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Hemodynamic_Monitoring_I_ABP_CVP_Ao.ppt
- 1. 1 Hemodynamic Monitoring Part I (ABP,CVP, Ao) MICU Competencies 2006-2007
- 2. 2 What is HemodynamicMonitoring? • Non-invasive = clinical assessment & NBP • Direct measurement of arterial pressure • Invasive hemodynamic monitoring
- 3. 3 Noninvasive Hemodynamic Monitoring •Noninvasive BP • Heart Rate, pulses • Mental Status • Mottling (absent) • Skin Temperature • Capillary Refill • Urine Output
- 4. 4 Proper Fit ofa 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
- 5. 5 Why A ProperlyFitting Cuff? • Too small causes false-high reading • Too LARGE causes false-low reading
- 6. 6 Indications for Arterial BloodPressure • Frequent titration of vasoactive drips • Unstable blood pressures • Frequent ABGs or labs • Unable to obtain Non-invasive BP
- 7. 7 Supplies to Gather •Arterial Catheter • Pressure Tubing • Pressure Cable • Pressure Bag • Flush – 500cc NS
- 8. 8 Supplies to Gather •Sterile Gown (2) • Sterile Towels (3) • Sterile Gloves • Suture (silk 2.0) • Chlorhexidine Swabs • Mask
- 9. 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
- 10. 10 Potential Complications Associated WithArterial Lines • Hemorrhage • Air Emboli • Infection • Altered Skin Integrity • Impaired Circulation
- 11. 11 Documentation • Insertion procedurenote • ABP readings as ordered • Neurovascular checks every two hours (in musculoskeletal assessment of HED) • Pressure line flush amounts (3ml/hr) • Tubing and dressing changes
- 12. 12 Central Venous PressureAssesses . . . • Intravascular volume status • Right ventricular function • Patient response to drugs &/or fluids
- 13. 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
- 14. 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
- 15. 15 Phlebostatic Axis • 4thintercostal space, mid-axillary line • Level of the atria (Edwards Lifesciences, n.d.)
- 16. 16 More on Levelingand Zeroing • HOB 0 – 60 degrees • No lateral positioning • Phlebostatic axis with any position (dotted line) (Edwards Lifesciences, n.d.)
- 17. 17 Dynamic Flush Dynamic flushensures 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. 18 System Maintenance • Changetubing and fluid bag q 96hrs • No pressors through CVP port • Antibiotics, NS boluses, blood, & IV pushes are allowed through the CVP line
- 19. 19 Troubleshooting • Improper set-upand 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
- 20. 20 Troubleshooting Damped Waveforms Pressure baginflated to 300 mmHg Reposition extremity or patient Verify appropriate scale Flush or aspirate line Check or replace module or cable
- 21. 21 Troubleshooting Inability to obtain/zerowaveform Connections between cable & monitor Position of stopcocks Retry zeroing after above adjustments
- 22. 22 Continuous Airway Pressure(Ao) • Also known as Paw, Ao • Purpose: – Improves accuracy of hemodynamic waveform measurements – Identification of end-expiration • Positive waveform deflections = positive pressure ventilation • Negative deflections = spontaneous inspiratory effort
- 23. 23 Supplies to Gather •Pressure Cable • Pressure Tubing • Connector (Edwards Lifesciences, n.d.)
- 24. 24 Setting up theAo • 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)
- 25. 25 Troubleshooting Ao • Donot 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
- 26. 26 1) Record Aoand 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. Pressure Measurement 15 10 5 0 -5 CVP=13
- 27.
- 28. 28 CPAP with PressureSupport Ao CVP 200 ms { 200 ms {
- 29. 29 CPAP without PressureSupport Ao CVP 200 ms { 200 ms {
- 30. 30 40 30 20 10 0 -10 Incorrect method! This pointwas 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.
- 31. 31 40 30 20 10 0 -10 Same patient 20minutes later 40 30 20 10 0 -10
- 32.
- 33. 33 Summary •Record Ao withCVP •Read mean CVP at end-expiration as described. No need read vascular pressure at any particular time in the cardiac cycle
- 34. 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)
- 35. 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