Advanced Nursing Concepts Part 1: Hemodynamic Monitoring

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Advanced Nursing ConceptsPart 1 Hemodynamic
Monitoring

• Sandra Lewis, ARNP-BC-ADM

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What Comes First?

• The PATIENT!!!
• View the patient first, the equipment is merely
  an adjunct.

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Anatomical review

• http//www.blaufuss.org/tutorial/
• Go to Start tutorial

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Cardiovascular System Review

• Heart- pumps blood forward through the
  vasculature
• Arteries- carry oxygenated blood from the heart
  to the body. (Constriction and Dilation regulate
  the blood flow delivered)
• Capillaries-microscopic vessels that allow for
  exchange of gases, nutrients and metabolic waste
  between plasma and the body cells

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Hemodynamics

• Basic tenet is the control of adequate oxygen
  delivery to the tissues.
• Interrelationship of various dynamic forces that
  affect the bloods circulation through the body.
• Knowledge of pressure, flow and resistance
  provide the foundation of understanding.

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Continued

• The ability to anticipate hemodynamic
  deterioration or detect adverse changes early is
  a major factor in preventing hemodynamic crisis,
  thus the major reason for hemodynamic monitoring.

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Indications for Hemodynamic Monitoring

• Dehydration
• Hemorrhage
• GI Bleed
• Burns
• Surgery
• Acute MI
• Cardiomyopathy

• Shock all types septic, cardiogenic,
  neurogenic, anaphylactic
• Congestive Heart Failure

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Cont..

• Veins return deoxygenated blood to the heart.
  About 70 of circulating blood volume is in the
  venous system at any one time.
• Blood has both a cellular and fluid component.
• About 60 of blood is plasma.
• The remainder consists of RBCs, WBCs,
  platelets.
• ERYTHROCYTES make up about 99 OF THE CELLULAR
  COMPONENTS AND ARE RESPONSIBLE FOR OXYGEN
  TRANSPORT.
• An increase in RBCs increases viscosity of
  blood.
• Increased viscosity makes blood flow through
  smaller vessels more difficult.

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Pressure, Flow and Resistance

• Basic physics law
• PressureFlow X Resistance

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• Pressurethe force exerted
• Blood Flow the amount of fluid moved per unit of
  time
• Resistancethe opposition to force or flow
  (influenced by the size, length and viscosity of
  the fluid)

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Cardiac Cycle

• Both the atria and the ventricles have filling
  phases (diastole) and contraction phases
  (systole)
• During diastole the left and right ventricles
  receive blood from the atria
• During systole the ventricles squeeze blood from
  the heart to the aorta and the pulmonary artery.
  See figure 7.4 p.131

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Atrial Kick

• Final contraction of the atrium filling the
  ventricle

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Preload

• Left ventricular end-diastolic VOLUME.
• The VOLUME left in the ventricle when the mitral
  valve closes determines the amount of blood
  ejected into the systemic circulation. The
  ventricle never ejects its entire volumejust a
  portion of itusually 60-70( this is the
  EF..(ejection fraction)
• The volume of blood EJECTED with each beat is
  referred to as Stroke Volume (SV).

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Arterial Blood Flow

• Arterial blood pressuremeasure of force exerted
  on the arterial walls by the blood

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Afterload

• The pressure or resistance of blood flow out of
  the ventricle.
• So, if arterial BP is high, the left ventricle
  must exert more force to pump blood out
  effectivelythis increases myocardial oxygen
  requirements.

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Contractility

• A measure of how forcefully the ventricle
  contracts to eject its volume.
• It is the intrinsic ability of the muscle fibers
  to shorten.

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Systemic Vascular Resistance (SVR)

• THE major factor that influences SVR is the lumen
  (diameter) of the vessel.
• This is an important concept, often in the
  critical care setting, medications are used to
  alter the lumen size of systemic vessels
  (primarily the arterioles).

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Hemodynamic Monitoring Equipment

• All contain a transducer, monitor, and fluid
  filled catheter, tubing and flush system

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Swan-Ganz Cath

• Normally has four ports (can have another
  proximal lumen for fluids or medication infusion)
  
• The thermistor lumen is used to measure cardiac
  output.
• The proximal port is used to measure right atrial
  pressure
• Distal lumen measures pulmonary artery pressure
• The balloon port has a special 1.5 ml syringe
  connectedthis is used to measure PCWP

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Functions of the Catheter

• Continuous hemodynamic monitoring, assessing
  vascular tone, myocardial contractility, and
  fluid balance.
• Measures PAP, CVP, and allows hemodynamic
  calculations. Cardiac output can be determined
  using thermodilution.
• Transvenous pacing

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Complications of a Swan/Ganz

• Infection
• Dysrhytmias
• Air Embolism
• Pulmonary thromboembolism
• Pulmonary artery rupture
• Pulmonary Infarction
• See table 7-1 p. 147

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Arterial Monitoring

• An invasive technique for monitoring arterial
  blood pressure.
• Preferred in unstable patients because it is
  accurate and continuous

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• Allen's test
• A test for integrity of the radial and ulnar
  arteries at the wrist. The examiner compresses
  the patient's radial and ulnar arteries at the
  wrist. The patient is then asked to open and
  close the hand rapidly until the palm appears
  white. The examiner then releases either the
  radial or the ulnar artery and looks for return
  of pink color and circulation to the hand. The
  test is then repeated releasing the other artery.
  The hand should return to its pink color within 6
  seconds if circulation through that artery is
  adequate.

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Indications for arterial Monitoring

• Patients requiring frequent ABGs or lab work
• Patients with low flow states, hypotensive
• Patients with severe hypertension
• Patients with severe vasoconstriction or
  vasodilation.

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Arterial Lines

• Placed in an artery, usually the radial, but can
  use femoral, or brachial.
• Connected to a pressurized source
• Complications include thrombosis, embolism,
  blood loss, infection
• Tubing and transducer replaced every 96 hours.

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Continued, Caveats

• Invasive monitoring is more accurate
• Invasive BP should by higher than cuff BP
• If cuff BP is higher look for equipment
  malfunction or technical error
• A dampened wave form can indicate a move toward
  hypotensionan immediate cuff pressure should be
  obtained

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Nursing Implications

• Prevent or reduce the potential for
  complications.
• Maintain 300mmHg on bag
• Maintain continuous flow through tubing
• Aseptic dressing change
• Sterile caps on openings
• Change tubing q 96 hrs.
• 5 min hold on discontinued site

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Arterial Measurements

• The systolic pressure is measured at the peak of
  the waveform.
• See fig. 7-10 p137
• This pressure reflects the function of the left
  ventricle.
• NORMAL value100-130 mmHg

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• The LOWEST point on the waveform represents the
  end diastolic pressure.
• This pressure reflects systemic resistance.
• Normal diastolic pressure is 60-90 mmHg

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Dicrotic notch

• The small notch on the downstroke of the wave
  form.
• It represents the closure of the aortic valve.
• This is the reference point between the systolic
  and diastolic phases of the cardiac cycle.

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Mean Arterial Pressure/MAP

• Is a calculated pressure that closely estimates
  the perfusion pressure in the aorta and its
  branches.
• It represents the average systemic arterial
  pressure during the ENTIRE CARDIAC CYCLE.
• Normal MAP 70-100 mmHg
• MAP MUST be maintained above 60 for the major
  organs to perfuse.

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CVP/ Right Atrial Pressure Monitoring

• A direct measure of the right atrium pressure
• Clinical significance REFLECTS RIGHT VENTRICULAR
  DIASTOLIC PRESSURE
• Abnormalities in RAP are caused by conditions
  that alter venous tone, blood volume, or right
  ventricular contractility

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Cont

• Low RAP indicates hypovolemia that may be
  attributed to dehydration, acute blood loss,
  extreme vasodilation (as in sepsis)
• High RAP indicates severe vasoconstriction, fluid
  overload, pulmonary hypertension