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Critical Care > Hemodynamics > Flashcards

Hemodynamics Flashcards

1
Q

The flow of blood is ejected from the heart to circulate throughout the body in order to effectively oxygenate the tissues of the body
Blood flow
More cardiac cath lab side - look at valve areas and shunt sizes

A

Hemodynamics:

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2
Q

Arterial pressures
Catheter that is inserted in an artery.
Continuous blood pressure measurement.

A

Intraarterial blood pressure monitoring (Arterial line)

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3
Q

See lot with central venous catheter - get waveform and number from central vein
Have Swan-Ganz/PA catheter - translated to lower third of IVC/SVC
Catheter that is inserted in a vein – the distal tip of the catheter is in a central vein (superior or inferior vena cava)
Monitor alterations in fluid volume.

A

Central venous pressure monitoring (Central venous catheter)

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4
Q

Fancy catheter
Have Introducer sheath in central vein - catheter put in - distal tip in PA
Multiple ports that do different things
Catheter that is inserted in a vein – the distal tip of the catheter is in the pulmonary artery.
Provide information about PA pressures (systolic, diastolic, mean), PAOP (Pulmonary Artery Occlusive Pressure), and CO. The location of the PA catheter provides access for measurement of mixed venous oxygen saturation.

A

Pulmonary Artery Catheter (PA catheter, Swan Ganz)

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5
Q

What is the primary purpose of an arterial line?
The most common insertion sites are the radial artery (most common) and the femoral artery (coming out of procedure - usually accessed via this so just hook to continuous monitor).
What are patients with an arterial line most at risk for?

A

Intra-arterial BP monitoring

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6
Q

Primary purpose: Continuous blood pressure
Will not infuse anything
May see with frequent ABGs
Can see continuous trends when giving meds that affect BP to see if getting better/worse or how long effect; transplant work up - put in PA catheter and start both dopamine and nitroprusside - see how long for PA to dilate out and then improve BP

A

What is the primary purpose of an arterial line?

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7
Q

Allen’s test
Smaller arteries that supply distal arm and hand - ensure adequate flow - to provide arterial blood flow to hand
Occlude both radial and ulnar at the same time - palm blanch - release ulnar artery (since not getting catheter and see if supplies blood to whole hand - if only ½ turns pink, not enough flow to give adequate perfusion to whole hand: then think of other options
Can do popliteal - anywhere can get access

A

The most common insertion sites are the radial artery (most common) and the femoral artery (coming out of procedure - usually accessed via this so just hook to continuous monitor).

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8
Q
  1. Infection
  2. Bleeding
    Like big IV - 4 Fr - like 16/18 Gauge - not as flexible - if at a bend, need to keep area straight - make puncture site bigger and start bleeding
A

What are patients with an arterial line most at risk for?

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9
Q

Once art line in - get nice waveform
Know what looks like - nice triangular up and down

A

Arterial pressure waveform interpretation

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10
Q

Lot stuff
LV beating - ejection seeing
AO - aorta pressure - more defined than when in peripheral
↓ Arterial perfusion (pulse deficit)– PVC’s (less ejection), a. Fib (lose AV synchrony), tachyarrhythmias (filling time lower) - waveform less pronounced
↓LV function
Something wrong with LV
Pulsus alternans: later stages of CHF
Pulsus paradoxus: cardiac tamponade (gradual and monitor over time), pericardial effusion (gradual and monitor over time), or constrictive pericarditis (happens suddenly - fine until not)

A

What can affect the arterial waveform?

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11
Q

When have an art line - make sure what seeing = accurate
Equipment is level
Abnormal - not something can fix easily
Squeezer or pigtail flushes it
A damped waveform can affect the arterial waveform.
The nurse must determine whether it is a patient problem or a problem with the equipment.

A

Dynamic response (AKA zeroing or square wave test)

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12
Q

Seeing if it is optimal
Rarely see perfect waveforms
Optimal: when squeeze: get vertical line then level off (squared off); when let off, have refurb: oscillations (1-2)
Series of 1-2 oscillations
Oscillations 1-2 small boxes apart or < 0.8 sec
Fast flush
Square off
Look at how wide and how many oscillations are present after the square wave.

A

Optimal square wave test/dynamic response

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13
Q

Squeeze and get vertical line, will square off; when let go, too many oscillations after - more than 2 and will be fatter
Care: systolic pressure not correct - overestimated; diastolic will be underestimated - still needs this and chronically underdamped - see order to just chart MAP because be accurate - cannot titrate meds based on diastolic underestimated but can on MAP
Characteristics
Causes
Corrective actions

A

Underdamped square wave test:

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14
Q

Extra oscillations
More than 2 little boxes apart
Narrow, peaked tracing

A

Characteristics - Underdamped square wave test:

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15
Q

Long catheter length
Increased vascular resistance
See if on lot vasopressors - clamped done; constricted over catheter
Hypothermia protocol
After codes

A

Causes - Underdamped square wave test:

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16
Q

Remove excess tubing - lot catheter - take the length off
Insert dampening device or filter
Never take vasoactive drugs off
Not discontinue hypothermia protocol - just chart underdamped

A

Corrective actions - Underdamped square wave test:

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17
Q

Still have when squeeze straight line going up = may be tilted; square off, then go down
Not as many/none oscillations/squiggles
MAP always same - systolic underestimated and diastolic overestimated
Characteristics
Causes
Corrective actions

A

Overdamped square wave test

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18
Q

Slurred upstroke
Loss of oscillations

A

Characteristics - Overdamped square wave test

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19
Q

Seen lot
Air bubble - at transducer or in tubing
Kink in the tubing
Overly compliant tubing - tubing on long enough, very stiff tubing, older tubing just not as compliant
Blood clots/fibrin - catheter in vessel - not flushing enough; esp after draw ABG
Check Stopcocks - stop cock not at perfect 90 - needs to be perfect
No fluid in flush bag - lot flushing; look up and nothing in there
Low flush bag pressure - as flush - bag not as big so need to pump it up

A

Causes - Overdamped square wave test

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20
Q

Correct the issue
Clear air or blood
Straighten tubing

A

Corrective actions - Overdamped square wave test

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21
Q

Veins - Lower pressures - if same as normal BP, something wrong with lungs or valve on that side
Can get lot patho by looking at lumps and bumps
Central Venous Catheter: An indwelling catheter inserted into a large, central vein
Definition: Pressure created by volume in the right side of the heart. When the tricuspid valve opens, the CVP reflects filling pressures in the right ventricle.
Normal CVP: 2 – 5 mm Hg
Purpose
Insertion sites

A

Central venous pressure monitoring

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22
Q

Central line
In IJ/subclavian

A

Central Venous Catheter: An indwelling catheter inserted into a large, central vein - Central venous pressure monitoring

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23
Q

Measure fluid status
Preload - indicator of this; use other assessment with it; good indicator; preload is volume status - in overload/dehydrated

A

Purpose - Central venous pressure monitoring

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24
Q

Internal jugular - not get first or second time go to femoral vein
Subclavian
Femoral vein - higher risk for infection esp if incontinent; movement inhibited some

A

Insertion sites - Central venous pressure monitoring

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25
Q

Not without risk during dressing change
Air embolus
Thrombus formation
Infection
Nursing management

A

Central venous catheter complications

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26
Q

Leave stopcock open - will suck in air
Broken catheter - see before insert - protocol is to flush before insertion
Drawing up meds and not seeing fluid level and seeing air in syringe

A

Causes: - Air embolus

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27
Q

Acute sudden onset of respiratory distress: suddenly drop O2 sats; anxious - not exchanging O2 at that level; big enough: code - complete resp collapse followed by cardiac collapse

A

Signs & symptoms: - Air embolus

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28
Q

1-3 <1 min
1st.
Cover the sight with an occlusive dressing - stop from getting bigger - cover catheter; bigger air embolus - more acutely ill; transparent occlusive dressing
2nd.
Put on 100% O2 - increase cannula if present then Nonrebreather - not stay stable long
3rd.
Drop on head and turn on left side so not move from RV - eventually reabsorb - do not want to go into pulmonary vasculature
4th.
Notify PCP

A

Priority intervention: - Air embolus

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29
Q

Same thing as peripheral IV hard to flush - can put low dose alteplase in it to help break it up
Causes
Signs & symptoms:
Priority intervention:

A

Thrombus formation

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30
Q

Operator error
Not flushing enough after giving medications/administering blood or blood products

A

Causes - Thrombus formation

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31
Q

IV pump always beeping that occluded on pt side
Not attached to continuous IV infusion - effort to push med
Draw blood out - not get pulled out; very sluggish if can get it to pull back

A

Signs & symptoms: - Thrombus formation

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32
Q

Prevention: flush; Protocol: up to 20mL
Can give thrombolytics if not contraindicated

A

Priority intervention: - Thrombus formation

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33
Q

Redness at the site, or red streaks around the site.
Swelling or warmth at the site.
Yellow or green drainage.
Pain or discomfort.
Fever.

A

Signs & symptoms: - Infection

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34
Q

Single most crucial step a nurse can take to help prevent central line-associated bloodstream infections is performing proper hand hygiene. Other interventions focus on dressing management, bathing practices, access of intravenous infusion sets, blood draws, and management of port line occlusions
Perform hand hygiene
Apply appropriate skin antiseptic
Ensure that the skin prep agent has completely dried before inserting the central line
Remove a central line as soon as it is no longer needed

A

Priority intervention: - Infection

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35
Q

Volume assessment
Central venous catheter removal

A

Nursing management

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36
Q

Physical assessment findings
Preload: CVP - 2-5: number on screen: assess pt after seeing low/high number

A

Volume assessment

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37
Q

What is the optimal position for the patient to be in?
Are in the bed - if complication cannot put on left side
When do you pull the catheter (inhale or exhale)?
Exhale/holding breath
About intrathoracic pressure
When inhaling - if tract - can suck air in threw that and get embolus
Pulling out quick
Prevents air embolus: exhale; occlusive dressing, stopcock closed
Volume assessment: CVP
Most common complications
Air embolus
Bleeding

A

Central venous catheter removal

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38
Q

Common
Decreased fluid in vasculature

A

Signs and symptoms: - Bleeding

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39
Q

Right sided probs - CVP high and good stream coming out - someone who is bleeding - Hold firm pressure; occlude and let go until see oozing and add more pressure
Holding pressure on veins/arteries not 100% occlussive because affecting blood flow - arterial - cold; venous - cause issues
Put firm pressure

A

Priority intervention: - Bleeding

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40
Q

Hemodynamics = blood flow

A

Pulmonary Artery Pressure Monitoring (Hemodynamics)

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41
Q

Ultimately want to know CO
CO = amount of blood pumped by each ventricle in one min; volume/min; product of SV (amount of blood pumped in one heartbeat) x HR
Increase in SV or HR increases CO
Ventricles do not eject all blood contain in one beat
EF = 60% typical from body
100 mL usually in ventricles = end diastolic volume (EDV); at end of diastole/filling
40 mL left = end systolic volume (ESV) - at end of systole/contraction
SV = EDV - ESV; dependent on contractility (force of contraction of heart muscle), preload (EDV - according to Frank-Starling mechanism - greater the stretch the greater the force of contraction), afterload (resistance ventricle must overcome to eject blood; includes: vascular pressure (pressure in LV - must be greater than systemic pressure for aortic valve to open; pressure in RV must exceed pulmonary pressure to open pulmonary valve)
Damage to valves - presents higher resistance and HTN does as well - leads to lower blood output

A

CO determinants

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42
Q

Affects CO
Elevated heart rate
Slow heart rate
Why is this important to know?

A

HR

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43
Q

Decreases filling time and BP; arterial waveforms lower
What contributes to an elevated heart rate?
External stimuli
Sympathetic nerve response
Excitement
Drug related
How do we manipulate the heart rate?
Taking away external stimuli
Give medications - beta blockers, calcium channel blockers
Most drugs not soley chronotropic - may be primary response to chronotropic to lower HR; but also other components but need to pick best option for it

A

Elevated heart rate

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44
Q

What contributes to a slow heart rate?
damage to your heart due to aging or heart diseases (such as heart attack), cardiomyopathy or myocarditis. Hypothyroidism.
a malfunction in the heart’s sinus node, its natural pacemaker
How do we manipulate the heart rate?
Atropine - common
Stable - dopamine - lot chronotropic effects - keep HR up
Pacemaker

A

Slow heart rate

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45
Q

Contributes to CO

A

Why is this important to know?

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46
Q

Volume
Fluid status
Preload: Volume of blood in the ventricle at end-diastole
What is left
2 numbers: PAOP and CVP
Left Ventricle Preload
Right Ventricle Preload
Frank-Starling Law:
Ejection fraction (EF):
Low preload is associated with:
How does a low preload affect the cardiac output?
Assessment findings
If preload is low what medications are given?
High preload is associated with:
How does a high preload affect blood pressure?
Assessment findings
If preload is high what medications are given?

A

Preload

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47
Q

Measured by pulmonary artery occlusive pressure (PAOP)
Normal PAOP (pulmary artery occlusive pressure): 5- 12 mm Hg

A

Left Ventricle Preload

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48
Q

Measured by the central venous pressure (CVP)
Normal CVP: 2 – 5 mm Hg

A

Right Ventricle Preload

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49
Q

Preload contributes to CO; affects stretch for it to recoil to eject - affects how dilated LV
The more you stretch the muscle fiber in diastole, or the more volume in the ventricle, the stronger the next contraction will be in systole until a physiological limit has been reached
In the heart, it is the ability to increase the force of contraction that converts an increase in venous return to an increase in stroke volume.
Stroke volume must match venous return, or the heart will fail.

A

Frank-Starling Law:

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50
Q

The percentage of preload volume ejected from the left ventricle per beat.
Normal: 50-70%
Hyperdynamic EF (80-100%) - something fundamentally wrong with LV
Not all of the preload volume is ejected

A

Ejection fraction (EF):

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51
Q

Lower Filling pressure, or less volume of blood at end-diastole

A

Low preload is associated with:

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52
Q

If do not have adequate filling pressures - CO will go down - translating to BP being lower
Extreme dehydration or lot blood on ground - BP low - give volume - no vasopressors - nothing to squeeze

A

How does a low preload affect the cardiac output?

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53
Q

s&s dehydration
Not perfusing organs - mainly kidneys (be first) - urine output first - not enough to filter to get adequate output; and have low BP; earlier part - on cusp being low - orthostatic hypotension
↓urine output, hypotension, orthostatic hypotension

A

Assessment findings

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54
Q

NS
Fluids
Losing blood: blood
Need to fill tank with something
Start with NS/LR - albumin - blood unless know frank blood - know blood prob
RBC carries O2 to perfuse end organs

A

If preload is low what medications are given?

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55
Q

High Filling pressure, or more/too much volume of blood at end-diastole.

A

High preload is associated with:

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56
Q

BP high with high preload

A

How does a high preload affect blood pressure?

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57
Q

Right or left CHF sx depending on which chamber effected
LV affected: left CHF sx; crackles bilaterally in lungs
Tachypnea, Tachycardia, Cough, Bibasilar crackles, Gallop rhythms (S3 and S4), Increased pulmonary artery pressures, Hemoptysis, Cyanosis, Pulmonary edema, Fatigue,
Dyspnea, Orthopnea, Paroxysmal nocturnal dyspnea, Nocturia
RV affected: rt CHF sx; JVD extended
Peripheral edema, Hepatomegaly, Splenomegaly, Hepatojugular reflux, Ascites, Jugular venous distention, Increased central venous pressure, Pulmonary hypertension, Weakness, Anorexia, Indigestion, Weight gain, Mental changes
Volume overload

A

Assessment findings

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58
Q

Least invasive - prob intake
Fluid restriction (IV and oral) - lot meds: double or quad strength so volume decreased; decrease fluid intake; volume intaking less
Venous dilators: Nitroglycerine - dilates venous sys so more room for extra fluid to go; holds more since bigger
Diuretics - get fluid off

A

If preload is high what medications are given?

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59
Q

Have bidirectional flow with an incompetent valve; measuring flow going back and forth in volume
PAOP indirect measurement of LA - leftsided preload - looking at volume of blood in LV; incompetent valve - increase pressure in chamber before it

A

A patient with mitral regurgitation (MR) has an elevated PAOP. Why is the PAOP elevated?

60
Q

Low

A

A patient presents to the ED with 4 days of vomiting and diarrhea. How does this impact preload?

61
Q

High
SOA - left sided
Anasarca - right sided; any edema = right

A

A patient presents to the ED with shortness of air and anasarca. He states he has missed his last 3 dialysis appointments. How does this impact preload?

62
Q

Decrease

A

A patient is on a nitroglycerine drip for chest pain. Will the preload increase or decrease?

63
Q

Low
Decreased
Look for PAOP or CVP since fluid status

A

A patient is in the MSTICU post open cholecystectomy. Vital signs are BP: 92/20, HR: 90, RR 20, Spo2 98% on 40% FIO2, Temp 98.9˚F. He has a central line where Central Venous Pressure is monitored – CVP: 1 mm Hg. What is this patient’s fluid status?

64
Q

s&s agree: BP; HR little high
Not enough O2 to organs - circulate more what have
Increase HR - brain
Decreased BP
RR can increase

A

Are there any compensatory mechanisms present?

65
Q

Urine output: low
Hypotensive
Echocardiogram: EF/CO: low
Everything low

A

Expected assessment findings?

66
Q

Look at left side with the PAOP - not just drop one in to look at left side
Central line - get all right-sided pressures

A

If the patient has a PA catheter, what other measure could you look at?

67
Q

Fluids
Bleeding - Hgb dropped - give blood products
Post-op: dry side since NPO - not enough to do this

A

How would you raise/lower the CVP?

68
Q

Vascular tone - constricted or dilated
Definition: The pressure the ventricle generates/has to generate to get the valve open to get the blood out; to overcome the resistance to ejection created by the arteries and arterioles.
Is calculated/calculation – not a waveform
Left Ventricle Afterload
Right Ventricle Afterload
High SVR
Elevated SVR:
Low SVR:

A

Afterload

69
Q

Measurement of the resistance of blood flow through the systemic vasculature
Measured as Systemic Vascular Resistance (SVR)
The normal value is 800 to 1400 dynes-sec-cm−5
800 to 1400 dynes-sec-cm−5

A

Left Ventricle Afterload

70
Q

All about pulmonary vasculature
Measurement of the resistance of blood flow through the Pulmonary vasculature
Measured as Pulmonary Vascular Resistance (PVR)

A

Right Ventricle Afterload

71
Q

High afterload - arteries that are constricted
All about resistance and what LV can overcome
Normal, health heart
Left ventricle dysfunction:

A

High SVR

72
Q

SVR elevated - compensatory mechanism to get BP higher
Not much impact of cardiac output
May increase blood pressure

A

Normal, health heart

73
Q

Decreased contractility (MI), global damage: cardiomyopathy, or regionally damage (MI)
Something wrong with LV - Big MI/CHF - LV cannot work any harder to overcome increased resistance for someone who has increases SVR - BP decreases
More effort
Lowers cardiac output
Lowers blood pressure

A

Left ventricle dysfunction:

74
Q

Caused by too much arterial constriction - all about arteries
Too clamped down/SVR too high - need consider if let ride since perfusing head leave, but maladaptive need treat it
To lower SVR
Continuous infusions of vasodilators
Sodium nitroprusside/Nipride
High-dose nitroglycerin - arterial; usually avoid since lot AE; liver metabolites issues; low-dose - impacts venous system

A

Elevated SVR:

75
Q

Too dilated out - not any resistance from arteries - BP low
Need fill extra space by giving volume
Caused by too much arterial dilation.
To increase SVR
First give volume, then vasopressors
Fluids (to fill the dilated vascular bed) - NS
Once extravascular space filled then do arterial constrictors
Vasoconstrictors: Norepinephrine - Increases MAP by vasoconstriction of the peripheral vasculature.
Nursing considerations: Frequent assessment of the peripheral circulation is required when medications that increase SVR are used because excessive vasoconstriction will negatively affect tissue perfusion.
Since actively restricting/intentionally squeezing - arteries small enough to where getting blue extremities - need to assess peripheral circulation

A

Low SVR:

76
Q

Not a normal assessment
Cool and clammy - dermis/skin not perfused as well; one cue arteries too constricted
> 3 sec - another cue that arteries too constricted and not perfusing distally
Something wrong with LV - LV not functioning well
Acute event - body tries to compensate with comp mechanisms - but not lot thought - maladaptive - does not work
Increased SVR

A

The nurse is assigned a patient who had a MI 2 days ago, he is cool and clammy. Capillary refill is > 3 seconds. What are these symptoms indicative of?

77
Q

Decreased CO
Came in with pneumonia - would be unchanged since nothing with heart unless sepsis

A

What is the effect on cardiac output? ↓ or ↑ or unchanged

78
Q

Sodium nitroprusside
High-dose Nitroglycerine

A

How should the afterload be manipulated?

79
Q

SVR going to change - arterial dilator - lower
SVR causing higher BP
BP high
PA pressure high
CVP high
CO normal
SVR: high
Ignore PVR

A

The nurse is caring for a client in the ICU. The hemodynamics for this client are: Arterial blood pressure 175/90 mm Hg; Pulmonary artery (PA) pressure: 48/18 mm Hg; Central venous pressure (CVP): 6 mm Hg; Cardiac output (CO): 2.3 L/min; Systemic vascular resistance (SVR): 1580 dynes-sec-cm−5; Pulmonary vascular resistance. If sodium nitroprusside is initiated, what hemodynamic value should change? Higher or lower? Why?

80
Q

SVR - would not give - increase - vasoconstrictor

A

If norepinephrine is initiated, what hemodynamic value should change? Higher or lower? Why?

81
Q

CVP - increase it; need something that messes with venous tone

A

If a fluid bolus is initiated, what hemodynamic value should change? Higher or lower? Why?

82
Q

Sodium nitroprusside - arterial - messes with arteries; does not touch veins
Biggest problem: address SVR
If clamping down - need something to unclamp them first - so not cause more issues later on

A

Which medication(s) should be given to this patient?

83
Q

SVR low

A

Too dilated

84
Q

SVR high

A

Too constricted

85
Q

Estimated by SV and PAOP or CVP.
Definition: The force with which the heart muscle contracts.
How well myocardium contracts
Is calculated – not a waveform
Left and right ventricular stroke work index values. These values estimate the force of ventricular contraction
Possible causes of High Left & Right ventricular stroke work index (LVSWI & RVSWI)
Possible causes of Low Left & Right ventricular stroke work index (LVSWI & RVSWI)
Medications that increase contractility - increase work index - LVWSI
Medications given to decrease contractility - LVWSI
How does the nurse know if the patient’s contractility is responding to treatment?
Summary

A

Contractility

86
Q

How well myocardium contracts
Is calculated – not a waveform

A

Definition: The force with which the heart muscle contracts.

87
Q

Left ventricle:
left ventricular stroke work index (LVSWI)
Condition impacts: HF and MI
Amount of work the left ventricle performs with each heartbeat.
LVSWI: 50-62 g-m/m2
Right ventricle:
right ventricular stroke work index (RVSWI)
RVSWI: 7.9 – 9.7 g-m/m2

A

Left and right ventricular stroke work index values. These values estimate the force of ventricular contraction

88
Q

Considering everything
preload/afterload prob or CNS related
Increased volume in the ventricle (↑ the stretch of the ventricle)
Low systemic vascular resistance (contractility is augmented)
CNS stimulation (exercise, fever, infection, pain, anxiety)

A

Possible causes of High Left & Right ventricular stroke work index (LVSWI & RVSWI)

89
Q

Overdistended ventricle (Volume overload in the ventricle) - Overstretched it and some point not go back to normal size since so stretched out - overextended it
High systemic vascular resistance (↑ resistance to ventricular ejection)
Hypoxemia (negative inotropic effect) - adequate O2 for it to work; global effect; severely hypoxemic
Decreased myocardial function (CHF, MI, cardiomyopathy)
Electrolyte imbalance - K, Mg big ones

A

Possible causes of Low Left & Right ventricular stroke work index (LVSWI & RVSWI)

90
Q

Dopamine
Dobutamine
Milrinone
Some afterload reduction as well

A

Medications that increase contractility - increase work index - LVWSI

91
Q

Beta blockers
Propranolol
Metoprolol

A

Medications given to decrease contractility - LVWSI

92
Q

Giving drugs to affect contractility - + inotropes - increase BP - very few drugs that affect one of them
Once start meds increase contractility - increase BP - get more ejection out so BP going higher
Beta blockers to decrease contracility - BP go down - chronotropic effects on HR; but if elevated - primary purpose decrease contractility to decrease BP

A

How does the nurse know if the patient’s contractility is responding to treatment?

93
Q

Contractility: The force with which the heart muscle contracts
Factors that impact contractility
Significant factors related to contractility that can be measured by the PA catheter
Hypoxemia acts as a negative inotrope because the myocardium must have oxygen available to the cells to contract efficiently.

A

Summary

94
Q

Preload volume as measured by PAOP - no stretch for recoil for elasticity
SVR - not have it for pumping; makes it harder
Myocardial oxygenation
Amount of myocardium available to contract.
Positive and negative inotropic medications
Amount of functional myocardium available to contribute to contraction.
Electrolyte balance

A

Factors that impact contractility

95
Q

Preload filling pressures
As volume in the ventricle rises, contractility increases. If the ventricle is overdistended with volume, contractility falls.
SVR
Change in resistance to ventricular ejection.
If SVR is high, contractility is decreased.
If SVR is low, contractility is augmented

A

Significant factors related to contractility that can be measured by the PA catheter

96
Q

Low BP sx: dizziness, lethargy
High HR: anxious (can feel it), diaphoretic
CO - relates to low BP
SVR: slow cap refill; skin cool and clammy because arterioles clamped down to nothing
LVSWI sx: dizziness, lethargy

A

The nurse is caring for a patient in the CICU who is has a pulmonary artery (PA) catheter. Using the following hemodynamic values, determine what is going on with this patient.

97
Q

High end of normal

A

Preload ↑, ↓, or normal?

98
Q

SVR
High

A

Afterload ↑, ↓, or normal?

99
Q

Looking at LVSWI and RVSWI
Decreased

A

Contractility ↑, ↓, or normal?

100
Q

Try have adequate perfusion
HR - high
SVR for the BP

A

Any compensatory mechanisms?

101
Q

MI and CHF all about LVSWI (low)
Either end stage CHF or had big anterior wall MI

A

Possible causes?

102
Q

Try decrease SVR so ailing LV can pump easily - give sodium nitroprusside for increased SVR
Help CO - on cusp of being low - compensatory mechanisms in place - start milirinone, dopamine, doputamine to help LVSWI up to normal so perfusing
If has doppled pulses, SVR - is vascular tone - if cannot palpate historically not having issue - dealing with dilation/constricting arteries - constricting in distal lens, need look at SVR

A

Anticipated treatment(s)?

103
Q

LV preload

A

PAOP

104
Q

LVSWI
RVSWI

A

Contractility

105
Q

Measuring afterload

A

SVR

106
Q

Cardiac output measurement with a pulmonary artery catheter
Definition: The amount of blood (Liters/minute) ejected from the ventricle in one minute.
Measured 2 ways

A

CO measurement

107
Q

In a healthy resting human adult, normal CO= 4 - 6 L/min; normal Cardiac Index (CI)= 2.2 - 4 L/min/m2

A

Definition: The amount of blood (Liters/minute) ejected from the ventricle in one minute.

108
Q

Fick - variety of numbers - measuring/how get CO - beginning/end of cycle
Thermodilution
PA catheter - injecting cold saline so calculate CO - thermodiluation - thermisters and insert saline just above ring and measures temp and as passes thermistor does calculation and difference makes calculation for CO
Specific quantity of cold fluid is injected into the proximal port
Inject rapidly and smoothly
Cold bolus passes thru RV then is ejected into the PA
Computer plots the difference in blood temp and bolus temp on a time/temperature curve

A

Measured 2 ways

109
Q

Endogenous catecholamines: Stress, exercise - compensatory response - more CO to supply O2 to the muscles
Exogenous catecholamines: Epinephrine, isoprel (right heart work up; not respond to transplants; use to increase HR), dobutamine, dopamine, milrinone - medications; stress test - dopamine until HR response
Positive inotropes: digitalis, amrinone
Hyperthyroidism - systemic probs
Anemia - systemic probs

A

What can cause increased CO?

110
Q

Inadequate left ventricular filling.
Inadequate left ventricular ejection.
LV not func as well

A

What can cause decreased CO?

111
Q

Decreased
Decreased filling time
Output is less

A

During a run of paroxysmal supraventricular tachycardia, the nurse would expect the CO to increase, remain unchanged, or decrease? Why:

112
Q

Right sided valve issue
Low
Affecting preload to LV
Stenotic valve - not as much blood ejected - leaflets stenosed and not opening as much so not as much blood to LV to have adequate preload

A

A patient is admitted for a tricuspid valve repair secondary to tricuspid stenosis. The nurse would expect the CO to be elevated or low? Why?

113
Q

Same as with low BP
Dizzy and lethargic
Also have low EF; left sided prob - left HF prob; right sided - right HF prob
Decreased CO and CHF s&s - same

A

What are the clinical manifestations of decreased CO?

114
Q

decreased cardiac output (e.g., diminished peripheral pulses, hypotension)
End organ perfusion - not circulating O2 blood adequately; end organs not getting oxygenated blood/perfused adequately
CV:
see if have extensive CAD, chest pain with exertion but as soon as sit down fine; left and right sided HF sx
Neuro:
Brain not perfused - start with dizziness, confusion, irritation
Lose cortex first then into higher functions (then to ataxic)
GU/GI:
Bump in creatinine after urine output
GU: perfusion to gut esp if underlying issues - constipation issues; mesenteric artery problems
Pulm:
Start seeing some ventilation probs - see more left-sided HF probs with crackles
Renal:
Kidneys easiest tell us
Output decrease - drop first then creatinine
Hepatic:
Not go right to jaundice
Labs and look at liver panels; ALT, AST

A

What assessment finding would indicate a decreased CO is affecting tissue prefusion?

115
Q

Preload
Goal of therapy:
Fluids

A

CVP 1 mm Hg

116
Q

Preload
Left
Goal of therapy:
Bring it down
High preload - need give fluid somewhere to give - nitroglycerin and diuretics - give somewhere to go then get rid of it

A

PAOP 22 mm Hg

117
Q

Low
Goal of therapy:
Get up
Look at other numbers and other assessment
Everything contributes to CO
See what causing it - preload, afterload, contractility

A

Cardiac Output 1.2 L/min

118
Q

Preload
High
Right
Goal of therapy:
Decrease
Fluid restriction
Diuretics
Nitroglycerin to dilate venous bed

A

CVP 12 mm Hg

119
Q

Afterload
Goal of therapy:
Decrease
Sodium nitroprosside - arterial dilator
SVR - dealing with arteries

A

SVR 2000 dynes-sec-cm−5

120
Q

Contractility
Goal of therapy:
Increase
Positive inotropes: dopamine, dobutimanine, milrinone

A

LVSWI 38 g-m/m2

121
Q

Definition and explanation
Average perfusion pressure created by arterial BP during the cardiac cycle. The normal cardiac cycle is ⅓ systole and ⅔ diastole. These three components are divided by 3 to obtain the average perfusion pressure for the whole cardiac cycle
Normal range
70-100mmHg

A

MAP

122
Q

Definition and explanation
Pressure created by volume in the right side of the heart. When the tricuspid valve is open, the CVP reflects filling pressures in the RV. clinically, the CVP is often used as a guide to overall fluid balance
Normal range
2-5mmHg

A

CVP

123
Q

Definition and explanation
Pressure created by the volume in the left side of the heart. When the mitral valve is open, the PAOP reflects filling pressures in the pulmonary vasculature and pressures in the left side of the heart are transmitted back to the catheter “wedged” into a small pulmonary arteriole
Normal range
5-12mmHg

A

PAOP

124
Q

Definition and explanation
Amount of blood pumped out by a ventricle over 1 min. Clinically, it can be measured using the thermodilution CO method, which calculates CO in L/min
Normal range
4-6L/min (at rest)

A

CO

125
Q

Definition and explanation
Mean pressure difference across the systemic vascular bed divided by blood flow. Clinically, SVR represents the resistance against which the LV must pump to eject its volume. Ths resistance is created by the systemc arteries and arterioles
As SVR increases, CO falls. SVR is measured in Wood units or dyn times s times cm-5. If the number of Wood is multiplied by 80, value is converted to dyn times s times cm-5
Normal range
10-18 Wood units or 800-1400 dyn times s times cm-5

A

SVR

126
Q

Definition and explanation
Amount of work the LV performs with each heartbeat. The hemodynamic formula represents pressure generated (MAP) multiplied by volume pumped (SV). a conversion factor is used to change mL/mmHG to g-m. Always represented as an indexed volume; increases or decreases because of changes in the pressure (MAP) or volume pumped (SV)
Normal range
50-62g-m/m2

A

LVSWI

127
Q

Definition and explanation
Amount of work the RVperforms with each heartbeat. The hemodynamic formula represents pressure generated (PAPm) multiplied by volume pumped (SV). a conversion factor is used to change mHG to g-m. Always represented as an indexed value (BSA chart). Similar to LCWI, RCWI increases or decreases because of changes in the pressure (PAPm) or volume pumped (SV)
Normal range
7.9-9.7g-m/m2

A

RVSWI

128
Q

Fancy Central venous catheter with multiple lumens and functions
Long and variety of lumens
Color coding always the same on all catheters
Diagnosis and evaluation of cardiac dysfunction, cardiogenic shock, management during and after heart surgery, transplant work-up, measure valve areas
AO - in ventricle - pulling back into aorta to see if systolic pressure stayed same; if dropped = incompetent aortic valve
Right arterial (RA) pressure
Pulmonary artery (PA) pressure
Pulmonary artery occlusive pressure (PAOP)
Cardiac output (CO)
Indications
Complications
PA Catheter waveform interpretation

A

Pulmonary Artery (PA) Catheter

129
Q

Measurement of CVP/preload

A

Right arterial (RA) pressure

130
Q

Below 30
Like arterial pressure
Where stays; colored yellow

A

Pulmonary artery (PA) pressure

131
Q

Measurement is obtained after the balloon on the distal tip of the catheter is briefly inflated.
Intermittent; when need it, inflate balloon at distal tip - get waveform; <10 sec - can cause pulm infarct; min amount of time as necessary
Tell if incompetent valve
Should not see RV - See this - pull blood out to see shunt - pull back on RA because put in tach arrhythmia; RV ignore - see go to tach arrhythmia

A

Pulmonary artery occlusive pressure (PAOP)

132
Q

Measurement is obtained after injecting cold fluid the proximal port.

A

Cardiac output (CO)

133
Q

Get information to make a diagnosis
Work up heart transplants - dilate out PA and get normal pressures - decrease right sided - so not take out new heart
Component of fluid volume status
Dx for shunts and incompetent valves - regurgent/stenotic
Observe response to therapies
inotropes/vasodilators/vasoconstrictors

A

Indications

134
Q

In the heart - more cardiac wise comps
Cardiac complications
Pulmonary complications
Infection

A

Complications

135
Q

Ventricular dysrhythmias
Endocarditis - something in heart can go through it - through RV to PA
Valvular damage - stenotic valve - hard go through so typ stop; can damage valves
Cardiac rupture - aggressive enough - punch through RV (wall thin)
Cardiac tamponade

A

Cardiac complications

136
Q

Chest pain (angina)
Dizziness.
Pounding heartbeat (palpitations)
Lightheadedness.
Shortness of breath.

A

Ventricular dysrhythmias

137
Q

Aching joints and muscles.
Chest pain when you breathe.
Fatigue.
Flu-like symptoms, such as fever and chills.
Night sweats.
Shortness of breath.
Swelling in the feet, legs or belly.
A new or changed whooshing sound in the heart (murmur)

A

Endocarditis - something in heart can go through it - through RV to PA

138
Q

dyspnea, chest pain, hypotension, cold extremities, and occasionally mental status changes

A

Cardiac rupture - aggressive enough - punch through RV (wall thin)

139
Q

Anxiety, restlessness.
Sharp chest pain that is felt in the neck, shoulder, back, or abdomen.
Chest pain that gets worse with deep breathing or coughing.
Problems breathing.
Discomfort, sometimes relieved by sitting upright or leaning forward.
Fainting, lightheadedness.
Pale, gray, or blue skin.

A

Cardiac tamponade

140
Q

Rupture of a PA - inflating balloon to get PAOP - not using syringe came with
PA thrombosis, embolism or hemorrhage
Infarction of a segment of lung.

A

Pulmonary complications

141
Q

PA waveform
Normal systolic pressure is 20 to 30 mm Hg and diastolic pressure is 10 mm Hg
(20 -30)/10 mm Hg
PA occlusion waveform (wedge) (left ventricle preload)
Normal pressure is 5 to 12 mm Hg

A

PA Catheter waveform interpretation

142
Q

Venous pressures - not have muscular wall - waveforms affected by intrathoracic pressure; all venous pressures not have perfect waveform - vary with inspiration and expiration; just make sure level
Patient position
The patient does not need to be flat for accurate pressure readings to be obtained.
Respiratory variation
Because patients remain on PEEP for treatment, they remain on it off during measurement of PA pressures. In this situation, the trend of PA readings is more important than one individual measurement.

A

PA catheter nursing management

143
Q

All Pulmonary artery diastolic pressure (PADP) and PAOP (wedge) tracings are subject to respiratory interference.
Positive-pressure, volume-cycled ventilator.
Will push it up
Vent valley
During the positive-pressure inhalation phase, the increase in intrathoracic pressure may “push up” the PA tracing, producing an artificially high reading
During inhalation with spontaneous breaths, negative intrathoracic pressure “pulls down” the waveform, producing an erroneously low measurement
To minimize the impact of respiratory variation, the PADP is read at end-expiration
On roller coaster with waveforms - need know where end-expiration is - that one waveform is where measure it

A

Respiratory variation

144
Q

Measure pressures at end-expiration.
Spontaneous respirations: Measure at the tip of the curve or “patient peak”
Own respiratory effort - measure at the tip of the curve
Intrathoracic pressure decreases during spontaneous inspiration
Negative deflection on waveforms
Intrathoracic pressure increases during spontaneous expiration
Positive deflection on waveform
Mechanical Ventilation: Measure at bottom of curve or “vent valley”
Messing with intrathoracic pressure - translates to intrathoracic pressures - completely changes it - changing with inspiration and expiration - at valley
Intrathoracic pressure increases during positive pressure ventilations (inspiration)
Positive deflection on waveforms
Intrathoracic pressures decrease during positive pressure expiration
Negative deflection on waveforms

A

PA catheter waveform

145
Q

Looks like roller coaster - watch go across screen and get pattern
Take in breath - baseline goes down; exhale - goes back up; watch it - focus on diastole
Where do you measure the PA pressure?
Get top of the hump and bottom; report 30/10
Spontaneous
Pick waveform at peak of waveform before trending down
Get at the top before go back down
Top one
Ventilator with PEEP
Always increased intrathoracic pressure - measure - right before goes up
Not normal change in intrathoracic pressure - falsely elevating - + pressure throughout inspiration and expiration throughout breathing - lose normal rhythm of breathing
Do: end expiration at pt peak but before go up
Measure it right before puff air - one measure - end expiration - ventilator causing hump; goes up and gets wonky waveform; before go up
Last one before end expiration when get hump
Exhalation before starts trending up

A

PA pressure

146
Q

Do not label
Venous pressure
Same intrathoracic variations
Instead 1 pump, series of pumps
When on vent - more bumps
Vent valley
Pt peak before trending down
Intermittent measurement
Not a continuous measurement. - cause infarct
The balloon on the distal tip of the PA catheter is briefly inflated to get the PAOP measurement.
Indirect measurement of the left atrial pressure (Preload).

A

Pulmonary artery occlusive pressure (PAOP)

Critical Care (41 decks)

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