Adult 2 Test

what does hemodynamic monitoring monitor?

physical factors and forces that affect cardiac function (cardiac output specifically)- DOES NOT REPLACE PHYSICAL ASSESSMENT (equipment could malfunction, etc)

common invasive hemodynamic monitoring systems

central venous pressure (CVP), arterial line, pulmonary artery catheter (swanganz)

what measurements can you collect from a pulmonary artery (swanganz) catheter?

CVP, SVR, PAP, PCWP, CO, CI (index), T, SVO2

what are the components of a hemodynamic monitoring system?

transducer (convert to electrical signal, disposable), amplifier/monitor, pressure tubing (3 way stop cocks), flush system (NS with/out heparin, continuous flushing system to avoid line clotting off)

where should the transducer be placed for accurate measure of pressure?

phlebostatic axis (4th ICS, midaxillary line- connects it to RA)

what sites can be used for arterial pressure monitoring?

*nondominant radial artery*, brachial artery, femoral artery (emergency setting only)

what test must you perform before inserting an a-line/arterial pressure monitor?

allen's test (determines if ulnar artery is patent enough to perfuse hand by itself without radial artery help (aka if a-line can go in radial))

allen's test

occlude both ulnar and radial artery until hand pales completely, release ulnar
if the hand pinks up, ulnar artery is good and you can utilize radial artery for a-line

what measurements are seen on an arterial line waveform?

SBP, DBP, dicrotic notch (indicating closure of aortic valve), MAP

what do you look for to determine a "good" vs "bad" arterial line waveform?

good- peaks and valleys (dicrotic notch going into valley)
bad/dampened wave form- humps, mountains

how do you calculate MAP?

(SBP + 2DBP)/3

nursing care for patients with arterial lines

direct observation of site q 1 hr, circulation checks, monitor alarms, cover site/possible restraints/wrist splint, monitor for privacy or transducer issues, neurovascular assessment (5 P's- pallor, pulselessness, pain, paresthesia, paralysis)

potential complications of arterial lines

infection, ischemia, arteriospasm (seen VS as incorrect BP), nerve damage, hemorrhage, hematoma, 5 P's (pain, pallor, paresthesia, paralysis, pulselessness)

pulmonary artery (swan ganz) catheter

most specific in measurement of heart and great vessels due to direct insertion into heart
measures CO and blood T

pulmonary artery (swan ganz) catheter ports

proximal port (CVP), distal port (PAP), balloon port, thermodilution port, VIP port, paceport access, SVO2 monitoring

what do you look for on the monitor with insertion of a PA catheter?

want to be in PA wedge for NO LONGER THAN 30 sec (see occlusion of blood flow and measures LH only), want return to regular rhythm after wedge

right atrial pressure (CVP)

right atrial filling pressure (PRELOAD)
normal 1-8 mmHg

what could cause a high CVP?

fluid overload, RHF

what could cause a low CVP?

hypovolemia

pulmonary artery pressure (PAP)

pressure in pulmonary system indicating overall volume status
normal 15/5-26/15

pulmonary capillary wedge pressure (PCWP)

measures LH function/pressure (balloon blocks RH pressure), taken at the end of an expiration
normal 4-12 mmHg

normal cardiac index (CI)

2.8-4.2 L/min (more specific than CO because it accounts for height and weight)

systemic vascular resistance (SVR)

assess force heart must pump against (AFTERLOAD)
normal 800-1200 dynes/sec/cm

SVO2

reflect overall metabolic state
normal 60-80%

potential complications of PA catheter

PA rupture (during insertion, balloon inflated too long), PA infarction (balloon inflated too long), catheter migration, infection, air embolism

what should you do in the event your patient with a PA catheter experiences an air embolism?

turn to left lateral trendelenburg position, notify HCP so they can remove catheter)

cardiac output (CO)

amount of blood ejected from LV every minute (SV x HR)
normal 4-7 L/min

ejection fraction

evaluates LV function
normal 60-70%

what is the formula to calculate ejection fraction?

amount of blood pumped out of LV/total amount of blood in LV before ejecting

stroke volume

amount of blood ejected from LV per beat
influenced by preload (volume), afterload (pressure), LV contractility

preload

amount of blood returning to RA (venous return)
measured via CVP

starling's law

increasing volume increases CO (but only to a certain extent....eventually CO will bottom out)

what factors can influence preload?

volume status: hypo/hypervolemia, venous obstruction

afterload

the resistance the heart must overcome to empty O2 blood into aorta
measured via SVR

what factors can influence afterload?

pressure status: hypo/hypertension, body temperature (hypermetabolic state increases), volume status/preload, sepsis (decreases), neurogenic shock (decreases)

contractility of LV

ejection fraction
measured via echo or infrared bedside measurement

what factors can influence LV contractility?

MI, acidosis, O2 status

management of CO- preload issues: volume overload

fluid overload
high CVP/preload
TX- diuretics, vasodilators

management of CO- preload issues: volume deficit

hypovolemia
low CVP/preload
TX- IVF/blood products, vasoconstrictors

management of CO- afterload issues: increased SVR

r/t HTN- vasodilators
r/t hypovolemia- IVF
r/t body T- normothermia (ibuprofen, abx)
r/t severe HF- IABP

management of CO- afterload issues: decreased SVR

r/t sepsis- use appropriate abx therapy
r/t neurogenic shock- vasoconstrictors

management of CO- contractility issues: increased EF

electrolyte replacement of Ca, Mg, K

contractility issues: decreased contractility causes

MI (permanent!), arrhythmias, beta blockade

commonly used vasoactive meds

dopamine, dobutrex, epi, levophed, neosynephrine, nitroprusside, inocor/primacor, nitroglycerin

first level priority problems

safety (ALWAYS FIRST), ABC, VS changes

second level priority problems

current/evolving disabilities i.e. neuro change, new onset stroke, acute pain, acute elimination issues, abnormal lab values

third level priority problems

health problems that are long term or do not fit into 1st/2nd categories i.e. health education, activity, discharge, rest, coping

PACE model

programs of all-inclusive care for the elderly
eligibility: 55+, live in service area of PACE organization, eligible for nursing home care, able to live safely in the community

NICHE model

nurses improving care for healthsystem elders
reduces falls, delirium, restraint use, pressure injuries

transitional care model

improve care of elderly adults with chronic conditions and navigation of the healthcare system

between what ribs is the heart located?

2nd and 6th

what is the normal blood flow pattern through the heart?

SVC IVC- RA- tricuspid valve- RV- pulmonic valve- PA- lung- PV- LA- mitral valve- LV- aortic valve- aorta- body

what is special about the pulmonary arteries?

only arteries carrying blood AWAY from the heart (deoxygenated)

chordae tendinae

link cusps of AV valves to the heart wall, controlled by papillary muscles

where does the left main coronary artery split?

at the left atrium, splits into left anterior descending (LAD) and left circumflex artery

left anterior descending artery (LAD)

"widow maker", diagonal branches
supplies anterior wall of LV, septum, papillary muscles, chordae tendinae

left circumflex artery

obtuse marginal branches
supplies lateral wall of LV, SA node, AV node

right main coronary artery

supplies RA, RV, inferior wall of LV

where to coronary arteries originate?

just above the cusp of the aortic valve (at point where oxygenated blood is leaving lungs)- freshest oxygenated blood goes to heart

when does coronary blood flow to the heart muscle occur?

diastole

what is the minimum MAP flow required?

60 mmHg

vascular system key functions

provide *conduits for BF to/from heart*, carry *cellular waste products* to excretory organs, *lymphatic flow to train tissue fluid* back into general circulation

arterial system key functions

deliver *blood to tissue* (via osmosis, filtration, diffusion), nutrients/O2 *exchanged for waste* and transported to excretory organs (kidney, lung, liver), contributes to *temperature regulation* (shunt blood to/from skin)

arterial system

high pressure system
larger arteries (femoral, aorta) are straight to allow high flow volume
smaller arteries (mesenteric, internal iliac) branch smaller to merge with venous capillaries

how is BP regulated?

autonomic nervous system (balance of SNS (fight/flight) and PNS (relax), baroreceptors, chemoreceptors, stretch receptors, renal system, endocrine system

BP regulation: baroreceptors

aorta/internal carotid arteries *stimulated with elevated BP* to inhibit vasomotor center in pons and medulla to *drop BP*

BP regulation: chemoreceptors

sensitive to *hypoxia*, increases vasoconstriction to increase perfusion and *increase BP*

BP regulation: stretch receptors

RA/VC sensitive to *volume changes*, causes increased HR and vasoconstriction causing *increased BP*

BP regulation: renin angiotensin aldosterone system (RAAS)

triggered by *renal flow/pressure decrease*, angiotensin causes vasoconstriction and aldosterone causes sodium retention
sodium retention causes water retention and *increased BP*

BP regulation: endocrine system

release of SNS hormones (catecholamines, kinins, histamine) causing ADH to release and promote volume retention and *increase BP*

venous system

low pressure system adjacent to arterial system and parallel to SUBQ tissue
flexible vessels to allow BF to travel from superficial to deep veins to return to heart...considered blood volume reservoirs, valves control BF direction (propelled by skeletal muscle)

what are the effects of gravity on hydrostatic pressure?

increases with standing, decreases when lying down

common age related changes to the heart

thickened and stiffened valves, SA node decreases in mass/function, decrease in myocardial contractility, coronary arteries become more tortuous/calcified

common age related changes to the blood vessels

thicken/stiffen, less responsive to intrinsic changes, slows exchange of nutrients from blood and tissues

common age related changes to blood

BV decreases, decrease in bone marrow production of RBC (decreased H/H), increased coagulability (increased platelet aggregation and decreased fibrinolytic action)

assessment of chest pain

PQRST- provocation (cause), quality of pain (burning, heaviness, pressure, indigestion), region/radiation, severity (0-10), timing/treatment

what is an early heart failure sign?

DOE (dyspnea on exertion)

paroxysmal nocturnal dyspnea

abrupt onset of SOB after lying flat for several hours (redistribution of blood flow)

orthostatic hypotension

drop 20 mmHg SBP or 10 mmHg DBP with 10-20% increase in HR

pulsus alternans

alternating strong and weak pulses

heart murmurs

turbulent BF across the valves, have to refer back to "normal" function to recognize abnormalities, graded 1-4 scale

S1 heart sound

long deep sound, closure of AV valves heart best at apex or LLSB (left lower sternal border) and during systole

S2 heart sound

short high pitch sound, closure of PV/AV valves, best heart at base and during diastole

S3 heart sound

ABNORMAL- low pitch sound after S2, fairly normal in those

S4 heart sound

ABNORMAL- low frequency sound after S1, shows atrial gallop, can mean HTN/MI/aortic or pulmonic stenosis

troponin I

released with any myocardial damage- gold standard of HF lab tests!- *any troponin is abnormal and should be treated as a cardiac event*
results available within 15 min

creatine kinase (CK-mb)

peak level within 24 hrs, rise begins within 3 hrs
CAN BE A FALSE POSITIVE- CK is found also in skeletal muscle and brain normally

myoglobin

earliest lab marker available, released by skeletal muscle also, not clinically useful because many things can raise it (such as heavy exercise)

serum lipids

risk for CAD is greater with hyperlipidemia (LDL and triglycerides are positively correlated with CAD- do not want these high)

normal total cholesterol

normal HDL (good cholesterol)

\>45 (men), \>55 (women)

normal LDL (bad cholesterol)

normal triglycerides (increase risk of CAD)

additional lab tests needing to be done in suspected cardiac event

INR, PTT, platelet count (coumadin, heparin, lovenox require)
CBC/electrolytes (for decreased H/H, potassium. magnesium)

what cardiac-related event can a chest xray reveal?

pulmonary edema (possibly related to HF)

*heart catheterization*

most definitive diagnostic cardiac assessment
invasive procedure (requires consent)
shows specific BP within the heart, coronary arteries, shunts, contractility, etc

echocardiogram

*transesophageal*- moderate sedation, NPO- requires consent OR transthoracic

what are the 3 main causes of heart failure?

systemic HTN, acute MI, valvular dysfunction

what are the main causes of LHF?

HTN, CAD, valvular dysfunction

LHF- systolic

loss of ability to contract forcefully: decreased EF, fluid in pulmonary system, increased risk of death