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N244 Advanced cardiac assessment and hemodynamic monitoring
Terms in this set (112)
In ICU, a full assessment, head to toe is done every?
Know the 5 P's?
In ICU, every patient must be weighed?
daily to closely monitor fluid balance.
What is hemodynamics referring too?
movement of blood. It refers to the constantly changing (dynamics) forces involved in the flow o blood as it circulates through the cardiovascular system to meet the constantly altering tissue oxygen needs.
When blood is viscous, thick, such as in DKA movement will be?
For hemodynamic pressure, blood pressure, we need three things:
What three things can bring up blood pressure?
You pt blood pressure is 140 over 90, what is their MAP?
*add systolic bp 140 plus two times dystolic 90 times 2=320 divide by 3=107
*systolic pressure + two dystolic pressures divided by three.
What does MAP describe?
average blood pressure during a single cardiac cycle.
What does a MAP need to be to indicate profussion throughout the body including the brain and kidney's?
How do we assess CVP without a central line?
Jugular vein distention
*place pt 45 degrees
*turn pt face to left
*a light is shone on the right internal jugular vein and casts a shadow
*a ruler is placed verticall at the sternal angle, and the level of IJ pulsation is observed and measure
Elevated CVP is present if the pulsations are higher than?
4.5 cm above the sternal angle
What other non-invasive things can tell us if patient blood pressure is low?
*pulse will rise
*neck veins flatten
*urine output <0.5/kg
*this helps determine fluid is in the vascular space.
What is central venous pressure?
*a direct measurement of blood pressure in the right atrium and vena cava. Central venous pressure reflects the amount of blood returning to the heart and the ability of the heart to pump the blood into the arterial system.
CVP catheters are placed and the distal tip is located right by the Superior vena cava. This is an indicator of?
*central blood volume that is influence by cardiac output, systemic venous return to the hear, total blood volume and other factors.
Sites for Central Venous catheter are?
PICC line (if correctly positioned)
What can we use a CVP catheter for?
*obtain blood samples
*obtain central venous pressures
What does a CVP basically tell us?
pt fluid status and profusion.
What are some complications that can occur from CVC lines?
*arterial puncture (IJ access)
Nursing considerations for the pt with a CVC?
*monitor for complications
*adherence of CLABSI(central line associated blood stream infections) protocol
*replace gauze every two days
*replace transparent dressing once a week
*replace tubing every 4 days and no longer than 7
*sterile procedure when placing were:mask, gloves, gown, sterile drape over pt.
What is the purpose of arterial lines?
to detect changes in pressure within the vascular system and convert those changes into digital signal which are displayed on a monitor as waveforms and numeric data.
*monitor response to medication titration and fluids.
Warning if a arterial line becomes disconnected what can happen?
pt can bleed to death.
Must have a pressurized source to
overcome arterial pressure/we use pressurized saline bag.
Observe the catheter site closely for?
* cap refill
Arterial line complications ?
Why do we use a pulmonary artery catheter?
Pulmonary artery catheters allow for direct assessment of cardiac function and volume status in acutely ill pts. The measurements can confirm the diagnosis and guide the management of HF. Right arterial pressure may be normal or elevated in left ventricular failure and is elevated in right ventricular failure. Pulmonary artery pressure (PAP) and pulmonary artery wedge pressure (PAWP) are elevated in left-sided heart failure because volumes and pressures are increased in the left ventricle.
Pre-Insertion of PAP?
*obtain informed consent
*gather supplies (sterile procedure)
*set up equipment
During insertion of Pulmonary artery catheter?
*Obtain initial reading of cardiac output
*catheter insertion measurement from doctor
*PCWP indirect measurement (left side of heart)
Post procedure of pulmonary catheter?
*chest x-ray (confirm placement, prior to use)
*doctors order on chart to use CVP
*daily 'needs' assessment, safety issues, documentation
PAWP is a ?
indirect measurement of Left ventricle pressure at the end of diastole. (LVEDP)
Why do we use a Pulmonary Artery Catheter?
*determines direct pressure and volume within right heart and pulmonary artery
*indirect measurement of left heart pressures
*determine cardiac output
*sample pulmonary artery mixed venous blood (SvO2)65-70 normal
*to provide various therapies
(IVF's, meds, cardiac pacing)
Contradictions for placing a PA catheter are?
*tricuspid/PA mechanica prosthesis
*right heart mass
*hx of angioplasty
Positioning with PA catheter is important and the measurements should be obtained 5-15 minutes after patient position change to allow patient to regain stability.
*supine w/hob 0-60 degrees
*lateral position with HOB flat and catheter at 20-30 or 90 degree
PAS , Pulmonary Systolic pressure reflects?
the highest pressure generated by the right ventricle during systole with a normal range of 20-30mmHg.
PAD , Pulmonary Artery Diastolic Pressure reflects?
the lowest pressure within the pulmonary artery usually 8-15mmHg.
PAWP is a indirect measurement of the Left side of the heart and the normal range is?
How to measure cardiac output using a PA line?
inject 10ml bolus of normal saline through proximal port (blue one); the right atrium
What is cardiac output?
the amount of blood that is pumped each min.
How much is normal cardiac output at rest?
4-8 L/min at rest
What is cardiac index?
relationship between cardiac output and body size (BSA)
How do we calculate cardiac index?
CO /BSA: N=2-4.0/L/min/m (squared)
How do we calculate cardiac output?
HR X SV
What is stroke volume ?
the amount of blood ejected with each heart beat.(60-70ml)
Heart rate is always the first to respond and rapidly compensates for changes in?
Heart rate is influenced also by?
What is normal stroke volume?
60-75 ml per heartbeat
Three things affect stroke volume. Name them?
If stroke volume drop what does the body do?
increase heart rate. This is known as compensatory tachycardia. However if the heart rate is >150, diastolic filling becomes so short that the tachycardia itself produces a drop and stroke volume and cardiac output can not longer be maintained.
**Higher volume equals higher stroke volume which?
increases the workload of the heart!!!
Stroke volume is affected by three factors?
What is preload?
the amount of stretch on the myocardial muscle fibers at the end of diastole just before contraction. (ventricle filling) How much gas you put in the tank per Professor Gomez.
Too much volume causes increased?
preload and increased stroke volume and causing the ventricles to work to hard and increased oxygen demand.
Too little volume to the heart causes
decreased preload and decreased stoke volume and decreased ventricular work and decrease myocardial oxygen demand.
What is Starling's law?
Increased preload =increased stoke volume=increased force of contraction.
What is afterload?
force of resistance that the Left ventricle must generate to open the aortic valve.
Vasoconstriction causes the vessels to?
constrict increasing the workload of the heart, and increase oxygen consumption by the myocardium.
Vasodilation cause the vessels to
dilate and this causes decrease workload on the heart and decrease oxygen consumption by the myocardium.
SVR normal range is?
800-1200dynes second/cm (5th)
Contractility is the force at which the heart muscles contract and is measured as stroke volume. It is influenced by preload and the greater the stretch of the myocardium the great the?
contraction. (Starling's Law)
What is a negative inotrope?
Decreased in contractility and decreased cardiac workload and oxygen demand.
What medications are negative inotropic med's?
*calcium channel blocker/diltiazem
****What medications are positive inotropics? (must know this) These increase contractibility!!
When stroke volume is <60ml/beat, it is decrease and this indicates?
Ventricular dysfunction!!!Know this
Ejection fraction is how much is removed from the left ventricle during each contraction. Normal is?
60-70% of the left ventricle fluid is ejected into circulation.
As ejection fraction decreases, heart failure increases. 30-35% means the heart is functions at?
half the normal ejection fraction.
10-15% means end stage heart failure/terminal
Echocardiograms can give us pt ?
stroke volume percentage remember 60-70% is normal.
Does an EKG give us information on:pumping action of the heart, cardiac output, blood pressure,cardiac muscle hypertrophy.
Atrial fib and atrial flutter are when the SA node is ?
Name the atrial dysthrythmias?
What is supraventricular tachycardia?
*pt is usually symptomatic showing signs of decreased cardiac output/ALOC/short of breath/faint/dizziness
First line of treatment for SVT is?
*have pt bear down like the are having a bowel movement this turns on the PNS and slows the heart.
*you can have the patient blow through the front of the syringe and try to blow off the plunger.
*Carotid massage by doctor only
What is the drug therapy for SVT?
*calcium channel blockers
If patient is unresponsive what do we do?
cardiovert this stops the heart for a second and then it should reboot like a computer back to normal rhythm.
What rythmns are the deadly rythmns indicating SA and AV are not firing and the purkinje fibers and bundle branches are in charge?
*3rd degree heart block
What rhythm is this?
What must we know first with V tach?
*pulse or no pulse
V tach with pulse how do we treat?
*if patient is stable
*amiodarone 150mg over ten minute push
*if patient is unsable/hypotensive/ALOC/pale
*synchronized shock 100-200 Jules
In v fib the ventricles are ?
fluttering not constricting and producing a pump.
How do we treat V fib?
Shock 120-200Jules unsychronized
Medications: epinephrine 1mg/amiodarone 1st dose 300/epinephrine1mg/Amiodarone 150mg
*amiodarone can only be given twice
*vasopressin 40 units can replace 1st or 2nd dose of epi only/otherwise it won't work.
other med's to consider:
lidocaine hydrochloride (xylocaine)
What rhythm is this?
What do we do if it is true asystole?
1mg epinephrine every 3-5 min
*begin pacing if possible
Sequence of events:
rhythm /pulse check
CPR and meds
CPR ad meds
Remember on patients with life threatening arrhythmias always start?
two large bore IV immediately.
What is PEA?
pulseless Electrical activity
*the pt is clinically dead despite some electrical activity in the heart.
*CPR and 1mg of epinephrine every 3-5 mins/same as asystole
What can cause PEA?
5 H's or 5T's
Hydrogen Ions (acidosis)
Medication therapy following a successful cardiac arrest can cause?
catecholamine adrenergic agonist effect
What is stable tachycardia vs unstable tachycardia?
Stable is HR less than 150
Stable blood pressure
no signs of shock
Patient comes in with stable tachycardia? Order of priority will be?
*Establish IV access
*Obtain 12 lead EKG
*MONA-morphine , oxygen, nitro, aspirin
*Adenosine for narrow complex tachycardia
How do we treat (unstable) supra ventricular tachycardia?
*sedate and cardiovert
Your patient is V tach with no pulse. What are we going to do?
In first degree heart block what will we see on the rhythm?
Pronged PRI>.20 sec
In 2nd degree, type one heart block what will we see?
PRI>.20 and progressively prolong until QRS drops off
In 2nd degree, type two heart block what will we see?
Prolonged PRI until QRS is dropped.
In third degree heart block what will the rhythm look like?
no atrial or ventricle communication/like one two separate rhythms, so synch.
When do we need a pacemaker?
**1. slow heart rates that produce unstable hemodynamics (low bp, low stroke volume, low cardiac output, syncope, SvO2
2. slow Heart rates (particularly escape rhythms) that do not respond to drug therapy.
3. Any condition as a temporary measure in preparation for a transvenous pacemaker
4. Sever myocardial depression form cardiac drugs
5. Complete heart block
What are basic principles of cardiac pacing?
*SENSING-dection of the intrinsic myocardial activity. Inhibits or stimulates an electrical pulse
*PACING - firing of the myocardium/pacing occurs when temporary pulse generator is activated and the requisite level of energy travels from the pulse generator through the temporary wires to the myocardium, which is know as pacemaker firing and is represented as a line or spike on the EKG strip.
*CAPTURE-stimulation of the myocardium, resulting in depolarization: this refers to the successful stimulation of the myocardium by the pacemaker resulting in depolarization
*Did the pacer do its job? assess the pt. Did the pt improve with capture?
*Evaluate blood pressure, SpO2, and pulse rate, Stroke volume. Capture alone does not guarantee that the CO has improved.
What is a demand rate on a pace maker?
Synchronous: paces when the pat's heart rate falls below a set rate. **This is the preferred mode of pacing because it paces only when the patients heart rate falls below a levels pre-set by clinician. This modes avoids problems such as pacer impulse landing or T-wave and possible causing a ventricular dysrhythmia.
What is a fixed rate on a pace maker?
Asynchronous: paces/fires at a rate set by the clinician regardless of patients HR or cardia activity.
What is triggered on a pacemaker mean?
Sensing allow the device to pick up intrinsic cardiac activity and adjust accordingly.
What is V-VVI on a pacemaker mean?
paces the ventricle, senses the ventricles and the pacemaker is inhibited when it senses a beat, so lets patient have their own rhythm
What is A-Atruium on pacemaker?
I (inhibited) Holds back when it it sense
What does dual mean on a pacemaker?
Atrial and ventricles both have a lead to send electrical impulse to make them fire.
Nursing care for this temporary pacemaker is?
*psychological preparation for the patient
*preparation of skin
*Check pads frequently and check for irritation or burns
*make sure their is a pulse with every QRS, otherwise a electrical dissociation may exist.
*advocate for prompt replacement w/permanent pacemaker
In a permanent dual pace maker where due the two leads go to?
How is the pacemaker implanted?
through the left subclavian vein
After pacemaker is implanted, make sure of the follow ?
*is your patient hemodynamically improving
*is it capuring
*is it sensing
*post insertion care
*MAGNET must always be available!!
A patient with a implanted pacemaker will have a weird EKG rhythm?
QRS will look wide and bizarre like PVC/ectopic beat. This is normal.
The muscles under the pacing pad will?
contract/this is normal
Effective capture of the cardiac muscle is seen by improving?
hemodynamics will improve.
If a pacemaker spikes in front of the QRS there is one of the following two problems?
*failure to capture /capture is the ability to cause a contraction after it giving an impulse/this usually occurs in demand or fixed mode . Increasing the output (mA) may obtain capture. Make sure that their is good skin contact. Check pads are in right position
*failure to sense-this occurs in demand mode only and is seen when the pacemaker discharges immediately after the pt's own QRS complex. This means the system is not sensing the patients heart beat. Select a different monitoring lead, or reposition the pads. Fixed pacing may be indicated.
Sensing is the pacemaker feather that detects pt heart beat. Make sure the pacemaker system?
*sensing light is flashing/if not change the battery
*assess pads and connections/troubleshoot
What are the only two rythmns we defib?
V tach with no pulse
What are the two rythms we cardiovert?
*VT with pulse
This set is often in folders with...
N244 Cardiac Medication
N244 Management of Cardiac disorders
N244 Cardiac Questions
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