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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 6 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 7 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 8 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 9 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 10 Insertion Sites Most common Subclavian Internal Jugular Second Choice Femoral Vein 11 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 15 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 18 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 19 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 21 CVP will Provide an early warning system for patients who are: Bleeding Vasodilating Receiving diuretics Being rewarmed after cardiac surgery 22 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 23 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 24 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 25 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 26 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 27 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 28 Balloon Lumen Inflated to obtain wedge pressures or PAOP pressure 29 Thermistor Lumen Fourth lumen Measures changes in blood temperature Used to obtain cardiac output 30 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 31 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 32 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 33 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 34 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 35 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 36 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 37 Blood pressure Put automatic bp on Confirm accuracy of the readings Put at q 5 minute intervals for close monitoring during the insertion procedure 38 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 39 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 41 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 42 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 43 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 44 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!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!! 45 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 46 47 48 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. 49 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. 50 51 52 53 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 54 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 55 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? 56 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. 57 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 58 Preventing Catheter Related Complications 59 Air Embolus Air entry into the circulation related to open pathway from the catheter to the heart Life Threatening Preventable 60 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 61 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 62 Air Embolus Patient symptoms Respiratory Distress Cardiac Arrest or Collapse Gasp reflex Mill wheel murmur Will be acute in onset 63 Air Embolus Action STAT Apply 100% oxygen Position – Trendelenburg Left lateral side Maintain calm – reassure your patient- stay with your patient Call Provider 64 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 65 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 66 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 67 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 68 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 69 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 70 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 71 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 72 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 73 74 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 75 Catheter Size Related to artery size Usually 20 gauge Type – over the catheter 76 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 78 79 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 81 82 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 88 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 91