Assessment of the Critically Ill Flashcards
Goals of Care Designation-Comfort (C)
Medical care and interventions that are focused on comfort
Does not mean that you receive less care but rather that the focus on care is on comfort and relieving symptoms and not on prolonging life
Monitoring
A repeated/continuous real-time measurement
Allows for rapid detection of a change in patients condition
Should always be correlated to what you are seeing with the patient as clinical condition may not match the monitor due to errors
Monitors allow us to see the “unseen”
Principal of Monitoring: Errors in Measurement
Errors Includes-Artifact, factitious events, and instrumental drift
Parallel shift-when the difference between the reading and the true value is consistent and constant (carbyhemoglobin will result in a consistent error in the oxygen saturation that is monitored through a pulse oximeter)
Therapist Driven Protocol
Therapist-driven protocol are a set of specific actions that enable respiratory therapists to initiate and adjust therapy on their own (with guidelines set by medical staff).
This is also known as ‘respiratory care protocol’.
GI/ Nutritional Assessment
OG/NG
Gastric residual volumes
Abdominal distention
Bowel sounds
Bowel movements
Accuracy and Precision
Accuracy: How closely the measured reflects the actual value
Precision: Index of dispersion of repeated measure-how often will the machine give you the correct number
Machines with poor accuracy but good precision are not useless as we can still figure out what the real reading is based on how far off the machine normally reads
But is a machine has both poor accuracy and precision then it has to go through maintenance
Cardiovascular
Capillary refill
JVD
Pedal/Pitting Edema
Skin colour
Skin turgor
Renal Assessment
Urine output/colour/concentration
Fluid Balance
Droplet Precautions
Need to apply droplet precautions when you are within 3 feet/ 1 meter of the patient
Need to wear a mask
Non-Patient Assessment
Maintenance of the current patient interventions and/or bedside equipment
Airway maintenance HME change, check ventilator circuit, suction equipment, calibration of monitors, check/stock appropriate bedside equipment
Contact Precautions
Wear gown and glove when in contact with patient or their bedding
Parellel Shift
Parallel Shift: The machine is becoming less and less accurate, which could be something like a clot developing on machine that needs to be cleared
Goals of Care Designation-Resuscitation
Medical care and intervention (ex. Medications, ventilators) including resuscitation followed by the ICU
R1: Can use any type of intervention including resuscitation and ICU care
R2: Can use any type of intervention including resuscitation, intubation and ICU care but excluding chest compression
R3: Can use any type of intervention including resuscitation and ICU care but excluding chest compression and intubation
Background Information Should Include
Patient history
Major clinical events
Current clinical status
Current orders
Patient care
Principal of Monitoring: Risk vs. Benefit
The most useful tests have little or no risk and high potential value. (e.g. Pulse oximeter), but there is a small risk in incorrect measurement
Hemodynamics, specifically PAC has high risks and high potential value. New tech (pico) is allowing us to obtain similar high value information with less risk.
There often is nearly complete trust in a digital value displayed but the monitor may be displaying an incorrect value
Dispersion Error
The machine needs to go through maintenance as there is no pattern as to what the error is
Principal of Monitoring: Calibration
Calibration: To check, adjust or determine by comparison with a standard
Most monitors will use some type of calibration, as callibration will help to reduce systematic errors
E.g. FiO2 analyzers, zeroing transducers (response to pressure changes in the blood), SjvO2 monitors
Instrumental Drift
When something with the monitor need troubleshooting because it is giving a false reading but it will change once the troubleshooting is done (ex. blood gas analyzer can become coated with protein resulting in a false reading)
Newer machines will have built in calibration that will clean the machine on it’s own
Re-calibration is a standard part of trouble-shooting.
Other Systems Assessment
Clinical lab data results
Lines (insertion sites/duration)
Skin (Petechia/ecchymosis/mottling)
Skin integrity
Goals of Care Designation-Medical (M)
Medical care and interventions excluding resuscitation
Factitious Events
Values that are a real measurement but out of the normal range (e.g. airway pressure spike during a cough).
A one time event that does not accurately effect the patients true state
Principal of Monitoring: Error Patterns
If there is occasional random errors this is of minor significance and should be disregarded
Usually the operator just need to repeat the QC sampling
Increases in the frequency of error or systematic errors should be investigated
Types of error patterns accuracy, precision, dispersion error, and parellel shift
Artifact Error
The value is susceptible to variability due to non-physiologic reasons.
Something that is interfering with the measurement due to an outside force and not the physiological state of the patient
Best Monitor
Caregiver who understands the equipment, alarms and, resulting data
Initial Impression
Visual inspection of pt. and bedside monitors
Inspection in IPPA
Gather overall impression of pt. clinical status
Many prefer to do the “monitoring” of the patient before the physical exam as it will allow a collection of “baseline” data before having to disturb the patient.
The visual inspection may reveal the need for an immediate intervention (ex. Coughing/desaturation requiring suctioning etc.)
Systematic Approach in Assessment of Critically Ill
Patient Information/Background
Body systems assessment
Interpreting/Integrating
Planning/Reporting/Communicating
Documentation
Non-Patient Assessment
Non-patient assessments help to ensure that the equipment that is needed is present and that the equipment being used is functional.
Includes checking Baggers, suction, emergency equipment, etc.
Body System Approach
The assessment is typically done in a body system approach in the following order Neurology Cardio Resp GI/Renal Other Systems
Four Primary Body Systems Assessed by the RT
Neurological
Cardiovascular
Respiratory
Other Systems (e.g. GI & Renal)
Principal of Monitoring: Quality Management
- Statistical methods are used to evaluate the accuracy and precision of the measurements to ensure calibration, stability, and reliability
- Assuring clinicians that laboratory results are accurate aids to patient management.
- Accuracy of devices
- Pre-analytical errors
- Post-analytical errors
- Performance characteristics of devices
- Accuracy of devices
- For RTs this typically applies to ABG machines and to test these machines we will
- Run a QC sample with known results through the machine and compare the machines results with the expected results
- Track this over time (usually done at least once in a 24 hour period)
Diagnostics
intermittent procedures used to obtain one time information When repeatedly done can be used to see a trend CXR, CTs, Ultrasound, lab data, 12 lead ECG Pulmonary Atrial Wedge Pressure (PAWP) and Cardiac Output (CO) are diagnostic PAWP is not continuous monitored even though the balloon is always inserted as in order to obtain you have to inflate the little balloon and if that was always inflated it would block blood flow from the heart
Respirtory System Assessment
IPPA
Artificial airway/NIV interface
Bronchopulmonary hygiene
Oxygenation and ventilation
Ventilator parameters and waveforms
Routine Precautions
Gloves at a minimum
Airborne Precautions
Negative pressure room Need to wear an N95 as soon as you enter the room
Neurological Assessment
Pupils
Reflexes/Posturing
GCS
LOC
Sedation assessment (RASS)
Delirium screening (CAM-ICU)
Therapuetic Interventions
The specific medical therapies that are being used to support a body system. Often the “life-support” for that body system.
This will include pharmacological therapies
Need to consider a holistic approach as one body system will affect other system
All therapies need to continuously be monitored for their effectiveness and need.They should be assessed in order so that they can be stopped in a timely fashion
ASSESS, INTERVENE AND REASSESS
Terns and Patterns
All the results of assessments of the patient needs to be
It is important to be able to identify both trends and patterns
A trend will provide more information than just looking at a one-time data point
Patterns in the data will be looking to see if things increase together or decrease together
What is seen in the data should always be link to the patients background (anatomy, physiology, and pathology)
Patient Care Plan
The patient care plan will be developed with collaboration between all members of the healthcare team, with the RT brining recommendations on how to manage the respiratory status of the patient taking into consideration the status of the other body systems
As the patient’s clinical status changes the plan for the patients also need to be updated
Shift Report
Will happen when there change from day shift to night shift and vice versa
Will be a summary of the days events, patients status, and patient care plan
RT talking to RT in the same unit
Shift report is “one of the most powerful arenas of professional socialization and communication.”
Round Report
Will be interdisciplinary approach and lead to the physician
Ex. The RN will report on the CNS, CVS, GI, GU and the RT will report on the RESP
Will present a summarized patient information from the past 24 hours
The patients plan is modified with the holistic view of their status
Patient Transfer Status
A summary report when transferring a patient in between wards (ex. ED to ICU)
Will be communicated with RT from the different wards
Active Charting
Round reports and shift report sheets
Kardex
Notes for you to help you remember
Static Charting
Increasing use of electronic charting (EMR- Electronic Medical Records)
Paper charting is still often use in places such as ED, post-op and rural areas
Paper charting is always the back up
Policy
A principal or rule to guide decision
NOT used to denote what is actually done
What is expected of us
We don’t “blindly follow” protocols our clinical judgment should help us to know when deviations from the protocol are required, and then we get the physician involved to get specific orders.
Procedure
The steps involved in performing the patient care or therapeutic/diagnostic intervention
Tell you how to do something
Protocol
Set of orders you can work within (a guideline)
A detailed often algorithmic/outline of the step that are to be followed in the treatment of a patient that is based upon best practice and evidence
Remeber don’t blindly follow protocol and always look at the patient as a whole and other factors that may be influencing the patient
Advantage of Protocols-Better allocation of respirtory care, reduce frequency of treatment, cost savings, ensure correct treatments
Zeroing Transducers and Chinooks
Because we are always under atmospheric pressure events wuch as a Chinook will influence machines and require recalibration
Non-Invasive Versus Invasive Procedures
Non-Invasive: May or may not come in contact with body
Invasive: Placed within the body
Prognostic/ Global Indices
Derived from large clinical data sets and will provide an indication of the seriousness of the patients illness and can calculate the risk of mortality
These indices are determinants of scoers from numberous monitors (isolated observations)
Usually derived during first 24 hours from admission
These are normally used in research as clinically their usefulness is often questioned
Ex. APAHE Scoring System
Aerosol Protocol
If patient is unable to hold their breath for 5 seconds then they should be given medication with a small volume nebulizer
While monitoring patients, signals or values are susceptible to variability due to all of the following, except:
a) Artifacts
b) Factitious events
c) Instrument drift
d) Seasonal variation
d) Seasonal variation
Temporary variation in pulmonary artery pressure readings due to movement of the hemodynamic monitoring line is an example of what type of variability?
a) Artifacts
b) Factitious event
c) Physiologic variation
d) Instrument drift
a) Artifacts
You are monitoring blood pressure during mechanical ventilation of a patient with pneumonia. A temporary increase in blood pressure occurs when the patient coughs. This temporary spike in blood pressure represents what type of variability?
a) Artifact
b) Factitious event
c) Physiologic variation
d) Instrument drift
b) Factitious event
Which of the following are the reasons monitors are needed?
I. Continuous assessment
II. Analysis of vital signs
III. Measurement of values that caregivers cannot detect
I and III
Which of the following is NOT a global monitoring index?
a) APACHE
b) APS
c) TISS
d) ATS
d) ATS
Why do we monitor lung volumes and flows?
To determine the effectiveness of gas exchange across the alveolar-capillary membrane.
To identify gas exchange in the lungs, to look for a change in clinical status, to look for a response to therapy, to check for a problem with the patient interface (circuit), and to evaluate the ability to wean.
Who should be monitored for lung volumes in non-intubated patients?
Preoperative patients, those with an increased respiratory rate greater than 30/minute, those with neuromuscular diseases, CNS depressed, decorating blood gas, and those on NIV.
What are the pulmonary diseases that typically have high tidal volumes?
Metabolic acidosis, sepsis, and neurologic injuries.
What is used to assess the Ventilation?
Respiratory rate, tidal volume, chest movement, breath sounds, PaCO2, and EtCO2.
What is used to assess Oxygenation?
Heart rate, color, sensorium, PaO2, and SpO2.
What is used to assess Circulation?
Cardiac output, heart strength, and heart rate.
What is used to assess perfusion?
Blood pressure, sensorium, temperature, urine output, and hemodynamics.
What do we visually inspect during a respiratory assessment at the bedside?
General appearance, edema, clubbing, venous distention, capillary refill, diaphoresis, skin color, chest configuration, chest movement, breathing patterns, accessory muscle use, muscle conditions, nasal flaring, cough, and evidence of a difficult airway.
What are some advantages of having an art line placed?
They are very accurate, they monitor continuously, and they measure HR constantly.
What are some disadvantages of having an arterial line in place?
It is invasive, there is an increased risk of infection and bleeding, and the transducer placement affects its effectiveness.
Where should the arterial line transducer be placed?
Phlebostatic Axis = level of the heart at the 4th intercostal.
An arterial line transducer that is placed too high results in what?
False hypotension
