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ASSESSMENT OF THE CRITICALLY ILL PATIENT

Prof. Ridulme

History 4. Pulsations
1. General Data 5. Clubbing & capillary refill
2. Chief Complaint
3. History of Present Illness Distinguishing Features of Internal JVP
4. Past Medical Hx from Internal Carotid Pulsations
5. Family Hx Internal Jugular Pulsations Internal Carotid Pulsations
6. Personal and Social Hx Rarely palpable Palpable
Soft undulating quality, usually A more vigorous thrust with a
The Symptoms of Cardiovascular Disease with 2 elevations and 2 troughs single outward component
Pulsation eliminated by light Pulsation not eliminated by
A. Coronary Artery Disease (CAD) and Myocardial Infarction (MI) pressure on the veins just light pressure
 Chest pain; chest discomfort above the clavicle
 Diaphoresis Level of pulsation usually Level of the pulsation not
 Hypotension descends with expiration affected by respiration
Level of the pulsation changes Level of the pulsation
B. Congestive Heart Failure (CHF) with position, dropping as unchanged by position
 Exertional dyspnea, easy fatiguability patient becomes more upright
 Orthopnea
 Paroxysmal nocturnal dyspnea Atrial Pulses
 Dyspnea at rest Types of Atrial Pulse Waves
 edema 1. Normal – brisker upstroke than downstroke
2. Bounding and collapsing
C. Arrhythmia  Aortic incompetence
 Palpitation  Hyperdynamic circulation
 Syncope  Patent ductus arteriosus
 Dizziness  Peripheral AV aneurysms
 Complete heart block
D. Infective Endocarditis/Rheumatic Fever 3. Plateau – slowly upsloping
 Fever  Aortic stenosis
 Peripheral emboli 4. Small Volume
 Shock
E. Peripheral Vascular Disease (PVD)  Aortic stenosis
 Intermittent claudication  Pericardial effusion
 phlebitis 5. Anacrotic
 Aortic stenosis
Physical Examination 6. Bisferiens – 2 systolic peaks
A. General Appearance of the Patient:  Combined aortic stenosis and Incompetence
 Tachypnea, cyanosis, peripheral edema  Hypertrophic Obstructive Cardiomyopathy (HOCM)
 Tiredness, apprehensive, toxic-looking 7. Dichrotic pulse – 2 palpable waves, 1 in systole and 1 in
 Congenital defects diastole
B. Blood Pressure  Severe heart failure
 ↑ BP, ↓ BP  Dilated cardiomyopathy
 ↑ pulse pressure, ↓ pulse pressure 8. Pulsus alternans
 Pressure difference between the arms and legs  Left ventricular failure
 Pulsus paradoxus – an exaggeration of the N dec. in BP 9. Pulsus Paradoxus
during inspiration Procedure
 Pulsus alternans – alternate strong and weak pulses  The cuff is inflated above the pt’s systolic BP.
C. Examination of the Head and Neck  This is deflated slowly while asking the pt to breath
normally
 Check for pink conjunctiva, anicteric sclerae, carotid bruit,
 The point wherein the first korotkoff sound is heard only in
jugular venous pulse, thyroid enlargement, and character
expiration
of carotid pulses
D. Examination of the Lungs
LABORATORY TESTS
 Check for vesicular, breath sounds, coarse and fine rales, 1. Complete Blood Cell Count
rhonchi, and wheezing 2. Cardiac Enzymes
 Check for symmetry of findings - CK-MB , LDH, Troponin I,C, & T
E. Examination of the Abdomen 3. Blood coagulation Tests
 Check for ascites, abnormal pulsation, renal bruits, 4. Serum Lipids
hepatomegaly, and splenomegaly 5. Serum Electrolytes
F. Examination of the Extremities 6. Blood Urea Nitrogen
 Check for cyanosis, clubbing, peripheral edema, 7. Blood Glucose
varicosities, and character of arterial pulses 8. Creatinine

Inspection DIAGNOSTIC PROCEDURES


1. Skin Color 1. Electrocardiogram ( ECG )
2. Neck vein distention 2. Electrophysiologic studies
3. Respirations 3. Cardiac Diagnostic Imaging
=== h@rYw@rY === ASSESSMENT OF THE CRITICALLY ILL PATIENT Prof. Ridulme 1
 Chest X- ray 1. Arterial pressure
 Magnetic Resonance Imaging 2. Intracardiac pressure and Indices
 Positron Emission Tomography  Pulmonary Aartery Pressure
 Echocardiography  Left Atrial Pressure
 Transesophageal Echocardiography  Right Atrial Pressure
 Phonocardiography  Calculated Indices
 Myocardial Scintigraphy
 Cardiac Catheterization
 Angiography Hemodynamic Monitoring : Swan-Ganz catheters
-invasive lines fed into a central vein, through the right of the heart
Echocardiography and into the pulmonary artery. Its placement allows for measuring
1. Non-invasive ultrasound pressures such as:
2. Looks at size, shape, and motion of heart
1. Central Venous Pressure (CVP)
HEMODYNAMIC MONITORING: “ BLOOD POWER “  a measurement taken from the right atrium and
represents the amount of blood return to the right atrium
(preload).
OBJECTIVES
1. State the purpose of hemodynamic monitoring  Normal pressure: 5-10 cm H20 or 0-8 mmHg.
2. Identify the components of a hemodynamic monitoring  Common causes of elevated waveforms: ventricular
system and their functions failure, pulmonary hypertension or stenosis, tricuspid
3. Review major nursing care considerations in the regurgitation, hypervolemia, cardiac tamponade and
preparation, insertion and implementation of hemodynamic constrictive pericarditis
monitoring
4. Examine the waveforms, normal values , clinicl 2. Right Ventricular Pressure (RVP)
applications and abnormalities with respect to the following  Measured directly only during the insertion of the Swan
hemodynamic pressures Ganz catheter
 Central Venous Pressure ( CVP )  Normal RV systolic: 20-30 mmHg
 Right Atrial Pressure ( RAP )  Normal RV diastolic: 0-5 mmHg
 Right Ventricular Pressure ( RVP )  In the absence of disease RV systolic and PA systolic
 Pulmonary Artery Pressure ( PAP ) pressures should be equal
 Pulmonary Artery Wedge Pressure ( PAWP )  Causes for RV pressure abnormalities: pulmonary
 Systemic Arterial Pressure hypertension, ventricular septal defects, pulmonic
5. Consider major complications with hemodynamic stenosis, right ventricular failure, cardiac tamponade and
monitoring techniques. constrictive pericarditis.
6. Investigate the physiologic significance of cardiac output
in terms of cardiac performance and overall tissue perfusion, 3. Pulmonary Artery Pressure (PAP)
and methods of determining cardiac output  Measure the pressure in the pulmonary artery and allow
7. Explain how continous monitoring of the oxygen for interpretation of left sided ventricular filling and
saturation of mixed venous blood ( Svo2 ) reflects the function
adequacy of tissue oxygenation  Normal PA pressures are systolic of 20-30 mmHg and
8. List important hemodynamic parameters that can be diastolic of 8-12 mmHg.
derived or calculated using directly measured hemodynamic  Mean PAP is 10-20 mm Hg.
data  Common causes of increased PA: pulmonary disease,
9. Delineate the nursing process in the care of the patient hypertension, mitral valve disease, left ventricular
undergoing hemodynamic monitoring, including assessment, hypertrophy and tachycardia of greater than 120 bpm.
diagnosis , and planning desired outcomes and nursing
intervention Pulmonary Capillary Wedge Pressures (PCWP)
 A balloon at the tip of the Swan Ganz Catheter is inflated
HEMODYNAMIC MONITORING enough to occlude blood flow to a branch of the
 Is an essential component of caring for post operative or pulmonary artery.
critically ill cardiac surgical patients  The pressures beyond the balloon are measured and
 Thus describes the observation and recording of the forces represent retrograde pressures from the left atrium and
generated within the vasculature that are associated with the the left ventricle at the end of diastole — reflecting
movement of blood. preload of the left side of the heart
HISTORICAL PERSPECTIVES  PCWP is an accurate indicator of the pump function of
 1733 – Stephen Hales cannulated the carotid artery of a the left ventricle.
horse and measured how hihg the resulting column of blood  Normal PCWP is 8-12 mmHg.
rose in a brass pipe  Elevated PCWP pressures are usually indicative of
 1962 – Wilson and associate described the monitoring blood pulmonary congestion
volume level in war injured patients by means of CVP  They may be falsely elevated if the patient is on PEEP or
 Late 1960’s – Drs Swan and Ganz developed the balloon tip CPAP or if the catheter tip is not in the correct place.
flotation Pulmonary Artery  Monitor tracing has 3 positive waves, A, C and V.
o A-wave- represents left atrial contraction
Purpose of bedside monitoring o C-wave- mitral valve closure
To survey and to optimize the determinants ( Heart Rate, Preload, o V-wave- left atrial filling pressure
afterload and contractility ) by direct appropriate therapeutic  Common Causes of elevated PCWP waveforms:
intervention for the purpose of providing the oxygen delay to the increased resistance to ventricular filling as with mitral
tissues. stenosis of left ventricular failure, mitral valve
regurgitation and ruptured papillary muscle,
HEMODYNAMIC MONITORING hypervolemia, tamponade or constrictive pericarditis.
=== h@rYw@rY === ASSESSMENT OF THE CRITICALLY ILL PATIENT Prof. Ridulme 2
3. Important indicators of sytemic perfusion, particularly to that of
TECHNICAL ASPECTS OF INVASIVE PRESSURE OF heart, brain , kidneys and other vital organs
MONITORING
A. Electrical System Catheter placement
 Amplifier Sites for intra arterial catheterization included the
 Oscilloscope 1. Radial – common site
 Processor or Display 2. Brachial
 Analyzer Recorder 3. Femoral
4. Dorsalis pedis
5. Axillary arteries
B. Fluid / Plumbing System
 Vasculature Catheter Complication
1. Infection
 Non compliant pressure tubing
2. Arterial thrombosis
 A continous flush device
3. Distal Ischemia
 Manual flushing of catheter tubing system 4. Embolization
 2 or three stopcock
 Pressure transducer INTRACARDIAC PRESSURE AND INDICES
 Infusion pressure bag Are measured to provide an estimate of preload which along with
 Flush solution afterload, heart rate and contractility , is major determinant of
Cardiac output.
ARTERIAL PRESSURE
1. It allows continous display of systemic, diastolic and Mean PULMONARY ARTERY PRESSURE
Arterial pressure as well as vasculature. 1. To monitor left ventricular preload continously
2. Access for obtaining arterial blood samples for gas analysis 2. To assess preload and guide clinical therapy
 Lymph nodes along the neck area
PULMONARY ARTERY PRESSURE  Use of accessory muscles of breathing, e.g.
Provide an index of the pressure which is the pulmonary sternocleidomastoid
vasculature and are affecting the compliance of the Left ventricle,  Intercostal spaces
pulmonary vessels pressure, Cardiac output ( blood flow to the
lungs ) and the state of the lung tissue ).
ABNORMAL FINDINGS
PULMONARY ARTERY WEDGE PRESSURE  CHEST WALL ABNORMALITIES
Is obtained by inflation of the balloon in the distal end of the  Barrel chest
Pulmonary artery catheter, which allows the catheter to float
 Pigeon Chest
forward to edge in a segment of the Pulmonary artery.
 Funnel Chest
Nursing diagnoses  Thoracic kyphoscoliosis
Alteration in cardiac output: Decreased
Alteration in tissue perfusion ( peripheral ) related to compromised ABNORMAL RESPIRATORY PATTERNS
circulation associated with invasive monitoring 1. Tachypnea
Potential for Infection related to invasive monitoring 2. Bradypnea
Physiologic Injury related to hemorrhage;thromboemboli;venous air 3. Apnea
embolism;pulmonary infarction or hemorrhage; cardiac 4. Hyperapnea
arrhythmias or condition disturbances 5. Kussmaul’s repirations
Anxiety related to fear of technologic equipment and procedures 6. Cheyne – Strokes Respirations
associated with hemodynamic monitoring
Sleep pattern disturbance related to invasive monitoring PALPATION
1. Identify tender areas
PHYSICAL ASSESSMENT OF THE RESPIRATORY SYSTEM 2. Masses or sinus tracts
3. Chest excursion
4. Tactile fremitus
INSPECTION
 General appearance: facial expression, posture, alertness,  Increased à pneumonia, tumor
speech pattern, signs of respiratory distress  Decreased à pleural effusion
 Examine the head and neck: “flaring” of the nares, color of
lips, gums, area under the tongue, neck veins PERCUSSING THE CHEST
 Chest: symmetry, shape, AP diameter Different sites, different sounds
Ringing with resonance
INSPECTING RELATED STRUCTURES Problem sounds
 Inspection of the skin, fingers, and nail beds Movement of the diaphragm
 Observe : color of nail beds
 Clubbing of fingers? AUSCULTATION OF BREATH SOUNDS
 Purse- lip breathing? 1. Preparing to auscultate
 Cyanosis : central, peripheral 2. What achange means
 [think ABGs] 3. Inspecting what you hear
4. Vocal Fremitus

PALPATING THE CHEST VOICE SOUNDS


 Equal chest expansion / symmetry 1. Ask person to repeat a phrase while you listen over the chest
 Tenderness and lumps wall.
2. Normal voice transmission is soft, muffled, and indistinct
=== h@rYw@rY === ASSESSMENT OF THE CRITICALLY ILL PATIENT Prof. Ridulme 3
3. Pathology that increases lung density enhances transmission
of voice sounds. Respiratory tests and procedure: invasive
 Bronchophony- repeat “99” while you listen with the 1. Fiberoptic bronchoscopy – to visualize abnormalities, take
stethoscope; should be muffled; CLEAR IS ABNORMAL biopsy samples of lesions, or remove foreign bodies; NPO 6-8
 Egophony- have person repeat long eee sound; should hear hrs or as required; till gag reflex returns; semi Fowler’s
eee; if eee changes to long aaa sound ABNORMAL (E-A position; VS
CHANGES) 2. Thoracentesis – pleural fluid is aspirated and examined for
 Whispered Pectoriloquy- have the person whisper “1-2-3” as pathogens; cells studied for malignancy; remove fluid;
you listen; should be faint to inaudible; clear or distinct is 3. VS; watch out for bleeding, asymmetric chest movement;
ABNORMAL patient is positioned on unaffected side after (Linton &
Maebius, 2003, MS Nursing p466)

ABNORMAL BREATH SOUNDS


Crackles PULMONARY FUNCTION TESTS
Wheezes 1. To diagnose respiratory disease, monitor progression, assess
Rhonchi extent of disability and effect of medication
Stridor 2. measures lung volumes (TV, MV, FER) and capacities (TLC,
Pleural friction rub IC, VC)
3. Assess mechanics of breathing (flow rates of gas in and out of
ASSESSMENT OF THE THORAX & LUNGS: IPPA the lungs) and diffusion (movement of gas along the alveolar –
1. Posterior thorax capillary membrane)
2. Anterior thorax
 Inspiration/expiration ratio PULSE OXIMETRY
 Breathing pattern 1. Is safe and simple method of assessing oxygenation
2. Passes a beam of light through the tissue, and a sensor
 Chest expansion
attached to the finger tip, toe, or ear lobe measures the
 Vocal/tactile fremitus
amount of light absorbed by the oxygen saturated hemoglobin.
 Percussion
 Breath sounds SPECIMEN RECOVERY AND ANALYSIS
1. Sputum collection
Elderly: Physical Changes of Thorax and Breathing Patterns 2. Nose and throat Cultures
1. Kyphosis 3. Thoracentesis
2. Anteroposterior diameter of the chest widens 4. Biopsy
3. Breathing rate and rhythm are unchanged at rest
4. Inspiratory muscles become less powerful, and inspiration BRONCHOSCOPY
reserve volume decreases. 1. Involves passage of lighted bronchoscope into the broncial
5. Expiration may require the use of accessory muscles tree
6. Deflation of the lung is incomplete. 2. It may be performed with rigid steel or flexible fiberoptic
7. Small airways lose their cartilaginous support and elastic recoil instrument
8. Elastic tissue of the alveoli loses its stretchability and changes
to fibrous tissue. Exertional capacity also decreases.
9. Cilia in the airways decrease in number and are less effective
in removing mucus à greater risk for pulmonary infections. Bronchoscopy: PREPROCEDURAL CARE
1. Explain the procedure
DIAGNOSTIC EXAMINATIONS 2. NPO for 6 hours prior to the procedure
1. Preparation of the patient 3. Explain that the throat may be sore after bronchoscopy and
2. Consent – ensure safety there will be some initial difficulty in swallowing
3. Knowledge of the preparation needed 4. Should remove dentures, contact lenses and prostheses
4. Allay patient’s anxiety and fear
5. Patient and family education Bronchoscopy: PROCEDURE
1. Local anesthesia and intravenous sedation
2. Topical anesthetic agent is also sprayed into the back of the
Diagnostic tests and procedures throat.
1. Pulmonary Function Tests – no smoking, heavy meal 4-6 hrs 3. Takes 30 to 45 minutes to complete
before test; void before the test 4. Client lies supine with the head hyperextended
2. Tuberculin test- -to assess present or past exposure to TB;
intra dermal, lower anterior forearm; read in 48- 72 hr; Bronchoscopy: POST PROCEDURE CARE
reaction- red, swelling > 5mm is (+) TB exposure; follow up 1. Monitor Vital signs
evaluation 2. Observe for signs of respiratory distress
3. Expectorated secretions are inspected for evidence of
Radiologic and Imaging Studies hemoptysis.
1. Chest X ray – respiratory screening, dx, progression, response 4. NPO until the cough and swallow reflexes have returned,
to treatment usually in 1-2 hours
2. [lungs appear black due to air filled spaces, as they absorb x- 5. Lung sounds are monitored
ray energy; bone appears white on film]
3. Fluoroscopy – motion radiographs ALVEOLAR LAVAGE
4. Lung Scan – assess ventilation/ perfusion/ pulmonary 1. Sterile saline can be injected during bronchoscopy to wash
embolism; small dose of radio isotope IV; excreted in urine tissues
5. Computer Tomography – visualize lesions, tumors; painless 2. Saline is aspirated and examined for atypical cells.
procedure; remain still during scanning; if contrast media
needed, assess for iodine allergy ENDOSCOPIC THORACOTOMY
=== h@rYw@rY === ASSESSMENT OF THE CRITICALLY ILL PATIENT Prof. Ridulme 4
1. Three small incisions are made into the middle chest wall 4. Extent of thrombo embolism
2. Scope attached to camera and video projector is inserted
through the first incision to inspect tissue
3. Chest tube is inserted

Endoscopic Thoracotomy Preparation


1. Explain the procedure
2. Obtained a signed informed consent THORACENTESIS
3. NPO post midnight 1. Is performed to drain pleural space of air found in the pleural
4. Explain that a chest tube will be in place and t that it will be space
necessary to perform coughing and deep breathing exercises 2. Therapeutic thoracentesis
3. Diagnostic thoracentesis

Thoracentesis: Preprocedural Care


PULMONARY ANGIOGRAPHY 1. Obtained Informed consent
1. Angiography and other procedures designed to examine 2. Explain the procedures
specific vascular structures. 3. Sit upright while leaning over the tray table
2. Congenital abnormalities
3. Abnormalities of the pulmonary venous circulation BATTLING ILLNESS : Treating ARDS
4. Acquired disease of the pulmonary arterial and venous Ventilation- mechanical ventilation and intubation
circulation. New Techniquues
Drugs – sedatives , narcotic and neuromuscular agents.
Pulmonary Angiography: indications
1. Destructive effects of emphysema
2. Potential benefits of resection for bronchogenic CA
3. Peripheral pulmonary lesions

=== h@rYw@rY === ASSESSMENT OF THE CRITICALLY ILL PATIENT Prof. Ridulme 5