1. Skills Lab MS II
Charnelle Lee, RN, MSN

2. 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

3. 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

4. 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

5. Learning Outcomes for the Nursing Student
Develop an understanding of the purpose for calibration of hemodynamic equipment
Identify the phlebostatic axis

6. 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

7. 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

8. 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

9. 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
Utilized for patient’s who are severely ill who need intricate monitoring to determine what is really needed. It is impossible in many situations to tell if a patient is having problems with poor pumping, to much constriction, not enough, lack of fluid or too much.

10. 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

11. Insertion Sites Most common Second Choice Subclavian Internal Jugular
Femoral Vein

12. Subclavian Advantages
Used if a dwell time over 5 days is anticipated
Lowest infection rate
Least patient discomfort

13. Subclavian Disadvantages
Harder to access by the provider
Higher risk of pneumothorax or collapsed
Lung

14. Internal Jugular Advantages
Easier to access
Most frequently used
Low risk of Pneumothorax

15. 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

16. 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

17. Femoral Vein Disadvantages
Retroperitoneal bleeding
High rate of nosocomial infection related to its location in the groin

18. 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

19. 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

20. Patients with Low CVP Occurs in the patient with Hypovolemia
Or in patients who are vasodilated creating an artifical low blood volume

21. 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

22. CVP will Provide an early warning system for patients who are:
Bleeding
Vasodilating
Receiving diuretics
Being rewarmed after cardiac surgery

23. 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

24. What does it do? Monitors pressures in the following areas
Pulmonary artery – systolic and diastolic pressure
Pulmonary artery mean pressure
PAOP – wedge pressure
Cardiac Output

25. 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

26. 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

27. 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

28. 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

29. Balloon Lumen
Inflated to obtain wedge pressures or PAOP pressure

30. Thermistor Lumen Fourth lumen Measures changes in blood temperature
Used to obtain cardiac output

31. 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

32. 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

33. 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

34. Awake patient Site Preparation
Sterile 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

35. 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

36. 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

37. 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

38. Blood pressure Put automatic bp on Confirm accuracy of the readings
Put at q 5 minute intervals for close monitoring during the insertion procedure

39. 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

40. Emergency medications
Know where they are
Crash cart medications are available
Atropine
Lidocaine
Have them available

41. 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
Patient needs to be informed of this – a communication method must be developed between the patient and the nurse if the patient panics during the procedure. If the patient is anxious to begin please medicate with physician drug of choice. Make sure you know what is ordered if the physician does not want to medicate the patient for anxiety. Ativan, Versed, morphine, fentynl. Commonly used drugs.

42. 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

43. 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

44. 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

45. Why the CXR? Assesses for: Catheter Placement
Complication of Pneumothorax/Hemothorax
Not to be left out ever – if you don’t have a standing order get an order from the provider!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

46. 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

49. 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.

50. 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.

54. Pulmonary Artery Values
Pulmonary Artery systolic mm hg
Pulmonary Artery diastolic 5 – 10 mm hg
PAP mm hg
Pulmonary artery occlusion pressure – also called Pulmonary capillary wedge pressure or Pulmonary artery wedge pressure mm hg

55. 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
Discuss these findings – RAP or CVP is 10 normal findings are 2 – 5 mm hg elevated
PAS – 42 – normal 20 – 30/PAD is mm hg normally 22 mm hg
PAWP is 22 mm hg which is high and matches the PAD Findings indicate fluid volume overload. This would indicate the need for diuresis, cardiac output changes etc.,

56. Application Case Study 5
On admission
Later that day
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
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?

57. Nursing Management Position Monitor waveforms
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
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.

58. 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

59. Preventing Catheter Related Complications

60. Air Embolus
Air entry into the circulation related to open pathway from the catheter to the heart
Life Threatening
Preventable

61. 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

62. 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

63. Air Embolus Patient symptoms
Respiratory Distress
Cardiac Arrest or Collapse
Gasp reflex
Mill wheel murmur
Will be acute in onset

64. Air Embolus Action STAT
Apply 100% oxygen
Position –
Trendelenburg
Left lateral side
Maintain calm – reassure your patient- stay with your patient
Call Provider

65. 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

66. 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

67. 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

68. 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

69. 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
Reinforce using a mask for the nurse and the patient.

70. 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

71. 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

72. 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

73. 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

75. 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

76. Catheter Size Related to artery size Usually 20 gauge
Type – over the catheter

77. Arterial Sites
Most common Radial
Femoral
Dorsalis-pedis
Brachial

78. 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

80. 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
If the hand does not receive a good reperfusion response the physician should be notified before placement of the radial artery catheter. Postive allen test – negative allen test

83. 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

84. 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

85. MAP (Diastolic value x 2)+(Systolic Value x 1) 3
Calculate the mean arterial pressures for the following
120/30
82/45
97/50
Which of the blood pressure listed below reflects an adequate MAP

86. 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.
The one with the blood pressure of 90/70 has a narrowed pulse pressure r/t vasoconstriction as a compensatory response. This patient still needs intervention to restore perfusion even though the MAP is 76 and considered ok.

87. 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

88. 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

89. 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

90. 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

91. Accuracy Assessment Square Waveform Test See page 134
Line is flushed the expected square waveform test should be the result