Monitoring of Patients in the ICU: Difference between revisions

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Introduction[edit | edit source]

Intensive care units (ICUs) are vital for enhancing the survival of critically ill patients through the continuous monitoring and maintenance of their vital functions.^[1]^[2] Vital signs indicate the status of the patient’s life-threatening functions in the ICU.^[3] Continuous monitoring of patients’ vital signs or physiological functions aids in ensuring patient safety through awareness of critical changes in the patient’s health status, and it guides daily therapeutic intervention.^[4]^[5]^[6] Early recognition of patient deterioration and timely intervention are critical in saving patients’ lives.^[5]^[7]^[8] Subtle changes in vital signs such as respiratory rate, blood pressure, heart rate, temperature and oxygen saturation are early signs of clinical deterioration that will eventually lead to adverse events.^[5]^[8]^[9]^[10] Through continuous monitoring of the vital signs, clinical deterioration can be identified well in advance of any adverse events occurring.^[5]^[8] In order to recognise an acute change in a patient’s physiology, their vital signs must first be accurately assessed.^[11]

Vital Signs[edit | edit source]

The NICE guidelines^[12] recommends that heart rate (HR), respiratory rate (RR), blood pressure (BP), oxygen saturation (SpO2), level of consciousness and temperature be measured at a minimum but that the additional monitoring of pain, urine output and biochemical analysis also be added.

Blood pressure

Blood pressure (BP) can be defined as the pressure exerted by the circulatory blood on the arterial walls.^[11]^[13]^[14] It provides an important reflection of the blood flow when the heart is contracting (systole) and relaxing (diastole).^[11] Three values are considered when measuring BP: systolic (SBP), diastolic (DBP) and mean (MBP) pressure. SBP indicates the peak pressure attained during the cardiac cycle whereas DBP is the trough. Mean arterial pressure (MAP) is defined as the mean pressure during the cardiac cycle and is an important parameter during resuscitation procedures.^[14] The difference between SBP and DBP is known as the pulse pressure (PP) and determines the peripheral palpability of the arterial pressure wave (for example at the radial or femoral site).^[14] Normative BP values^[15] can be found in Table 1.

Parameter	Normal range
Systolic blood pressure (SBP)	90-140 mmHg
Diastolic blood pressure (DBP)	60-90 mmHg
Mean arterial pressure (MAP) [SBP + (2 x DBP)]/3	70-105 mmHg
Right atrial pressure	2-6 mmHg

Table 1. Normative haemodynamic data. Adapted from Parillo & Dellinger.^[15]

Alterations in BP can be reflective of underlying pathologies or of the body’s attempts to maintain homeostasis.^[11] A decrease in BP is often seen in patients prior to cardiac arrest.^[11] Hypotension can also lead to inadequate perfusion of the vital organs. During hypertension the myocardial workload is increased and it can therefore precipitate cerebral vascular incidents (CVI).^[13]

There are many factors with the ability to influence BP, these include:^[13]

Nicotine
Pain
Position of the patient
Medication
Alcohol
Illicit drugs

Inherently BP is also influenced by cardiac output, peripheral vascular resistance, blood volume and viscosity as well as vessel wall elasticity.^[11]

BP can be measured non-invasively using a sphygmomanometer (BP cuff) but is often measured invasively using arterial lines which are generally inserted in large blood vessels such as the radial or femoral artery^[13]^[14]^[16]. Data from intra-arterial catheters are considered more reliable and provides continuous BP monitoring while also allowing easy collection of arterial blood (to assess blood gas and acid-base analysis) without further peripheral puncturing.^[14] Another invasive method of measuring BP is through a central venous pressure (CVP) line where the tip of the catheter is positioned close to the right atrium.^[13]^[14] The internal jugular and subclavian veins are often used when inserting a CVP line. The CVP line reflects right atrial filling pressure and helps with the assessment of intraventricular volume and right-sided heart function.^[13]^[16]

CC Attribution – Share alike 3.0

https://commons.wikimedia.org/wiki/File:Blood_Pressure_Information.jpg

Match Health. Systole vs. Diastole. Published 10 Feb 2016. [last accessed 15 Feb 2021]. https://www.youtube.com/watch?v=o3UA-bTbWDc

Respiratory rate

Respiratory rate refers to the number of breaths as calculated over one minute, with a normal RR being 12-20 breaths per minute. A rise in RR is the most sensitive indicator of clinical deterioration and impending adverse events such as cardiac arrest or death.^[11]^[13]

Tachypnoea refers to a rate of more than 20 breaths per minute and is a sign of respiratory distress. During bradypnoea the RR is less than 10 breaths per minute and is often caused by drugs (e.g. opioids), hypothermia, fatigue or central nervous system depression.^[13] A RR of more than 24 breaths per minute is considered a medical emergency as it indicates the possibility for respiratory failure. Common respiratory terminology can be found in Table 2.

Terminology	Definition
Tachypnoea	Abnormally quick RR (>20 breaths/minute)
Bradypnoea	Abnormally slow RR (<12 breaths/minute)
Dyspnoea	Difficulty with breathing
Orthopnoea	Difficulty breathing necessitating an upright sitting position to alleviate
Hypoxia	Insufficient oxygen at a cellular level
Hypoxaemia	Low levels of oxygen in the blood
Anoxia	Lack of oxygen

Table 2. Explanation of respiratory terminology^[13]

While the measurement of RR is vital, it is also important to assess:^[11]^[13]^[17]

Respiratory effort - including depth of inspiration, use of accessory muscles and the sound of breathing (noisy breathing is indicative of an increased workload in breathing)
Chest movement - is it equal, bilateral and symmetrical
Pattern/rhythm of breathing

The inability to breathe spontaneously inevitably leads to the need for mechanical ventilation (MV). MV is an essential supportive treatment for critically ill patients and is a frequent occurrence in the ICU.^[13] It is connected to the patient through the use of an endotracheal tube or a tracheostomy tube via a closed circuit. Ventilators are classified based on the methods utilized to cycle between the inspiratory and the expiratory phases. These include the:^[13]^[14]^[16]

pressure control mode - the inspiratory pressure is set, the rate is set and the volume is dependent on the patient’s lung compliance.
volume control mode - the tidal volume is pre-set, the rate is set but the peak inspiratory pressure varies depending on the patient’s degree of lung compliance.

It is important to be aware of the ventilator modes frequently used. These are described in Table 3.

Ventilator mode	Description
SIMV (Synchronised intermittent mandatory ventilation)	Delivers pre-set volume or pressure at a pre-set rate and it is synchronised with the patient’s own respiratory effort. Volume or pressure cycled Most commonly used ventilator mode Can be used as a weaning mode
CMV (Controlled mandatory ventilation)	Delivers gas at a pre-set volume and rate is is not synchronised with spontaneous breaths
PSV (Pressure support ventilation)	A pre-set inspiratory pressure enhances the spontaneous breaths of the patient. The rate and volume of the ventilation is controlled by the patient
PC (Pressure control ventilation)	Gas is delivered at a pre-set rate and inspiratory pressure, volume is dependent on the patient’s lung compliance
BIPAP (Bilevel positive airway pressure)	Pressure-controlled ventilation that allows spontaneous breaths from the patient anywhere in the cycle. Provides high and low positive end expiratory pressure
CPAP (Continuous positive airway pressure)	Provides constant positive airway pressure in spontaneous mode (often seen with PSV). Promotes exchange of gasses through the opening of alveoli and by increasing the functional residual capacity.
PEEP (Positive end expiratory pressure)	Same principle as CPAP but in a non-spontaneous mode

Table 3. Mechanical ventilator modes. Adapted from Jevon et al ^[13]

Pulse

Pulse is defined as “the palpable rhythmic expansion of an artery produced by the increased volume of blood pushed into the vessel by the contraction and relaxation of the heart”.^[11] It reflects both the circulating volume and the strength of contractility.^[11] There are many factors that can impact the pulse of a patient and includes:^[11]

age
medication (e.g. beta-blockers)
existing medical conditions (e.g. fever)
fluid status (hyper/hypovolaemia)

Pulse incorporates more than just heart rate, which is the measurable characteristic of pulse. When palpating pulse, the strength/amplitude of the pulse, regularity of the pulse and the peripheral equality of pulses should also be considered.^[11] Many of the characteristics of pulse is monitored using an electrocardiograph (ECG) which is essential in diagnosing cardiac rhythm disorders.^[13] The incidence of cardiac arrhythmias is as high as 40% in patients in the ICU and can be attributed to electrolyte imbalances, metabolic disturbances, invasive lines, multiple drug therapy and quick changes in their intravascular volumes.^[18] The bedside cardiac monitor (oscilloscope) in the ICU provides a continuous display of not only the patient’s ECG, which includes heart rate (measured as the number of QRS complexes) and rhythm, but also the oxygen saturation (SpO2).^[13] Continuous ECG monitoring facilitates quick identification of arrhythmias and therefore staff can promptly respond to such events.^[14] The 3- or 5-lead ECG provides easy attachment and immediate information about the electrical activity of the heart, but the 12-lead ECG provides a more accurate assessment.^[14]

Heart rate is reflected by the number of QRS complexes in a minute (QRS rhythm) and a rate of 60-100 beats per minute (bpm) is considered to be within normal limits.^[13] In order to detect any abnormalities in rhythm, it is recommended that the HR be assessed for a full 60 seconds.^[11] Definite arrhythmias are diagnosed based on an ECG, but arrhythmias can be broadly classified into two groups based on heart rate. These include tachycardias (HR > 100 bpm) and bradycardias (HR < 60 bpm).^[18]

CC. Atribution 3.0 Unported (CC by 3.0)

https://commons.wikimedia.org/wiki/File:2028_Cardiac_Cycle_vs_Electrocardiogram.jpg

LUXSONTube. Electrocardiograph. Published 10 Sept 2012. [last accessed 15 Feb 2021]. https://www.youtube.com/watch?v=ygsvAZVA6sc

Oxygen saturation/pulse oximetry

Pulse oximetry is the technique used to measure arterial oxygen saturation in the peripheral blood vessels.^[13]^[14] It can be defined as “the ratio between oxygenated haemoglobin and the total amount of haemoglobin” in the blood^[13]^[14] and is expressed as SpO2. A SpO2 of 95-100% is considered within normative ranges and if less than 90% it is of grave concern.^[13]^[15] It is an easy, painless, non-invasive method wherein a probe is placed on the fingertip or earlobe to measure the oxygen saturation indirectly. A fall in SpO2 indicates the development of hypoxaemia long before any visual evidence of cyanosis (SpO2 of 80-85%) becomes evident.^[13]

Various factors influence the accuracy of pulse oximetry and these include:^[11]^[14]

Movement of the patient
Incorrect positioning of the probe
Hypothermia
Hypovolaemia
Vasoconstriction
Nail polish - as it absorbs the light waves used to measure SpO2

Temperature

Body temperature is represented by “the balance between heat produced and heat lost (thermoregulation)”.^[11] Clinically, three types of body temperature have been described:^[11]

Patient’s core body temperature
Patient’s report of how they feel
Surface body temperature/how the patient feels to touch

Temperature can be affected by many factors, including the underlying pathophysiology (e.g. infection or sepsis), skin exposure (e.g. in the operating theatre), age. The site of where the temperature is measured can also be affected by local factors such as the oral temperature immediately after consumption of hot/cold beverages.^[11] It is therefore important to consider not only proper calibration of the measuring device but also the variation of core temperature between different anatomical sites. Documentation of the site of measurement together with the measured temperature is essential for the accuracy of the measurement.^[11] Core thermometers (located on catheters and probes inserted into the pulmonary artery, esophagus, bladder or rectum) is considered to be more accurate than peripheral thermometers (oral, axillary, temporal artery, tympanic membrane) and preferred in critically ill patients.^[16]^[18]

Normal body temperature in healthy individuals is considered to be 36.8°C ± 0.4°C (measured in the oral cavity) with normal circadian variations of 0.5°C.^[16]^[18] Clinically, temperatures of 33-36°C are considered as mild hypothermia, 28-32°C as moderate hypothermia and below 28°C as deep hypothermia (Deutschmann 2020), whereas any temperature above 38.3°C is considered a fever.^[16]^[18]

A cool skin temperature can also be indicative of poor peripheral perfusion (circulatory problem) and the capillary refill time (CRT) (normative <2 secs) should therefore also be assessed.^[13]

Level of consciousness

Level of consciousness (LOC) is the single most important indicator of cerebral functioning.^[17] It can be defined as the “degree of arousal and awareness” of a patient.^[13] In the critically ill patient, the LOC is most commonly assessed using the Glasgow Coma Scale (GCS)^[12]^[17] but the simpler AVPU rapid neural assessment method can also be used:^[13]

Alert

Responsive to Verbal stimulation

Responsive to Painful stimulation

Unresponsive

The GCS assesses two aspects of consciousness, namely:

Arousal/Wakefulness
Patient awareness in demonstrating an understanding of what a practitioner said through the ability to complete tasks

A GCS score of less than 12 is considered concerning and a patient with a score of less than 9 will probably require airway intervention and intubation. A reduction of 2 points on the GCS is considered significant in indicating clinical deterioration of the patient.^[13]

A patients’ LOC or mental status can be affected by several factors including side effects of some medications (sedatives or analgesics, e.g. benzodiazepines, anxiolytics, opioids), hypoxia, hypercapnia, hypoglycaemia, hypotension, alcohol, cerebral pathology, etc.^[11]^[13]

Ausmed. Glasgow Coma Scale (GCS). Published 15 Dec 2019. [last accessed 15 Feb 2021]. https://www.youtube.com/watch?v=_BGMQDmwRmA

Pain

Critically ill patients in the ICU frequently experience acute pain. Many factors can lead to pain in the critically ill patient, including surgical and posttraumatic wounds, prolonged immobilisation, the use of invasive monitoring devices and mechanical ventilators, and even routine nursing care (for example, changing dressings).^[18] Patients experience pain differently, but the physiological consequences of inadequately managed pain are predictable and potentially harmful.^[18] Physiological responses to pain include increases in RR, HR and BP. Pain also increases patients’ anxiety and leads to sleep disturbances which will affect the optimal recovery of the patient.^[19] Pain can incur functional limitations such as impaired mechanics of the pulmonary system and delayed ambulation which could lead to higher morbidity in critically ill patients.^[18] Assessment of pain is therefore vital for patient recovery and improved functional outcomes.^[11] Tools for the assessment of pain in the ICU includes the numeric pain rating scale, the analogue scale, the behavioural pain scale and the critical care pain observation scale.^[14]^[18] Heightened sympathetic activity like hypertension, increased heart rate and restlessness can be indicators of pain in heavily sedated or paralyzed patients.^[18]

Physiotherapy treatment can also be hampered by pain in that patient participation is reduced and mobilisation is limited. Early proactive steps should therefore be taken to address the patient’s requirements for analgesia before commencement of physiotherapy treatment.^[19] Pain can be managed with analgesics together with physiotherapeutic modalities. Physiotherapeutic interventions for pain does not aim to substitute for the analgesic medication but to rather reduce the total dose of analgesic medication needed in order to reduce their unavoidable side effects.^[19]

Urine output

Even though urine output is an indicator of renal perfusion, it is frequently used as an indicator of cardiac output (25% of cardiac output perfuses the kidneys).^[13] Normal urine output in adults is at least 0.5 ml/kg/h, which also signals adequate renal perfusion.^[11]^[13]^[18] With urine output of less than 500ml in 24 hours, the kidneys are unable to excrete the waste products of metabolism which can result in uremia, metabolic acidosis and hyperkalaemia.^[13]^[18]

A drop in urine output may the the first clinical indicator of fluid and electrolyte imbalance and is considered an early sign of hypovolaemia.^[11]^[13] When cardiac output falls so does renal perfusion, ultimately leading to renal failure.^[11]^[13]

The parameters for urinary output disorders can be found in Table 4.

Urinary Output condition	Parameters
Anuria	<50ml urine in 24 hours
Oliguria	<400 ml urine in 24 hours [<0.5ml/kg/h]
Polyuria	>3000 ml urine in 24 hours
Dysuria	Painful micturition

Table 4. Urinary output conditions^[13]^[18]

Conclusion[edit | edit source]

It is essential to initiate early mobilisation and physical rehabilitation in critically ill patients to ensure better outcomes for the patient.^[1]^[20] But it is also known that changing patient position causes changes in their haemodynamic balance.^[18] Changes in vital signs are often the first indicators of clinical deterioration of the patient^[9] and play an important role in informing the most appropriate course of treatment to pursue.^[4] It is therefore essential for physiotherapists to closely monitor and interpret the vital signs of patients to guide their treatment and if necessary, to quickly intervene or alert the rest of the ICU team when alarming rapid changes occur. Close and continuous monitoring by the physiotherapist during and immediately after mobilisation is essential for patient safety as clinically stable patients can potentially become unstable during and/or after mobilisation.^[19]

Rodnie Oro. Monitors. Published 1 April 2020. [last accessed 15 Feb 2021]. https://www.youtube.com/watch?v=FeakHyjnkEY

ICU Advantage. Basic Vent Modes MADE EASY – Ventilator Settings Reviewed. Published 27 Jan 2020. [last accessed 15 Feb 2021]. https://www.youtube.com/watch?v=E5uLM41URmE

Resources[edit | edit source]

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References[edit | edit source]

↑ ^1.0 ^1.1 Swaminathan N, Praveen R, Surendran P. The role of physiotherapy in intensive care units: a critical review. Physiotherapy Quarterly. 2019;27(4):1-5. DOI:10.5114/pq.2019.87739
↑ Mercadante S, Gregoretti C, Cortegiani A. Palliative care in intensive care units: why, where, what, who, when, how. BMC anesthesiology. 2018 Dec;18(1):1-6. DOI:10.1186/s12871/018-0574-9
↑ Chang D, Chang D, Pourhomayoun M. Risk prediction of critical vital signs for ICU patients using recurrent neural network. In 2019 International Conference on Computational Science and Computational Intelligence (CSCI) 2019 Dec 5 (pp. 1003-1006). IEEE.
↑ ^4.0 ^4.1 Poncette AS, Spies C, Mosch L, Schieler M, Weber-Carstens S, Krampe H, Balzer F. Clinical requirements of future patient monitoring in the intensive care unit: qualitative study. JMIR medical informatics. 2019;7(2):e13064. DOI:10.2196/13064
↑ ^5.0 ^5.1 ^5.2 ^5.3 Khanna AK, Hoppe P, Saugel B. Automated continuous noninvasive ward monitoring: future directions and challenges. Critical Care. 2019 Dec;23(1):1-5. DOI:10.1186/s13054-019-2485-7
↑ Cardona-Morrell M, Prgomet M, Lake R, Nicholson M, Harrison R, Long J, Westbrook J, Braithwaite J, Hillman K. Vital signs monitoring and nurse–patient interaction: A qualitative observational study of hospital practice. International journal of nursing studies. 2016 Apr 1;56:9-16. DOI:10.1016/j.ijnurstu.2015.12.007
↑ Baig MM, Afifi S, GholamHosseini H, Ullah E. Deterioration to decision: a comprehensive literature review of rapid response applications for deteriorating patients in acute care settings. Health and Technology. 2020 May;10(3):567-73. DOI:10.1007/s12553-019-00403-7
↑ ^8.0 ^8.1 ^8.2 Mok WQ, Wang W, Liaw SY. Vital signs monitoring to detect patient deterioration: An integrative literature review. International journal of nursing practice. 2015 May;21:91-8. DOI:10.1111/ijn.12329
↑ ^9.0 ^9.1 Brekke IJ, Puntervoll LH, Pedersen PB, Kellett J, Brabrand M. The value of vital sign trends in predicting and monitoring clinical deterioration: A systematic review. PloS one. 2019 Jan 15;14(1):e0210875.DOI:10.1371/journal.pone.0210875
↑ Van Graan AC, Scrooby B, Bruin Y. Recording and interpretation of vital signs in a selected private hospital in the KwaZulu-Natal province of South Africa. International Journal of Africa Nursing Sciences. 2020 Jan 1;12:100199. DOI:10.1016/j.ijans.2020.100199
↑ ^11.00 ^11.01 ^11.02 ^11.03 ^11.04 ^11.05 ^11.06 ^11.07 ^11.08 ^11.09 ^11.10 ^11.11 ^11.12 ^11.13 ^11.14 ^11.15 ^11.16 ^11.17 ^11.18 ^11.19 ^11.20 ^11.21 ^11.22 Elliott M, Coventry A. Critical care: the eight vital signs of patient monitoring. British Journal of Nursing. 2012 May 23;21(10):621-5.
↑ ^12.0 ^12.1 National Institute for Clinical Excellence. Acutely ill adults in hospital: recognising and responding to deterioration. NICE Guidelines no July. 2007:1-30.
↑ ^13.00 ^13.01 ^13.02 ^13.03 ^13.04 ^13.05 ^13.06 ^13.07 ^13.08 ^13.09 ^13.10 ^13.11 ^13.12 ^13.13 ^13.14 ^13.15 ^13.16 ^13.17 ^13.18 ^13.19 ^13.20 ^13.21 ^13.22 ^13.23 ^13.24 ^13.25 ^13.26 ^13.27 ^13.28 ^13.29 ^13.30 Jevon P, Ewens B, Pooni JS. Monitoring the critically ill patient. 3rd ed. Londres: Wiley-Blackwell; 2012.
↑ ^14.00 ^14.01 ^14.02 ^14.03 ^14.04 ^14.05 ^14.06 ^14.07 ^14.08 ^14.09 ^14.10 ^14.11 ^14.12 Comisso I, Lucchini A, Bambi S, Giusti GD, Manici M. Nursing in Critical Care Setting. Switzerland: Springer International Publishing; 2018. DOi:10.1007-978-3-319-50559-6
↑ ^15.0 ^15.1 ^15.2 Parrillo JE, Dellinger RP. Critical care medicine: Principles of diagnosis and management in the adult. 5th ed. Philadelphia: Elsevier; 2019.
↑ ^16.0 ^16.1 ^16.2 ^16.3 ^16.4 ^16.5 Deutschman CS, Neligan PJ, editors. Evidence-based practice of Critical Care. 3rd ed. Philadelphia: Elsevier; 2020.
↑ ^17.0 ^17.1 ^17.2 Burns SM, Delgado SA, editors. AACN essentials of critical care nursing. 4th ed. New York: McGraw Hill Education; 2019.
↑ ^18.00 ^18.01 ^18.02 ^18.03 ^18.04 ^18.05 ^18.06 ^18.07 ^18.08 ^18.09 ^18.10 ^18.11 ^18.12 ^18.13 Vincent JL, Abraham E, Kochanek P, Moore FA, Fink MP. Textbook of Critical Care. 7th ed. Philadelphia: Elsevier; 2017.
↑ ^19.0 ^19.1 ^19.2 ^19.3 Ahmad AM. Essentials of physiotherapy after thoracic surgery: What physiotherapists need to know. A narrative review. The Korean Journal of thoracic and cardiovascular surgery. 2018 Oct;51(5):293. DOI:10.5090/kjtcs.2018.51.5.293
↑ Nydahl P, Sricharoenchai T, Chandra S, Kundt FS, Huang M, Fischill M, Needham DM. Safety of patient mobilization and rehabilitation in the intensive care unit. Systematic review with meta-analysis. Annals of the American Thoracic Society. 2017 May;14(5):766-77. DOI:10.1513/AnnalsATS.201611-843SR

[:7-1] 1.0 ^1.1 Swaminathan N, Praveen R, Surendran P. The role of physiotherapy in intensive care units: a critical review. Physiotherapy Quarterly. 2019;27(4):1-5. DOI:10.5114/pq.2019.87739

[2] Mercadante S, Gregoretti C, Cortegiani A. Palliative care in intensive care units: why, where, what, who, when, how. BMC anesthesiology. 2018 Dec;18(1):1-6. DOI:10.1186/s12871/018-0574-9

[3] Chang D, Chang D, Pourhomayoun M. Risk prediction of critical vital signs for ICU patients using recurrent neural network. In 2019 International Conference on Computational Science and Computational Intelligence (CSCI) 2019 Dec 5 (pp. 1003-1006). IEEE.

[:8-4] 4.0 ^4.1 Poncette AS, Spies C, Mosch L, Schieler M, Weber-Carstens S, Krampe H, Balzer F. Clinical requirements of future patient monitoring in the intensive care unit: qualitative study. JMIR medical informatics. 2019;7(2):e13064. DOI:10.2196/13064

[:0-5] 5.0 ^5.1 ^5.2 ^5.3 Khanna AK, Hoppe P, Saugel B. Automated continuous noninvasive ward monitoring: future directions and challenges. Critical Care. 2019 Dec;23(1):1-5. DOI:10.1186/s13054-019-2485-7

[6] Cardona-Morrell M, Prgomet M, Lake R, Nicholson M, Harrison R, Long J, Westbrook J, Braithwaite J, Hillman K. Vital signs monitoring and nurse–patient interaction: A qualitative observational study of hospital practice. International journal of nursing studies. 2016 Apr 1;56:9-16. DOI:10.1016/j.ijnurstu.2015.12.007

[7] Baig MM, Afifi S, GholamHosseini H, Ullah E. Deterioration to decision: a comprehensive literature review of rapid response applications for deteriorating patients in acute care settings. Health and Technology. 2020 May;10(3):567-73. DOI:10.1007/s12553-019-00403-7

[:1-8] 8.0 ^8.1 ^8.2 Mok WQ, Wang W, Liaw SY. Vital signs monitoring to detect patient deterioration: An integrative literature review. International journal of nursing practice. 2015 May;21:91-8. DOI:10.1111/ijn.12329

[:9-9] 9.0 ^9.1 Brekke IJ, Puntervoll LH, Pedersen PB, Kellett J, Brabrand M. The value of vital sign trends in predicting and monitoring clinical deterioration: A systematic review. PloS one. 2019 Jan 15;14(1):e0210875.DOI:10.1371/journal.pone.0210875

[10] Van Graan AC, Scrooby B, Bruin Y. Recording and interpretation of vital signs in a selected private hospital in the KwaZulu-Natal province of South Africa. International Journal of Africa Nursing Sciences. 2020 Jan 1;12:100199. DOI:10.1016/j.ijans.2020.100199

[:2-11] 11.00 ^11.01 ^11.02 ^11.03 ^11.04 ^11.05 ^11.06 ^11.07 ^11.08 ^11.09 ^11.10 ^11.11 ^11.12 ^11.13 ^11.14 ^11.15 ^11.16 ^11.17 ^11.18 ^11.19 ^11.20 ^11.21 ^11.22 Elliott M, Coventry A. Critical care: the eight vital signs of patient monitoring. British Journal of Nursing. 2012 May 23;21(10):621-5.

[:10-12] 12.0 ^12.1 National Institute for Clinical Excellence. Acutely ill adults in hospital: recognising and responding to deterioration. NICE Guidelines no July. 2007:1-30.

[:3-13] 13.00 ^13.01 ^13.02 ^13.03 ^13.04 ^13.05 ^13.06 ^13.07 ^13.08 ^13.09 ^13.10 ^13.11 ^13.12 ^13.13 ^13.14 ^13.15 ^13.16 ^13.17 ^13.18 ^13.19 ^13.20 ^13.21 ^13.22 ^13.23 ^13.24 ^13.25 ^13.26 ^13.27 ^13.28 ^13.29 ^13.30 Jevon P, Ewens B, Pooni JS. Monitoring the critically ill patient. 3rd ed. Londres: Wiley-Blackwell; 2012.

[:4-14] 14.00 ^14.01 ^14.02 ^14.03 ^14.04 ^14.05 ^14.06 ^14.07 ^14.08 ^14.09 ^14.10 ^14.11 ^14.12 Comisso I, Lucchini A, Bambi S, Giusti GD, Manici M. Nursing in Critical Care Setting. Switzerland: Springer International Publishing; 2018. DOi:10.1007-978-3-319-50559-6

[:5-15] 15.0 ^15.1 ^15.2 Parrillo JE, Dellinger RP. Critical care medicine: Principles of diagnosis and management in the adult. 5th ed. Philadelphia: Elsevier; 2019.

[:6-16] 16.0 ^16.1 ^16.2 ^16.3 ^16.4 ^16.5 Deutschman CS, Neligan PJ, editors. Evidence-based practice of Critical Care. 3rd ed. Philadelphia: Elsevier; 2020.

[:11-17] 17.0 ^17.1 ^17.2 Burns SM, Delgado SA, editors. AACN essentials of critical care nursing. 4th ed. New York: McGraw Hill Education; 2019.

[:12-18] 18.00 ^18.01 ^18.02 ^18.03 ^18.04 ^18.05 ^18.06 ^18.07 ^18.08 ^18.09 ^18.10 ^18.11 ^18.12 ^18.13 Vincent JL, Abraham E, Kochanek P, Moore FA, Fink MP. Textbook of Critical Care. 7th ed. Philadelphia: Elsevier; 2017.

[:13-19] 19.0 ^19.1 ^19.2 ^19.3 Ahmad AM. Essentials of physiotherapy after thoracic surgery: What physiotherapists need to know. A narrative review. The Korean Journal of thoracic and cardiovascular surgery. 2018 Oct;51(5):293. DOI:10.5090/kjtcs.2018.51.5.293

[20] Nydahl P, Sricharoenchai T, Chandra S, Kundt FS, Huang M, Fischill M, Needham DM. Safety of patient mobilization and rehabilitation in the intensive care unit. Systematic review with meta-analysis. Annals of the American Thoracic Society. 2017 May;14(5):766-77. DOI:10.1513/AnnalsATS.201611-843SR

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 </div>
 == Introduction ==
-Intensive care units (ICUs) are vital for enhancing the survival of critically ill patients through the continuous monitoring and maintenance of their vital functions.<ref>Swaminathan N, Praveen R, Surendran P. [https://pdfs.semanticscholar.org/f87d/85ed9f7b860bd47e2666c118c223ce873480.pdf The role of physiotherapy in intensive care units: a critical review]. Physiotherapy Quarterly. 2019;27(4):1-5. DOI:10.5114/pq.2019.87739 </ref><ref>Mercadante S, Gregoretti C, Cortegiani A. [https://bmcanesthesiol.biomedcentral.com/articles/10.1186/s12871-018-0574-9?utm_source=Weibo&utm_medium=Social_media_advertisingSocial_media_organic&utm_content=CelZha-MixedBrand-OAB-Multidisciplinary-China&utm_campaign=OAB_AWA_CelloZH_WeiboPost_Unpaid Palliative care in intensive care units: why, where, what, who, when, how]. BMC anesthesiology. 2018 Dec;18(1):1-6. DOI:10.1186/s12871/018-0574-9 </ref> Vital signs indicate the status of the patient’s life-threatening functions in the ICU.<ref>Chang D, Chang D, Pourhomayoun M. [https://www.researchgate.net/profile/Mohammad-Pourhomayoun/publication/340810975_Risk_Prediction_of_Critical_Vital_Signs_for_ICU_Patients_Using_Recurrent_Neural_Network/links/5f705131299bf1b53ef73df9/Risk-Prediction-of-Critical-Vital-Signs-for-ICU-Patients-Using-Recurrent-Neural-Network.pdf Risk prediction of critical vital signs for ICU patients using recurrent neural network]. In 2019 International Conference on Computational Science and Computational Intelligence (CSCI) 2019 Dec 5 (pp. 1003-1006). IEEE. </ref> Continuous monitoring of patients’ vital signs or physiological functions aids in ensuring patient safety through awareness of critical changes in the patient’s health status, and it guides daily therapeutic intervention.<ref>Poncette AS, Spies C, Mosch L, Schieler M, Weber-Carstens S, Krampe H, Balzer F. [https://medinform.jmir.org/2019/2/e13064/PDF Clinical requirements of future patient monitoring in the intensive care unit: qualitative study]. JMIR medical informatics. 2019;7(2):e13064. DOI:10.2196/13064 </ref><ref name=":0">Khanna AK, Hoppe P, Saugel B. [https://ccforum.biomedcentral.com/articles/10.1186/s13054-019-2485-7 Automated continuous noninvasive ward monitoring: future directions and challenges]. Critical Care. 2019 Dec;23(1):1-5. DOI:10.1186/s13054-019-2485-7 </ref><ref>Cardona-Morrell M, Prgomet M, Lake R, Nicholson M, Harrison R, Long J, Westbrook J, Braithwaite J, Hillman K. Vital signs monitoring and nurse–patient interaction: A qualitative observational study of hospital practice. International journal of nursing studies. 2016 Apr 1;56:9-16. DOI:10.1016/j.ijnurstu.2015.12.007</ref> Early recognition of patient deterioration and timely intervention are critical in saving patients’ lives.<ref name=":0" /><ref>Baig MM, Afifi S, GholamHosseini H, Ullah E. [https://sci-hub.se/https://link.springer.com/article/10.1007/s12553-019-00403-7 Deterioration to decision: a comprehensive literature review of rapid response applications for deteriorating patients in acute care settings]. Health and Technology. 2020 May;10(3):567-73. DOI:10.1007/s12553-019-00403-7 </ref><ref name=":1">Mok WQ, Wang W, Liaw SY. [https://www.researchgate.net/profile/Wenru_Wang2/publication/279628974_Vital_signs_monitoring_to_detect_patient_deterioration_An_integrative_literature_review/links/5cd826d992851c4eab982144/Vital-signs-monitoring-to-detect-patient-deterioration-An-integrative-literature-review.pdf Vital signs monitoring to detect patient deterioration: An integrative literature review]. International journal of nursing practice. 2015 May;21:91-8. DOI:10.1111/ijn.12329 </ref> Subtle changes in vital signs such as respiratory rate, blood pressure, heart rate, temperature and oxygen saturation are early signs of clinical deterioration that will eventually lead to adverse events.<ref name=":0" /><ref name=":1" /><ref>Brekke IJ, Puntervoll LH, Pedersen PB, Kellett J, Brabrand M. [https://storage.googleapis.com/plos-corpus-prod/10.1371/journal.pone.0210875/1/pone.0210875.pdf?X-Goog-Algorithm=GOOG4-RSA-SHA256&X-Goog-Credential=wombat-sa%40plos-prod.iam.gserviceaccount.com%2F20210209%2Fauto%2Fstorage%2Fgoog4_request&X-Goog-Date=20210209T163615Z&X-Goog-Expires=3600&X-Goog-SignedHeaders=host&X-Goog-Signature=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 The value of vital sign trends in predicting and monitoring clinical deterioration: A systematic review]. PloS one. 2019 Jan 15;14(1):e0210875.DOI:10.1371/journal.pone.0210875  </ref><ref>Van Graan AC, Scrooby B, Bruin Y. [https://reader.elsevier.com/reader/sd/pii/S2214139119300599?token=685EAEC606134F4E79946BD2110DCC0CE8A2B8ADD2865700BF60AE9E7BC5918EA03EEFFDDD89789872BB8B5A606E9255 Recording and interpretation of vital signs in a selected private hospital in the KwaZulu-Natal province of South Africa]. International Journal of Africa Nursing Sciences. 2020 Jan 1;12:100199. DOI:10.1016/j.ijans.2020.100199 </ref> Through continuous monitoring of the vital signs, clinical deterioration can be identified well in advance of any adverse events occurring.<ref name=":0" /><ref name=":1" /> In order to recognise an acute change in a patient’s physiology, their vital signs must first be accurately assessed.<ref name=":2">Elliott M, Coventry A. [https://publicationslist.org/data/m.elliott/ref-22/The%20eight%20vital%20signs%20of%20patient%20monitoring.pdf Critical care: the eight vital signs of patient monitoring]. British Journal of Nursing. 2012 May 23;21(10):621-5. </ref>
+Intensive care units (ICUs) are vital for enhancing the survival of critically ill patients through the continuous monitoring and maintenance of their vital functions.<ref name=":7">Swaminathan N, Praveen R, Surendran P. [https://pdfs.semanticscholar.org/f87d/85ed9f7b860bd47e2666c118c223ce873480.pdf The role of physiotherapy in intensive care units: a critical review]. Physiotherapy Quarterly. 2019;27(4):1-5. DOI:10.5114/pq.2019.87739 </ref><ref>Mercadante S, Gregoretti C, Cortegiani A. [https://bmcanesthesiol.biomedcentral.com/articles/10.1186/s12871-018-0574-9?utm_source=Weibo&utm_medium=Social_media_advertisingSocial_media_organic&utm_content=CelZha-MixedBrand-OAB-Multidisciplinary-China&utm_campaign=OAB_AWA_CelloZH_WeiboPost_Unpaid Palliative care in intensive care units: why, where, what, who, when, how]. BMC anesthesiology. 2018 Dec;18(1):1-6. DOI:10.1186/s12871/018-0574-9 </ref> Vital signs indicate the status of the patient’s life-threatening functions in the ICU.<ref>Chang D, Chang D, Pourhomayoun M. [https://www.researchgate.net/profile/Mohammad-Pourhomayoun/publication/340810975_Risk_Prediction_of_Critical_Vital_Signs_for_ICU_Patients_Using_Recurrent_Neural_Network/links/5f705131299bf1b53ef73df9/Risk-Prediction-of-Critical-Vital-Signs-for-ICU-Patients-Using-Recurrent-Neural-Network.pdf Risk prediction of critical vital signs for ICU patients using recurrent neural network]. In 2019 International Conference on Computational Science and Computational Intelligence (CSCI) 2019 Dec 5 (pp. 1003-1006). IEEE. </ref> Continuous monitoring of patients’ vital signs or physiological functions aids in ensuring patient safety through awareness of critical changes in the patient’s health status, and it guides daily therapeutic intervention.<ref name=":8">Poncette AS, Spies C, Mosch L, Schieler M, Weber-Carstens S, Krampe H, Balzer F. [https://medinform.jmir.org/2019/2/e13064/PDF Clinical requirements of future patient monitoring in the intensive care unit: qualitative study]. JMIR medical informatics. 2019;7(2):e13064. DOI:10.2196/13064 </ref><ref name=":0">Khanna AK, Hoppe P, Saugel B. [https://ccforum.biomedcentral.com/articles/10.1186/s13054-019-2485-7 Automated continuous noninvasive ward monitoring: future directions and challenges]. Critical Care. 2019 Dec;23(1):1-5. DOI:10.1186/s13054-019-2485-7 </ref><ref>Cardona-Morrell M, Prgomet M, Lake R, Nicholson M, Harrison R, Long J, Westbrook J, Braithwaite J, Hillman K. Vital signs monitoring and nurse–patient interaction: A qualitative observational study of hospital practice. International journal of nursing studies. 2016 Apr 1;56:9-16. DOI:10.1016/j.ijnurstu.2015.12.007</ref> Early recognition of patient deterioration and timely intervention are critical in saving patients’ lives.<ref name=":0" /><ref>Baig MM, Afifi S, GholamHosseini H, Ullah E. [https://sci-hub.se/https://link.springer.com/article/10.1007/s12553-019-00403-7 Deterioration to decision: a comprehensive literature review of rapid response applications for deteriorating patients in acute care settings]. Health and Technology. 2020 May;10(3):567-73. DOI:10.1007/s12553-019-00403-7 </ref><ref name=":1">Mok WQ, Wang W, Liaw SY. [https://www.researchgate.net/profile/Wenru_Wang2/publication/279628974_Vital_signs_monitoring_to_detect_patient_deterioration_An_integrative_literature_review/links/5cd826d992851c4eab982144/Vital-signs-monitoring-to-detect-patient-deterioration-An-integrative-literature-review.pdf Vital signs monitoring to detect patient deterioration: An integrative literature review]. International journal of nursing practice. 2015 May;21:91-8. DOI:10.1111/ijn.12329 </ref> Subtle changes in vital signs such as respiratory rate, blood pressure, heart rate, temperature and oxygen saturation are early signs of clinical deterioration that will eventually lead to adverse events.<ref name=":0" /><ref name=":1" /><ref name=":9">Brekke IJ, Puntervoll LH, Pedersen PB, Kellett J, Brabrand M. [https://storage.googleapis.com/plos-corpus-prod/10.1371/journal.pone.0210875/1/pone.0210875.pdf?X-Goog-Algorithm=GOOG4-RSA-SHA256&X-Goog-Credential=wombat-sa%40plos-prod.iam.gserviceaccount.com%2F20210209%2Fauto%2Fstorage%2Fgoog4_request&X-Goog-Date=20210209T163615Z&X-Goog-Expires=3600&X-Goog-SignedHeaders=host&X-Goog-Signature=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 The value of vital sign trends in predicting and monitoring clinical deterioration: A systematic review]. PloS one. 2019 Jan 15;14(1):e0210875.DOI:10.1371/journal.pone.0210875  </ref><ref>Van Graan AC, Scrooby B, Bruin Y. [https://reader.elsevier.com/reader/sd/pii/S2214139119300599?token=685EAEC606134F4E79946BD2110DCC0CE8A2B8ADD2865700BF60AE9E7BC5918EA03EEFFDDD89789872BB8B5A606E9255 Recording and interpretation of vital signs in a selected private hospital in the KwaZulu-Natal province of South Africa]. International Journal of Africa Nursing Sciences. 2020 Jan 1;12:100199. DOI:10.1016/j.ijans.2020.100199 </ref> Through continuous monitoring of the vital signs, clinical deterioration can be identified well in advance of any adverse events occurring.<ref name=":0" /><ref name=":1" /> In order to recognise an acute change in a patient’s physiology, their vital signs must first be accurately assessed.<ref name=":2">Elliott M, Coventry A. [https://publicationslist.org/data/m.elliott/ref-22/The%20eight%20vital%20signs%20of%20patient%20monitoring.pdf Critical care: the eight vital signs of patient monitoring]. British Journal of Nursing. 2012 May 23;21(10):621-5. </ref>
 == Vital Signs ==
-The NICE guidelines<ref>National Institute for Clinical Excellence. [https://www.nice.org.uk/guidance/cg50/resources/acutely-ill-adults-in-hospital-recognising-and-responding-to-deterioration-pdf-975500772037 Acutely ill adults in hospital: recognising and responding to deterioration]. NICE Guidelines no July. 2007:1-30. </ref> recommends that heart rate (HR), respiratory rate (RR), blood pressure (BP), oxygen saturation (SpO2), level of consciousness and temperature be measured at a minimum but that the additional monitoring of pain, urine output and biochemical analysis also be added.
+The NICE guidelines<ref name=":10">National Institute for Clinical Excellence. [https://www.nice.org.uk/guidance/cg50/resources/acutely-ill-adults-in-hospital-recognising-and-responding-to-deterioration-pdf-975500772037 Acutely ill adults in hospital: recognising and responding to deterioration]. NICE Guidelines no July. 2007:1-30. </ref> recommends that heart rate (HR), respiratory rate (RR), blood pressure (BP), oxygen saturation (SpO2), level of consciousness and temperature be measured at a minimum but that the additional monitoring of pain, urine output and biochemical analysis also be added.
 '''<u>Blood pressure</u>'''
-Blood pressure (BP) can be defined as the pressure exerted by the circulatory blood on the arterial walls.<ref name=":2" /><ref name=":3">Jevon P, Ewens B, Pooni JS. [https://dl.uswr.ac.ir/bitstream/Hannan/138807/1/9781444337471.pdf Monitoring the critically ill patient]. 3rd ed. Londres: Wiley-Blackwell; 2012. </ref><ref name=":4">Comisso I, Lucchini A, Bambi S, Giusti GD, Manici M. [https://1lib.us/book/3525811/a96058 Nursing in Critical Care Setting]. Switzerland: Springer International Publishing; 2018. DOi:10.1007-978-3-319-50559-6 </ref> It provides an important reflection of the blood flow when the heart is contracting (systole) and relaxing (diastole).<ref name=":2" /> Three values are considered when measuring BP: systolic (SBP), diastolic (DBP) and mean (MBP) pressure. SBP indicates the peak pressure attained during the cardiac cycle whereas DBP is the trough. Mean arterial pressure (MAP) is defined as the mean pressure during the cardiac cycle and is an important parameter during resuscitation procedures.<ref name=":4" /> The difference between SBP and DBP is known as the pulse pressure (PP) and determines the peripheral palpability of the arterial pressure wave (for example at the radial or femoral site).<ref name=":4" /> Normative BP values<ref name=":5">Parrillo JE, Dellinger RP. [https://1lib.us/book/3707743/375ee3 Critical care medicine: Principles of diagnosis and management in the adult]. 5th ed. Philadelphia: Elsevier; 2019. </ref> can be found in Table 3.
+Blood pressure (BP) can be defined as the pressure exerted by the circulatory blood on the arterial walls.<ref name=":2" /><ref name=":3">Jevon P, Ewens B, Pooni JS. [https://dl.uswr.ac.ir/bitstream/Hannan/138807/1/9781444337471.pdf Monitoring the critically ill patient]. 3rd ed. Londres: Wiley-Blackwell; 2012. </ref><ref name=":4">Comisso I, Lucchini A, Bambi S, Giusti GD, Manici M. [https://1lib.us/book/3525811/a96058 Nursing in Critical Care Setting]. Switzerland: Springer International Publishing; 2018. DOi:10.1007-978-3-319-50559-6 </ref> It provides an important reflection of the blood flow when the heart is contracting (systole) and relaxing (diastole).<ref name=":2" /> Three values are considered when measuring BP: systolic (SBP), diastolic (DBP) and mean (MBP) pressure. SBP indicates the peak pressure attained during the cardiac cycle whereas DBP is the trough. Mean arterial pressure (MAP) is defined as the mean pressure during the cardiac cycle and is an important parameter during resuscitation procedures.<ref name=":4" /> The difference between SBP and DBP is known as the pulse pressure (PP) and determines the peripheral palpability of the arterial pressure wave (for example at the radial or femoral site).<ref name=":4" /> Normative BP values<ref name=":5">Parrillo JE, Dellinger RP. [https://1lib.us/book/3707743/375ee3 Critical care medicine: Principles of diagnosis and management in the adult]. 5th ed. Philadelphia: Elsevier; 2019. </ref> can be found in Table 1.
 {| class="wikitable"
-|Parameter
+|'''Parameter'''
-|Normal range
+|'''Normal range'''
 |-
 |Systolic blood pressure (SBP)
@@ Line 31: / Line 31: @@
 |2-6 mmHg
 |}
-Table 3 Normative haemodynamic data. Adapted from Parillo & Dellinger.<ref name=":5" />
+Table 1. Normative haemodynamic data. Adapted from Parillo & Dellinger.<ref name=":5" />
 Alterations in BP can be reflective of underlying pathologies or of the body’s attempts to maintain homeostasis.<ref name=":2" /> A decrease in BP is often seen in patients prior to cardiac arrest.<ref name=":2" /> Hypotension can also lead to inadequate perfusion of the vital organs. During hypertension the myocardial workload is increased and it can therefore precipitate cerebral vascular incidents (CVI).<ref name=":3" />
@@ Line 54: / Line 54: @@
 '''<u>Respiratory rate</u>'''
-Respiratory rate refers to the number of breaths as calculated over one minute, with a normal RR being 12-20 breaths per minute. A rise in RR is the most sensitive indicator of clinical deterioration and impending adverse events such as cardiac arrest or death (Jevon 2012, Elliott 2012, Churpek 2016).
+Respiratory rate refers to the number of breaths as calculated over one minute, with a normal RR being 12-20 breaths per minute. A rise in RR is the most sensitive indicator of clinical deterioration and impending adverse events such as cardiac arrest or death.<ref name=":2" /><ref name=":3" />
-Tachypnoea refers to a rate of more than 20 breaths per minute adn is a sign of respiratory distress. During bradypnoea the RR is less than 10 breaths per minute and is often caused by drugs (e.g. opioids), hypothermia, fatigue or central nervous system depression (Jevon 2012). A RR of more than 24 breaths per minute is considered a medical emergency as it indicates the possibility for respiratory failure. Common respiratory terminology can be found in Table 1
+Tachypnoea refers to a rate of more than 20 breaths per minute and is a sign of respiratory distress. During bradypnoea the RR is less than 10 breaths per minute and is often caused by drugs (e.g. opioids), hypothermia, fatigue or central nervous system depression.<ref name=":3" /> A RR of more than 24 breaths per minute is considered a medical emergency as it indicates the possibility for respiratory failure. Common respiratory terminology can be found in Table 2.
 {| class="wikitable"
-|Terminology
+|'''Terminology'''
-|Definition
+|'''Definition'''
 |-
 |Tachypnoea
@@ Line 82: / Line 82: @@
 |Lack of oxygen
 |}
-Table 1 Explanation of respiratory terminology
+Table 2. Explanation of respiratory terminology<ref name=":3" />
-While the measurement of RR is vital, it is also important to assess:(Jevon 2012, Elliot 2012, Burns 2019)
+While the measurement of RR is vital, it is also important to assess:<ref name=":2" /><ref name=":3" /><ref name=":11">Burns SM, Delgado SA, editors. [https://1lib.us/book/5638640/18d652 AACN essentials of critical care nursing]. 4th ed. New York: McGraw Hill Education; 2019. </ref>
 * Respiratory effort - including depth of inspiration, use of accessory muscles and the sound of breathing (noisy breathing is indicative of an increased workload in breathing)
 * Chest movement - is it equal, bilateral and symmetrical
 * Pattern/rhythm of breathing
-The inability to breathe spontaneously inevitably leads to the need for mechanical ventilation (MV). MV is an essential supportive treatment for critically ill patients and is a frequent occurrence in the ICU (Jevon 2012). It is connected to the patient through the use of an endotracheal tube or a tracheostomy tube via a closed circuit. Ventilators are classified based on the methods utilized to cycle between the inspiratory and the expiratory phases. These include the: (Jevon 2012, Lucchini in Comisso 2018, Deutchman 2020)
+The inability to breathe spontaneously inevitably leads to the need for mechanical ventilation (MV). MV is an essential supportive treatment for critically ill patients and is a frequent occurrence in the ICU.<ref name=":3" /> It is connected to the patient through the use of an endotracheal tube or a tracheostomy tube via a closed circuit. Ventilators are classified based on the methods utilized to cycle between the inspiratory and the expiratory phases. These include the:<ref name=":3" /><ref name=":4" /><ref name=":6" />
 * pressure control mode - the inspiratory pressure is set, the rate is set and the volume is dependent on the patient’s lung compliance.
 * volume control mode - the tidal volume is pre-set, the rate is set but the peak inspiratory pressure varies depending on the patient’s degree of lung compliance.
-It is important to be aware of the ventilator modes frequently used. These are described in Table 2. (Jevon 2012)
+It is important to be aware of the ventilator modes frequently used. These are described in Table 3.
 {| class="wikitable"
-|Ventilator mode
+|'''Ventilator mode'''
-|Description
+|'''Description'''
 |-
 |SIMV
@@ Line 143: / Line 143: @@
 |Same principle as CPAP but in a non-spontaneous mode
 |}
-Table 2 Mechanical ventilator modes. Adapted from Jevon (Jevon 2012)
+Table 3. Mechanical ventilator modes. Adapted from Jevon et al <ref name=":3" />
 '''<u>Pulse</u>'''
-Pulse is defined as “the palpable rhythmic expansion of an artery produced by the increased volume of blood pushed into the vessel by the contraction and relaxation of the heart” (Elliott 2012). It reflects both the circulating volume and the strength of contractility (Elliott 2012). There are many factors that can impact on the pulse of a patient and includes: (Elliott 2012)
+Pulse is defined as “the palpable rhythmic expansion of an artery produced by the increased volume of blood pushed into the vessel by the contraction and relaxation of the heart”.<ref name=":2" /> It reflects both the circulating volume and the strength of contractility.<ref name=":2" /> There are many factors that can impact the pulse of a patient and includes:<ref name=":2" />
 * age
 * medication (e.g. beta-blockers)
 * existing medical conditions (e.g. fever)
 * fluid status (hyper/hypovolaemia)
-Pulse incorporates more than just heart rate, which is the measurable characteristic of pulse. When palpating pulse, the strength/amplitude of the pulse, regularity of the pulse and the peripheral equality of pulses should also be considered (Elliot 2012). Many of the characteristics of pulse is monitored using an electrocardiograph (ECG) which is essential in diagnosing cardiac rhythm disorders. (Jevon 2012). The incidence of cardiac arrhythmias is as high as 40% in patients in the ICU and can be attributed to the electrolyte imbalances, metabolic disturbances, the invasive lines, multiple drug therapy and the quick changes in their intravascular volumes (Vincent 2017). The bedside cardiac monitor (oscilloscope) in the ICU provides a continuous display of not only the patient’s ECG, which includes heart rate (measured as the number of QRS complexes) and rhythm, but also the oxygen saturation (SpO2) (Jevon 2012). Continuous ECG monitoring facilitates quick identification of arrhythmias and therefore staff can promptly respond to such events (Comisso 2018). The 3- or 5-lead ECG provides easy attachment and immediate information about the electrical activity of the heart, but the 12-lead ECG provides a more accurate assessment (Comissio 2018).
+Pulse incorporates more than just heart rate, which is the measurable characteristic of pulse. When palpating pulse, the strength/amplitude of the pulse, regularity of the pulse and the peripheral equality of pulses should also be considered.<ref name=":2" /> Many of the characteristics of pulse is monitored using an electrocardiograph (ECG) which is essential in diagnosing cardiac rhythm disorders.<ref name=":3" /> The incidence of cardiac arrhythmias is as high as 40% in patients in the ICU and can be attributed to electrolyte imbalances, metabolic disturbances, invasive lines, multiple drug therapy and quick changes in their intravascular volumes.<ref name=":12">Vincent JL, Abraham E, Kochanek P, Moore FA, Fink MP. [https://1lib.us/book/2858938/c10165 Textbook of Critical Care]. 7th ed. Philadelphia: Elsevier; 2017. </ref> The bedside cardiac monitor (oscilloscope) in the ICU provides a continuous display of not only the patient’s ECG, which includes heart rate (measured as the number of QRS complexes) and rhythm, but also the oxygen saturation (SpO2).<ref name=":3" /> Continuous ECG monitoring facilitates quick identification of arrhythmias and therefore staff can promptly respond to such events.<ref name=":4" /> The 3- or 5-lead ECG provides easy attachment and immediate information about the electrical activity of the heart, but the 12-lead ECG provides a more accurate assessment.<ref name=":4" />
-Heart rate is reflected by the number of QRS complexes in a minute (QRS rhythm) and a rate of 60-100 beats per minute (bpm) is considered to be within normal limits. (Jevon 2012).In order to detect any abnormalities in rhythm, it is recommended that the HR be assessed for a full 60 seconds (Elliott 2012). Definite arrhythmias are diagnosed based on an ECG, but arrhythmias can be broadly classified into two groups based on heart rate. These include tachycardias (HR > 100 bpm) and bradycardias (HR < 60 bpm). (Vincent 2017)
+Heart rate is reflected by the number of QRS complexes in a minute (QRS rhythm) and a rate of 60-100 beats per minute (bpm) is considered to be within normal limits.<ref name=":3" /> In order to detect any abnormalities in rhythm, it is recommended that the HR be assessed for a full 60 seconds.<ref name=":2" /> Definite arrhythmias are diagnosed based on an ECG, but arrhythmias can be broadly classified into two groups based on heart rate. These include tachycardias (HR > 100 bpm) and bradycardias (HR < 60 bpm).<ref name=":12" />
 CC. Atribution 3.0 Unported (CC by 3.0)
@@ Line 164: / Line 164: @@
 '''<u>Oxygen saturation/pulse oximetry</u>'''
-Pulse oximetry is the technique used to measure arterial oxygen saturation in the peripheral blood vessels (Jevon 2012, Lucchini in Comisso . It can be defined as “the ratio between oxygenated haemoglobin and the total amount of haemoglobin” in the blood (Lucchini in Comisso et al nursing in critical care setting, Jevon 2012) and is expressed as SpO2. A SpO2 of 95-100% is considered within normative ranges and if less than 90% it is of grave concern (Jevon 2012, Parillo). It is an easy, painless, non-invasive method wherein a probe is placed on the fingertip or earlobe to measure the oxygen saturation indirectly. A fall in SpO2 indicates the development of hypoxaemia long before any visual evidence of cyanosis (SpO2 of 80-85%) becomes evident (Jevon 2012).
+Pulse oximetry is the technique used to measure arterial oxygen saturation in the peripheral blood vessels.<ref name=":3" /><ref name=":4" /> It can be defined as “the ratio between oxygenated haemoglobin and the total amount of haemoglobin” in the blood<ref name=":3" /><ref name=":4" /> and is expressed as SpO2. A SpO2 of 95-100% is considered within normative ranges and if less than 90% it is of grave concern.<ref name=":3" /><ref name=":5" /> It is an easy, painless, non-invasive method wherein a probe is placed on the fingertip or earlobe to measure the oxygen saturation indirectly. A fall in SpO2 indicates the development of hypoxaemia long before any visual evidence of cyanosis (SpO2 of 80-85%) becomes evident.<ref name=":3" />
-Various factors influence the accuracy of pulse oximetry and these include: (Elliot 2012, Lucchini in Comisso 2018)
+Various factors influence the accuracy of pulse oximetry and these include:<ref name=":2" /><ref name=":4" />
 * Movement of the patient
 * Incorrect positioning of the probe
@@ Line 176: / Line 176: @@
 '''<u>Temperature</u>'''
-Body temperature is represented by “the balance between heat produced and heat lost (thermoregulation)” (Elliott 2012). Clinically, three types of body temperature has be been described: (Elliott 2012)
+Body temperature is represented by “the balance between heat produced and heat lost (thermoregulation)”.<ref name=":2" /> Clinically, three types of body temperature have been described:<ref name=":2" />
 * Patient’s core body temperature
 * Patient’s report of how they feel
 * Surface body temperature/how the patient feels to touch
-Temperature can be affected by many factors, including the underlying pathophysiology (e.g. infection or sepsis), skin exposure (e.g. in the operating theatre), age. The site of where the temperature is measured can also be affected by local factors such as the oral temperature immediately after consumption of hot/cold beverages (Elliott 2012). It is therefore important to consider not only proper calibration of the measuring device, but also the variation of core temperature between different anatomical sites. Documentation of the site of measurement together with the measured temperature is essential for the accuracy of measurement (Elliott 2012). Core thermometers (located on catheters and probes inserted into the pulmonary artery, esophagus, bladder or rectum) is considered to be more accurate than peripheral thermometers (oral, axillary, temporal artery, tympanic membrane) and preferred in critically ill patients (Deutschman 2020, Vincent 2017)
+Temperature can be affected by many factors, including the underlying pathophysiology (e.g. infection or sepsis), skin exposure (e.g. in the operating theatre), age. The site of where the temperature is measured can also be affected by local factors such as the oral temperature immediately after consumption of hot/cold beverages.<ref name=":2" /> It is therefore important to consider not only proper calibration of the measuring device but also the variation of core temperature between different anatomical sites. Documentation of the site of measurement together with the measured temperature is essential for the accuracy of the measurement.<ref name=":2" /> Core thermometers (located on catheters and probes inserted into the pulmonary artery, esophagus, bladder or rectum) is considered to be more accurate than peripheral thermometers (oral, axillary, temporal artery, tympanic membrane) and preferred in critically ill patients.<ref name=":6" /><ref name=":12" />
-Normal body temperature in healthy individuals is considered to be 36.8°C ± 0.4°C (measured in the oral cavity) with normal circadian variations of 0.5°C (Deutschmann 2020, Vincent 2017). Clinically, temperatures of 33-36°C are considered as mild hypothermia, 28-32°C as moderate hypothermia and below 28°C as deep hypothermia (Deutschmann 2020), whereas any temperature above 38.3°C is considered as feverish (Vincent 2017, Deutschman 2020).
+Normal body temperature in healthy individuals is considered to be 36.8°C ± 0.4°C (measured in the oral cavity) with normal circadian variations of 0.5°C.<ref name=":6" /><ref name=":12" /> Clinically, temperatures of 33-36°C are considered as mild hypothermia, 28-32°C as moderate hypothermia and below 28°C as deep hypothermia (Deutschmann 2020), whereas any temperature above 38.3°C is considered a fever.<ref name=":6" /><ref name=":12" />
-A cool skin temperature can also be indicative or poor peripheral perfusion (circulatory problem) and the capillary refill time (CRT) (normative <2 secs) should therefore also be assessed (Joven 2012).
+A cool skin temperature can also be indicative of poor peripheral perfusion (circulatory problem) and the capillary refill time (CRT) (normative <2 secs) should therefore also be assessed.<ref name=":3" />
 '''<u>Level of consciousness</u>'''
-Level of consciousness (LOC) is the single most important indicator of cerebral functioning (Burns 2019). It can be defined as the “degree of arousal and awareness” of a patient (Joven 2012). In the critically ill patient the LOC is most commonly assessed using the Glasgow Coma Scale (GCS)(Burns 2019, NICE 2007) but the simpler AVPU rapid neural assessment method can also be used: (joven 2012)
+Level of consciousness (LOC) is the single most important indicator of cerebral functioning.<ref name=":11" /> It can be defined as the “degree of arousal and awareness” of a patient.<ref name=":3" /> In the critically ill patient, the LOC is most commonly assessed using the Glasgow Coma Scale (GCS)<ref name=":10" /><ref name=":11" /> but the simpler AVPU rapid neural assessment method can also be used:<ref name=":3" />
-Alert
+'''A'''lert
-Responsive to Verbal stimulation
+Responsive to '''V'''erbal stimulation
-Responsive to Painful stimulation
+Responsive to '''P'''ainful stimulation
-Unresponsive
+'''U'''nresponsive
 The GCS assesses two aspects of consciousness, namely:
 * Arousal/Wakefulness
 * Patient awareness in demonstrating an understanding of what a practitioner said through the ability to complete tasks
-A GCS score of less than 12 is considered concerning and a patient with a score of less than 9 will probably require airway intervention and intubation. A reduction of 2 points on the GCS is considered significant in indicating clinical deterioration of the patient (Joven 2012).
+A GCS score of less than 12 is considered concerning and a patient with a score of less than 9 will probably require airway intervention and intubation. A reduction of 2 points on the GCS is considered significant in indicating clinical deterioration of the patient.<ref name=":3" />
-Ausmed. Glasgow Coma Scale (GCS). Published 15 Dec 2019. [last accessed 15 Feb 2021]. <nowiki>https://www.youtube.com/watch?v=_BGMQDmwRmA</nowiki>
+A patients’ LOC or mental status can be affected by several factors including side effects of some medications (sedatives or analgesics, e.g. benzodiazepines, anxiolytics, opioids), hypoxia, hypercapnia, hypoglycaemia, hypotension, alcohol, cerebral pathology, etc.<ref name=":2" /><ref name=":3" />
-A patients’ LOC or mental status can be affected by several factors including side effect of some medications (sedatives or analgesics, e.g. benzodiazepines, anxiolytics, opioids), hypoxia, hypercapnia, hypoglycaemia, hypotension, alcohol, cerebral pathology, etc (Elliott 2012, Joven 2012).
+Ausmed. Glasgow Coma Scale (GCS). Published 15 Dec 2019. [last accessed 15 Feb 2021]. https://www.youtube.com/watch?v=_BGMQDmwRmA
 '''<u>Pain</u>'''
-Critically ill patients in the ICU frequently experience acute pain. Many factors can lead to pain in the critically ill patient, including surgical and posttraumatic wounds, prolonged immobilisation, the use of invasive monitoring devices and mechanical ventilators, and even routine nursing care (for example, changing dressings) (Boldt chap 3 in Vincent 2017). Patients experience pain differently, but the physiological consequences of inadequately managed pain are predictable and potentially harmful (Boldt in Vincent 2017). Physiological responses to pain include increases in RR, HR and BP. Pain also increases patients’ anxiety and leads to sleep disturbances which will affect optimal recovery of the patient (Ahmad 2018). Pain can incur functional limitations such as impaired mechanics of the pulmonary system and delayed ambulation which could lead to higher morbidity in critically ill patients (Boldt in Vincent 2017). Assessment of pain is therefore vital for patient recovery and improved functional outcomes (Elliott 2012). Tools for the assessment of pain in the ICU includes the numeric pain rating scale, the analog scale, the behavioural pain scale and the critical care pain observation scale (Boldt in Vincent 2017, Comisso 2018). Heightened sympathetic activity like hypertension, increased heart rate and restlessness can be indicators of pain in heavily sedated or paralyzed patients (Boldt in Vincent 2017).
+Critically ill patients in the ICU frequently experience acute pain. Many factors can lead to pain in the critically ill patient, including surgical and posttraumatic wounds, prolonged immobilisation, the use of invasive monitoring devices and mechanical ventilators, and even routine nursing care (for example, changing dressings).<ref name=":12" /> Patients experience pain differently, but the physiological consequences of inadequately managed pain are predictable and potentially harmful.<ref name=":12" /> Physiological responses to pain include increases in RR, HR and BP. Pain also increases patients’ anxiety and leads to sleep disturbances which will affect the optimal recovery of the patient.<ref name=":13">Ahmad AM. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6200172/pdf/kjtcv-51-293.pdf Essentials of physiotherapy after thoracic surgery: What physiotherapists need to know. A narrative review]. The Korean Journal of thoracic and cardiovascular surgery. 2018 Oct;51(5):293. DOI:10.5090/kjtcs.2018.51.5.293 </ref> Pain can incur functional limitations such as impaired mechanics of the pulmonary system and delayed ambulation which could lead to higher morbidity in critically ill patients.<ref name=":12" /> Assessment of pain is therefore vital for patient recovery and improved functional outcomes.<ref name=":2" /> Tools for the assessment of pain in the ICU includes the numeric pain rating scale, the analogue scale, the behavioural pain scale and the critical care pain observation scale.<ref name=":4" /><ref name=":12" /> Heightened sympathetic activity like hypertension, increased heart rate and restlessness can be indicators of pain in heavily sedated or paralyzed patients.<ref name=":12" />
-Physiotherapy treatment can also be hampered by pain in that patient participation is reduced and mobilisation is limited. Early proactive steps should therefore be taken to address the patient’s requirements for analgesia before commencement of physiotherapy treatment (Ahmad 2018). Pain can be managed with analgesics together with physiotherapeutic modalities. Physiotherapeutic interventions for pain does not aim to substitute for the analgesic medication, but to rather reduce the total dose of analgesic medication needed in order to reduce their unavoidable side effects (Ahmad 2018).
+Physiotherapy treatment can also be hampered by pain in that patient participation is reduced and mobilisation is limited. Early proactive steps should therefore be taken to address the patient’s requirements for analgesia before commencement of physiotherapy treatment.<ref name=":13" /> Pain can be managed with analgesics together with physiotherapeutic modalities. Physiotherapeutic interventions for pain does not aim to substitute for the analgesic medication but to rather reduce the total dose of analgesic medication needed in order to reduce their unavoidable side effects.<ref name=":13" />
 '''<u>Urine output</u>'''
-Even though urine output is an indicator of renal perfusion, it is frequently used as an indicator of cardiac output (25% of cardiac output perfuses the kidneys).(Jevon 2012) Normal urine output in adults is at least 0.5 ml/kg/h, which also signals adequate renal perfusion (Jevon 2012, Vincent 2017, Elliott 2012). With urine output of less than 500ml in 24 hours, the kidneys are unable to excrete the waste products of metabolism which can result in uremia, metabolic acidosis and hyperkalaemia (Jevon 2012, Vincent 2017).
+Even though urine output is an indicator of renal perfusion, it is frequently used as an indicator of cardiac output (25% of cardiac output perfuses the kidneys).<ref name=":3" /> Normal urine output in adults is at least 0.5 ml/kg/h, which also signals adequate renal perfusion.<ref name=":2" /><ref name=":3" /><ref name=":12" /> With urine output of less than 500ml in 24 hours, the kidneys are unable to excrete the waste products of metabolism which can result in uremia, metabolic acidosis and hyperkalaemia.<ref name=":3" /><ref name=":12" />
-A drop in urine output  may the the first clinical indicator of fluid and electrolyte imbalance, and is considered an early sign of hypovolaemia.(Jevon 2012, Elliott 2012) When cardiac output falls so does renal perfusion, ultimately leading to renal failure (Jevon 2012, Elliott 2012)
+A drop in urine output  may the the first clinical indicator of fluid and electrolyte imbalance and is considered an early sign of hypovolaemia.<ref name=":2" /><ref name=":3" /> When cardiac output falls so does renal perfusion, ultimately leading to renal failure.<ref name=":2" /><ref name=":3" />
-The parameters for urinary output disorders can be found in Table 4 (Jevon 2012, Vincent 2017)
+The parameters for urinary output disorders can be found in Table 4.
 {| class="wikitable"
-|Urinary Output condition
+|'''Urinary Output condition'''
-|Parameters
+|'''Parameters'''
 |-
 |Anuria
@@ Line 236: / Line 236: @@
 |Painful micturition
 |}
-Table 4 Urinary output conditions
+Table 4. Urinary output conditions<ref name=":3" /><ref name=":12" />
 == Conclusion ==
-It is essential to initiate early mobilisation and physical rehabilitation in critically ill patients to ensure better outcomes for the patient (Nydahl 2017, Swaminathan 2019). But it is also known that changing patient position causes changes in their haemodynamic balance (Vincent 2017). Changes in vital signs are often the first indicators of clinical deterioration of the patient (Brekke 2019) and play an important role in informing the most appropriate course of treatment to pursue (Poncette 2019). It is therefore essential for physiotherapists to closely monitor and interpret the vital signs of patients to guide their treatment and if necessary, to quickly intervene or alert the rest of the ICU team when alarming rapid changes occur. Close and continuous monitoring by the physiotherapist during and immediately after mobilisation is essential for patient safety as clinically stable patients can potentially become unstable during and/or after mobilisation (Ahmad 2018).
+It is essential to initiate early mobilisation and physical rehabilitation in critically ill patients to ensure better outcomes for the patient.<ref name=":7" /><ref>Nydahl P, Sricharoenchai T, Chandra S, Kundt FS, Huang M, Fischill M, Needham DM. [https://www.atsjournals.org/doi/pdf/10.1513/AnnalsATS.201611-843SR Safety of patient mobilization and rehabilitation in the intensive care unit. Systematic review with meta-analysis]. Annals of the American Thoracic Society. 2017 May;14(5):766-77. DOI:10.1513/AnnalsATS.201611-843SR </ref> But it is also known that changing patient position causes changes in their haemodynamic balance.<ref name=":12" /> Changes in vital signs are often the first indicators of clinical deterioration of the patient<ref name=":9" /> and play an important role in informing the most appropriate course of treatment to pursue.<ref name=":8" /> It is therefore essential for physiotherapists to closely monitor and interpret the vital signs of patients to guide their treatment and if necessary, to quickly intervene or alert the rest of the ICU team when alarming rapid changes occur. Close and continuous monitoring by the physiotherapist during and immediately after mobilisation is essential for patient safety as clinically stable patients can potentially become unstable during and/or after mobilisation.<ref name=":13" />
 Rodnie Oro. Monitors. Published 1 April 2020. [last accessed 15 Feb 2021]. <nowiki>https://www.youtube.com/watch?v=FeakHyjnkEY</nowiki>

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