Patient Monitoring and Vital Signs
CVP
Especially in patients admitted to the ICU, central venous pressure (CVP) can be measured. This method measures the blood pressure in the vena cava and right atrium. The values range from 6 to 12 cm of water in the vena cava and between 0 and 4 cm of water in the right atrium. During the process, the patient should be supine.
The nursing assistant cannot measure this parameter but should assist at any time in the process, having all the material ready, assisting in the development of the procedure, collecting all the used material at the end, and recording the values in the hospitalization graph.
Fluid Balance Measurement Procedure
The balance is determined by measuring the amount of liquid that the patient ingests and removes in 24 hours. In a normal balance, the value is zero, meaning the same amount is ingested as eliminated. The balance is positive when the volume of fluid produced is greater than the liquid removed and negative when the volume of liquid lost is greater than the liquid contained.
The balance of liquid can be part of a graph or on a separate sheet or record.
Measurement of Fluid Loss
To make a correct balance, every loss or expense should be measured: diuresis, stools, sweating, and insensible loss. Besides these, pathological losses are also noted: hemorrhages, drains, vomiting, etc.
After adding all the partial sums of each shift, determine the total volume of fluid lost and record it in the chart. The balance is made by subtracting the outputs from the income.
Ratio of Fluid Intake and Output
Intake
- Liquid ingested orally: This includes liquid administered directly, such as the liquid content of food and water, or through enteral feeding.
- Perfused liquid: Liquid administered by any route except the gastrointestinal tract, such as serum, blood, parenteral feeding, etc.
Output
- Diuresis (urine output)
- Sweat
- Feces or droppings
- Insensible losses (respiration, secretion)
- Vomiting
- Aspiration (gastric and drains)
- Hemorrhages
Hospitalization Graph
The hospital graph is a document that is part of a patient’s clinical history. It allows medical staff to obtain prompt and clear information regarding the patient’s physical state.
Types of Graphs
There are many types of hospital graphs. The graphs at the center are divided into two groups: regular or monthly and hourly or special.
Monthly or Routine Graphs
This graph is designed to collect all the data of vital signs every day, including two controls, one upon admittance and later, during 30 days of observation. In this graph, data is recorded such as:
- Pulse
- Respiration
- Temperature
- Blood tension and venous blood pressure (exceptionally)
- Patient weight
- Depositions
- Sputum
- Therapeutic
- Fluid balance: fluid intake and loss
Special or Hourly Graphs
This graph records data related to the patient, hour by hour, for 24 hours. It is used mostly in the ICU, resuscitation rooms, coronary care units, operating rooms, and emergency rooms. It is used in situations where the patient’s mind must be rigorously controlled.
Data recorded includes:
- Constant vital signs: including central venous pressure always
- Liquid balance
- Analytical and hemodynamic parameters
- Information provided by respirators and oxygen
- Therapeutic
A commentary section is used to record all the interesting facts related to the patient.
Vocabulary
- Tachycardia: Heart rate increased above normal values
- Bradycardia: Frequency decrease below normal values
- Bigeminal pulse: Grouping of heartbeats in couples, both mixed
- Blood pressure: Pressure exerted by blood within the arteries
- Diastolic pressure: Artery pressure at the time of diastole, relaxation of the right ventricle, ranging from 60 to 90 mmHg
- Systolic pressure: Blood pressure at the time of systole, left ventricular contractions
- Hypertension: Increased artery tension above the limits of normal values
- Hypotension: Decrease of artery tension below the limits of normal values
- Sphygmomanometer: Instrument for measuring artery pressure
- Auscultation: Listening to sounds that occur within the body, especially in the heart, blood vessels, and respiratory system
- Venous pressure: Arterial blood pressure in the vena cava or right atrium
- Balance of liquid: Liquid equilibrium resulting from the balance of fluid entering and leaving the body
- Temperature: Physical magnitude that expresses the degree of heat, expressed in °C
- Hypothalamus: Brain region located at the base of the brain, where the vital center is located
- Hypothermia: Drop in body temperature below normal values
- Hyperthermia: Pathological increase as evidenced by the elevation of body temperature above normal values
- Fever: Pathogenic phenomenon manifested by the elevation of body temperature above normal values
- Pyrexia: Fever
- Slight fever: Mild fever
- Breath: Function by which the body takes in air (oxygen) into the lungs (inspiration), i.e., performs gas exchange
- Medulla oblongata: Location in the brain where the controlling organ of respiration is situated
- Inspiration: The act of breathing through which air enters the lungs; aspiration
- Eupnea: Normal respiration
- Hyperpnea: Increased depth of respiration
- Orthopnea: Inability to breathe while lying horizontally
- Tachypnea: Increased rate of respiration
- Rattling breath: Breathing in which you hear noise due to the presence of bronchial secretions
- Pulse: Expansion and contraction of the arteries