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NR202 Test 2 Hemodynamic Pressure Monitoring


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Define Hemodynamics
Hemodynamics-Cardiovascular physiology dealing with the forces the pump has to circulate blood.
Purpose of Hemodynamic Pressure monitoring
Purpose: Hemodynamic monitoring aids in diagnosis to CV disorders, guides therapies to treat disorders, and evaluates responses to therapies.
Disorders which may require hemodynamic monitoring include:
Hypertension, Hypotension, Heart failure.
Pulmonary embolism-blood clot around vessels in alveoli;
Pulmonary hypertension-High BP in the lungs.
Valvular disease
Define Stroke volume (SV)
the volume ejected by ventricles per contraction
Normal – 60-130 ml/beat
List and describe the Determinants of Stroke Volume
-Venous return-Influences how much the blood is filling
- Blood return,
-Vasodilation-Decreases volume of blood that is going to the heart. Blood pools and it is harder to get back to the heart.
-Afterload: Resistance ventricle must overcome to pump blood out.
-Peripheral vascular resistane increases afterload-vasoconstriction
-Blood viscosity-A raised hematocrit increases thickness of blood
-Aortic impedence-Stop aortic blood flow, stiff valve does not want to open or plaque builds up-Causes a narrow artery. (Increased in hypertension or vasoconstriction)
-Contractility: Strength of myocardium, the strength of heart muscle
-Starlings Law: farther cardiac muscle fiber is stretched, the more forceful the contraction. The more the cardiac muscle is stretched, the forceful the contraction.
-MI Drugs, CHF
Determinants of Stroke Volume
Describe Ejection fraction
Ejection fraction EF-Percentage of blood pumped from the ventricle with each beat.
Determinants of Stroke Volume
Describe Cardiac output
Cardiac output (CO)
Cardiac output = Stroke volume X Heart Rate SV X HR
-Volume pumped per minute
-Normal: 4-8 L/min
-Factors affecting: decreased myocardial contractility, circulating volume, systemic vascular resistance, valve disease. You have to have enough blood volume to have enough cardiac output.
Determinants of Stroke Volume
Describe Systemic vascular resistance
Systemic vascular resistance (SVR): Same as afterload.
-Afterload: resistance the left ventricle must overcome to pump blood out.
-Peripheral vascular resistance
-Blood viscosity
-Aortic impedence
-Hypertension increases SVR
Vasodilators decrease SVR
Determinants of Stroke Volume
Describe Blood pressure, give equation
Blood pressure = cardiac output X systemic vascular resistance
-Most accurate noninvasive measurement of cardiac output
-Systemic Vascular Resistance: Afterload for left ventricle
High: vasoconstriction
Low: Vasodilation
Determinants of Stroke Volume
Describe Pulmonary Vascular resistance
Pulmonary Vascular resistance: Afterload for right ventricle
-Increase: Pulmonary embolism, decreased left ventricular function
-Decrease: vasodilation, diuretics
Determinants of Stroke Volume
Describe Cardiac index
CI (Cardiac index) CO divided by body surface area
What factors might increase afterload? Decrease afterload?
Increase: Peripheral vascular resistance, hypertension, vasoconstriction
Lowered: Blood viscosity, aortic impedence, vasodilation, and diuretics.
Central pressure monitoring
-Central Venous Pressure (CVP) –Right Atrial

-Pulmonary Artery Pressure (PA)-Pulmonary arteries
Describe Central Venous Pressure (CVP) –Right Atrial
-Central Venous Pressure (CVP) –Right Atrial
measures pressure in the systemic venous system
CVP is measured at the mouth of the right atrium
Changes in CVP reflect changes in fluid levels (blood volume)
CVP is a reflection of the right atrial pressure (RAP)
“Since the end-diastolic pressure, or the pressure measured at the end of filling the chamber is equivilant to the preload pressure (the pressure filling the chamber), then the CVP is equivilant to the right ventricular end-diastolic pressure.”
This is known as right heart Preload
Describe -Pulmonary Artery Pressure (PA)-Pulmonary arteries
The PAP measures the pressure of the blood flow moving from the right venticle, through the pulmonary artery into the lungs. uPAP is sometimed referred to as right ventricular afterload. uNormal PAP is 25/8 or around 14 mmHg mean. Increases in PAP are consistent with the presence of lung disease (COPD)
Pressure (PA)-Pulmonary arteries

Conditions Resulting in an Increased PAP
Pulmonary Hypertension
Pulmonary Embolism
High PEEP (increased intrathoracic pressure)
MI/CHF/Left Heart Failure
Pressure (PA)-Pulmonary arteries
Conditions Resulting in a Decreased PAP
Right Heart Failure (Cor Pulmonale)
-Pulmonary Wedge Capillary Pressure (PWCP) Functioning of the left side of the heart)
-Reflect pressure of blood in right atrium or vena cava
-Reflects right ventricular end-diastolic pressure
-Evaluate right ventricular function, fluid volume, right ventricular pressures.
Why is this important to know?
Since the pulmonary veins empty into the left side of the heart, any problems with the left side of the heart or malfunction of the mitral valve will cause blood to back up into the pulmonary veins and increase the wedge pressure.
What causes Increased PAP, Normal PWP
Pulmonary embolus
Primary Pulmonary Hypertension (PPH)
What causes Increased PAP, Increased PWP
Pulmonary Edema (LVF)
High PEEP Effect
What causes Decreased PAP, Decreased PWP
Right Heart Failure
Shock, Vasodialtion
Pulmonary Wedge Pressure
Other Names-
Left Ventricular End Diastolic Pressure
Left Heart Preload
Pulmonary Venous Pressure
Left Atrial Filling Pressure
Central Venous Pressure is affected by:
-Intravascular blood volume
-Intrathoracic pressure-inhale, exhale
-Vascular tone-Vasodilated, vasoconstricted, increased Central venous pressure
-Depressed cardiac function
-Pulmonary hypertension-Rt ventricle more to work against.
Catheter insertion
-Inserted into antecubital, jugular, femoral, or subclavian and into the vena cava close to the right atrium. Further—see pronounced heart waves
-If inserted into right atrium waveform will become more pronounced and catheter is withdrawn several centimeters.
⬢ Formed at catheter tip
⬢ Loss of hemodynamic waveform and inability to infuse fluid or withdraw blood
⬢ Edema of arm
⬢ Neck Pain
⬢ Jugular vein distension
⬢ Report to physician
-Air embolism
⬢ Air entering system and traveling to right ventricle
⬢ Associated with disconnection of catheter from IV tubing
⬢ Hypotension, confusion, light-headedness, anxiety, and unresponsiveness
Nursing considerations
-Low CVP
⬢ Hypovolemia
⬢ Vasodilation
⬢ Hemmorhage
⬢ Spontaneous Inspiration
Nursing considerations
-High CVP
⬢ Right Ventricular failure (Cor Pulmonale)
o Back up of blood pressure in Right atria and Vena cava.
⬢ Mechanical ventilation
o increased intrathoracic pressure (positive pressure ventilation, or pneumothorax)
⬢ Fluid Overload (fluid overload)
⬢ Increased Intrathoracic Pressure
⬢ Cardiac Tamponade
⬢ Pulmonary Hypertension
⬢ Pulmonary Embolisim
⬢ Tricuspid or Pulmonary Valve Stenosis
⬢ Left Heart Failure

CVP increases with inspiration
CVP decreases with expiration
CVP waveform
A wave: atrial contraction
-Increased resistance to ventricular filling
X descent: Atrial relaxation
C wave: Tricuspid closure (small backward bulge)
V wave: atrium filling (corresponds to T wave)
Y descent: tricuspid valve opens
-smaller than X, in tamponade
V wave: should be same height as A wave
-Elevated: tricuspid insufficiency, tamponade, heart failure.
Pulmonary artery Pressure monitoring (SWAN)
Flow directed, balloon tipped catheter
-RV function
-Pulmonary vascular status
-Indirect (LV) left ventricle function
Insertion of pulmonary Artery Catheter.
-into large vein using an introducer
-Left and right subclavian veins
Jugular/Femoral veins less common
-Vena cava into right atrium
Balloon inflated to help “float” catheter through tricuspid valve into right ventricle, across pulmonic valve into Pulmonary artery, then deflated, after wedge waveform noted
-Ventricular dysrhythmias most common complication
Pulmonary Artery Pressure Monitoring includes:
-CVP or RA monitoring
-PA monitoring
-PCWP monitoring
Pulmonary Artery Catheter
Function & Design
4 Lumens on Standard Catheter
Name and describe the four lumens
⬢Distal Lumen- located at the very tip of the catheter, function to measure PAP when balloon is deflated and PWP when inflated. Can also be used to withdraw mixed venous blood for shunt calculation.

⬢Proximal Lumen- located in the right atrium, measure CVP, and is used to inject fluids or blood, and is the port for injecting saline for cardiac output measurements.

⬢Balloon Lumen- used to inject air or CO2 to inflate the balloon during wedge measurements.

⬢Thermister Lumen- located near tip, measure temperature change for cardiac output measurment
Proximal (CVP or RA) blue port
⬢ Opens into right atrium
⬢ Used for infusions
⬢ CVP or RA waveform
⬢ Used as injecate port for C.O.
⬢ Affected by
⬢ Blood volume
⬢ Vascular tone
⬢ Pulmonary hypertension
⬢ Thoracic pressure
SWAN-yellow distal lumen hub
-PA waveform (pulmonary artery pressure)
Distal or PA
*Resistance of pulmonary vasculature
*Systolic phase of PA reflects right ventricular contraction
-Attached to transducer and continuous flush system
-Not used for fluids or medicines
-Increases with:
⬢ LV failure
⬢ Pulmonary hypertension
⬢ Mechanical failure
⬢ PE
-Decreases with:
⬢ Tricuspid Stenosis
⬢ Hypovolemia
Balloon inflation Port and lumen
-PAWP: inflation occludes forward blood flow (wedge pressure)
-Left Ventricle end diastolic pressure
-May indicate:
LV dysfunction or hypervolemia
Mitral valve disease
-Never infuse fluids
Thermistor (Button)-What does it measure?
-Cardiac output
⬢ Average of several measurements
⬢ 3 or more, within 10% to 15% of each other
Complications of CVP insertion
•Pneumothorax: caused by insertion of catheter through subclavian vein wall
• Infection: Contamination of catheter, insertion site, or pressure monitoring system
• Ventricular dysrhythmias: Irritation of endocardium when catheter passes through right ventricle—resolve when advanced into PA
•Pulmonary artery rupture or perforation: during insertion or manipulation of catheter. Rupture may occur during inflation of balloon if catheter has moved into a small PA
Pressure monitoring system
⬢Basic equipment
-Noncompliant pressure tubing
⬢Transmits pressure to transducer
⬢Sends signals up the connections
⬢Senses changes in cardiac chambers or vessels
⬢ Changes electrical flow to amplifier/monitor
⬢Converts electrical signal to pressure tracing and digital value
Zeroing and Leveling
-Carpenter type level placed even with the zero reference
-supine or head of bed elevated to 40 degrees
•Position of transducer to patient’s atria
-Zero reference
•Intersection of mid anterior-posterior line and 4th ICS phlebostatic axis
•After leveling
-turn stopcock off to patient and open to air and activate zero key
•When monitor reads 0/0, close to air, then turn stop cock on to patient
Nursing care of the patient undergoing PA Monitoring
⬢Interpret waveforms and pressure data
⬢Be alert to potential complications
⬢ Minimize operator error
-consistency of leveling
-Obtain measures at end of expiration
⬢Set alarm parameters closely-why
-Acute rise in PA pressure may indicate pulmonary embolus
-distal migration of PA catheter may cause spontaneous wedge
-Large elevated a or v RA waves
⬢a: impaired atrial emptying
⬢ b: incompetence of tricuspid valve
Use of monitoring system
-Air bubbles or blood in tubing
-Distortions due to transducer system
-soft distensible tubing
-Loose connections cracks/leaks
-Lack of zeroing-Make sure it has been zeroed
⬢Nursing considerations
-Decreased C.O. May be related to decreased preload (RAP & PAWP)
Caused by?
-Vasoconstriction elevates afterload
Caused by?
-C.O. increases with volume resuscitation—increases?
-Vasodilation decreases?
Describe Arterial Monitoring
⬢Intra-arterial catheter connected to pressure monitoring system
⬢ Continuous monitoring of BP
⬢ Blood samples (ABGs)
⬢ Indicated with vasoactive IV infusions
⬢ Arterial line insertion
-radial and femoral arteries most common
-Sterile technique
Complications of Arterial Monitoring
⬢sterile dressing changes
⬢ Tubing changes
⬢Flush stopcocks each time blood is withdrawn
⬢Accidental blood loss
⬢Luer lock all connections
⬢Immobilize extremity
⬢Check Color, sensation, pulses, and movement q8hrs
Arterial Monitoring
⬢Nursing considerations
-Compare to auscultated cuff BP
Usually 5-20mmHg higher than the cuff
-Bedside monitor alarms
•Set for systolic, diastolic, and mean pressures within 10-20 mmHg of patient’s typical pressure
-Square wave form test
-Bleeding at insertion site
-Kinking of tubing
•Do not flush with syringe
• No IV solutions or medications!!!!

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