Lesson 3

Acute/Critically Ill Patients

in Hemodynamic Monitoring
(Assessment)

Hemodynamics ultimately begins with the heart which supplies the driving
force for all blood flow in the body. Cardiac output propels blood through the arteries
and veins as a function of ventricular contraction. Ventricular motion results from the
shortening of cardiac myocytes concentrically. This squeezing motion is translated into
the cardiac output, which is a function of both heart rate and ejection fraction (the
starting volume after diastolic filling minus the final ventricular volume after systole).
Hemodynamics represents the governing principals of this blood flow and its behavior
in the blood vessels.

Hemodynamic monitoring measures the blood pressure inside the veins,

heart, and arteries. It also measures blood flow and how much oxygen is in the blood.
It is a way to see how well the heart is working. A mean arterial pressure (MAP) of 70
mm Hg may be considered a reasonable target, associated with sign of adequate organ
perfusion, in most clients. The goal of hemodynamic monitoring is to maintain
adequate tissue perfusion and oxygen delivery while maintaining adequate mean
arterial blood pressure.

Technologic advances in miniaturization, biosensors, and computer processing

coupled with an improved understanding of critical illness at the molecular level will
lead to development of new monitoring systems that will integrate physiologic and
biochemical information in a relatively noninvasive manner. When coupled with more
effective therapies, these integrated, closed-loop systems promise to help improve
outcome in critically ill patients.

Hemodynamic Technique:
 Noninvasive, or indirect, hemodynamic monitoring provides physiologic
information without the risks of invasive monitoring and can be used in many
settings.

 Invasive, or direct, measurements are obtained by penetrating the skin and

inserting a cannula or catheter into a blood vessel, chamber of the heart, or both.
The cannula or catheter is attached to a monitoring system, which consists of a
transducer, amplifier, and oscilloscope for the display of the vascular waveforms
and pressure measurements. Invasive, or direct, measurements are obtained by
penetrating the skin and inserting a cannula or catheter into a blood vessel,
chamber of the heart, or both. The cannula or catheter is attached to a monitoring

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 system, which consists of a transducer, amplifier, and oscilloscope for the display
of the vascular waveforms and pressure measurements.

The primary hemodynamic parameters include heart rate (HR) and blood
pressure (BP), while the advanced hemodynamic parameters include stroke volume
(SV), cardiac output (CO), and total peripheral resistance (TPR). The measurement
technique for hemodynamic parameters, particularly CO, previously utilized an
invasive pulmonary artery catheter and an arterial or central venous catheter for
gravely ill patient. Recently, non-invasive methods for the evaluation of hemodynamic
parameters have been developed, and the results of these techniques are highly
correlated with those of invasive methods for determining the type of circulatory
shock. Similarly, a number of bedside ultrasonography protocols to estimate the
cardiac preload have become widely used for determining the type of circulatory
shock.

Central venous pressure (CVP) is often used as sole parameter to monitor

hemodynamic. However CVP alone may not differentiate between changes in volume
(different venous return curve) or changes in contractility (different starling curve).
Finally, other techniques such as echocardiography, transesophageal Doppler and
volume-based monitoring system are now available.

images+CVP&tbm

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 Patterns of hemodynamic variables often suggest cardiogenic, hypovolemic,
obstructive, or distributive (septic) etiologies to cardiovascular insufficiency, thus
defining the specific treatments required. 

Advances in hemodynamic monitoring with focus on oxygen delivery at

the cellular level may ultimately provide the edge to effective
monitoring that can impact outcome.

The ultimate in monitoring that will provide 100% sensitivity to

survival outcome will require the care provider to monitor oxygen delivery to all the
tissue beds at all times when the patient’s life is possibly under threat. Even if we
have some details of the flow in the microcirculation, the actual amount of oxygen a
cell receives still depends on its diffusing in adequate amounts from the capillary all
the way to the mitochondria where it performs the most important task of ATP
production with energy metabolism.

The spectrum of hemodynamic monitoring ranges from simple clinical

assessment and routine bedside monitoring to point of care ultrasonography and
various invasive monitoring devices. The clinician must be aware of the range of
available techniques, methods, interventions and technological advances as well as
possess a sound approach to basic hemodynamic monitoring prior to selecting the
optimal modality.

Various methods and techniques that are used or applied include; clinical
assessment, passive leg raising, blood pressure, finger based monitoring devices, the
mini-fluid challenge, the end-expiratory occlusion test, central venous pressure
monitoring, the pulmonary artery catheter, ultrasonography, bioreactance and other
modern invasive hemodynamic monitoring devices.

Correlation of Pathophysiology to Nursing Assessment

1. Hemodynamic monitoring is primarily used in patients with known or suspected

shock; to identify mechanism responsible for shock, select appropriate therapy,
and evaluate response to therapy.
In shock the circulation is inadequate, blood pressure is low, heart rate is
rapid, and irreversible tissue damage from insufficient blood supply may occur if
the condition is not terminated

Suggestive mechanism of shock based on hemodynamic monitoring findings

1. elevated cardiac output may suggest distributive shock
2. low blood pressure and volumes may suggest hypovolemic shock
3. low cardiac output and increased systemic vascular resistance (SVR) may
suggest cardiogenic shock
4. increased pulmonary artery pressure and dilated right-sided cavities may
suggest obstructive shock or cardiogenic shock
2. In Intracranial pressure (ICP) monitoring, pressure exerted by the brain, blood,
and CSF against the inside of the skull is measured. ICP monitoring enables prompt
intervention, which can avert damage caused by cerebral hypoxia and shifts of
brain mass.

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 Indications for ICP monitoring include:
 Head trauma with bleeding or edema
 Overproduction or insufficient absorption of CSF
 Cerebral hemorrhage
 Space-occupying lesions

3. Spinal cord trauma results from acceleration, deceleration, or other deforming

forces.

What to look for?

 History of trauma, a neoplastic lesion, an infection that could produce a spinal
abscess, or an endocrine disorder.
 Muscle spasm and back or neck pain that worsens with movement; in cervical
fractures, pain that causes point tenderness; in dorsal and lumbar fractures,
pain that may radiate to other areas, such as the legs
 Mild paresthesia to quadriplegia and shock, if the injury damages the spinal
cord; in milder injury, symptoms that may be delayed several days or weeks.

4. In intracranial or cerebral aneurysm, a weakness in the wall of a cerebral artery

causes that area of the artery to dilate or bulge. The most common form is the
berry aneurysm, a saclike out-pouching in a cerebral artery.

What to look for?

Occassionaly, your patient may exhibit signs and symptoms due to blood
oozing into the subarachnoid space. The symptoms, which may persist for several
days, include:
 Headache
 Intermittent nausea
 Nuchal rigidity
 Stiff back and legs.

5. Stroke, also known as a cerebrovascular accident or brain attack, is a sudden

impairment of cerebral circulation in one or more blood vessels. A stroke
interrupts or diminishes oxygen supply and commonly causes serious damage or
necrosis in the brain tissues.

What to look for?

A stroke in the left hemisphere produces symptoms on the right side of the
body; in the right hemisphere, symptoms on the left side.
 Hemiparesis on the affected side (may be more severe in the face and arm than
in the leg)
 Unilateral sensory defect (such as numbness, or tingling) generally on the same
side as the hemiparesis.
 Slurred or indistinct speech or the inability to understand speech.
 Blurred or indistinct vision, double vision, or vision loss in one eye (usually
described as a curtain coming down or gray-out of vision).

Fill-in the blanks

Here’s what happens when a hemorrhage causes a stroke:

o Impaired cerebral perfusion causes _________________________________________
_______________________________________________________________________
_______________________________________________________________________
o The brain’s regulatory mechanisms attempt to _______________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

o If the hemorrhage is small, the client may have ______________________________

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 _______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
o Initially, the ruptured cerebral blood vessels may constrict to limit the blood loss.
This vasospasm further ___________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
o If a clot forms in the vessel, ______________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
o Blood cells that pass through the vessel wall into the surrounding tissue may
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

6. Hypertensive Crisis refers to the abrupt, acute, and marked increase in blood
pressure from the patient’s baseline that ultimately leads to acute and rapidly
progressing end-organ damage. In the brain, hypertensive crisis can result in
hypertensive encephalopathy because of cerebral vasodilation from an inability to
maintain autoregulaion. Blood flow increases, causing an increase in pressure and
subsequent cerebral edema. This increase in pressure damages the intimal and
medial lining of the arterioles.

What to look for?

Your assessment of a patient in hypertensive crisis almost always reveals a
history of hypertension that’s poorly controlled or has not been treated. Signs and
symptoms may include:
 severe, throbbing headache in the back of the head
 dizziness, nausea, vomiting
 anorexia
 irritability
 confusion, somnolence, or stupor
 vision loss, blurred vision, or diplopia
 dyspnea on exertion, orthopnea, or paroxysmal nocturnal dyspnea
 edema
 angina
 possible left ventricular heave palpated at the mitral valve area
 S4 heart sound
 Acute retinopathy and hemorrhage, retinal exudates, and papilledema

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7. Heart Failure occurs when the heart can’t pump enough blood to meet the
metabolic needs of the body. It results in intravascular and interstitial volume
overload and poor tissue perfusion. An individual with heart failure experiences
reduced exercise tolerance, a reduced quality of life, and a shortened life span.

What to look for?

 Early signs and symptoms of left-sided heart failure include: dyspnea,
orthopnea, paroxysmal nocturnal dyspnea, fatigue, nonproductive cough
 Later-clinical manifestations of left-sided heart failure may include: crackles
on auscultation, hemoptysis, displacement of the PMI toward the left anterior
axillary line, tachycardia, S3 heart sound, S4 heart sound, cool & pale skin,
restlessness and confusion
 Clinical manifestations of right-sided heart failure include: jugular vein
distention, hepatojugular reflux and hepatomegaly, right upper quadrant pain,
anorexia, fullness & nausea, nocturia,weight gain, edema, ascites or anasarca

Fill-in the blanks

All types of heart failure eventually lead to reduced cardiac output, which
triggers compensatory mechanisms that improve cardiac output at the expense of
increased ventricular work. The compensatory mechanisms include:

o Increased ________________________________
o Activation of _____________________________________________________
o Ventricular __________________
o Ventricular __________________

ASSIGNMENT

List several purposes of cardiac catheterization.

 _________________________________________________________________
_________________________________________________________________
 _________________________________________________________________
_________________________________________________________________
 _________________________________________________________________
_________________________________________________________________
 _________________________________________________________________
_________________________________________________________________

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