OBJECTIVE
Without reference, identify basic facts about
the clinical applications of pulse oximeters
with at least 70 percent accuracy.
 Purpose
 Provides continuous, noninvasive
monitoring of patient oxygenation
 Provides rapid indication of a patient’s
changing level of oxygenation
 Determines arterial blood oxygen saturation
(SpO2) using spectrophotometric oximetry
principles
• Spectrophotometric Oximetry is the measurement of blood
oxygen concentration using an instrument that makes
measurements based on the comparison of light being output
to the amount received. The more light received the less that
was absorbed by the blood.
 Determines pulse rate using
plethysmographic techniques

Principles
 Differential light absorption is used to
determine the percent of oxygen saturation
of hemoglobin in arterial blood
 Hemoglobin - an iron-containing
compound found in red blood cells that
carries oxygen from the lungs to the body
tissues
 Two different wavelengths of light
Red
Infrared
 Emitted from a probe
 Passes through a pulsating arterial bed
Fingertip
Earlobe
Forehead
 To a photodetector
• Light absorption
Absorption characteristics
» Oxygenated hemoglobin absorbs less
than deoxygenated hemoglobin at the
red wavelength
» They are more similar at the infrared
wavelength
Each pulse of arterial blood causes small
arteries and arterioles to expand and
contract, this varies the amount of light
absorbed by the arterial blood
A portion of the passing light is
absorbed by tissue constituents
» Venous blood
» Muscle
» Cartilage
» Bone
The absorption due to these
constituents is constant allowing the
microprocessor to eliminate them from
the calculations
 Plethysmographic technique
Plethysmogram corresponds to the
patient's pulse waveform
This signal is used to calculate the
patient's pulse rate, and is determined
from the peaks of the arterial blood
waveforms
• Sensor probes
Transmittance probes - light from each
LED is passed through the measurement
site to a single photodetector on the
opposite side
Reflectance probes - light scattered
along the tissue surface is collected by a
photodetector adjacent to the LED
In both probes, LED's alternately pulse
on and off
This allows differentiation between red
and infrared light at the photodetector
OBJECTIVE
Without reference, identify basic facts about
the clinical applications of patient monitoring
systems with at least 70 percent accuracy.

Intended Purpose -To watch or monitor a
patient's vital signs and display waveforms
and/or numerical data
 Vital signs
 Heart rate and ECG
When the heart contracts an electrical
signal can be detected by electrodes
placed on the patient's chest and
extremities
This electrical signal can be plotted as a
function of time, and the resultant
waveform is referred to as an
electrocardiogram (ECG)
• Pulse
• Temperature
• Blood pressure
Systolic - the peak blood pressure felt in
the circulatory system
Diastolic - the resting pressure of heart
Mean - average of the systolic and diastolic




Respiration
Arterial O2 saturation
Cardiac Output
Airway CO2 Concentration
 The medical and nursing staff analyze these
physiological parameters
 To reveal changes in patient's condition
 To determine proper treatment
 Typical locations
 Acute care units
Intensive care units
Cardiac care units
 Surgery and recovery units

Description of Monitoring Systems
 Bedside monitor mainframe
 Has a display and possibly a printer
 Can be switched with any bedside monitor
 Has ports for different modules or
different modules are built in
 Modules of a bedside monitor
 ECG module
Amplification of the cardiac signal is
performed within the ECG module
Displays electrical activity of the heart by
waveform presentation on CRT
Can display
oHeart rate - determined from the R to R
interval
oHeart irregularities
 Heart rate alarms
Tachycardia - heart rate is too fast
Bradycardia - heart rate is too slow
 Blood pressure module
To monitor patients when fluids are
being lost; in burn victims or major
surgery
To monitor patients when fluids are
gained; during infusions of blood or
other fluids
To detect hypotension (low blood
pressure) which can lead to vascular
collapses because of hypovolemia (low
blood volume)
To detect hypertension (high blood
pressure) which can overload the heart
because of hypervolemia (high blood
volume)
 Temperature module (body temperature)
Usually measured by means of a
thermistor probe
Probe is inserted in mouth, armpit, or
rectum
 Respiration module
Methods
» Most common - impedance
pneumography - measurement of the
change of impedance across patient's
chest during respiration
Pressure sensitive capsules placed on
abdomen to detect body movement
Thermistor near mouth or nose to
measure change in temperature
between inhaled and exhaled breaths
 May also include an apnea alarm
 Carbon dioxide (CO2) module
• Measures CO2 concentration at the end of
an exhaled breath
• Two types
Capnograph
» Measures the increase and decrease in
CO2 during each inspiratory /
expiratory cycle
» Displays both CO2 waveform and
numerical data
Capnometer
Continuously measures CO2
Displays only numerical data
When connected to a patient monitor,
becomes a capnograph
 Pulse oximeter module
Noninvasive and continuous means of
monitoring percent of O2 saturation
(SaO2) of arterial blood
Reduces the need for arterial puncture
and blood gas analysis
 Physiological monitors are often equipped
with 2 types of alarms
 System faults
Loose electrodes
Defective electrodes
 Physiological parameters have exceeded
the limits set by the operator
OBJECTIVE
Without reference, identify basic facts about
the clinical applications of electrocardiograph
units with at least 70 percent accuracy.

Intended Purpose
 To detect the electrical activity of the heart
and produce an electrocardiogram (ECG)
which is a graphic record of voltage versus
time
 To diagnose cardiac abnormalities
 To monitor patient's response to drug
therapy
 To revel major changes in heart rate and
cardiac rhythm (ECG disturbances)
 Pericarditis - inflammation of the sac
containing the heart
 Atria and ventricular hypertrophy enlargement f the walls due to obstruction
 Myocardial infarctions - coagulation in the
muscular tissue of the heart resulting from
obstruction of circulation
 Ventricular fibrillation
 Asystole
 Electrolyte concentrations and acid base
balance
 Increased metabolic activity
 Drug reactions
 Hypoxemia - low oxygen content in the
blood
 Hypothermia - low body temperature
 ECG monitors typically measure and display
up to three physiological parameters
 Electrocardiogram (ECG)
 Heart rate
 Body temperature or respiration

Elements of the ECG
 P-wave - represents depolarization of both
atria
 Begins with electrical impulse from the SA
node
 Impulse spreads in wave-like fashion,
stimulating both atria
 Both atria depolarize (contract) and
produce electrical activity
 PR Segment
 Electrical impulse from atria passes to the
AV node
 There is a 1/10 second pause allowing
blood to enter the ventricles
 The AV node is depolarized
 Duration - .12 - 2.0 seconds
 Measures from the onset of the P-wave to
the onset of the QRS complex
 QRS complex
 Represents the electrical impulse as it
travels from the bundle of HIS into the
bundle branches into the Purkinje fibers
and into the myocardial cells (causing
ventricular contraction)
 The depolarization of the ventricles
 Duration - .08 - .12 seconds
 Consists of:
 Q-wave
First down stroke of the QRS complex
Not always present
 R-Wave - first upward deflection of the
QRS complex
 S-Wave - first downward stroke after the
R-wave
 ST segment
 Used to identify myocardial infarctions
 Serves as the isoelectric line from which to
measure the amplitudes of other
waveforms
 J-point - junction between the QRS complex
and the ST segment
 T-wave - represents the repolarization of
the ventricles

Principles of Operation
 The heart rate is determined by the R to R
interval of successive QRS waves
 Electrocardiographs record small voltages
(about 1mv) that appear on the skins
surface as a result of cardiac activity by
using various electrode configurations
discussed earlier
 Multichannel electrocardiographs
 Operate similarly to single channel units in
that the user selects certain similar
functions:
Automatic or manual lead switching
Signal sensitivity
Chart speed
 Unlike signal channel units, multichannel
units have some advantages:
Record 3 or more leads simultaneously
Tracings can be held in memory
Tracings are printed out in a one-page
format
 Modes
Manual mode
» User selects three leads to be recorded
» Unit traces signal from these leads until
others are selected
Automatic mode
» Each standard 12 leads are recorded for
a preset time period
» Switching from one lead to another
occurs automatically
» Some units can be programmed to
record tracings from any lead sequence
Units with integral timers and selectable
chart speeds can also be programmed
for
» Stress testing
» Trending
» Rhythm monitoring
Semi-automatic mode
» Recorder scans through first lead group
Semi-automatic mode
» Recorder scans through first lead group
» Then switches to observe mode
o Allows user to preview next lead group
for signal quality before recording
o User restarts recording of next group
manually
• Lead hold feature
Overrides programmed timer
Allowing longer recording time for a
particular lead
 Sensitivity setting
User selectable
Determines size of the recorded ECG
waveform
ECG signals that become too large and
produce a waveform that goes over scale
(arrhythmic beat)
» Most units will automatically switch to
lower sensitivity setting immediately
Other units allow user to choose
between recording
» Affected channel at lower sensitivity
» All channels at lower sensitivity
» Waveform as is, followed by rerecording at lower sensitivity
 Frequency response
Factory-set to detect ECG signals
between 0.05 and 100 Hz for diagnostic
purposes
Electrical interference also occurs within
this range producing artifacts by
recording
» Muscle movement
» Line power frequency
To reduce such interference, notch
filters can be selected to block these
frequencies
» Because filters limit frequency
response, they can affect diagnoses
based on certain details (amplitude)
» Therefore, they are not usually used for
diagnostic recording
 ECG tracings
Single-channel units require cutting and
pasting to achieve standard format
Mutichannel electrocardiographs require
less preparation time - 3 leads are
recorded simultaneously
In some mutichannel units, no cutting or
pasting is necessary
» ECG signals from each lead are stored
in memory
» Then traced all at once on a single page
» Therefore, all 12 ECG tracings are
representations of the heart's electrical
activity from same heart beat
 Formatting options
One-page formatting
Formatting according to number of
pages programmed
Formatting according to number of
heart beats recorded in each lead group
Formatting according to number of
seconds for overall recording
Automatic formatting saves time but an
atypical waveform may be missed
Some units are capable of producing
multiple copies of recent ECGs
 Data which can be printed at the top of
ECG recordings
Patient data (entered by alphanumeric
keyboard if available)
Time
Lead identifiers
Heart rate
Recording parameters
» Sensitivity setting
» Chart speed
» Filtered mode
 Options
Heart rate LED or LCD displays
Alarms
» Tachycardia
» Artifacts
» Loose electrodes
» Out-of-paper
» System fault (leads/electrodes)
» Automatic recording
Capability of storing rhythm strips for
later retrieval
Ability to extend recording time if
arrhythmia is detected
ECG report editing capability
"Freeze" capability
» ECG will be held and displayed
indefinitely
» The current trace will be lost or
transferred to another channel (printer)
"Memory delay" feature - the last few
seconds of the trace prior to an alarm
will be lost or transferred to another
channel or printer
Some store, compute, and display trends
in data through the use of a
microprocessor
» Trend plot is a graph of a physiological
parameter over a period of time
» Heart rate trend is an example
 Where
Multichannel Electrocardiographs
are Found
 Doctor's office
 Flight medicine clinics
 Physical exams and standards clinics
 Intensive care units
 Coronary care units
 Emergency rooms
 Cardiopulmonary labs
 Special care units
OBJECTIVE
Without reference, identify basic facts about
the clinical applications of defibrillators with
at least 70 percent accuracy.

Terms and Definitions
 Arrest - cessation of the electrical activity of
the heart
 Atrial flutter - very rapid (250-150/min)
electrical discharge and contraction of the
upper chambers (atria) of the heart
 Cardiogenic shock - shock resulting from
the diminishment of cardiac output
 Fibrillation - irregular, totally disorganized
electrical activity of the atria or ventricles or
both
 Defibrillation - electrical termination of
fibrillation
 Cardioversion - the restoration of the sinus
rhythm by electrical shock
 Synchronous - occurring at the same time
 Stored energy - the energy stored within the
defibrillator by the capacitor
 Joule - a unit of work; the energy expended
by 1 amp flowing for 1 second through 1
ohm of resistance
 Also called a watt second
 The unit of calibration for the output of a
defibrillator

Intended Purpose
 To apply controlled monophasic (single
phase) or biphasic (two phase) DC
defibrillating pulse to the heart
 Monophasic
One pulse of electricity
One direction of current flow between
the paddles
High amounts of energy needed
 Biphasic
• Current reverses itself
• Two directions of current flow
• Uses smaller amounts of energy
• Can compensate for differences in
patient impedance
Chest size
Tissue density
 Sync mode
 To perform elective cardioversion
 Uses the patient's generated R-wave as a
timing reference
 Most defibrillators also monitor the ECG
signal
 To verify fibrillation
 To verify effectiveness of treatment
 Patient signals can be picked up by the
external paddles which are transcutaneous
leads

Paddle Types
 Standard adult external
 Anterior/posterior
 Internal
 Pediatric
 Neonatal (newborn)
 Disposable
 Modes of Operation
 External emergency defibrillation
Discharge into the patient by pressing
the 2 discharge buttons (one on each
handle) simultaneously
2,000 to 4,000 volt shock
For less than 20 msec
Using gels and pastes to improve
conductivity between paddles and chest
 AHA ( American Heart Association)
 Studies indicate that about 98% of patients
can be defibrillated with 300 joules or less
 Recommends not exceeding 360 joules
delivered to the patient
 Internal defibrillation
 Energy is delivered directly to the exposed
heart
 All defibrillators are designed to limit the
output energy to 50 joules to prevent injury
to the heart muscle
• Paddles are small (50 mm in dia.) and
able to withstand sterilization between
uses
 Synchronized cardio version (Sync Mode)
• Uses a discharge of 25-100 joules
• Used to correct certain arrhythmias
Ventricular tachycardia
Atrial flutter
• Sync marker will show up on the
defibrillator monitor on the R-wave
 The shock is delivered
On the first down stroke of the R-wave
detected after both paddle discharge
buttons are pressed
Must occur within 30 msec of the Rwave
 Timing is critical because discharge during
the T-wave could cause fibrillation
OBJECTIVE
Without reference, identify at least four out of
six basic facts about the clinical applications
of invasive and noninvasive blood pressure
monitors.

Purpose
 The presence of an ECG signal does not
assure effective pumping of blood
 Automatic electronic sphygmomanometers
noninvasively measure and display a
patient's arterial blood pressure
 Terms
and Definitions
 Systolic pressure - the highest arterial
pressure of the blood
 Diastolic Pressure - the lowest arterial
pressure of the blood
 Mean - midway or an average of the systolic
and diastolic pressures
 Pulse pressure - the difference between the
systolic and diastolic pressures
 Korotkoff sounds - sounds heard through
the stethoscope as the blood flow changes
 Hypotension - low blood pressure
 Hypertension - high blood pressure
 Hypovolemia - inadequate blood volume
 Hypervolemia - excessive blood volume
 Noninvasive - uses a cuff
 Invasive - uses a catheter and puts patient
at a higher risk of infection or emboli
 Normal pressure - 120/80 mmHg
expressed as systolic over diastolic
pressures
 Principles of Blood Pressure
 Left ventricle of heart contracts
• Blood is forced into arteries
• Creates a pressure increase, peak of which
is called systolic pressure
 Ventricles then relax
 Pressure in the arteries decrease as blood
leaves arteries and enters capillaries
 Lowest point the pressure reaches before
the next ventricular contraction represents
the diastolic pressure
 Pressure values are recorded in millimeters
of mercury (mmHg)

Noninvasive Method
 Peripheral blood flow sounds were
correlated to systolic and diastolic pressures
by Nicolai Korotkoff in 1905
 Uses a cuff wrapped around patient's arm
and a stethoscope
 Cuff is inflated to pressure greater than
systolic pressure
 Patient's artery closes
 Blood flow stops
 Cuff pressure is gradually lowered, pressure
falls below systolic pressure but higher than
diastolic pressure
 Some blood forces its way through artery
 Blood flow not normal, the resulting
turbulence produce korotkoff sounds
 Sounds persist until cuff pressure falls
below the diastolic pressure and blood flow
returns to normal

Techniques for Automatic Measurement
 Auscultatory
 Same principles as sphygmomanometers,
detection of korotkoff sounds
Pressures at which korotkoff sounds
first begin mark the systolic pressure
Pressures at which sounds disappear
marks the diastolic pressure
 Cuff with transducer wrapped around
patient's arm
 Cuff is inflated with transducer positioned
against compressed artery
Transducer detects korotkoff sounds
Enables user to determine both systolic
and diastolic values
 Oscillometric
 Cuff is wrapped around a patient's arm
and inflated
 Pressure in the cuff is released
 Sensor located in the monitor detects air
pressure fluctuations in the cuff
 Due to arterial volume changes
 Occur because blood is pulsing through
artery, rather than flowing smoothly
 Pressure at which oscillations peak
correspond to mean arterial pressure (MAP)
 Unit calculates the systolic and diastolic
pressures from the increasing and
decreasing magnitude of the oscillations
 Differential sensor
 Cuff with dual-head sensor inflates around
a patient's arm
 Cuff pressure is released
Sensor against artery detects korotkoff
sounds, oscillometric pressures and
artifact signals
Sensor against the cuff (air bladder)
detects only oscillometric sounds and
artifact signals
 The monitor subtracts the two signals
leaving only the korotkoff sounds
 Process should remove some of the
unwanted interference signals
 Light-emitting diode (LED)
 Cuff bladder - slipped over patient's finger
or thumb
 Cuff is inflated stepwise under
microprocessor control
Signals from optical sensor determine
mean arterial pressure which is sufficient
enough to permit the artery to remain
open
Procedure repeated several times in first
minute until volume of finger under cuff
is stabilized
» Once stabilized, unit is calibrated to
patient
» Calibration procedure takes place every
minute in some units
 Changes in blood volume causes the optical
sensor to send signals to an electropnuematic
servo-controlled valve
Increases and decreases the cuff pressure
A transducer detects the cuff pressure and
produces a corresponding electrical signal
 Arterial pressure waveform can be displayed
on a monitor or sent to a printer
 Advantages of Noninvasive
 Low risk to patient compared to invasive
 Simplicity - easy to set up
 Locations
 Emergency room
 Intensive care unit
 Surgery
 Recovery
OBJECTIVE
Without reference, identify basic facts about
the clinical applications of infusion pumps
with at least 70 percent accuracy.

Introduction to Fluid Therapy
 Body fluid balance depends upon
• Fluid intake
• Body requirements for fluids
 Functioning regulatory systems
• Cardiovascular system (volume and blood
pressure)
• Urinary system (Kidneys)
• Nervous system
• Endocrine system (Hormones)
 Electrolytes and other chemical substances
which keep body fluids in balance
 Disturbances in fluid balance
 Dehydration - insufficient body water
Causes
» Inadequate fluid intake
» Vomiting and diarrhea
» Fever and excessive sweating
 Signs and symptoms
Thirst
Weight loss
Low fluid output/concentrated urine
Dry membranes in mouth and eyes
 Treatment
Replace fluids orally when mild
Replace fluids by standard IV drip when
severe
 Edema - accumulation of excess fluid in
body tissue
 Causes
Heart failure or vessel obstruction
Protein loss (starvation, burns)
Systemic infection/inflammation
Kidney problems/renal failure
 Signs and symptoms
Swollen eyelids/puffy face
Swollen feet and ankles
Abdominal distention
 Treatment
Special IV fluids which pull water from
tissue into vessels
Low sodium diet
• Other disturbances in fluid balance
Dysfunction in almost any organ system
can affect fluid balance
Fluid balance can be affected by certain
drugs - hormones, diuretics

Fluid Therapy By Intravenous Route
 IV regular and special use
• Provides route for fluids when oral route
cannot be used or is not practical
GI problems (obstruction, malabsorption)
Inability to swallow (oral surgery,
unconscious patient)
Intolerance to oral fluids (nausea,
vomiting)
Some medications are more effective
when given by IV route (antibiotics)
 Used pre- and post-operatively
GI tract must be at rest for anesthesia
related safety purposes (i.e. no food)
Gives emergency access to the
circulatory system during surgery for
fluid replacements, blood, medication,
etc
 Emergency
Effects of IV fluids/drugs are realized
immediately (within seconds)
Gives rapid access to circulatory system
Lack of good peripheral circulation in a
shock patient causes poor absorption of
IM (intramuscular) or subcutaneous
injection. Therefore, IV is the method of
choice
 Limitation/problems of IV therapy
• Requires special skill
• Certain fluids/drugs cannot be given through
an IV
• Complications associated with venous IV site
Infection
Tissue breakdown due to drugs or reaction
of tissue with IV line
Blood clots (embolism)
Air embolus (air bubbles in blood stream)

Monitoring IV Therapy
 Drip rate - measured in cc/hr, is the correlation
between number of drops/minute with actual
volume (cc)/hour
 Leaves room for error due to multiplier effect
 Changes due to filter clogging or kinked tube
 Ratio of drops/minute to cc/hr differs with
infusion sets and viscosity of liquid being
infused
Thicker fluids have slower drops/minute
 Importance of monitoring
• Assure proper amount of drug/fluid is
administered
• Required to prevent too much or too little
fluid intake (edema or dehydration)
 Infusion Therapy
 Best way to provide continuous, well controlled
infusion
• Controlled/preset volume
• Delivery is at a constant rate
• Can monitor rate, volume, or both depending
on model or style
 Types
 Controllers
Use gravity feed
Monitor the rate by counting drops/minute
Control rate by pinching infusion line
 Pumps - use pressure to move fluid from
IV bag to the patient
Peristaltic (usually not direct volumetric, but
counts drops)
Piston - known volume per stroke Therefore,
rate of stroke controlled
Uses - provides continuous, well controlled
administration of critical drugs/fluids when
continuous levels and/or well controlled
volume is required
• Children and infants who have a small
body volume
• Drug therapy
Antibiotics (systemic)
Cardiac drugs
Anticoagulants
Insulin
Electrolytes
• Hyperalimentation - providing the body with
nutrition intravenously
 Advantages of infusion pumps over
standard IV methods
 Usually more accurate/consistent than
standard drip method
 Allows for better measurement of total
fluid input when this is critical (edema)
 Warn the staff when there are problems
like extremely high or low pressure in the
IV line (occlusion or dislodged line)
 Disadvantages - always be aware
• Requires power, therefore can stop
running unexpectedly
• If no battery backup, patient's movement
is limited
• Pumps can build up extremely high
pressure in the IV line or patient
• Can be inaccurate
Too little infused - insufficient
Too much infused - overdose,
circulatory overload, edema, death
Only as accurate
as the BMET who
calibrates it!