COMPS+CLINIC:FINAL: Unit 3: Lines and Tubes in Acute Care Flashcards
1
Q
Ex’s of NON-invasive monitoring equipment
A
- EKG/Telemetry/Holter
- PulseOX
- BP machine
- EKG w/ RR
- Temp monitor
- Electroencephalogram (EEG)
2
Q
Cardiac monitoring
Arterial Line
fun fact about this…..
A
Restricts joint mvmt***
3
Q
Cardiac monitoring
Arterial Line
2 Functions:
A
- Continuously measures arteral BP—SBP/DBP (MAP)
- Allows access for drawing blood for ABG
4
Q
cardiac monitoring
Arterial Line
LOCATION
A
Radial aa
Femoral aa
5
Q
cardiac monitoring
Arterial Line
*talk about Positioning
A
POSITIONING for arterial line transducer is IMPORTANT***
*needs to be moved BEFORE pt if hanging
MUST STAY ABOVE RT. ATRIUM
6
Q
Arterial Line
Ex. Radial Artery
A
see pics
7
Q
PRECAUTIONS for Arterial Line
A
- Transducer for Arterial line shoud be pos’d @ lvl of Rt. Atrium—-> assures accurate pressure values
- Transducer LOW== HIGHER BP
- Transducer HIGH == LOWER BP
-
**if A-line dislodged—–apply pressure and notify nursing
- Maintain SLACK on line to prevent dislodge
- DO NOT let pt FLEX/EXT wrist to prevent aa damage
8
Q
A-Line Transducer Pos’ing
If too LOW
A
HIGHER BP
9
Q
A-line Transducer pos’ing
Transducer too HIGH
A
LOWER BP
10
Q
Cardiac monitoring
Swan-Ganz cath/Pulm aa cath
EASIEST WAY TO RECOGNIZE IT
A
ITS YELLOW****
11
Q
Swan Ganz cath/Pulm aa cath
Gets ALL PRESSURES of heart EXCEPT….
A
SBP
12
Q
Swan Ganz cath/Pulm aa cath
Measures hemodynamic status in critically ill cardiac pts
What does this include??
A
- Pulm Cap Wedge Pressure (PCWP)
- pts w/ pulm edema OR pulm HTN
- Left atrial and Ventricular End-diastolic pressures
- Central venous pressure (CVP)
- CO
13
Q
Cardiac Output
HR*SV===
A
amt. of blood pumped by the heart per unit of TIME
14
Q
Swan Ganz Cath/Pulm aa cath
computes Cardiac Index
what is this?
A
Cardiac Index
- CO per sq meter of body surf area
-
SHOULD BE 3 OR >
- IF <2.1====Acute heart failure or cardiogenic shock
15
Q
Swan Ganz cath/ pulm aa cath
allows IV access for what?
A
Medication admin AND obtain mixed venous blood gases
16
Q
Swan Ganz/Pulm aa cath
Dx if using this:
A
Pulm edema OR Pulm HTN
LV heart failure
RV failure
17
Q
Swan Ganz Cath/Pulm AA cath
Route/Pic
A
see below
18
Q
Swan Ganz Cath
Has a balloon…what should you remember about this balloon???
A
NEVER see pt when balloon is Inflated
*Stops blood flow
19
Q
Swan Ganz Cath and various pressures it reports:
A
- Balloon inflated== PCWP
- Prox Port in R. Atrium==CVP
- PCW==LAP
- ALL GIVES CO
20
Q
Possible Complications of the PA Cath (Swan Ganz)
*remember its YELLOW!!!
A
- Comps of insertion and dislodgement of the PA Cath (swan ganz):
- Malignant arrhythmias
- Pulm aa rupture
- Pulm valve tear
- Infection
- ****if mobility is essential——need EXP’d clinician only AFTER pt is det’d hemodynamically stable
21
Q
Green Light
Yellow Light
Red Light
ALL DEFINED
A
see pics
KNOW THIS!!!
22
Q
Cardiovascular Considerations
Pulm aa cath (swan ganz) OR other continuous cardiac output monitoring devices
In-bed vs. Out-of-bed
A
IN BED====GREEN
OUT-OF-BED===YELLOW (CAUTION
23
Q
CARDIAC monitoring
Rectal Temp Monitor
A
- Typ used w/ pts who are:
- Comatose
- Intubated
- HypOthermic
- Septic w/ HypERthermia
**Goes UP IN rectum
24
Q
Cardiac monitoring
Trans Venous Pacemaker
A
- TEMP PM for the heart post-sx
- @ risk for arrhythmias W/OUT an underlying arrhythmia
- DO NOT MAKE TAUT
- goes thru diaphragm
- SA component vs. AV component—-has BOTH
25
Transvenous PM
GREEN light vs. YELLOW vs. RED
**Dependent rhythm vs. Stable rhythm**
* **DEPENDENT RHYTHM----**PM does EVERYTHING, pot. to go into arrhythmia
* IN-BED**==YELLOW**
* OUT-OF-BED**==RED**
* **STABLE RHYTHM**
* IN-BED**==GREEN**
* OUT-OF-BED**==GREEN**
26
CARDIAC MONITORING
**Automatic Implantable Cardiac Defribrillator**
**AICD**
* TEMP Defribillator ----\> **Life Vest**
27
PERMANENT PM'S and
AICD (Automated Implantable Cardiac Defrib.)
**Sx placed WHERE**
UNDER **Left Clavicle**
## Footnote
**\*ALWAYS LEFT**
28
INTRA-Aortic Balloon Pump
## Footnote
**IABP**
* Assists w/
* **Circulation of blood**
* **Reduces O2 consumption**
* **PT Imps** for **mobilizing pts on IABP**
* ****Femoral
* Axilla
* **\*CAN ALSO BE A PM**
* ****CA perfusion
* Pacing
* SV
29
Intra Aortic Balloon Pump
IABP
**Inflation/Deflation**
**INFLATES** during **Diastole ----CA perfusion**
**DEFLATES** during **Diastole-----pumps blood OUT**
30
**Femoral IABP**
**IN-BED vs. OUT-OF-BED EX'S**
* IN-BED====**GREEN LIGHT**
* OUT-OF-BED===**RED LIGHT**
31
Cardiac monitoring
## Footnote
**Ventricular Assistive Device**
**VAD**
Augments the **pumping capability** of the Heart
32
Ventricular Assistive Device
VAD
**2 types:**
1. **LVAD**
1. ****L.Vent Assistive Device
2. **BiVAD**
1. ****Bilateral Vent Assist Device
* **Dx:**
* **NON-reversible _End-Stage HF_**
33
2 Reasons for **Receiving VAD**
1. **Bridge to Transplant**
1. ****NON-reversible **L. HF** and MUST be candidate for transplant
2. **Destination Therapy _Criteria_===**No hope _outside_ LVAD
1. NYHA Class 4
2. **Failed optimal med mgmt 40/60 days**
1. ****IABP \>7days OR IV Inotropes 14days
3. **LVEF \<25%**
4. **VO2 \<14 OR _unable to perform_ due to IABP, inotropes**
34
Ventricular Assistive Device
VAD
**PT Imps:**
* Keep **MAP b/w 60-80 (LOWER end)**
* **\*\*NORM==80-90**
* **MAP--\>** avg. PRESS in pts **arteries** during **one cardiac cycle**
* **BEST** indicator of **perfusion to vital organs**
* Take BP w/ **doppler (like ABI)**
* ALL **anticoagulation precautions----bleed risk**
* **Tx BALANCE \*\*\*\***
35
VAD MACHINE
* \*\*REMEMBER **ONLY GETS MAP**
* ****NO **systole**
* NO **diastole**
* NO **pulse**
* **BECAUSE NO SYSTOLE\*\*\***
36
VAD
**IN BED vs. OUT-OF-BED EX'S**
* IN-BED====**GREEN LIGHT**
* OUT-OF-BED===**GREEN LIGHT**
37
Neurological Monitoring
\***Usually looking @ ICP**
**Ex. SHUNT**
Before vs. After Shunt
38
**What should you ABSOLUTELY REMEMBER about pts w/ INCd ICP???**
DO NOT LAY THEM DOWN FLAT!!
## Footnote
**Flat OR Trendelenberg INCs ICP\*\*\***
39
Neurological monitoring
## Footnote
**ICP monitoring**
**Dx (who?)**
* Pts w/ **severe brain injury OR s/p _cranial sx_**
40
Neuro Monitoring
## Footnote
**ICP monitor**
**Values (value of ICP)**
* NORMAL: **0-10 (adults)**
* **KEEP \<20mmHg for** **_Mobility_**
41
Neuro monitoring
## Footnote
**ICP monitoring**
**PT Imps:**
* \*HOB _must be_ \>20degs **w/ ICP monitor**
* HOLD activities that can cause an **INC in ICP**
* **\*\*\*REMEMBER**
* **NEVER LAY THEM FLAT**
* **Flat or Trendelenberg INCs ICP\*\*\*\***
42
Neuro Monitoring
**ICP monitor**
**Ventriculoperitoneal Shunt/VP Shunt**
**INTRAVENTRICULAR CATH**
**AD vs. DISAD**
* ADVANTAGES
* **allows for BOTH _monitoring_ and for _therapeutic drainage of CSF_ to _reduce ICP_**
* DISADVANTAGES
* **Risk for _infection_ bc Invasive**
43
Neuro Monitoring
## Footnote
**ICP monitoring**
**Subarachnoid Screw**
**ICP BOLT**
**AD vs. DISAD**
* ADVANTAGES
* **relatively Easy to install**
* DISADVANTAGE\*\*\*
* **Accuracy LESS than _ventriculostomy drain_ w/ HIGHER ICP and _lack of CSF drainage_ if needed**
44
Neuro monitoring
**ICP monitoring**
**EPIDURAL SENSOR**
**AD** **vs. DISAD**
* ADVANTAGES
* **LESS invasive: epidural lining is not perforated**
* DISADVANTAGES
* **LACK of CSF drainage if needed**
45
ICP Monitoring
## Footnote
**Ventriculoperitoneal Shunt**
**VP shunt**
**Intraventricular Catheter**
**Defined :**
Catheter placed thru a **burr hole** into the **lateral ventricle**
46
ICP Monitoring
## Footnote
**Subarachnoid Screw**
**ICP Bolt**
\*Hollow screw inserted thru **burr hole** drilled into **Dura mater (OUTERMOST LAYER)**
47
ICP Monitoring
## Footnote
**Epidural Sensor**
* **Sensory device** placed thru a **burr hole** just over the **epidural covering**
48
VP shunt
see pics
49
ICP Monitoring
**_Active mgmt of intracranial HTN_**
**ICP NOT in Desired Range**
**IN-Bed vs. OUT-of-Bed**
IN-BED===**RED**
OUT-OF-BED===**RED**
50
ICP MONITORING
## Footnote
**ICP Monitoring _W/OUT active mgmt of Intracranial HTN_**
**IN-BED vs. OUT-OF-BED**
* IN-BED===**GREEN** (**w/ HOB elevated \>20degs)**
* OUT-OF-BED===**YELLOW (Caution)**
51
Pulmonary monitoring
## Footnote
**Chest Tubes:**
**2 Functions**
1. Used to remove fluid from **pleural** OR **mediastinal space** w/ a **hemothorax, pleural effusion, OR pus in pleural space**
2. Provide **intrapleural pressure** in a **pneumothorax**
1. ****CLOSED PRESSURE
1. GREATER PRECAUTIONS\*\*\*
52
EX:
**Chest Tube for a _L. Sided Pneumothorax_**
\*\*\***Makes a _Closed System_**
see pics
53
Refresher\*\*\*\*
## Footnote
**Serosanguinous**
Blood + Edema (fluid)
54
Chest Tube Precautions
## Footnote
**Effective Mobilization**
For **Effective Mobilization:**
* ****Ensure pt is **premedicated for pain**
* ALWAYS keep chest tube drainage system **BELOW chest lvl**
* Check for air leaks
* ALWAYS discuss w/ Dr or Nurse BEFORE disconnecting **suction**
* Portable suction may be used when indicated
* AFTER chest tube **removed**---HOLD THERAPY until **radiography R/O _Pneumothorax_**
* __see pt BEFORE tube removed
* NEVER KNOCK OVER THE filter system (usually on floor next to bed)
55
Pulmonary monitoring
## Footnote
**Extracorpeal Membranous Oxygenation**
**ECMO\*\*\***
* **External circulatory assist** device that provides **direct oxygenation** of the blood AND **assists w/ removal of CO2**
* **\*\*SUSTAINS LIFE\*\***
56
3 Methods of **Mechanical Ventilation**
1. Nasal pharyngeal tube
2. Oral ET tube ----**short-term**
3. Tracheostomy tube---**long-term (3d-3wks)**
57
ECMO
**IN-bed vs. OUT-of-Bed**
* IN-BED===**GREEN**
* OUT-OF-BED===**YELLOW (CAUTION)**
58
RESP CONSIDERATIONS
**Intubation**
* **ET Tube**
* **Tracheostomy Tube**
**IN-bed vs. Out-of-Bed**
* BOTH IN-BED and OUT-OF-BED===**GREEN**
59
Vascular Monitoring
**_CENTRAL LINE_**
**Triple Lumen Cath**
**"Triple" why?**
Jugular
Subclavian
Femoral
60
CENTRAL LINE
## Footnote
**Triple Lumen Catheter**
see pics
61
**Delayed Risks Assoc'd w/ Central Venous Access**
* Infection
* Cath fx
* Cath dislodge
* Cath occlusion
* Air in Cath
62
Renal monitoring
## Footnote
**Hemodialysis**
**How OFTEN ?**
@ LEAST 3x/week
63
Renal monitoring
**Hemodialysis**
**Replaces** function of Kidneys
64
Renal monitoring
## Footnote
**Hemodialysis**
**2 entry options:**
1. **Arteriovenous fistula**
1. **\*AVOID using arm when measuring BP**
2. **Hemodialysis catheters---\> Permacath**
65
**Hemodialysis**
**2 Types:**
* HD--**3x/week**
* CVVHD--**more stable bc _constant_**
66
**HD**
**Hemodialysis**
* 3x/week if **end-stage kidney failure**
* **2hr pd of time**
* **5-8L fluid removed in 2hrs**
* **Pts WILL BE EXHAUSTED!!!**
67
CVVHD
## Footnote
**Continuous**
**\*ONLY ICU---\> Critically ill and cannot tolerate dialysis**
**IN-BED vs. OUT-OF-BED**
**\*NOTE:** TAKE BP FREQ'LY\*
* **IN-BED====GREEN**
* **OUT-OF-BED===GREEN**
68
What should you **ABSOLUTELY REMEMBER about NG tube feeding?**
NO LYING FLAT W/IN **30MINS OF NG TUBE FEEDING\*\*\***
69
GI Monitoring
## Footnote
**SHORT-TERM**
**NG Tube**
**Nasogastric**
* Tube: **nostril--\> stomach**
* oral meds and temp feeding
* **short-term gastric suctioning**
* **EX:** Dubhoff tube
* mouth taped off
70
GI monitoring
SHORT-TERM
**IV Fluids or Feedings**
**"Tube Feedings"**
see pics
71
GI Monitoring
**LONG-TERM**
**All PERMANENT---Sx implanted**
**3 types**
1. Gastrostomy Tube **(GT Tube)**
2. Percutaneous Endoscopic Gastrostomy Tube **(PEG Tube)**
3. Jejunostomy Tube **(J Tube)**
72
Rectal Monitoring
**SHORT-TERM**
**Rectal Tube**
smells
Not fully secure
73
Rectal monitoring
## Footnote
**LONG-TERM**
**Ostomy Bag**
LONG TERM Rectal monitoring
74
Urinary Monitoring
4:
1. Foley
2. Supra-pubic
3. Texas (condom) Cath
4. \*\***Nephrostomy Tube** (NEW)
75
Urinary monitoring
**Nephrostomy Tube**
* RIGHT BEFORE **Loop of Henle**
* **renal aa into kidneys**
* **takes OUT fluids**
76
Integumentary Invasive Monitoring Equipment
WOUND VAC
77
ALL OTHER DRAINS AND TUBES
IN-BED vs. OUT-OF-BED
NG
Central Venous Cath
Pleural Drain
Wound Drain
Intercostal Cath
Urinary Cath
**IN-BED and OUT-OF-BED===GREEN**
78
EQUIPMENT FOR **DVT PREVENTION**
## Footnote
**2:**
1. Sequential Compression Device (**SCD Stockings)**
1. **Intermittent compression**
1. **Timed squeezes**
2. TEDs
79
What can go on **SUCTION**
## Footnote
**suction attached to wall**
**OR chest tube tower**
* 1. NG tube to **suction**
* **bile/poop**
* 2. Chest tube to **suction**
* **ALL PNEUMOTHORAX _MUST BE_ ON SUCTION\*\*\***
* 3. ET Tube or Tracheostomy w/ **suction**
80
