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Critical Care > Hemodynamic Monitoring > Flashcards

Hemodynamic Monitoring Flashcards

1
Q

What is cardiac output?

A

Volume of blood in liters pumped by the heart in 1 minute

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2
Q

What is cardiac index?

A

Measurement of cardiac output adjusted for body surface area

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3
Q

What is the stroke volume?

A

The volume ejected from the heart with each beat

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4
Q

What is stroke volume index?

A

Measurement of SV adjusted for BSA (body surface area)

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5
Q

What determines blood pressure?

A

Cardiac output and the forces opposing blood flow

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6
Q

What is systemic vascular resistance (SVR)?

A

opposition encountered by the left ventricle

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7
Q

What is pulmonary vascular resistance (PVR)?

A

Opposition encountered by the right ventricle

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8
Q

What makes up the resistance to blood flow by the vessels?

A

PVR + SVR

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9
Q

What determines stroke volume?

A

Preload, afterload, and contractility

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10
Q

What is preload?

A

The volume within the ventricle at the end of diastole

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11
Q

How is preload measured?

A

Various pressures are used to estimate the volume

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12
Q

What is the preload of the left ventricle called?

A

Left ventricular end-diastolic pressure

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13
Q

What is used to measure the left ventricular end-diastolic volume?

A

Pulmonary artery wedge pressure (PAWP)

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14
Q

What does the pulmonary artery wedge pressure indicate?

A

It reflects left ventricular end diastole under normal conditions

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15
Q

What is pulmonary artery wedge pressure?

A

A measurement of pulmonary capillary pressure

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16
Q

When might pulmonary artery wedge pressure NOT reflect left ventricular end-diastolic pressure?

A

Mitral valve dysfunction, intracardiac defect, dysrhythmias

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17
Q

The value of the pulmonary artery wedge pressure thus reflects the __ of the left ventricle

A

preload

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18
Q

The value of the pulmonary artery wedge pressure thus reflects the preload of the __ ventricle

A

left

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19
Q

What does CVP stand for?

A

Central venous pressure

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20
Q

Where is central venous pressure (CVP) measured?

A

Right atrium or in the vena cava close to the heart

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21
Q

What does the central venous pressure (CVP) indicate?

A

Right ventricular preload

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22
Q

How is the preload of the right ventricle measured?

A

By using the CVP

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23
Q

Right ventricular preload aka

A

right ventricular end-diastole pressure

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24
Q

When does the central venous pressure (CVP) NOT indicate the right ventricular end-diastolic pressure?

A

Tricuspid valve dysfunction, intracardiac defects, or dysrhythmias

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25
Q

What does Frank Starling’s law explain?

A

The effects of preload

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26
Q

What is Frank Starling’s law?

A

The more a myocardial fiber is stretched during filling, the more it shortens during diastole and the greater the force of the contraction

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27
Q

As preload increased, what happens?

A

The force generated in the subsequent contraction increases

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28
Q

If preload increases, what happens to stroke volume and cardiac output?

A

They both increase

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29
Q

The greater the preload, the greater the myocardial __

A

stretch

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30
Q

The greater the preload, the greater the myocardial __ __

A

oxygen requirement

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31
Q

What can decrease preload?

A

Diuresis and vasodilation

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32
Q

What action will increase preload?

A

Fluid administration

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33
Q

What is afterload?

A

The forces opposing ventricular ejection

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34
Q

What opposing forces make up afterload? (3)

A

Systemic arterial pressure
Resistance offered by aortic valve
Mass and density of blood

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35
Q

What two measurements indicate left ventricular afterload?

A

Systemic vascular resistance
Arterial pressure

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36
Q

What two measurements indicate right ventricular preload?

A

Pulmonary vascular resistance
Pulmonary arterial pressure

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37
Q

An increase in afterload results in a decreased __ __

A

cardiac output

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38
Q

What effect does afterload have on myocardial oxygen requirement?

A

Increased afterload results in need of more oxygen

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39
Q

What drug is often used to reduce afterload?

A

Milrinone

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40
Q

What is the effect of milrinone?

A

Vasodilator

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41
Q

What is contractility?

A

The strength of contraction

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42
Q

When does contractility increase?

A

When preload is unchanged and the heart contracts more forcefully

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43
Q

Epinephrine __ contractility

A

increases

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44
Q

Norepinephrine __ contractility

A

increases

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45
Q

Isoproterenol (Isuprel) __ contractility

A

increases

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46
Q

Dopamine __ contractility

A

increases

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47
Q

Dobutamine __ contractility

A

increases

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48
Q

Digitalis (digoxin) __ contractility

A

increases

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49
Q

Calcium __ contractility

A

increases

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50
Q

Milrinone __ contractility

A

increases

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51
Q

A drug that increases contractility is called a __ __.

A

positive inotrope

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52
Q

A drug that decreases contractility is called a __ __.

A

negative inotrope

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53
Q

An increase in contractility results in an increase in myocardial __ __

A

oxygen demand

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54
Q

Calcium channel blockers __ contractility

A

decrease

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55
Q

Beta-adrenergic blockers __ contractility

A

decrease

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56
Q

What acid-base imbalance reduces contractility?

A

Acidosis

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57
Q

What is contractility measured?

A

There are no direct clinical measures of contractility

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58
Q

What indirectly measures contractility?

A

Preload (pulmonary artery wedge pressure) and cardiac output, then graphing the results

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59
Q

A graphing of a patients pulmonary artery wedge pressure and cardiac output measures what?

A

An indirect measure of contractility

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60
Q

How can one know if contractility has been changed?

A

Preload, heart rate, and afterload remain the same, but cardiac output increases

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61
Q

What parts of invasive arterial BP monitoring system are disposable?

A

The catheter, pressure tubing, flush system, and transducer

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62
Q

What does referencing a pressure monitoring equipment mean?

A

Placing the transducer so that the zero-reference point is at the level of the atria of the heart

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63
Q

What is used for a zero-reference point?

A

Stopcock nearest the transducer

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64
Q

What is a good way to make sure a transducer is at the level of the atria?

A

Use an external landmark on the patient called the phlebostatic axis, mark it on the patient’s skin

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65
Q

How is the phlebostatic axis determined?

A

Draw a horizontal line through the fourth intercostal space along the chest wall and draw a vertical line down from the axilla midway between chest walls, the intersection of the two lines

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66
Q

What should you do after you have found the phlebostatic axis when setting up invasive hemodynamic monitoring?

A

Mark the spot on the patient, take the transducer to the spot, or ideally mount it on a bedside pole

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67
Q

What is the purpose of zero balancing invasive pressure monitoring equipment?

A

It confirms that when pressure within the system is zero, the monitor reads zero

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68
Q

How do you zero balance invasive pressure monitoring equipment?

A

Open the reference stopcock to room air and observe the monitor for a reading of zero

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69
Q

By opening the reference stopcock to room air, is allows the invasive pressure monitoring device to…

A

use atmospheric pressure as a reference for zero

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70
Q

When is the transducer of invasive pressure monitoring equipment zeroed?

A

During the initial setup, immediately after insertion of the arterial line, when the transducer has been disconnected from the pressure cable/pressure cable has been disconnected from monitor OR when accuracy of measurement is questioned

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71
Q

What should you ALWAYS do when setting up invasive pressure monitoring equipment?

A

Follow the manufacturer’s guidelines

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72
Q

What is the normal range for pulmonary artery diastolic pressure (PADP)?

A

4-12 mmHg

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73
Q

What is the normal range for pulmonary artery wedge pressure (PAWP)?

A

6-12 mmHg

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74
Q

What is the normal range for left arterial pressure (LAP)?

A

6-12 mmHg

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75
Q

What is the normal range for right arterial pressure (RAP)?

A

2-8 mmHg

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76
Q

What is the normal range for central venous pressure (CVP)?

A

2-8 mmHg

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77
Q

What is the equation for right ventricular end-diastolic volume (preload)?

A

Stroke volume / Right ventricular ejection fractions (RVEF)

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78
Q

What does RVEF stand for?

A

Right ventricular ejection fraction

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79
Q

What does right ventricular end-diastolic volume indicate?

A

Right ventricular preload

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80
Q

What is the normal range for right ventricular end-diastolic volume (preload)?

A

100-160 mL

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81
Q

How is MAP calculated?

A

Systolic + 2(diastolic) / 3
diastolic + 1/3(systolic - diastolic)
diastolic + 1/3*(pulse pressure)

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82
Q

How is pulse pressure calculated?

A

Systolic - diastolic

83
Q

What is the normal range for pulse pressure?

A

40-60

84
Q

What is the normal range for MAP?

A

70-105 mmHg

85
Q

What does PAMP stand for?

A

Pulmonary artery mean pressure

86
Q

How is pulmonary artery mean pressure (PAMP) measured?

A

Pulmonary artery systolic pressure (PASP) + 2(PADP) / 3

87
Q

What is the normal range for pulmonary artery mean pressure (PAMP)?

A

10-20 mmHg

88
Q

How is pulmonary vascular resistance (PVR) calculated?

A

(PAMP - PAWP) * 80 / CO

89
Q

What is the normal value for pulmonary vascular resistance?

A

<250 dynes/sec/cm-5

90
Q

How is pulmonary vascular resistance index (PVRI) measured?

A

(PAMP - PAWP) * 80 / Cardiac index

91
Q

What is the normal range for pulmonary vascular resistance index?

A

160-380 dynes/sec/cm-5

92
Q

How is systemic vascular resistance (SVR) calculated?

A

(MAP - CVP) * 80 / CO

93
Q

What is the normal range for systemic vascular resistance?

A

800-1200 dynes/sec/cm-5

94
Q

How is the systemic vascular resistance index (SVRI) calculated?

A

(MAP - CVP) * 80 / Cardiac index

95
Q

What is the normal range for systemic vascular resistance index?

A

1970-2390 dynes/sec/cm-5/m2

96
Q

How is cardiac index measured?

A

CO / BSA

97
Q

What is the normal range for cardiac index?

A

2.2-4 L/min/m2

98
Q

What is the normal range for cardiac output?

A

4-8 L/min

99
Q

What is the normal range for heart rate?

A

60-100 bpm

100
Q

What is the normal range for right ventricle ejection fraction?

A

40-60%

101
Q

How is right ventricle ejection fraction (RVEF) calculated?

A

SV / RVEDV * 100

102
Q

What is the calculation for stroke volume?

A

Cardiac output / Heart rate

103
Q

What is the normal range for stroke volume?

A

60-150 mL/beat

104
Q

How is stroke volume index (SVI) calculated?

A

Cardiac index / heart rate

105
Q

What is the normal range for stroke volume index?

A

30-65 mL/beat/m2

106
Q

How is stroke volume variation (SVV) calculated?

A

SV max - SV min / SV mean

107
Q

What is the normal value for stroke volume variation?

A

<13%

108
Q

What is stroke volume variation?

A

A naturally occurring phenomenon in which the arterial pulse pressure falls during inspiration and rises during expiration due to changes in intra-thoracic pressure secondary to negative pressure ventilation (spontaneously breathing)

109
Q

What is the normal range for arterial hemoglobin O2 saturation?

A

95-100%

110
Q

What is the normal range for mixed venous hemoglobin O2 saturation?

A

60-80%

111
Q

What is the normal value for venous hemoglobin O2 saturation?

A

70%

112
Q

Why should a dynamic response test be performed on invasive pressure monitoring equipment?

A

Checking that the equipment reproduces without distortion, a signal that changes rapidly

113
Q

What is another name for a dynamic response test?

A

Square wave test

114
Q

How often should a dynamic response test (aka square wave test) be performed?

A

Every 8-12 hours, when the system is open to air, or you question the accuracy of the measurements

115
Q

What are possible indications for a patient to have an invasive arterial BP monitor?

A

Acute hypotension/hypertension
Respiratory failure
Shock
Neurologic injury
Coronary interventional procedures
Continuous infusion of vasoactive drugs (norepi)
Frequent ABG sampling

116
Q

What type of catheter is typically used to cannulate an artery?

A

Nontapered Teflon catheter

117
Q

What arteries are typically used for arterial BP monitoring?

A

Radial, femoral

118
Q

What measurements can be obtained from an arterial line?

A

Systolic, diastolic, and MAP

119
Q

What measurement from an arterial line is most accurate?

A

Readings from a printed pressure tracing at the end of expiration

120
Q

Why should you use measurements from the end of expiration?

A

To limit the effect of respiratory cycle on arterial blood pressure

121
Q

What position should you position a patient for initial readings from an arterial line?

A

Supine, if possible

122
Q

If you are unable to position a patient supine, what is the next best alternative for arterial blood pressure readings?

A

Head of bed elevated at 45 degrees is generally equal to supine

123
Q

When would having the head of the bed elevated to 45 degrees be contraindicated for initial arterial line readings?

A

If the patient’s BP is extremely sensitive to orthostatic changes

124
Q

How can the nurse make sure of accurate continuous readings from an arterial line?

A

Keep the zero-reference stopcock level with the phlebostatic axis

125
Q

On an arterial pressure tracing, what does the dicrotic notch indicate?

A

aortic valve closure

126
Q

List 5 complications of arterial lines

A

Hemorrhage
Infection
Thrombus formation
Neurovascular impairment
Loss of a limb

127
Q

If a catheter dislodges or the arterial line disconnects, what is the likely complication?

A

Hemorrhage

128
Q

How can you avoid hemorrhaging from the arterial line becoming disconnected or catheter dislodging?

A

Use Luer-lok connections
Always check the arterial waveform
Activate alarms

129
Q

How can you avoid infection from arterial lines?

A

Inspect site for inflammation
Monitor patient for signs of systemic infection
Change pressure tubing, flush bag, and transducer

130
Q

How often should you change the pressure tubing, flush the bag and transducer of arterial line equipment?

A

Every 96 hours or according to agency policy

131
Q

What should the nurse do if they suspect infection of an arterial line?

A

Notify HCP
Remove the catheter
Replace equipment

132
Q

How can an arterial line result in circulatory impairment?

A

Formation of a thrombus around the catheter, release of an embolus, spasm, or occlusion of the circulation by the catheter.

133
Q

Before an arterial line is inserted into a radial artery, what test should be performed?

A

An Allen test

134
Q

What does the Allen test confirm?

A

Ulnar circulation to the hand is adequate

135
Q

How do you conduct an Allen test?

A

Apply pressure to radial and ulnar arteries, ask patient to open and close hand. Hand should blanch. Release pressure. If color does not return in 6 seconds ulnar artery is not adequate

136
Q

When a patient has an arterial line, what should then nurse assess hourly?

A

Neurovascular status distal to the insertion site

137
Q

If the limb of an arterial line is compromised, what might it look like?

A

Cool, pale, prolonged capillary refill

138
Q

What symptoms might a patient have is their limb is compromised from an arterial line?

A

Paresthesia, pain, paralysis

139
Q

How can a nurse maintain arterial line patency and limit thrombus formation?

A

Assess the flush system every 1-4 hrs

140
Q

When the nurse assesses the flush system of an arterial line, what is she checking?

A

1) Pressure bag inflated to 300 mmHg
2) Flush bag contains fluid
3) System is delivering a continuous slow flush

141
Q

What should the pressure bag of an arterial line be inflated to?

A

300 mmHg

142
Q

How much should the flush system of an arterial line be delivering?

A

1-3 mL/hr

143
Q

What does APCO stand for?

A

Arterial pressure-based cardiac output

144
Q

What does an arterial pressure-based cardiac output (APCO) calculate?

A

Continuous cardiac output/continuous cardiac index

145
Q

What does an arterial pressure-based cardiac output measurement assess?

A

Patient’s ability to respond to fluids by increasing stroke volume aka preload responsiveness

146
Q

How does the arterial pressure-based cardiac output (APCO) measurement determine preload responsiveness?

A

By using SVV (stroke volume variation) or by measuring the percent increase in SV after a fluid bolus

147
Q

What is stroke volume variation (SVV)?

A

The variation of the arterial pulsation caused by the heart-lung interaction

148
Q

In certain patients, stroke volume variation is sensitive indicator of __ __

A

preload responsiveness

149
Q

Atrial pressure-based cardiac output (APCO) is only used with __ patients

A

adult

150
Q

Atrial pressure-based cardiac output (APCO) cannot be used in patients who are on what type of therapy?

A

IABP

151
Q

What is IABP therapy?

A

Intra-aortic balloon pump therapy

152
Q

What type of dysrhythmia might the APCO not be able to filter?

A

Atrial fibrillation

153
Q

Stroke volume variation is only used with patients who are…

A

On controlled mechanical ventilation with a fixed respiratory rate and tidal volume

154
Q

What is arterial pressure?

A

The force generated by the ejection of blood from the left ventricle into the arterial circulation

155
Q

Arterial pulse pressure is proportional to __ __

A

Stroke volume

156
Q

What does the APCO use to calculate stroke volume?

A

Arterial waveform characteristics, along with demographic data (age, weight, height, gender)

157
Q

APCO monitoring is frequently used with a…

A

central venous oximetry catheter

158
Q

APCO monitoring combined with central venous oximetry catheter allows for…

A

Continuous monitoring of central venous o2 saturation and SVR that is derived from the CVP

159
Q

How is central venous O2 saturation abbreviated?

A

ScvO2

160
Q

List 5 contraindications to a pulmonary artery catheterization

A

Coagulopathy
Endocardial pacemaker
Endocarditis
Mechanical tricuspid or pulmonic valve
Right heart mass (thrombus/tumor)

161
Q

What are 7 indications for a pulmonary artery catheterization?

A

Cardiogenic shock
Assessment of response to therapy
Differential diagnosis of pulmonary hypertension
MI with complications
Potentially reversible systolic HF
Severe chronic HF
Transplantation workup

162
Q

What is a differential diagnosis?

A

Occurs when your symptoms match more than one condition and additional tests are necessary before making an accurate diagnosis

163
Q

What is fulminant myocarditis?

A

Uncommon syndrome characterized by sudden and severe diffuse cardiac inflammation often leading to death resulting from cardiogenic shock, ventricular arrhythmias, or multiorgan system failure

164
Q

What two measurements increase in patients with heart failure and fluid volume overload?

A

Pulmonary artery diastolic pressure (PADP)
Pulmonary artery wedge pressure (PAWP)

165
Q

What is the name of the pulmonary artery flow-directed catheter?

A

Swan-Ganz

166
Q

What does the Swan-Ganz measure?

A

Pulmonary artery pressures, including pulmonary artery wedge pressure

167
Q

Where is the distal lumen port (catheter tip) of the Swan-Ganz?

A

Within the pulmonary artery

168
Q

What is the distal lumen port?

A

Catheter tip

169
Q

What is the catheter tip of the Swan-Ganz called?

A

distal lumen port

170
Q

What does the Swan-Ganz measure?

A

pulmonary artery pressures and sample mixed venous blood

171
Q

The Swan-Ganz has a balloon on the distal lumen port to…

A

1) allow the catheter to float
2) to meausure PAWP

172
Q

Why is there a thermometer near the distal tip of the Swan-Ganz?

A

It monitors core temperature and is used for the thermodilution method of measure cardiac output

173
Q

What can an advanced technology Swan-Ganz (PA catheter) monitor?

A

SvO2, CCO, RVED

174
Q

What are less invasive options than a Swan-Ganz?

A

APCO monitoring and beside echocardiogram

175
Q

Where is a PA catheter (Swan-Ganz) inserted?

A

By HCP at bedside

176
Q

What conditions may be contraindications to a PA catheter (Swan-Ganz)?

A

Hypokalemia
Hypomagnesemia
Hypoxemia
Acidosis
Coagulopathy

177
Q

What are key nursing roles during a PA catheter insertion?

A

Observe characteristic waveforms on monitor
Watch EKG
Obtain chest x ray
Note and record measurement at exit point
Apply occlusive sterile dressing

178
Q

What is a measurement of right ventricular preload and reflects fluid volume status?

A

Central venous pressure (CVP)

179
Q

Where is a CVP catheter most often placed?

A

In the internal jugular or subclavian vein

180
Q

CVP is measured as a…

A

mean pressure at the end of expiration

181
Q

What does a high CVP indicate?

A

Right ventricular failure or volume overload

182
Q

What does a low CVP indicate?

A

Hypovolemia

183
Q

How is a CVP catheter measured?

A

With a PA catheter using the proximal lumen in the right atrium

184
Q

What is the reason for measuring the O2 saturation of venous blood in critically ill patients?

A

It helps to determine the adequacy of tissue oxygenation

185
Q

What is ScvO2?

A

Central venous O2 saturation

186
Q

What is SvO2?

A

Mixed venous O2 saturation

187
Q

What do SvcO2 and ScO2 reflect?

A

The balance among oxygenation of the arterial blood, tissue perfusion, and tissue O2 consumption

188
Q

What is normal ScvO2 or SvO2?

A

60-80%

189
Q

What does a high ScvO2 or SvO2 indicate?

A

More oxygen supply, less oxygen demand

190
Q

What conditions might cause a high ScvO2?

A

Receiving more O2 than needed
Anesthesia
Hypothermia
Sepsis

191
Q

Why can anesthesia cause a high ScvO2?

A

Causes sedation and decreased muscle movement

192
Q

Why can hypothermia cause a high ScvO2?

A

Decreases metabolic demand

193
Q

What is an example of high ScvO2 caused by hypothermia?

A

Cardiopulmonary bypass

194
Q

How does sepsis cause a high ScvO2?

A

Decreases the ability of tissues to use oxygen at the cellular level

195
Q

What does a low ScvO2 or SvO2 mean?

A

Increased O2 demand
Low hemoglobin
Low arterial saturation
Low cardiac output

196
Q

What are potential causes of low ScvO2?

A

Anemia
Bleeding
Hypoxemia
Cardiogenic shock
Increase in metabolic demand, such as muscle movement

197
Q

What is cardiogenic shock?

A

When your heart cannot pump enough blood to the brain and vital organs to meet oxygen demand

198
Q

ScvO2 values are generally slightly __ than SvO2 values

A

higher

199
Q

How can the nurse indirectly assess CO and tissue perfusion?

A

Change in mental status
Strength and quality of peripheral pulses
Capillary refill
Urine output
Skin color and temperature

200
Q

What does a fall in ScvO2 or SvO2 indicate if arterial oxygenation, CO, and Hgb are unchanged?

A

Increased O2 consumption or extraction

201
Q

What could cause an increase in O2 consumption in a patient with a PA catheter?

A

Increased metabolic rate
Pain
Movement
Fever
Shivering

202
Q

If the nurse is trying to reposition a patient, their heart rate increases and ScvO2 decreases, what does this mean?

A

The patient is not tolerating the move well and the nurse should wait to reposition until the ScvO2 returns to normal

203
Q

What conditions make an accurate SpO2 hard to get?

A

Hypothermia
IV vasopressor therapy
Hypoperfusion/vasoconstriction

Critical Care (2 decks)

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