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Hemodynamic Monitoring
Generalist Nursing Practice IV: Tertiary Care Across the Lifespan (NURS 4889)
Temple University
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Adult Health IIIPreview text
Critical Care Nursing: Introduction to Hemodynamic Monitoring:
Cardiac Monitoring: Measurements: - Heart Rate & Rhythm - Blood Pressure o Arterial
o Noninvasive
Pulmonary Artery Pressure (PAP)
Cardiac Output
Pulse Oximetry Purpose:
Assess heart function
Manage fluid balance
Evaluate effects of medications o Cardiac output o Blood pressure Types of Invasive Pressure Monitoring:
Arterial pressure monitoring o Indicated when continuous BP measurements is useful o 20-gauge, 2-inch nontapered Teflon catheter into peripheral artery o Suture in place
Continuous arterial BP monitoring is indicated for patients in many situations, including acute hypertension and hypotension, respiratory failure, shock, neurologic injury, coronary interventional procedures, continuous infusion of vasoactive drugs (e., sodium nitroprusside [Nitropress]), and frequent arterial blood gas (ABG) sampling.
A 20-gauge, 2-inch (5-cm) nontapered Teflon catheter is typically used to cannulate a peripheral artery (e., radial, femoral) using a percutaneous approach. After insertion, the catheter is usually sutured in place. You must immobilize the insertion site to prevent dislodging or kinking of the catheter line. Arterial Pressure: (Art-Line or A-line)
Sites: o Radial Artery o Femoral Artery
o Brachial Artery
Continuous flush irrigation system
Delivers 3–6 mL of saline/hour
Maintains line patency
Limits thrombus formation
Assess neurovascular status distal to arterial insertion site hourly o Capillary refill, sensation, pulses, color, temp
Balancing and Calibrating: - Zeroing: confirms that when pressure within system is zero, monitor reads zero - Done by opening reference stopcock to room air - With initial setup and periodically thereafter - Phlebostatic Axis: 4th intercostal space, mid-axillary line o Right Atrium If placement too low, pressure will be too high If too high, pressure will be too low
Dynamic Response Test: (Square Wave Test): - Optimizing dynamic response characteristics involves checking that the equipment reproduces, without distortion, a signal that changes rapidly. - Perform a dynamic response test (square wave test) every 8 to 12 hours and when the system is opened to air or the
accuracy of the measurements is questioned. It involves activating the fast flush and checking that the equipment reproduces a distortion-free signal. Arterial Pressure Waveform:
Arterial Pressure Monitoring: - High- and low-pressure alarms o The high- and low-pressure alarms are set based on the patient’s current status and then activated. - Risks/complications o Hemorrhage o Infection o Thrombus formation
o Neurovascular impairment o Loss of limb
- Arterial lines carry the risk of hemorrhage, infection, thrombus formation, neurovascular impairment, and loss of limb.
- Hemorrhage is most likely to occur when the catheter dislodges or the line disconnects. To avoid this serious complication, use Luer-Lok connections, always check the arterial waveform, and activate alarms. If the pressure in the line falls (e., when the line is disconnected), the low-pressure alarm sounds immediately, allowing you to promptly correct the problem.
- Infection is a risk with any invasive line. To limit the risk of catheter-related infection, inspect the insertion site for local signs of inflammation and monitor the patient for signs of systemic infection. Change the pressure tubing, flush bag, and transducer every 96 hours or according to agency policy. If infection is suspected, remove the catheter and replace the equipment.
- Circulatory impairment can result from formation of a thrombus around the catheter, release of an embolus, spasm, or occlusion of the circulation by the catheter. Before inserting a line into the radial artery, perform an Allen test to confirm that ulnar circulation to the hand is adequate. In this test, apply pressure to the radial and ulnar arteries simultaneously. Ask the patient to open and close the hand repeatedly. The hand should blanch. Release the pressure on the ulnar artery while maintaining pressure on the radial artery. If pinkness fails to return within 6 seconds, the ulnar artery is inadequate and you should not use the radial artery for line insertion.
o CI = CO/BSA o Normal CI = 2 – 4 L/Min/M Stroke Volume (SV):
Volume of blood ejected with each heart beat
Preload
Afterload
Contractility
Preload: think VOLUME - Volume of blood filling the ventricle at end-diastole - Right ventricle o Central Venous Pressure (CVP): 2 – 6 mm Hg - Left ventricle o Pulmonary Artery Diastolic Pressure (PAD): 6 - 12 mm Hg o Pulmonary Capillary Wedge Pressure (PCWP): 6 - 12 mm Hg - Fluid Management o Elevated filling pressures Findings on physical exam Edema -> Right sided HF Symptoms of Left sided HF o Crackles -> Ventricular dysfunction o Jugular vein distention o SOB o Hypoxia -> check O2 sats Treatment Diuretics o Low filling pressures Findings on physical exam Hypotension Hypovolemic
Increased HR Dehydration Treatment Fluids Afterload: think RESISTANCE
- Resistance the ventricle needs to overcome to eject blood o Indirectly measured o Left ventricle Systemic Vascular Resistance (SVR) 900 - 1300 dynes/sec/cm o Right ventricle Pulmonary Vascular Resistance (PVR) 40 – 150 dynes/sec/cm
- What impact does elevated afterload have on cardiac output?
- Resistance high -> CO low
- Causes of increased afterload include: o narrowing of vessels o Arteriosclerosis
o HTN o Sepsis -> Vasodilation r/t bacteria
- Increased afterload is treated by: (decrease resistance) o Beta blockers o ACE inhibitors o Nitroglycerin
o ARBs o CCBs
- What impact does reduced afterload have on cardiac output? Blood pressure?
- Causes of reduced afterload include: ...
- Reduced afterload is treated with: ... o Vasoconstricters (inc BP)
Dopamine Vasopressin
Epinephrine Norepinephrine
- Drug classes that impact afterload include: ...
- What diagnostic studies and/or laboratory tests evaluate cardiac performance? o Echocardiogram, cardiac enzymes, BNP (elevated with acute/chronic HF) Contractility: think PERFORMANCE:
- Performance of cardiac muscle
- If myocardial performance changes while preload, afterload, heart rate, and conduction velocity are all constant, then the change in performance must be due to the change in contractility
- What class(es) of drugs impact cardiac contractility? o Digoxin o Epinephrine
o Dobutamine o Milrinone Critical Care Drugs Impacting Hemodynamics:
- Antiarrhythmics o Amiodarone o Diltiazem o Lidocaine o Esmolol o Metoprolol
- Inotropes o Dobutamine o Milrinone o Dopamine
- Vasopressors o Dopamine o Epinephrine o Norepinephrine o Vasopressin
- Vasodilators o Nicardipine o Nitroprusside o Nitroglycerin
Hemodynamic Monitoring
Course: Generalist Nursing Practice IV: Tertiary Care Across the Lifespan (NURS 4889)
University: Temple University
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