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159 Cards in this Set
- Front
- Back
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What is the normal value for SVR
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800-1200
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Normal value for cardiac index
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2.5-4.0
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A swan ganz catheter sits in this area of the heart
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Pulmonary Artery
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THis is the measurement of left sided preload
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wedge pressure and PAD
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This intervention would be appropriate in an attempt to decrease a patients afterload
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vasodilators
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It is the volume of blood pumped out of the left ventricle each minute
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cardiac output
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preload is made up of these componenets
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CVP, PAWP, RAP
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This intervention would be appropriate in an attempt to increase a pts after load
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fluid, vasopresser (EPi, norepi, levo, vaso, neo, dopamine 10-20 mcg
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Normal range for SVO2
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60-80%
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Intervention would be appropriate when trying to increase a pts contractility
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Inotrope B1 (Milronone, dopamine 5-10
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Afterload is made up of these components
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SVR, PVR (Pulmon ary Vascular resistance), MAP (pressure in aorta afterload)
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This is the equivalent to end diastoylic volume
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preload
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Normal value for PAP
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(15-25)/(8-15)
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Intervention would be appropriate when trying to decrease a pts preload
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Diuretic, vasodilator, inotrope
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Hemodynamic component can tell us how well our organs and cells are extracting O2 from Hgb?
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SVO2
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This intervention would be primary tx for a RAP/CVP of 2
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give fluid
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This hemodynamic value is the force that the left ventricle must overcome to pump blood to the rest of the body
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afterload
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normal range for CVP and RAP
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2-6
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This intervention is appropriate when trying to increase a pts preload
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volume
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A CO of 4.5 with a SVO2 of 50$ is adequate?
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no bc your SVO2 is low and hasnt shown clinically yet
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Treatment for R side heart attack
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FLUIDS
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Treatment for L side heart attack
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inotrope, vasodilate, Beta Blocker
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When priming pressure tubing normal saline should initially be primed under this type of pressure
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gravity
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This intervention would be the most appropriate initial tx for a PAOP of 17.
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Diuretics
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This type of ventialtion produces a positive wedge wave form
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Mechanical Positive pressure
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This is the process for wave and number selection in CO monitoring
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average of 3 waves withing 10% of eachother
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This action is routinely done to verify accuracy of waveform?
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Square wave form test
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If a square wave form test is too spikey
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Underdamp & gives you a falsely high systolic bp
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This waveform would be the correct wave form to pull back a swan cath to in the event it is migrated into the right ventricle
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RA waveform
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When measuring hemodynamic waveform it is important to take the measurement at this phase of the respiratory cycle
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end expiratory bc it has the least amount of interference with REspiratory Cycle
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A high preload, low CO, and high SVR are indicative of this type of shock
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cardiogenic shock, pump is the problem, give an inotrope
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injectate should be administered over this amount of time and when do you push?
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4 seconds start at end expiration push over the respiratory cycle
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Injectate is always administered through this port on a swan?
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Blue or proximal Port!!!
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In thermodilution cardiac output monitoring a larger curve indicates this
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low cardiac output
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this term refers to a nursing action which clears the transducer of atmospheric pressure
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zeroing the line
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Continuous CO monitoring is also capable of continuously monitoring this specific value
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SVO2
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This device takes a mechanical impulse and converts it to an electrical signal
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transducer
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A low average preload, low SVR and high CO are indicative of this type of shock,
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beginning Septic shock....give fluids first
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This is the most deadly adverse event caused by a PAC
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Pulmonary Artery Infarct
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This is the landmark for the proper placement of transducer
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Phlebo axis 9$th intercostal space or mid chest for fat peopl
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Low preload, high SVR, Low CO?
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Hypovolemic shock....give fluid
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These 3 types of distributve shock
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septic neurogenic and anaphylactic
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This type of CO monitoring uses a solution referred to as injectate
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thermodilution
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What is the formula for MAP
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SBP+2DBP/3
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What is the average numbers for CVP or RAP
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2-6
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What is the normal wedge pressure
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6-12
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what is the normal Cardiac Output
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4-8
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what is the normal SV
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60-100
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what is normal SVI
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35-60
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Afterload
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describes the resistance that the heart has to overcome, during every beat to send blood to the aorta. These resistive frorces include vasoactivity and blood viscosity
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Central Venous Pressure
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readings are used to approximate the Right Ventricular end diastolic pressure
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Low CVP means
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hypovolemia or decreased venous return
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High CVP means
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overhydration, increased venous return or right sided cardiac failure
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MAP
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reflects changes in the relationship between cardiac output and systemic vascular resistance and reflects the arterial pressure in the vessels perfusing the organs
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Increased PA pressure may indicate
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a left to right cardiac shunt, pulmonary hypertension, COPD or emphysema, PE, Pulmonary edema, Left ventricular failure
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Wedge pressures are used to approximate
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left ventricular end diastolic pressure
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High wedge may indicate
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left ventricle failure, mitral valve pathology, and cardiac insufficiency, cardac compression post hemorrhage
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Pulmonary vascular resistance
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the measurement of resistance or the impediment of the Pulmonary vascular bed to blod flow
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High Right ventricular Pressure
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pulmonary hypertension, right ventricle failure, and congestive heart failure
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An increased SVI my be indicative of
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early septic shock, hyperthermia, hypervolemia, or by meds
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decreased SVI may be bc of
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CHF, late septic shock, beta blockers or MI
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Increased SVR may mean
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vasoconstrictors, hypovolemia, or late septic shock
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decreased SVR may mean
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early septic shock, vasodilators, morphine, nitrates or hypercarbia
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What does the square wave test do
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test determines if the tubing is transmitting an accurate frequency and should be performed when values are obtained.
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What do you do for an overdamped waveform
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1. Check for blood clots
2. use low compliance short tubing 3 Connect all line components securely 4. Check for kinks in the line |
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What do you do for an underdamped system
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remove all airbubbles, use large bore, shorter tubing or use a damping device
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What vessels return blood to the heart
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superior vena cava, inferior vena cava, coronary sinus
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When is there the most volume in the heart
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end of diastole right before systole
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End diastole
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period of time when valves are open when equal amounts of volume
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When is the body hypermetabolic
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pain, infection, stress, damage, critical illness
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Normal pulse pressure
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40
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Frank-starling law
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length of the myocardial fibers is directly proportional to the strength of the cardiac contraction...balloon stretching
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If patient has low EF then what to give better SV
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inc preload....fluid
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What are released when cardiac output is low to compensate and increase SV
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catecholimines...epi and norepiniphren
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cardiac output is inversely proportional to
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SVR
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What is BP made up of
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resistance, flow, volume
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5 types of invasive hemodynamic monitoring
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1. Central venous pressure
2. Arterial pressure 3. Pulmonary Artery Catheter 4. SVO2 5. Cardiac Output |
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2 types of CVP monitoring
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Swan Ganz (PAC) or triple lumen
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Triple lumen Brown port
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Most distal, measure pre load of R side of heart
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CVP is measured with
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Triple Lumen Catheter
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RAP is measured with
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PAC
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Blue Port of Swan Ganz
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RAP, proximal....sits at the top of R atrium..
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Yellow Port of Swan Ganz
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Monitors PAP, Directly Pulmoary artery pressure..most de oxygenated blood
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White port of Swan Ganz
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RA infusion port (distal)
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Red Port of Swanz
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measures LAP (Wedge or PAOP)
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Purple Port of Swan Ganz
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Right Ventricle infusion Port
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How do we decrease Preload
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Diuretics, vasodilate (npride, nitrates, morphone, milrinone, Natrecor), & PEEP (dec venuous return)
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If pt is on more than 10 of PEEP then
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subtract 5 from CVP
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How do we inc preload
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Fluids, vasoconstrict, blood products, trendelinberg
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SVR calculation
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(MAP-CVP)/CO * 80
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how do we inc afterload
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volume, vasoconstrictors
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3 Factors that affect Cardiac output
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1. COntractility
2. Preload/volume 3. afterload |
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What are 3 factors that affect SV
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1. hr
2. preload/volume 3. contractility |
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How do you increase stroke volume
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1. Volume
2. Inotropes 3. Vasodilators 4. vasopressors |
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How do you decrease stroke volume
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1. diuretics
2. Negative inotropes |
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An increase n afterload tends to inc stroke volume and cardiac output
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false
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Afterload may be best described as
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the impedance of ejection of blood from the Left ventricle
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The hemodynamic parameter that clinically measures afterload is
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SVR
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Increased preload usually corresponds to increased contractility
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true
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1 word to describe preload
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volume
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1 word to describe afterload
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resistance
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6 reasons for increasure CVP/RA pressures
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1. volume overload
2. RV and/or LV failure 3. Tricuspid stenosis 4. Pulmonary hypertension 5. Cardiac Tamponade 6. Transducer inappropriately zeroed |
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2 reasons for Decreased CVP/RA pressure
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1. hypovolemia
2. Transducer inapporpriately leveled |
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CVP/RAP 'a wave' is
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due to the increase atrial pressure at the end of PR interval
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CVP/RAP 'c wave'
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caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction
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CVP/RAP 'v wave'
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when tricuspid valve is closed, at the end of the t wave
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What do you use Swan Ganz catheters for
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to guide therapy for patient
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Increased PAP
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1. Pulmonary diseases,
2. Pulmonary hypertension 3. hypoxia 4. PE 5. ARDS 6. PEEP |
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Inc Pulmonary flow
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atrial or ventricular defect
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increased pulmonary diastolic pressure
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mitral stenosis, LV failure, fluid overload
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Decreased Pulmonary Artery Pressure
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hypovolemia, misplaced transducer
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Wedge Pressure measures
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indirectly the preload of the Left Ventricle
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What port do you measure the Wedge pressure
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distal (yellow)
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Increased PAWP pressures can mean 5 things
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1. LV failure
2. Mitral stenosis 3. Mitral regurgitation 4. Cardiac tamponade 5. Volume overload |
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Decreased PAWP pressure
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1. hypovolemia
2. transduce ar the inappropriate height |
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CausSymptoms of CHF
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Dyspnea on exertion, orthopnea, paroxysmal nocurnal dyspnea, fatigue, RUQ fullness/pain, anorexia, nausea, vomiting
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signs of CHF
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JVD, peripheral edema, pulmonary congestion, Pleural effusions, S3, narrow pulse pressure, inc hr, pale, cool skin, dec urine output, mental confusion
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The rate, extent and force of fiber shortening during systole for a given set of loading conditions
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contractility
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Left sided heart failure has these kind of sx
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pulmonary
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Right sided heart failure has these kind of sx
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peripheral
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Forward failure
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inadequate CO at rest or with exercise....primary R side failure
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Backwards failure
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Decreased contractility results in increased LV diastolic pressure causing fluid build up in the pulmonary vasculature...primary L side failure
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Systolic dysfunction
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enlarged ventricles....cant contract
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Diastolic dysfunction
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stiff ventricles cannot fill
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3 types of cardiomyopathy
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1. Dilated
2. Hypertrophic (thick walls) 3. Restrictive (Stiff walls) |
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BNP
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peptide released from brain when ventricles are not working. Trying to oppose the sympathetic nervous system
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Natrecor
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synthetic BNP. oposes sympathetic nervous system through Natriuresis
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Warm and Dry
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Low Wedge, low CI
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Warm and Wet
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High Wedge, High CI
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Cold and Dry
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Low Wedge, Low CI
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Cold and Wet
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High Wedge, Low CI
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Dobutamine.
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Inotrope, inc contractility, mild arterial vasodilation.
Drip start at 1-2 mcg/kg/min titrate to max of 10 mcg/kg/min max sure has enough fluid! |
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Milrinone
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vasodilation. inotrope.
Drip start at 0.1mcg/kg/min up to 0.75 |
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Dopamine
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inotrope
< 3 mcg/kg/min vasodilatory higher doses B and alpha stimulation |
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What are the 3 Beta Blockers
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Carvedilol ( Co reg), Metoprolol, and bisoprolol
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What do ACE inhibitors do
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block conversion of angiotension to angiotension 2. Whcih blocks the sympathetic response and vasoconstriction
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Spironaldactone
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diuretic, closely follow K and Cr
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B/c pt has low cardiac output you need to add this drug
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warfarin....high risk for blood clots
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If the pt has ischemic cardiomyopathy or atherosclerotic vascular disease add this drug
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ASA
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Medications to avoid with CHF
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1. NSAIDS
2. antiarrhythmics (neg inotropes) 3. Ca Channel blockers (heart loves CA) 4. Thiazolidineiones |
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Underdamping
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exaggerated response where the upstroke of the waveform ends in an 'overshoot' spike followed by multiple, small spikes on the down stroke
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overdamping
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the waveform looks indistinct, the systolic pressure is underestimated and the dichrotic notch may not be visible
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what do you need to do with vented caps
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replace with non vented or injection caps
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to what pressure do you inflate the bag to
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300mmHg
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the pressure the bag is at ensures this flow rate
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3 to 6 mL per hour
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Zero the system with the stopcock in what position?
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Off to the patient with the system open to air
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Re zero the A line when?
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Every 4 hours or when break in connection
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How do you take the thermodilution correct measurements
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Take the 3 waveforms within 10 % of each other
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Initial stage of shock
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Subclinical hypoperfusion....level of consciousness
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2nd stage of schok
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Compensatory stage.....SNS, renin-angiotensionaldosterone, glucocorticoids.....augment cardiac output, redistributing blood flow and restoring blood volume
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3rd stage of shock
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Progressive stage....perfusion to vital organs is diminished. Clinical hypoperfusion and anaerobic metabolism.
Lactic acid and SVO2 effects |
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Clinical Presentation of Compensatory stage
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tachy, narrow pulse pressure, cool skin, oliguria, dec bowel sounds, restless
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Clinical Presentation of Progressive stage
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dysrhythmias, hypotension, cold, clammy, anuria, absent bowel sounds
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4th stage of shock
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refractory state. hypoperfusion is so profound and death is inevitable
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What drug do you use for refractory shock
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vasopressin
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3 types of shock
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hypovolemic, cardiogenic, distributive
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4 possible causes of hypovolemic shock
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hemorrhage, dehydration, diuresis, and plasma shifts
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What type of shick?
1. RAP PAP, PAOP decreased 2. SVR increased 3. CO decreased 4. SVO2 decreased 5. DO2 decreased |
hypovolemic
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What type of sock is this
1. RAP PAP PAOP elevated 2. SVR increase 3. LVSWI decreased 4. CO decreased 5. SaO2 decreased 6. DO2 decreased |
Cardiogenic shock
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