HEMODYNAMICS MONITORING

INTRODUCTION
Critically ill patients require continuos assessment of their cardiovascular system to diagnose and
manage their complex medical conditions.This is most commonly achieved by the use of direct
pressure monitoring systems,often refered to as hemodynamic monitoring.Heart function is the
main focus of hemodynamic studies. Hemodynamic pressure monitoring provides information
about blood volume , fluid balance and how well the heart is pumping. Nurses are responsible for
the collection measurement and interpretation of these dynamic patient status parameters.

HEMODYNAMICS
Hemodynamics are the forces which circulate blood through the body. Specifically,
hemodynamics is the term used to describe the intravascular pressure and flow that occurs when
the heart muscle contracts and pumps blood throughout the body.
DEFINITION
Hemodynamic monitoring refers to measurement of pressure, flow and oxygenation of blood
within the cardiovascular system.
OR
Using invasive technology to provide quantitative information about vascular capacity, blood
volume, pump effectiveness and tissue perfusion.
OR
Hemodynamic monitoring is the measurement and interpretation of biological systems that
describes the performance of cardiovascular system.

PURPOSES
 Early detection, identification and treatment of life threatening conditions such as heart failure
and cardiac tamponade.
 Evaluate the patient’s immediate response to treatment such as drugs and mechanical support.
 Evaluate the effectiveness of cardiovascular function such as cardiac output and index.

INDICATIONS
  Any deficits or loss of cardiac function: such as myocardial infarction, congestive heart
failure, cardiomyopathy.
 All types of shock; cardiogenic shock, neurogenic shock or anaphylactic shock.
 Decreased urine output from dehydration, hemorrhage. G.I bleed, burns or surgery.

SPECIALISED EQUIPMENTS NEEDED FOR INVASIVE MONITORING

 A CVP,pulmonary artery ,arterial catheter

 A flush system composed of intravenous solution,tubing stop cocks and a flush device which
provides for continous and manual flushing of system.
 A pressure bag placed around the flush solution that is maintained at 300 mmhg pressure ;the
pressurized flush system delivers 3-5ml of solution per hour through the catheter to prevent
clotting and backflow of blood into the pressure monitoring system.
 A tranducer to convert the pressure coming from artery or heart chamber into an electrical
signal
 An amplifier or moniter which increases the size of electrical signal for display on an
occilloscope.

SETUP FOR HEMODYNAMIC PRESSURE MONITORING

 Obtain barrier kit, sterile gloves and correct swan catheter. Also need extra iv pole,
transducer holder, boxes and cables.
 Check to make sure signed consent is in chart , and that patient and or family
understand procedure.
 Everyone in the room should be wearing a mask.
 Position patient supine and flat if tolerated.

 On the monitor , press “change screen” button , then select “swan ganz” to allow
physician to view catheter wave forms which inserting.
 Assist physician in sterile draping and sterile setup for swan insertion.

 Setup pressure lines and transducers. Level pressure flush monitoring system and
transducers to the phlebostatic axis.
 Connect tubings to patient when patient is ready to flush the swann.
 While floating the swann, observe for ventricular ectopy on the monitor.
  After swann is in place, assist with cleanup and let patient know procedure is
complete.
 Obtain all the values. For cardiac output inject 10mls of D5w after pushing the start
button.
 Perform hemocalculations.
 Document findings in ICU flow sheet.

DETERMINANTS OF CARDIAC PERFORMNACE

 PRELOAD (estimated by end diastolic volume CVP for RVEDV ; PAOP (wedge)
pressure for LVEDV
 AFTERLOAD (SVR = [MAP-CVP]/CO*80)
 CONTRACTILITY METHODS OF HEMODYNAMIC MONITORING
1.ARTERIAL BLOOD PRESSURE
 a)Non Invasive
 b)Intra arterial blood pressure measurement
2.CENTRAL VENOUS PRESSURE
3.PULMONARY ARTERY CATHETER PRESSURE MONITORING
 With manual or automated devices
 Method of measurement
 Oscillometry (most common)  MAP most accurate DP least accurate
 Auscultatory (korotkoff sounds)
 Combination

LIMITATIONS
 Cuff must be placed correctly and must be appropriately sized
 Auscultatory method is very inaccurate (Korotkoff sound is difficult to hear)
 Significant underestimation in low flow (shock)
  Oscillometric also mostly in accurate ( >5mmhg off directly recorded pressures)

DIRECT INTRA ARTERIAL BP MONITORING

 Intra-arterial BP monitoring is used to obtain direct and continuous BP measurements
in critically ill patients who have severe hypertension or hypotension PROCEDURE
 Once an arterial site is selected (radial, brachial, femoral, or dorsalis pedis), collateral
circulation to the area must be confirmed before the catheter is placed. This is a safety precaution
to prevent compromised arterial perfusion to the area distal to the arterial catheter insertion site.
If no collateral circulation exists and the cannulated artery became occluded, ischemia and
infarction of the area distal to that artery could occur.
 Collateral circulation to the hand can be checked by the Allen test
 With the Allen test, the nurse compresses the radial and ulnar arteries simultaneously
and asks the patient to make a fist, causing the hand to blanch.
 After the patient opens the fist, the nurse releases the pressure on the ulnar artery while
maintaining pressure on the radial artery. The patient’s hand will turn pink if the ulnar artery is
patent.

COMPLICATIONS
 Local destruction with distal ischemia
 external hemorrhage
 massive ecchymosis
 dissection
 air embolism
 blood loss
 pain
 arteriospasm and
 infection.

NURSING INTERVENTIONS
 Before insertion of a catheter, the site is prepared by shaving if necessary and by
cleansing with an antiseptic solution. A local anesthetic may be used.
  Once the arterial catheter is inserted, it is secured and a dry, sterile dressing is applied.

 The site is inspected daily for signs of infection. The dressing and pressure monitoring
system or water manometer are changed according to hospital policy.
 In general, the dressing is to be kept dry and air occlusive.
 Dressing changes are performed with the use of sterile technique.

 Arterial catheters can be used for infusing intravenous fluids, administering

intravenous medications, and drawing blood specimens in addition to monitoring pressure.
 To measure the arterial pressure, the transducer (when a pressure monitoring system is
used) or the zero mark on the manometer (when a water manometer is used) must be placed at a
standard reference point, called the phlebostatic axis .
 After locating this position, the nurse may make an ink mark on the chest

CENTRAL VENOUS PRESSURE MONITORING

The CVP, the pressure in the vena cava or right atrium, is used to assess right ventricular
function and venous blood return to the right side of the heart. The CVP can be continuously
measured by connecting either a catheter positioned in the vena cava or the proximal port of a
pulmonary artery catheter to a pressure monitoring system

PROCEDURE
 Before insertion of a CVP catheter, the site is prepared by shaving if necessary and by
cleansing with an antiseptic solution.
 A local anesthetic may be used. The physician threads a single lumen or multilumen
catheter through the external jugular, antecubital, or femoral vein into the vena cava just above
or within the right atrium

NURSING INTERVENTIONS
 Once the CVP catheter is inserted, it is secured and a dry, sterile dressing is applied.

 Catheter placement is confirmed by a chest x-ray, and the site is inspected daily for
signs of infection. The dressing and pressure monitoring system or water manometer are changed
according to hospital policy.
 In general, the dressing is to be kept dry and air occlusive.
 Dressing changes are performed with the use of sterile technique.
  CVP catheters can be used for infusing intravenous fluids, administering intravenous
medications, and drawing blood specimens in addition to monitoring pressure.
 To measure the CVP, the transducer (when a pressure monitoring system is used) or
the zero mark on the manometer (when a water manometer is used) must be placed at a standard
reference point, called the phlebostatic axis .
 After locating this position, the nurse may make an ink mark on the chest

PULMONARY ARTERY PRESSURE MONITORING

 Pulmonary artery pressure monitoring is an important tool used in critical care for
assessing left ventricular function, diagnosing the etiology of shock, and evaluating the patient’s
response to medical interventions (eg, fluid administration, vasoactive medications). Pulmonary
artery pressure monitoring is achieved by using a pulmonary artery catheter and pressure
monitoring system.

PULMONARY ARTERY CATHETER

 Development of the balloon-tipped flow directed catheter has enabled continuous
direct monitoring of PA pressure. Pulmonary artery catheter otherwise known as “swan- ganz
catheter”

INSERTION OF PAC
 PA monitoring must be carried out in a critical care unit under careful scrutiny of an
experienced nursing staff.
 Before insertion of the catheter , explain to the client that;
 The procedure may be uncomfortable but not painful.

 A local anesthetic will be given at the catheter insertion site. Support of the critically ill
client at this time helps promote cooperation and lessen anxiety. Procedure
 This procedure can be performed in the operating room or cardiac catheterization
laboratory or at the bedside in the critical care unit.Catheters vary in their number of lumens and
their types of measurement (eg, cardiac output, oxygen saturation) or pacing capabilities.
 All types require that a balloon-tipped, flowdirected catheter be inserted into a large
vein (usually the subclavian, jugular, or femoral vein); the catheter is then passed into the vena
cava and right atrium.
  In the right atrium, the balloon tip is inflated, and the catheter is carried rapidly by the
flow of blood through the tricuspid valve, into the right ventricle, through the pulmonic valve,
and into a branch of the pulmonary artery.
 (During insertion of the pulmonary artery catheter, the bedside monitor is observed for
waveform andECG changes as the catheter is movedthrough the heart chambers on the right side
and into the pulmonary Artery)
 When the catheter reaches a small pulmonary artery, the balloon is deflated and the
catheter is secured with sutures.
 Fluoroscopy may be used during insertion to visualize the progression of the catheter
through the heart chambers to the pulmonary artery.
 After the catheter is correctly positioned, the following pressures can be measured:
 CVP or right atrial pressure
 pulmonary artery systolic and

 diastolic pressures, mean pulmonary artery pressure, and pulmonary artery wedge
pressure).

NORMAL RESULTS
 Normal pulmonary artery pressure is 25/9 mm Hg, with a mean pressure of 15 mm Hg.

 Pulmonary capillary wedge pressure is a mean pressure and is normally 4.5 to 13 mm

Hg.

NURSING INTERVENTIONS
 Catheter site care is essentially the same as for a CVP catheter. As in measuring CVP,
the transducer must be positioned at the phlebostatic axis to ensure accurate readings .
 The nurse who obtains the wedge reading ensures that the catheter has returned to its
normal position in the pulmonary artery by evaluating the pulmonary artery pressure waveform.
 The pulmonary artery diastolic reading and the wedge pressure reflect the pressure in
the ventricle at enddiastole and are particularly important to monitor in critically ill patients,
because they are used to evaluate left ventricular filling pressures (preload)
 At end-diastole, when the mitral valve is open, the wedge pressure is the same as the
pressure in the left atrium and the left ventricle, unless the patient has mitral valve disease or
pulmonary hypertension.
 Critically ill patients usually require higher left ventricular filling pressures to optimize cardiac
output. These patients may need to have their wedge pressure maintained as high as 18 mm Hg.

COMPLICATIONS
 Infection
 pulmonary artery rupture
 pulmonary thromboembolism
 pulmonary infarction
 catheter kinking,
 dysrhythmias, and
 air embolism.

TECHNIQUES WITH PULMONARY ARTERY CATHETER

 CARDIAC OUTPUT MONITORING
 THERMODILUTION
 CONTINUOUS CARDIAC OUTPUT MONITORING
 FICK'S CARDIAC OUTPUT MEASUREMENT
 CO = VO2 ---------CA-CV
DERIVED PARAMETERS
 Cardiac o/p measurements may be combined with systemic arterial, venous, and PAP
determinations to calculate a number of variables useful in assessing the overall hemodynamic
status of the patient.
 Cardiac index = Cardiac output / Body surface area

 Systemic vascular resistance = [(Mean arterial pressure - resistance CVP or rt atrial

pressure)/Cardiac output] x 80
 Pulmonary vascular resistance = [(PAP - PAWP) / Cardiac vascular resistance output] x 80
 Mixed venous oxygen saturation (SvO2) (SvO2 = SaO2 - [VO2 / (1.36 x Hb x CO)]

NURSING RESPONSIBILITIES
 Site Care and Catheter Safety:
 A sterile dressing is placed over the insertion site and the catheter is taped in place. The
insertion site should be assessed for infection and the dressing changed every 72 hours and prn.
 The placement of the catheter, stated in centimeters, should be documented and assessed every
shift.
 The integrity of the sterile sleeve must be maintained so the catheter can be advanced or pulled
back without contamination.
 The catheter tubing should be labeled and all the connections secure. The balloon should
always be deflated and the syringe closed and locked unless you are taking a PCWP
measurement
Patient Activity and Positioning:
 Many physicians allow stable patients who have PA catheters, such as post CABG patients, to
getout of bed and sit. The nurse must position the patient in a manner that avoids dislodging the
catheter.
 Proper positioning during hemodynamic readings will ensure accuracy.

Dysrhythmia Prevention:
 Continuous EKG monitoring is essential while the PA catheter is in place.
 Do not advance the catheter unless the balloon is inflated.
 Antiarrhythmic medications should be readily available to treat lethal dysrhythmias.
Monitoring Waveforms for Proper Catheter Placement:
 The nurse must be vigilant in assessing the patient for proper catheter placement. If the PA
waveform suddenly looks like the RV or PCWP waveform, the catheter may have become
misplaced. The nurse must implement the proper procedures for correcting the situation.

Monitoring Hemodynamic Values for Response to Treatments:

 The purpose of the PA catheter is to assist healthcare team members in assessing the patient’s
condition and response to treatment. Therefore, accurate documentation of values before and
after treatment changes is necessary.

Assessing the Patient for Complications Associated with the PA Catheter:

 Occluded ports
 Balloon rupture caused by overinflating the balloon or frequent use of the balloon.
 Pneumothorax - may occur during initial placement.
 Dysrhythmias - caused by catheter migration
 Air embolism - caused by balloon rupture or air in the infusion line.
 Pulmonary thromboembolism - improper flushing technique, non-heparinized flush solution.

 Pulmonary artery rupture - perforation during placement, overinflation of the balloon, overuse
of the balloon.
 Pulmonary infarction - caused by the catheter migrating into the wedge position, the balloon
left inflated, or thrombus formation around the catheter which causes an occlusion.

CONCLUSION
 Hemodynamics is the forces involved in blood circulation. Hemodynamic monitoring started
with the estimation of heart rate using the simple skill of 'finger on the pulse' and then moved on
to more and more sophisticated techniques like stethoscope, sphygmomanometer, ECG etc. The
status of critically ill patients can be assessed either from non-invasive single parameter
indicators or various invasive techniques that provide multi parameter hemodynamic
measurements. As a result, comprehensive data can be provided for the clinician to proactively
address hemodynamic crisis and safely manage the patient instead of reacting to late indicators
of hemodynamic instability
 BIBLIOGRAPHY

 Brunner & Suddhart’s Textbook of Medical Surgical Nursing, vol 2, 12th ed, 2010: pp 2161 –
2163
 Colmer ; Moroney’s Surgery for Nurses, 16th ed, 1981 : pp 98 – 106
 Howard, Steinmann, Sheehy’s emergency nursing principles & practice, 6th ed, 2003 pp
 Thygerson, Gulli & Krohmer, First Aid, 5th ed, 2006 : pp 23 – 27
 wikipediahttp://europepmc.org/abstract/CHILD/6517266
 SCHOOL OF NURSING SCIENCES AND RESEARCH
SHARDA UNIVERSITY

SUBJECT=ADVANCE NURSING PRACTICE

ASSIGNMENT ON

TOTAL PARENTRAL NUTRITION

Submitted to:- Submitted BY:-

Ms. Kiran Sharma Ms. Bhawna joshi
HOD and Professor Msc. 1st Year
Medical Surgical Nursing Deptt. SNSR
SNSR