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Mar: Sem 3 - Principles I (Full) > Exam 1 Clinical Monitoring Part 1 [6/6/24] > Flashcards

Exam 1 Clinical Monitoring Part 1 [6/6/24] Flashcards

1
Q

AANA Monitoring Standards for Oxygenation

A
  • Clinical Observation (watch your patient for chest rise and fall)
  • Continuous Pulse Oximetry
  • ABG’s as indicated

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2
Q

AANA Monitoring Standards for Ventilation

A
  • Auscultation
  • Chest excursion (rise/fall of chest)
  • ETCO2 documentation
  • Pressure monitors as indicated
  • Monitor RR q 5 mins [in practice q3min]

CEAP’M Ventilated

S2

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3
Q

AANA Monitoring Standards for Cardiovascular System

A
  • Electrocardiogram [its okay to have just the pulse OX as long as its showing the HR continuously]
  • Auscultation as needed
  • BP and HR documentation q 5 mins

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4
Q

AANA Monitoring Standards for Thermoregulation

A
  • When clinically significant changes in body temp are anticipated or suspected
  • Continuous monitor of temperature in cases longer than 20 minutes, pediatric cases, or elderly patients.
  • in children, we set the OR to be warm bc they lose body heat very rapidly compared to adults

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5
Q

AANA Monitoring Standards for Neuromuscular System

A
  • When neuromuscular blocking agents are administered.
  • TOF are charted q 15 mins

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6
Q

Additional means of monitoring depends on the needs of ?

A
  • patient, surgical technique, or procedure

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7
Q

If not charting monitoring standards, what must be done?

A
  • Omission with reason must be charted

S3

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8
Q

Name factors that will cause the Hb dissociation curve to shift left

A

Left:
* Alkalosis
* Hypocarbia
* Hypothermia
* Decreased 2,3 DPG
* COHb
* Fetal Hb

Right shift = ↓ Hb affinity to O2.
Left shift = ↑ Hb affinity to O2*

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9
Q

Name factors that will cause the Hb dissociation curve to shift right.

A

Right
* acidosis
* hypercarbia
* hyperthermia
* Increased 2,3 DPG

Right shift = ↓ Hb affinity to O2.
Left shift = ↑ Hb affinity to O2

S5

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10
Q

How low can a healthy normal adult patient’s PaO2 decrease before:
* their O2 saturation drops below 90%?
* their O2 saturation drops below 75%?
* their O2 saturation drops below 50%?

A
  • PaO2 can decrease to 60 mmHg before O2 saturation drops below 90%.
  • PaO2 can decrease to 40 mmHg before O2 saturation drops below 75%
  • PaO2 can decrease to 27 mmHg before O2 saturation drops below 50%

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11
Q

Light through matter
is ______, ______, or _____.

A

Transmitted, absorbed, or reflected

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12
Q

Upon what law of physics is pulse oximetry based?

A
  • Beer-Lambert Law

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13
Q

What is the beer-lambert law?

A
  • Law of absorption
  • Relates the transmission of light through a solution to the concentration of the solute in the solution
  • Light absorption must be measured at wavelengths that are proportional to the number of solutes

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14
Q

Explain how concentration of a solute affects light absorption in pulse oximetry.

A
  • Amount of light absorbed is proportional to the concentration of the light absorbing substance (Beer’s Law)
  • Higher Hb concentration, more light absorption

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15
Q

Explain how distance affect light absorption in pulse oximetry.

A
  • Amount of light absorbed is proportional to the length of the path that the light has to travel in the absorbing substance (Lambert’s Law)
  • Wider arteries, more light absorption

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16
Q

What were the four species of Hb in adult blood discussed in lecture?

A
  • Oxyhemoglobin (O2Hb)
  • Deoxyhemoglobin (deO2Hb)
  • Methemoglobin (metHb)
  • Carboxyhemoglobin (COHb)

S8

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17
Q

What is sulfahemoglobin?

A
  • Sulfahemoglobin is not normally present in the body.
  • Made from oxidation of iron in the body usually from drugs.

S8

Most common etiology of sulfhemoglobinemia is the use/misuse of sulfur-containing medications such as AZO

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18
Q

What is considered the gold standard for SaO2 measurements and is relied on when pulse oximetry readings are inaccurate or unobtainable?

A
  • CO-oximetry
  • instead of looking at 2 wavelengths like a pulse ox it looks at 4 wave lengths.

S8

pulse ox is inaccurate with COhb [will show higher than normaly] so this is the gold standard.

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19
Q

All types of hemoglobin are read at 940 nm except?

A
  • Carboxyhemglobin

S8

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20
Q

The wavelength of red light

A
  • 660 nm

S9

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21
Q

The wavelength of infrared light

A
  • 940 nm

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22
Q

__________ absorbs more infrared light.

___________ absorbs more red light.

A
  • Oxyhemoglobin (O2Hb) absorbs more infrared light than deoxyhemoglobin
  • Deoxyhemoglobin (deO2Hb) absorbs more red light than oxyhemoglobin
  • SeXy DARLing:
    SiX hundred wavelength, DeoxyHb Absorbs Red Light.

S9

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23
Q

Pulsatility of arterial blood flow estimates _____

A
  • SaO2

S10

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24
Q

Light is transmitted through

A
  • Skin
  • Soft tissue
  • Venous blood
  • Arterial blood
  • Capillary blood

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25
Q

Ratio of AC and DC light absorption

  • Pulsatile expansion of the artery ____ length of light path which _____ absorbency
  • Pulsatile component divided by?
A
  • Pulsatile expansion of the artery increases length of light path which Increases absorbency
  • Pulsatile component divided by non-pulsatile component for each wavelength

S10

AC= alternating current = pulsatile
DC=direct current = non-pulsatile

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26
Q

Schematic of the Pulse Principle.

A
  • Light absorption through tissue is characterized by a pulsatile component (AC) and a non-pulsatile component (DC).
  • The pulsatile component of absorption is due to arterial blood. The non-pulsatile component is due to venous blood and the remainder of the tissues.
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27
Q

____ absorbs as much light in the 660 nm range as oxyhemoglobin does. What is the clinical relevance?

A
  • Carboxyhemoglobin
  • Falsely elevates SpO2

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28
Q

What patients are we concered about with in regards to carboxyhemoglobin?

A
  • Pts who have been in fires
  • Carbon monoxide poisoning.

S11

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29
Q

Each 1% increase in COHb will increase SpO2 by _____%.

A
  • 1%

S11

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30
Q

Many smokers have > ______% of COHb.

A
  • 6%

S11

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31
Q

What factors cause signal artifacts in pulse oximetry?

A
  • Ambient light: Usually solved by alternating red/infrared
  • Low perfusion: Signal amplitude reduced
  • Venous blood pulsations: Detection of venous O2Hb sat, results in reduction of presumed arterial SpO2
  • Additional light absorbers (methylene blue/IV dyes)
  • Additional forms of Hb
  • Nail polish

NAAALV

S12

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32
Q

Advantage of Pulse Ox

How accurate is pulse oximetry when measured against ABGs as long as the patient’s O2 saturation is >70%?

A
  • Pulse oximetry’s accuracy is within 2% of an ABG.

S13

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33
Q

List advantages of pulse oximetry. (Long list, common sense)

A
  • Accurate/ Convenient
  • Not affected by anesthetic vapors
  • Noninvasive
  • Continuous
  • May indicate decreased cardiac output
  • Tone modulation
  • Probe variety (Ear probe)
  • Battery-operated
  • Economical

S13

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34
Q

List disadvantages of pulse oximetry. (Long list, common sense)

A
  • Poor function with poor perfusion
  • Delayed hypoxic event detection
  • Erratic performance with dysrhythmias
  • Inaccuracy with different hemoglobin (COHb)
  • Inaccuracy with dyes
  • Optical interference
  • Nail polish and coverings
  • Motion artifact

S14

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35
Q

Useful Tips

Fingers are relatively sensitive to ________

A
  • vasoconstriction

S15

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36
Q

Useful Tips

Useful tips to take into consideration about SPO2:
* Fingers are relatively sensitive to ____
* Dark polish or synthetic nails ____ transmission
* Detection of desaturation and resaturation is ____ peripherally
* Should not be placed on ____ _____.
* ____ may be more reliable with epidural blocks
* _____, _____, _____ less affected by vasoconstriction, reflects desaturation quicker

A
  • Fingers are relatively sensitive to vasoconstriction
  • Dark polish or synthetic nails inhibit transmission
  • Detection of desaturation and resaturation is slower peripherally
  • Should not be placed on index finger
  • Toes may be more reliable with epidural blocks
  • Tongue, Cheek, Forehead less affected by vasoconstriction, reflects desaturation quicker

S15

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37
Q

Useful Tips

Why shouldn’t the pulse oximeter be placed on the index finger?

A
  • ↑ risk of corneal abrasion
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38
Q

Where will you place a pulse oximeter for the most accurate reading during an epidural block?

A
  • Toes

Toes will be more dilated than fingers with an epidural block.

S15

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39
Q

What three parts of the body are least affected by vasoconstriction and will reflect desaturation quickly?

A
  • Tongue
  • Cheek
  • Forehead

S15

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40
Q

Most indirect methods of blood pressure measurement utilize a sphygmomanometer.

What is the series of audible frequencies produced by turbulent flow beyond the partially occluded cuff called?

A
  • Korotkoff sounds

S17

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41
Q

Describe the phases of the Korotkoff sounds.

During what phase will you hear SBP and DBP?

A
  • Phase I: the most turbulent/audible (SBP)
  • Phase II: softer and longer sounds
  • Phase III: crisper and louder sounds
  • Phase IV: softer and muffled sounds
  • Phase V: sounds disappear (DBP)

2-cheese pull, 3 lays chip, 4 brownie

S17

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42
Q

Give the formula to calculate MAP

A
  • MAP = DBP + 1/3 (SBP - DBP)

s17

43
Q

What factors will limit BP auscultation?

A
  • Decrease peripheral flow (shock/vasoconstriction)
  • Changes in vessel compliance (atherosclerosis, severe edema)
  • Incorrect cuff size
  • Obesity
44
Q

What is the best way to measure BP in pediatric patients?

A
  • Use the automatic NIBP

S18

45
Q

Blood pressure cuff bladder should should be ____% of arm circumference and _____ % of length of upper arm.

A
  • Blood pressure cuff bladder should should be 40% of arm circumference and 80% of length of upper arm.

S18

46
Q

What method is used by many automatic NIBP devices to measure blood pressure non-invasively.

A

Oscillometry
* The maximal amplitude of oscillations = MAP
* SBP and DBP calculated from algorithm
* SBP – the least agreement with invasive BP

Automatic NIBP correlates well with invasive BP in healthy pts.

S19

47
Q

What factors will cause errors in automatic NIBP resulting in low SBP and high DBP?

A
  • Atherosclerosis
  • Edema
  • Obesity
  • Chronic HTN

S19

48
Q
  • What will be the result of a BP reading if the patient’s BP cuff is too large?
  • What will be the result of a BP reading if the patient’s BP cuff is too small?
A
  • Large cuff = falsely low BP
  • Small cuff = falsely high BP

S19

49
Q

For standards of automatic NIBP they must be within how many mmHg?

A
  • +/- 5 mmHg

Deviations up to 20 mmHg are acceptable

S20

50
Q

What part of the arm is preferable in obese patient when measuring their BP? What should the clinician be aware of in this pt?

A
  • Forearm
  • Overestimating SBP; underestimating DBP

S20

51
Q

What are the problems with estimations for automatic NIBP?

A
  • Underestimate MAP during hypertension
  • Overestimate MAP during hypotension
  • Underestimating SBP; overestimating DBP

Averaging/trending is necessary for measurements to be reliable

S20

52
Q

What are advantages of automatic NIBP?

A
  • Eliminate clinician subjectivity
  • Improved quality and accuracy
  • Automaticity [helps reduce white coat syndrome]
  • Noninvasive

S21

53
Q

What are disadvantages of automatic NIBP?

A
  • Unsuitable in rapidly changing situations
  • Patient discomfort
  • Complications

S22

54
Q

What complications can arise from automatic NIBP?

A
  • Compartment syndrome
  • Pain
  • Petechiae and ecchymoses
  • Limb edema
  • Venous stasis and thrombophlebitis
  • Peripheral neuropathy

PPP.com Very Late

S22

55
Q

Caution use of automatic NIBP in:

A
  • Severe coagulopathies
  • Peripheral neuropathies
  • Arterial/venous insufficiency
  • Recent thrombolytic therapy

S22

56
Q

List indication for invasive BP monitoring [arterial line]

A
  • Continuous, real-time
  • Planned pharmacologic manipulation
  • Repeated blood sampling
  • Determination of volume responsiveness
  • Timing of balloon pump counterpulsation

S23

57
Q

Arterial monitoring sites

A
  • Radial [Most common site, Easy to access, Complications uncommon]
  • Ulnar
  • Brachial
  • Axillary
  • Femoral
  • Posterior tibial
  • Dorsalis pedis

S24

58
Q

What test is used to assess collateral blood flow to the hands before radial arterial line placement.

If there is good circulation, how long before color returns?
> how many seconds indicates severely reduced collateral flow?

A
  • Allen’s Test
  • Good circulation: Color returns <5 seconds
  • > 10 seconds indicate severely reduced collateral flow

Predictive value of this test is poor

S25

59
Q

Describe the Seldinger technique for arterial placement.

A
  1. insert the needle
  2. pass guidewire through needle
  3. Remove needle
  4. Insert catheter

S27

60
Q

Describe the Transfixion technique for arterial placement.

A
  • Front and back walls are punctured intentionally
  • Needle removed
  • Catheter withdrawn until pulsatile blood flow appears and then advanced
61
Q

When placing an arterial line, the needle should enter at a _______ degree angle (range) to the skin directly over the point at which the pulse is palpated.

A
  • 30 to 45 degrees

S26

62
Q

What is used to prevent thrombus formation in an arterial line?
Fluid lacks ____ or ____

A
  • 1-3 ml/hr automatic NS flush (pressure bag)
  • dextrose or heparin

S29

63
Q

What does zeroing an arterial line do?

A
  • The measuring system must also be zeroed to obtain accurate data.
  • References pressure against atmospheric air

S29

64
Q

Where is the arterial line leveled?

A
  • Aortic root (mid axillary chest)

S29

65
Q

How can the waveform of an arterial line be maximized?

A
  • Limit stopcocks
  • Limit tube length
  • Use non-distensible tubing (hard tubing)

Short hard cocks

S29

66
Q

Label parts 1-6 of the arterial waveform.

A
  • 1: systolic upstroke
  • 2: systolic peak pressure
  • 3: systolic decline
  • 4: dicrotic notch (closing of the aortic valve)
  • 5: diastolic runoff
  • 6: end-diastolic pressure

SBP is measured at 2 and the DBP is measured at 6.

S30

67
Q

As the pressure wave moves to the periphery, what happens to the:

  • Arterial upstroke
  • Systolic Peak
  • Dicrotic notch
  • End Diastolic pressure
A
  • Arterial upstroke will be steeper
  • Systolic Peak will be higher
  • Dicrotic notch will appear later
  • End Diastolic pressure will be lower

S31

68
Q

What causes the difference in morphologies of arterial pressures measured at different sites?

A
  • Impedance and harmonic resonance along the vascular tree

S31

69
Q

What two waves make up a typical pressure wave (summation wave)?

A
  • Fundamental wave
  • Harmonic wave

S32

70
Q

What is the square wave test?

A
  • The arterial line can measure BP inaccurately unless properly calibrated.
  • Rapidly flushing the line generates a square wave.
  • Counting 2 or less oscillations after the square wave indicates that the arterial line works properly.
  • The amplitude of each oscillation should be no greater than 1/3rd of the previous osscilation

S32

71
Q

Describe an under-dampened arterial waveform.

A
  • Systolic pressure is falsely high
  • diastole pressure is underestimated.
  • MAP is accurate.
  • > 2 oscillations
  • Multiple dicrotic notches/ artifacts

S34

72
Q

Describe an over-dampened arterial waveform

A
  • Systolic pressure is falsely low
  • Absence of dicrotic notch
  • Loss of detail
  • Falsely narrowed pulse pressure, but accurate MAP
  • Fails to oscillate normally

S34

73
Q

What factors affect pressure gradient changes in arterial waveforms?

A
  • Age: lack of distensibility
  • Atherosclerosis
  • Peripheral vascular resistance changes
  • Septic shock
  • Hypothermia

S35

74
Q

Compare the arterial waveforms between a normal young person and an elderly person.

A
  • The elderly patient will have an ↑ SBP & decreased DBP
  • The elderly patient will be a widened Pulse Pressure
  • This is due to the decrease in distensibility in the elderly patient

S35

75
Q

List arterial line complications.

A
  • Distal ischemia or pseudoaneurysm
  • Hemorrhage, hematoma (hold pressure longer)
  • Arterial embolization (Art line staying in too long)
  • Local infection
  • Peripheral neuropathy

S36

76
Q

Cyclic arterial BP variations d/t respiratory-induced changes in intra-thoracic pressure are related to what two factors?

A
  • Positive pressure ventilation
  • Lung volume changes

S37

77
Q

During the EARLY inspiratory phase of PPV, the increase in intrathoracic pressure simultaneously ____ LV afterload while ____ total lung volume, which displaces blood from the pulmonary venous reservoir forward into the left side of the heart and _________ LV preload.

A

During EARLY the inspiratory phase of PPV, the increase in intrathoracic pressure simultaneously decreases LV afterload while increasing total lung volume, which displaces blood from the pulmonary venous reservoir forward into the left side of the heart and increases LV preload.

Miller pg. 1167

S38

78
Q

During the EARLY inspiratory phase of PPV, the increase in LV preload and decrease in afterload produce an increase in what three variables?

A
  • ↑ LV SV
  • ↑ CO
  • ↑ Systemic arterial pressure

Miller pg. 1167

S38

79
Q

Rising intrathoracic pressure impairs systemic venous return and RV preload; this will ____ RV afterload by slightly ____ pulmonary vascular resistance. These effects combine to reduce RV ejection during the early phase of inspiration.

A

Rising intrathoracic pressure impairs systemic venous return and RV preload; this will increase RV afterload by slightly increasing pulmonary vascular resistance. These effects combine to reduce RV ejection during the early phase of inspiration.

Miller pg. 1167

S38

80
Q

What happens to RV stroke volume during the early phase of inspiration?

A
  • RV SV drops

S38

81
Q

During the expiratory phase, the decreased stroke volume ejected from the RV during inspiration travels through the pulmonary vascular bed and enters the left heart, reducing what three variables?

A
  • ↓ LV filling
  • ↓ LV SV
  • ↓ Systemic arterial pressure

S40

82
Q

The cycle of increasing and decreasing stroke volume and systemic arterial blood pressure in response to inspiration and expiration is known as _________________.

A
  • Systolic pressure variation (SPV).

S40

83
Q

In mechanically ventilated patients, normal SPV is __________ mmHg (range).

A
  • 7-10 mmHg

S41

84
Q

What is a normal Δ up SPV?

A
  • 2-4 mmHg

S41

85
Q

What is a normal Δ down SPV?

A
  • 5-6 mmHg

S41

86
Q

What does an increased SPV indicate?

A
  • Patient may be volume responsive or have residual preload reserve
  • Possible early indicator of hypovolemia
  • Critically ill patients will have an increased SPV with a drastic Δ down component.

S41

87
Q

This variable is used as a dynamic indicator of preload reserve by utilizing the max and min pulse pressure over the entire respiratory cycle.

A
  • Pulse Pressure Variation

S42

88
Q

What is considered a normal pulse pressure variation?
A PPV > than this indicates what?

A
  • < 13 -17%
  • PPV >13 - 17% will indicate a positive response to volume expansion*

S42

89
Q

PPV formula

A

[difference in arterial pulse pressure] / [ Average of Max and Min pulse pressure]

S42

90
Q

The changes in stroke volume between the inspiratory and expiratory phases of positive pressure ventilation.

A
  • Stroke Volume Variation

S43

91
Q

How do you calculate SVV?

A

(SV max - SV min) / SV mean

S43

92
Q

What is normal SVV?

A
  • 10-13%

SVV >10-13% indicates a positive response to volume expansion.

S43

93
Q

SVV uses computer analysis of arterial pulse pressure waveforms and correlates resistance and compliance based on what two factors?

A
  • age
  • gender

S43

94
Q

Mechanical ventilation should have a tidal volume of ______ (range).

A
  • 8-10 mL/kg

S44

95
Q

To predict accurate results of residual preload reserve through SPV, PPV, and SVV, what factors need to be met in mechanically vented patients?

A
  • Tidal volume of 8 to 10 mL/kg
  • Positive end-expiratory pressure ≥ 5 mm Hg
  • Regular cardiac rhythm
  • Normal intra-abdominal pressure
  • A closed chest
  • can also be altered by pt position: L lat or trendelenburg not accurate

Miller pg. 1168

S44

96
Q

What is the importance of the Frank-Starling Law?

A
  • Left ventricular filling determines the left ventricular end-diastolic volume (LVEDV), which is generally directly proportional to left ventricular preload and CO.
  • The Frank–Starling Law describes the relationship between LVEDV and CO.
  • According to the Starling Law, CO increases with increasing left ventricular preload.

S45

97
Q

Which artierial line monitoring site is the most common site and easy to access with complications being uncommon?
what kind of complication is most common with arterial lines?
What are the 6 other sites?

A

Radial artery
hematoma
ulnar, brachial, axillary, femoral, posterior tibial, and dorsalis pedis

S24

98
Q

Describe the process of performing an Allen’s test

A

Patient makes a tight fist (which exsanguinates the palm)
patient opens hand
examiner releases ulnar artery and observes the return of color

S25

99
Q

Allen’s test is only ____ % accurate for color change at ____ seconds.
T/F
Pulse oximetry and ultrasound improve the accuracy.

A

80%
5 seconds
False! doesnt improve accuracy

S25

100
Q

T/F
The transfixion technique is associated with more frequent complications

A

False, it is not associated with more frequent complications

S28

101
Q

____ to ____ harmonics are required for most arterial pressure waveforms.

A

6-10

S32

102
Q

____ ____ is the analysis of the summation of multiple sine waves

A

Fourier Analysis

S32

103
Q

In order to calculate accurate results for SVV, PPV, and SPV, the patient must be ____ ____

A

Mechanically ventilated

S44

Mar: Sem 3 - Principles I (Full) (29 decks)

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