Download Waveform = Pressure

Name: _______________________________
Unit: _____________________
Hemodynamic Monitoring: An Independent Study Program
Comprehensive Test
Directions: Answer the questions to the case scenario below, complete the evaluation, and
return to Pat Juarez, RN, MS, CCRN, Clinical Education Consultant c/o Trinity Education
Office. The INA certificate for 6.0 contact hours will be sent to you if your score is 80% or
>. If your score is < 80%, the test will be returned to you to redo the missed questions.
It was your weekend to work. You just received report on your patients and were informed by
the physician that he is going to insert an arterial line and pulmonary artery catheter in one of
your patients. The patient, Mr. Jones, was a 68-year old admitted from the ED 2 hours earlier
with acute respiratory failure. The charge nurse told you to set up the equipment while she
obtained the consent and answered patient/family questions.
1.
Number the steps below in the order in which you would set up the equipment:
___ Flush tubing and transducer with heparinized saline.
___ Zero the transducer
___ Gather supplies.
___ Inflate pressure bag to 300 mm Hg pressure.
___ Tighten tubing connections.
___ Level transducer at phlebostatic axis.
2.
The charge nurse pointed out to you that the level of the transducer was too low. This
would result in:
a)
b)
c)
d)
3.
No effect on accuracy.
False high pressures.
False low pressures.
Backflow of blood into tubing.
You prepped the site for the arterial catheter insertion. The most commonly used site is:
a)
b)
c)
d)
Radial artery
Ulnar artery.
Femoral artery.
Brachial artery.
Hemodynamic Monitoring – Comprehensive Test
77
4.
The arterial line was placed and you performed a square wave (dynamic response) test
after the transducer was leveled and zeroed. You noted there were 3.5 boxes between
oscillations. Results are below:
After examining the strip, the appropriate action would be to:
a) Take a cuff pressure reading immediately in order to check accuracy.
b) Shorten tubing by removing extensions, check for pinpoint bubbles and then redo the
square wave test.
c) Restrain the patient’s extremity, then redo the square wave test.
d) Check the pressure bag and inflate to 300 mm Hg, examine the system for blood and
air bubbles, reflush, then redo the square wave test.
5.
What is the patient’s arterial blood pressure according to the strip below?
a)
b)
c)
d)
104/44
112/50
114/50
100/40
Hemodynamic Monitoring – Comprehensive Test
78
6.
The physician then prepped the right subclavian site, prepared the PA catheter, and began
the insertion procedure. You started the strip recorder in order to document the
waveforms. Which pressure is only obtained during insertion and usually not available
afterwards?
.
a)
b)
c)
d)
7.
Which port of the catheter is attached to the transducer in order to continuously measure
the PA pressures?
a)
b)
c)
d)
8.
Right atrial (RA) pressure.
Right ventricular (RV) pressure.
Pulmonary artery (PA) pressure.
Pulmonary capillary wedge (PCW) pressure.
Proximal port.
Distal port.
Balloon port.
Thermistor port.
After the catheter leaves the right atrium, identify the waveforms below and put them in
the order in which you would expect to see them on the monitor (1,2,3). Note: These
were not your patient’s waveforms and pressures.
a) __________ waveform
b)__________ waveform
Hemodynamic Monitoring – Comprehensive Test
79
c) __________ waveform
Order in which they would appear after RA:
_____
_____
_____
9.
What is the most common complication during PA catheter insertion?
a)
b)
c)
d)
Infection.
Pulmonary infarction.
Arrhythmias.
Spontaneous wedge.
After the procedure you gathered the waveform strips in order to interpret and document accurate
pressures. The RA pressure and PCWP looked similar, and you knew the mean a wave needed
to be identified in order to differentiate the 2 waveforms.
10.
The difference between the RA and PCWP for the patient in NSR is:
a)
b)
c)
d)
There is no difference found in NSR.
The a wave in RA pressure occurs during the PR interval.
The a wave in the PCWP occurs during the PR interval.
The a wave of the RA pressure occurs after the QRS.
Hemodynamic Monitoring – Comprehensive Test
80
Examine the strip below obtained from your patient.
11.
What was the patient’s PA pressure?
a)
b)
c)
d)
12.
30/18 mm Hg
38/20 mm Hg
40/15 mm Hg
30/25 mm Hg
What was the patient’s PCWP?
a)
b)
c)
d)
22 mm Hg
10 mm Hg
20 mm Hg
15 mm Hg
Hemodynamic Monitoring – Comprehensive Test
81
Examine the following waveform (ECG omitted due to space):
13.
The patient’s RV pressure was:
a)
b)
c)
d)
14.
42/10 mm Hg
40/2 mm Hg
45/8 mm Hg
45/5 mm Hg
Based on the patient’s arterial pressures in question #5 and PA pressures in questions #11
and #12, what would be a possible intervention ordered?
a)
b)
c)
d)
Fluids.
Dobutamine.
Antibiotics.
Norepinephrine (Levophed).
The next time you wedged the catheter, you saw the following waveform:
15.
The appropriate intervention for the above would be to:
a)
b)
c)
d)
Slowly let air out of the syringe and re-wedge with less air.
Call the physician to advance the catheter.
Take the pressure reading at the low point.
Re-level the transducer.
.
Hemodynamic Monitoring – Comprehensive Test
82
Later in the shift the patient required intubation and mechanical ventilation. The A/C (CMV)
mode was ordered. You obtained the following waveform when you wedged the catheter:
16.
What was the PCWP at that time?
a)
b)
c)
d)
17.
Which of the below best describes how a CO should be measured?
a)
b)
c)
d)
18.
20 mm Hg.
12 mm Hg
10 mm Hg
15 mm Hg
Inject 10 cc of injectate within 10 seconds through the thermistor port.
Inject 5 cc of injectate within 5 seconds through the balloon port.
Inject 5 cc of injectate within 5 seconds through the distal port.
Inject 10 cc of injectate within 5 seconds through the proximal port.
After treatment was initiated you performed another set of CO measurements. Which of
the following cardiac output values should be discarded?
a)
b)
c)
d)
e)
3.5 L.
4.3 L
4.6 L.
4.8 L.
5.0 L.
Hemodynamic Monitoring – Comprehensive Test
83
19.
Which of the following parameters would be the best measure of tissue oxygenation for
your patient?
a)
b)
c)
d)
20.
PCWP
SVI
SvO2
CO
You obtained the following complete hemodynamic profile for your patient after the
second CO measurement.
B/P
PA
SVR
SVI
112/60 mm Hg
44/24 mm Hg
1600 dynes/sec/cm5
30 ml/m2
RA
3 mm Hg
PCWP 22 mm Hg
CI
1.9
SvO2 0.62
What problem did your patient most likely have?
a)
b)
c)
d)
Hypovolemia
Heart failure
Sepsis
ARDS
At the end of your shift, you wedged the catheter and obtained the following:
Hemodynamic Monitoring – Comprehensive Test
84
21.
What is the waveform and what is the pressure?
Waveform =_________________________ Pressure =_____________
22.
What would be the most appropriate intervention?
a) Document the strip, interpret the pressure, and notidy the physician.
b) Attempt to re-wedge, then call the physician if the same waveform appeared for
possible catheter repositioning.
c) Document the strip, administer the PRN order for Lasix for PCWP > 16 mm Hg, and
reassess in 1 hour.
d) Call for a stat chest X-Ray to assess catheter placement.
23.
Which of the following would best increase an abnormally low afterload?
a)
b)
c)
d)
24.
On the next day, Mr. Jones’ SvO2 dropped to 0.50. Priority interventions would include
each of the following EXCEPT:
a)
b)
c)
d)
25.
Dopamine 7mcg/kg/min.
Dobutamine 5 mcg/kg/min.
Norepinephrine 0.5 mcg/kg/min.
Nitroprusside 0.5 mcg/kg/min.
Check pH.
Check B/P and CO.
Check O2 sat with pulse oximeter.
Check temperature.
Which of the following is true regarding hemodynamic parameters?:
a)
b)
c)
d)
All patients need to be within normal limits in order to be clinically stable.
The systemic vascular resistance is an indicator of left ventricular preload.
Preload, afterload and contractility determine the stroke volume.
The cardiac output is a more meaningful parameter than the cardiac index.
You have completed the test…complete the evaluation that follows.
Hemodynamic Monitoring – Comprehensive Test
85
Hemodynamic Monitoring – Comprehensive Test
86
Hemodynamic Monitoring – Comprehensive Test
87