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Nursing 272: Final Semester > Unit 2: Hemodynamic Monitoring > Flashcards

Unit 2: Hemodynamic Monitoring Flashcards

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1
Q

Hemodynamic Monitoring

A

-identification and treatment of the complex medical problems early
-assess for the presence of shock, cardiac and pulmonary abnormalities, and complications following MI
-helps evaluate patients immediate response to treatments including inotropic medications and mechanical support
-provides pressure readings that correspond to BP, right atrial (RA) or central venous pressure (CVP), and pulmonary artery pressures
>system include arterial, central venous, and pulmonary artery (PA or Swan-Ganz) catheters

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2
Q

Methods for Obtaining Accurate Readings

A
  • Transducer secured at the phlebostatic axis
  • Transducer routinely calibrated
  • Tubing between the Transducer and the cannula must be stiff, nonpliant, and less than 120 cm in length
  • Transducer and tubing free from blood and air
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3
Q

Phlebostatic axis

A

where the transducer needs to be secured for accurate readings
-midpoint of the left atrium, 4th ICS in the midaxillary line w/ patient supine

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4
Q

Cardiac Output

A

volume of blood pumped by the heart each minute

-dependent on stroke volume (SV) and heart rate (HR)

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5
Q

Heart Rate

A

number of ventricular contractions per minute

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6
Q

Stroke Volume (SV)

A

volume of blood pumped by the left ventricle w/ each heart beat
-dependent on preload, afterload, and contractility

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7
Q

Preload

A

end diastolic pressure or volume that stretches the right or left ventricle

  • reflects fluid volume status
  • “filling pressures”
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8
Q

Afterload

A

force or resistance the ventricles must overcome to eject blood into the pulmonary circuit or aorta

  • right heart afterload reflected in the pulmonary vascular resistance (PVR)
  • left heart afterload reflected in the systemic vascular resistance (SVR) and is representative of the force that the left heart must pump against to deliver the SV into the periphery
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9
Q

Contractility

A

ability of the heart muscle to contract independent of preload and afterload

  • good contractility is a component of SV, helping to produce adequate CO
  • poor contractility directly affects CO and decreases SV
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10
Q

Oxygen Delivery (DO2)

A

amount of oxygen delivered to the tissues
-determined through CO and arterial oxygen content
>hemoglobin levels, hemoglobin oxygen saturation, and amount of oxygen dissolved in the plasma

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11
Q

Oxygen Utilization an Oxygen Consumption (VO2)

A

reflects relationship between oxygen delivery and oxygen extraction at tissue level

  • measured through a blood sample (venous oxygen saturation) that reflects amount of oxygenated blood returned to the right heart
  • Normal Values: between 60 and 75%
  • Value falls below normal: tissues are extracting more oxygen than normal; results from a decreased oxygen delivery (DO2), which may be a decrease in oxygen content, hemoglobin, or CO
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12
Q

Arterial Line

A

small catheter inserted into an artery used to display a constant systemic BP

  • can be used to obtain arterial blood gas (ABG) samples; ABGs used to monitor acid-base and oxygenation status
  • inserted into radial artery; axillary, brachial, femoral, or dorsalis pedis artery
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13
Q

Systemic Normal BP Parameters

A
  • Systolic BP: less than 120 mmHg
  • Mean Arterial Pressure: 70 to 105 mmHg
  • Diastolic BP: less than 80 mmHg

> MAP of 65 mmHg = necessary for end-organ perfusion

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14
Q

Formula for Calculating MAP

A

MAP = [(2x diastolic) + systolic] / 3

ex: SBP: 120, DBP: 80

[(2 x 80) + 120] / 3
[160 + 120] / 3
[280] /3
93.33333

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15
Q

Nursing Interventions for Using an Arterial Line

A
  • before insertion by trained provider, nurse must ensure the provider performs an Allen test to confirm there is sufficient blood supply through the ulnar artery; negative Allen test = not safe
  • nurse is responsible for setting up the monitoring system; transducer, tubing, and flush bag
  • securing arterial line at the phlebostatic axis
  • “zeroing” or calibrating the line once it is secured
  • verifying appearance of appropriate waveform
  • troubleshooting line if needed
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16
Q

Complications From Use of Arterial Line

A

-blood loss if tubing becomes disconnected or line is accidentally displaced
-infection
-occlusion of artery
-air emboli
-user error (inaccurate readings)
-damage to artery
>arterial lines should be marked so that IV medications are not given via this route
>inadvertent intra-arterial IV infusions can lead to tissue necrosis, gangrene, and loss of limb

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17
Q

When Arterial Line is Being D/C

A

-dressing and sutures are first removed
-catheter then removed; pressure applied over and above insertion site for 3 to 5 minutes or until hemostasis achieved
>if risk for bleeding (receiving anticoagulation), pressure applied for 10 minutes or longer to ensure homeostasis
-pressure dressing then applied
-insertion site monitored to make sure hemostasis maintained

18
Q

Central Venous Catheter (CVP)

A

long catheter placed in the internal jugular (IJ), subclavian (SC), or femoral vein
-threaded through the superior vena cava w/ the distal port/tip resting at the junction of the superior vena cava and right atrium
-measures mean right atria pressure
-used as an estimate of right ventricular filling pressures or volume returning to the right heart from systemic circulation (preload)
-Normal CVP: 5 to 10 cm H20
-Decreased: indicative of a low volume state caused by hypovolemia or peripheral vasodilation which occurs in sepsis and reduces venous return
-Elevated: indicate increased volume that may occur w/ right heart failure
TX: fluid bolus, vasopressor therapy or both

19
Q

Central Venous Pressure Level (CVP)

A

RA pressure

  • used as an estimate of right ventricular filling pressures or volume returning to the right heart from systemic circulation (Preload)
  • used as an indication of right ventricular function
20
Q

Venous Oxygen Consumption via Central Venous Oximetry (Scv02)

A

-monitored by central line
-allows monitoring of venous oxygenation in the superior vena cava
-reflects the oxygen in the blood returning to the heart from the upper body
>Decreased SCV02: indicates inadequate cardiac output and potential tissue hypoxia

21
Q

Nursing Implications for Central Venous Monitoring

A

central venous catheter often has multiple ports to facilitate many uses in addition to CVP and Scv02 monitoring:
-routine fluid and medication administration
-volume resuscitation
-frequent blood draws
-long-term IV antibiotics
-parenteral nutrition administration
-transvenous pacemaker insertion
>can also be used when IV therapy is needed, and peripheral veins are not accessible or when infusing medications that are caustic to tissues when given through peripheral administration
-those medications are: calcium chloride, hypertonic solutions, amiodarone. potassium, and vasoactive medications

22
Q

Central Line Insertion

A
  • central line attached to a transducer via stiff, non compressible tubing
  • tubing kept flushed ad open w/ the pressurized normal saline flush bad
  • informed consent, explanation of the procedure, benefits, risks, and complications must be obtained prior to placement
  • positioning for IJ or SC may include placing towel under scapula to make site and landmarks prominent
  • patient in Trendelenburg position (flat on back w/ feet 15 to 30 degrees higher than head)
  • post procedure, catheter is secured by a suture, occlusive dressing applied
  • verified by chest x-ray prior to use
23
Q

Guidelines for Central Line Insertion

A
  • experienced provider inserting line or providing supervision
  • perform a time-out
  • proper hand hygiene
  • appropriate attire: cap, mask, sterile gown and gloves, and eye protection
  • prep site with chlorhexidine antiseptic skin prep and let air dry
  • drape patient utilizing sterile technique
  • insert line; maintain sterile technique
  • clean site w/ chlorhexidine and cover w/ sterile occlusive dressing
  • optimal catheter site selection (avoid use of femoral vein)
  • daily review of the necessity of the line and prompt removal when unnecessary
24
Q

Nursing Implications for Central Line Maintenance

A
  • closely monitor patient; maintenance of catheter site and system closely observed
  • central line well secured to patient to avoid removal or displacement
  • patency maintained by normal saline or heparin flush, continuous IV fluids, or pressurized flush solution
  • monitored lines must have appropriate alarm limit set
  • transducer location reference point is phlebostatic axis
  • waveforms monitored w/ appropriate scale
  • waveforms monitored for dampered waveforms; can be a sign of line malfunction, or air or blood in transducer
  • assess insertion site for bleeding and signs of infection
  • use aseptic technique w/ any line care; minimize line handling, maintain occlusive dressing
  • daily evaluation of line necessity
  • prompt removal when not necessary
25
Q

Central Venous Catheters: What to Report to Provider

A
  • pressures outside ordered parameters
  • impaired circulation
  • inability to correct a dampened waveform
  • catheter dislodgment
  • bleeding or swelling at the insertion site
  • signs of infection (swelling, redness, or discharge)
26
Q

Nursing Implications for Central Line Removal

A
  • prior to D/C, explain procedure
  • dressing is removed
  • positioned in Trendelenburg or supine position to prevent air embolism
  • suture holding the central venous catheter are removed while ensuring it does not migrate out
  • make sure all suture material removed
  • ask patient to hold breath as catheter is removed (prevent air embolism)
  • immediately cover area w/ sterile gauze and apply pressure until hemostasis achieved
  • observe patient after line removal for S/S of bleeding, air embolism, or infection of site
27
Q

Potential Complications of Central Line Catheters

A
  • accidental arterial insertion
  • pneumothorax
  • nerve injury
  • vessel perforation
  • guidewire induced arrhythmias
  • air embolism
  • venous thrombosis
  • bleeding
  • infection
28
Q

Pulmonary Artery Catheter Monitoring

A

(PA) or “Swan-Ganz”
-flexible, balloon-tipped catheter
-guided through the right side of the heart and into pulmonary artery
-inserted through subclavian, internal or external jugular, or femoral vein
-allows measurement of afterload via systemic vascular resistance (SVR) and pulmonary vascular resistance (PVR)
-readings r/t preload, afterload, contractility, and cardiac output
-blood samples give info about oxygen utilization at the tissue level; mixed venous oxygen saturation (Sv02)
>4 Lumens:
-proximal port: used to monitor RA pressure (CVP)
-distal port: used to monitor systolic, diastolic, and mean pulmonary artery pressures
-inflation lumen: leads to the balloon where the pulmonary artery wedge pressure (PAWP) is obtained by inflating balloon with 1.5 ml of air

29
Q

(PA)/Swan-Ganz: Distal Lumen Port

A

located at the tip, or end of PA catheter

  • systolic, diastolic, and mean pulmonary artery pressures can be measured; provides info about left heart
  • pulmonary artery pressures reflect BP in the pulmonary artery; generated by the right ventricle ejecting blood into the pulmonary circulation
  • Normal: Systolic 15 to 30 mmHg, PA diastolic 4 to 12 mmHg
  • used for drawing venous oxygen saturation via a mixed venous hemoglobin saturation (Sv02); value reflects the oxygen saturation of blood returned to the heart from both superior and inferior vena cava reflecting total body venous oxygen saturation
30
Q

(PA)/Swan-Ganz Proximal Port

A

located 30 cm from the tip of catheter in the right atrium
-monitors RA pressure (CVP)
>CVP is a reflection of right heart preload or right ventricular and diastolic volume
-used to inject the solution used to obtain a thermodilution cardiac output (CO)

31
Q

(PA)/Swan-Ganz Thermistor Lumen

A
  • temperature sensor built in
  • at tip of PA catheter
  • for thermodilution measurement of CO
  • measures the ambient blood temperature around it continuously
32
Q

“Thermodilution” method of obtaining CO

A

-a small bolus of cooler normal saline is injected through the proximal injection port
-b/c of injection of cooler fluid, the temp of the blood flowing by the sensor changes
-the time it takes for the cold injectate to pass the sensor is measured in liters of blood pumped per minute
-Normal CO: 4 to 8 L/min
(calculated on basis of BSA)
-Normal Cardiac Index (CI): 2.5 to 4 L/min/m2

33
Q

(PA)/Swan-Ganz Inflation Lumen

A
  • inflates the balloon
  • pulmonary artery wedge pressure or pulmonary artery occlusion pressure (PAWP/PAOP) is obtained
  • PAOP reflects left heart preload or left ventricular end diastolic pressure
  • Normal: 4 to 12 mmHg
34
Q

Nursing Implications for the PA catheter

A
  • nurses receive education and training to assist w/ the insertion, measure parameters, and interpret data
  • during insertion, nurse monitors the waveforms while catheter passes through the different chambers of the heart and into the pulmonary artery
  • make sure in Trendelenburg during insertion
  • once catheter is advanced into the right atrium, and as directed by provider, the nurse must inflate the balloon before any further advancement of catheter; help PA catheter float into the pulmonary artery and prevents trauma to the cardiac structures as it moves through the heart chambers and valves
  • When PAOP is obtained, the balloon must be inflated no more than 1.5 ml
  • after value obtained, ensure balloon is immediately deflated; balloon will passively deflate and not be manually deflated or forced to deflate
  • PA catheter should never be inflated and remain in wedge position for more than 10 to 15 seconds; risk of accidental PA occlusion, hemorrhage, or PA infarction
  • handling of the line kept to a minimum
  • occlusive transparent dressing maintained and changed per policy
  • place in Trendelenburg position for removal
  • remove any sutures holding catheter in place, taking care not to cut the catheter before removal
  • if possible, have pt take deep breath in ad holding it during withdrawal of catheter
  • after removal, apply pressure for 3 to 5 minutes or until hemostasis is achieved
  • observe insertion site for potential bleeding
  • subclavian veins are not compressible and are more prone to bleeding if coagulation studies are not within normal limits
35
Q

Complication w/ a PA/Swan-Ganz Catheter

A
  • may be r/t insertion, maintenance and use, or interpretation of data
  • risk of infection and bleeding
  • carries risk of PA rupture, infarction, or air embolism as a result of balloon rupture during inflation to measure wedge pressure
36
Q

(PA) Catheter Insertion Complications

A
  • arrhythmias
  • misplacement
  • knotting of the long flexible catheter
  • myocardial, vessel, or valve rupture
  • pneumothorax during catheter insertion
37
Q

(PA) catheter use + maintenance complications

A
  • pulmonary infarction from lack of blood supply if balloon left in wedge position
  • pulmonary artery rupture from balloon inflation
  • air embolism from balloon rupture
  • bleeding
  • central line bloodstream infection
  • right heart/valve trauma
38
Q

(PA) catheter data misinterpretation complications

A
  • improperly calibrated monitors
  • over or underestimation of PAOP
  • lung zone misplacement
39
Q

Assessment of CO: Central Venous Pressure (CVP)

A

> Normal: 5 to 10 cm H20

> Abnormal Low: hypovolemia or peripheral vasodilation
-Intervention: fluid bolus, vasopressor

> Abnormal High: right heart failure, tension pneumothorax, pulmonary hypertension, pericardial tamponade
Intervention: inotropic and vasodilator therapies; tx of cause i.e., chest tube for pneumothorax

40
Q

Assessment of CO: Pulmonary Artery (PA)

A

> Systolic (PAS): 15-30 mmHg
Diastolic (PAD): 4-12 mmHg

  • Low: may be normal state or signs of hypovolemia and vasodilation
  • Intervention: only tx if other concerns present
  • High: pulmonary hypertension, right heart failure
  • Intervention: inotropic or vasodilator therapy; diuresis
41
Q

Assessment of CO: Pulmonary Capillary Wedge Pressure (PAOP/PAWP)

A

> Normal: 4-12 mmHg

> Low: normal state or signs of hypovolemia + vasodilation
-Intervention: only if other concerns present

> High: pulmonary hypertension, cardiogenic shock, hypoxia, acute respiratory distress syndrome (ARDs)
-Intervention: inotropic and vasodilators; diuresis

42
Q

Assessment of CO: Cardiac output/Cardiac index

A

> Normal:

  • 4 to 8 L/min
  • 2.5 to 4 L/min/m3

> Low: MI, all forms of shock except early septic shock
Interventions: fluid bolus, inotropic therapy, treatment of cause ie. MI

> High: early septic shock, hypervolemia, hyperthermia
-Interventions: only if concerns present

Nursing 272: Final Semester (79 decks)

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