Transcript Skills Lab MS II

Skills Lab MS II
Charnelle Lee, RN, MSN
1
Bedside Hemodynamic Monitoring
Major competency for critical care nursing
 Requires hands on experience to obtain
an understanding and ability to accurately
manage
 Nursing Student Goals are to develop an
understanding of the basic principles of
hemodynamic monitoring

2
Learning Outcomes for the Nursing Student
Understand the purpose of using
Hemodynamic monitoring for patient care
with the focus on
 PA catheters
 CVP catheters
 Intrarterial catheters
 SvO2 monitoring

3
Learning Outcomes for the Nursing Student
Describe the differences between the
different types of hemodynamic monitoring
 Distinguish visually between a PA
catheter, CVP catheter and an arterial
catheter
 Describe the equipment used in these
systems and their purpose

4
Learning Outcomes for the Nursing Student
Develop an understanding of the purpose
for calibration of hemodynamic equipment
 Identify the phlebostatic axis

5
Learning Outcomes for the Nursing Student
Define the different types of hemodynamic
pressures and their expected normal
values
 Identify the significance of abnormal
values in the patient with fluid volume
abnormalities

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Learning Outcomes for the Nursing Student

Describe the implications of patient
positioning to obtain accurate
hemodynamic values
 Ideal
Positioning
 Positioning for the patient with respiratory
discomfort
 Lateral positioning and its effects on
monitoring values
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Learning Outcomes for the Nursing Student

Define patient safety priorities
 Establish
alarm limits
 Verbalize alarms that need to be left on
 Verbalize actions needed to trouble shoot over
alarming
 Develop an understanding of the complications of
hemodynamic monitoring and nursing actions to
prevent them and manage them if they occur
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Learning Outcomes I – Why do we use
Hemodynamic monitoring in health care?

Evaluates a patient’s
 Cardiac
function
 Circulating
blood
volume
 Physiologic
response
to treatment
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CVP or Central Venous Pressure
Catheter

Used for assessment of patients with
 Fluid
volume problems
 Can be used to assess deficits or overload
 Most common is for an IV line with multiple
ports for use in the infusions of incompatible
medications, thick solutions that cannot be
infused into a peripheral site, or for those
patients who are extremely ill and need IV
access
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Insertion Sites

Most common
 Subclavian
 Internal

Jugular
Second Choice
 Femoral
Vein
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Subclavian Advantages



Used if a dwell time
over 5 days is
anticipated
Lowest infection rate
Least patient
discomfort
12
Subclavian Disadvantages


Harder to access by
the provider
Higher risk of
pneumothorax or
collapsed
Lung
13
Internal Jugular Advantages
Easier to access
 Most frequently used
 Low risk of Pneumothorax

14
Internal Disadvantages


High infection risk r/t
to exposure of the site
to patient respiratory
secretions
Very high risk for
patients who are
intubated or have
trach’s
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Femoral Vein
Advantages/Disadvantages



Easiest to cannulate
Largest diameter
Activity limitation
 Patient
should not
bend at the hip due to
the risk of interrupted
blood flow through the
catheter leading to
potential thrombus
formation
16
Femoral Vein Disadvantages


Retroperitoneal
bleeding
High rate of
nosocomial infection
related to its location
in the groin
17
CVP and Fluid Volume Status



Measures pressure
during diastole when the
tricuspid valve is open
The catheter sits in the
right atrium and receives
information about the
right ventricles pressures
These pressure are
created by resting blood
volume
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Normal Pressures CVP

Normal – 2 to 5 mm
hg(mercury) page 133



3 to 8 cm H2O
When a patient is hooked
up to a monitoring system
the equipment measure
mercury
When a patient is hooked
up to a manometer it is
measured in cm of water
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Patients with Low CVP

Occurs in the patient
with
 Hypovolemia
 Or
in patients who are
vasodilated creating
an artifical low blood
volume
20
What else will you see with Low
CVP
Tachycardia
 Lower blood pressure and mean arterial
pressure
 The CVP will be lower before the
compensatory mechanisms of heart rate
and vasoconstriction kick in

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CVP will
Provide an early warning system for
patients who are:
 Bleeding
 Vasodilating
 Receiving diuretics
 Being rewarmed after cardiac surgery

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What is a pulmonary artery
catheter?




Known as Swan –
Ganz catheter
Most invasive
Used for critically ill
patients who need
advanced
assessment to
manage their care
Not a routine insertion
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What does it do?

Monitors pressures in
the following areas
artery –
systolic and diastolic
pressure
 Pulmonary artery
mean pressure
 PAOP – wedge
pressure
 Cardiac Output
 Pulmonary
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Four lumens




110 cm in length
Marked every 10 cm
Sizes 7.5 or 8.0
french
Each lumen has an
exit in a different area
of the heart or
pulmonary artery
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Right Atrial Lumen
Proximal Port – CVP (Central Venous
Pressure)
 Uses

 IV
infusion
 Withdrawal of venous blood samples
 Fluid injection for cardiac output
 Measurement of CVP or right atrial pressures
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Pulmonary Artery Lumen
Distal Port
 Located at the very tip of the PA catheter
 Sits in the pulmonary artery
 Records PA pressures
 Used for withdrawal of blood samples to
measure venous oxygen

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Balloon Lumen
Opens into a balloon at the end of the
catheter that can be inflated with 0.8 ml of
air.
 Purpose

 Helps
float the catheter safely and gently into
the heart and pulmonary artery during
insertion
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Balloon Lumen

Inflated to obtain wedge pressures or
PAOP pressure
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Thermistor Lumen

Fourth lumen
 Measures
changes in blood temperature
 Used to obtain cardiac output
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Plebostatic Axis



Used to position the
transducer to obtain
accurate CVP or PA
catheter readings
When obtaining
values this must be
assessed
Know what this is and
why it is important
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Nursing Care of the Patient During Insertion
of Pressure Monitoring Catheters




Patient is awake for most
of these procedures
Explain the procedure in
simple terms
Explain the patient’s role
during the insertion
Reassure the patient
about comfort measures
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Consent
Must have a signed consent form with the
exact procedure to be implemented before
the procedure starts
 The physician must explain the procedure
as well as clearly explaining the risks
 Family should be included if possible

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Awake patient

Site Preparation
technique – site will be cleansed with
chlorhexidine or betadine
 Warn the patient that it will be cool
 Site will be anesthetized with a local anesthetic –
expect a sting with the insertion of the Lidocaine
 Assess for allergies to shellfish (Betadine) or
lidocaine
 Sterile
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Draping
The physician and the nurse who assists
will be in sterile dress – mask, eye shield,
sterile gown
 The patient’s face and neck will be
covered

 Assess
for claustrophobia and medicate prn
before the procedure
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Assure oxygenation




Secure oxygen delivery devices to prevent them
from moving during the insertion procedure
Tape nasal cannula in place prn
Support ETT, suction your patient before the
procedure prn
Make sure the oxygen saturation is reading
appropriately – need continuous readings
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IV access/cardiac monitoring
Make sure you have a patent IV
 It should have running fluid for
administration of medications if problems
occur during insertion
 Assess cardiac monitoring – need to have
a clear readable waveform

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Blood pressure
Put automatic bp on
 Confirm accuracy of the readings
 Put at q 5 minute intervals for close
monitoring during the insertion procedure

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Equipment Gathered







Insertion tray
Gloves – physician size and nurse size
4x4’s (sterile)
Saline Flushes
Heparin Flushes
NS 500 ml with primary tubing
Pressurized system with transducer primed and
zeroed
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Emergency medications
Know where they are
 Crash cart medications are available
 Atropine
 Lidocaine
 Have them available

40
Patient Position



CVP insertion or Cordis
during PA cath insertion
Prep/anesthesia in supine
position
Insertion of the cordis or
CVP catheter when the
catheter is inserted into
the vein patient is in
trendelenburg position to
prevent air embolus
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After catheter is in place




Make sure saline is running through the distal
port – Peripheral IV
Extra ports are flushed with 10 ml of NS utilizing
aseptic technique
Clamped during the end of the flush to prevent
thrombus formation in the lumens
Flush with heparin if the catheter lumen is not
going to be utilized for greater than eight hours
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After Successful Insertion of the
Pressure Monitoring Catheter





Uncover your patient
Cleanse the site of blood and betadine using
sterile 4x4’s and NS – nurse must use sterile
gloves
Dry the site – apply skin protectant around the
catheter site
Apply a transparent dressing
Tape coming out of the insertion site with patient
friendly tape (HYPAFIX) Pad underneath site if
needed
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Ask the unit secretary to order



Portable Chest X-ray
Be aware the catheter
must be secured, sharps
removed, blood cleaned
up before the chest x-ray
If at all possible unless of
course the patient is
having problems
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Why the CXR?




Assesses for:
Catheter Placement
Complication of
Pneumothorax/Hemothor
ax
Not to be left out ever – if
you don’t have a standing
order get an order from
the
provider!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!!!!!
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Nursing Care of the Patient with a
PA catheter or CVP




Assess the patient
Assess the site q2h noting skin, evidence of
redness or purulent drainage, leaking
Dressing intactness – should not be loose or
elevated off of the skin – Replace prn
Flush unused ports q8h and prn after
medications infused if the ports are capped
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PA waveforms and their findings
Waveforms as the catheter is advanced. Wedge pressure gives
you the fluid balance as it is reflected from the Left ventricle which
reflects the pulmonary system as well.
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Another example of PA waveforms on
insertion
Becoming familiar with these waveforms will help the nurse identify
when the catheter migrates out of position, or is in correct position.
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Pulmonary Artery Values
Pulmonary Artery systolic 20- 30 mm hg
 Pulmonary Artery diastolic 5 – 10 mm hg
 PAP
10-15 mm hg
 Pulmonary artery occlusion pressure –
also called Pulmonary capillary wedge
pressure or Pulmonary artery wedge
pressure 5-12 mm hg

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Interpretation of PA readings
Case Study of patient with an MI # 1
 RAP – right atrial pressure 10
 PAS – 42 mm hg/PAD – 22 mm hg
 PAD – 22 mm hg
 PAWP – 22 mm hg

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Application Case Study 5
On admission








Bp 190/100, HR 130
Respirations 42
PAP 50/22 PCWP 24
CVP 19
CO 4.64 CI 2.34
SVR 1810
Medications used Lasix 100
mg IVP, Digoxin 0.5 mg IVP,
Dobutamine at 5 ug/kg/min
Then More lasix Nipride added
and Dobutamine increased to
10 ug/kg/mon
Later that day
 B/P 140/90 HR 109 R-24
 PAP 30/10 PAWP 12
 CO 5.5 CI 2.8
 CVP 8
 SVR 1340
Describe the change in the
pulmonary artery
readings.
How would the patient feel?
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Nursing Management
Position
 Can be turned per usual
with attention to security
of lines
 During measurements
supine 30 degrees is best
if tolerable
 Zero transducer regularly
and prn at the plebostatic
axis
Monitor waveforms





If the line is in the PA
The waveform should reflect this
Watch for continuous wedge
without the balloon being inflated
If wedge waveform occurs assess
patient, turn the patient, flush the
line
If wedge continues notify
physician and or obtain order to
withdraw the pa catheter to the
point where a PA waveform is
reestablished.
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Hazards of Continuous Wedge
Pulmonary artery hemorrhage
 Pulmonary artery infarct
 Can only be tolerated for short periods of
time
 Wedge time less than 10 seconds

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Preventing Catheter Related
Complications
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Air Embolus



Air entry into the
circulation related to
open pathway from
the catheter to the
heart
Life Threatening
Preventable
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When does it occur?
Insertion
 Tubing runs dry and some unfortunate
nurse hangs IV fluid without removing the
air from the tubing, thereby infusing air into
the patient
 Caps on the tubings fall off or are loose, or
are the wrong type allowing air into the
system

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Air embolus continued
Catheter is removed without an occlusive
dressing being applied and secured for
twenty four hours
 Air enters along the pathway created by
the removed pressure line
 Enters during inhalation when the
intrathoracic pressure is decreased

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Air Embolus Patient symptoms
Respiratory Distress
 Cardiac Arrest or Collapse
 Gasp reflex
 Mill wheel murmur
 Will be acute in onset

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Air Embolus Action STAT
Apply 100% oxygen
 Position –

 Trendelenburg
 Left
lateral side
 Maintain calm – reassure your patient- stay
with your patient

Call Provider
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Treatment Air Embolus



Provider may:
Treat the patient
symptomatically
Do a cardiac needle aspiration
of the air from the heart


Supplies: Pericardiocentesis
tray, long cardiac needle, prep
the site, provide sterile gloves
Closely monitor vitals, cardiac
rhythm, bp, sat during
aspiration, expect problems,
have access to your crash cart
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Thrombus Formation
Very common complication
 Can be asymptomatic
 Symptomatic patient will experience
symptoms similar to pulmonary emboli
 Higher risk with multiple insertion sticks
 Symptoms – Sudden CVC occlusion
 Difficulty drawing blood from the catheter

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Infection
Risks: age extremes, malnutrition, extreme
illness, presence of other invasive lines
 50,000 infection occur each year r/t
invasive catheters
 Increased risk with those left in greater
than 3 to 7 days

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Symptoms of Infection
Systemic – fever, leukocytosis, sepsis –
hypotension, decreased LOC
 Site may not look infected
 Always suspect catheter r/t infection with
new onset of fever etc.,
 Removal is the treatment, culture the tip

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Prevent Infection
Handwashing by the nurse
 Aseptic technique during dressing
changes
 Change the dressing when it is needed
 Aseptic technique when the catheter is
opened for blood draws, tubing changes,
no compromise

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SVO2 monitoring



Assessment in the critically ill
patient through a centrally
placed catheter
It measures the state of
oxygen supply and demand
relative to tissue metabolism
Used to guide hemodynamic
fluid resuscitation in septic
patients
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Normal Values
75% - (60-80%)
 Low SVO2 indicates assessment of the
four factors that contribute to its values
 Cardiac Output
 Hemoglobin
 Arterial Oxygen saturation
 Tissue Metabolism

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Nursing Actions

Low SVO2
 Assess
oxygen supply
 Perform a cardiac output measurement
 Assess a hemoglobin value
 Assess if patient movement, or nursing action
may have decreased the patient’s venous
oxygenation
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Prolonged Low SVO2
May result in lactic acidosis
 Acidosis results in cellular death
 Increasing the deteoriation of the patient
 All attempts to correct this deficit must be
intiated in order to protect and restore
health to your patient

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Inaarterial Blood Pressure
Monitoring




Known commonly as an
“Art Line”
Named because of its
location
Designed to directly
measure blood pressure
Provide a site for blood
draws without poking the
patient
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Catheter Size



Related to artery size
Usually 20 gauge
Type – over the
catheter
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Arterial Sites




Most common Radial
Femoral
Dorsalis-pedis
Brachial
77
Assessment of Collateral
Circulation
Radial artery is the safest because it
usually has the ulner artery to provide
blood flow to the arm when an arterial
catheter is in place in the Radial site
 Perform the Allen Test prior to Radial
arterial catheter placement

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Allen Test
Radial and Ulnar arteries are compressed
simultaneously
 The patient is asked to clench and
unclench the hand until it blanches
 Pressure is released from one of the
arteries and the hand should immediately
flush from side – Repeat the procedure
with release from the other artery

80
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Facts to remember
A mean arterial pressure of 60 mm hg is
required to perfuse coronary arteries
 MAP is the parameter most often used to
assess perfusion
 Represents perfusion pressure throughout
the cardiac cycle

83
Pathophysiology and MAP
One third of the cardiac cycle is spent in
systole
 Two thirds is spent in diastole
 MAP reflects diastolic perfusion pressure
 This reflects coronary artery perfusion

84
MAP
(Diastolic value x 2)+(Systolic Value x 1)
3
Calculate the mean arterial pressures for the
following
1. 120/30
2. 82/45
3. 97/50

85
MAP is a guide to care
Not an absolute
 As always look at your patients clinical
assessment
 Book page 158 describes the difference in
assessment of a patient with a blood
pressure of 90/70 and 150/40. Both have a
MAP of 76 mm hg.

86
Caring for the patient with an
arterial line
Hemorrhage – prevent exsanguination
 Make sure are connections are tight
 Check these qshift manually tighten each
connection
 Tighten connections before insertion into
the patient

87
Caring for the patient with an Art
Line
Assess the patient and the reading with
low blood pressure readings
 A damped waveform occurs for many
reasons

 Position
problems
 Clot formation
 Transducer failure
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What to do?





Assess the site
Reposition the wrist
Flush the line
Make sure the
pressure bag is
inflated to 300 mg hg
Take a manual blood
pressure
89
Manual Blood pressure
Should be taken once a shift to assess
arterial line accuracy
 Will not be the same if the patient is in
shock
 Or if the line has problems

90
Accuracy Assessment
Square Waveform Test
 See page 134
 Line is flushed the expected square
waveform test should be the result

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