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2. What is Hemodynamic Monitoring?
• Non-invasive = clinical assessment & NBP
• Direct measurement of arterial pressure
• Invasive hemodynamic monitoring
2
3. Noninvasive Hemodynamic Monitoring
• Noninvasive BP
• Heart Rate, pulses
• Mental Status
• Mottling (absent)
• Skin Temperature
• Capillary Refill
• Urine Output
3
4. Proper Fit of a Blood Pressure Cuff
• Width of bladder = 2/3 of upper arm
• Length of bladder encircles 80% arm
• Lower edge of cuff approximately 2.5 cm above the antecubital
space
4
5. Why A Properly Fitting Cuff?
• Too small causes false-high reading
• Too LARGE causes false-low reading
5
6. Indications for
Arterial Blood Pressure
• Frequent titration of vasoactive drips
• Unstable blood pressures
• Frequent ABGs or labs
• Unable to obtain Non-invasive BP
6
9. Leveling and Zeroing
• Leveling
• Before/after insertion
• If patient, bed or transducer move
• Zeroing
• Performed before insertion & readings
• Level and zero at the insertion site
9
11. Documentation
• Insertion procedure note
• ABP readings as ordered
• Neurovascular checks every two hours (in musculoskeletal assessment of
HED)
• Pressure line flush amounts (3ml/hr)
• Tubing and dressing changes
11
12. Central Venous Pressure Assesses…
• Intravascular volume status
• Right ventricular function
• Patient response to drugs &/or fluids
12
13. Central Venous Pressure (CVP)
• Central line or pulmonary artery catheter
• Normal values = 2 – 8 mm Hg
• Low CVP = hypovolemia or ↓ venous return
• High CVP = over hydration, ↑ venous return, or right-sided heart
failure
13
14. Leveling and Zeroing
• Leveling
• Before/after insertion
• After patient, bed or transducer move
• Aligns transducer with catheter tip
• Zeroing
• Performed before insertion & readings
• Level and zero transducer at the phlebostatic axis
14
15. Phlebostatic Axis 15
• 4th intercostal space,
mid-axillary line
• Level of the atria
(Edwards Lifesciences, n.d.)
16. More on Leveling and Zeroing
• HOB 0–60 degrees
• No lateral positioning
• Phlebostatic axis with any
position (dotted line)
16
(Edwards Lifesciences, n.d.)
17. Dynamic Flush 17
• Dynamic flush ensures the
integrity of the pressure
tubing system. Notice how it
ascends, forms a square
pattern - and bounces below
the baseline before returning
to the original waveform.
• Check dynamic flush after
zeroing any pressure
tubing system.
18. System Maintenance
• Change tubing and fluid bag q 96hrs
• No pressors through CVP port
• Antibiotics, NS boluses, blood, & IV pushes are allowed through
the CVP line
18
19. Troubleshooting
• Improper set-up and equipment malfunction are the primary
causes for hemodynamic monitoring problems
• Retracing the set-up process or tubing (patient to monitor) may
identify the problem and solution quickly
• Use your staff resources: Help All, Charge Nurse, Educator,
Preceptors, MICU experts
19
20. Troubleshooting
Damped Waveforms
Pressure bag inflated to 300 mmHg
Reposition extremity or patient
Verify appropriate scale
Flush or aspirate line
Check or replace module or cable
20
24. Setting up the Ao
• Discard infusion spike end & cap port
• Connect pressure tubing to vent tubing (using connector opposite
heating cable)
• Connect cables
• Zero the tubing (leveling not necessary)
24
25. Troubleshooting Ao
• Do not prime tubing with fluids!
• Damping will occur with fluid or secretions
• To evacuate any fluids, disconnect pressure tubing from vent
tubing and push air through the pressure tubing with a 10 ml
syringe connected at one end until fluid-free
25
26. Pressure Measurement
1. Record Ao and CVP on the same strip
2. Find end-expiration by drawing a
vertical line with a straight edge 200
ms prior to the rise or dip in Ao (1
large box) associated with a breath.
3. Draw a horizontal line through the
visually assessed average vascular
pressure starting at end-expiration
going backward 200 ms (1 large box).
4. Read the pressure at the horizontal
line.
26
15
10
5
0
-5
CVP=13
30. 30
40
30
20
10
0
-10
Incorrect method!
This point was
identified as end-
expiration for a pt.
who did not have an
Ao set up.
Correct method!
30 sec after the above
tracing, Ao was added & true
end-expiration clearly
identified.
33. Summary
• Record Ao with CVP
• Read mean CVP at end-expiration as described. No need read
vascular pressure at any particular time in the cardiac cycle
33
34. Documentation of CVP
• Include on waveform strip
• Position of the HOB
• Vasopressors and rates
• Amount of PEEP
• Scale
• CVP measurement
• Signature of the nurse
(post in green chart behind graphics tab)
34
35. References & Resources
Burns, S. M. (2004). Continuous airway pressure monitoring. Critical Care Nurse, 24(6), 70-74.
Chulay, M., & Burns, S. M. (2006). AACN Essentials of critical care. McGraw-Hill: New York.
Edwards. (2006). Pulmonary Artery Catheter Educational Project. http://www.pacep.org
Edwards Lifesciences. (n.d.) Educational videos. www.edwards.com
MICU Routine Practice Guidelines. www.vanderbiltmicu.com
MICU Bedside Resource Books
MICU Education Kits (Red cart in conference room)
MICU Preceptors, Help All Nurses, & Charge Nurses
VUMC policies. http://vumcpolicies.mc.vanderbilt.edu
35