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Course: Medical Surgical Nursing

Topic: Hemodynamic Monitoring

The Nurses International Community

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COPYRIGHT

NI Privacy Policy and Terms of Use.

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Module Goals

Learners will be able to

Discuss central venous pressure monitoring.
Discuss pulmonary artery pressure monitoring.
Discuss Intra-arterial blood pressure monitoring.

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Central Venous Pressure (CVP) Monitoring

Measure of pressure in the vena cava
CVP is used to:

assess preload and right atrial pressure
monitor hemodynamic status
guide fluid resuscitation.

Can be measured via central venous catheter (CVC), ultrasound.
A normal CVP reading is between 8 to 12 mmHg.
Elevated CVP indicates myocardial contractile dysfunction and/or fluid retention.
Low CVP indicates volume depletion or decreased venous tone.

Shah and Louis, 2022

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Use of Central Venous Catheter (CVC)

Uses:

administration of intravenous fluids
medications
blood products
parenteral nutrition
vasoactive medications
hemodialysis
hemodynamic monitoring

Ball and Singh, 2022

Insertion sites:

internal jugular vein
subclavian vein
femoral vein

To prevent infection:

skin cleansing prior to insertion
keep insertion site dry and clean
use permeable dressing
flush the lumen
routine inspections

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Procedure

Place client’s upper body at a 45-degree angle to the bed
Zero the transducer before insertion
Assess CVC every 8 hours
Continuously monitor the CVP waveform
Obtain hemodynamic value hourly
Change the hemodynamic monitoring system every 96 hours
Provide a dynamic response test before each shift
Maintain pressure device at 300 mm Hg

McVay, 2021

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Interventions

Training of healthcare professionals
Creation of a CVC care team
Thorough skin preparation (cleansing)
Use of sutureless securement devices
Implementation of a catheter site dressing regimen
Regular client cleansing after insertion of catheter
Avoid regular replacement of catheters

Ball and Singh, 2022

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Pulmonary Artery Pressure (PAP) Monitoring

Measure of pressure in the pulmonary artery
Important tool for diagnosing and monitoring:

heart conditions
lung conditions

Pulmonary arterial pressure (mPAP) ≥25 mmHg at rest indicates pulmonary hypertension
PAP can be measured via an intravascular catheter (pulmonary artery catheterization)

Simonneau et. al, 2019

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Procedure for Pulmonary Artery Catheterization

Selection of site for catheter insertion:

femoral
jugular
antecubital
brachial

Sterilization and barrier techniques on site.
Flushing of needles, access sheaths, and catheters.
Catheter is advanced through the sheath into the vein.
Balloon is inflated approximately 15 cm to ensure catheter advances to the right atrium easier.
Conducted under fluoroscopy or at the bedside.

Mani and Chaudhari, 2023

Ziccardi and Khalid, 2022

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Indications

Risks and complications

Procedure used to diagnose and monitor:

pulmonary hypertension
heart failure
various lung diseases
effectiveness of various medications or surgery

Ziccardi and Khalid, 2022

bleeding
infection
pneumothorax
hemothorax
air embolism
blood clots

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Interventions

Pulmonary hypertension does not have a cure, but there are several treatment options available. These include:

Inhaled medicine
Medicine given through the veins under the skin
Medicine to reduce swelling in the feet (diuretics)
Oxygen therapy

CDC, 2019

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Intra-arterial blood pressure monitoring

The measure of blood pressure directly from the artery.
Conducted through cannulation of a peripheral artery (catheterization).
Reviews indications and contraindications to the placement of an arterial catheter.
Produces beat-to-beat arterial waveforms and numerical pressure.

Nguyen and Bora, 2022

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Procedure for Intra-arterial blood pressure monitoring

Selection of site for catheter insertion:

radial artery
brachial artery
femoral artery
dorsalis pedis artery

Sterilization and barrier techniques on site
Flushing of needles, access sheaths, and catheters
Catheter is advanced through the sheath into the vein
Catheter is connected to the transducer to monitor blood pressure

Devasahayam et. al, 2020

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Indications

Risks and complications

Procedure used to diagnose and monitor:

critically ill clients
clients treated with vasoactive medications
surgical clients with increased risk of morbidity or mortality
clients requiring frequent lab draws

Nguyen and Bora, 2022

Artery damage
Bleeding
Blood clots
Blood loss
Infection
Lack of collateral circulation

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Interventions

Fluid management
Monitor the effectiveness of medication use
Monitoring of blood levels
Treatment of electrolyte imbalances
Evaluating a client's responsiveness to fluid resuscitation, administration of blood products and calcium.

Nguyen and Bora, 2022

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Case Study/ Critical Thinking Question/ What Would the Nurse Do?

Discuss the significance of pulmonary artery pressure.

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The pulmonary artery pressure is a measurement that provides important information about the function and condition of the pulmonary circulation. It represents the pressure within the pulmonary artery, which carries deoxygenated blood from the right ventricle of the heart to the lungs for oxygenation.

The significance of pulmonary artery pressure lies in its ability to reflect various conditions and diseases affecting the pulmonary vasculature and heart function. Here are a few key points regarding the significance of pulmonary artery pressure:

Assessment of Pulmonary Hypertension: Pulmonary artery pressure is crucial in diagnosing and monitoring pulmonary hypertension, a condition characterized by elevated pressure in the pulmonary arteries. Increased pulmonary artery pressure can be an indication of pulmonary vascular disease, such as primary pulmonary hypertension, secondary pulmonary hypertension (due to underlying heart or lung conditions), or chronic thromboembolic pulmonary hypertension.
Evaluation of Heart Function: Pulmonary artery pressure indirectly provides insights into the function of the right side of the heart, particularly the right ventricle. Elevated pulmonary artery pressure may suggest right ventricular dysfunction or failure, which can occur in conditions such as right-sided heart failure, pulmonary valve disease, or pulmonary embolism.
Monitoring Response to Treatment: Serial measurements of pulmonary artery pressure can help assess the response to treatment in patients with pulmonary hypertension or heart failure. A decrease in pulmonary artery pressure over time may indicate the effectiveness of therapy, while persistent or increasing pressure may suggest inadequate management.
Prognostic Indicator: Pulmonary artery pressure measurements have prognostic value in predicting outcomes for patients with certain cardiovascular conditions. Higher pulmonary artery pressures are associated with increased morbidity and mortality rates, especially in cases of severe pulmonary hypertension or advanced heart failure.
Guiding Interventions: Pulmonary artery pressure can guide the decision-making process for interventions such as the use of vasodilators, diuretics, or inotropic agents to optimize cardiac function and reduce pulmonary vascular resistance.

In summary, the significance of pulmonary artery pressure lies in its ability to provide valuable information about the status of pulmonary circulation, assess heart function, guide treatment decisions, monitor response to therapy, and serve as a prognostic indicator in various cardiac and pulmonary conditions.

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Red Flags

Sudden increase or decrease in CVP, PAP or blood pressure.
Abnormal heart rate
Signs of bleeding

Pinsky, 2015

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures, talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures, family members play a large role in healthcare decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting and following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may affect health-seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be okay in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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References

Agency for Healthcare Research and Quality (AHRQ). (2020). Health Literacy Universal Precautions Toolkit, 2nd Edition. https://www.ahrq.gov/health-literacy/improve/precautions/tool10.html

Ball, M., & Singh, A. (2022). Care Of A Central Line. https://www.ncbi.nlm.nih.gov/books/NBK564398/

Centers for Disease Control and Prevention. (2019). Pulmonary Hypertension. https://www.cdc.gov/heartdisease/pulmonary_hypertension.htm

Devasahayam, S., Surekha, C., Baskaran, B., Gangadharan, N., Mukadam, F. A., & Subramani, S. (2022). Intra-Arterial Blood Pressure Measurement: Sources of Error and Solutions. Medical & Biological Engineering & Computing. https://doi.org/10.1007/s11517-022-02509-z

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References

Mani, B. C., & Chaudhari, S. S. (2023). Right Heart Cardiac Catheterization. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557404/

McVay, R. (2021). Central Venous/Right Atrial Pressure Monitoring. https://www.aacn.org/docs/Photos/Procedure-67-hgavcgfd.pdf

Nguyen, Y., & Bora, V. (2023). Arterial Pressure Monitoring. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK556127/

Pinsky, M. (2015). Functional Hemodynamic Monitoring. Critical Care Clinic. doi: 10.1016/j.ccc.2014.08.005

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References

Shah, P., & Louis, M. A. (2023). Physiology, Central Venous Pressure. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519493/

Simonneau, G., Montani, D., Celermajer, D. S., Denton, C. P., Gatzoulis, M. A., Krowka, M., Williams, P. G., & Souza, R. (2019). Haemodynamic Definitions and Updated Clinical Classification of Pulmonary Hypertension. Eur Respir J, 53(1), 1801913. doi: 10.1183/13993003.01913-2018

Rodriguez Ziccardi, M., & Khalid, N. (2023). Pulmonary Artery Catheterization. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482170/

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