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High Acuity > Hemodynamic Monitoring > Flashcards

Hemodynamic Monitoring Flashcards

1
Q

Hemodynamic Monitoring

A

Measures pressure, flow, and oxygenation in CV system

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2
Q

What does it assess?

A

Heart function, fluid balance, and effects of drugs on the CO (frequent lab draws)

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3
Q

Components of Pressure Monitoring system

A

Pressure bag (300 mmHg) with flush solution

3-way stopcock (zero to atmosphere)

Transducer

Continuous flush valves (1-3 mL/hr) patency of cath.

Pressure cable (transducer to monitor)

Fast flush device (zeroing/ square wave test) clearing the line after drawing labs

Pressure tubing

Connection for specimen collection

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4
Q

What do you do immediately after the pressure monitoring system is set up?

A

Zero to determine correct waveform and device is in correct position

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5
Q

Principles of Invassive Pressure Monitoring

A

Zero to the environment and dynamic response characteristics optimized

Referencing the transducer at the phlebostatic axis aka the atria of the heart) at the midaxillary line

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6
Q

Leveling Transducer

A

Above Phlebostatic Axis = Falsely LOW BP

Below Phlebostatic Axis = Falsely HIGH BP

Re-zero the device when position changes and q12 hours

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7
Q

Dynamic Response Test (Square Wave Test)

A

Fast Flush to determine pressure and waveforms are accurate q12 hours

Done on initial insertion, blood draws (clots/thrombus), open air

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8
Q

Expected square wave test

A

NORMAL

Box and 1-2 oscillations (return of the waveform)

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9
Q

Overdamped

A

Box = slopped

Air bubbles, kinks, clots = damped/flatten waveform

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10
Q

Underdamped

A

MORE oscillations/vibrations before returning to normal

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11
Q

Inaccurate Monitor Reading

A

Air Bubbles
Thrombosis ( clots at tip or clot at the end)
Displacement
Stopcocks if there are >3
Tubing (too long)
Pressure Bag (not inflated enough)

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12
Q

Troubleshooting Overdamped

A

Problem = Inaccurate readings

Completely flush line and/or catheter (no air bubbles)
Back flush through the system to clear bubbles from the tubing/transducer

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13
Q

Troubleshooting Underdamped

A

Problem = falsely high values

Perform a fast-flush square wave test to verify optimal damping on the monitoring system

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14
Q

Troubleshooting Normal Waveform + low/high pressure reading

A
  1. Check the patient
  2. Ensure the system is leveled correctly
  3. Recalibrate (re-zero) if the transducer changes positions
  4. Reposition to phlebostatic axis
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15
Q

Troubleshooting with NO waveform

A
  1. Check patient
  2. Check the equipment - catheter kinked (vessel wall, different position), stopcock turned off (aka wrong way)
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16
Q

Potential Complications

A

Clot Formation
Hemorrhage
Air Emboli (resp. distress, cv collapse r/t PE) occluded area where air escapes
Infection

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17
Q

Nursing Interventions related to potential complications

A

CLOT
Low-rate infusion via in-line flush device to maintain patency
Gently aspirating the line via small syringe @ proximal stopcock and flush after clot removed

Hemorrhage
Use luer-lock connections (screws) in-line setup, close and cap stopcock when not in use
Tighten all connections, flush the line, and estimate blood loss

Air Emboli
Prevention (no air bubbles within the in-line setup
100% O2 and place on left lateral trendelenberg

Infection
Aseptic technique, proper hand hygiene, remove as soon as stable/possible

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18
Q

Alarm safety

A

ALARM IDENTIFICATION
Audible and visual indication (make sure you can hear and differentiate)
Life-threatening should sound different than noncritical alarm solutions

DISABLING AND SILENCING ALARMS
Silenced alarms need to have visual alarms (disabled)
Critical alarms should not be “turned off”

ALARM LIMITS
Adjusted per patient needs (decrease alarm fatigue)
Displayed on monitor

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19
Q

Nursing Interventions

A
  1. Check patient
  2. Check the equipment (function properly)

General appearance, LOC, skin color/temp, VS, peripheral pulses, cap. refill, UOP
Monitor trends
S/S decrease perfusion = tiredness, exhaustion, mental status differences, pale skin, weak and thready pulse, absent bowel sounds, UOP decrease

20
Q

Arterial Blood Pressure Monitoring

A

Continuous BP measurements (CO status) (low or high BP, respiratory failure, neuro injury, vasoactive drugs, etc.)

Continuous assessment of arterial perfusion to the major organ systems of the body, fluid volume status

Minimally invasive

Frequent labs/ABGs

Obtain MAP (aka whole cardiac cycle)

Low BP (check patient and equipment)
Dampened/flattened waveform (an issue in communication with artery and transducer causing false low)

21
Q

Insertion of Arterial Blood Pressure Cath

A

Sites = radial and femoral
Do Allen test to determine if perfusion (ulnar) is good
(+) = perfusion adequate
(-) = no return w/in 6 secs (no ulnar perfusion)

Don’t use femoral artery because it was hard to keep clean (increased risk of infection)

Cath canulates peripheral artery longer, sutured in place, and immobilize insertion site with Tegaderm (dislodge/kink)

22
Q

Nursing Interventions after inital insertion

A

Make sure there are no air bubbles, pressure bag is pumped to 300 mmHg, level and zeroed at phlebostatic axis, do a fast flush square test to ensure accuracy

Set high- and low-pressure alarms

Continuous flush irrigation system (decrease thrombus formation and maintain patency) 1-3 ml/hr q 1-4hrs

23
Q

Assessing Arterial BP

A

MAP = 70-90 ideally
> 60 to perfuse coronary arteries (higher dependent on disease process)

Systolic and diastolic pressures monitored to determine what is happening with vasculature

24
Q

Arterial Pressure Monitoring Risks and Complications

A

Hemorrhage
Infection
Thrombus Formation r/t impaired flow
Neurovascular Impairment
Loss Limb - assess neurovascular status distal to arterial insertion site hourly
Monitor s/s of compromised arterial flow - cool, pale, sluggish, cap. refill > 3 sec., paraesthesia, pain, paralysis (nerve damage)
Exsanguination (bleeding) - lure locks not tight, in-line stopcock open to air

25
Q

Arterial Pressure Monitoring

A

Check pt.
Troubleshoot (clots @ end) - reposition pt./flush line

Systolic = highest

Dicrotic Notch = downward stroke
Aortic valve closes causing blood flow into arterial vasculature

26
Q

Central Venous Pressure (CVP)

A

Measures right ventricular preload (fluid volume via vena cava)

Large volumes needed rapidly (traumas/burn/shock)

Invasive (via CVC or PA cath.)

27
Q

CVC Placements

A

Internal Jugular (IJ) = Easiest access and to cannulated, lower pneumothorax risk, secretions from trach contaminate (trach and on vent), pt. discomfort when moving head and neck

Subclavian = Most comfortable although increased risk for hemothorax/pneumothorax

Femoral = Increased risk of infection, used for super hemodynamically unstable patients/emergencies
Usually changed to IJ/ Subclavian

28
Q

Insertion of CVC

A

Trendelenberg position
Sterile technique (hair cover, mask, gown and gloves)
Educate patient to take deep breath and hold it during insertion
Pt. = awake,
Provide brief explanation of the procedure (decrease anxiety and more cooperative)
Monitor EKG (increase risk of dysrhythmias developing)
CXR to verify placement and no pneumothorax/hemothorax present
Removal = nursing responsibility
Bed flat, hold deep breath before removal, occlusive dressing to prevent air and bleeding
U/S with contrast

29
Q

Assessing Fluid Volume Status

A

Right side preload; normal = 2-8 mmHg

High CVP = Right ventricular pressure

Low CVP = hypovolemia

Passive leg raise to determine fluid responsiveness
Venous blood from lower extremities flow rapidly into vena cava into the right side of the heart
Increased CVP, (+) fluid bolus response

30
Q

Increased CVP Nursing Interventions

A

Restrict fluid and sodium intake
Diuretics (furosemide)

31
Q

Decreased CVP Nursing Intervention

A

VasoCONSTRICTING meds (norepi/epi/vasopressin)
IV fluids (crystalloids)
Transfusion

32
Q

Nursing Management

A

Prevent complications
Pneumothorax - CXR
Localized hematoma, bleeding- apply an occlusive dressing (then transition to sterile dressing), estimated blood loss, and notify HCP
Thrombus - Check CVC cath q 1-2 hrs that all lumens draw and flush, tPA/heparin to help remove clot.
Air emboli - monitor for s/s respiratory distress, immediately occlude the site, 100% O2, and place in left later trendelenberg, secure lure locks secured when not in use
CLABSIs - sterile technique on insertion, review need and remove if applicable, site dressing with CHG, hand hygiene, change dressing when soiled/per policy, change caps pre policy, use cath securement device (increased movement increased risk for infection)

Assess fluid volume status
Accommodate for changes in pt. positioning
Accurate interpretation of CVP waveforms

33
Q

Complications Related to CVC

A

CLABSI
Pneumothorax with subclavian placement
Thrombus at the end of catheter
Air Embolus during insertion with disconnected/broken catheter/stopcock open to air and during CVC removal
Localized hematoma, bleeding - loss connection/open stopcock where blood backs up into line (removed = bleeding related to increased P system)

34
Q

Pulmonary Artery Pressure

A

Swan Ganz Cath/ right heart cath used for acute HF, open heart sx, acute pulmonary hypertension

Left Ventricular function and fluid volume status via PA diastolic pressure and PAWP

Guide fluid therapy more precisely

35
Q

Parts of a PA Cath

A

PROXIMAL INJECTATE LUMEN - Sits in the right atrium; IVF, CVP, venous blood sampling, injection of fluids for CO

DISTAL LUMEN HUB - Pulmonary artery pressure; helps with forward motion of cath lowering ectopy from cath tip

BALLOON INFLATION VALVE - PAWP (inflated)

THERMISTOR CONNECTOR - Monitors temp.

36
Q

Contraindications PA

A

Blood clotting issues
Endocardial pacemaker
Mechanical tricuspid valve replacement

37
Q

Nursing Management

A

Prep equipment - monitor, cables, infusion, and pressurized flush solutions
Ensure system is leveled and zero-referenced to the phlebostatic axis

Check pt.’s electrolytes (hypokalemia, hypomagnesemia, hypoxemia = heart irritable causing dysrhythmias), ABGs, O2, coagulation status (increased hemorrhage)

Trendelenberg position to promote venous filling and facilitate insertion and prevent air emboli
CONTRAINDICATED for pt. with increased ICP and resp. distress

Monitor waveform (pulmonary infarction if too far into vasculature) on monitor as cath proceeds forward and ECG for dysrhythmias

Obtain CXR to confirm cath placement

Note exit point - assess or place dressing and change according to agency policy

38
Q

Effect of Overinflated Balloon

A

PA vessel rupture from pressure

  1. cushion tip - right ventricle wall - decrease irritability of heart - decrease ventricular dysrhythmias
  2. inflation - helps flow from right ventricle - pulmonary artery
39
Q

PA Cath Complications

A

Infection and Sepsis

Air emboli - an upright position where air is pulled into a venous system that increases (-) thoracic P during inhalation

A large rate of air entering causes resp. distress and CV collapse

Pulmonary Infarction/PA rupture

Ventricular dysrhythmias

40
Q

PA Cath Complications Nursing Interventions

A

Infection and Sepsis
Asepsis (insertion and maintenance), change flush bag, pressure tubing, transducer, and stopcock per agency policy

Air emboli
Monitor cath integrity, luer-lok connections, and alarm on

Pulmonary Infarction/PA rupture
Remove when not needed
Do not inflate > 1.5 mL
Monitor waveforms (occlusion, dislocation, spontaneous wedging, decrease thrombi and emboli formation)
Continuous flush system maintenance

Ventricular dysrhythmias
Monitor ECG during insertion and removal
CXR -monitor cath migration

41
Q

Ventricular Assist Devices (VADs)

A

HF
Shunts blood from left atrium/ventricle - device - aorta
Left/right/biventricular (LVAD is most common)

42
Q

LVADs Things to Note

A

Art. lines for BP monitoring (no palpable BP) MAP can be done with doppler and manual BP

ABG&raquo_space; Pulse Ox for oxygenation related to low perfusion to extremities

s/s of adequate circulator support mentation, UOP, etc.

43
Q

Indications for LVAD

A

Failure to wean from cardiopulmonary bypass
Bridge while waiting for heart transplant
MI, Tx
NY Heart Association Class IV failed med therapy

44
Q

Contraindications for LVAD

A

Higher BMI
Irreversible end-stage organ damage
Comorbidities where life expectancy < 3 years

45
Q

Nursing Management of LVAD

A

Frequent Assessments
Note device setting and flow rate
Auscultation (humming), cap refill, skin, arrhythmias
Tele, Doppler Manual BP (MAP)
Radial/distal pulse wk/absent

Activity plan
In-depth pt. teaching

Goals
recovery through ventricular improvement
receive artificial heart
heart transplant

Provide emotional support for patient and caregiver - patients die/choose to no longer seek treatment

High Acuity (7 decks)

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