TEAM: Camila Seixas Calina Helena Garrido Isabelle Cristiani Cristinne Susana Co sta INTRODUCTION Monitoring The which

is MONITOR: prevent, assess, advise, act. Methodical observation of clinical and la boratory parameters, measurable in an objective way, which will allow continuous monitoring of a system of the body, providing data for therapeutic and diagnost ic approaches. Visa measurements, frequent and repeated physiological variables. Hemodynamics The which is Hemodynamic Monitoring study the movements and pressures from the bloodstream. Study the movement and pressure of blood flow through the methodical observation of clinical and laboratory, which will allow continuous monitoring of a system of the organism, invasive and noninvasive. Hemodynamic Monitoring PURPOSE Assisting the diagnosis of various disorders cardivasculares; Targeting therapie s to minimize cardiovascular dysfunction; Forecast data obtained; Treating disor ders; evaluate response to therapy; Provides qualitative and quantitative inform ation of intravascular pressures. Hemodynamic Monitoring PURPOSE Recognize and evaluate potential problems in a timely manner, aiming to establis h an immediate and appropriate therapy. Hemodynamic Monitoring METHODS

Invasive and noninvasive, covering a range of physiological variables. Hemodynamic Monitoring LIABILITY Nurse Medical Intensive Evaluation and interpretation of hemodynamic data (qualified assistance) Invasive monitoring Critically ill patients continuous assessment of your cardiovascular system moni toring systems direct pressure

Hemodynamic Monitoring Methods used for pressure measurement Water or mercury manometers: The intravascular catheter is filled with liquid an d connected directly to the water column (Central Venous Pressure) or a column o f mercury (Systemic Blood Pressure) graduated. Methods used for pressure measurement Electronic pressure transducers: The intravascular catheter is filled with liqui d and connected to a electromanometry (Straing-Gauge). Methods used for pressure measurement As the mechanical impulse is transformed into electrical Intravascular pressure wave Mechanical drive sf rm n the air Diaphragm transducer to Tr Electrical impulse Invasive monitoring Monitoring SBP MBP C Monitoring Monitoring Monitoring PAP PVC Monitoring of IAP Monitoring PI

MONITORING OF SYSTEMIC ARTERIAL PRESSURE MONITORING OF PAS BLOOD PRESSURE that the blood exerts pressure within the arteries during systole and diastole o f the ventricles depends on the DC, PVR, blood volume and blood viscosity. BP = CO X PVR (mmHg) PA NORMAL Ventricular systole Ventricular diastole PAS MONITORING STATEMENT:

Postoperative period of cardiac surgery, Post-operative recovery can not occur i n which large changes in systemic arterial pressure (eg carotid endarterectomy, resection of aortic aneurysm) In situations where there is a need for strict con trol of blood pressure (eg control hypotension) When a strict control of blood g

ases is necessary; MONITORING OF LOCAL PAS DE CATHETER INSERTION: Radial artery Pedis artery axillary artery Femoral artery MONITORING OF LOCAL PAS DE CATHETER INSERTION: It is considered: Pot choice Complications Radial artery Located distal Small diameter Rather accurate measurement MONITORING OF LOCAL PAS DE CATHETER INSERTION: The puncture of the brachial artery should be avoided due to the potential risk of thromboembolic complications in the forearm and hand. Brachial artery MONITORING OF LOCAL PAS DE CATHETER INSERTION: The axillary and femoral arteries are the larger vessels available for puncture, and therefore would present the lowest risk of stroke by the presence of an int raluminal catheter. Axillary artery Femoral artery The inconvenience of punctures in the axilla and inguinal region are the difficu lty of achieving healing and greater potential for contamination of these region s. MONITORING OF LOCAL PAS DE CATHETER INSERTION: The arterial line can be achieved by: Biopsy; It is indicated or arterial dissection.

Percutaneous puncture with the needle on plastic device that reduces the possibi lity of arterial injury The percutaneous catheter on the needle is a nursing procedure. It should be: us e aseptic technique, a topical local anesthetic (xylocaine gel) and infiltration with 2% xylocaine without vasoconstrictor. MONITORING OF LOCAL PAS DE CATHETER INSERTION: If you are unable to puncture the radial artery: The second choice is the dorsal is pedis artery; And finally, you should try the femoral artery. MONITORING OF PAS BP has a normal characteristic curve with two components: ANACRÓTICO ejection of b lood and the systolic pressure. dicrotic dicrotic node represents diastole and t he closure of the aortic valve. Arrhythmias, hypotension, aortic valve disease or constrictive pericarditis can

affect the curve of the PA hematomas, intraluminal thrombus, or impaction of the tip folds may dampen the curve. MONITORING OF RISKS AND COMPLICATIONS PAS Vascular compromise (eg thrombosis, hematoma, vasospasm); disconnection and exsa nguination; accidental injections of drugs, local and systemic infection, nerve injury (compressive neuropathy), aneurysmal formations, arteriovenous fistulas, necrosis and gangrene of the digits, and distal embolic phenomena Proximal; Embo lization of vertebral artery (axillary puncture). MONITORING OF PAS NON-INVASIVE Low Easy Easy INVASIVE High cost cost application maintenance as low Personal Risks Delay skilled Time Maintenance Perfusion cuff (Bat - bat) NURSING CARE IN INVASIVE MONITORING OF PAS Precision Speed

Drive Positioning

Careful observation of signs and symptoms of complications: Use of radial artery and dorsalis pedis wherever possible realization of the modified Allen test bef ore radial artery cannulation, use of aseptic technique for puncture; Use of cat heter over needle, 20G, avoiding larger catheters; secure catheter fixation and fixation with wrist splint; continuous irrigation catheter system with low flow (heparinized sterile saline solution); The transducers should have disposable ho ods; Perform daily check of the site of catheter insertion; Limitation of cannul ation blood for the shortest time possible without leaving the catheter for more than 72 hrs; MEAN ARTERIAL PRESSURE MONITORING MONITORING OF PAM Measurement of blood pressure throughout the cardiac cycle. MAP = PS + (2 X PD) __________________________ 3

Value trusted only by direct measurement of MAP NORMAL: 70 to 105 mm Hg. MONITORING OF PAM Procedure: 1) catheter inserted into the artery: the Seldinger technique. 2) connected to a transducer mechanical signals (radial pulse) ELECTRICAL SIGNALS 3) curves on th e monitor - or mercury manometer sphygmomanometer (HOLDERS OF INFECTION) MONITORING OF PAM CURVE OF BLOOD PRESSURE: 1) Represents the LV ejection of blood into the aorta First phase of the pressur e wave is preceded by QRS ECG intraventricular pressure falls in relation to aor tic pressure - aortic valve closure of the second wave of pressure - dicrotic no tch (ECG : end of the T wave, ie at the end of systole and early ventricular dia stole) Represents the end of ventricular diastole and continuous fall in the int ra-aortic 2) 3) MONITORING OF PAM 1 2 3 NURSING CARE IN THE TECHNIQUE OF CATHETER INSERTION Explain to the client the procedure to be performed; Organize all material next to the bed; Perform cleansing the skin with the germ solution (circular motion f rom center to periphery); Remove excess solution with germ SF; Protect Local wit h sterile gauze or bandage; Assist the physician in the scrub; After insertion o f the catheter tip to the nurse provides the system for the physician to make th e connection; dressing in place; Level and reset the system for proper reading o f the curve pressure, remembering to do this procedure every time you change the client's position on the bed, dressing Perform daily, inspecting the areas of c atheter insertion and adjacent; NURSING CARE IN THE TECHNIQUE OF CATHETER INSERTION

Communicate changes; Observe end of the member involved; Promote adequate fixati on of the catheter; Explain about the withdrawal of the system, the fluid Close heparinized catheter; Depressurise the system, remove the bandage from the punct ure site and remove the attachment point of the catheter (aseptic technique) wit h sterile gauze and using the index and middle fingers of one hand press about 2 cm above the puncture site with the other hand, remove the catheter and despise him; Press with index finger and average over the puncture site; Decrease manua l compression gradually until all bleeding cessse; Make dressing and keep it for 12-12 hours. MONITORING OF CENTRAL VENOUS PRESSURE MONITORING OF PVC Right atrial pressure

Preload of the RV Capacity Filling up the RV at end diastole MONITORING OF PVC What is the main purpose of the measurement of PVC? It is estimate the RV end-diastolic pressure; It is an indication of hydration s tatus and right heart function; Giving information of the need for infusion of f luids. Reserve in patients with heart failure and normal pulmonary vascular resistance, CVP can drive the global hemodynamic handling. MONITORING OF PVC INDICATIONS guide for fluid replacement; Assessment of cardiac function; Aspiration of air i n neurosurgery; Collection of blood; Infusion drugs; Passage of a pacemaker; Pas s the pulmonary artery catheter. MONITORING OF PVC PROCUREMENT OF PVC It is usually obtained through a catheter located in superior vena cava; The pul monary artery catheter can also measure the PVC through the proximal hole that l eads to AD. MONITORING OF PVC PROCUREMENT OF PVC The main veins used CVP monitoring are: to Brachial vein Subclavian vein Jugular vein MONITORING OF PVC PREVIEW MONITORING OF PVC PREVIEW It is checked radiographically to ensure that the catheter is properly positione d and not within the right atrium. MONITORING OF PVC How can the pressure be monitored? Gauge water (intermittently) Transducer Electronic (continuously) MONITORING OF PVC What are the average normal PVC? 3-6 6-12 cmH2O mmHg or vary

It is measured through the midaxillary line as zero reference. MONITORING OF PVC Materials needed to monitor a PVC water column: to MONITORING OF PVC Factors that affect the real value of PVC: For the patient: Changing position in bed;

Handling excessive;

large and laborio

us breathing movements (inspiratory or expiratory) Patients connected to mechani cal ventilators with inspiratory pressure or PEEP, it will decrease venous retur n and consequently levels modified PVC. MONITORING OF PVC Factors that affect the real value of PVC: In relation to the catheter and syste ms connection: Bad positioning of the catheter tip; clot in the catheter; Catheters too thin or high-complacency; Presence of air bubbles in the system; Catheters bent or bottlenecks; MONITORING OF PVC Factors that affect the real value of PVC: Regarding the measurement system: Zero reference improperly positioned, inadequa te electrical zero; Change in membrane transducer; improperly calibrated transdu cer and amplifier; Small response range of the water column in relation to hemod ynamic parameters. MONITORING OF PVC Changes in the values of PVC: PVC PVC • Hypervolemia (bradycardia) • Hypovolemia (tachycardia) • The venodilation ca used by sepsis, drugs or neurological causes, may also decrease the PVC. • Drugs v asoconstrictor norepinephrine • Severe RV; • Cardiac tamponade; • Overload volume of l iquid; • pulmonary hypertension • Disease of the tricuspid valve, • chronic left ventr icular failure. • Drugs vasodilator NURSING CARE IN INVASIVE MONITORING OF PVC Check radiological catheter position before installing the PVC; Fill the system with s aline; Remove any air bubbles of the measurement system; NURSING CARE IN INVASIVE MONITORING OF PVC

Measure the PVC through the water column in cm or graduated measuring through a transducer and monitor calibrated in mmHg; observe the oscillation of the water column or from baseline on the monitor electric; Keep the puncture site with ste rile dressing; Use aseptic technique for handling the system; Observe puncture s ite for the presence of pain, heat, redness and swelling, do not let the cathete r for more than five days; MONITORING OF THE PULMONARY ARTERY PRESSURE MONITORING OF PAP OBJECTIVES: Assess right ventricular function or indirectly from the left; evaluate the pulm onary vascular function of the state; Monitor the changes of hemodynamic status; Targeting therapy with pharmacological agents and nonpharmacological; provide d ata indicative of prognosis

MONITORING OF PAP PAP pulmonary artery pressure curves of PAP is divided into three phases: • • Systol ic Diastolic • Average MONITORING OF PAP PAP pulmonary artery pressure Systolic Phase VEM RV fast blood flow PAPS = RVSP Opening of the pulmonary valve AFTER Pulmonary artery MONITORING OF PAP PVD <PAP After the RV ejection Period Pulmonary valve closes Aparecend the Notch on the curve, the knot dicrotic MONITORING OF PAP PAP pulmonary artery pressure es 15-30 mmHg Phase Systolic Normal Values: Systolic (PAPS) Vari

MONITORING OF PAP PAP pulmonary artery pressure Phase Diastolic It is measured before the new systole Normal Values: Diastolic (PAPD) Varies 4-12 mmHg

MONITORING OF PAP PAP pulmonary artery pressure Phase Average The PAP (mPAP) can be calculated using the following formula: PAPD 3 x 2 + PAPS MONITORING OF PAP PAPS high Hypervolemia high PAPD Diseases of pulmonary parenchyma, pulmonary emb olism decreased PAP Hypovolemia Monitoring of the PCP or PAPO Pulmonary capillary wedge pressure or pulmonary wedge pressure Mirrors the pressure of LA and indicates how the VE is running. APO decreased Hypovolemia Swan-Ganz Function: To supply parameters for hemodynamic diagnosis. Value: 8-12 mmHg Note: P

Description of the Catheter: There in sizes newborn (3 French), children (5 French) and adult (7F). adult varies in two lengths: 85 and 110 cm. Swan-Ganz catheter

Structures of Catheter: Via Proximal gauge PVC and harvest blood. blood. Via Distal measure PAP and harvest Via Balloon assists in the migration and wedged catheter. thermistor measures the temperature of blood in the pulmonary a rtery. Via extra Medication Swan-Ganz Swan-Ganz Catheter insertion: It is a sterile procedure and must be performed by the physician.

Insertion site: internal jugular and subclavian Remarks: The integrity of the cuff should be tested d be made an x-ray to confirm position. Swan-Ganz Indication: Acute heart failure right ventricle infarction, congestive heart failure refract ory pulmonary hypertension Situations circulatory hemodynamic instability comple x (burned) Emergencies (ARDS, sepsis) Determination of cardiac output (thermodil ution) venous blood collection and infusion solutions Swan-Ganz Contraindications: Patients with recurrent sepsis patient with hypercoagulable patients with abnorm al heart rhythm Wolff-Parkinson-White Swan-Ganz Complications: A) Related venipuncture: - Pneumothorax - Horner's syndrome - transient phrenic nerve injury B) relating to the passage of the catheter: - Arrhythmias - Rupture of the pulmonary artery - Drilling RV After insertion of the catheter shoul

Swan-Ganz C) relating the presence of a pulmonary artery catheter: - Venous thrombosis at the site - pulmonary infarction - Sepsis Video Insertion of catheter SwanGanz Swan-Ganz The purple curve represents the central venous pressure characterized by the pre sence of waves AEV defined by atrial contraction and filling, respectively. Swan-Ganz The extent to which the catheter is introduced, there is the pressure curve and right ventricular diastolic pressure value is usually low, as in purple in the p icture. Swan-Ganz After the catheter reaches the right ventricle to pulmonary artery pressure curv e which is characterized by an increase in diastolic pressure and the presence o f the dicrotic notch. Swan-Ganz Once the pulmonary artery catheter, progress carefully to obtain the pressure cu rve of pulmonary artery occlusion also characterized by the presence of waves a and v. Swan-Ganz The end of the procedure should perform the aseptic dressing and chest X-ray con trol, which can observe the proper placement of the catheter and no complication s. Intracath It is a catheter for introduction by vein puncture, usually the internal jugular or subclavian vein, aimed at positioning its distal end in the right atrium. Ex cellent way to administer drugs and volume as well as to record the right atrial pressure, also called central venous pressure (CVP).

MONITORING OF INTRA-ABDOMINAL PRESSURE MONITORING OF PIA reduction of DC normal values 0-12 mm Hg increase in respiratory pressure decrea sed urine output • Respiratory failure and reduced cardiac output are caused by chest compression. • The reduction in cardiac output is also influenced by decreased venous return ca used by compression of the inferior vena cava and portal vein. 15-20 mmHg MONITORING OF PIA PRESSURE MONITORING OF INTRA - CRANIAL

MONITORING OF PIC It the pressure exerted by the volume of the braincase • Blood Amendment of vol. • cerebrospinal fluid (CSF) Element Cap PIC Ability to adapt, adjust to maintain normal ICP (10 mmHg) Cause of death ECA Intracranial hypertension High volume MONITORING OF INTRACRANIAL PRESSURE Classification - ICP <10mmHg - Normal. - Peak between 10 and 20 mmHg - slightly increased. - Pe ak between 21 and 40 mmHg - moderately increased. - ICP above 40 mmHg - seriousl y high. (Gambarota, 2006) MONITORING OF INTRACRANIAL PRESSURE PIC 15mmHg Capillary network compressed Comprometiment the microcirculation Damaged areas Brain dysfunction Avoidance of blood Edematous areas s Insufficient blood flow to the cellular metabolism MONITORING OF INTRACRANIAL PRESSURE FUNCTIONS Monitoring continuous ICP; Targeting therapy and nursing care.

MONITORING OF INTRACRANIAL PRESSURE Procedures - trepanation skull catheter or fiber pressure to external equipment - Monitoring PIC MAP CPP (70 mmHg) maintain blood flow. CPP = MAP ICP The choice of location will denpender: clinical conditions Etiology of neurologi cal disease size of the lateral ventricle MONITORING OF INTRACRANIAL PRESSURE Factors Place of distal tip position of sensor type Media Player external transmission w ill

that affect the application of the method: Lateral ventricle to brain parenchyma and subdural space and subarachnoid membra ne (dome) Metallic Fiber Mechanic Electronic (chip) Water Optical fiber Equipament the specific Invasive pressure MONITORING OF INTRACRANIAL PRESSURE INDICATION severe TBI; postoperative cerebral edema; achnoid hemorrhage serious; Encephalitis; arrest extended. MONITORING OF INTRACRANIAL PRESSURE CATHETER PIC OF CARE NURSING IN INVASIVE MONITORING THE PAS careful handling and collectively; H ead centralized patient body alignment to avoid compression of jugular veins; De cubitus lateral prevent hip flexion; Patients with TOT fixture over the ears to avoid compression of the jugular ; Register values of ICP and MAP hourly; MAP an d ICP values near or equal brain death blood flow; Perform daily change of dress ing; NON-INVASIVE MONITORING NON-INVASIVE MONITORING OBJECTIVE Reduce complications associated with the techniques used for invasive hemodynami c monitoring. NON-INVASIVE MONITORING Why choose noninvasive monitoring? less invasive procedure; Easy handling; ducibility of results; Cost-benefit in the ICU invasive procedures, use of Confirmation by imaging studies. NON-INVASIVE MONITORING What are the physiological variables monitored? arterial blood pressure, heart r ate , Temperature; Respiratory rate; Electrocardiogram; Non-invasive respiratory monitoring; Doppler echocardiography (DC); Rating neurological non-invasive. SSVV NON-INVASIVE MONITORING VITAL SIGNS Repro ischemic and hemorrhagic stroke, subar Hydrocephalus; Post-cardiorespiratory

Variables are simple and commonly used in inpatient units. Vital signs Temperatu re Fc Respiratory rate Blood pressure NON-INVASIVE MONITORING VITAL SIGNS-HEART RATE period of one minute. It is told by manual palpation of the radial artery for a

Places where the pulse can be checked NON-INVASIVE MONITORING VITAL SIGNS-HEART RATE What can evaluate with the CF? Rhythm pulse; Feature own vessel; NON-INVASIVE MONITORING VITAL SIGNS-HEART RATE 100bat/min • Deficits in blood flow and blood volume; FC • Infection Anxiety, stress, exercise, pain, malaise, fever. The faster heart rate, greater hypovolemia or cardiac deficit. NON-INVASIVE MONITORING VITAL SIGNS-HEART RATE FC slow • Ischemia; • Blocking the sinoatrial node, • coronary heart disease, • coronary blood f low insufficient. Should evaluate the pace, where disordered rhythm may indicate arrhythmia requir ing electrocardiogram. NON-INVASIVE MONITORING VITAL SIGNS-HEART RATE The shape of the wrist often conveys important informatio n such as Determine if there is aortic valve stenosis (decreased pulse and weak) , aortic valve insufficiency (elevation of pulse wave abrupt and sudden loss). The ideal pulse to be observed is the palpation of the carotid artery. NON-INVASIVE MONITORING VITAL SIGNS TEMPERATURE- It is usually found in the rectum (ill patients), or mou th; The core body temperature can be checked in the tympanic membrane or mesoesôfa go; The temperature of the pulmonary artery (= core temperature) can be taken by thermodilution catheter - invasive - pulmonary artery. NON-INVASIVE MONITORING VITAL SIGNS-TEMPERATURE Hyperthermia • Infection • Tissue necrosis; • Carcinomatosis; • Diseases hypermetabolic. Hypothermia • Trauma surgery; • Or accidental. NON-INVASIVE MONITORING VITAL SIGNS RESPIRATORY FREQUENCY It is given by the movements of inspiration an d expiration, corresponding to the metabolic process of gas exchange with the en vironment. During the evaluation it should be noted: Frequency; Depth; Rhythm; NON-INVASIVE MONITORING Frequency Waveform

VITAL SIGNS RESPIRATORY FREQUENCY DURING 1 MINUTE NON-INVASIVE MONITORING VITAL SIGNS RESPIRATORY FREQUENCY

How to tell?

The breath can be:

Superficial;

Normal;

Deep.

The pace and character of breathing are seen through the movements of the chest and pulmonary auscultation. NON-INVASIVE MONITORING VITAL SIGNS, BLOOD PRESSURE movement reflects the general situation, but it requ ires specific diagnostic data. of the It refers to the pressure that blood exerts within the arteries. d with: When blood volume, and the circulatory system. NON-INVASIVE MONITORING VITAL SIGNS, BLOOD PRESSURE Blood pressure Amount of blood released by the heart with each contraction Force of contraction of the heart ventricle depends on the ability to pump blood The greater the capacity of heart pump blood, more blood will be ejected. NON-INVASIVE MONITORING VITAL SIGNS, BLOOD PRESSURE What can alter blood pressure? Decreased circulating blood volume (PA) Changes in elasticity of the muscular layer of blood vessel w alls; Blood viscosity; NON-INVASIVE MONITORING VITAL SIGNS, BLOOD PRESSURE What is the normal value of arterial blood pressure? Systolic pressure is equal to 120mmHg and 80mmHg diastolic Hypertension: 140/90 mmHg NON-INVASIVE MONITORING VITAL SIGNS, BLOOD PRESSURE Mean blood pressure: one third of the sum of SBP + 2 x PAD Provide information on: • systemic vascular resistance; • Work heartbeat LV • Cardiac output. NON-INVASIVE MONITORING VITAL SIGNS, BLOOD PRESSURE Systolic blood pressure: the pressure corresponding to the end of systole. It is determined by (the): • LV systolic volume; • Speed ejection of blood; • Elasticity of the aortic wall. NON-INVASIVE MONITORING VITAL SIGNS, BLOOD PRESSURE Diastolic blood pressure: the pressure corresponding to the relaxation of the ve ntricle. It is established by: • Peripheral Resistance; • And by the FC. Pulse pressure is the difference between the SBP and DBP. NON-INVASIVE MONITORING It is associate

VITAL SIGNS, BLOOD PRESSURE

How to measure the blood pressure?

Esfingmomanômetro Stethoscope + It is recommended that you use the invasive method in patients in critical condition and / or in shock. Electrocardiographic monitoring Electrocardiographic monitoring FUNCTION:

Frequency measurement; Measurement of cardiac rhythm; detect arrhythmias, ischem ia cardiac pacemaker function Electrocardiographic monitoring OBJECTIVES: Produce and display faithfully the signal and eliminate unwanted signals - noise or interference; Electrocardiographic monitoring AREAS Problems: Patient

Intallation electrode; Preparation of the skin, or oily skin moist, hairy sur e; Skin; Interference muscle; Movements; Electrocardiographic monitoring Positioning of electrodes: V1 - fourth intercostal space, right edge D1 - MSD an d MSE sternum D2 - MSD and MIE V2 - 4th EI, board left sternal D3 - MSE and MIE V3 - between V2 and V4 avr - MSD V4 - 5th EI , midclavicular line aVL - MSE V5 5 EI, anterior axillary line aVF - MIE V6 - 5 EI, midaxillary line Electrocardiographic monitoring AREAS Problems: Electrodes: type electrode, the electrode gel dry, wrapping the electrodes, electrodes cold - low adhesion; Skin; Electrocardiographic monitoring AREAS Problems: wires: fasteners loose or worn; Links shoddy; breaks in wires; Movement of the cable;€ e stripped wire Do not leave loose strands hanging over motors, lamps or electri c instruments; Electrocardiographic monitoring AREAS Problems:

Environment: electrosurgical equipment; Must withstand discharges issued by the defibrillator ; keep out the patient, drivers and cables of known sources of 60Hz; Electrocardiographic monitoring AREAS Problems: Patient Cables: Loose; bare wires or loose; NON INVASIVE MONITORING RESPIRATORY NON-INVASIVE RESPIRATORY Critically ill patients suffer circulatory disorders that alter the perfusion an d tissue oxygenation. Parameters to monitor this variable: Arterial blood gases (INVASIVE) Oxygenation - pulse oximeter and transcutaneous oxygen measurement an d Ventilation - capnography and transcutaneous measurement of carbon dioxide NON-INVASIVE RESPIRATORY Oxygenation - pulse oximetry detect the presence of hypoxemia in patients with p otential respiratory disorders who are on mechanical ventilation and oxygen ther apy in patients with neurological deficits that can affect breathing. Oxygen saturation => amount of hemoglobin bound with oxygen. NON-INVASIVE RESPIRATORY Oxygenation - pulse oximeter two technologies for calculating the oxygen saturat ion of arterial hemoglobin: Plethysmography optical pulse information Espectrofitometria Deduct the vascular bed NON-INVASIVE RESPIRATORY Oxygenation - pulse oximeter plethysmography optical technology that produces fo rms where the blood pulsing through different amounts of light absorbed. Changes that occur in the absorption of light by the blood pressure is reproduced graph ically: FORMS OF PULSE WAVE NON-INVASIVE RESPIRATORY Oxygenation - pulse oximeter Spectrophotometry Represents quantitative measurements through the wavelengths o f light which are absorbed and passed directly through a given substance. The ab sorption and light transmission by this substance can be determined by two light emitting diodes (LEDs) NON-INVASIVE RESPIRATORY Oxygenation - pulse oximeter sensor pulse oximeter: Source of light photodetecto r receives light from the sensors and detects the difference in transmitted ligh t, which was absorbed by hemoglobin molecules.

NON-INVASIVE RESPIRATORY Oxygenation - pulse oximeter Chills, pressing activities, patient restless in bed, low perfusion and edema

Interfere with oximeter readings NON-INVASIVE RESPIRATORY Measurement of transcutaneous oxygen tension The skin is suitable for measuring oxygen tension - PtcO2. The oxygen tension is a variable for the perception of early disturbances in the systemic circulation and assessment of tissue perfusion. Clark electrodes and heated miniturizados = > Non-invasive measurements of PtcO2. Heated electrodes were used as substitutes for measurements of oxygen partial pressure - PaO2 in newborns, in order to red uce the need for arterial puncture.

NON-INVASIVE RESPIRATORY Measurement of transcutaneous oxygen tension PtcO2 enables continuous monitoring and real-time location of oxygen transport. PtcO2 depends on: O2 partial pressure in arterial blood, and DC BLOOD FLOW. RN h emodynamically stable satisfactory. Infants with circulatory problems PtcO2

PtcO2 <PaO2.

Adults: PtcO2 <PaO2 (tissue stains and thicker NON-INVASIVE RESPIRATORY Measurement of transcutaneous oxygen tension Proper blood flow: PtcO2 parallel to the PaO2. Decreased blood flow: PtcO2 paral lel to the stream.

Heating of the skin: more rapid diffusion of oxygen, which can affect the tissue s and blood due to decreased solubility of oxygen. T ° C PtcO2 to the electrodes. NON INVASIVE MONITORING RESPIRATORY VENTILATION - Capnometers Capnometry Capnography End tidal CO2 Essence of monitoring of respiratory function

NON INVASIVE MONITORING RESPIRATORY VENTILATION - Capnometers UTILITY: Possibility of monitoring, each respiratory cycle, the CO2 concentratio n of expired air at the end of expiration. PetCO2: concentration of CO2 in alveo lar air (partial pressure of CO2 in arterial blood PaCO2). Useful because it ind icates possible changes in the dynamics of CO2, which may be at risk for the pat ient. The measurement can be performed by mass spectrometry or infrared spectrop hotometry. NON INVASIVE MONITORING RESPIRATORY VENTILATION - Capnometers Capnography: Partial pressure of CO2 during the respiratory cycles by a sensor applied to the VA's patient or the aspiration of an air sample of VA's processed by a sensor. NON INVASIVE MONITORING RESPIRATORY VENTILATION - Capnometers Capnography: PaCO2 of 0 in inspiratory phase. rise rapidly after the onset of expiration. alveolar plateau. NOTE: During spont aneous breathing is a new slump for CO2 inspired 0. Capnography is used as a par ameter to indicate incipient respiratory acidosis and as a tool to aid in weanin g from the ventilator. NON INVASIVE MONITORING RESPIRATORY VENTILATION - Capnometers CAPNOGRAM A: NON INVASIVE MONITORING RESPIRATORY Measurement of transcutaneous CO2 tension Voltage measurement of CO2 (PtcCO2) to calculate the PaCO2: Stowe-Severinghaus e lectrode PtcCO2> PaCO2 local heating of the skin and increased CO2 production. Cardiac output monitoring MONITORING OF DC Cardiac output is the important factor for bloodstream transport of substances b etween the tissues DC = FC X VS VS PRE-LOAD Contractility POST-LOAD MONITORING OF DC Checking DC - Doppler thoracic bioimpedance Doppler echocardiography - Access roads Supra-sternal Transesophageal

MONITORING OF DC Suprasternal - ADVANTAGES Comfort conscious patient - DISADVANTAGES Keep in position transducers Use of pulsed Doppler (ambiguity between distance / speed. And variations) Patients with tracheostomy does not perform the supraste rnal dressings sterile conditions unfavorable thoracic measurements ulta sonic A verage sternotomy mediastinal emphysema MONITORING OF DC Access transesophageal - - - - Relatively easy to measure causes discomfort to the patient m Uneasy malformatio ns or injuries prevent anatomical deformities of the oropharynx the introduction of the toracomediastinais probe MONITORING OF DC Introduction probe - Determined for each patient transducers on the chest 3rd intercostal space justa esternal - Via nasal or oral - not disposable sterile probe after use Probe filled balloon fixed electrical connection to the flowmeter MONITORING OF DC Bioimpedance Thoracic - Notes: Cardiac output id index MONITORING OF DC Steps Installation interpretation of the figures and - Cleaning the thoracic and cervical alcohol or ether to remove sweat or grease - Exclusive use of silver electrodes impedance known and fixed - two electrodes in the cervical and thoracic region - exactly two electrodes in the cervical (5c m above and below the points MONITORING OF DC Left ventricular function study of the cardiac cycle thoracic flu

- Two electrodes on the anterior chest capture electrical axis running from the monitor - Monitor weight height sex date 6 digit printer - Control of the electr o magnetic environment MONITORING OF DC Thermodilution catheter arterial diameter 4F, through the femoral artery and con nected to a computer for analysis of the pulse wave for assessment of left ventr icular cardiac output and thus determine the remnant right ventricular function. MONITORING OF DC Advantages Method - - Low cost Ease of installation Continuous data with precise interpretations - no risk of morbidity and mortality. Neurological monitoring Neurological monitoring Held every hour depending on the patient's condition What's the point? To reduce morbidity and mortality in the ICU, without jeopardizing patient care.

Neurological monitoring TERMS: transcranial spectroscopy; Ecoencefalografia; Electroencephalography, Tra nscranial Doppler; Potential wrong Neurological monitoring

Transcranial spectroscopy; Monitor the supply of O2 and cerebral hemodynamics Utilizes an injection verdein docianina marker that displays intense infrared absorption Neurological monitoring Ecoencefalografia; It is the record of echoes inside the skull through ultrasound; transcribed The images are stored on the oscilloscope; It determines the position of brain struc tures and delinha average distance from it to the wall of the lateral ventricle or the wall It detects the third ventricle midline shift caused by cerebral subd ural hematoma, intracerebral hemorrhage, neoplasms Neurological monitoring Electroencephalography: Record of electrical activity generated in the brain Provides physiological asse ssment of brain activity;€ It is useful in the diagnosis of seizures, Assessment of coma or brain syndromes and somo indicator of brain death Neurological monitoring

Doppler Transcranial: It measures the flow velocity of middle and anterior cerebral arteries c cerebral vasospasm resulting from subarachnoid hemorrhage Neurological monitoring Potential evoked: It is used to define the absence of structural lesions in the toxic and metaboli c comas and to localize lesions of the brainstem, and reports on post-traumatic coma Assistance NURSING PLAN OF CARE • nursing diagnosis Risk for decreased cardiac output related to vascular resistan ce, blood vessel constriction, myocardial ischemia, hypertrophy / ventricular st iffness. Expected Outcomes • Patient present stable cardiac rhythm and frequency w ithin the normal range of the individual; • Maintain BP within the range acceptabl e spoke individually • Monitor PA; • Observe the presence and quality of peripheral pulses • Auscutar heart sounds and breath sounds; • Observe skin color, moisture, te mperature, • Observe edema; • Monitor responses to medication to control blood press ure. • Check vital signs Nursing diagnosis Expected Results Interventions • Conduct procedure aseptic technique; • Wash hands using the techniqu e before and after invasive procedures • Check the vital signs of 2/2h (8:00, 10:0 0, 12:00, 14:00, 16: 00, 18:00, 20:00, 22:00, 24:00, 02:00, 04:00, 06:00) • Use PP E before procedures • Carry out general hygiene 12/12h • Observe the general hygiene in the hours established. • Patient risk for infection not related to infection present performance of invas ive procedures Nursing diagnosis related to perceptual change sensory cranial edema characteriz ed by absence of pupillary reaction Expected Outcomes • Patient recover sensory perception reacting to sensory stimuli Speakers • Maintain dialogue with the patient during procedures (where necessary) • Administer analgesics that do not mask the level of consciousness as prescriptio n; • Apply cold compress to eye with saline in the morning, noon and night; • Reques t Evaluation neurological. Nursing diagnosis Expected Results Speakers Cerebral tissue perfusion altered: less than body requirements related to inabil Diagnosti

ity to ingest and eat characterized by the presence of trauma • patients improved their neurological homeostasis • Raising the threshold to 30; • Control the levels of PIC when installed; • Evaluate when an arterial saturation less than 85% • Check SSVV Nursing diagnosis ineffective breathing pattern related to brain damage characte rized by decreased vital capacity Expected Outcomes • Patient submit breathing patterns to normal or satisfactory • Speakers Aspire trachea and pharynx (where necessary) • Maintain controlled mechan ical ventilation; • Observe alarms; • Auscutar respiratory sounds of 10/10h • Monitor mechanical ventilation. FINAL