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Advanced Nursing Concepts Part 1: Hemodynamic Monitoring

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Anatomical review Cardiovascular System Review Hemodynamics Continued Indications for Hemodynamic Monitoring Cont.. Pressure, Flow and ... – PowerPoint PPT presentation

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Title: Advanced Nursing Concepts Part 1: Hemodynamic Monitoring


1
Advanced Nursing ConceptsPart 1 Hemodynamic
Monitoring
  • Sandra Lewis, ARNP-BC-ADM

2
What Comes First?
  • The PATIENT!!!
  • View the patient first, the equipment is merely
    an adjunct.

3
Anatomical review
  • http//www.blaufuss.org/tutorial/
  • Go to Start tutorial

4
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

5
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.

6
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.

7
Indications for Hemodynamic Monitoring
  • Dehydration
  • Hemorrhage
  • GI Bleed
  • Burns
  • Surgery
  • Acute MI
  • Cardiomyopathy
  • Shock all types septic, cardiogenic,
    neurogenic, anaphylactic
  • Congestive Heart Failure

8
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.

9
Pressure, Flow and Resistance
  • Basic physics law
  • PressureFlow X Resistance

10
  • 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)

11
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

12
Atrial Kick
  • Final contraction of the atrium filling the
    ventricle

13
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).

14
Arterial Blood Flow
  • Arterial blood pressuremeasure of force exerted
    on the arterial walls by the blood

15
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.

16
Contractility
  • A measure of how forcefully the ventricle
    contracts to eject its volume.
  • It is the intrinsic ability of the muscle fibers
    to shorten.

17
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).

18
Hemodynamic Monitoring Equipment
  • All contain a transducer, monitor, and fluid
    filled catheter, tubing and flush system

19
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

20
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

21
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22
Complications of a Swan/Ganz
  • Infection
  • Dysrhytmias
  • Air Embolism
  • Pulmonary thromboembolism
  • Pulmonary artery rupture
  • Pulmonary Infarction
  • See table 7-1 p. 147

23
Arterial Monitoring
  • An invasive technique for monitoring arterial
    blood pressure.
  • Preferred in unstable patients because it is
    accurate and continuous

24
  • 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.

25
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.

26
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.

27
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

28
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

29
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

30
  • The LOWEST point on the waveform represents the
    end diastolic pressure.
  • This pressure reflects systemic resistance.
  • Normal diastolic pressure is 60-90 mmHg

31
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.

32
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.

33
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

34
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
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