Lesson 4

Acute/Critically Ill Patients in

Hemodynamic Monitoring
(Management)

Hemodynamic monitoring in itself cannot impact survival. Outcome is more

closely related to therapeutic measures that should rightly be instituted to improve
survival with the hemodynamic details that monitoring provides. A new trend in
monitoring—functional hemodynamic monitoring—with emphasis on how the
parameters (e.g., with preload responsiveness) change with treatment strategies holds
promise. Failure to institute the correct therapeutic measure by care providers may
limit the correlation between hemodynamic monitoring and outcome. Care providers
must understand how the hemodynamic parameters impact survival so that they may
make a right choice in using these parameters to guide therapeutic measures in
patient care.

Correlation of Pathophysiology to Nursing Assessment and Management

A. Neurologic – a complete neurologic examination can be long and

detailed. It’s unlikely that you would perform one in its entirety. However, if your
initial screening suggests a neurologic problem, you may need to conduct a more
detailed assessment. Examine the patient’s neurologic system in an orderly way.
Beginning with the highest levels of neurologic function and working down to the
lowest, assess these five areas:
 Mental status
 Cranial nerve functions
 Sensory function
 Motor function
 reflexes

The most common imaging studies used to detect

Neurologic disorders include computed tomog-
Raphy (CT) scan, magnetic resonance imaging
(MRI), positron emission tomography (PET) scan,
And skull and spinal X-rays.

Nursing Management on Imaging Studies:

1. Confirm that the client isn’t allergic to iodine or shellfish to avoid an
adverse reaction to the contrast medium.
2. If the test calls for a contrast medium, tell the client that it’s injected into
an existing I.V. line or that a new line may be inserted.
3. Preprocedure testing should include evaluation of renal function (serum
creatinine and blood urea nitrogen (BUN) levels) because the contrast
medium can cause acute renal failure.
4. Warn the client that he may feel flushed or notice a metallic taste in his
mouth when the contrast medium is injected.

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5. Tell the client that the scanner circles around him for 10 to 30 minutes,
depending on the procedure and type of equipment.
6. Explain that the client must be still during the test.
7. Instruct the client to remove all metallic items, such as hair clips, bobby
pins, jewelry, watches, eyeglasses, hearing aids, and dentures.
8. For MRI: explain that the procedure can take up to 1½ hours, tell the client
that he must remain still for intervals of 5 to 20 minutes.
9. Explain that the test is painless, but that the machinery may seem loud and
frightening and the tunnel confining. The client may receive earplugs to
reduce the noise.
10.Provide sedation, as ordered, to promote relaxation during the test.
11.After the procedure, increase the I.V. flow rate, as ordered, or encourage
the patient to increase his fluid intake to flush the contrast medium from
his system.

ASSIGNMENT
Name five (5) medications/drugs that can cause adverse central nervous system reactions
and affect cognitive function in critically ill patients. Discuss briefly the mechanism of
action of each drug.

B. Cardiovascular – hemodynamic monitoring is used to assess cardiac

function . Follow your facility’s procedure for setting up, zero referencing,
calibrating. Maintaining, and troubleshooting equipment. Common uses of
hemodynamic monitoring include arterial blood pressure monitoring and pulmonary
artery pressure.

1. Arterial blood pressure – in arterial blood pressure monitoring, the doctor

inserts a catheter into the radial or femoral artery to measure blood pressure
or obtain samples of arterial blood for diagnostic tests such as arterial blood
gas (ABG) studies. A transducer transforms the flow of blood during systole and
diastole into a waveform, which appears on an oscilloscope.

Nursing Management:
o Explain the procedure to the patient and his family, including the purpose
of arterial pressure monitoring.
o After catheter insertion, observe the pressure waveform to assess arterial
pressure.
o Assess the insertion site for signs of infection, such as redness and swelling.
Notify the doctor immediately if you note such signs.
o Document the date and time of catheter insertion, catheter insertion site,
type of flush solution used, type of dressing applied, and patient’s
tolerance of the procedure.

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 Pulmonary artery pressure – continuous pulmonary artery pressure (PAP) and

intermittent pulmonary artery wedge pressure (PAWP) measurements provide
important information about left ventricular function and preload. Use this
information for monitoring and for aiding diagnosis, refining assessment,
guiding interventions, and projecting patient outcomes.

PAP and PAWP procedure:

A balloon-tipped, multilumen catheter is inserted into the client’s
internal jugular or subclavian vein. When the catheter reaches the right
atrium, the balloon is inflated to float the catheter through the right ventricle
into the pulmonary artery. This permits the PAWP measurement through an
opening at the catheter’s tip.
The deflated catheter rests in the pulmonary artery, allowing diastolic
and systolic PAP readings. The balloon should be totally deflated except when
taking a PAWP reading because prolonged wedging can cause pulmonary
infarction.

Nursing Management:
o Inform the patient he’ll be conscious during catheterization and he may
feel temporary local discomfort from the administration of the local
anesthetic. Catheter insertion takes about 30 minutes.
o After catheter insertion, you may inflate the balloon with a syringe to take
PAWP readings. Be careful not to inflate the balloon with more than 1.5 cc
of air. Over inflation could distend the pulmonary artery causing vessel
rupture. Don’t leave the balloon wedged for a prolonged period because
this could lead to a pulmonary infarction.
o After each PAWP reading, flush the line, if you encounter difficulty, notify
the doctor.
o Maintain 300 mm Hg pressure in the pressure bag to permit a flush flow of 3
to 6 ml/hour.
o If fever develops when the catheter is in place, inform the doctor, he may
remove the catheter and send its tip to the laboratory for culture.
o Make sure stopcocks are properly positioned and connections are secure.
Loose connections may introduce air into the system or cause blood
backup, leakage of deoxygenated blood, or inaccurate pressure readings.
Also make sure the lumen hubs are properly identified to serve the
appropriate catheter ports.
o Because the catheter can slip back into the right ventricle and irritate it,
check the monitor for a right ventricular waveform to detect this problem
promptly.
o To minimize valvular trauma, make sure the balloon is deflated whenever
the catheter is withdrawn from the pulmonary artery to the right ventricle
or from the right ventricle to the right atrium.
o Adhere to your facility’s policy for dressing, tubing, catheter, and flush
changes.
o Document the date and time of catheter insertion, the doctor who
performed the procedure, the catheter insertion site, pressure waveforms
and values for the various heart chambers, balloon inflation volume
required to obtain a wedge tracing, arrhythmias that occurred during or
after the procedure, type of flush solution used and its heparin
concentration, type of dressing applied, and the patient’s tolerance of the
procedure.

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Trends in Hemodynamic Management

Recent developments include the move from static to dynamic variables to
assess conditions such as cardiac preload and fluid responsiveness and the transition to
less-invasive or even noninvasive monitoring techniques, at least in the perioperative
setting. Even though the thermodilution method remains the gold standard for
measuring cardiac output (CO), the use of the pulmonary artery catheter has declined
over the last decades, even in the setting of cardiovascular anesthesia.

The Move From Static to Dynamic Measurements

In the last century, monitoring has developed from initially pressure focused
and noninvasive (eg, finger on the pulse and listening to heart and Korotkoff sounds)
to invasive (eg, central venous pressure, arterial pressure, and pulmonary artery
pressure). However, invasive technology is associated with complications such as
infection and perforation. In recent years, the focus has been on trying to develop
noninvasive technology without losing significant accuracy and precision, avoiding the
complications of invasive monitors, and analyzing flow and response to fluid therapy.

Transition to Minimally Invasive and Noninvasive Hemodynamic Monitoring Techniques

There undoubtedly has been a trend in recent years from more invasive
hemodynamic monitoring tools and techniques (eg, pulmonary artery catheter [PAC]
for measuring CO, mixed venous oxygen saturation, and pulmonary arterial pressures),
to less-invasive techniques (eg, CO monitoring using arterial pressure waveform
analysis or the esophageal Doppler), and even completely noninvasive techniques (eg,
volume clamp using finger cuffs, bioimpedance and bioreactance, carbon dioxide
(CO2)-rebreathing, and pulse wave transit time). This trend became possible through
the technical development of innovative devices that have penetrated the market
with variable success. The core question to be asked is whether less invasiveness also
is accompanied by less accuracy, which would limit the use of these devices markedly.

Introduction of Artificial Intelligence to Predict Hemodynamic Changes

Artificial intelligence, machine learning, big data, and predictive analytics are
key words that infiltrate modern medicine just as they do in any other technology-
associated field of science. These words describe a process of incorporating large
amounts of disparate data into a unified algorithm, which then is used to predict and
solve a clinical problem. Examples of their application include image processing of
radiographic images, analysis of whole-slide pathology images, fully automated
echocardiogram interpretation, and text analysis of clinical notes.

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New methods of hemodynamic monitoring have the potential to improve

management of the cardiovascular patient during anesthesia and postoperative care
because they provide accurate, precise, and repeatable measurements that can be
used to detect hemodynamic alterations and their causes, optimize hemodynamic
conditions such as oxygen delivery to the tissues, and provide feedback on the
adequacy of therapeutic interventions. Recent developments include the move from
static to dynamic variables to assess for conditions such as cardiac preload and fluid
responsiveness and the transition to less-invasive monitoring techniques, at least in
the perioperative setting. Future objectives include wearable sensors and wireless
remote monitoring, broadening continuous vital sign monitoring to lower care units
such as general hospital wards. Furthermore, the introduction of artificial intelligence
and machine learning will, based on big data, allow for predictive analytics of
hemodynamic problems before they actually occur.
https://www.sciencedirect.com/science/article

Fill-in the blanks

1. After having a cardiac catheterization, the patient is to remain in bed for

_______________ to _______________ hours.
2. Three major cardiovascular risk factors are _________________________,
__________________________, and _________________________.
3. The three factors that determine stroke volume are
____________________, __________________________, and
_________________________.
4. Homocysteine, an amino acid is linked to the development of
__________________________ because it can damage the endothelial lining
of arteries and promote thrombus formation.
5. __________________________, _________________________, and
_________________________ are measured to evaluate a person’s risk of
developing coronary artery disease (CAD), especially if there is a family
history of premature heart disease, or to diagnose a specific lipoprotein
abnormality.

Psychosocial Concerns in Acute/Critical Illness

The stress of critical illness may manifest itself in many ways. Patients
may deny or be unable to accept diagnosis or treatment, and they may
persistently ask why there is no improvement. They may express anxiety, often
extreme, with near panic and unspecified fears about dying. They may
experience intense feelings of ambivalence and guilt regarding their personal
relationships.

Religion and spirituality may be most helpful to

patients and families and should therefore be
recognized and encouraged.

A family member may have more difficulty than the

patient in coping with the illness; this may irritate
and distract caregivers and ultimately disrupt the
relationship between the physician and the family.
Therefore, the entire family is the appropriate focus

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of treatment.

Given the difficulties that can follow the disclosure

of a life-threatening illness, it may be tempting to
avoid telling the patient the diagnosis. This tactic
has ancient roots: Hippocrates himself recommended
concealing bad news from patients, lest they
become discouraged. Tell the truth.

The most important component of communication is listening. The real issue

is not what you tell your patients but, rather, what you let your patients tell
you.

Psychological difficulties experienced during acute/chronic illness include:

 persistent worries and fears about the illness and its long-term effects.
 fear of dying.
 fear of the hospital or medical procedures.
 persistent sadness, anger, irritability, or excessive moodiness.
 changes in self esteem.
 powerlessness
 guilt and resentment
 frustration

CLINICAL APPLICATION

Mr. Sibus, a 50-year-old carpenter, is brought to the ER/ED by ambulance with a

suspected diagnosis of MI. He appears ashen, is diaphoretic, has a heart rate of 110
beats per minute (bpm), and reports severe chest pain. The nursing diagnosis is
decreased cardiac output, related to decreased myocardial tissue perfusion.

1. The nurse is aware that there is a critical time period for this patient. When should the
nurse be most vigilant in monitoring this patient?

____________________________________________________________________
2. The nurse is interpreting the results of the ECG. What findings does the nurse
understand are indicative of initial myocardial injury?

____________________________________________________________________
_
3. The nurse evaluates a series of laboratory tests within the first few hours. What
laboratory results are positive indicators of myocardial infarction (MI)?

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____________________________________________________________________
_
____________________________________________________________________
_
4. The nurse should closely monitor the patient for a complication of an MI that leads to
sudden death during the first 48 hours. Which complication should the nurse monitor
for?

____________________________________________________________________
_

END OF MODULE 1

 MODULE SUMMARY
There are four lessons in module I.

Lesson 1 outlines the University’s philosophy, vision and mission. Included also
are the Department goals and program outcomes, and an overview of the core
competency standards.

Lesson 2 is an overview of what critical care nursing is and the role of critical
care/ICU nurses. It covers the classification of critical care patients and the
principles of critical care nursing. Assessing cultural considerations and holistic
health care are also emphasized.

Lesson 3 deals with the critically ill patients in hemodynamic monitoring. It

covers the techniques in hemodynamic monitoring, the nurses’ role in assessing
the acute/critically ill patients and how these assessments correlates with the
pathophysiological aspect of underlying conditions.

Lesson 4 covers the nurses’ role in the collaborative management of critically

ill patients in hemodynamic monitoring. Included also are the psychosocial
concerns in the care of the acute/critically ill patients.

Congratulations! You may now proceed to module 2 after taking the

graded quiz.

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SUMMATIVE TEST

1. Graded quiz, covering the four lessons, will be administered thru

correspondence.

FEEDBACK

After using this module I perceived that this module is

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I would recommend that ______________________________________________
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