Hemodynamic Monitoring Flashcards
Hemodynamic Monitoring
Measures pressure, flow, and oxygenation in CV system
What does it assess?
Heart function, fluid balance, and effects of drugs on the CO (frequent lab draws)
Components of Pressure Monitoring system
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
What do you do immediately after the pressure monitoring system is set up?
Zero to determine correct waveform and device is in correct position
Principles of Invassive Pressure Monitoring
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
Leveling Transducer
Above Phlebostatic Axis = Falsely LOW BP
Below Phlebostatic Axis = Falsely HIGH BP
Re-zero the device when position changes and q12 hours
Dynamic Response Test (Square Wave Test)
Fast Flush to determine pressure and waveforms are accurate q12 hours
Done on initial insertion, blood draws (clots/thrombus), open air
Expected square wave test
NORMAL
Box and 1-2 oscillations (return of the waveform)
Overdamped
Box = slopped
Air bubbles, kinks, clots = damped/flatten waveform
Underdamped
MORE oscillations/vibrations before returning to normal
Inaccurate Monitor Reading
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)
Troubleshooting Overdamped
Problem = Inaccurate readings
Completely flush line and/or catheter (no air bubbles)
Back flush through the system to clear bubbles from the tubing/transducer
Troubleshooting Underdamped
Problem = falsely high values
Perform a fast-flush square wave test to verify optimal damping on the monitoring system
Troubleshooting Normal Waveform + low/high pressure reading
- Check the patient
- Ensure the system is leveled correctly
- Recalibrate (re-zero) if the transducer changes positions
- Reposition to phlebostatic axis
Troubleshooting with NO waveform
- Check patient
- Check the equipment - catheter kinked (vessel wall, different position), stopcock turned off (aka wrong way)
Potential Complications
Clot Formation
Hemorrhage
Air Emboli (resp. distress, cv collapse r/t PE) occluded area where air escapes
Infection
Nursing Interventions related to potential complications
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
Alarm safety
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
Nursing Interventions
- Check patient
- 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
Arterial Blood Pressure Monitoring
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)
Insertion of Arterial Blood Pressure Cath
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)
Nursing Interventions after inital insertion
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
Assessing Arterial BP
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
Arterial Pressure Monitoring Risks and Complications
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
Arterial Pressure Monitoring
Check pt.
Troubleshoot (clots @ end) - reposition pt./flush line
Systolic = highest
Dicrotic Notch = downward stroke
Aortic valve closes causing blood flow into arterial vasculature
Central Venous Pressure (CVP)
Measures right ventricular preload (fluid volume via vena cava)
Large volumes needed rapidly (traumas/burn/shock)
Invasive (via CVC or PA cath.)
CVC Placements
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
Insertion of CVC
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
Assessing Fluid Volume Status
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
Increased CVP Nursing Interventions
Restrict fluid and sodium intake
Diuretics (furosemide)
Decreased CVP Nursing Intervention
VasoCONSTRICTING meds (norepi/epi/vasopressin)
IV fluids (crystalloids)
Transfusion
Nursing Management
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
Complications Related to CVC
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)
Pulmonary Artery Pressure
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
Parts of a PA Cath
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.
Contraindications PA
Blood clotting issues
Endocardial pacemaker
Mechanical tricuspid valve replacement
Nursing Management
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
Effect of Overinflated Balloon
PA vessel rupture from pressure
- cushion tip - right ventricle wall - decrease irritability of heart - decrease ventricular dysrhythmias
- inflation - helps flow from right ventricle - pulmonary artery
PA Cath Complications
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
PA Cath Complications Nursing Interventions
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
Ventricular Assist Devices (VADs)
HF
Shunts blood from left atrium/ventricle - device - aorta
Left/right/biventricular (LVAD is most common)
LVADs Things to Note
Art. lines for BP monitoring (no palpable BP) MAP can be done with doppler and manual BP
ABG»_space; Pulse Ox for oxygenation related to low perfusion to extremities
s/s of adequate circulator support mentation, UOP, etc.
Indications for LVAD
Failure to wean from cardiopulmonary bypass
Bridge while waiting for heart transplant
MI, Tx
NY Heart Association Class IV failed med therapy
Contraindications for LVAD
Higher BMI
Irreversible end-stage organ damage
Comorbidities where life expectancy < 3 years
Nursing Management of LVAD
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
