6/16/2020 Monitoring the Critically Ill Patient - BSAVA2012 - VIN

Monitoring the Critically Ill Patient

Monitoring a critical patient can be one of the most challenging aspects of nursing, but can
also be the most rewarding.
When people think about a monitoring lecture, technically advanced monitors and machines
spring to mind. The fact is 'fancy' machines are always nice to have and can be incredibly
useful, but this never removes the fact that careful and diligent hands-on monitoring/nursing is
the most important aspect of patient monitoring. The critical care nurse should be continually
reassessing the patient's status, response to treatment and the need for any alterations to the
patient's management plan.
There are many reasons why a patient may need critical care monitoring; this includes
diseases and condition affecting the major body systems (e.g., heart failure, pneumonia,
seizures) but also severe disease affecting other organs (e.g., pancreas, liver, kidneys) with
secondary effects on the major body systems. Some patients may be admitted directly to the
critical care unit following trauma or other acute incident (e.g., toxicity); others may be
admitted following deterioration of a pre-existing medical condition and yet others may be
admitted for postoperative monitoring following major surgery. The list of potential patients is
endless and the critical care nurse needs to be familiar with the pathophysiology of many
illnesses as well as a wide range of diagnostic and therapeutic procedures.
The status of critically ill patients may change rapidly either in response to therapies or to
their underlying disease. Changes in status of patients should be recorded and acted on
rapidly. Early detection of deterioration or complications gives the best chance of successful
intervention to address the problem.
Once you have taken over responsibility for the nursing care of a patient you should
familiarise yourself with the history and perform a physical examination, to establish baseline
parameters, so changes in the patient condition can be detected. A minimum of a
temperature, pulse rate/quality, respiratory rate and effort and mentation should be
performed. Depending on the patient condition other baseline parameters may need to be
checked for instance chest auscultation, bladder size. The history may be obtained from
nursing rounds, where important information can be passed between shifts so continuity of
care is achieved. Once the patient has been quickly assessed and notes reviewed, plans for
monitoring and assessment can be formulated.
A good critical care nurse will think ahead and anticipate problems and complications before
they happen. It is important that any instructions on the patient's care are clarified and the
nurse should feel confident to ask the clinician questions and make suggestions, to allow the
best nursing care.
Patient monitoring is an essential part of the critical care unit and something with which
nurses are intimately involved. It allows management plans to be regularly reassessed and
deterioration or complications to be detected in a timely fashion. Repeated physical
examination is the most important monitoring tool and does not require expensive equipment.
Get to know your patients!
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Hands-On Monitoring
Monitoring needs to be tailored to the individual patient. However, there are certain
parameters that should be recorded regularly regardless of the patient's status. These
include:
Perfusion parameters: heart rate, pulse quality, mucous membrane colour, capillary refill
time
Respiratory rate and effort
Chest auscultation
Demeanour
Rectal temperature
Bodyweight
The frequency of assessment will vary both between individual parameters and individual
patients; this should be reviewed on a daily basis.
Neurological Patient Monitoring
The Modified Glasgow Coma Scale may be used for initial and ongoing assessment;
however, it is often preferable to modify or focus the checks being performed according to
the needs of each individual patient in discussion with the clinician. Checks that may be
performed include:
Mentation: alert, obtunded (mentally dull), stuporous (semiconscious but rousable by a
painful stimulus), comatose (unconscious and unable to be aroused)
Pupils: size, symmetry, pupillary light reflexes
Presence and direction of nystagmus
Menace responses
Facial asymmetry and abnormal posture (e.g., head tilt)
Presence of gag reflex (in stuporous or comatose patients only)
Pain sensation and withdrawal reflexes in limbs
In addition, regular monitoring of heart rate and systemic blood pressure may indicate the
onset of Cushing reflex secondary to significantly raised intracranial pressure.
Other Monitoring Considerations - the Use of Equipment
The use of modern technology to aid patient monitoring should never replace the physical
examination and values generated by machines should always be interpreted carefully,
especially if they do not agree with the physical assessment. Action should be taken on any
unexpected findings; there is no point performing monitoring, if the findings are not going to
be acted upon.
Further monitoring tools can include:
Continuous electrocardiogram (ECG) - useful for patients with dysrhythmias or those
with rapidly changing heart rates. It may also be useful for monitoring patients with
intracranial disease or certain electrolyte abnormalities such as hyperkalaemia.
Arterial blood pressure - arterial blood pressure can be measured by either indirect
(Doppler or oscillometric) or direct (arterial catheter) means. The information provided
is dependent on the method used and whether a systolic, diastolic or mean pressure is
obtained. Arterial blood pressure represents the driving force for tissue perfusion.
Prolonged hypo- or hypertension should be avoided.
Central venous pressure - this measures the blood pressure in the central venous
compartment usually via a catheter in the jugular vein. It provides the best measure of
vascular filling and is especially useful in patients at risk of volume overload such as
those with heart failure or renal failure that also require fluid therapy.

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Pulse oximetry - this provides a measure of haemoglobin saturation. It is easy to perform
although can be unreliable especially in conscious patients. It is not sensitive to early
hypoxia but identification of subtle trends can be an important clue that the patient's
oxygen status is altering and can prompt a more accurate assessment such as arterial
blood gas analysis.
End-tidal CO2 - this provides a measure of the amount of carbon dioxide present in
exhaled air and is closely related to the patient's arterial CO2 and ventilation status.
Bloodwork - the ability to perform regular in-house monitoring tests of certain parameters
is important. Which parameters are monitored will depend on the nature of the patient's
disease and the facilities available. Consideration should be given to regular
monitoring of PCV/TS (packed cell volume/ refractometric total solids), blood glucose,
electrolytes, venous or arterial blood gas, clotting parameters and blood smear
examination.
Again, which parameters are monitored and how frequently this is done will depend on the
changing needs of the individual patient. Although the final decision regarding making
treatment changes typically lies with the veterinarian, it is very important for the critical care
nurse to continually review and interpret the results of monitoring in particular to decide on the
urgency with which the clinician needs to be notified. This can be greatly helped by having
specified 'Notify if...' criteria for each patient.
Fluid balance is often disrupted in critical patients, and monitoring fluid ins and outs is an
important nursing role. 'Ins' include water consumption, nutrition (enteral or parenteral) and
parenteral fluid therapy; 'outs' include urine, faeces, vomitus, fluid lost from wounds and fluid
lost into body cavities (so-called third spacing). In addition to these considerations,
parameters such as bodyweight and PCV/TS can provide further information with respect to
fluid balance.
Pain Management Assessment
The veterinary nurse is the person who normally spends the most time with the patient, and
is often in an ideal position to comment on the patient's analgesia requirements and
response to therapy. Pain assessment scores can be used to allow a more objective
assessment of the patient especially between different shifts and nurses. Nurses should be
encouraged to be proactive in informing the veterinarian if they believe the patient's
analgesia regime is not sufficient. The provision of adequate analgesia is mandatory and a
liberal approach with frequent reassessment is recommended.
Nutritional Monitoring
Adequate nutrition, commenced at the appropriate time, is a vital part of the recovery of
many critically ill patients, especially cats. This will serve to prevent gut stasis and potentially
the translocation of bacteria from the gastrointestinal tract, help prevent or treat
hypoproteinaemia, ensure adequate calorific intake for the patient's metabolic state and, in
cats, help prevent hepatic lididosis. Each animal should have its resting calorific
requirements calculated (the use of nutritional factors is no longer recommended) and the
nurse should regularly monitor, to ensure adequate nutrition is received.
Monitoring Indwelling Catheters and Other Tubes
The critical patient will often have a number of indwelling catheters and other tubes in place.
It is important to manage these appropriately with all devices being checked at least once
daily. Minimising the risk of infection, ensuring patency/purpose, and preventing
complications are the main considerations. All devices should be clearly labelled with respect
to their location.
Drug Therapies
Critical patients are often on a number of different drug therapies and nurses are typically
responsible for their administration. It is therefore important for nurses to have a good
working knowledge of various aspects involving commonly used drugs, i.e.,
pharmacodynamics, pharmacokinetics, side effects and interactions with other drugs.
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Keeping Good Records
Clinical notes are important for all animals but never more important than in critical patients.
Good, thorough, legible records are essential to provide details on how a case is being
managed.

S I
(click the speaker's name to view other papers and abstracts submitted by this speaker)
Belinda Andrews-Jones, VTS(ECC), DAVN(Surgical), LCGI, RVN
Queen Mother Hospital for Animals
Royal Veterinary college
London, UK

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