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