i bc27f85be50b71b1 (248 page)

APPENDIX III-A: MEDICAL -SURCICAL EQUIPMENT fN THE AClITE CARE SITTING

791

Figure IU-A.9. Pulmonary artery {PAl catheter (four lumen model) in a

branch of a PA with the bal/oon inflated; the pulmonary capillary wedge pres·

SlIre (peWP) ref/ects left atrial pressllre (LAP). (LA = left atrillm; LV = left

ventricle; RV= right vemricle.) (Reprinted with permission from LD Kersten

led/. Comprehensive Respiratory Nursing: A Decision·Making Approach.

Philadelphia: Sallllders, 1989;758.)

lotracranial Pressure Monitoring

Intracranial pressure (ICP) and cerebral perfusion pressure may be

measured in a variety of ways, depending on how urgently ICP values

are needed and the patient's neurologic or hemodynamic stability.

Refer to Intracranial and Cerebral Perfusion Pressure in Chapter 4 for

a description of these terms, Table 4-20 for a description of the early

and late signs of increased ICP, and Table 4-21 for a list of treatment

options to decrease ICP.

Table lll-A.S describes the different types of ICP monitors. For some

lCP monitors, such as the inrravenrricuJar catheter, the sensor and the

transducer must be level. Often, the zero point for the transducer is at the

traglls, or the top of the ear. A normal ICP waveform has a triphasic sinusoidal waveform and should correspond to heart rate.

General Physical Therapy Considerations with

Intracranial Pressure Monitoring

•

As with hemodynamic monitoring, be aware of the lCP value and

the corresponding waveform on the monitor. The waveform may

change shape (plateau wave) if cerebral hypoxia or ischemia occurs.1J

Table OJ-A.S. Intracranial Pressure (ICP) Monirors

.....

'"

N

Device

Description

Clinical Implications

Epidural sensor

Purpose: to monitor fCP.

§

•

The transducer does not need [Q be adjusted

Consists of: a fiberoptic sensor. It is placed

(releveled) with position changes.

()

>-

"

in the epidural space (i.e., superficial ro

•

Fair reliability.

'"

the dura) and connects to a transducer

J:

>and monitor.

Z

o

Subarachnoidl

Purpose: ro directly monitor ICP and provide

•

The physician will determine the level to which the

g

subdural bol,

access for CSF sampling.

transducer should be positioned. This is documented

"

Consists of: a bolt or screw placed in the

in the chart and posted at me bedside.

"

"

subarachnoid or subdural space through a

•

The transducer must be repositioned to the

�

J:

burr hole.

appropriate level with position changes.

-<

�

•

Poor reliability.

�

Intraventricular

Purpose: to directly monitor ICi> and provide

r

•

The nondominant hemisphere is the preferable

catheter

access for the sampling and drainage of

insertion site.

J!

'"

"

(ventriculosromy)

CSF. Occasionally used to administer

•

There are twO different types of drainage

>

medications.

systems: intermittent and continuous.

�

Consists of: a small catheter that is placed in

•

The intermittent system allows the nurse to drain

the anterior horn of the lateral ventricle

CSF for 30-120 secs by momentarily opening a

through a burr hole. The catheter connects

stopcock when the lCP exceeds the parameters set

to a transducer and to a drainage bag,

by 'he physician.

where CSF collects.

•

A continuous system allows the drainage of CSF to

occur against a pressure gradient when the

collection bag is positioned (leveled) above [he

foramen of Monro. This is usually 15 cm above the

external auditory meatus.

,.

• The transducer must be repositioned to the

�

appropriate level with position changes.

'Z

'"

• Very reliable.

x

Fiberoptic transducer

Purpose: co monicor fCP. Can also monitor

• The transducer does not need to be adjusted

tipped catheter

incraparenchymal pressure (if the catheter

(releveled) with position changes.

;:

is placed in the parenchyma).

•

Very reliable.

b

Consists of: a fiberoptic transducer-tipped

9

catheter. It is placed in the venrricle, within

r

J,

the parenchyma, or in the subarachnoid or

C

"

subdural space.

Cl

l'

>

CSF

r

= cerebrospmal fluid.

Sources: Data from A£ Davis, TL Briones. Intf3cranial Disorders. In MR Kinney, S8 Dunbar, JM Virello-Cicciu) et al. (cds), AACN's Clinical E

c

Reference Manual for Critical Care Nursing (4th cd), St. Louis: Mosby, 1998; and LA Thelan, KM Stacy, LD Urden, ME Lough (cds). Neuro

;;

l::

logic Therapeutic Management, Critical Care Nursing: Diagnosis and Managemem (3rd ed). St. Louis: Mosby, 1 998.

�

z

J!

"'

>

n

!OJ

"'

n

,.

'"

"'

�

"

'"

'"

7 94 ACtJrE CARE HANDBOOK FOR PHYSICAL THERAPISTS

•

Momentary elevations in ICP will normally occur. It is a sustained elevation in ICP that is of concern and should be reported to the nurse.

•

Patients with elevated ICP are often positioned with the head

of the bed at 30 degrees, which maximizes venous blood flow

from the brain to help decrease ICP.'4 Therefore, be aware that

lowering the head of the bed may increase ICP. Other positions

that increase ICP are the Trendelenburg position, lateral neck

flexion, and extreme hip flexion.

•

Additional conditions that increase ICP are the Valsalva maneuver, noxious stimuli, pain, and coughing.

Medical-Surgical Management Devices

Different lines, tubes, catheters, and access devices comprise the wide

variety of medical-surgical equipment used in the acute care setting.

In general, these devices may be peripheral or central, for shorr- or

long-term use, and inserted or applied at the bedside in a special procedure (e.g., under fluoroscopic guidance) or in the operating room.

Table LII-A.6 describes the medical-surgical management devices most

commonly encountered in the acute care setting.

General Physical Therapy Considerations with

Medical-Surgical Management Devices

The following clinical tips apply to medical-surgical equipment, as

well as to the 02 therapy and noninvasive, invasive, and ICP moniroring equipment previously discussed.

Clinical Tip

•

Before entering a patient's room, review the medical

record, particularly new orders, recent progress notes, and

test results. Review graphic sheets for vital signs, noting

trends or variations from the norms.

•

Note whether any particular precautions protecting the

patient or the caregiver from specific pathogens are in