HEMODYNAMICS

NURSING CARE GUIDELINES

 CENTRAL VENOUS PRESSURE

 Central Venous Pressure

(CVP) – is the pressure within
the right atrium and
represents the filling
pressure of the right
ventricle.
INDICATIONS
 Estimates blood volume deficits
and status after surgery.
 Determines pressures in the RA
and RV filling Pressure
Normal Values:
 Serves as a guide for fluid 2-6 mmhg
replacement. 5-12 cmH2O
 Serves as a route for
hyperalimentation
 CATHETERIZATION SITES

 Peripheral arm veins

Basilic, cephalic, median,
cubital or axillary

 Peripheral leg veins

Femoral, saphenous

 Peripheral neck vein

External jugular

 Central neck vein

Internal jugular

 Central chest vein

Subclavian vein

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 Increased CVP:  Decreased CVP:
RV Failure Reduced Circulating Blood Volume
 Volume Overload (Hypovolemia)
 Tricuspid Stenosis
 RV infarct
 Constructive Pericarditis
 Pulmonary Hypertension
 Cardiac Tamponade
POSSIBLE COMPLICATIONS:
CAUSE PREVENTION
 Infection on the *Irritation of insertion site *Strictobservance of aspetic
site of insertion or vein or break in aseptic technique
technique *Always wash hands before
 Pneumothorax
and after manipulation
•Usually associated with
subclavian insertion and Prevent patient from moving
accidental injection of air unnecessary during the
into the pleural space or procedure.
laceration of the lung apex
 Dsyrrythmia
•Irritation of the •Monitor ECG tracings.
endocardium by the
catheter
 TROUBLE SHOOTING OF CVP LINE
PROBLEMS CAUSE NURSING ACTION /
RATIONALE
1. Central Line does  Kinks  Relieve line of kinks
not flow  Make sure that stopcocks is
“ON” towards the patient
and IVF
 Clots  Make sure that IV fluid is
running on the desired rate.
 Withdraw clot from the Iv
line. Never push the IV line
because it can cause
embolus.
 Improper potion of
2.CVP reading appears the patient and  Place the patient flat on
to be inaccurate manometer bed if tolerated or place the
transducer or manometer in
line with phelbostatic axis.
 Bubbles/ Clots / Kinks  Ascertain that the lines are
free from bubbles, clots or
kinks.
3. Bleeding back into  Leaks or IV fluid has  Check the connections if
the infusion run dry or was they are secured
disconnected
How to Measure CVP
using a Manometer

1. Position the patient flat on bed if the

patient can tolerate. If not use baseline
position.
2. Connect CVP Manometer to the 3-way
stopcock and position CVP at the level
of the right atrium or at the
phlebostatic axis.
3. Turn the stopcock towards the
intravenous fluid. Fill the manometer
with up to 10cm H2O or above the
anticipated reading.
4. Turn the Stopcock towards the patient
and observe the fall in the height of the
column of the fluid in the manometer.
5. Record the level where the solution
stabilizes or stops moving downward.
6. Turn the stopcock on towards the
patient and IVF and regulate the flow.
 ARTERIAL PRESSURE
(ALINE)

 Arterial Pressure (A-Line) - is a

direct monitoring device which permits
continuous measurement of systolic.
diastolic and mean pressure.
Determines left ventricular afterload
and workload of the heart.

 Indications:
 Obtains continuous blood pressure
reading. For patients with unstable
hemodynamics (shock; blood loss)
 Access for blood samples (Arterial
Blood Gas Analysis or other blood
works)

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COMMON A-LINE SITES

Radial Artery

Ulnar Artery

Brachial Artery

Femoral Artery

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 TROUBLESHOOTING OF A-LINE
POSSIBLE CAUSE TROUBLESHOOTING
COMPLICATIONS
 Arterial  Loose Connections  Check entire system. Secure
Bleeding connections at all times.

 Oozing around the  Assess oozing around catheter

insertion site and insertion site or soaked
system connection dressing.

 Infection  Failure to maintain  Maintenance of aseptic

Aseptic technique technique at all times. Do
during Aline handwashing at all times.
insertion, set-up ,
tubing changes or
blood withdrawal
 Air Embolism  Entry of air into the  Check entire system and
system secure connections. Vent
bubbles through stopcocks
 Assess patient for symptoms of
air embolism such as
11/21/2023hypotension weak and rapid
 Arterial Spasam or  Over distension of  Immobilize insertion
Thrombosis artery walls site to prevent arterial
wall irritation .
 Check extremity distal
to insertion site for
color, pulse, sensation
and temperature
 Damped waveform  Aline not calibrated,  Check connections.
pressure bag deflated or Always flush the tubing
presence of blood clot after blood withdrawal.
inside the tubing Recalibrate Aline on the
monitor.
 Loss of waveform  Loose connections,  Check patency of line.
accidental removal of  Check position of Aline
Aline, line not patent. and transducer. Always
recalibrate the system
 Clot formation  Tubing not flushed after  Aspirate the line until
blood withdrawal, clot is removed. Then
Pressure bag deflated, flush the system. Check
Heparinzed solution connections at all times.
consumed Do not allow Aline to dry
out.
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 How to Extract Blood from
Arterial Line
1. Get a 10ml syringe, remove the needle and place it at the
center of the stopcock that is nearest to the patient.
2. Open the stopcock towards the patient and obtain a blood
sample around 10 ml of blood and discard extracted blood if
there is a visible clot formation do not flush specimen back to
the patient.
(Note that this blood sample contains heparin and cannot be used
as a specimen for ABG and other laboratories. Results will vary
and be inaccurate if this is sent to the laboratory)
3. Close the stopcock. Using another 10 ml of syringe extract
another 10 ml of fresh blood. Place blood samples immediately
inside tops and send specimens to laboratory.
4. Close the stopcock and if there is no clots noted inside the first
specimen obtain you may flush the specimen back towards the
patient and flush the system/ tubing using the transducer. Make
sure that the tubing are clear and no strikes of blood is seen to
avoid clot formation.
 COMMON SITES OF INSERTION

 Jugular Vein

 Subclavian Vein

 Femoral Vein

 Antecubital Vein
Parts and Function of
Swan-Ganz Catheter
 Proximal Lumen (BLUE)
Measures CVP or right heart
pressure.
Route
for IV fluid infusion and
medication
 Distal Lumen (YELLOW)
 Measures PA pressures
 Access for obtaining mixed
venous blood sample
 Balloon Inflation Lumen
(RED)
 Measures pulmonary capillary
wedge pressure (PCWP)
 Assesses LV Function
 Thermistor Connector
Lumen (4-Lumen Catheter)
 Contains temperature-
sensitive wires which feed
information into a computer
for cardiac output
Measurements
 Pacemaker Wire Lumen
(5 Lumen Catheter)
 Provides a port for pacemaker
electrode or measurement of
mixed venous oxygen
saturation with opticath catheter

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 Indications of Swan-Ganz Catheter

 Obtains pressure measurements in the RA, RV, Pulmonary Artery and the
Pulmonary Capillary.

 Evaluates responses/ effects of fluid replacement and medications

 Measures cardiac output n thermodilution technique

 Serves as access in obtaining mixed venous blood samples and as an

access site for iv fluid and medication administration

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 Normal Values & Indications
 Right Atrial Pressure (RAP)
= 0 – 8 mmHg
 Increased RAP: Volume
overload, RV failure, Tricuspid
stenosis, Pulmonary HPN, LV Failure,
Constrictive Pericarditis
Decreased RAP: Hypovolemia
 Right Ventricular Pressure
(RVP) = 20 – 30 mmHg
0 – 8 mm Hg
 Increased RVP : Pulmonary HPN,
RV Failure, Constrictive Pericarditis
Chronic CHF
 Pulmonary Artery
Pressure (PAP) = 20 – 30 mmHg
8- 15 mmHg
 Increased PAP: L to R shunt,
LV Failure, Mitral Stenosis,
Pulmonary HPN
• Important in evaluating patients
in cardiogenic shock, severe
LV Failure and Ventricular
Septal Rupture
 Pulmonary Capillary
Wedge Pressure (PCWP)
= 4- 12 mmHg
 Increased PCWP: LV Failure
Mitral Insufficiency,
Mitral Stenosis
PCWP reflects atrial pressure or
left ventricular filling pressure
 How to Monitor PA Pressure
1. Position the Patient flat on bed, or use baseline position if not tolerated.

2. Position the transducer at the level of the RA (mid-axillary line) or phlebostatic

level

3. Gently inflate the balloon catheter about 1.5 ml of air and observe the waveform
changes from PA to PCW. (Note: do not overinflate the balloon it may cause super
wedge waveform leading to inaccurate data and may rupture the balloon.

4. Deflate the catheter as soon as reading is obtained. Prolonged wedging may cause
pulmonary artery ischemia or arrthymia.

5. Document initial reading, medications given and untoward incidences.

6. Maintain pressure bag at 300 mmHg to deliver heparinized flushing 3cc/hr thus
preventing clot formation and backward flow of blood in the system.

7. Monitor for leaks, air bubbles clots and security of connections to prevent air
embolism or accidental bleeding or clotting. Monitor ECG tracing for dysrrthmias.

8.Prevent infection of the site. Change dressing daily observe for signs of infection.
always maintain aseptic technique

9. Assess involvement if extremity color, temperature , capillary filling and sensation

due to inadequate flow. 11/21/2023
 TRANSDUCER
CALIBRATION
 Wash hands thoroughly
 Make sure the transducer is
at the level of the Right
Atrium
 Open the stopcock to the
atmosphere and close to the
patient. Press the “0”
reading which means
calibrated.
 Immediately turn the
stopcock and open to the
patient and close to the
atmosphere and flush, Ensure
the system is free from blood
and clots

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 Cardiac Monitor with
Hemodynamic Monitoring

Arterial Line

p Pulmonary
Artery Pressure

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Hemodynamic Waveforms
Possible Complications and Nursing Care
COMPLICATION CAUSE NURSING CARE
1. Local Infection  Irritation of insertion site or  Strict observation
vein of aseptic
 Break in aseptic technique technique.
 Always wash hands
before
manipulation
2. Pneumothorax/  Usually associated with  Prevent patient
Hemothorax subclavian insertion and from moving during
accidental injection of air into insertion of Swan-
the pleural space or laceration Ganz
of the apex of the lung
3. Arrthymias (Premature  Irritation of the endocardium or  Monitor ECG tracings
Arterial /Ventricular heart valves by the catheter constantly and keep
crash cart and
Contractions)  Catheter falling back into the RV defibrillator on
and PA standby
4. Pulmonary Artery  Over distention of artery walls  Inflate the balloon
 Migration of catheter into small slowly just enough to
Perforation obtain PCWP to
artery branches minimize stress on
 Due to pulmonary HPN in some artery walls.
patients  Never fill the balloon
with fluids
5. Pulmonary Infarction  Frequent prolonged wedging of
the catheter
or Hemorrhage
 Over inflation of the balloon
 Thrombus formation within or
around the catheter
 Migration of the catheter into
small artery branches
6. Pulmonary Embolism/  Migration of thrombus from the
Thrombophlebitis catheter to the blood vessels
7. Balloon Rupture and  Over inflation of the balloon and
Air Embolism thin latex material of the balloon
gradually looses elasticity in
prolonged use
8. Endocarditis  Mechanical irritation of the
endocardium in combination
with bacterial growth
 Deflate balloon
immediately after
recording of PCWP
 Inflate with 1.5ml of air
only
 Try to aspirate blood if
you suspect clotting
 Obtain CXR and refer if
with catheter migration
 Never flush catheter if
you suspect clotting,
aspirate instead
 Always inflate the
balloon gradually.
 Do not over inflate.
 If possible the catheter
should be used not
more than 72 hours.
 Maintain strict aseptic
technique
 Trouble Shooting of Potential Problems
PROBLEM CAUSE NURSING ACTION/ RATIONALE
1. No tracing, damped  Incorrect position 

Ensure the stopcock is open towards the patient and IVF
Make sure the connections are tight
of stopcocks
tracing, reduced wave  Loose connection  Instruct the patient to avoid unnecessary movements.
fluctuation  Aspirate bubbles, never flush
of tubing/  Ensure pressure bag has 300mmHg pressure to prevent
stopcocks backflow
 Always calibrate

2. Failure to wedge  Balloon rupture as  Never inflate the balloon with water as it may cause air
embolism
manifested by
 Label the syringe that balloon is ruptured
decreased or no
resistance when
inflated

3. Permanent wedge  Balloon 


Ensure the balloon is deflated at all times.
Turn the patient side to side
inadvertently
tracing inflated  Elevate the height of the bed from 15-90 degrees.
Always calibrate.
 Catheter  Instruct patient to take deep breaths and to cough or
migration into the ambu bag several times if intubated
smaller pulmonary  If above fails inform the doctor CXR may be done to
vessels verify the positioned Catheter may be repositioned by
doctor

4. Migration into the  Displacement into  Inform the doctor

the RV manifested  Observe for ventricular dysrrthmias. Keep
RV by decreased or Lidocaine on standby.
no resistance  Inflate the balloon to help decrease irritability;
when inflating catheter might float forward the Pa
 Facilitate CXR to verify potion. May require
11/21/2023repositioning by the doctor
 Thank You
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