What are the Primary Indications for Hemodynamic Monitoring?

- Heart failure
- Acute Pulmonary Edema
- Circulatory Failure
Who needs Hemodynamic Monitoring?
critically ill patients with or who have the potential for life threatening physiological
conditions:

(Fluid/Blood Loss)
- dehydration
- GI bleed (hemorrhage)
- surgery

(Heart Conditions)
- CHF --> cardiac output --> shock
- acute MI
- cardiomyopathy
What kind of Hemodynamic Monitoring can be done?
- CVP (central venous pressure)
- PAP (pulmonary artery pressure)
- IABP (intra arterial BP monitoring)
When would you do Hemodynamic Monitoring?
- other measures are not reliable
- close monitoring is required
Where does Hemodynamic Monitoring occur?
- If UNSTABLE --> critical care units and progressive care units
- If STABLE --> step down can admit stable patients with CVP or IABP devices for
monitoring
Why is Hemodynamic Monitoring Needed?
- to evaluate immediate response to treatement --> drugs --> mechanical support
- for early detection, identification and treatment of life threatening conditions
Who inserts the Catheters for Hemodynamic Monitoring?
Physicians do!!
What is the GENERAL role of the nurse during Hemodynamic Monitoring?
To monitor the PATIENT not just the equipment
What are the 4 Components of Hemodynamic Monitoring?
1. monitor
2. pressure bag --> inflate it to 300 mm Hg
3. 3-way stop cock
4. transducer
How do you prep the pressure bag for Hemodynamic Monitoring?
you must get rid of the air in the bag of before you run it:
- turn it over
- spike it and squeeze out the air
- then purge tubing
- then hang it
remember: 50 mL of air will kill your patient!
What is the function of the transducer in Hemodynramic Monitoring?
- it turns elelctrical energy into mechanical energy
- it lets you see the wave form
What is the Transducer connected to in the Hemodynamic Setup
to the pressure bag
What is the PIGTAIL used for on the transducer?
to manually flush the line

this must be done anytime the line is accessed

What are the functions of the PRESSURE BAG?
- stops back flow
- flush rate is 3-5 mL/hr --> keeps line patent

Remember: the flush solution may be heparinized

What does an Arterial Line Monitor?
It measures Blood Pressure
What are some of the benefits of Having an Arterial Line?
- you can monitor BP (invasive)
- direct monitoring
- it is continuous
- it is accurate
- you can take blood gas samples
- you can obtain lab samples
What is Normal Adult Blood Pressure?
less than 120/80
What is the normal range for adult respirations?
12 to 20
What is the normal range for adult Heart Rate?
60- 100 BPM
What is the Average Normal Body Temperature?
98.6 F or 37.0 C
Who inserts and assesses an Arterial Line?
- a physician inserts it
- a nurse assesses it

it is sutured in place
Hyperaemia
- the increase of blood flow to different tissues in the body
Points of Access for Arterial Lines:
- radial --> best: splint it to keep it stable
- brachial
- femoral --> worst: location and far away from heart
What test needs to be performed before inserting an arterial line?
- The Allen's Test!
What are the steps in the Allen's Test?
- occlude the both arteries (radial/Ulnar) together until the hand blanches
(hyperanemia),
- then release the ulnar artery to see if it can perfuse the hand by itself
- then place the canula in the radial artery
How often do you change an arterial line dressing?
- Every 72 hours unless hospital policy states otherwise
What happens if a patient's arterial line disconnects?
- the patient can hemorrhage/exsanguinate
What do you need to remember when you are hanging bags of fluid?
- make sure to keep the label turned out on bags of hanging fluid so that the label can
be easily read
Where are Central Venous Pressure Lines placed?
- usually in the Right Atrium

Remember: for "CENTRAL" think HEART and for" VENOUS" think

Inferior/Superior Vena cava empties into the Right Atrium
What are the Percutaneous Access points for CVP Lines?
- jugular
- subclavian
- antecubital
- femoral

it is sutured in place
What information do CVP Lines give?
- it gives an indication of the amount of blood returning to the right side of the heart

Remember: for "CENTRAL" think HEART and for" VENOUS" think

Inferior/Superior Vena cava empties into the Right Atrium
What is the Normal Range for CVP?
- 2-6 mm Hg
What can ELEVATE CVP?
- extra fluid in circulation
- overhydration
- HYPERvolemia

Think about what it is measuring--> FLUID STATUS --> PRELOAD --> what makes
more circulating fluid??
What can DROP CVP?
- too little fluid in circulation
- dehydration
- HYPOvolemia
- excessive vomit
- excessive diarrhea
- excessive diureses
What does CVP lines monitor in General?
- fluid status --> preload
What are the benefits of CVP lines:
- its continuous
- its accurate
- you can take blood samples
Preload is:
- the degree of stretch of the cardiac muscle at diastole --> as blood enters the right
heart
How do you "zero-out" a CVP Line?
- when you are monitoring you have to zero it out to atmospheric pressure -->
- patient in supine position (HOB CAN be up to 60 degrees),
- take cock stop/transducer and tape it to the patient at the phlebostatic access site -->
at the 4th intercostal space and mid axillary line
- turn it off to the patient,
- open it up to the outside air and zero it to atmospheric patient.

mark the spot and tape the line to that spot each shift --> you are making sure
that the phlebostatic access site and the transducer are level
What can you bolus into CVP Lines?
- 3% saline
- potassium (more than 10mEq/hr)
- Blood
Pulmonary Artery Pressure Monitoring Percutaneous Access Points
- Subclavian --> Best
- Jugular --> Better
- Femoral --> Worst

it is sutured in place
What are other names for PAP monitoring Lines?
- PA Catheter
- Swan-Ganz
Key Aspects of Swanz-Ganz Catheter Placement
- a flow directed catheter --> carried through the cardiac system by the blood flow and a
balloon at the tip of catheter
- balloon blown up to 1.5 mL of air
- syringe that comes with a swan-ganz catheter only has a 1.5 mL syringe --> if you
drop it, get another kit!
- allow balloon to deflate passively do not pull back
- make sure line is locked before you leave the syringe and balloon is deflated

- can be done by fluoroscopy

- will use pressure bag --> 300 mm Hg
Where can you infuse IV fluids in a Swan-Ganz Catheter
- the proximal infusion port (right atrium/superior vena cava) or
- the cordis port which is a side port used for infusing blood mostly
Where are the Proximal and Distal ports of the Swan-Ganz located in the heart?
- the proximal port is in the right atrium and measures CVP and right atrial pressure

- the distal port is going to go into the pulmonary artery and it measures the pulmonary
artery pressure
What must occur before you can use a newly placed PAP line or Swan-Ganz line?
- you must have a chest x ray before you can use this line after it is inserted (post
procedure)

- remember that these lines can also cause pneumonia r/t placed too far in
To avoid bolus of potential medications you must NOT:
- infuse vasoactive (norepi, nitro, etc) medications into the cardiac injectate port --> blue
port (blue port for blue syringe for water bolus for cardiac output)
Normal Ranges for Pulmonary Artery Pressure Monitoring
BP in the peripheral artery

Systolic: 15-25 mmHg

Diastolic 8-15 mmHg
What is the sterile sleeve for on the Swan-Ganz?
it allows for re-positioning of the catheter if it displaced and for wedging
Can the Nurse Re-position the Swan-Ganz?
The nurse has to be certified to reposition themselves --> if not they must call md
immediately
How do you take Pulmonary Artery Wedge Pressure?
- the longest you will leave the balloon tip wedged is 10 seconds --> just long enough for
you can read the numbers on the monitor
- you should passively deflate the balloon
- make sure to lock the syringe before you remove the syringe - remove the syringe and
expel the air
- then reattach the syringe and make sure it is locked

- remember: "OFF to the patient before ON to the air."

if the balloon is kept inflated it will get wedged in the pulmonary capillary it will
cause ischemia
What is the WORST type of Heart Failure??
- Left Sided Heart Failure r/t the pumping of the blood to the body (systemic)
Nursing Roles for PAP monitoring:
- get consent --> unless it is an emergency procedure
- equipment set up
- always keep extra sterile gloves
What does Pulmonary Artery Wedge Pressure Measure?
- it measures left ventricular function
How does Pulmonary Artery Wedge Pressure Monitoring Occur?
- you are occluding the pulmonary artery to get readings from the left ventricle -- >
pulmonary capillary wedge pressure helps measure Left ventricular pressure
- the catheter tip is pointed towards the lungs
- you wedge it in the capillary to measure
- the blood is flowing back through the left ventricle back into the lungs and to the left
atrium to the catheter tip and the monitor reads it (its similar to CHF)
- remember there are no valves in the pulmonary arteries
What are the Normal Ranges for Pulmonary Artery Wedge Pressure?
- 4-12 mmHg

- if you have CHF, the readings will be higher than 4-12 mmHg
What is the waveform like if the PAP catheter is in the RIGHT VENTRICLE
- it is an up sweeping, down slopping and steep wave form
- you do not want it here... it can cause v fib
keep it moving
What is the waveform like if the PAP catheter is in the PULMONARY ARTERY
- you will see the wave form with a dicrotic notch
What is a dicrotic notch
- it is a small dip in the waveform in the pulmonary artery that represents the closure of
the aortic valve
What happens if you notice a RV waveform on the monitor following proper placement
of the PAP into the pulmonary artery?
- the catheter has sliped back into the right ventricle, assess the patient and call the
physician immediately
What are the Nurse's Roles for Patients Needing Hemodynamic Monitoring?
- prepartion: as for CVP clip their hair not shave r/t infection
- maintenance: assess site; assess focusing on cardiac /respiratory systems
- trending/interpretation: obtain pressure and report abnormalities
- trouble shooting: observe for any complications, always change the caps from white to
yellow
What are Complications of Hemodynamic Monitoring?
- Pneumothorax
- Infections
- Air Embolism
- Dysrhythmias
What is a pneumothorax?
- an abn collection of air in the chest that seperates the lung from the chest wall and
may interfere with normal breathing
- you will see it on a CXRAY
What are some S/Sx of Pneumothorax?
- tachypneia
- nasal flaring
- accessory muscle use (retractions)
- decreased O2 stat
- tracheal deviation
- absent air sounds on affected side
What kind of Dysrhythmias might you see with Hemodynamic Monitoring?
- Premature Ventricular Contractions
- Ventricular Tachycardia

both are r/t the catheter being in right ventricle

How do you Manage a Patient with an Air Embolism?
turn them to their left side to keep air pocket on right side.
How do you PREVENT an Air Embolism in a Patient with Hemodynamic Monitoring?
- remember to purge tube
- lock lines
- use air detection on your pumps