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Critical Care Nursing > Chapter 8 Hemodynamic Monitoring > Flashcards

Chapter 8 Hemodynamic Monitoring Flashcards

1
Q
  • Hemodynamic monitoring common in critical care unit

* Studies relationships among several variables:

A
  • Heart rate
  • Blood flow
  • Oxygen delivery
  • Tissue perfusion
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2
Q 
Cardiovascular system
• Pressure = 
• Pressure—
• Flow: 
• Resistance:
A
  • Pressure = flow × resistance
  • Pressure—force exerted on the liquid
    • mm Hg
  • Flow: amount of fluid moved over time
    • L/min or mL/min
  • Resistance: opposition to flow
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3
Q 
CARDIAC OUTPUT
• Cardiac output:
• CO =
• Ejection fraction—
• Normal:
A

• Cardiac output—volume of blood ejected from heart/min
• CO = HR × Stroke volume (volume of blood ejected with each beat)
• 4 to 8 L/min
• Ejection fraction—fraction of blood ejected with
each beat
• Normal 60% to 70%

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4
Q 
PRELOAD
• Degree of?
• Volume of blood in?
• Frank-Starling law
• Example =
A
  • Degree of muscle fibers’ stretch before systole
  • Volume of blood in ventricle prior to contraction (LVEDV/LVEDP)
  • Frank-Starling law
    • Increased stretch = increased volume
    • Stretch is within physiological limits
  • Example = balloon
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5
Q 
AFTERLOAD
• Pressure or?
• Related to?
• Systemic vascular resistance?
• Pulmonary vascular resistance?
• Example =
A

• Pressure or resistance against flow
• Related to lumen size and viscosity
• Systemic vascular resistance: Force overcome by the left ventricle upon contraction
• Pulmonary vascular resistance: Force overcome by the right ventricle upon contraction
• Example = opening door against wind

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6
Q

CONTRACTILITY



A
  • Force of ventricular contraction

* How well the heart is pumping

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7
Q

SYSTEMIC VASCULAR RESISTANCE (SVR)

A
  • Peripheral vascular resistance
  • Diameter of blood vessels
  • Arterial BP = CO × SVR
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8
Q

CARDIAC OUTPUT VERSUS INDEX
• Index is a better assessment; based on?
• CI =
• Calculated on?

A
  • Index is a better assessment; based on body size
  • CI = CO ÷ body surface area
  • Calculated on the computer after entering patient’s height and weight
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9
Q

HEMODYNAMIC MONITORING

• Noninvasive modalities

A

• Noninvasive blood pressure
• Assessment of jugular venous pressure
• Assessment of serum lactate levels (to see if the patient is meeting their metabolic needs).
-normal they will go to med surg or tele
-elevated they need more intensive care
-correlation/indicator if patient will decompensate and crash

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10
Q

central venous pressure normal range

A

Normal is 7 to 9 cm

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11
Q

HEMODYNAMIC MONITORING

• Invasive modalities

A
  • Arterial pressure monitoring
  • Pulmonary artery pressure monitoring
  • Right atrial pressure monitoring
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12
Q

COMPONENTS OF INVASIVE HEMODYNAMIC MONITORING (5)

A
  • Invasive catheter
  • Noncompliant pressure tubing
  • Transducer and stopcocks
  • Flush system
  • Bedside monitor
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13
Q

ACCURACY IN HEMODYNAMIC MONITORING
• Level =
• Zero reference
• Dynamic response testing

A

• Level = phlebostatic axis
• Fourth intercostal space, midaxillary line
• Approximate level of right atrium
• Zero reference
• Negate atmospheric pressure
• Zeroing stopcock is leveled at phlebostatic axis and “zeroed”
• Dynamic response testing
• Square wave test (to make sure tube is in proper place and you are getting right reading from it)
-always assess patient and make sure your readings are accurate

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14
Q

ARTERIAL PRESSURE MONITORING

A

Invasive technique to monitor arterial blood pressure
• Sites:
1) Radial artery
• Allen’s test prior to insertion to verify collateral circulation in the extremity
• Issues related to predictability of Allen’s test
2) Brachial artery
3) Femoral artery

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15
Q

ARTERIAL PRESSURE MONITORING

• Equipment

A
  • Pressurized flush solution with transducer
  • Pressure at 300 mm Hg (Why does this need to be high?) because it has to counteract their blood pressure.
  • A-line catheter (angiocath)
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16
Q

Arterial Pressure Monitoring Complications

A 
Major complications 
1) Thrombosis
• Clot if flush not used appropriately 
2) Embolism
• Air entering system/clot dislodgment 
3) Hemorrhage
• Loose connections/catheter dislodgment (they can loose blood rapidly)
4) Infection (can have phlebitis of artery itself)
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17
Q

RAP/CVP MONITORING



A

1) Right atrial pressure (RAP)—catheter in right atrium
• Proximal port of pulmonary artery catheter
2) Central venous pressure (CVP)—catheter in superior or inferior vena cava
• Triple lumen
- Values similar and terms interchanged

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18
Q

RAP/CVP
• Direct measurement of?
• Right ventricular (RV) preload or?
• Normal value

A
  • Direct measurement of pressure in right atrium
  • Right ventricular (RV) preload or right ventricular end diastolic pressure (RVEDP)
  • Normal value: 2 to 6 mm Hg
  • Recorded end exhalation as a mean value
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19
Q

NURSING IMPLICATIONS RAP/CVP

A
  • Zero/balance
  • Wave form analysis
  • Respiratory variation and PEEP
  • Patient position: Head of bed between 0 and 60 degrees
  • Correlate values with assessment
  • Monitor for complications
20
Q

COMPLICATIONS OF RAP/CVP

A
  • Infection
  • Pneumothorax or hemothorax
  • Carotid puncture
  • Heart perforation
  • Dysrhythmias
21
Q

Which patient would benefit the most from central venous/right atrial pressure monitoring?
A. Patient admitted in cardiogenic shock
B. Patient admitted with a bowel obstruction
C. Patient taking routine doses of furosemide
D. Patient receiving two units of blood

A

B.

A. can also be one too

22
Q

PULMONARY ARTERY CATHETER
• Flow-directed catheter
• Variations

A 
1) Flow-directed catheter
• Inserted via subclavian, internal jugular, or femoral vein
• Balloon tipped
• Multiple lumens
2) Variations
• SvO2 catheter
• Continuous cardiac output (CCO)
23
Q 
INSERTION OF PA CATHETER
• Proper position of patient
• Trendelenburg common
• Towel roll between shoulder blades
• Inserted with balloon deflated, selected inflation to “float” catheter into PA
• Waveform changes as catheter progresses
• Check for proper “wedging” for PAOP
• Chest x-ray
A 
INSERTION OF PA CATHETER
• Proper position of patient
• Trendelenburg common
• Towel roll between shoulder blades
• Inserted with balloon deflated, selected inflation to “float” catheter into PA
• Waveform changes as catheter progresses
• Check for proper “wedging” for PAOP
• Chest x-ray
24
Q

INSERTION OF PA CATHETER

A

• Proper position of patient
• Trendelenburg common
• Towel roll between shoulder blades
• Inserted with balloon deflated, selected inflation to “float” catheter into PA
• Waveform changes as catheter progresses
• Check for proper “wedging” for PAOP
• Chest x-ray

25
Q

PULMONARY ARTERY CATHETER

• Measurement capabilities

A 
• PA systolic
• PA diastolic
• PAOP/PCWP/PAWP
  - Inflated balloon flows into wedge position in pulmonary capillary, measuring pressure
• Cardiac Output/Index
  - ThermodilutionCO
  - Proximal injectate port
26
Q

NURSING IMPLICATIONS
• Mr. Smith’s condition continues to deteriorate. His attending physician arrives in the unit to insert a pulmonary artery catheter.
• What is the nurse’s role prior to the insertion of the pulmonary artery catheter?
• After implementing the central line bundle, the physician prepares to insert the catheter.
• What is the nurse’s role during the insertion of the catheter?

A
  • prepare patient
  • do they need sedation?
  • have all pressurized tubing set up and primed
  • after implementation take care of insertion site
  • make sure no infection
  • no autowedge
  • make sure pressure bags are good
27
Q

NURSING IMPLICATIONS

• Measure pulmonary artery pressures

A
  • Pulmonary artery occlusive pressure (PAOP) reflects left ventricular end-diastolic pressure
  • In many patients the PADP can be substituted for PAOP measurements if values are similar
  • Record amount of air to inflate balloon— no more than 1.5 mL (small amount, we don’t want to overinflate and cause injury to pulmonary artery itself)
28
Q

COMPLICATIONS OF PA CATHETERS

A
  • Infection
  • Dysrhythmias
  • Air embolus
  • Thromboembolism
  • Pulmonary artery (PA) rupture
  • Pulmonary infarction
29
Q 
The nurse prepares to measure pulmonary artery pressures in Mr. Smith. Based on Mr. Smith’s diagnosis of cardiogenic shock, which values should the nurse anticipate?
A. Decreased PAP; decreased PAOP.
B. Increased PAOP; decreased CO.
C. Increased CO; increased PAOP.
D. Decreased PAOP; elevated CI.
A

B. Increased PAOP; decreased CO

30
Q

MONITORING O DELIVERY AND CONSUMPTION 2



A
  • Calculated values
  • Obtained via monitoring catheters
  • SvO2—mixed venous oxygen saturation via specialized PAC
  • ScvO2—central venous oxygen saturation via specialized central line
31
Q 
MONITORING O DELIVERY AND 2
CONSUMPTION
• Normal values
• High values = 
• Low values =
A

• Normal values
• SvO2—60%-75% = adequate balance between
supply and demand
• ScvO2—65%-85% = adequate balance between supply and demand
• High values = tissues not able to use oxygen
• Low values = oxygen demand exceeds delivery

32
Q

MONITORING O2 DELIVERY AND CONSUMPTION 2



A
  • Calculated values
  • Obtained via monitoring catheters
  • SvO2—mixed venous oxygen saturation via specialized PAC
  • ScvO2—central venous oxygen saturation via specialized central line
33
Q 
MONITORING O2 DELIVERY AND 2
CONSUMPTION
• Normal values
• High values = 
• Low values =
A
  • Normal values
  • SvO2—60%-75% = adequate balance between supply and demand
  • ScvO2—65%-85% = adequate balance between supply and demand
  • High values = tissues not able to use/extract oxygen
  • Low values = oxygen demand exceeds delivery
34
Q

DOPPLER TECHNOLOGY METHODS

A

1) Echocardiography
2) Esophageal Doppler Monitoring (EDM)
• Placement
• Monitoring
• Outcomes

35
Q

PULSE CONTOUR METHOD

A
  • Less risk than a PA catheter
  • Better predictor of fluid responsiveness in mechanically ventilated patients
  • Full mechanical ventilation
36
Q

PASSIVE LEG RAISING (PLR)



A
  • Done to determine preload-responsiveness

* Completed prior to IV fluid challenges

37
Q

Related to lumen size and viscosity

A

Afterload

38
Q

Pressure or resistance against flow

A

Afterload

39
Q

Force overcome by the left ventricle upon contraction

A

Systemic vascular resistance

40
Q

Force overcome by the right ventricle upon contraction

A

Pulmonary vascular resistance

41
Q

Force of ventricular contraction

-how well the heart is pumping

A

Contractility

42
Q

Systemic vascular resistance (SVR)

A
  • Peripheral vascular resistance

- Diameter of blood vessels

43
Q

Medications that are vasodilators for humoral regulation

A
  • Prostaglandins
  • Kinins
  • Endothelial- derived factors (nitric oxide)
44
Q

Medications that are vasoconstrictors for humoral regulation

A
  • Angiotensin
  • Epinephrine
  • Ca++
  • Endothelial- derived factors
45
Q

Pulmonary artery montioring

A

its in the major blood vessels of the lung

Critical Care Nursing (15 decks)

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