BACHELOR OF SCIENCE IN NURSING:

NCMB 418: CARE OF THE CLIENT WITH LIFE-

THREATENING CONDITIONS, ACUTELY ILL / MULTI-
ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY
SITUATION (ACUTE AND CHRONIC)
COURSE MODULE COURSE UNIT WEEK
2 6 7
Hemodyamics and Cardiophysiology

✓ Comprehend the course and laboratory unit objectives.

✓ Peruse through the study guide prior to class attendance.
✓ Analyze the required learning resources; refer to course unit
terminologies for jargons.
✓ Proactively participate in classroom discussions.
✓ Participate in weekly discussion board (Canvas).
✓ Answer and submit course unit tasks on time

At the end of the course unit (CU), learners will be able to:
1. Discuss the pathophysiologic responses of clients with life- threatening conditions, acutely ill,
high acuity and emergency situation due to hemodynamic and cardio physiologic
compromise.
2. Analyze the health status/competence of an adult client with hemodynamic and cardio
physiologic compromise.
3. Formulate a plan of care based on client’s priorities to address the needs/ problems.
4. Institute appropriate corrective actions to prevent or minimize harm arising from adverse
effects.
5. Apply safe and quality interventions to address the client’s identified needs/ problems.
 6. Offer client health education as appropriate for the client with hemodynamic and cardio
physiologic compromise.

Burns, S. (2018) AACN Essentials of Critical Care Nursing. Mc Graw Hill Education.

Hemodynamics
- the study of forces involved in the flow of blood through the cardiovascular and circulatory system.
The circulatory system is controlled by homeostatic mechanisms. The hemodynamic response
continuously monitors and adjusts to conditions in the body and its environment.

Physiologic principles of hemodynamics:

1. Factors that affect myocardial function
2. Regulate BP
3. Determine cardiac performance and cardiac output.

Hemodynamic Monitoring
Hemodynamics or pressure of the cardiovascular and circulatory system can be measure by invasive
methods such as direct arterial BP monitoring, CVP monitoring and indirect measurements of left
ventricular pressures via a flow directed, balloon-tipped catheter (e.g. Swan-Ganz catheter = PAC,
“A-line” catheter = Arterial catheter).

Goals:
1. Ensure adequate perfusion
2. Detecting inadequate perfusion
3. Measure tissue O2
4. Qualifying the severity of the illness
5. Differentiating system dysfunction

The Pulmonary Artery Catheter (PAC) – a tool for observing fluid balance (cardiopulmonary
problems). A balloon-tipped Swan-Ganz catheter is commonly used.
− Standard PAC is 7.0, 7.5 or 8.0 French in circumference and 110 cm in length divided in 10 cm
intervals
− PAC has 4-5 lumens:
a. Temperature thermistor located proximal to balloon to measure pulmonary artery blood
temperature
b. Proximal port located 30 cm from tip for CVP monitoring, fluid and drug administration
c. Distal port at catheter tip for PAP monitoring
 d. +/- Variable infusion port (VIP) for fluid and drug administration
e. Balloon at catheter tip
− Purposes – to detect adequate perfusion, to diagnose and evaluate the effects of therapy
− Parameters measured:
1. Central Venous Pressure (CVP) – the blood pressure in the vena cava; reflects the amount
of blood returning to the heart and the ability of the heart to pump the blood back into the
arterial system
2. Pulmonary Artery Pressure (PAP) - reflects RV function, pulmonary vascular resistance, and
LA filling pressures (measured at the tip of the PAC with balloon deflated)
3. Pulmonary Capillary Wedge Pressure (PCWP) – also known as the pulmonary artery
occlusion pressure (PAOP); provides an indirect estimate of left atrial pressure
− Complications:
1. Dysrhythmias
2. Thromboembolism
3. Mechanical, catheter knots
4. Pulmonary Infarction
5. Infection, Endocarditis
6. Endocardial damage, cardiac valve injury
7. Pulmonary Artery Rupture

Nursing Care
➢ During PAC insertion: check for the signed consent and follow aseptic techniques
➢ Tubing is a source of infection (follow hospital protocol in changing the tubing;
usually after 3-5 days)
➢ Educate client regarding the procedure and catheter care
➢ Monitor the pressures regularly or as indicated
➢ During removal

Review: Anatomy and Physiology of the Cardiovascular System

The heart is a hollow muscular organ located in the middle mediastinum. Being a muscle, it
has contractile ability. Aside from contractility, heart also has properties like conductivity, rhythmicity,
automaticity and excitability. The heart although innervated by the autonomic nervous system has
its own conducting system, the reason why heart transplant has been possible because even if the
hear is removed from its location it will continue to contract. This is made possible by the heart’s
conducting system.

o The heart pumps a constant volume of blood through this system to maintain
balance between oxygen delivery and demand.

A. Functions of the Heart:

o Is to pump blood through the body.
 o The heart is composed of two upper chambers called the atria. And two lower chambers
called ventricles.
o The atria are separated from the ventricles by atrioventricular valves.
o The tricuspid valve separates the right atrium from the right ventricle and the mitral valve
separates the left atrium from left ventricle.
o Two other valves, the pulmonic semilunar and the aortic semilunar, helps control the flow of
blood from the ventricles to the lungs and systemic circulation.

Depolarization – the electrical activation of the muscle cells of the heart and stimulates
cellular contraction.
Repolarization – they return to their original state of electrolyte balance

B. The Heart’s Electrical Conductivity

- Starts with the sino-atrial (SA) node – the pace maker; the one that initiates an impulse.
- Then the impulse travel to the AV node, then to the Bundle of His, to the left and right branches
and finally to the Purkinje fibers.
- These electrical activities stimulate the heart to contract (in the cardiac muscle, impulses are
transmitted by action potential).
Figure 1. Figure 2.

An action potential is the rapid change in the membrane potential. The heart’s membrane
potential is its electrical charge it is about – 60 to -90 mv. Rapid changes in the membrane
potential allow impulses to spread to the heart muscles.

C. Process of Conduction
- When the SA node initiates an impulse, sodium channels open, there will be influx of sodium into
the cardiac cells. This will make the membrane potential more positive, (referred to as
depolarization or phase 0)
- After sodium channels open, calcium channels open causing influx of calcium into the cells
creating a plateau formation in the action potential of the heart (phase 2).
- Then potassium channels open causing efflux of potassium out of the cardiac cells which make
the membrane potential more negative again (referred to as repolarization or phase 3)
- Membrane potential reaches its resting phase (phase 4).
 ✓ This electrical activity stimulates the heart to contract. When impulse travel from SA
node to AV node, the atria depolarize and repolarize this will stimulate the atria to
contract. When impulse travel from AV node to Purkinje fibers, this will stimulate the
ventricles to contract.
✓ One contraction of the atria and one contraction of the ventricle is one heartbeat.
✓ One heart beat represents one cardiac cycle.

D. Cardiac cycle – refers to events taking place in the heart in one heartbeat.
➢ The right atrium receives venous blood from the systemic circulation while the left atrium receives
reoxygenated blood from the lungs.
1. Stroke volume (SV) – the volume of blood that is ejected during systole.
- Factors affecting the stroke volume
a. Preload – this refers to the volume of blood that is already in the heart before it
contracts. This is all the venous return.
✓ Factors affecting preload
1) Position – standing will cause pulling of blood into the lower extremities causing
a decrease preload while supine position increases venous return
2) Breathing – deep inspiration causes an increase in venous return while the
Valsalva maneuver decreases venous return
b. Afterload – this refers to the pressure that must be exceeded by the heart before it
contracts, such pressure is the blood pressure in the aorta. Therefore, if BP increases, the
heart must exert too much pressure to pump blood into the aorta.
✓ Factors affecting afterload
1) Hypertension
2) Atherosclerosis of the aorta
2. Contractility – increase contraction also increases stroke volume and decrease contraction
decreases stroke volume
3. Left ventricular end-systolic volume (LVESV) – the amount of blood that remains in the left
ventricle at the end of systole.
4. Left Ventricular end- diastolic volume (LVEDV) – the amount of blood that is in the ventricle
just before ejection occurs.
5. Ejection Fraction – the portion of the volume it does eject, which is approximately 70 % of the
total volume at the end of diastole.
6. Blood Pressure – defined as the tension exerted by blood on the arterial walls
7. Systemic vascular resistance (SVR) – it is the peripheral vascular resistance that is elevated
when there is vasoconstriction (elevations of SVR increase the workload of the heart and
myocardial oxygen consumption, but when SVR decreases, CO increases in an attempt to
maintain BP)
✓ BP = CO x SVR (Pressure = Flow x Resistance)
✓ Mean Arterial Pressure (MAP) = CO x Total Peripheral Resistance (TPR) or
Systemic vascular resistance (SVR); the average BP
✓ MAP = SP + 2DP BP = CO x TPR or SVR
3
 8. Cardiac Output (CO) – the amount of blood ejected from the heart in 1 minute
9. Stroke Volume (SV) – the amount of blood ejected from the heart with each beat.
➢ Three factors that influence SV:
b. Preload – the filling volume of the ventricle at the end of diastole
c. Afterload – the amount of resistance against which the left ventricle pumps
d. Contractility – defined as the strength of myocardial fiber shortening during systole
✓ Frank-Starling law states “the greater the stretch, the greater the force of next
contraction.”
✓ SVR – Reflection of peripheral vascular resistance and is the opposition to blood
flow from the blood vessels.
Factors affecting Heart Rate
a. Sympathetic & parasympathetic Nervous Systems
b. Thyroid hormones
c. Temperature and exercise

Dysrhythmias
- can be classified into slow and fast dysrhythmias.
- If normal ECG tracings can be identified, then abnormal rhythms can be easily recognized.

SINUS TACHYCARDIA

Rhythm: Regular
Rate: Fast (> 100 bpm)
P Wave: Normal may merge with T wave at very fast rates
PR Interval: Normal (0.12-0.20 sec)
QRS: Normal (0.06-0.10 sec)
Note: QT interval shortens with increasing heart rate

SINUS BRADYCARDIA

Rhythm: Regular
Rate: Slow (< 60 bpm)
P Wave: Normal
PR Interval: Normal (0.12-0.20 sec)
QRS: Normal (0.06-0.10 sec)
SINUS ARRHYTHMIA

Rhythm: Irregular, varying with respiration

Rate: Normal (60-100 bpm) and rate may increase during inspiration
P Wave: Normal
PR Interval: Normal (0.12-0.20 sec)
QRS: Normal (0.06-0.10 sec)
Note: Heart rate frequently increases with inspiration, decreasing with expiration

FIRST DEGREE HEART BLOCK

Rhythm: Atrial and ventricular rhythms regular

PR interval: > 0.20 second
P wave: Precedes QRS complex
QRS: Normal
P : QRS ratio 1:1

SECOND DEGREE HEART BLOCK TYPE 1

Rhythm: Irregular but with progressively longer PR interval lengthening

Rate: The underlying rate
P Wave: Normal
PR Interval: Progressively longer until a QRS complex is missed, then cycle repeats
QRS: Normal (0.06-0.10 sec

SECOND DEGREE BLOCK TYPE 2

Rhythm: Regular (atrial) and irregular (ventricular)
Rate: Characterized by Atrial rate usually faster than ventricular rate (usually slow)
P Wave: Normal form, but more P waves than QRS complexes
PR Interval: Normal or prolonged
QRS: Normal or wide

THIRD DEGREE HEART BLOCK

Rhtthm: No relation between P waves and QRS complexes

Rate: Atrial rate regular; Ventricular rate slow and regular
PR interval: Not constant
QRS interval: Normal
P:QRS ratio more P waves than QRS

BUNDLE BRANCH BLOCK

Rhythm: Regular
Rate: The underlying rate
P Wave: Normal
PR Interval: Normal (0.12-0.20 sec)
QRS: Wide (>0.12 sec)

ATRIAL FLUTTER

Rhythm: Regular or irregular

Rate: Fast (250-350 bpm) for Atrial, but ventricular rate is often slower
P Wave: Not observable, but saw-toothed flutter waves are present
PR Interval: Not measureable
QRS: Normal (0.06-0.10 sec)
ATRIAL FIBRILLATION

Rhythm: Irregular
Rate: Very fast (> 350 bpm) for Atrial, but ventricular rate may be slow, normal or fast
P Wave: Absent - erratic waves are present
PR Interval: Absent
QRS: Normal but may be widened if there are conduction delay

PREMATURE VENTRICULAR CONTRACTION

Rhythm: Irregular
Rate: The underlying rate
P Wave: Absent
PR Interval: Not measurable
QRS: Wide (> 0.10 sec), bizarre appearance
Note: Two PVCs together are termed a couplet while three PVCs in a row with a fast rhythm
is ventricular tachycardia

VENTRICULAR TACHYCARDIA

Rhythm: Regular or irregular

Rate: Fast (100-300 bpm)
P Wave: Absent
PR Interval: Not measurable
QRS: Normal or wide (>0.10 sec), bizarre looking
TORSADES DE POINTES

Rhythm: Irregular
Rate: Fast (200-250 bpm)
P Wave: Absent
PR Interval: Not measurable
QRS: Wide (>0.10 sec), bizarre looking

VENTRICULAR FIBRILLATION

Rhythm: Highly irregular

Rate: Unmeasurable
P Wave: Absent
PR Interval: Not measurable
QRS: None
Note: EcG tracing is a wavy line

ASYSTOLE

Causes of Dysrhythmias:
- Most common: Myocardial infarction.
- Many dysrhythmias can occur without possible cause (usually related to an intrinsic cardiac
disease)

Management for Dysrhythmias

- Requires pharmacologic interventions and defibrillation.
- For slow dysrhythmias, most common drug = atropine sulfate (anti cholinergic that increases HR)
- For fast dysrhythmias like atrial flutter or defibrillation or premature ventricular contractions, the
following anti arrhyhtmic drugs are given:
1. Drugs acting on phase 0 – inhibit depolarization of an abnormal rhythm. Ex. Lidocaine IV
2. Drugs acting on phase 4 – prolong cardiac resting. Ex. Beta blockers by decreasing heart
rate, abnormal rhythms are removed
3. Drugs acting on phase 3 – prolong cardiac repolarization thus slowing down heart rate and
removing the abnormal rhythm Ex. Amiodarone
4. Drugs acing on phase 2 – block Ca channels to stop impulse transmission of the abnormal
rhythm. Ex. Verapamil, Diltiazem
Table 1. Commonly used Medications for Dysrhythmias

Nursing Management:
1. Obtain health history to identify previous occurences, if any, of decreased CO, inlcuding
syncope, fatigue, lightheadedness, dizziness, chest discomfort,a nd palpitations.
2. Identify comordities; i.e. heart disease(s), COPD, etc.)
3. Review the client’s medications that can cause dysrhythmias (i.e. Digoxin).
4. Assess and observe for signs of diminished CO (i.e. changes in LOC).
5. Inspect client’s skin for paleness and temperature (cold).
6. Assess signs of fluid retention (i.e. JVD, crackles and/or wheezes)
7. Auscultate for presence of S4 and S4.
8. Periodic checks of BP and pulse pressures (a declining PP indicates reduced
CO).

Cardiac action potential – refers to rapid change in the membrane potential of the heart

Cardiac output – volume of blood ejected by the heart in one minute

Hemodynamics – the study of the interrelationships and movement of the blood flow
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

Pace maker – the Sino Atrial node, the one that initiates an impulse

Stroke volume – volume of blood ejected by the heart in one beat

Systemic vascular resistance – also referred to a total peripheral resistance, the pressure in the
blood vessels determined by the viscosity of the blood and the size of the vessel diameter

Emergency Nurses Association. (2019). Sheehy’s Manual of Emergency Care, 7th ed. St. Louis:
Elsevier Mosby. pp 504-593

Secomb, T.W. (2016). Hemodynamics, Comprehensive Physiology, 6(2):975-1003. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4958049/#

1. Write down all the regulatory mechanisms that maintain normal blood pressure.
2. Get examples of at least 5 abnormal electrocardiograms. Identify and write the management for
each.
3. Get a case scenario on a client with dysrhythmias of any type and formulate a nursing care plan.
4. Draw and label the parts of a pulmonary artery catheter (PAC). Describe the function(s) of each
part and how hemodynamic measures are obtained. Indicate the nursing care/ management of
a client with a PAC.

Burns, S. (2018) AACN Essentials of Critical Care Nursing. Mc Graw

Hill Education.

Emergency Nurses Association. (2019). Sheehy’s Manual of Emergency

Care, 7th ed. St. Louis: Elsevier Mosby.

Secomb, T.W. (2016). Hemodynamics, Comprehensive Physiology,

6(2):975-1003. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4958049/#

Schumacher, L., & Chernecky, C. C. (2010). Saunders nursing survival guide: critical care &
emergency nursing. St. Louis, Mo.: Elsevier Saunders.