Hemodynamic monitoring Flashcards
What is considered to be an early indicator of cellular dysfunction?
Respiratory rate and quality. the rate and depth of respirations will initially increase in response to cellular hypoxia
What should respiratory assessment include
rate,
depth,
regularity,
and sound
How long should respiratory rate be counted?
over a full minute as critically ill women may have irregular or labored breathing
A normal respiratory rate is usually between
12 and 20
tachypnea
is greater than 18/20
bradypnea
less than 12
How are pulse ox useful?
they can provide a useful continuous view of trends and responses to (or need for) oxygen therapy, and can act as an indicator of a deterioration in condition
a normal reading for a pulse ox is?
greater than 95%
What affects accuracy of a pulse ox?
shivering, dark nail polish, false nails, or poorly-fitted probe
tachycardia
pulse over 90
bradycardia
pulse under 60
Observations of the peripheries can assess?
color and warmth
mottled/pale, cold, and/or clammy peripheries may indicate what?
poor perfusion
abnormal warmth and/or flushing may indicate?
excessive dilation perhaps caused by sepsis
what could affect examination of capillary refill?
edema
Performing capillary refill
the woman’s hand is elevated to the level of her heart (or slightly higher) and her finger nail or finger tip is pressed on for 5 seconds. the blanching should disappear within 2 second release
a delayed response of capillary refill is?
more than 2 seconds
a delayed response in capillary refill suggests?
poor peripheral perfusion (can be influenced by poor lighting or cold temperature)
What is considered the first indicator of infection or sepsis
An increased temperature
