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PATIENT MONITORING
BYDr: Moatez Abdella
Senior registrar Anesthesia
What is monitoring? to monitor Physiologic parameter & Patient safety parameter Clinical skills & Monitoring equipments Data collection, interpretation, evaluation, decision Problem seeking, Severity assessment,
Therapeutic assessment.
ADVANTAGES OF MONITORING
Monitoring level of consciousness reduces morbidity and mortality rate.
The gold standard role is to avoid adverse drug responses and if detected and should be treated in a timely manner i.e., before the development of RESPIRATORY AND CARDIOVASCULAR complications
So standard and consciousness level monitoring {at least} are vital
BLOOD PRESSURE OXYGENE SATURATION HEART RATE END TIDAL CO2 ? STANDARD
TEMPERATURE? MONITORING
WHAT ARE THE ANTICIPATED COMPLICATIONS
Mainly RESPIRATORY and CARDIOVASCULAR no ventilation in the face of open airway
central depression
obstruction partial complete snoring no ventilation
gasping no breathing crowing noise
Respiratory
WHAT ARE THE ANTICIPATED COMPLICATIONS
Cardiovascular bradycardia
hypotension
hemodynamic in stability
WHO IS MONITOR THE PATIENT? The patient must be monitored by a practitioner
who is not directly assisting the patients care procedure.
The practitioner should immediately report to the physician any unexpected response by the patient.
Monitoring in the Past Visual monitoring of
respiration and overall clinical appearance
Finger on pulse Blood pressure
(sometimes)
Examples of Multiparameter Patient MonitorsExamples of Multiparameter Patient Monitors
Recording of Monitored Parameters (1) before the beginning of the procedure (2) after administration of sedative medications analgesic agents at 1-2 min interval (3) at regular intervals ( 5-min) during the procedure (4) every 15 min after at least 30 min after last dose (5) just before discharge to PACU
Monitoring Level of Consciousness Pt. Response to commands/light tactile stimuli
should be frequently assessed using the patient sedation scale eg RSS{Ramsay sedation score}.
One sedation scale should be applied in all hospital Document the patient’s level of consciousness at
least every 15 minutes AND inform the doctor about any bad events
Conscious level monitoring Ramsay sedation scale (RSS)
1 Anxious, agitated or restless
2 Cooperative, oriented and tranquil
mild sedation 3 Responds to commands only
4 Asleep brisk response to glabellar tap or loud auditory stimuli moderate
5 Asleep sluggish response to glabellar tap or loud auditory stimuli sedation
6 No response deep sedation (by anesthesiologist only)
RSS DISCUSSION HOW TO ASSESS ??? Check if the patient is
AWAKE? OR SLEEP
restless?
RASS 1 RSS 1 RSS 3 RSS 2
AgitatedAnxiousrestless
CalmCo-operative
communicative
Respond quickly
to voice command
RASS DISCUSSION HOW TO ASSESS ??? Check if the patient is SLEEP RSS 4 RSS 5
RSS 6
If the patient response
is slow to loud stim
ulus
Or glabellar tap
Sluggish
response
No response
Cardiovascular monitoring Baseline measurements and recordings
are required. Routine monitoring
Cardiac activity Non-invasive blood pressure ( NIBP ) concern the suitable sizeNon-invasive blood pressure ( NIBP ) concern the suitable size Monitor for hypotension and extremes of BPMonitor for hypotension and extremes of BP Electrocardiography ( ECG )Electrocardiography ( ECG ) monitor for heart rate, arrhythmia and myocardial monitor for heart rate, arrhythmia and myocardial
infarctioninfarction
Respiratory monitoring Ventilatory monitoring Oxygenation monitoring
Clinical skills and monitoring devices are required
Monitoring Respiration Respiration
Baseline assessment made & recorded prior to administration of drugs and at least every 15 minutes thereafter.
Note and record respiratory rateContinually observe for adequacy of
spontaneous ventilation/airway patency.Auscultate; Watch the chest rise & fall!May utilize capnometry
Ventilatory monitoring Clinical skills
Direct observation: rate, rhythm, volume of respirationAuscultationPalpation.
Pulmonary ventilationCapnography, measurement of end tidal carbon
dioxide (35-45 mmhg)may be useful in prolonged cases
Ventilatory monitoring Capnogram : normal curve
1. Dead space air (no CO2)2. Mixed bronchus & alveolus air (CO2 upstroke)3. Alveolus air (CO2 plateau)
Inspiration ETCO2
12
3
Monitoring & Oxygen Administration Hypoxemia more likely to be detected by pulse oximeter Oxygen saturation should be recorded prior to
administration of supplemental oxygen & prior to initiating sedation. Pulse oximeter tone should be in the “on” position.
Oxygen should be administered to all patients undergoing sedation.
PLEASE don’t ignore change of alarm tone
Emergency Equipment A number of items must be immediately
available & operational before undertaking procedural sedation.Supplemental monitorsBasic & advanced airway management
equipment IV supplies Emergency drugsDefibrillator
Monitoring & Equipment It is the responsibility of the person
monitoring the patient to ensure that the following items are present & operational prior to initiating conscious sedation:Source of oxygen & suctionSuction cathetersNasal cannula, simple face masks, & blow-by
sets for oxygen deliveryPulse oximeter & probesB/P machine /manometer and cuffsEKG machine and/or stethoscope.
MonitoringThe person monitoring the patient can not have additional
assignments.Physiological monitoring is the only way to ensure that patients
get the supportive treatment they need.The following need to be monitored in some or all patients: Heart rate and oxygenation—should be continuously
monitored by pulse oximetry. Respiratory rate--& pulmonary ventilation should be
continuously monitored Blood pressure—should be measured at regular intervals. ECG—should be monitored:
MCQ
The number one monitor is comprised of
_ the patient and the nurse monitor_ blood pressure and pulse oximetry_ EKG and pulse oximeter_ blood pressure and ventilator