INTRODUCTION

Critically ill patients require continues assessment of their cardiovascular system to diagnose and
manage their complex medical conditions. This is most commonly achieved by the use of direct
pressure monitoring systems, often referred to as hemodynamic monitoring. Heart function is the
main focus of hemodynamic studies. Hemodynamic pressure monitoring provides information
about blood volume, fluid balance and how well the heart is pumping. Nurses are responsible for
the collection measurement and interpretation of these dynamic patient status parameters.

HEMODYNAMIC MONITORING

HEMODYNAMICS
Hemodynamics are the forces which circulate blood through the body. Specifically,
hemodynamics is the term used to describe the intravascular pressure and flow that
occurs when the heart muscle contracts and pumps blood throughout the body. Hemo
-Blood Dynamics - Movement Hemo Dynamics - Movement of blood flow

DEFINITION

Hemodynamic monitoring refers to measurement of pressure, flow and oxygenation of blood

within the cardiovascular system.
OR

Using invasive technology to provide quantitative information about vascular capacity, blood
volume, pump effectiveness and tissue perfusion.

OR
Hemodynamic monitoring is the measurement and interpretation of biological systems that
describes the performance of cardiovascular system

METHODS OF HAEMODYNAMIC MONITORING

 Noninvasive hemodynamic assessment
 Arterial Blood Pressure
 Central Venous Pressure
 The Pulmonary Artery Catheter
 Cardiac Output Measurement
NON INVASIVE HAEMODYNAMIC ASSESSMENT
 Take vital signs
 Precordium Inspect anterior chest for heaves and an increase in visible pulsations
 Palpate the PMI
 Ausultate the aortic, pulmonic, second pulmonic, mitral and tricuspid areas of the
precordium
 Peripheral vascular
 Inspect and palpate the skin for colour, texture, moisture and turgor

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  Palpate the peripheral pulses and check nail bed capillary refill
 Inspect the neck for jugular venous distension
 Auscultate and palpate the carotid arteries

PURPOSES
 Early detection, identification and treatment of life threatening conditions such as heart
failure and cardiac tamponade.
 Evaluate the patient’s immediate response to treatment such as drugs and mechanical
support.
 Evaluate the effectiveness of cardiovascular function such as cardiac output and index.

INDICATIONS
 Any deficits or loss of cardiac function: such as myocardial infarction, congestive heart
failure, and cardiomyopathy.
 All types of shock; cardiogenic shock, neurogenic shock or anaphylactic shock.
 Decreased urine output from dehydration, hemorrhage. G.I bleed, burns or surgery.

SPECIALISED EQUIPMENTS NEEDED FOR INVASIVE MONITORING

 A CVP , pulmonary artery ,arterial catheter
 A flush system composed of intravenous solution, tubing stop cocks and a flush device
which provides for continuous and manual flushing of system.
 A pressure bag placed around the flush solution that is maintained at 300 mmhg pressure;
the pressurized flush system delivers 3-5ml of solution per hour through the catheter to
prevent clotting and backflow of blood into the pressure monitoring system.
 A transducer to convert the pressure coming from artery or heart chamber into an
electrical signal
 An amplifier or monitor which increases the size of electrical signal for display on an
oscilloscope.

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HEMODYNAMIC MONITER
SETUP FOR HEMODYNAMIC PRESSURE MONITORING

 Obtain barrier kit, sterile gloves and correct swan catheter. Also need extra iv pole,
transducer holder, boxes and cables.
 Check to make sure signed consent is in chart , and that patient and or family understand
procedure.
 Everyone in the room should be wearing a mask.

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  Position patient supine and flat if tolerated.
 On the monitor, press “change screen” button, then select “swan ganz” to allow physician
to view catheter wave forms which inserting.
 Assist physician in sterile draping and sterile setup for swan insertion.

 Setup pressure lines and transducers.

 Level pressure flush monitoring system and transducers to the phlebostatic axis.
 Connect tunings to patient when patient is ready to flush the swann.
 While floating the Swann, observe for ventricular ectopic on the monitor.
 After Swann is in place, assist with cleanup and let patient know procedure is complete.
 Obtain all the values. For cardiac output inject 10mls of D5w after pushing the start
button.
 Perform hemocalculations.
 Document findings in ICU flow sheet.

METHODS OF HEMODYNAMIC MONITORING

1.ARTERIAL BLOOD PRESSURE
a)Non Invasive
b)Intra arterial blood pressure measurement

2.CENTRAL VENOUS PRESSURE

3.PULMONARY ARTERY CATHETER PRESSURE MONITORING

NON INVASIVE ARTERIAL BP MONITORING

 With manual or automated devices
 Method of measurement
 Oscillometry (most common)  MAP most accurate DP least accurate
 Auscultatory (korotkoff sounds)
 Combination

NON INVASIVE HEMODYNAMIC MONITORINGLIMITATIONS

 Cuff must be placed correctly and must be appropriately sized
 Auscultatory method is very inaccurate (Korotkoff sound is difficult to hear)
 Significant underestimation in low flow (shock)
 Oscillometric also mostly in accurate ( >5mmhg off directly recorded pressures)

DIRECT INTRA ARTERIAL BP MONITORING

 Intra-arterial BP monitoring is used to obtain direct and continuous BP measurements in
critically ill patients who have severe hypertension or hypotension

PROCEDURE
 Once an arterial site (radial, brachial, femoral, is selected or dorsalis pedis),
collateral circulation to the area must be confirmed before the catheter is placed.

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 This is a safety precaution to prevent compromised arterial perfusion to the area
distal to the arterial catheter insertion site. If no collateral circulation exists and
the cannulated artery became occluded, ischemia and infarction of the area distal
to that artery could occur.
 Collateral circulation to the hand can be checked by the Allen test
 With the Allen test, the nurse compresses the radial and ulnar arteries
simultaneously and asks the patient to make a fist, causing the hand to blanch.
 After the patient opens the fist, the nurse releases the pressure on the ulnar artery
while maintaining pressure on the radial artery. The patient’s hand will turn pink
if the ulnar artery is patent.

COMPLICATIONS
 Local destruction with distal ischemia external hemorrhage massive ecchymosis dissection
air embolism blood loss pain arteriospasm and infection.

 NURSING INTERVENTIONS
 Before insertion of a catheter, the site is prepared by shaving if necessary and by
cleansing with an antiseptic solution. A local anesthetic may be used.
 Once the arterial catheter is inserted, it is secured and a dry, sterile dressing is
applied.
 The site is inspected daily for signs of infection. The dressing and pressure
monitoring system or water manometer are changed according to hospital policy.
 In general, the dressing is to be kept dry and air occlusive.
 Dressing changes are performed with the use of sterile technique.
 Arterial catheters can be used for infusing intravenous fluids, administering
intravenous medications, and drawing blood specimens in addition to monitoring
pressure.
 To measure the arterial pressure, the transducer (when a pressure monitoring system
is used) or the zero mark on the manometer (when a water manometer is used) must
be placed at a standard reference point, called the phlebostatic axis .
 After locating this position, the nurse may make an ink mark on the chest

CENTRAL VENOUS PRESSURE MONITORING

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The CVP, the pressure in the vena cava or right atrium, is used to assess right ventricular
function and venous blood return to the right side of the heart. The CVP can be continuously
measured by connecting either a catheter positioned in the vena cava or the proximal port of
a pulmonary artery catheter to a pressure monitoring system

PROCEDURE
 Before insertion of a CVP catheter, the site is prepared by shaving if necessary and by
cleansing with an antiseptic solution.
 A local anesthetic may be used.
 The physician threads a single lumen or multilumen catheter through the external
jugular, antecubital, or femoral vein into the vena cava just above or within the right
atrium

NURSING INTERVENTIONS
Once the CVP catheter is inserted, it is secured and a dry, sterile dressing is applied.
Catheter placement is confirmed by a chest x-ray, and the site is inspected daily for signs of
infection. The dressing and pressure monitoring system or water manometer are changed
according to hospital policy.
In general, the dressing is to be kept dry and air occlusive.
Dressing changes are performed with the use of sterile technique.
CVP catheters can be used for infusing intravenous fluids, administering intravenous
medications, and drawing blood specimens in addition to monitoring pressure.
To measure the CVP, the transducer (when a pressure monitoring system is used) or the zero
mark on the manometer (when a water manometer is used) must be placed at a standard
reference phlebostatic axis. Point, called the

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After locating this position, the nurse may make an ink mark on the chest

PULMONARY ARTERY PRESSURE MONITORING

 Pulmonary artery pressure monitoring is an important tool used in critical care for
assessing left ventricular function, diagnosing the etiology of shock, and evaluating the
patient’s response to medical interventions (eg, fluid administration, vasoactive medications).
Pulmonary artery pressure monitoring is achieved by using a pulmonary artery catheter and
pressure monitoring system.
PULMONARY ARTERY CATHETER
 Development of the balloon-tipped flow directed catheter has enabled continuous direct
monitoring of PA pressure. Pulmonary artery catheter otherwise known as “swan- ganz
catheter”.

COMPONENTS OF CATHETER
INSERTION OF PAC
 PA monitoring must be carried out in a critical care unit under careful scrutiny of an
experienced nursing staff.
 Before insertion of the catheter , explain to the client that;
 The procedure may be uncomfortable but not painful.
 A local anesthetic will be given at the catheter insertion site. Support of the critically ill
client at this time helps promote cooperation and lessen anxiety.

 
Procedure
 This procedure can be performed in the operating room or cardiac catheterization
laboratory or at the bedside in the critical care unit. Catheters vary in their number of lumens
and their types of measurement (eg, cardiac output, oxygen saturation) or pacing capabilities.
 All types require that a balloon-tipped, flow directed catheter be inserted into a large vein
(usually the subclavian, jugular, or femoral vein); 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.
 (During insertion of the pulmonary artery catheter, the bedside monitor is observed for
waveform and ECG changes as the catheter is moved through the heart chambers on the right
side and into the pulmonary Artery)
 When the catheter reaches a small pulmonary artery, the balloon is deflated and the
catheter is secured with sutures.
 Fluoroscopy may be used during insertion to visualize the progression of the catheter
through the heart chambers to the pulmonary artery.
 After the catheter is correctly positioned, the following pressures can be measured:
 CVP or right atrial pressure
 Pulmonary artery systolic and diastolic pressures, mean pulmonary artery pressure, and
pulmonary artery wedge pressure).

NORMAL RESULTS
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 Normal pulmonary artery pressure is 25/9 mm Hg, with a mean pressure of 15 mm Hg.
 Pulmonary capillary wedge pressure is a mean pressure and is normally 4.5 to 13 mm Hg.

NURSING INTERVENTIONS
 Catheter site care is essentially the same as for a CVP catheter. As in measuring CVP, the
transducer must be positioned at the phlebostatic axis to ensure accurate readings.
 The nurse who obtains the wedge reading ensures that the catheter has returned to its
normal position in the pulmonary artery by evaluating the pulmonary artery pressure
waveform.
 The pulmonary artery diastolic reading and the wedge pressure reflect the pressure in the
ventricle at end diastole and are particularly important to monitor in critically ill patients,
because they are used to evaluate left ventricular filling pressures (preload)
 At end-diastole, when the mitral valve is open, the wedge pressure is the same as the
pressure in the left atrium and the left ventricle, unless the patient has mitral valve disease or
pulmonary hypertension.
 Critically ill patients usually require higher left ventricular filling pressures to optimize
cardiac output. These patients may need to have their wedge pressure maintained as high as
18 mm Hg.

COMPLICATIONS

Infection pulmonary artery ruptures pulmonary thromboembolism pulmonary infarction

catheter kinking, dysrhythmias, and air embolism.

TECHNIQUES WITH PULMONARY ARTERY CATHETER

CARDIAC OUTPUT MONITORING THERMODILUTION CONTINUOUS CARDIAC

OUTPUT MONITORING FICK'S CARDIAC OUTPUT MEASUREMENT

. DERIVED PARAMETERS
 Cardiac o/p measurements may be combined with systemic arterial, venous, and PAP
determinations to calculate a number of variables useful in assessing the overall
hemodynamic status of the patient.
 They are, Cardiac index = Cardiac output / Body surface area
 Systemic vascular resistance = [(Mean arterial pressure - resistance CVP or rt atrial
pressure)/Cardiac output] x 80
 Pulmonary vascular resistance = [(PAP - PAWP) / Cardiac vascular resistance output] x 80
 Mixed venous oxygen saturation (SvO2) (SvO2 = SaO2 - [VO2 / (1.36 x Hb x CO)] (6)

NURSING RESPONSIBILITIES
Site Care and Catheter Safety:

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 A sterile dressing is placed over the insertion site and the catheter is taped in place. The
insertion site should be assessed for infection and the dressing changed every 72 hours and
prn.  The placement of the catheter, stated in centimeters, should be documented and
assessed every shift.
 The integrity of the sterile sleeve must be maintained so the catheter can be advanced or
pulled back without contamination.
 The catheter tubing should be labeled and all the connections secure. The balloon should
always be deflated and the syringe closed and locked unless you are taking a PCWP
measurement

Patient Activity and Positioning:

 Many physicians allow stable patients who have PA catheters, such as post CABG
patients, to get out of bed and sit. The nurse must position the patient in a manner that avoids
dislodging the catheter.
 Proper positioning during hemodynamic readings will ensure accuracy.

Dysrhythmia Prevention:
 Continuous EKG monitoring is essential while the PA catheter is in place.
 Do not advance the catheter unless the balloon is inflated.
 Antiarrhythmic medications should be readily available to treat lethal dysrhythmias.

. Monitoring Waveforms for Proper Catheter Placement:

 The nurse must be vigilant in assessing the patient for proper catheter placement. If the PA
waveform suddenly looks like the RV or PCWP waveform, the catheter may have become
misplaced. The nurse must implement the proper procedures for correcting the situation.

Monitoring Hemodynamic Values for Response to Treatments:

 The purpose of the PA catheter is to assist healthcare team members in assessing the
patient’s condition and response to treatment. Therefore, accurate documentation of values
before and after treatment changes is necessary.
 Assessing the Patient for Complications Associated with the PA Catheter:
 Occluded ports
 Balloon rupture caused by overinflating the balloon or frequent use of the balloon.

Pneumothorax - may occur during initial placement. Dysrhythmias - caused by catheter

migration

Air embolism - caused by balloon rupture or air in the infusion line.

Pulmonary thromboembolism - improper flushing technique, non-heparinized flush solution.
Pulmonary artery rupture - perforation during placement, overinflation of the balloon,
overuse of the balloon. Pulmonary infarction - caused by the catheter migrating into the
wedge position, the balloon left inflated, or thrombus formation around the catheter which
causes an occlusion.

 CONCLUSION

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 Hemodynamics is the forces involved in blood circulation. Hemodynamic monitoring started
with the estimation of heart rate using the simple skill of 'finger on the pulse' and then moved
on to more and more sophisticated techniques like stethoscope, sphygmomanometer, ECG
etc. The status of critically ill patients can be assessed either from non-invasive single
parameter indicators or various invasive techniques that provide multiparameter
hemodynamic measurements. As a result, comprehensive data can be provided for the
clinician to proactively address hemodynamic crisis and safely manage the patient instead of
reacting to late indicators of hemodynamic instability
REFERENCE

 Black MJ,Hawks HJ.Medical Surgical Nursing .8th ed.Haryana :ELSEIVER

publications ;2014 page no: 1532-37
 Lewis Ls ; “Medical Surgical Nursing”, 7th edition(2011): page no: 597-618.

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