CHAPTER 5 CIRCULATION Cynthia Howe, RN, CPAN
CHAPTER 5 OVERVIEW Purpose: The perianesthesia nurse will demonstrate thorough cardiac assessment skills to safely care for the perianesthesia patient and prevent/intervene related to any cardiac complications. Competency Statement: Perform a cardiovascular assessment. Criteria: 1. Obtain a baseline heart rate (HR), blood pressure (BP) and oxygen saturation (SpO2). Baseline vital signs establish reference points for the nurse to compare to and trend over time. HR, BP and SpO2 are key components affecting tissue oxygenation and perfusion. 2. Assess skin for color, temperature, turgor, edema and diaphoresis. Skin assessment is indicative of overall cardiovascular status: • Pale, cool or clammy skin indicates vasoconstriction • Warm, dry and flushed skin indicates vasodilation • Poor skin turgor or decreased elasticity is noted with dehydration • Extremity edema results as fluid shifts from the intravascular to the interstitial space (3rd spacing), accumulating in dependent body areas • Cyanosis of the mucous membranes, earlobes, cheeks and around the lips is termed “central cyanosis” and is usually reflective of reduced oxygen concentration • Peripheral cyanosis is observed in the distal extremities and is associated with localized hypoxia related to poor circulation, reduced blood flow, congestive heart failure or shock. The skin temperature of the affected areas is usually cold to touch 3. Inspect nail beds for capillary refill. Capillary refill within 3 seconds reflects adequate blood flow to the extremities. 4. Palpate peripheral arterial pulses for rhythm, amplitude and bilateral equality. Presence and volume of peripheral pulses reflect extremity perfusion. A discrepancy in volume between central and peripheral pulses may be due to hypothermia, diminished stroke volume (often seen in children) or pathogenic changes (contractility or mechanical). 5. Auscultate heart sounds. Auscultation provides information regarding the functioning of the heart valve and chambers. Normal Heart Sounds: • S1, the first heart sound occurs with closure of the mitral and tricuspid valves o Reflects the onset of ventricular systole o Almost synchronous with the carotid pulse o Sound is “Lub” best heard at the apex and right lower sternal border • S2, second heart sound occurs with closure of the aortic and pulmonic valves o Signals ventricular diastole o Sound is “Dub” best heard at the 2nd interspace just to the side of the sternum Extra Heart Sounds: • S3 or Ventricular Gallop caused by early rapid filling of the ventricles resulting in vibrations o Usually indicates decreased compliance of the ventricle o Common in children and young adults o May be heard with advanced CHF, ischemia, mitral or tricuspid insufficiency ASPAN 2009 Edition
103
CHAPTER 5 o Low pitched sound heard in early diastole immediately following S2 – sound is “Lub-Dub-Up or like Ken-tuc-ky o Best heard with bell of stethoscope at apex with patient in left lateral position • S4 or Atrial Gallop may occur with atrial contraction o Result of atria working harder to fill a ventricle which is resistant/stiff o May indicate ventricular hypertrophy, hypertension, mitral/aortic stenosis or coronary artery disease o Occurs late in diastole, just prior to S1 – sound is “La-Lub-Dub or Ten-nes-see • Murmurs – associated with turbulence or blood flow through the heart, such as forward flow through a constricted valve, backward flow through an incompetent valve, an abnormal connection between chambers and blood flow into a dilated heart o Describe as either systolic or diastolic o Grade on audible scale from I to VI (I indicating faint to VI very loud and may be heard with the stethoscope just off the chest wall) • Pericardial Friction Rub – associated with pericarditis o High pitched, scratching – a “to and fro” sound with each heartbeat o Auscultate between the apex and left sternal border with the patient sitting upright and leaning forward 6. Assess for presence of central and peripheral intravenous lines. The integrity of IV access is assessed for the delivery of fluids, medications, and blood products. 7. Inspect for internal jugular vein distention. Jugular distention is indicative of congestive heart failure (CHF), cardiac tamponade, or fluid overload. Inspection should be done with the patient at a 45 degree angle. 8. Obtain and interpret a baseline cardiac rhythm strip. A baseline rhythm strip allows for comparison of rate or rhythm changes which may be related to anesthetic agents, medications, pain, myocardial perfusion, metabolic demands, and aberrant pathways. 9. Review patient medications. • For potential or real interactions with medications to be administered in the perianesthesia setting • Drug name, dose, and last dose taken 10. Communicate and document all pertinent information per facility/unit specific policy/protocol. Bibliography Blach D. Assessment of the Cardiovascular System. In: Ignatavicius, ed. Medical Surgical Nursing Critical Thinking for Collaborative Care. 5th ed. St Louis, MO: Elsevier Saunders; 2006: 676-683. Carroll RJ. A&P Review, The Circulatory System. In: Black, ed. Medical Surgical Nursing Clinical Management for Positive Outcomes. 7th ed. St Louis, MO: 2005: 1465-1478. Lessig ML. The Cardiovascular System. In: Alspach, ed. Core Curriculum for Critical Care. 6th ed. St Louis, MO: Saunders Elsevier; 2006: 185-199. Smartt S. Cardiovascular Care. In: Quinn DM, Schick L, eds. Perianesthesia Nursing Core Curriculum: Preoperative, Phase I and Phase II PACU Nursing. St Louis, MO: Saunders; 2004: 532-540.
104
A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
CHAPTER 5 CARDIAC RHYTHM INTERPRETATION, INTERVENTION, AND TREATMENT MODALITIES Purpose: A step-by-step interpretation to enable the nurse to recognize dysrhythmias with correlation to the patient’s condition. ECG monitoring provides continuous observation of the patient’s cardiac electrical activity allowing for the anticipation and treatment of various dysrhythmias associated with recovery from anesthesia. Early identification, treatment, and termination of potentially life-threatening dysrhythmias are essential to optimal patient outcomes. In the perianesthesia setting, both 3 and 5 lead ECG monitoring are acceptable. • 3-lead monitoring is commonly an MCL-1(modified chest lead) or limb lead II o Lead II produces upright P waves and QRS complexes o MCL-1 is excellent for distinguishing ectopy versus aberrance and to identify bundle branch blocks • Does not interfere with auscultation or defibrillation • Produces variable P wave polarity and a negative QRS complex • 5-lead monitoring system allows rapid ECG monitoring in multiple leads including I-II-III- aVR – aVL and aVF Competency Statement: The perianesthesia nurse will demonstrate appropriate assessment, interpretation, and interventions for the patient experiencing cardiac dysrhythmias. Criteria: 1. Obtain a baseline ECG tracing – at least 6 seconds in length as a reference point for comparison and trending over time. 2. Identify components of ECG tracing. P wave – Indicates SA node function and atrial depolarization, best observed in leads II and V1 where it is upright. Abnormal configurations or inconsistencies in appearance may indicate a pacemaker other than the SA node. PR Interval (PRI) – Indicates atrioventricular conduction. QRS Complex – Indicates ventricular depolarization and may be positive, negative or biphasic. • Q wave – First negative/inverted deflection following the P wave o Represents conduction through the septum o Not present in all leads o Abnormal presence represents myocardial necrosis • R wave – First positive wave following P o Represents conduction toward the left ventricle o Prominent R waves are seen in ventricular hypertrophy, thin chest wall patients and in young adults • QT interval – Time of complete ventricular depolarization o Prolonged by ischemia, antiarhythmic drugs, electrolyte imbalances o A prolonged QT is associated with an increase incidence of polymorphic VT • S wave – First negative wave after the R wave o Represents conduction through both ventricles and subsequent contraction ASPAN 2009 Edition
105
CHAPTER 5 ST Segment – Indicates initial ventricular repolarization. • Isoelectric or flat line between end of the S wave and start of the T wave • Length varies with changes in HR, administration of medications and electrolyte disturbances • ST changes in a single lead are not diagnostic • ST changes throughout all leads may be diagnostic o Elevation of >1mm or depressions of >0.5mm can be caused by myocardial injury, ischemia or infarction, conduction abnormalities or the administration of medications T wave – Indicates ventricular repolarization, deflection tends to follow direction of QRS. • Inverted T wave may indicate infarct, ischemia, hypertrophy • R on T Phenomenon – ectopic stimulus excites the ventricles during repolarization leading to lethal dysrhythmias U wave – Indicates ventricular repolarization of the Purkinje fibers. • Abnormal prominence suggests hypokalemia J-Point – The point at which the QRS complex meets the ST wave. • The J-Point and the ST segment should be at baseline • If the J-Point and ST segment slope downward and are below baseline, this indicates ischemia • If the J-Point and ST segment slope upward and are above baseline, this indicates injury or infarct 3. Complete a Rhythm Analysis. A. Rate determination: • Atrial and ventricular, is it slow or fast, does it generate a pulse? B. Rhythm determination: • If R to R interval is regular, then rhythm is considered regular • If irregular, is it irregularly irregular or regularly irregular? • Look for beats that are early or premature, episodic rate variables, sudden or prolonged pause, group beating C. Analyze P waves: • Normal width < 0.10 • Is the shape consistent? • Is there a P for every QRS – and is there an established relationship between P waves and the QRS? • P waves > 2.5 wide = LA enlargement (seen in V4-6) > 2.5 tall = RA enlargement (seen in II-III-aVF) D. Measure the P-R interval: • Normal is 0.12-0.20 • Is the interval constant? • Short PR indicates impulse origination other than SA Node • Prolonged PR indicates delay in conduction at AV node • Irregular PR’s are found only in Wenckebach and 3rd degree block E. Analyze the QRS: • Normal width 0.12 seconds • Is the interval wide? The rhythm is ventricular in origin • Is the interval narrow? The rhythm is supraventricular in origin • QRS is absent in ventricular fibrillation and asystole • Review the QRS relationship with the P wave
106
A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
CHAPTER 5 4. Interpret the cardiac rhythm. Always correlate with clinical observation of the patient. Initiate interventions/treatments according to ACLS algorithms. Treatments listed below are initial treatments only. Refer to complete ACLS algorithms.
Rhythm
Hallmark
Clinical
Treatment
CARDIAC ARREST Ventricular Fibrillation (VF)
No P, QRS or T. Up and down pattern. May be fine or course.
Pulseless.
Shock - *CPR 5 cycles. Epinephrine or Vasopressin. Shock – *CPR 5 cycles. Amiodarone or Lidocaine. Shock – 5 cycles CPR.
Organized pattern but does not produce contraction – NO pulse with rhythm.
Can be Narrow (non-cardiac), Wide (cardiac), Slow (cardiac), Fast (non-cardiac).
CPR – 5 cycles. Epinephrine or Vasopressin. Consider Atropine – slow rate. CPR 5 cycles.
No ventricular activity of 150 with sudden onset and/or cessation. Occurs without warning.
Palpitations – anxious, uncomfortable. Reduces cardiac output / increases O2 demand and consumption.
UNSTABLE =Amiodarone. Prepare for cardioversion.
Stable Ventricular Tachycardia (VT)
STABLE = vagal maneuvers, Adenosine.
VENTRICULAR TACHYCARDIAS Monomorphic VT
All QRS look alike (remember no P wave). QRS is wide/bizarre.
Patient may be awake/alert. Acute ischemic event.
See VT above.
Polymorphic VT
Variation and inconsistent QRS.!
Rapidly deteriorates Most patients symptomatic.
See VT above.
Torsades de Pointes
Spindle pattern – amplitude > then < polarity changes with each new spindle.
Most commonly occurs with prolonged QT intervals – overdose, alcoholism, hypomagnesia, etc.
Use Magnesium – loading dose, not IV push.
Regular complex with rate < 60.
Treat only if . symptomatic
No symptoms: observe.
**Sustained = runs lasting > 30 seconds
BRADYCARDIA Sinus Bradycardia
Symptomatic: treat. Prepare to pace. Consider atropine. Consider Epinephrine or Dopamine. AV BLOCKS 1st Degree
108
PR > .20 Can be SR, SB, ST.
Usually asymptomatic. May be due to drugs –blockers: Beta, Ca channel, Digitalis. Can be from vasovagal reaction.
Observe.
A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
CHAPTER 5 2nd Degree – Type I standby (Mobitz 1 / Wenckebach)
**site is at AV node shocky.
PR interval is Short,
Atrial regular /
External pacemaker on
long, longer, till a QRS is dropped.
ventricular irregular.
lest the rhythm further deteriorates, the block progresses, or the patient becomes symptomatic or
“QRS drop-out”
Consider atropine. Consider Epinephrine or Dopamine. 2nd degree – Type II Infranodal* / Mobitz II)
PR constant.
Symptomatic from ventricular bradycardia.
“P waves march-out” * below AV node
QRS narrow = high block relative to AV node. QRS wide = low block to AV node.
3rd Degree * *a type of AV dissociation
No relationship of P to QRS – no marriage of wave forms. PR intervals irregular. Atrial and Ventricular rhythms are regular – but not married.
PACE without delay.
Consider Epinephrine or Dopamine.
P waves are completely independent from the QRS. Atrial rate is usually 60-100. Ventricular rate varies on rate of ventricular escape beats.
PACE without delay. Consider atropine. Consider Epinephrine or Dopamine.
ACLS Drugs: Drug
Indications / Actions
Side Effects
Dosage
Adenosine
1st line drug for narrow complex SVT. Acts on AV node to slow conduction and inhibit reentry pathways.
Transient chest pain, dyspnea, bradycardia, flushing and asystole.
6 mg rapid (1-3 seconds) IV push followed by 20 ml NS bolus. If no conversion follow with 12 mg IV. May repeat 12 mg dose once.
Amiodarone
VF/VT wide complex tachycardias. Both alpha and beta blocking.
Hypotension, bradycardia.
Cardiac arrest: 300 mg IV push, consider repeating 150 mg IV push in 3-5 minutes. Wide complex tachycardias: 150 mg/250 ml D5W IV over 10 minutes. Repeat as needed to max dose of 2.2g/24 hours.
ASPAN 2009 Edition
109
CHAPTER 5 Atropine
1st line drug for symptomatic bradycardia. 2nd line drug for asystole or PEA. Anticholinergic: reduces vagal tone, increases automaticity and AV conduction.
Dopamine
Symptomatic hypotension. 2nd line drug for symptomatic bradycardia.
Epinephrine
1st line drug for pulseless arrest/Ventricular Fibrillation. Also used for Ventricular tachycardia and symptomatic bradycardia. Vasoconstictor which increases perfusion pressure and stimulates spontaneous contraction.
1 mg IV. Repeat every 3 to 5 minutes. 2-10ug/min infusion.
Lidocaine
Alternative to Amiodarone in VF/VT. Decreases sensitivity (automaticity) of the heart.
1 to 1.5 mg/kg IV initial dose. Then 0.5 to 0.75 mg/kg IV push to a max of 3 mg/kg. Post conversion drip at 1-4 mg/min.
Magnesium
Recommended for Torsades de pointes and suspected hypomagnesemia.
Precautions: hypotension.
Loading dose 1 to 2 g diluted in 10 ml D5W IV over 5-20 minutes.
Procainamide
Recurrent VF/VT. PSVT uncontrolled by adenosine and vagal maneuvers.
Use in arrest is limited by the need for slow infusion and uncertain efficiacy. Stop with hypotension, QRS widening by > 50% or 17 mg/kg given.
20 mg/min IV infusion to maximum total dose of 17mg/kg.
Sodium Bicarbonate
Acidosis. Hyperkalemia.
Not recommended for routine use in cardiac arrest patients. Administer based on specific indications only.
1 mEq/kg IV bolus.
Vasopressin
Alternative pressor to epinephrine in VF. May be useful in asystole and PEA.
40 units IV push to replace 1st or 2nd dose of epinephrine. One dose for cardiac arrest.
Versed
May be given as a sedative for synchronized cardio version.
1 or more mg IV titrated for sedative effect.
110
Symptomatic bradycardia: 0.5 mg IV to a total of 3 mg. Asystole / PEA: 1 mg IV push every 3-5 minutes to a total of 3 mg.
Correct hypovolemia with volume before initiating dopamine.
2 to 20 mcg/kg/min infusion. Mix 400 to 800 mg in 250 ml.
A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
CHAPTER 5 Oxygen
Immediately for any shockable rhythm or symptomatic patient.
Delivery mode and amount as indicated.
Transcutaneous Pacing
Symptomatic or hemodynamically unstable bradycardia.
Set rate and MA until capture achieved. Then increase MA by 10% to ensure capture threshold.
5. Assess patient response to dysrhythmia/interventions. Complete a thorough patient assessment when rhythm change is identified – evaluate if rhythm is cardiac driven or the effect of another event. Evaluate other pertinent information. 6. Communicate and document all pertinent information per facility/unit specific policy/protocol. Include a rhythm tracing, patient response to rhythm, interventions, and outcomes. Bibliography American Heart Association (AHA). ACLS Provider Manual. AHA; 2006. Cain A, Melander S. Management of Clients with Dysrhythmias. In: Black, ed. Medical Surgical Nursing Clinical Management for Positive Outcomes. 7th ed. St Louis, MO: Elsevier Saunder; 2005: 1671-1700. Carroll RJ. A&P Review, The Circulatory System. In: Black, ed. Medical Surgical Nursing Clinical Management for Positive Outcomes. 7th ed. St Louis, MO: Elsevier Saunder; 2005: 1468-1475. Goldberger A. Clinical Electrocardiology, A Simplified Approach. 7th ed. Philadelphia, PA: Mosby; 2006: 157-215. Lessig ML. The Cardiovascular System. In: Alspach JD, ed. Core Curriculum for Critical Care. 6th ed. St. Louis, MO: Saunders Elsevier; 2006: 221-326. Smartt S. Cardiovascular Care. In: Quinn DM, Schick L, eds. Perianesthesia Nursing Core Curriculum: Preoperative, Phase I and Phase II PACU Nursing. St. Louis, MO: Saunders; 2004: 553-566. Zickenfoose P. Interventions for Clients with Dysrhythmias. In: Black, ed. Medical Surgical Nursing Critical Thinking for Collaborative Care. 5th ed. St Louis, MO: Elsevier Saunders; 2006: 708-747.
ASPAN 2009 Edition
111
CHAPTER 5 FLUID FILLED MONITORING SET UP Used for Central Venous Pressure (CVP) and Arterial (A-Line) Competency Statement: Demonstrate set-up, assessment, and interventions for the patient requiring invasive hemodynamic monitoring. Criteria: 1. Demonstrate proper set up of a fluid filled monitoring system. Assemble necessary equipment and supplies to ensure appropriate monitoring, including: • Flush solution for transducer system o 500 ml bag of Normal Saline - heparinized based on facility policy • Pressure transducer system and tubing o CVP, arterial line alone requires single transducer o 2 or more lines require a triple transducer set • Several 3 way stopcocks, pressure extension tubing as desired • Pressure bag – transducer holder – IV pole • Carpenter’s level • Monitor, modules and cables The pressure tubing system, including transducer, extensions, and all stopcocks should be flushed prior to inflation of the pressure bag to reduce small air bubbles. Pressure bag inflation to 300mm Hg prior to attachment to the patient reduces the risk of air embolism. The system will deliver 3 to 4ml/hour of flush fluids to the patient while maintaining system integrity. 2. Properly calibrate transducer to atmosphere. A. The zeroing stopcock is leveled to the phlebostatic axis, which approximates the location of the right atrium. Identification of the phlebostatic axis: • Position patient supine • Palpate the 4th intercostal space at the sternum • Follow the 4th intercostal space to patient’s side • Determine midway point between anterior and posterior • Locate intersection between the midway point and the line from the 4th intercostals • Mark the spot with an X in indelible ink Each time the patients position is changed the transducer must be re-leveled. B. Properly perform zero referencing. Zero reference procedure eliminates the effects of atmospheric and hydrostatic pressure from the measured pressure readings. The zero reference procedure should be done at setup, once a shift, any time the validity of the monitored value is in question or the system is opened to air. Procedure for zero referencing: • Allow system to warm up for 5 – 15 minutes • Check to see that the fluid filled components of the system are free of air • Turn stopcock off to the patient and open to the atmosphere (air) • Select zero monitor – wait for display to read 0 (zero) • When properly zeroed, close stopcock to air and open to patient again, checking that the system is free of air
112
A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
CHAPTER 5 3. Properly select appropriate scale and alarm limits. Scale selection is based on the invasive line type and monitor. CVP scales are generally set no higher than 18, arterial line scale set no greater than 20 mm Hg above the systolic reading. High and low alarm limits must be set and alarms on. High and low limits are variable based on patient condition, presence of titrating drugs and fluid administration, among other factors. 4. Recognize potential complications and appropriate interventions. Troubleshoot dampened wave form tracings: • Assess patient for physiologic alterations • If patient stable – investigate system o Check for air in tubing or loose connections o Ensure pressure is maintained at 300 mm Hg o Check tubing for kink or knot o Flush tubing for patency check (positional, clotted tip, etc.) o Check scale selection 5. Communicate and document all pertinent information per facility/unit specific policy/protocol, including: • Date and time of setup • Scale and alarm parameters • Times leveled and zeroed • Type of flush solution • Flush solution infused • Complications/interventions associated with insertion
ASPAN 2009 Edition
113
CHAPTER 5 INVASIVE HEMODYNAMIC MONITORING Purpose: Hemodynamic monitoring directly measures pressure in the heart and great vessels. Hemodynamic pressure monitoring provides information reflecting the earliest changes in the circulatory system that is not yet clinically detectable. Invasive hemodynamic monitoring provides quantitative information on blood volume, fluid balance, and the hearts pumping ability. CVP Competency Statement: Demonstrate assessment and interventions for the patient requiring CVP monitoring. CVP monitoring reflects pressure in the great veins and is a measurement of right heart preload. Preload is the amount of blood presented to the heart or when the ventricle is full before the next ejection. Preload is the right ventricular end diastolic pressure. 1. Recognize indications for CVP monitoring. • Known cardiovascular disease • Rapid infusion of fluids or blood • Fluid status assessment 2. Identify CVP waveform. A triphasic wave produced by changes in pressure within the right atrium. The waveform consists of three peaks (a,c,v) and two descents (x,y) that are directly related to the ECG. Proper placement of the catheter tip is in the lower third of the superior vena cava near the junction of the right atrium. a wave – o most prominent peak o reflects “atrial kick” responsible for loading the right ventricle
114
A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
CHAPTER 5
This figure was published in the Journal of PostAnesthesia Nursing, Volume 7, Number 5, 1992. Author Christensen B, title of article Hemodynamic Monitoring: What it Tells You and What it Doesn’t. Reprinted with permission from the Journal of PostAnesthesia Nursing, Copyright Elsevier. Permission obtained February 27, 2009. 3. Identify normal ranges for CVP readings. CVP readings should always be measured during end-expiration. Normal right atrial pressures range from 0 to 7 mm Hg.
Vascular Tone
ASPAN 2009 Edition
Ý
Blood Volume
Early LV failure.
circulating volume
Vasodilation. Peripheral pooling. Septic shock.
Right sided failure. Chronic LV failure. Pericarditis. Cardiac tamponade. Pulmonary hypertension. Ý
Right side heart
HIGH CVP
LOW CVP
CLINICAL ASSESSMENT
circulating volume.
Vasoconstriction. Hypertension.
115
CHAPTER 5 4. Recognize potential complications and appropriate interventions. LINE
SITES
CVP
Venous Jugular Subclavian Brachial Cephalic Femoral
COMPLICATIONS Pneumothorax. Arrythmias. Cardiac perforation. Hemorrhage. Sepsis. Clot-thrombus. Air emboli.
INTERVENTIONS 1. Tighten all connections. 2. Continual ECG monitor. 3. Physical assessment: neck veins, heart sounds, pulse pressure, cyanosis, dyspnea, and tachypnea followed with appropriate therapy. 4. Site observation. 5. Alarm limits. 6. CXR post insertion. 7. Continual wave form monitoring.
5. Communicate and document all pertinent information per facility/unit specific policy/protocol.
116
A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
CHAPTER 5 Arterial Line Competency Statement: Demonstrate assessments and interventions for the patient requiring arterial pressure monitoring. Direct intra-arterial monitoring is considered by many to be the gold standard for blood pressure measurement. Direct measurement is usually 10-15 mm Hg greater than indirect (cuff) measurements and provides beat to beat information facilitating the earliest possible recognition of adverse situations. 1. Recognize indications for Arterial Line Monitoring. • Wide fluctuations in BP are expected (endarterectomies, craniotomies and aneurysms) • Titration of vasoactive drugs • Require multiple ABG’s or laboratory tests • Strict BP control is mandated • Excessive peripheral vasoconstriction • Low cardiac output • Fluctuating hemodynamic status 2. Identify Arterial Line Waveform. Wave A illustrates the anacrotic limb – inotropic phase. • Inotropic component reflected by initial steep upstroke o Indicator of LV contractility o Reflects ejection of blood from the left ventricle • Peak – anacrotic notch/rounded shoulder shape o Represents peak systolic blood pressure Wave B illustrates the dichrotic notch. • Represents closure of the aortic valve – ventricle completes systolic ejection and enters diastole Wave C represents the dichotic limb – end diastolic pressure.
This figure was published in the Journal of PostAnesthesia Nursing, Volume 7, Number 5, 1992. Author Christensen B, title of article Hemodynamic Monitoring: What it Tells You and What it Doesn’t. Reprinted with permission from the Journal of PostAnesthesia Nursing, Copyright Elsevier. Permission obtained February 27, 2009.
ASPAN 2009 Edition
117
CHAPTER 5 Potential alterations in wave form patterns: • Vasodilation = rapid upstroke and a narrow systolic peak (a wave) • Pulsus alterans = pattern of alternating large and small pulse waves (may occur transiently after an arrhythmia episode) • Pulsus paradoxus = decrease in systolic BP by 10 mm Hg or more during inspiration – classically associated with cardiac tamponade, most commonly associated with hypovolemia in the perianesthesia setting 3. Recognize the importance of correlation of arterial pressure to cuff pressure. Arterial line monitors the wave of pressure generated by ventricular contraction and is affected by vascular distensibilty or vasoconstriction. Cuff pressures measure blood flow through the artery as external pressure is applied and released. An arterial pressure significantly higher than a cuff pressure often indicates increased sympathetic tone and vasoconstriction. As blood pressure differences of 10-20 mm Hg can be noted between left and right side readings it is important to obtain both readings from the same side. A decision must be made to treat the patient by either the cuff OR the arterial line, not both. If a patient is going to a critical care unit and/or is receiving vasoactive medications, treatment by arterial pressures is recommended. To avoid fluctuations in readings ensure that the line is leveled to the phlebostatic axis and the site is marked, the transducer is correctly zeroed, and no loose connections, kinks, air, or clots are present. 4. Assess circulation based on arterial insertion site. Color, pulse, temperature, motor and sensory assessment is completed distal to the arterial line insertion site for evidence of circulatory compromise. 5. Recognize potential complications and appropriate interventions. LINE A-line
SITES Arterial Radial Brachial Femoral
COMPLICATIONS Hemorrhage. Nerve damage. Sepsis. Embolization. Arterial occlusion. Spasms.
INTERVENTIONS 1. 2. 3. 4. 5. 6.
Tighten all connections. Motor assessment. Site observation. Vascular assessments. Set alarm limits. Continual wave form monitoring.
6. Communicate and document all pertinent information per facility/unit specific policy/protocol.
118
A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
CHAPTER 5 Bibliography Blach D. Assessment of the Cardiovascular System. In Ignatavisius, ed. Medical Surgical Nursing Critical Thinking for Collaborative Care. 5th ed. St Louis, MO: Elsevier Saunders; 2006: 703-705. Carroll R. A&P Review, The Circulatory System. In Black,ed. Medical Surgical Nursing Clinical Management for Positive Outcomes. 7th ed. St. Louis, MO: Elsevier Saunders; 2005: 1953-96. Lessig ML. The Cardiovascular System. In Alspach JD, ed. Core Curriculum for Critical Care. 6th ed. St Louis, MO: Saunders Elsevier; 2006: 195-214. Smartt S. Hemodynamic Monitoring. In Quinn, ed. PeriAnesthesia Nursing Core Curriculum. St. Louis, MO: Saunders; 2004: 497-512. Vanriper S. Fluid Filled Monitoring System. In Darnovic, ed. Hemodynamic Monitoring: Invasive and Noninvasive Clinical Application. 2nd ed. Philadelphia, PA: WB Saunders; 1995: 156-174.
ASPAN 2009 Edition
119
CHAPTER 5
QUESTIONS CIRCULATION COMPETENCY QUESTIONS 1. This type of cyanosis presents as cyanosis of the mucous membranes, earlobes, cheeks, and lips, and is reflective of reduced oxygen concentration: a. Hypoxic cyanosis b. Central cyanosis c. Peripheral cyanosis d. Hypercarbaric cyanosis 2. This heart sound results from the atria working harder to fill against a stiff ventricle: a. S1 b. S2 c. S3 d. S4 3. The following rhythm is a regular rhythm that is associated with an atrial and ventricular rate of 150-250: a. ST b. SVT c. Atrial Flutter d. Atrial Fibrillation 4. The dichrotic notch of the arterial waveform is associated with closure of the: a. Tricuspid valve b. Pulmonic valve c. Mitral valve d. Aortic valve 5. Pulsus paradoxus in the PACU is most commonly associated with: a. Severe hypovolemia b. Sympathetic blockade c. Cardiac tamponade d. Tension pneumothorax 6. The most common cause of PEA in the perianesthesia setting is hypovolemia. a. True b. False 7. Risks and complications associated with central venous cannulation include: a. Heart block b. Valvular damage c. Ventricular tachycardia d. Pneumothorax
120
A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
CHAPTER 5 8. This naturally occurring anti-diuretic hormone will act as a powerful vasoconstrictor when given at high doses: a. Epinephrine b. Ephedrine c. Vasopressin d. Voltaren 9. To avoid erroneous readings, CVP should always be measured at end-inspiration. a. True b. False 10. The most common cause of decreased CVP in the PACU is: a. Sepsis b. Sympathetic blockade c. Hypovolemia d. Lymphatic blockage
ASPAN 2009 Edition
121
CHAPTER 5
KEY CIRCULATION COMPETENCY QUESTIONS 1. This type of cyanosis presents as cyanosis of the mucous membranes, earlobes, cheeks, and lips, and is reflective of reduced oxygen concentration: a. Hypoxic cyanosis b. Central cyanosis c. Peripheral cyanosis d. Hypercarbaric cyanosis 2. This heart sound results from the atria working harder to fill against a stiff ventricle: a. S1 b. S2 c. S3 d. S4 3. The following rhythm is a regular rhythm that is associated with an atrial and ventricular rate or 150-250: a. ST b. SVT c. Atrial Flutter d. Atrial Fibrillation 4. The dichrotic notch of the arterial waveform is associated with closure of the: a. Tricuspid valve b. Pulmonic valve c. Mitral valve d. Aortic valve 5. Pulsus paradoxus in the PACU is most commonly associated with: a. Severe hypovolemia b. Sympathetic blockade c. Cardiac tamponade d. Tension pneumothorax 6. The most common cause of PEA in the perianesthesia setting is hypovolemia. a. True b. False 7. Risks and complications associated with central venous cannulation include: a. Heart block b. Valvular damage c. Ventricular tachycardia d. Pneumothorax
122
A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
CHAPTER 5 8. This naturally occurring anti-diuretic hormone will act as a powerful vasoconstrictor when given at high doses: a. Epinephrine b. Ephedrine c. Vasopressin d. Voltaren 9. To avoid erroneous readings, CVP should always be measured at end-inspiration. a. True b. False 10. The most common cause of decreased CVP in the PACU is: a. Sepsis b. Sympathetic blockade c. Hypovolemia d. Lymphatic blockage
ASPAN 2009 Edition
123
CHAPTER 5
ASPAN 2009 Edition
125
CHAPTER 5
126
A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
CHAPTER 5
ASPAN 2009 Edition
127
CHAPTER 5
128
A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
CHAPTER 5
ASPAN 2009 Edition
129
