coma Scale of </= 8 - Reye's syndrome - cerebral hemmorage - space occupying brain lesions
what is pulmonary artery wedge pressure?
-indicative of left atrial and left ventricular end diastolic pressures -an integrated measurement of the compliance of the left side of the heart and pulmonary circulation
what are normal ICP pressures?
0-10 mmHg with the head of the bed elevated (30 degrees)
what does a normal intracranial pressure waveform look like, and what is the mean range?
0-15 mmHg
right atrial pressure waveform (CVP) has a mean of:
0-8mmHg
normal systolic arterial pressure is
100-130 mmHg
pulmonary artery pressure waveform, normal systolic:
15-32 mmHg
cuff pressure should remain below:
25 cmH2) to minimize ischemic damage of the tracheal mucosa
how many peaks does the normal ICP waveform have?
3
most drainage containers have ___ compartments, and they are:
3 - under-water-seal drainage - a collecting chamber for air or fluid - a suction chamber
pulmonary artery wedge pressure. normal mean range:
4-12 mmHg
pulmonary artery pressure waveform, normal diastolic:
4-13 mmHg
normal mean arterial pressure is
60-110 mmHg, average is 92 mmHg
what is a normal CPP
60-80mmHg,- but can shift to right or left depending upon the physiology of the person
normal end diastolic arterial pressure is
60-90 mmHg
A SpO2 of 90% corresponds to a PaO2 of:
60mmHg
pulmonary artery pressure waveform, normal mean:
9-19 mmHg
what is done to confirm TLC placement?
A STAT CXR (chest x ray) is performed to confirm placement and to rule out pneumothorax
what PT can be administered to patient tolerance
C/S ROM and prone positioning
in mechanical ventilation you will generally start with a ____________ and after 7-10 days you will have a ____________
E-T tube, tracheostomy
what is the purpose of a temporary pacemaker
Electrically stimulates myocardium to control or maintain heart rate
is pain related to the size of the tube?
False
how can the CPP be calculated
MABP-ICP (mean arterial blood pressure - intracranial pressure)
what is the equation for MAP (mean arterial pressure)
MAP={(2 x DBP) +SPB}/3 *DBP: diastolic *SBP: systolic
why should mechanical ventilation be discontinued at the earliest possible time
MV can have life-threatening complications
Can you mobilize a patient with a femoral sheath? How about a shiley?
Not with a femoral sheath but yes with a shiley
with ICP patients when should PT be performed?
PT interventions after a rest is better tolerated by the patient
what is TPN
Total parenteral nutrition (TPN) is a method of feeding that bypasses the gastrointestinal tract. formula though veins w nutrients
(A-line) what may air bubbles or blood clots in the tubing cause
a dampened waveform
what happens when the CPP dips below 50mmHg?
a decrease in tissue perfusion occurs and a prolonged cerebral perfusion pressure (CPP) below 40mmHb is inadequate to support brain function
in a peripheral arterial catheter the catheter is connected to
a flush device and transducer
what information do neurologic monitoring devices provide
all provide information regarding brain function to minimize secondary complications and maximize outcomes following a brain insult
in order to avoid displacement of TLC catheter, you want to:
allow slack in lines before moving patient
before moving the patient with a PICC a PT must:
allow slack in lines before moving patient to avoid displacement
air bubbles except in the suction chamber are indicative of:
an air leak and may indicate a bronchopleural fistula
invasive hemodynamic monitoring allow direct measurement of:
arterial blood pressure central Venus pressure intracardiac pressures pulmonary artery pressures
what is the most common mode mode of invasive hemodynamic monitoring (HDM)
arterial pressure monitoring via an indwelling peripheral catheter
where are trachs inserted
below the vocal cords, usually between the third and fourth tracheal rings
if a PICC is in place do not take __________________ in the extremity
blood pressure
where is the peripherally inserted central line catheter PICC inserted
catheter is inserted percutaneously usually into a vein in the antecubital fossa
what are CVP catheters?
central venus pressure catheters
what is CPP?
cerebral perfusion pressure, the driving pressure of blood to the brain
for patients connected to wall suction, and portable suction units, in order to mobilize you must first:
check w the MD
what ate some hemo cath implications for pt **neck site**
clarify orders for UE ROM with physician who placed catheter
in order to ROM an extremity with a PICC a PT must:
clarify orders with MD
what are some hemo cath implications for PT **femoral site**
clarifying order for LE ROM, transfer training, OOB (out of bed), ambulation with physician who placed catheter
what are some complications with peripheral arterial catheters
complication of continuous arterial pressure monitoring include: - ecchymosis (skin discoloration stained by blood) - hematoma - soreness
what is CVVHD
continuous veno-venous hemodialysis
hemodynamic monitoring contributes to:
diagnosis of the patients underlying condition and can be useful in predicting prognosis --devices are usually sutured in place
what are some other sites for an A-line?
dorsalis pedis, femoral, and brachial artery
with low perfusion and vasoconstriction problems, the probe (pulse ox) can be placed on the:
ear
what does ECMO mean?
extracoporeal membrane oxygenation
pulse ox signals are more easily detected using a ___________ than a ___________probe
finger, forehead
how Is the placement of a hemo cath verified
followed up with a chest X-ray before the catheter is used
what can be used to warm the extremity (pulse ox placement)
friction
ICP devices help in:
guiding the therapeutic intervention to decrease ICP and maximize cerebral perfusion
pulmonary artery catheters are used to detect
heart failure, sepsis, pulmonary edema
as a PT working with a patient w a neck insertion TLC you want to avoid:
hypertension of the neck during bed mobility, positioning, and suctioning procedures (for neck insertion sites)
what is the insertion of the temporary pacemaker facilitated by?
insertion is facilitated by direct visualization with fluoroscopy or by the use of standard ECG
when the breath is patient triggered it is referred to _______________. when the vent delivers the breath it is _________________
intermittent mandatory ventilation IMV, synchronized intermittent mandatory ventilation SIMV.
what is the primary tool used in the management of acute brain insult?
intracranial pressure monitors (ICP)
what does SIMV allows or requires the patient to do?
it allows or requires the patient to sustain some of the work of breathing if the RR is set low.
what can the normal autoregulatory ability of the individual compensate for? (ICP)
it can only compensate for modest fluctuations in these volumes (0-10 mmHg)
where is the swan ganz inserted
it is inserted though the right atrium, right ventricle, and passed into the pulmonary artery
what is mechanical ventilation used for?
it is used as a life saving intervention for those in respiratory failure. it is used to improve pulmonary gas exchange during acute hypoxemic or hypercapnic respiratory failure with resoiratory acidosis * hypercapnic: elevation of arterial carbon dioxide tension
during ambulation, where might the transducer be moved to? (A-line)
it may need to be moved to a pole
what's the purpose of an implantable port?
it provides vascular access for patients requiring repeated infusion of drugs, TPN, blood product and other fluids
what what level should the transducer be placed? (A-line)
it should be placed at the level of the right atrium
what oes SIMV deliver?
it will deliver a minimum number of fully assisted breaths per minute. the volume of the unassisted breathes are determined by patient's strength, effort and lung mechanics. they can breath at their own rate as well
you want to avoid ___________________ the tube
kinking
what would happen is the SIMV is set high
little or no spontaneously breathing will occur
most tracheal tubes have a ___________________ that is inflated during mechanical ventilation
most tracheal tubes have a low-pressure cuff that is inflated during mechanical ventilation - check with the nurse if the cuff is deflated when you see the patient
PICC is also able to eliminate complications of ________________
neck/chest insertion
precautions with femoral A line include:
need to check with the MD first before ambulation or sitting, some o not allow any hip flexion with the line in place
does pulse oximeter report absolute measurements?
no, it is a trend indicator
can a neurologic monitoring devise locate the lesion?
no, they will only indicate a worsening lesion when the pressure increases
what must a PT do before changing the height of the bed?
notify the nurse!
where are ICP devices usually placed?
on the injured side of the brain
when does artery wedge pressure waveform appear
once the PA catheter's ballon becomes wedged in a small vessel (left of this picture)
synchronized intermittent mandatory ventilation (SIMV) is a ____________ support mode
partial.
(A-line) what else can compromise the wave form?
patient movement and electrical interference
A- line is also known as
peripheral arterial catherers
what is a PICC
peripherally inserted central catheter
how is placement of PICC done?
placement is done under fluoroscopic guidance in the radiology dept.
when several tubes are necessary______________ placement might be needed
posterior
what does swan ganz calculate
preload, contractile state of the heart, afterload
what would happen if the transducer is below the right atrium? (A-line)
pressure readings will be falsely high
what would happen if the transducer is above the right atrium? (A-line)
pressure readings will be falsely low
compared with pressure support ventilation and spontaneous breathing trials, research has shown that IMV can:
prolong weaning.
what does a PICC (peripherally inserted central catheter) provide vents access for?
provides Venus access for intermediate length of time for infusion of med, nutrition (TPN), fluids of blood products
A Swan Ganz is a _____________ catheter
pulmonary
chest tube placement is confirmed___________
radiologically
Dampening or flattening of the waveform should always be:
reported to the nurse
CVP are also an important tool to monitor:
right atrial pressure to assess cardiac function and intravascular fluid status
what PT ROM can patients with central Venus pressure (CVP) and pulmonary artery (PA) have?
shoulder ROM
ROM to the ________________ is necessary with breathing exercises
shoulders
what might slight fluctuation of ICP waveform be related to?
slight fluctuations may be observed and usually correlate with respiration or blood pressure fluctuations
what does α wave demonstrate
sudden increases in ICP with peaks of 50-100 mmHg, and it correlates with a poor prognosis
chest tubes are ______________ in place and not easily _____________
sutured, dislodged
during the PT intervention with Neuro patients the therapist needs to be aware of
the CPP and the ICP
what could happen to the CVP if the right ventricular is failing?
the CVP will rise
(pulmonary artery catheters) if this waveform is noted on the monitor what should the PT do prior to intervention
the PT must inform the nurse because treating the patient may cause rupture of the pulmonary artery
erroneous values in pulse ox can be detected by:
the inappropriate heart rate
fenestrated trach have an opening in:
the posterior wall of the tube above the cuff (below vocal chord)
(pulmonary artery catheters) what is calculated during balloon inflation?
the pulmonary artery wedge pressure. - the wave is dampened (less strong)
what is the most common site for placement of an A-line
the radial artery
if there are other modes of ventilations you should ask:
the respiratory care professional about the mode and what means to the patient
where is the tip of the catheter moved into?
the superior vena cava and right atrium
where are central Venus pressure (CVP) catheters placed
they are placed in the right atrium to monitor right artrial pressure
are arterial laceration, artery-venous fistula, and false aneurysms common or rare with HDM- A-line?
they are rare
when are neurologic monitoring devices used?
they are used in the medical management of the patient with acquired brain injury
what are pulse oximeters used for
they are used to detect clinically unsuspected hypoxemia and to determine Os flow rate and necessary O2 concentrations in spontaneously breathing and mechanically ventilated patients
what do ICP monitors measure?
they measure the pressure exerted by the brain matter, blood, and CSF against the skull
what might high ICP result in?
they might result in decreased cerebral perfusion without clinical indicators
(pulmonary artery catheters) why should the ballon not be inflated for more than 15 seconds?
this can cause ischemia of the lung segment distal to the catheter, pulmonary artery injury, or rupture
if a patient can not get off A/C or CMV what does it mean?
this is generally considered a bad prognostic sign
for patients with TLC with a femoral site insertion PT needs:
to clarify orders for transfer training and out of bed with MD who place the catheter
what is a TLC
triple lumen catheter
drainage container is upright and below the level of the chest connecting the tubes to an:
under-water-seal drainage system and applying suction
a hemo cath permits for urgent_______________
urgent dialysis (acute renal failure)
what is continuous veno-venous hemodialysis CVVHD used for?
used for critically I'll patients with CRF (chronic renal failure) especially after surgery
with A/C or CMV _____________ support is provided
ventilatory
does the presence of the A-line interfere with PT treatment?
very little
SIMV is a _____________ mode. the intent is to:
weaning. - the intent is to provide respiratory muscle rest during the mandatory breaths and exercise during spontaneous breaths
when can decompensation and secondary brain injury occur? (ICP)
when a significant increase in ICP occurs (20-25), as cerebral blood flow and tissue perfusion is decreased due to issue compression
when is ECMO used?
when conventional methods for cardiac and respiratory failure are unsuccessful
when is the swan Ganz indicated
when precise measurement of a patient's hemoglobin status including CP pressures, flow, and circulating volumes are indicated
clinical signs are not always predictive of:
worsening brain injury
what are two waveforms in ICP indicative of?
worsening brain injury
can P/V percussion vibration be performed with chest tubes?
yes!
can patients connected to under-water-seal drainage be mobilized and ambulated
yes!
what does β wave demonstrate
β is a sawtooth pattern, it correlates with respiratory changes and occurs w decreasing brain compliance
