Alterations in Tissue Perfusion

HYPERTENSIVE CRISIS ASSESSMENT

Who are vulnerable to Hypertensive Crisis? Hemodynamic Monitoring

Hypertensive crisis may occur in clients with:  Extremely close hemodynamic monitoring of the
patient’s blood pressure and cardiovascular status is
1. poorly controlled hypertension required during treatment of hypertensive emergencies
2. undiagnosed hypertension and urgencies
3. abrupt discontinuance of antihypertensive
medications
 Exact frequency of monitoring is a matter of clinical
Necessary: A complete evaluation (to review the patient’s judgment and varies with the patient’s condition
ongoing treatment plan and strategies to minimize the occurrence
of subsequent hypertensive crises) once the hypertensive crisis has
been managed  Taking vital signs every 5 minutes is appropriate if the
blood pressure is changing rapidly
What are the Classifications of Hypetensive Crisis?

Two classes of hypertensive crisis that require immediate

 Taking vital signs at 15- or 30- minute intervals in a
more stable situation may be sufficient
intervention:



hypertensive emergency
hypertensive urgency (pressures above 180 mm Hg
 A precipitous drop in blood pressure can occur that
systolic and/or above 120 mm Hg diastolic) would require immediate action to restore blood
pressure to an acceptable level
1. Hypertensive emergency

 Acute, life-threatening blood pressure elevations that require

prompt treatment in an intensive care setting because of the
 Critically ill patients require continuous assessment of
serious target organ damage that may occur their cardiovascular system to diagnose and manage
their complex medical conditions
 Therapeutic goals:

 reduction of the mean blood pressure by 20% to  This type of assessment is achieved by the use of direct
25% within the first hour of treatment pressure monitoring systems, referred to as
 a further reduction to a goal pressure of about hemodynamic monitoring
160/100 mmHg over a period of up to 6 hours
a more gradual reduction in pressure over a period
 Common forms: CVP, pulmonary artery pressure, and

of days
intra-arterial BP monitoring
Exceptions to these goals: treatment of ischemic stroke (in
which there is no evidence of benefit from immediate
pressure reduction) and treatment of aortic dissection (in
which the goal is to lower systolic pressure to less than 100  Patients requiring hemodynamic monitoring are cared
mm Hg if the patient can tolerate the reduction) for in critical care units

2. Hypertensive urgency

 A situation in which blood pressure is very elevated but
there is no evidence of impending or progressive target
organ damage
 Elevated blood pressures associated with severe
headaches, nosebleeds, or anxiety are classified as
urgencies
 To perform hemodynamic monitoring, a CVP,
pulmonary artery, or arterial catheter is introduced into
the appropriate blood vessel or heart chamber.
It is connected to a pressure monitoring system that
has several components

 Oral agents can be given with the goal of normalizing Components of the pressure monitoring system
blood pressure within 24 to 48 hours
o Recommended treatment: Oral doses of fast-
acting agents such as beta-adrenergic blockers
 A disposable flush system: composed of IV normal
saline solution (which may include heparin), tubing,
(i.e., labetalol [Trandate]), ACE inhibitors (i.e., stopcocks, and a flush device, which provides
captopril [Capoten]), or alpha2-agonists (i.e., continuous and manual flushing of the system.
clonidine [Catapres])

 A pressure bag: placed around the flush solution
that is maintained at 300 mm Hg of pressure
The pressurized flush system delivers 3 to 5 mL of
solution per hour through the catheter to prevent
clotting and backflow of blood into the pressure
monitoring system

A transducer: converts the pressure coming from
the artery or heart chamber into an electrical signal
 An amplifier or monitor: increases the size of the
electrical signal for display on an oscilloscope
1. Central Venous Pressure Monitoring
 CVP is a measurement of the pressure in the vena cava
or right atrium
 The pressure in the vena cava, right atrium, and right
ventricle are equal at the end of diastole; thus, the CVP
also reflects the filling pressure of the right ventricle
(preload)
 Normal CVP: 2 to 6 mm Hg
 It is measured by positioning a catheter in the vena
cava or right atrium and connecting it to a pressure
monitoring system
 The CVP is most valuable when it is monitored over
time and correlated with the patient’s clinical status
 A CVP greater than 6 mm Hg indicates an elevated
right ventricular preload
There are many problems that can cause an
elevated CVP, but the most common problem is
hypervolemia (excessive fluid circulating in the body)
or right-sided HF
 A low CVP (less than 2 mm Hg) indicates reduced
right ventricular preload, which is most often from
hypovolemia
o Dehydration, excessive blood loss, vomiting or
diarrhea, and over diuresis can result in
hypovolemia and a low CVP
o This diagnosis can be substantiated when a
rapid IV infusion of fluid causes the CVP to
increase.
 Before insertion of a CVP catheter, the site is prepared
 The preferred site is the subclavian vein; the femoral
vein is generally avoided
 A local anesthetic agent is used
 During this sterile procedure, the physician threads a
single-lumen or multilumen catheter through the vein
into the vena cava just above or within the right atrium
 Once the CVP catheter is inserted, it is secured and a
dry sterile dressing is applied
 Position of the catheter is confirmed by a chest x-ray
Central Venous Pressure Monitoring
A. The phlebostatic axis is the reference point for the
atrium when the patient is positioned supine.
It is the intersection of two lines on the chest wall:
(1) the midaxillary line drawn between the anterior
and posterior surfaces of the chest and
(2) the line drawn through the fourth intercostal
space.
Its location is identified with a skin marker. The stopcock of
the transducer used in hemodynamic monitoring is “leveled”
at this mark prior to taking pressure measurements.
B. Measurements can be taken with the head of the bed
(HOB) elevated up to 60°. Note the phlebostatic axis
changes as the HOB is elevated; thus, the stopcock and
transducer must be repositioned after each position change.
2. Pulmonary Artery Pressure Monitoring
 Used in critical care for:
 assessing left ventricular function,
 diagnosing the etiology of shock, and
 evaluating the patient’s response to medical
interventions (e.g., fluid administration, vasoactive
medications)
 A pulmonary artery catheter and a pressure monitoring
system are used
 A variety of catheters are available for cardiac pacing,
oximetry, cardiac output measurement, or a
combination of functions
 Pulmonary artery catheters are balloon-tipped, flow-
directed catheters that have distal and proximal lumens
o The distal lumen has a port that opens into the
pulmonary artery
o Once connected by its hub to the pressure
monitoring system, it is used to continuously
measure pulmonary artery pressures
o The proximal lumen has a port that opens into the
right atrium

o It is used to administer IV medications and fluids
or to monitor right atrial pressures (i.e., CVP)
 Each catheter has a balloon inflation hub and valve
 A syringe is connected to the hub, which is used to
inflate or deflate the balloon with air (1.5-mL capacity)
 The valve opens and closes the balloon inflation lumen
 A pulmonary artery catheter with specialized
capabilities has additional components
For example, the thermodilution catheter has three
additional features that enable it to measure cardiac output:
o a thermistor connector attached to the cardiac
output computer of the bedside monitor,
o a proximal injectate port used for injecting fluids
when obtaining the cardiac output, and
o a thermistor (positioned near the distal port)
Pulmonary Artery Pressure Monitoring
The pulmonary artery catheter used for obtaining
pressure measurements and cardiac output.
A. The pressure monitoring system is connected to the distal
lumen hub.
B. Intravenous solutions are infused through the proximal
infusion and injectate lumen hubs. C. An air-filled syringe
connected to the balloon inflation valve is used for balloon
inflation during catheter insertion and pulmonary artery
wedge pressure measurements.
D. To obtain cardiac output, the thermistor connector is
inserted into the cardiac output component of the bedside
cardiac monitor, and
5 to 10 mL of normal saline is injected in 4 seconds into the
proximal injectate port. E. The thermistor located near the
balloon is used to calculate the cardiac output.
 The pulmonary artery catheter, covered with a
sterile sleeve, is inserted into a large vein,
preferably the subclavian, through a sheath
 The femoral vein is avoided; insertion techniques
and protocols mirror those used for inserting a
CVP catheter
 The sheath is equipped with a side port for
infusing IV fluids and medications
 The catheter is then passed into the vena cava and
right atrium
 In the right atrium, the balloon tip is inflated, and
the catheter is carried rapidly by the flow of blood
through the tricuspid valve into the right ventricle,
through the pulmonic valve, and into a branch of
the pulmonary artery
 When the catheter reaches the pulmonary artery,
the balloon is deflated and the catheter is secured
with sutures.
Pulmonary artery (PA) catheter and pressure monitoring
systems
A. Bedside monitor that connects with cables to the pressure
monitoring systems (includes intravenous [IV] solution in a
pressure bag, IV tubing, and two transducers with stopcocks
and flush devices)
B. This system connects to the proximal infusion port that
opens in the right atria
C. and is used to infuse fluids or medications and monitor
central venous pressures and the distal infusion port
D. This port opens in the PA and is used to monitor PA
pressures.
E. The thermistor connector is attached to the bedside
cardiac monitor to obtain cardiac output.
F. An air-filled syringe is attached to the balloon inflation
valve during catheter insertion and measurement of PA
wedge pressure.
G. PA catheter positioned in the pulmonary artery. Note the
sterile sleeve over the PA catheter. The PA catheter is
threaded through the sheath until it reaches the desired
position in the PA. The side port on the sheath is used to
infuse medications or fluids. ECG, electrocardiogram; RA,
right atrium.
 Once the catheter is in position, the following are
measured:

 right atrial,
 pulmonary artery systolic,
 pulmonary artery diastolic,
 mean pulmonary artery, and
 pulmonary artery wedge pressures
 Monitoring of the pulmonary artery diastolic and
pulmonary artery wedge pressures is particularly
important in critically ill patients because they are used
to evaluate left ventricular filling pressures (i.e., left
ventricular preload
 It is important to note that the pulmonary artery wedge
pressure is achieved by inflating the balloon tip, which
causes it to float more distally into a smaller portion of
the pulmonary artery until it is wedged into position
 This is an occlusive maneuver that impedes blood
flow through that segment of the pulmonary artery
 Therefore, the wedge pressure is measured
immediately and the balloon deflated promptly to
restore blood flow
Quality and Safety Nursing Alert
 After measuring the pulmonary artery wedge
pressure, the nurse ensures that the balloon is
deflated and that the catheter has returned to its
normal position
 This important intervention is verified by
evaluating the pulmonary artery pressure
waveform displayed on the bedside monitor
3. Intra-Arterial Blood Pressure Monitoring
 Intra-arterial BP monitoring is used to obtain direct and
continuous BP measurements in critically ill patients
who have severe hypertension or hypotension
 Arterial catheters are also useful when arterial blood gas
measurements and blood samples need to be obtained
frequently
 The radial artery is the usual site selected
 However, placement of a catheter into the radial artery
can further impede perfusion to an area that has poor
circulation
 As a result, the tissue distal to the cannulated artery can
become ischemic or necrotic
 Patients with diabetes, peripheral vascular disease, or
hypotension, receiving IV vasopressors, or having had
previous surgery are at highest risk for this
complication
 Traditionally,
collateral circulation to the involved
extremity was assessed by using the Allen test
 The hand is elevated and the patient is asked to
make a fist for 30 seconds
 The nurse compresses the radial and ulnar arteries
simultaneously, causing the hand to blanch
 After the patient opens the fist, the nurse releases
the pressure on the ulnar artery
 Allen test result: If blood flow is restored (hand
turns pink) within 6 seconds, the circulation to the
hand may be adequate enough to tolerate
placement of a radial artery catheter
 Evidence suggests that pulse oximetry and
plethysmography are additional reliable methods for
assessing circulation to the hand
 Site preparation and care are the same as for CVP
catheters
 The catheter flush solution is the same as for pulmonary
artery catheters
 A transducer is attached, and pressures are measured in
millimeters of mercury (mm Hg)
 The nurse monitors the patient for complications (local
obstruction with distal ischemia, external hemorrhage,
massive ecchymosis, dissection, air embolism, blood
loss, pain, arteriospasm, and infection)
NURSING
DIAGNOSIS
 Deficient knowledge regarding the relation between the
treatment regimen and control of the disease process
 Noncompliance with therapeutic regimen related to side
effects of prescribed therapy
Collaborative Problems
 Risk for complications of hemodynamic monitoring

(pneumothorax, air embolism, infection)
Left ventricular hypertrophy
 Myocardial infarction

Heart failure
 TIA
 Cerebrovascular disease (stroke or brain attack)
 Renal insufficiency and chronic kidney disease
 Retinal hemorrhage

PLANNING and
GOALS
The major goals for patients include:
 understanding of the disease process and its
treatment
 participation in a self-care program

absence of complications
IMPLEMENTATIO
N  Establishing the zero-reference point in order to ensure
Medical
Management
The medications of choice in hypertensive emergencies are
those that have an immediate effect
Initial treatment: Intravenous vasodilators, including:
 sodium nitroprusside (Nitropress),
 nicardipine (Cardene),
 clevidipine (Cleviprex),
 enalaprilat (Vasotec), and
 nitroglycerin have immediate actions that are
short-lived (minutes to 4 hours), and they are
therefore frequently used for initial treatment.
 Nicardipine and labetalol (Trandate) have
demonstrated safety and effectiveness in treating
hypertensive crises, with nicardipine
demonstrating more predictability in controlling
blood pressure.
 Volume replacement: Experts also recommend
assessing the patient’s fluid volume status
If there is volume depletion secondary to
natriuresis caused by the elevated blood pressure, then
volume replacement with normal saline can prevent
large sudden drops in blood pressure when
antihypertensive medications are given
Look at last page
Nursing Management
Nurses caring for patients who require
hemodynamic monitoring receive training prior to using this
sophisticated technology
The nurse helps ensure safe and effective care by
adhering to the following guidelines:
 Ensuring that the system is set up and maintained
properly. For example, the pressure monitoring system
must be kept patent and free of air bubbles
 Checking that the stopcock of the transducer is
positioned at the level of the atrium before the system is
used to obtain pressure measurements
o This landmark is referred to as the phlebostatic
axis
o The nurse uses a marker to identify this level on
the chest wall, which provides a stable reference
point for subsequent pressure readings.
that the system is properly functioning at atmospheric
pressure
o This process is accomplished by placing the
stopcock of the transducer at the phlebostatic axis,
opening the transducer to air, and activating the
zero function key on the bedside monitor
 Measurements of CVP, BP, and pulmonary artery
pressures can be made with the head of the bed elevated
up to 60°; however, the system must be repositioned to
the phlebostatic axis to ensure an accurate reading
Complications of hemodynamic monitoring
(uncommon): PNEUMOTHORAX
 The nurse observes for signs of pneumothorax during
the insertion of catheters using a central venous
approach (CVP and pulmonary artery catheters)
Complications of hemodynamic monitoring
(uncommon): AIR EMBOLISM
 Air emboli can be introduced into the vascular system if
the stopcocks attached to the pressure transducers are
mishandled during blood drawing, administration of
medications, or other procedures that require opening
the system to air
o Therefore, nurses handling this equipment must
demonstrate competence prior to caring
independently for a patient requiring hemodynamic
monitoring
Complications of hemodynamic monitoring:
INFECTION
 The longer any of these catheters are left in place (after
72 to 96 hours), the greater the risk of infection
 Catheter-related bloodstream infections are the most
common preventable complication associated with
hemodynamic monitoring systems
 Collaborative Practice Interventions to Prevent Central
Line–Associated Bloodstream Infections (CLABSIs)
o Current best practices can include the
implementation of specific evidence-based bundle
interventions that when used together (i.e., as a
“bundle”) improve patient outcomes
o This chart outlines specific parameters for the
central line bundled collaborative interventions that
have been found to reduce central line–associated
bloodstream infections (CLABSI)
FIVE KEY ELEMENTS OF THE CENTRAL LINE
BUNDLE:
 Hand hygiene
 Maximal sterile barrier precautions during line insertion
(see later discussion)
 Chlorhexidine skin antisepsis
 Optimal catheter site selection with avoidance of using
the femoral vein for central venous access in adult
patients
 Daily review of line necessity, with prompt removal of
unnecessary lines
When to perform hand hygiene in the care of a patient
with a central line:
All clinicians who provide care to the patient
should adhere to good hand hygiene practices, particularly:
 Before and after palpating the catheter insertion site
 With all dressing changes to the intravascular catheter
access site
 When hands are visibly soiled or contamination of
hands is suspected
 Before donning and after removing gloves
Changes that can be made to improve hand hygiene:
 Implement a central line procedure checklist that
requires that clinicians perform hand hygiene as an
essential step in care.
 Post signage stating the importance of hand hygiene.
 Have soap and alcohol-based hand sanitizers
prominently placed to facilitate hand hygiene practices.
 Model hand hygiene practices.
 Provide patient and family education and engage family
in hand hygiene practices during visitation.
Maximal sterile barrier precautions implemented during
central line insertion:
 For the primary provider, this means strict compliance
with wearing a cap, mask, sterile gown, and sterile
gloves. The cap should cover all hair, and the mask
should cover the nose and the mouth tightly. The nurse
should also wear a cap and a mask.
 For the patient, this means covering the patient from
head to toe with a sterile drape, with a small opening
for the site of insertion. If a full-size drape is not
available, two drapes may be applied to cover the
patient, or the operating room may be consulted to
determine how to procure full-size sterile drapes,
because these are routinely used in surgical settings.
 Nurses should be empowered to enforce use of a central
line checklist to be sure that all processes related to
central line placement are properly executed for every
line placed.
Antiseptic to be used to prepare the patient’s skin for
central line insertion:
 Chlorhexidine skin antisepsis has been proven to
provide better skin antisepsis than other antiseptic
agents, such as povidone–iodine solutions.
 An alcohol chlorhexidine antiseptic should be applied
using a back- and-forth friction scrub for at least 30
seconds; this should not be wiped or blotted dry.
 The antiseptic solution should be allowed time to dry
completely before the insertion site is
punctured/accessed (approximately 2 minutes).
Essential nursing interventions to reduce the risk of
infection:
 Maintaining sterile technique when changing the central
line dressing
 Always performing hand hygiene before manipulating
or accessing the line ports
 Wearing clean gloves before accessing the line port
 Performing a 15- to 30-second “hub scrub” using
chlorhexidine or alcohol and friction in a twisting
motion on the access hub (reduces biofilm on the hub
that may contain pathogens)
 Using chlorhexidine-containing dressings in patients
older than 2 months
 Consider using antiseptic-containing port protectors to
cover connectors
When to discontinue central lines:
 Assessment for removal of central lines should be
included as part of the nurse’s daily goal sheets.
 The time and date of central line placement should be
recorded and evaluated by staff to aid in decision
making.
 The need for the central line access should be reviewed
as part of multidisciplinary rounds.
 During these rounds, the “line day” should be stated to
remind everyone how long the central line has been in
place (e.g., “Today is line day 6”).
 An appropriate time frame for regular review of the
necessity for a central line should be identified, such as
weekly, when central lines are placed for long-term use
(e.g., chemotherapy, extended antibiotic
administration).
Nursing
Management:
INCREASING
KNOWLEDGE
 The patient needs to understand the disease process
and how lifestyle changes and medications can control
hypertension. The nurse needs to emphasize the concept
of controlling hypertension rather than curing it.

The nurse can encourage the patient to consult a
dietitian to help develop a plan for improving nutrient
intake or for weight loss. The program usually consists
of restricting sodium and fat intake, increasing intake of
fruits and vegetables, and implementing regular
physical activity.
 Explaining that it takes 2 to 3 months for the taste
buds to adapt to changes in salt intake may help the
patient adjust to reduced salt intake.
 The patient should be advised to limit alcohol
intake, and tobacco should be avoided because anyone
with high blood pressure is already at increased risk for
heart disease, and smoking amplifies this
Nursing Management:
PROMOTING
ADHERENCE TO THE
THERAPEUTIC
REGIMEN
 Adherence to the therapeutic regimen increases when
patients actively participate in self-care, including self-
monitoring of blood pressure and diet, possibly because
patients receive immediate feedback and have a greater
sense of control
 Nurse-led wellness programs that are tailored to take
into account patients’ behaviors and eating and exercise
practices are more effective than generic programs
 Patients with hypertension must make considerable
effort to adhere to recommended lifestyle modifications
and to take regularly prescribed medications
 Continued education and encouragement are usually
needed to enable patients to formulate an acceptable
plan that helps them live with their hypertension and
adhere to the treatment plan
The effort needed to follow the therapeutic plan
may seem unreasonable to some, particularly when they
have no symptoms without medications but do have
side effects with medications
 Compromises may have to be made about some aspects
of therapy to achieve higher-priority goals
The nurse can assist with behavior change by
supporting patients in making small changes with each
visit that moves them toward their goals
 Another important factor is following up at each visit to
see how the patient has progressed with the plans made
at the prior visit
If the patient has had difficulty with a particular
aspect of the plan, the patient and nurse can work
together to develop an alternative or modification to the
plan that the patient believes will be more successful
 Support groups for weight control, smoking cessation,
and stress reduction may be beneficial for some
patients; others can benefit from the support of family
and friends.
The nurse assists the patient to develop and adhere
to an appropriate exercise regimen, because regular
activity is a significant factor in weight reduction and a
blood pressure–reducing intervention in the absence of
any loss in weight
Nursing Management:
PROMOTING HOME,
COMMUNITYBASED,
AND TRANSITIONAL
CARE
Educating Patients About Self-Care
 The nurse can help the patient achieve blood pressure
control through education about managing blood
pressure (see earlier discussion), setting goal blood
pressures, and providing assistance with social support.
 Involving family members in education programs Nursing Management:
enables them to support the patient’s efforts to control
hypertension. MONITORING AND
 Providing written information about the expected MANAGING
POTENTIAL
effects and side effects of medications is important.
When side effects occur, patients need to understand the
importance of reporting them and to whom they should
be reported
COMPLICATIONS
 Patients need to be informed that rebound hypertension  Symptoms suggesting that hypertension is progressing
(i.e., abnormally high blood pressure) can occur if to the extent that target organ damage is occurring must
antihypertensive medications are suddenly stopped be detected early so that appropriate treatment can be
initiated

o Patients should be advised to have an adequate
supply of medication, particularly when traveling
and in case of emergencies such as natural disasters
o If traveling by airplane, patients should pack the
medication in their carry-on luggage
 All patients should be informed that some medications,
such as beta-blockers, might cause sexual dysfunction
and that other medications are available if problems
with sexual function or satisfaction occur.
o When the patient returns for follow-up care, all body
systems must be assessed to detect any evidence of
vascular damage
o An eye examination with an ophthalmoscope is
particularly important because retinal blood vessel
damage indicates similar damage elsewhere in the
vascular system
o The patient is questioned about blurred vision, spots
in front of the eyes, and diminished visual acuity

o The heart, nervous system, and kidneys are also

 The nurse can encourage and educate patients to

carefully assessed

measure their blood pressure at home

 Any significant findings are promptly reported to
o This practice involves patients in their own care and determine whether additional diagnostic studies are
required
emphasizes that failing to take medications may
result in an identifiable rise in blood pressure  Based on the findings, medications may be changed to
improve blood pressure control
o Patients need to know that blood pressure varies
continuously and that the range within which their
pressure varies should be monitored

EVALUATION
Continuing and Transitional Care
Expected Patient
 Regular follow-up care is imperative so that the
disease process can continue to be optimally
assessed and treated
Outcomes
o A history and physical examination should be 1. Reports knowledge of disease management
sufficient to maintain adequate tissue perfusion
completed at each clinic visit

o The history should include all data pertaining to

any potential problem, specifically medication-
A.
related problems such as postural (orthostatic)
hypotension (experienced as dizziness or
lightheadedness on standing)
Maintains blood pressure at less than
140/90 mm Hg (or less than 150/90 mm Hg for
adults older than 60 years of age) with lifestyle
modifications, medications, or both
 B. Demonstrates no symptoms of angina,
palpitations, or vision changes

C. Has stable BUN and serum creatinine

levels

D. Has palpable peripheral pulses

2. Adheres to the self-care program

A. Adheres to the dietary regimen as

prescribed: reduces calorie, sodium, and fat intake;
increases fruit and vegetable intake

B. Exercises regularly

C. Takes medications as prescribed and

reports any side effects

D. Measures blood pressure routinely

E. Abstains from tobacco and excessive

alcohol intake

F. Keeps follow-up appointments

3. Has no complications

A. Reports no changes in vision

B. Exhibits no retinal damage on vision

testing

C. Maintains pulse rate and rhythm and

respiratory rate within normal ranges

D. Reports no dyspnea or edema

E. Maintains urine output consistent with

intake

F. Has renal function test results within

normal range

G. Demonstrates no motor, speech, or

sensory deficits

H. Reports no headaches, dizziness,

weakness, changes in gait, or falls