Hemodynamic Monitoring Flashcards by Janna Z

Purpose of Hemodynamic Monitoring

Assess heart function, fluid balance, effects of fluids and drugs on CO
Assess resistance of systemic and pulmonary arterial vasculature and O2
content, delivery and consumption

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Noninvasive

-Cuff pressures
-Pulse Ox

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Mean Arterial Pressure (MAP)

pressure in our arteries during 1 cardiac cycle. It tells us how well our vital organs are being perfused.

Normal range: 70-105 mmHg

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How to calculate MAP

Systolic BP+ 2 (Diastolic BP) / 3

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Trouble shooting Pulse ox

1) Assess waveform
2) Assess pulse rate as compared to ECG heart rate
3) Best location
4) Inaccurate readings

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Invasive Pressure Monitoring

Pressure monitoring system

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Pressure monitoring system Equipment

-Catheter
-Transducer with noncompressible pressure tubing (KNOW WHERE THE TRANDUSER LEVELS GOES IN 4TH INTERCOSTAL SPACE, MID AXILLARY (Heart level))
-Pressurized normal saline flush bag (300mmhg pressure)
-cable and monitor

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For pressure bags

you need to label each tubing and bag

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Optimal dynamic response. When you flush an art line it..

creates a square in the ECG, called square wave test

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Other factors that impact accuracy of pressure readings

a) Confirm no blood or air in line
b) Client position (head elevation 0-45 degrees)

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Arterial blood pressure monitoring purpose

Measure continuous systemic blood pressure directly in artery (More accurate than blood pressure cuff)

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Arterial blood pressure uses

(1) Evaluate interventions continuously, including vasoactive medications (norepinephrine, phenylephrine, epinephrine, vasopressin)
(2) Obtain arterial blood samples
(3) If pt is in shock or hypotension or post op pt might get this.
(4) Need a more accurate measure than blood pressure cuff)

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Locations for arterial blood pressure monitoring

(1) Radial* MOST COMMON LOCATION

(2) Other arteries utilized: femoral, axillary, brachial

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Normal values for Systolic and diastolic pressure and MAP

(1) Systolic pressure (SBP) 80-100
(2) Diastolic pressure (DBP) 60-80
(3) Mean arterial pressure (MAP) GOAL IS GREATER THAN 65 mmHg

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Insertion of Arterial blood pressure monitoring

Perform Allen’s test (a way to measure blood flow in hand)
Set up monitoring system (Flush line, zero, perform square wave test, set high and low alarms)
Immobilize insertion site
Apply transparent dressing waveform (they stitch it, so you must assess site just like IV. Assess for bleeding, circulation, color of hand)
Label tubing as arterial line

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Management of arterial blood pressure monitoring

Verify arterial waveform
Maintain continuous fluid irrigation; check every 1 to 4 hours
Assess insertion site and area distal to the site hourly
Assess for bleeding at catheter site or from tubing
connections
Observe ECG and pressure tracing with
dysrhythmias.

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Complications to monitor for with aterial blood pressure monitoring

1) *hemorrhage
2) infection
3) thrombus formation
4) *neurovascular impairment (emergency and must be reported)

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Removal of Arterial blood pressure monitoring

a) Apply direct pressure over and above insertion site
10 minutes or until bleeding has stopped. Apply pressure sterile dressing as needed. If pt has low platelets you hold for a long time.

b) Continue to assess hemostasis maintained

Central venous access devices (CVADS) purpose

Rapid administration of IV fluids, blood and blood products, parenteral nutrition and medications.

When pt doesn’t need anymore, get with MD to take out. Need Xray for placement bc may cause pneumothorax

Risk from CVADs

systemic infection, leakage of fluids

Types of CVADS

centrally inserted cathether
nontunneled (wasnt tunneled under skin)
tunneled catheter (surgically placed under skin)
PICC
Implanted ports (port-a-cath)
Midline cath

Nontunneled caths can

Can measure RAP (right atrial pressure) or CVP (central venous pressure). RAP and CVP are used interchangeable. NORMAL for ICU pts is 7-14.

Tunneled caths provide

b) Provides catheter stability and reduces infection risk
c) After site heals, client does not need dressing

PICC are used for

a) Used for vascular access for 1 week to 6 months
b) Advantage lower risk infection, fewer insertion related complications
c) Risk: deep vein thrombosis and phlebitis (if happens, occurs within 7-10 days of insertion
d) Not take BP or draw blood in arm with PICC

Implanted ports

a) Access with special needle (Huber needle) tip deflected to prevent damage to port b) Can directly inject into reservoir or through an established IV c) Monitor for infiltration

Midline Cath

can stay in place up to 4 weeks

Procedure for insertion of centrally or peripherally inserted catheters – guidelines to prevent CLABSI

1) Verify Informed consent 2) Set up monitoring system (RAP) 3) Position – supine or trendelenberg (15-30 degrees) unless femoral insertion 4) Perform time-out 5) Hand hygiene, don cap, mask, sterile gown and gloves, eye protection 6) Skin prep with chlorhexidine and allow to air dry 7) Drape client using sterile technique 8) Secure Catheter and apply transparent occlusive dressing 9) Verify placement with X-ray or fluoroscopy if inserted in Interventional Radiology 10) Daily review of necessity of the line and prompt removal when unnecessary. If saline locked and not using, needs to be taken out.

Decreased RAP/CVP

indicate low volume Action: fluid bolus or vasopressors

Increased RAP/CVP

increased volume, increased intrathoracic pressure or pulmonary pressures increased Action: treat cause

Do not use a newly placed CVAD until

until tip position is verified with x-ray (After x-ray, need order saying its ok to use)

Before hanging a new medication of fluid

verify compatibilites

CVAD removal

a) Nurses may be allowed to remove PICC and nontunneled catheters b) Place supine c) Remove dressing and suture if applicable d) Have client valsalva during last 5 to 10 cm of catheter removal. e) Immediately apply pressure to site with sterile gauze f) inspect catheter tip g) After bleeding stopped, apply sterile dressing

Catheter related infection (local or systemic) MOST COMMON

a) Presentation -Local: redness, tenderness, purulent drainage, warmth, edema; Systemic: fever, chills, malaise b) Actions: local- culture drainage, apply warm moist compresses, remove catheter if needed; Systemic – obtain blood culture, give antibiotics and antipyretics prescribed, remove catheter if needed. *PRIORITY: CALL DOCTOR TO GET LINE OUT!!!!!!!!!!

Pulmonary artery catheters – pulmonary artery pressures

-Measures RAP/CVP (make sure CVP is connected to brown port), PAP (PAS, PAD, PAM), PWP, CO/CI, SVO2, and temp -Obtain information about right and left sides of the heart -Obtain information about preload, afterload, and contractility -Manage hemodynamically unstable client

Pulmonary artery catheters locations

Inserted through subclavian, internal or external jugular, or femoral vein

Pulmonary artery normal values

1) PA systolic pressure - amount of pressure needed to open pulmonic valve; 2) PA diastolic pressure – Under normal conditions reflects left ventricular end-diastolic pressure

To obtain measurements with pulmnary artery cath

1) Zero, level to phlebostatic axis with head elevation 0-45 degrees 3) PAP: at end expiration 5) Never inflate balloon with more than 1.5 mL 6) Do not inflate for more than four respiratory cycles or 10–15 seconds 7) Leave balloon lumen deflated and locked position except for intermittent reading

Pulmonary artery cath - Utilize proximal lumen to

measure RAP, infuse IV fluids, sample blood, infuse IV meds

Pulmonary artery cath Utilize distal lumen to

measure PA pressures – lumen not used for IV fluids, only irrigation fluids

Arterial oxygen saturation (SaO2)

represents the actual amount of oxygen bound to Hgb divided by the maximum amount oxygen that could bind to Hgb; measure with pulse oximetry

Mixed venous oxygen saturation (SVO2)

reflects the oxygen saturation of Hgb in venous blood returning to heart; Requires PA catheter

Central venous oxygen saturation (ScVO2)

utilizes central line and specialized monitor

Minimally invasive hemodynamic monitoring

Arterial pressure based cardiac output monitoring (APCO) provides a minimally invasive method to measure CO; arterial catheter and monitor permit continuous calculation of CO