Advanced Hemodynamics Flashcards
(172 cards)
1
Q
What three assessment criteria tell us about preload?
A
crackles if cardiogenic
POCUS
x-ray
2
Q
What three measured pressure numbers/values tell us about preload?
A
CVP
PCWP (PAOP)
PADP
3
Q
What three assessment criteria tell us about afterload?
A
PP
Cap refill
DBP
4
Q
What three measured numbers/values tell us about afterload?
A
SVR
PVR
PASP
5
Q
What three assessment values tell us about contractility?
A
EF
Medical history
Frank starling law
6
Q
What measured number/value tells us about contractility
A
SVO2
7
Q
Which measured values give us information about the RIGHT side of the heart, and which CO determinant do they each tell us about?
A
CVP (preload)
PVR (afterload)
SVO2 (contractility)
8
Q
Which measured values give us information about the LEFT side of the heart, and which CO determinant do they each tell us about?
A
PCWP (preload)
PADP if no lung pathology (preload)
SVR (afterload)
SVO2 (contractility)
9
Q
What are the two ways we can obtain a CVP and how do they differ?
A
from CVC (less accurate)
from Proximal port of a PAC (an accurate/true CVP)
10
Q
What does TTE assess in the critical care setting? (from Urden)
A
- central venous pressure
- circulating volume status
- unexplained hypotension
- suspected cardiac tamponade
- pulmonary embolism
- cardiac arrest situations (eg: PEA)
- also used to assess the effectiveness of interventions such as fluid therapy,
vasoactive drug administration and more
POCUS is generally the go-to beside TTE choice
11
Q
What does echo give us? (from slides)
A
some numbers that a PA would give
eg PAPs, RA
12
Q
What is TEE used for in the critical care setting? (from Urden)
A
- similar to TEE but:
- close to heart, therefore high quality pictures of heart parts
+ suspected aortic dissection
+ prosthetic heart valves (especially in the mitral
position)
+ source of cardiac emboli, valvular vegetations, and possible intra-cardiac shunts
Some forms of TEE (e.g. CardioQ-ODM) can be left in situ and offer continuous information of
cardiac function and fluid responsiveness (used
occasionally in critical care units)
13
Q
What is the Fick method used to do?
A
Calculate CO using arterial and venous blood oxygenation data
14
Q
Which diagnostic procedures are typically undertaken for patients experiencing symptomatic heart disease, who are being considered for interventional cardiology procedures or cardiac surgery?
A
Cardiac catheterization and coronary arteriography
15
Q
Information related to LV function can be gained from:
A
cardiac catheterization
transthoracic echo
transesophageal echo
16
Q
Echocardiography provides information about:
A
ventricular function and wall motion, volume status and chamber size
17
Q
Cardiac catheterization and arteriography provides information related to:
A
- patency of coronary arteries
- ventricular wall motion
- ejection fraction, valve function
- intracardiac pressures
18
Q
the insertion of a balloon-tipped, flow-
directed catheter into a patient’s pulmonary artery
A
PA pressure monitoring
19
Q
when the catheter is connected to a monitoring system it facilitates:
A
the measurement and calculation of various hemodynamic parameters
20
Q
Swan-Ganz catheter is another name for a
A
PA Catheter (PAC) (PA line)
21
Q
To find the phlebostatic axis:
A
A theoretical line is drawn from the fourth sternal intercostal space, where it joins the sternum, to a theoretical line on the side of the chest that is one half of the depth of the lateral chest wall.
This theoretical line approximates the level of the atria.
It is used as the reference mark for central venous pressure (CVP) and pulmonary artery (PA) catheter transducers.
22
Q
Levelling aligns the transducer with the level of the:
A
left atrium
23
Q
The purpose of levelling is to:
A
line up the air–fluid interface with the left atrium to correct for changes in hydrostatic pressure in blood vessels above and below the level of the heart.
24
Q
What does PAOP stand for, and what is another name for it?
A
pulmonary artery occlusion pressure
pulmonary artery wedge pressure
pulmonary capillary wedge pressure
wedge
25
To measure PAP, CVP or wedge, the patient's HOB should be:
0-60 degrees if supine and pt is normovolemic, but low HOB if hemodynamically quite unstable (most patients do not need HOB lowered to 0 if midaxillary line is used)
26
PA catheters are less common due to their risks, and are seen sometimes in 3 situations:
- open-heart surgery
- management of acute heart failure
- management of acute pulmonary hypertension
27
The thermodilution PA catheter is reserved for what kind of patient:
the most hemodynamically unstable patients for the diagnosis and evaluation of cardiogenic shock, pulmonary hypertension, and management during and after heart surgery
28
What data/information does the PA catheter provide?
- PA pressures (systolic, diastolic, mean)
- PAOP (wedge pressure)
- CO
- SVO2
29
What is the difference between SVO2 and ScVO2?
SVO2 (mixed venous) is a slightly lower number than ScVO2 (central venous) because it is a true mixed venous, including the blood returning from the entire body (SVC, IVC AND the coronary arteries). The ScVO2 is blood from the upper body (SVC only) and does not include the coronary arteries' blood
30
Normal adult SV is:
60-70mL/beat
31
Clinical factors that contribute to SV are:
preload, afterload, contractility (can be monitored using a PA catheter)
32
CO is usually recorded from the:
ECG leads
33
"Filling pressures" is another term for
preload
34
Breaking preload down into it's "pressure parts" further, what comprise the right and left sided heart measurements of preload?
preload in the right side of heart is comprised of CVP, preload in the left side of heart is comprised of PADP and PCWP (aka PAOP)
35
in most clinical situations, PCWP (aka PAOP) represents:
LVEDP
During diastole, when the mitral valve is open, there are no other valves or other obstructions between the tip of the catheter and the left ventricle (LV). The pressure exerted by the volume in the LV is reflected through the left atrium (LA), through the pulmonary veins, and to the pulmonary capillaries.
36
Which law states that the force of ventricular ejection is directly related to the following two elements:
1. Volume in the ventricle at end-diastole (preload)
2. Amount of myocardial stretch placed on the ventricle as a result
Frank Starling's Law
37
In what common critical care diagnosis do we see overstretch of the left ventricle leading to reduced/suboptimal CO, and measured as increased wedge pressure (PAOP)?
acute heart failure with pulmonary edema
38
The effect of preload on CO creates what kind of shaped graph, over time, as a patient starts hypovolemic, is fluid resuscitated, then given a second bolus to the point of fluid overload?
A parabola
39
Effect of Preload and Venodilation on CO:
1, After an acute anterior wall myocardial infarction that has created significant left ventricular dysfunction, this patient has left ventricle pump failure with low CO and elevated filling pressures identified by an elevated pulmonary artery occlusion pressure (PAOP). One of the clinical problems faced by this patient is what? And how do we address it?
too much preload.
After administration of diuretics to reduce volume and nitroglycerin to dilate the venous system, preload is reduced, and CO rises.
40
A normal EF in a healthy heart is:
70%
41
In clinical practice, most cardiologists accept what EF as normal?
greater than 50%
42
The volume ejected from the left ventricle with each beat is known as the:
SV
43
SV can be calculated at the bedside with what equation:
SV = CO / HR
44
Interventions to reverse high LV preload and low CO in a patient in heart failure include:
decreasing LV preload through
(1) restriction of IV and oral fluids
(2) venodilation
(3) diuresis
45
It is physiologically impossible for the PAOP to be higher, or lower, than what other pressure value?
Why?
It is physiologically impossible for the PAOP (PCWP) to be higher than the PAD, because PAD measures additional pressures that the wedge does not
Normally, the PADP should be 1-3mmHg higher than the wedge. If the PADP is 4mmHg+ higher than the wedge, consider it an indicator of lung pathology
46
If PAOP (PCWP) is showing as higher than the PAD, what does it mean and what should you do?
It means there is a problem with the monitoring equipment
Recalibrate and troubleshoot the monitoring equipment if this occurs
47
If the patient has healthy lungs, what two pressure values can be used interchangeably/considered to mean?
PAOP (PCWP) and PADP
They are used interchangeably to denote LVEDP (reflects blood in the left ventricle at end diastole)
48
What is the most accurate way to measure LVEDP?
PAOP (PCWP)
49
In pulmonary hypertension, which pressures are elevated?
PASP and PADP are higher than LV pressures, therefore the PADP does not accurately reflect function of the left side of the heart, aka a large gradient exists between PAOP (PCWP) and PADP.
50
What is PAS (PASP)?
the systolic pressure in the pulmonary vasculature
51
In a patient with healthy lung vasculature, PAD pressure reflects what?
LVEDP
52
In the presence of acute respiratory distress syndrome or pulmonary hypertension, PAD pressure is not an accurate reflection of what?
PAOP (PCWP)
53
PAPmean is used in the calculation of what two values?
PVR and PVRI
54
High PAPmean (high mean pressures) can reflect what?
Low PAPmean (mean pressures) reflect what?
High PAPmean = cardiac or pulmonary disease
Low PAPmean = hypovolemia
55
When is PAOP (PCWP) higher than normal?
When is PAOP (PCWP) lower than normal?
PAOP is high in mitral valve regurgitation and many cardiac disease states in which left ventricular function is compromised
PAOP is low in hypovolemia
56
What is defined as the pressure the ventricle generates to overcome the resistance to ejection created by the arteries and arterioles?
afterload
57
What instrument gives us information from which we can derive afterload?
PA catheter
58
What is the technical name for afterload?
SVR (systemic vascular resistance)
aka resistance to ejection from the left side of the heart
tension in the ventricular wall goes up when afterload goes up; goes down when afterload goes down
59
Normal range of SVR
800-1200 dynes/sec/cm5
60
The lower the SVR, the higher the
CO
aka arteries are more dilated
61
Two drugs to reduce SVR
sodium nitroprusside
&
high dose nitroglycerin
62
if SVR is extremely low (as in sepsis) what happens to CO and MAP? What do we give to treat it?
CO will be elevated at first and then drop, and the MAP will be low
volume (fluid resuscitation) and vasopressors (Levophed) are infused to increase MAP and CO
63
In a heart with decreased contractility after an acute MI, an SVR measurement above the normal range does what to CO?
lowers CO
64
For a person with a normal heart without cardiac dysfunction, an elevated SVR may have what kind of effect on CO?
In a normal healthy heart, elevated SVR typically has minimal effect on CO
65
The importance of SVR on CO is related to what?
The functional quality of the myocardium
Both global myocardium dysfunction as in cardiomyopathy, and regional damage as in an MI, can considerably magnify the impact of small changes to SVR on CO.
66
Resistance to ejection from the right side of the heart is
PVR (Pulmonary Vascular Resistance)
67
What is the normal range of PVR?
100-250 dynes/sec/cm5
(normally 1/6th of SVR)
68
What PA pressure defines pulmonary HTN?
a PA pressure of greater than 25 mmHg
(the acute rise in PVR can cause the right ventricle to fail, although LV pressures remain normal)
69
pulmonary HTN can occur as a sequelae to what syndrome?
severe ARDS
(we no longer monitor ARDS with a PA catheter because it was too often associated with mortality)
70
preload volume as measured by PAOP, SVR, myocardial oxygenation, electrolyte balance, positive and negative inotropic medications, and amount of functional myocardium available to contribute to contraction, are all factors contributing to what?
contractility
they can all have a positive inotropic effect (increasing contractility) or a negative inotropic effect (reducing contractility)
71
What contractility factors can be measured by a PA catheter?
preload filling pressures, SVR, and CO
72
Name three drugs that increase contractility
positive inotropes:
dopamine
dobutamine
milrinone
73
How do you know positive inotropes are working (increasing LV contractility)?
changes in wedge pressure and increased CO
74
How many lumens does a PAC (pulmonary artery catheter) have?
four
(can have five or seven)
75
Whom invented the PAC?
Swan and Ganz
76
What does a PAC measure?
RAP
PAP (PAS and PAD)
PAOP (PCWP)
CO
SVO2
(can even pace transvenously if pacing electrodes are included)
77
name the four basic ports of the PAC
Distal lumen (at end of catheter, where balloon is)
Balloon inflation valve
Thermister
Proximal port (prox injectate)
78
How long is the PAC?
110cm
79
Common size of PAC
7.5-8.0 Fr
80
PAC proximal lumen is used for:
Sits in the right atrium (RA)
IV injection
CVP measurement
venous blood samples
injection of fluid for CO determinations
aka "right atrial port"
81
The distal PA catheter lumen is located at the
tip of the catheter
sits in the pulmonary artery
records pressures in the PA
used to withdraw mixed venous blood samples (SVO2)
82
The balloon lumen of the PAC can be inflated to what amount?
0.8 to 1.5mL of air
(especially important to remember the max # because exceeding it can be lethal for patient - with the minimum # - less than that and it could be in the wrong spot)
83
When is the PAC balloon inflated?
during insertion of the PAC, once the catheter is in the right atrium (RA), to guide it via blood flow towards the PA without traumatizing the myocardium, and for less than 15 seconds when it is in the PA to obtain PAOP/PCWP/wedge pressure
84
What is the thermister for in the PAC and where is it's opening located on the catheter?
measures changes in blood temperature
measures thermodilution CO
4cm from the distal tip of the PAC
85
What is required for inserting a PAC?
similar to inserting a CVC
aseptic technique
BUT also involves:
- using an introducer aka Cordis (cordis is sutured in place)
- line must be functionally checked beyond just patency, prior to insertion (inflating/deflating balloon, shaking distal port once connected to pressure monitoring to ensure waveform appears on monitor)
- nurse monitors during: waveforms, complications
86
Prior to PAC insertion, 3 nurse jobs:
1. gather supplies (pressure tubing and cables, saline bags)
2. prepare the patient (explain process, treat anxiety, local and general anesthesia?)
3. attach pressure cables to tubing and tubing to proper lumens
*make sure everything works*
*ASK FOR HELP FROM CNE/EXPERIENCED NURSE - DO NOT ATTEMPT ALONE*
87
During PAC insertion, four nurse jobs:
1. inflate/deflate balloon as requested by doctor
2. capture (print) waveforms as PA line migrates to PA (RA > RV > PA > PCWP)
3. monitor for complications and ECG changes
4. ongoing patient support
88
Post insertion, four nurse jobs
1. measure INTERNAL length
2. CXR for confirmation/rule out complications
3. get data (ScVO2, CO)
4. monitor for complications
89
Path of PA line
SVC/IVC to RA through Tricuspid valve to RV through Pulmonary valve to PA (often ends up in right PA but does not matter which one)
90
PAC Insertion steps
- PA inserted through cordis
- balloon inflated in RA until end of catheter's journey to PA, where the balloon goes down asap
- print waveform from RA, RV, PA, PCWP
91
compare your PAC measurement with:
the original confirmed length at the date/time of insertion
92
Name 7 complications of the PAC
dysrhythmias (PVCs or worse - though these can tell you you're in the right place during insertion)
Pneumothorax
Balloon rupture
Pulmonary infarction
PA rupture
knotting
Infection if insitu >72-96hrs
93
Normal RAP (not intubated or without NIVPP)
normal right atrium pressure is:
2-6mmHg
same as CVP but CVP inferring, RAP is direct measure
94
CO determinant of RAP
preload
95
Is RAP a measure of right of left side of heart?
right side of heart
96
Normal RAP if intubated or NIVPP
8-12mmHg
97
Normal RVP
normal right ventricular pressure is:
20-30/0-6 mmHg
This value is not monitored as it does not give much useful data
98
normal PASP
normal pulmonary artery systolic pressure is:
20-30 mmHg
99
Normal PADP
normal pulmonary artery diastolic pressure is:
8-15 mmHg
100
Normal PCWP
normal pulmonary capillary wedge pressure is:
8-12 mmHg
101
CO determinant of PASP
afterload
102
CO determinant of PADP
preload
103
CO determinant of PCWP
preload
104
PASP is measurement of which side of the heart?
Right
105
PADP is measurement of which side of the heart?
Left
if lungs are normal, it gives us LVEDP.
if lungs are abnormal or the pt is in HF, PAD is falsely elevated
106
PCWP is a measurement of which side of the heart?
Left
107
Normal CO range?
4-8L/min
108
Normal CI range?
2.5-4.0L/min/m2
109
CO and CI are determined by:
HR and SV. AND when all other factors are considered, it can give indirect CONTRACTILITY information
110
Normal SVR range?
800-1400 dynes/sec/cm5
111
What is SVR?
Systemic vascular resistance is the measurement of left sided afterload - the resistance to ejection from the left side of the heart
112
What happens to afterload if the SVR is high?
left-sided afterload is increased
high SVR = increased left-sided afterload
113
What happens to afterload if SVR is low?
left sided afterload is decreased/low
low SVR = decreased left-sided afterload
114
Normal PVR range?
100-250 dynes/sec/cm5
(approx 1/6th of SVR)
115
What is PVR?
resistance to ejection from the right side of the heart
aka right afterload (pulmonary)
116
What does high PVR mean?
increased right heart afterload
increased stress on the right heart
?right heart failure
seen with lung pathology, eg:
COPD, ARDS, pulmonary HTN
117
Why do we not use low PVR as much?
we do not use data from low PVR as much because it does not give a lot of clinical information/does not mean much
118
Right sided preload measured via:
RAP
CVP
119
Treat HIGH right sided preload with:
Diuretics
Nitro
120
MEASURE left sided preload with:
PADP
PCWP
(interchangeable if PADP within 1-4mmHg higher than PCWP and NO lung disease - PCWP cannot be higher than PADP)
also indicator of LVEDP
121
TREAT with what, if Left sided preload is LOW?
IVF: colloids and crystalloids
122
MEASURE right sided heart afterload with:
PVR
123
If Right sided afterload is HIGH, treat with:
vasodilators
nitric oxide
Nipride
Milrinone
Dobutamine
124
Measure left sided afterload with:
SVR
125
treat LOW left sided SVR with:
Levophed (norepinephrine)
Epinephrine
Pheylephrine
126
Normal SV (stroke volume)
60-70mL
127
CO determinants of SV?
stroke volume is determined by preload, afterload and contractility
128
Normal range of SVO2 is?
60-80%
129
SVO2 tells us about:
Oxygen Supply and Demand balance
130
Is ScVO2 higher or lower than SVO2?
slightly higher than SVO2 because the SVC is only measuring blood from the upper body and does not include the coronary blood supply return, whereas SVO2 includes the whole body's blood supply including the coronary arteries' blood return
131
If SVO2 is below 60%, this means that:
supply is DOWN, or demand is UP, because not as much oxygenated blood returned to the heart
132
If SVO2 is above 80%, this means that:
supply is UP, or demand is DOWN
133
list four causes of low SVO2 (<60%)
- low Hgb (bleeding)
- low SaO2 (hypoxemia from lung disease)
- reduced contractility (LV damage from MI)
- increased oxygen consumption (shivering, seizures)
134
list four causes of high SVO2 (>80%)
+ increase oxygen supply (increased FiO2)
+ decreased oxygen demand (paralyzed, oversedated)
+ catheter mispositioned
+ sepsis (causing dead cells, demanding less oxygen)
135
What is O2ER?
oxygen extraction ratio
the inverse of SVO2
the amount of oxygen consumed by tissues, relative to supply
Normal range is 25-35%
136
O2ER formula
SaO2 - SVO2/SaO2 = %
137
Low O2ER means what?
<25%
O2 supply is up, O2 demand is down
138
High O2ER means what?
>35%
O2 supply is down, O2 demand is up
139
O2ER is used in conjunction with what three other things?
SVO2
CO determinants
SaO2
140
What is a quarter over a dime referring to, with PA pressures?
It is referring to the normal ratio of PASD and PADP, which is 25mmHg/10mmHg
141
Both PAD and PCWP estimate what?
LVEDP
142
PAD is directly influenced by _________ and is always 1-4mmHg higher than _________even when pulmonary vasculature is normal. If PAD is >4mmHg higher, it means:
vascular tone
PCWP
probable lung pathology
(PCWP cannot be higher than PADP)
143
How do we perform a wedge? (the long answer - 9 points)
1. Level/zero/position patient
2. Pt on back, HOB up to 45degrees
3. Inflate balloon 1-1.5cc (less means in wrong place, more can be lethal)
4. watch PA waveform on monitor throughout
5. slow consistent, easy gentle pressure
6. inflate balloon with MINIMUM amount of air needed to get wedge waveform
7. 2-3resps or MAX 15seconds, or risk hypoxemia
8. Read PCWP at EE (end expiration)
9. Balloon deflates passively (DO NOT DRAW BACK)
144
4 key points for obtaining a wedge (on exam)
Pt should be supine, HOB less than or equal to 45 degrees
Read PCWP at end expiration
measure PCWP and hold for no more than 10-15 seconds
Deflate balloon passively
145
When do I read the PCWP on the monitor?
At end-expiration
146
When reading wedge waveform, is my patient ventilated? How does this impact the waveform?
If spontaneously breathing, end expiration with be negative.
If ventilated or NIVPP, end expiration will be positive.
147
What is the old school way to manually measure CO with a PAC?
Thermodilution
148
How do you perform thermodilution?
injectate solution is either D5W or NS
Amount is usually 10cc
Inject through proximal port ("prox injectate")
Fast and steady (no longer than 4 seconds)
Minimum of three CO's (within 10%) and take their average
149
How do you interpret CO waveform in thermodilution, if CO is LOW?
If CO low, it takes longer for the blood temp to return to baseline, so there is a greater area under the curve, aka a WIDE, LONGER CURVE
150
How do you interpret CO waveform in thermodilution, if CO is HIGH?
If CO high, cooling fluid is carried faster thru heart and temp returns to baseline faster, so smaller area under cure, aka a SHARPER, SHORTER CURVE
151
How do you know you had improper injection technique (during thermodilution)?
The curve is not smooth-looking
152
What is an indexed value?
A measurement that considers a person's body surface area (via their height and weight) to produce a more sensitive, person-specific value
153
Calculate Cardiac Index (CI)
CI = CO/BSA
154
Normal CI range
2.5-4
155
Normal SVRI
1970 - 2390 dynes/sec/cm5/m2
156
Normal PRVI
255-285 dynes/sec/cm5/m2
157
When is it ok to treat contractility?
only AFTER addressing preload and afterload issues
158
What meds do you give if CO/CI are HIGH?
Beta Blocker
CCB
159
What meds do you give if CO/CI are LOW?
Dobutamine
Milrinone
(Epinephrine
Dopamine)
160
What are the three kinds of shock?
cardiogenic, distributive, hypovolemic
161
Say which of the following are HIGH and which are LOW, and if it is a CAUSE, COMPENSATION, or CONSEQUENCE, in CARDIOGENIC shock:
Preload, Afterload, Contractility, HR, CO
Preload - high - consequence
Afterload - high - compensation
Contractility - low - cause
HR- high - compensation
CO - low - consequence
162
Say which of the following are HIGH and which are LOW, and if it is a CAUSE, COMPENSATION, or CONSEQUENCE, in DISTRIBUTIVE shock:
Preload, Afterload, Contractility, HR, CO
Preload - low - consequence
Afterload - low - cause
Contractility - low - consequence
HR - high - compensation
CO - high then low - consequence
163
Say which of the following are HIGH and which are LOW, and if it is a CAUSE, COMPENSATION, or CONSEQUENCE, in HYPOVOLEMIC shock:
Preload, Afterload, Contractility, HR, CO
Preload - low - cause
Afterload - high - compensation
Contractility - low - consequence
HR - high - compensation
CO - low - consequence
164
Possible causes (and nursing actions) of a dampened waveform in a PA catheter/monitoring system
+ air in monitoring system (check for bubbles)
+ blood in tubing (flush system)
+ clot in system (aspirate, DO NOT FLUSH if can't aspirate, Notify MD, MD may irrigate with heparinized saline)
+ catheter kinked, overwedged, or malpositioned (eg tip against arterial wall) (HAVE PT COUGH, gently flush, check catheter position with X-Ray)
+ <300mmHg of pressure for flush solution (increase pressure so it flows forward against systolic pressure)
+ loose connections (tighten)
+ incorrect stopcock position (check and reposition, flush line)
+ crack in disposable transducer (replace monitoring system)
165
Possible causes (and nursing actions) of PCWP pressuring tracing unattainable with a PAC waveform
+ balloon has ruptured (if no resistance to inflation, stop immediately. NOTIFY MD STAT, CLOSE GATE AT BALLOON PORT, TAPE IT AND LABEL BALLOON RUPTURED - as long as balloon gate is closed, can be used short term to monitor PAPs and measure CO)
+catheter no longer in proper position (Notify physician to reposition catheter)
166
Possible cause (and nursing actions) of spontaneous change in waveform from PA waveform to PCWP waveform
+ Catheter wedged (deep breath and cough, change pt position -roll side to side, NOTIFY MD STAT, catheter needs to be repositioned - if left for long period in wedged position, can cause damage)
167
Possible causes (and nursing actions) of Right ventricular waveform appearing:
+ Catheter slipped back into RV (NOTIFY MD STAT for repositioning, observe pt for ventricular dysrhythmias)
168
Possible causes (and nursing actions) of when PA balloon is inflated, wedge pressure drifts upward or downward on monitor screen. Straight line may be seen instead of a waveform.
+ Catheter balloon may be over inflated whereby the balloon occludes the tip of the catheter/changes waveform and sense pressure (watch screen when inflating. as soon as waveform changes from PA to wedge, stop inflating)
+ Catheter may not be advanced far enough (NOTIFY MD to reposition catheter)
169
Possible causes (and nursing actions) of no waveform on the monitor
+ Transducer connected incorrectly (check and correct)
+ Incorrect scale setting on the monitor (ensure scale is correct)
+ Transducer not open to patient (check all stopcocks)
+ Monitor malfunction (Replace monitor or if applicable "PA monitoring attachment")
170
Possible causes (and nursing actions) of false low PA pressure values
+ tip of catheter against arterial wall (flush with mechanism or get MD to reposition catheter)
+ Transducer height is higher than phlebostatic axis (level transducer)
+ Disconnected or loose tubing (tighten all stopcocks and connections)
171
Possible causes (and nursing actions) false high PA pressure values
+ Transducer level is lower than phlebostatic axis (level transducer)
+ Tip of catheter against arterial wall (flush catheter or have MD reposition catheter)
+ Clotted catheter (attempt to aspirate clot - DO NOT FLUSH)
+ Catheter kinked under dressing (Check under dressing for kinked catheter)
172
