Module Name – Continuous Monitoring
Attendance
The Organization designs and carries out its own processes
to provide continuity of patient care services in the hospital and
coordination among health care practitioners.
During all phases of inpatient care, there is a qualified
nurse allocated as responsible for the patient’s care.
Patient was connected with the hemodynamic
monitor in critical care unit and never left alone.
There is continuous monitoring of the critically ill
patient as critically ill patient requires continuous
assessment of their cardiovascular system to diagnose
and manage their complex medical conditions.
Purpose of Continuous Monitoring
Monitoring patients beat to beat haemodynamic
condition.
Early detection and identification of life-
threatening conditions.
Prompt response based on detection
Evaluate the patient’s immediate response to
treatment such as drugs and mechanical
support.
Components of Continuous Monitoring
SpO2
Heart Rate
ECG
ABP
CVP
Urine output
Ventilator parameter
Clinical Alarm
Continuous monitoring - SpO2
Oxygen saturation or SpO2 is a measure of how much hemoglobin is currently bound
to oxygen compared to how much hemoglobin remains unbound. Normal SpO2 is
95% or higher.
Altered Condition Action to be taken
SpO2 < 95%, Monitor the patient’s breathing pattern, rate and depth.
Re-site the probe
Warm and rub the skin
Try a different probe
Use a different machine
Inform to on call Doctor & In-charge
Give oxygen as ordered
Nursing Responsibility on SpO2 Monitoring
• Remove nail paint if any.
• Check peripheral temperature.
• Apply probe correctly.
• Change the site of probe every 2hourly.
• Set the alarm limit for HR as per doctor advice.
• Document in observation chart.
• Inform to doctor if less than 95%.
Heart Rate
Heart rate, is the number of times one's heart beats per minute. A normal resting
heart rate is between 60 to 100 beats per minute,
Altered Condition Action to be taken
Heart Rate < 60 beats per minute Monitor the patient’s level of consciousness, breathing
pattern, BP and SpO2.
Administer oxygen
Inform to on call Doctor & In-charge
Heart Rate > 100 beats per minute Keep Inj. Atropine ready for symptomatic bradycardia
Rule out the cause
Symptomatic management
ECG
ECG, is the graphical representation of the electrical activity of heart. In normal ECG (Sinus Rhythm) -
Every P wave is followed by QRS complex
Regular P-P interval and R-R interval.
Rate varies between 60 - 100
Altered Condition Action to be taken
Monitor the patient’s level of consciousness, breathing
pattern, BP and SpO2.
Sinus Bradycardia Administer oxygen
Inform to on call Doctor & In-charge
Keep Inj. Atropine ready for symptomatic bradycardia
Rule out the cause
Sinus Tachycardia Symptomatic management
ECG
Altered Condition Action to be taken
Monitor the patient’s hemodynamic status
Missed Beat Document the rhythm
Inform to on call Doctor & In-charge
Keep Inj. Atropine ready
Sinus Arrest Keep Temporary pacemaker ready
Sick Sinus Syndrome /
Tachy – Brady Syndrome
ECG
Altered Condition Action to be taken
Monitor the patient’s hemodynamic status
Document the rhythm
Inform to on call Doctor & In-charge
Valsalva maneuver
SVT (Supraventricular Tachycardia) Carotid Sinus Message
Synchronized Cardioversion
Injection Adenosine
Monitor the patient’s hemodynamic status
Document the rhythm
Inform to on call Doctor & In-charge
Atrial Flutter Injection Cordarone
Consent
sedation
Synchronized Cardioversion
Atrial Fibrillation
ECG
Altered Condition Action to be taken
Monitor the patient’s hemodynamic status
Document the rhythm
Ventricular Ectopic
Inform to on call Doctor & In-charge
Check electrolytes
Correct electrolytes
Couplet
Ventricular Bigeminy
Ventricular Trigeminy
ECG
Altered Condition Action to be taken
Inform to on call Doctor, In-charge & RRT
Check Pulses
Defibrillation
Ventricular Tachycardia
Injection Cordarone
Injection Magnesium
Activate Code Blue
Torsade D Points VT
CPR
Defibrillation
Injection Adrenaline
Ventricular Fibrillation Injection Vasopressine
ECG
Altered Condition Action to be taken
Check the position of ECG Leads and connect
If ECG remains same -
Activate Code Blue
CPR
Asystole
Advance Airway
Injection Adrenaline
ECG changes
Certain ECG changes need to monitor, document and report immediately -
ST Elevation in MI Complete Heart Block
Tall T wave in Hyperkalemia Flat or Inverted T wave in Hypokalemia
ECG changes in Pacemaker
Pacing Failure
Ventricular Pacing Rhythm
Capture Failure
Dual Chamber Pacing Rhythm
Sensing Failure
Nursing Responsibility on ECG Monitoring
• Put the electrodes with ECG cable and fix on the chest wall.
• Set the alarm limit for HR as per doctor advice.
• Select the appropriate lead and keep in the filter mode.
• Change the electrodes every 3rd day and SOS.
• If arrhythmia is present, inform to doctor and do proper
management.
• Document in observation chart.
• Make sure ECG leads are always connected to the patient
Arterial Blood Pressure - ABP
ABP is a measure of pressure within large arteries in the systemic circulation and measured through
canulation of a peripheral artery. In normal adult systolic blood pressure ranges from 90 – 140 mm of
Hg and diastolic blood pressure ranges from 60 – 90 mm of Hg.
Altered Condition Action to be taken
Check for any –
• Loose connections.
• Air bubbles.
• Kinks.
• Blood clots.
Normal Under-damped Over -damped Rectify the cause
ABP > 140/90 mm of Hg Flushing
ABP < 90/60 mm of Hg Zeroing and calibration
Inform to on call Doctor, In-charge & RRT
Administer medication or fluid as order.
Nursing Responsibility on ABP Monitoring
• Continuous arterial pressure monitoring is indicated for patients with acute hypertension, hypotension, shock
respiratory failure, neurological injury, coronary interventional procedure, continuous infusion of vocative drugs
and frequent ABG sampling.
• ABP may be from radial, brachial or femoral arterial lines.
• Check the arterial waveform continuously and activate the alarms.
• Maintain the arterial line patency by the continuous flush irrigation system in order to prevent thrombus
formation.
• Inflate the pressure bag to 300mmHg and check whether the flush rate is 1-3ml/hr.
• Assess the Neuro vascular status distal to the arterial site (Colour, temperature and pulse of the limb) every
hourly.
• Monitor the pressure waveform continuously for over damping or under damping and in low cardiac output
and arrhythmias (during this time ECG and pressure wave form are checked simultaneously).
• Do zeroing and calibration and document.
Pressure Monitoring Troubleshooting
Damped Waveforms:
Pressure bag inflated to 300 mmHg
Reposition extremity or patient
Verify appropriate scale
Flush or aspirate line
Check or replace module or cable
Inability to obtain zeroing:
Connections between cable & monitor
Position of stopcocks
Retry zeroing after above adjustments
Central Venous Pressure - CVP
CVP is a measure of pressure in the vena cava, can be used as an estimation of preload and right atrial
pressure. In normal adult CVP ranges from 2 – 10 mm of Hg.
Altered Condition Action to be taken
Check for -
• Transducers position
CVP > 15 mm of Hg • Loose connections.
CVP < 2 mm of Hg • Air bubbles.
• Kinks.
• Blood clots.
Rectify the cause, Flushing, Zeroing and calibration
Inform to on call Doctor, In-charge & RRT
Administer medication or fluid as order.
Urine Output
The normal urine output is 0.5 ml – 1 ml/ kg /hour and pale yellow in colour
Altered Condition Action to be taken
Hourly measure urine output
Urine Output < 0.5 ml/kg/hour
Check for –
Urine Output > 1 ml/kg/hour
• Placement of uro-bag
Hematuria
• Catheter Kink or any clot
Rectify the cause
Inform to on call Doctor, In-charge & RRT
Administer medication or fluid as order.
Special Points on Continuous Monitorin
1. All patient in critical care unit are considered as Potential for hemodynamically unstable.
2. Patient should be always on continuous monitoring gadgets as applicabe.
3. Alarm should be set based on patients condition and will be always on mode.
4. Nurse must look on the monitor continuously and hear actively to assess - Heart rate, Respiratory rate, Saturation, ECG
rhytm, ABP, CVP which are applicable.
5. For mechanically ventilated patients nurse must set alarm and monitor for Tidal volume, Minute volume, Respiration rate
and airway pressure. Alarm for battary backup also need to monitor(if applicable).
6. Allocation of nurse in critical care unit should be always sidewise for better monitoring and avoid reverse allocation.
7. Observation trolley should be kept in leg end side, so that monitoring of more than one patient can be done easily.
Monitor screen should be visible enough to the staff.
8. Monitoring handover including alarm set, UPS connection should be given in each shift.
9. Ensure all cables are attached properly during care for ensuring continuous monitoring .
10. Allocated nurse will always inform to the sister incharge or other senior nurses to monitor her patient if she has to leave her
allocated patient due to any reason.
11. In case of 1:2 allocation and curtain is provided to one patient for maintaining privacy, make sure that curtain should be in
such a manner that the monitor of other patient is visible enough
Shift Incharges Responsibility on Continuous Monitoring
Make sure that all patients are assigned to the monitor.
Make sure that all monitors are functional and connected to the UPS.
During care schedule shift-Incharge should be inside the ITU to ensure continuous monitoring of patient in mobile
Intermittent round and monitoring of patient.
In case shift incharge has to move out of unit, she should hand over to other senior staff to do continuous monitoring.
Clinical Alarm
Monitoring devices with alarm provide critical information to staff about patient’s
physiologic condition as well as status of machine function. Alarm can be both auditory and
visual
Alarm protocol and standard procedure:
A clinical alarm may indicate- • Set patient specific alarm threshold.
• Document set alarm parameters in medical record file
• A serious fatal incident or everyday and when changed.
• A medical device malfunction • Only silence alarm when you are attending the alarm
and during CPR.
• How to respond to alarm: alarm- silence- respond
• Time to respond to alarm: should be monitored by
senior staff
Alarm Inventory per bed per 24 hrs
• Cardiac Monitor Parameter Setup
parameters threshold parameters threshold
Arterial systole high 180 / low 90 Extreme bradycardia 35
Arterial diastole high 120 / low 50 Extreme tachycardia 180
Arterial mean high 120 / low 50 Asystole delay 10 sec
HR high 150 / low 50 Ventricular tachy rate 150
RR high 40 / low 10 Ventricular brady rate 40
SPO2 high 100 / low 90 Ventricular tachy PVC 3 beats
Desaturation on Ventricular brady PVC 3 beats
Alarm volume 10 (high) Pause time 2 sec
RAP/CVP/PAP/QTC off
Alarm Management Protocol
Device Protocol
Set alarm threshold for each patient every day and document it
Switch off non actionable alarm like RAP, CVP , PAP, QTC
Alarm Volume 10
Recording should be on
All arrhythmia alarms should be on and high volume
Nail polish if any should be removed for SPO2 checking
ECG electrodes should be changed when loose
Identify source of alarm silence and attend it
Ambience noise should be 45 DB in the morning 40 in the evening and
20 at night
Alarm Management Protocol
Device Protocol
Mechanical set alarm threshold for each patient every day and document it
ventilator
standard alarm TV 200 ml up and down
setting
Minute volume 2 L up and down
Airway pressure high 40
Respiration rate high 40 low 10
Dialysis default alarm setting continue, alarm volume high
machine
IABP default alarm setting continue, alarm volume high
Warm blanket default alarm setting continue, alarm volume high
Syringe pump default alarm setting continue, alarm volume low
Air mattress default alarm setting continue, alarm volume low
Questionnaire
Choose the best possible option.
1. Patient is sleeping. Monitor showing straight line. What should be your response?
A. Assess the patient response and act accordingly.
B. Check for loose or disconnected leads.
C. Increase the gain of the ECG
D. All of the above.
2. If you have 2 patient allocation and going to do Folley’s catheter care, how will you ensure the
continuous monitoring of both the patient
A. Provide privacy with applying curtain.
B. Inform to your other patient that you are going to give care to near by patient.
C. Curtain should be in such a manner that the monitor of both the patient is visible enough for
monitoring and in case If it is not possible to monitor the other patient ,then ask the help of another staff
or shift in-charge to monitor your patient.
D. Non of the above
3. Patient is intubated with high inotropes. Suddenly monitor showing ABP 70/40 mmhg with damped wave.
What is your first response?
A. Inform to doctor.
B. Start bolus fluid
C. Increase Inotropes
D. Flush or aspirate line and reposition the hand.
4. How will you response to clinical alarm?
A. Inform to doctor - Document
B. Identify the reason- Silence- Respond/Act accordingly
C. Document – Respond – Silence
D. Document – Respond – Inform the doctor
5. Which is the accurate place to keep the transducer?
A. Near to the line.
B. Head end side of patient
C. At the level of 2nd intercostal space
D. At the cut point of 4th Inter costal space and mid-axillary line
6. How long monitor, ventilator, defibrillator should be attached with UPS ?
A. When Using for the patient
B. Alwyays 24 x 7
C. Untill battery backup is complete
D. None of The above
7. In visiting hour you are going to shift one of your allocated patient from critical care unit to ward. What will you do for
another patient.
A. Inform the patient that you will be returning soon.
B. Inform the relatives that you will be returning soon.
C. Inform the senior staff nurse and asked her to monitor.
D. All of the above
8. Following which condition you will inform ?
A. Patients SpO2 - 98%
B. Patients SpO2 - 100%
C. COPD patient SpO2 - 94%
D. LVF patient SpO2 - 95%, patient tachypnic
9. Which are the alarms you will monitor when a patient is on mechanical ventilator?
A. Tidal volume, Minute Volume
B. Airway pressure, Respiration rate
C. All ofthe above
D. None of The above
10. In hemodynamic monitoring pressure bag should be inflated to -
A. 200 mm of Hg.
B. 250 mm of Hg.
C. 280 mm of Hg
D. 300 mm of Hg.
THANK
YOU
