When is hemodynamic monitoring used for a patient?
Monitoring of cardiac conditions, sepsis, respiratory distress, shock- when their condition can deteriorate quickly
Watch immediate cardiac response to meds, ventilation
What are the indications that a patient needs hemodynamic monitoring?
Deficiency of cardiac function (CAD), neuro-, cardio-, or anaphylactic shock
Decreased urine output due to GI bleed, surgery, burns, etc
Pulmonary Artery Lines are AKA..?
PA Line
PAC
Swan Ganz
Where/ how are pulmonary artery lines placed?
Through a major vein- jugular, subclavian, sometimes femoral--> through vena cava--> right atria --> right ventricle --> pulmonary artery (confirmed with X-ray before you move them)
List the components of a Swan- Ganz (5)
1) Proximal- measures CVP/ RAP and delivers bolus for cardiac output measurements
2) Distal- measures PAP
3) Balloon- pulmonary wedge pressure
4) Thermistor- core body temp
5) Infusion- fluids
Phlebostatic axis
level of transducer
Preload is
-the degree of muscle fiber stretching in the ventricles right before systole
-"filling pressures"
-amount of blood in the ventricle before it contracts
-related to EDV
PAWP
Pulmonary Artery Wedge Pressure- pulmonary circulation is so compliant it can measure pressures on left side of heart
-known as LV preload
-can also measure LVEDP, LAP, LV preload
CVP
Central Venous Pressure
normal is 0-8 mmHg
CVP also= RAP, RVEDP, RV preload
Afterload
any resistance the ventricles have to pump against to eject their volumes
"resistance flow"
influenced by blood volume, ventricle size, vascular distensibility
SVR
Systemic Vascular Resistance
measurement of left ventricular afterload
PVR
Pulmonary Vascular Resistance
reflection of right ventricular after load
Cardiac Output
heart rate x stroke volume
Cardiac Index
CO adjusted for body surface area
PAP
Pulmonary Artery Pressure
equal to RVP
complications of monitoring
1) infections
2) thrombosis/embolism
3) catheter wedges permanently- too far into pulmonary artery, can cause pulmonary infarction, notify MD
4) Ventricular irritation- catheter migrates back into right ventricle, can cause ventricular tachycardia, notify
Central Venous Catheter
hooked up to transducer
used to monitor right heart function
CVP 0-8
Arterial Lines (A-Lines)
in brachial, radial, or femoral artery
SBP, DBP, and MAP monitered
MAP- perfusion pressure of organs
can't really mobilize if in femoral
ABG measures
hooked up to transducer- must be kept level for accurate readings
pt can lose a lot of blood if dislodged
PT implications of PA line
pt usually on bedrest
be careful to not disrupt lines
avoid movement of bed
Sodium (value and implication)
135- 145 mEq/L
lethargy, confusion
monitor water intake
Potassium
3.5- 5.5 mEq/L
weakness, potential for dysrhythmias
monitor cardiac rhythms
Chloride
104- 110 mEq/L
weakness, mental state changes
Bicarbonate
22-28 mEq
monster kidneys and/or lungs
BUN
5-30 mg/ dL
fatigue, lack of concentration
monitor kidneys
Creatinine
0.5-1.5 mg/ dL
fatigue, lack of concentration
monitor kidneys
Glucose
70-100 mg/ dL (fasting)
>126 is DM
consider a carb snack if <70; give insulin if >240
HbA1C
4-6% if pt doesn't have diabetes
an average over the last 120 days
DM pts. shoot for 6%
1 hour glucose screen for GDM
gestational diabetes mellitus
>140mg/ dL requires further testing
<140 is normal
GTT for GDM
glucose tolerance test
<140 mg/ dL
>200 is GDM
Total cholesterol
<200 mg/dL
>240 is high risk
WBC
5,000- 10,000/uL
<1800 neutropenic precautions
Hemoglobin
12-18 g/dL
<8 g/dL therapy may be contraindicated, will likely need blood transfusion
Hematocrit
37-52%
<20% will likely have tachycardia, fainting
monitor vitals
Platelets
150,000-450,000/uL
<140K- light exercise only
<50K- AROM only w/ some ambulation
<20K- risk for spontaneous bleeding, no teeth brushing
What is normal ICP?
4- 15 mmHg
sustained >20 mmHg is a problem
Name 5 of the early signs of increased ICP
1) confusion/ lethargy
2) dilated/sluggish pupil
3) contralateral paresis
4) blurry vision/ diplopia
5) headache/ seizure
Name some causes of increased ICP
aneurysm, tumor, encephalitis, meningitis,
stroke, TBI
What is CPP?
cerebral profusion pressure
Why should an ICP patient be well ventilated?
to keep the acid/base balance and maximize O2 delivery
What position is best for an ICP patient?
around 30 degrees
describe each monitoring device for an ICP patient:
1) Epidural sensor
2) Subarachnoid bolt
3) Intraventricular catheter (EVD)
1) placed in epidural space, does not drain CSF
2) placed in subarachnoid space, least accurate, cannot drain CSF
3) external ventricular drain/ ventriculostomy
most accurate
can drain CSF- can be bloody, cloudy, or clear
placed in lateral ventricle
MUST
Name the PT implications with an ICP patient
ALWAYS talk to the nurse before moving
a change of ICP for > than 5 minutes is concerning
be very careful when changing bed position
be cautious of activities that increase ICP (pain, valsalva, coughing, stress)
nurse MUST clamp drain while PT performs mo
Pulse Oximetry measures ___ which is an indirect measure of ___?
SpO2; SaO2
What do pulse ox units require to get a measurement?
a pulsing arterial bed
What is the most accurate range of a pulse oximeter?
80-100% saturation (<80 is inaccurate)
What will cause erroneous reading with a pulse ox?
fingernail polish, carbon monoxide, dirty site, ambient light, dysrhythmias, movement, hypothermia
Pulse oximetry gives an indications of the pts.'s ___ not ___.
oxygenation; ventilation
Why is CO-oximetry the gold standard for oximeters?
it differentiates types of hemoglobin
How is a PEFR taken?
the pt. takes a deep breath in then blows out as hard and fast as possible into the monitoring mouthpiece
Guidelines for Treatment of Asthma : Red vs. Yellow
RED:
50% of less initial rate when compared to past tests
calls for aggressive bronchodilators
go to hospital if still <50% after 15 minutes
look at ABG's--> could be hypercarbia (PaCO2>45) or hypercapnia (PaO2<60)
YELLOW:
initial rate 50-80% of normal te