Module I – Critical Care

Nursing
Introduction
Nurses constitute the largest category of healthcare personnel in nearly every country of the global
community. They are the key professionals who need to be included in the process of setting a worldwide
agenda for holistic patient care.
As you begin the study of critical care nursing, you may be excited, uncertain, and even somewhat anxious.
The field of critical care nursing often seems a little unfamiliar or mysterious, making it hard to imagine
what the experience will be like or what nurses do in this area.
This module presents essential information about how to safely and competently care for critically ill
patients and their families.

Lesson 1: Critical Care Nursing Concepts

What is Critical Care Nursing?
Critical care nursing is the delivery of specialized care to critically ill patients— that is, ones who have life-
threatening illnesses or injuries. Such patients may be unstable, have complex needs, and require intensive
and vigilant nursing care. Illnesses and injuries commonly seen in patients on critical care units (CCUs)
include:
• gunshot wounds
• traumatic injuries from such events as automotive collisions and falls
• cardiovascular disorders, such as heart failure and acute coronary syndromes (unstable angina and
myocardial infarction [MI])
• surgeries, such as abdominal aortic aneurysm repair and carotid endarterectomy
• respiratory disorders, such as acute respiratory failure and pulmonary embolism
• GI and hepatic disorders, such as acute pancreatitis, acute upper GI bleeding, and acute liver failure
• renal disorders, such as acute and chronic renal failure
• cancers, such as lung, esophageal, and gastric cancer
• shock caused by hypovolemia, sepsis, and cardiogenic events (such as after MI).
Meet the Critical Nurse
Critical care nurses are responsible for making sure that critically ill patients and members of their families
receive close attention and the best care possible.
What do you do?
Critical care nurses fill many roles in the critical care setting, such as staff nurses, nurse-educators, nurse-
managers, case man- agers, clinical nurse specialists, nurse practitioners, and nurse researchers. (See Role
call.)
Where do you work?
Critical care nurses work wherever critically ill patients are found, including:
• adult, pediatric, and neonatal CCUs
• coronary care and progressive coronary care units
• emergency departments
• post-anesthesia care units.
What makes you special?
As a nurse who specializes in critical care, you accept a wide range of responsibilities, including:
• being an advocate
• using sound clinical judgment
• demonstrating caring practices
• collaborating with a multidisciplinary team
• demonstrating an understanding of cultural diversity • providing patient and family teaching.
Role Call
By filling various nursing and management roles, a critical care nurse helps promote optimum health,
prevent illness, and aid coping with illness or death. Here are various capacities in which a critical care nurse
may function.
1. Staff nurse
• Makes independent assessments
• Plans and implements patient care
• Provides direct nursing care
• Makes clinical observations and executes interventions
• Administers medications and treatments
• Promotes activities of daily living
2. Nurse-educator
• Assesses patients’ and families’ learning needs; plans and implements teaching strategies to meet those
needs
• Evaluates effectiveness of teaching
• Educates peers and colleagues
• Possesses excellent interpersonal skills
3. Nurse-manager
• Acts as an administrative representative of the unit
• Ensures that effective and quality nursing care is pro- vided in a timely and fiscally sound environment
4. Case manager
• Manages comprehensive care of an individual patient
• Encompasses the patient’s entire illness episode, crosses all care settings, and involves the collaboration of
all personnel who provide care
• Is involved in discharge planning and making referrals
• Identifies community and personal resources
• Arranges for equipment and supplies needed by the patient on discharge
5. Clinical nurse specialist
• Participates in education and direct patient care
• Consults with patients and family members
• Collaborates with other nurses and health care team members to deliver high quality care
6. Nurse practitioner
• Provides primary health care to patients and families; can function independently
• May obtain histories and conduct physical examinations
• Orders laboratory and diagnostic tests and interprets results
• Diagnoses disorders
• Treats patients
• Counsels and educates patients and families
7. Nurse researcher
• Reads current nursing literature
• Applies information in practice
• Collects data
• Conducts research studies
• Serves as a consultant during research study implementation
Nursing Responsibilities
As a critical care nurse, you’re responsible for all parts of the nursing process: assessing, planning,
implementing, and evaluating care of critically ill patients. Remember that each of these steps gives you an
opportunity to exercise your critical thinking skills.
1. Assessment
Critical care nursing requires that you constantly assess the patient for subtle changes in condition and
monitor all equipment being used. Caring for critically ill patients may involve the use of such highly
specialized equipment as cardiac monitors, hemodynamic monitoring devices, intra-aortic balloon pumps,
and ICP monitoring devices. As part of the patient assessment, you also assess the patient’s physical and
psychological statuses and interpret laboratory data.
To obtain assessment data:
• ask relevant questions
• validate evidence or data that has been collected
• identify present and potential concerns.
Then be sure to analyze the assessment data and determine the nursing diagnoses. To do this, you must
interpret the collected data and identify gaps. For example, if laboratory values are missing, call to obtain
test results or schedule a test that wasn’t performed.
2. Planning
Planning requires you to consider the patient’s psychological and physiological needs and set realistic
patient goals. The result is an individualized care plan for your patient. To ensure safe passage through the
critical care environment, you must also anticipate changes in the patient’s condition. For example, for a
patient admitted with a diagnosis of MI, you should monitor cardiac rhythm and anticipate rhythm changes.
If an arrhythmia such as complete heart block develops, the treatment plan may need to be changed and new
goals established.
What’s the problem?
In planning, be sure to address present and potential problems, such as:
• pain
• cardiac arrhythmias
• altered hemodynamic states
• impaired physical mobility
• impaired skin integrity
• deficient fluid volume.
During the planning stage, critical thinking skills come in handy when considering how the patient is
expected to achieve goals. During this stage, consider the consequences of planned interventions. This is
also the time to set priorities of care for the patient.
3. Implementation
As a nurse, you must implement specific interventions to address existing and potential patient problems.
A call to intervene.
Examples of interventions include:
• monitoring and treating cardiac arrhythmias
• assessing hemodynamic parameters, such as pulmonary artery pressure, central venous pressure, and
cardiac output
• titrating vasoactive drips
• managing pain
• monitoring responses to therapy.
There’s more in store
Some other common interventions are:
• repositioning the patient to maintain joint and body functions
• performing hygiene measures to prevent skin breakdown
• elevating the head of the bed to improve ventilation.
During the implementation stage, use critical thinking to involve the patient and other members of the
health care team in implementing the care plan.
4. Evaluation
It’s necessary for you to continually evaluate a patient’s response to interventions. Use such evaluations to
change the care plan as needed to make sure that your patient continues to work toward achieving his
outcome goals.
During the evaluation stage, use critical thinking to continually reassess, modify, and individualize care.
Evaluation enables you to assess the patient’s responses and determine whether expected outcomes have
been met.
Meet the Team
Various members of the multidisciplinary team have collaborative relationships with critical care nurses.
Here are some examples.
1. Patient-care technician
• Provides direct patient care to critically ill patients
• Bathes patients
• Obtains vital signs
• Assists with transportation of patients for testing
2. Physical therapist
• Assesses muscle groups and mobility and improves motor function of critically ill patients
• Develops specialized care plan and provides care based on the patient’s functional abilities and the disease
process or physical injury
• Teaches gait and transfer training to patients and other health care team members
3. Occupational therapist
• Assesses a patient’s activities of daily living
• Teaches the patient and his family methods for completing these tasks and achieving the discharge plan
4. Speech pathologist
• Assesses the critically ill patient’s ability to swallow and develops a care plan with appropriate
interventions
• Assesses for speech and language disorders
• Teaches techniques for dealing with swallowing impairment, communication methods for those with
aphasia, and techniques to assist with auditory processing difficulties
• Works with health care providers to reinforce treatment
5. Wound-ostomy-continence nurse
• Assesses, monitors, and makes recommendations to the practitioner regarding the patient’s skin integrity
and bowel and bladder issues
• Helps to develop a treatment plan
6. Dietitian
• Monitors a critically ill patient’s dietary intake
• Assesses the patient’s daily caloric intake and reports deviations
• Devises meal plans to meet the practitioner- recommended needs for the patient
• Recommends dietary interventions
7. Pastoral caregiver
• Also known as a chaplain
• Meets patient’s and family’s spiritual and religious needs
• Provides support and empathy to the patient and his family
• Delivers patient’s last rites if appropriate
8. Social services
• Assists patients and families with such problems as difficulty paying for medications, follow-up physician
visits, and other health-related issues
• Assists patients with travel and housing if needed

Lesson 2: Hemodynamic Monitoring Devices

Critically ill patients require continuous 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.
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.
Definition
Hemodynamic monitoring refers to:
• measurement of pressure, flow and oxygenation of blood within the cardiovascular system
• using invasive technology to provide quantitative information about vascular capacity, blood volume,
pump effectiveness and tissue perfusion
• the measurement and interpretation of biological systems that describes the performance of cardiovascular
system
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,
cardiomyopathy.
• All types of shock; cardiogenic shock, neurogenic shock or anaphylactic shock.
• Decreased urine output from dehydration, hemorrhage. G.I bleed, burns or surgery.
Specialized Equipment 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.

Setup for Hemodynamic Pressure Monitoring

1. Obtain barrier kit, sterile gloves and correct swan catheter. Also need extra iv pole, transducer holder,
boxes and cables.
2. Check to make sure signed consent is in chart, and that patient and or family understand procedure.
3. Everyone in the room should be wearing a mask.
4. Position patient supine and flat if tolerated.
5. On the monitor, press “change screen” button, then select “swan ganz” to allow physician to view catheter
wave forms which inserting.
6. Assist physician in sterile draping and sterile setup for swan insertion.
7. Setup pressure lines and transducers. Level pressure flush monitoring system and transducers to the
phlebostatic axis.
8. Connect tubings to patient when patient is ready to flush the swann.
9. While floating the swann, observe for ventricular ectopy on the monitor.
10.After swann is in place, assist with cleanup and let patient know procedure is complete.
11.Obtain all the values. For cardiac output inject 10mls of D5w after pushing the start button.
12.Perform hemocalculations.
13.Document findings in ICU flow sheet.
Phlebostatic Axis
Methods of Hemodynamic Monitoring
1.ARTERIAL BLOOD PRESSURE
a) Non-Invasive
• With manual or automated devices
Method of measurement
• Oscillometry (most common)
o MAP most accurate DP least accurate
• Auscultatory (korotkoff sounds)
• Combination
Limitations
1. Cuff must be placed correctly and must be appropriately sized
2. Auscultatory method is very inaccurate (Korotkoff sound is difficult to hear)
3. Significant underestimation in low flow (shock)
4. Oscillometric also mostly in accurate (>5mmhg off directly recorded pressures)
b) Intra-arterial blood pressure measurement
• Intra-arterial BP monitoring is used to obtain direct and continuous BP measurements in critically ill
patients who have severe hypertension or hypotension

Procedure
1. Once an arterial site is selected (radial, brachial, femoral, or dorsalis pedis), collateral circulation to the
area must be confirmed before the catheter is placed. 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.
2. Collateral circulation to the hand can be checked by the Allen test
3. 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.
4. 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
• infection
Nursing Interventions
1. 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.
2. Once the arterial catheter is inserted, it is secured and a dry, sterile dressing is applied.
3. The site is inspected daily for signs of infection. The dressing and pressure monitoring system or water
manometer are changed according to hospital policy.
4. In general, the dressing is to be kept dry and air occlusive.
5. Dressing changes are performed with the use of sterile technique.
6. Arterial catheters can be used for infusing intravenous fluids, administering intravenous medications, and
drawing blood specimens in addition to monitoring pressure.
7. 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.
8. After locating this position, the nurse may make an ink mark on the chest.
2.CENTRAL VENOUS PRESSURE
• 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
1. Before insertion of a CVP catheter, the site is prepared by shaving if necessary and by cleansing with an
antiseptic solution.
2. 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
1. Once the CVP catheter is inserted, it is secured and a dry, sterile dressing is applied.
2. 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.
3. In general, the dressing is to be kept dry and air occlusive.
4. Dressing changes are performed with the use of sterile technique.
5. CVP catheters can be used for infusing intravenous fluids, administering intravenous medications, and
drawing blood specimens in addition to monitoring pressure.
6. 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 point, called the
phlebostatic axis.
7. After locating this position, the nurse may make an ink mark on the chest.

Measuring CVP with a Water Manometer

1. Prime the IV tubing and manometer setup. Attach the water manometer to an IV pole or place it next to
the patient’s chest.
2. Connect the IV tubing to the CV catheter. Trace the tubing from the patient to its point of origin to make
sure that it’s attached to the proper port.
3. Align the base of the manometer with the zero-reference point by using a leveling device and secure the
manometer in place. Because CVP reflects right atrial pressure, you must align the right atrium (the zero-
reference point) with the zero mark on the manometer. (See Measuring CVP with a water manometer.)
4. Typically, markings on the manometer range from −2 to 38 cm H2O. However, manufacturer’s markings
may differ, so be sure to read the directions before setting up the manometer and obtaining readings.
5. Turn the stopcock off to the patient and slowly fill the manometer with IV solution until the fluid level is
10 to 20 cm H2O higher than the patient’s expected CVP value. Don’t overfill the tube because fluid that
spills over the top can become a source of contamination.
Intermittent CVP Readings using a Water Manometer
1. Turn the stopcock off to the IV solution and open to the patient. The fluid level in the manometer will
drop. When the fluid level comes to rest, it will fluctuate slightly with respirations. Expect it to drop during
inspiration and to rise during expiration.
2. Record CVP at the end of expiration, when intrathoracic pressure has a negligible effect and the
fluctuation is at its highest point.1 Depending on the type of water manometer used, note the value either at
the bottom of the meniscus or at the midline of the small floating ball.
3. After you’ve obtained the CVP value, turn the stopcock to resume the IV infusion. Adjust the IV drip rate,
as required.
4. Place the patient in a comfortable position.
5. Remove and discard your personal protective equipment and perform hand hygiene.
6. Document the procedure.
Continuous CVP Readings using a Water Manometer
1. Make sure the stopcock is turned so that the IV solution port, CVP column port, and patient port are open.
Be aware that with this stopcock position, infusion of the IV solution increases CVP. Therefore, expect
higher readings than those taken with the stopcock turned off to the IV solution.
2. If the IV solution infuses at a constant rate, CVP will change as the patient’s condition changes, although
the initial reading will be higher. Assess the patient closely for changes.
3. Record CVP values at appropriate intervals.
4. Remove and discard your personal protective equipment and perform hand hygiene.
3.PULMONARY ARTERY CATHETER 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”.
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
• Normal pulmonary artery pressure is 25/9 mm Hg, with a mean pressure of 15mm Hg.
• Pulmonary capillary wedge pressure is a mean pressure and is normally 4.5 to 13mm 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 rupture
• 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
• CO = VO2
CA-CV
Derived Parameters
• Cardiac output 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:
• 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.

Summary:
Hemodynamic monitoring is the assessment of the patient’s circulatory status; it includes measurements of
heart rate (HR), intra-arterial pressure, CO, central venous pressure (CVP), PAP, pulmonary artery wedge
pressure and blood volume.
The primary purpose is the early detection, identification, and treatment of life-threatening conditions, such
as heart failure, cardiac tamponade, and all types of shock (septic, cardiogenic, neurogenic, anaphylactic).
Cardiac Output
CO is the amount (volume) of blood ejected by the left ventricle into the aorta in 1 minute. Normal CO is 4
to 8 L/minute.
Underlying Concepts
1. CO is determined by stroke volume (SV) and HR. Thus, CO = SV x HR. CO must be maintained to
adequately oxygenate the body.
a. HR = number of cardiac contractions per minute.
b. SV = amount of blood ejected from ventricle per beat (normal SV is 50 to 100ml/beat). The amount of
blood returning to the heart (preload), venous tone, resistance imposed on the ventricle before ejection
(afterload), and the integrity of the cardiac muscle (contractility) influence the functioning of this
determinant.
2. The body alters CO through increases or decreases in one or both of these parameters. CO is maintained if
the HR falls by an increase in SV. Likewise, a decrease in SV produces a compensatory rise in HR to keep
the CO normal.
3. CO will decrease if either of the determinants cannot inversely compensate for the other.
4. CO measurements are adjusted to patient size by calculating the cardiac index (CI). CI equals CO divided
by body surface area (BSA); BSA is determined through standard charts based on individual height and
weight. Normal CI is 2.5 to 4 L/minute/m2.
Central Venous Pressure Monitoring
1. Refers to the measurement of right atrial pressure or the pressure of the great veins within the thorax
(normal range: 5 to10 cm H2O or 2 to 8 mm Hg).
a. Right-sided cardiac function is assessed through the evaluation of CVP.
b. Left-sided heart function is less accurately reflected by the evaluation of CVP but may be useful in
assessing chronic right- and left-sided heart failure and differentiating right and left ventricular infarctions.
2. Requires the threading of a catheter into a large central vein (subclavian, internal or external jugular,
median basilic, or femoral). The catheter tip is then positioned in the right atrium, upper portion of the
superior vena cava, or the inferior vena cava (femoral approach only).
3. Purposes of CVP catheter and monitoring include:
a. To serve as a guide for fluid replacement.
b. To monitor pressures in the right atrium and central veins.
c. To administer blood products, total parenteral nutrition, and drug therapy contraindicated for peripheral
infusion.
d. To obtain venous access when peripheral vein sites are inadequate.
e. To obtain central venous blood samples.
Purposes of Pulmonary Artery Pressure Monitoring:
1. To monitor pressures in the right atrium (CVP), right ventricle, pulmonary artery, and distal branches of
the pulmonary artery (pulmonary capillary wedge pressure [PCWP]). The latter reflects the level of the
pressure in the left atrium (or filling pressure in the left ventricle); thus, pressures on the left side of the heart
are inferred from pressure measurement obtained on the right side of the circulation.
2. To obtain blood for central venous oxygen saturation.

Lesson 3: Circulatory Assist Devices

Mechanical circulatory assist devices (CADs), such as the intra-aortic balloon pump (IABP) and left or right
ventricular assist device (VAD), are used to decrease cardiac work and improve organ perfusion in patients
with heart failure when conventional drug therapy is no longer adequate. The type of device used depends
on the extent and nature of the heart problem. CADs provide interim support in three types of situations:
• The left, right, or both ventricles require support while recovering from acute injury (e.g., post
cardiotomy);
• The patient must be stabilized before surgical repair of the heart (e.g., a ruptured septum); and
• The heart has failed, and the patient is awaiting cardiac transplantation.
All CADs decrease cardiac workload, increase myocardial perfusion, and augment circulation. The most
commonly used CAD is the IABP.
Intra-aortic Balloon Pump
IABP therapy is known as Counter pulsation, a method of assisting the failing heart and circulation by
mechanical support when the myocardium is unable to generate adequate CO. The mechanism of counter
pulsation therapy is opposite to the normal pumping action of the heart; counter pulsation devices pump
while the heart muscle relaxes (diastole) and relax when the heart muscle contracts (systole).
Indications are:
1. Post cardiotomy support.
2. Cardiogenic shock/left-sided heart failure after MI, myocarditis, cardiomyopathy, and myocardial
contusion.
3. Postinfarction ventricular septal defects or mitral insufficiency resulting in shock.
4. Emergency support following PTCA or cardiac catheterization.
5. Hemodynamic deterioration in patients awaiting heart transplant.
Function of IABP:
1. A balloon catheter is introduced into the femoral artery percutaneously or surgically, threaded to the
descending thoracic aorta, and positioned 1 to 2 cm distal to the subclavian artery (see Figure 1).

2. The balloon catheter is attached to an external console, allowing for inflation and deflation of the balloon
with gas such as CO2.
3. The external console integrates the inflation and deflation sequence with the mechanical events of the
cardiac cycle (systole-diastole) by “triggering” gas delivery in synchronization with the patient’s ECG, the
patient’s arterial waveform, or an intrinsic pump rate.
a. The most common method of “triggering” the IABP is from the R wave of the patient’s ECG signal
(IABP catheter will deflate on the R wave).
b. The balloon is automatically set to inflate in the middle of the T wave or at the dicrotic notch of the
arterial waveform.
4. Eases the workload of a damaged heart by increasing coronary blood flow (diastolic augmentation) and
decreasing the resistance in the arterial tree against which the heart must pump (afterload reduction).
5. This results in an increase in CO and a reduction in myocardial oxygen requirements.
6. The balloon is inflated at the onset of diastole; this results in an increase in diastolic aortic pressure
(diastolic augmentation), which increases blood flow through the coronary arteries.
7. The balloon is deflated just before the onset of systole, facilitating the emptying of blood from the left
ventricle and decreasing pressure within the aorta. This action results in less work for the left ventricle.
Contraindications
1. Aortic aneurysm—IABP catheter may perforate a weakened vessel wall leading to thrombus formation,
and inflation and deflation of the catheter may cause a thrombus to break off to become an embolus.
2. Peripheral vascular disease—femoral or iliac artery insertion may be impossible in a patient with severe
vascular disease.
3. Terminal illness—outcome will not be affected, unless the patient meets the criteria for heart
transplantation.
4. Coagulopathy—increases the risk of bleeding.
Complications
1. Vascular injuries that may occur from IABP are:
a. Plaque dislodging
b. Laceration of the aorta
c. Ischemia of the limb distal to the insertion site
d. Arterial perforation.
2. Peripheral nerve damage can occur from IABP if a cutdown was used to insert the catheter.
3. Impairment of cerebral circulation due to balloon migration occluding the subclavian artery or by embolus
and impairment of renal circulation due to balloon malposition or embolus. (Impaired circulation occurs
more frequently in patients with peripheral vascular occlusive disease, in women with small vessels, and in
patients with insulin-dependent diabetes.)
4. Infection at the insertion site and septicemia occurs in 0.2% of patients with IABP.
5. Thrombocytopenia.
6. Hemorrhage due to anticoagulation.
Nursing Diagnosis
• Anxiety related to invasive procedure, critical illness, and environment
• Decreased Cardiac Output related to myocardial ischemia and/or mechanical intervention
• Impaired Tissue Perfusion related to foreign body in aorta
Nursing Interventions:
Relieving Anxiety
1. Explain IABP therapy to patient and family geared to their level of understanding.
a. Review purpose of therapy and how the IABP functions.
b. Reinforce mobility restrictions: supine position with head of bed elevated 15 to 30 degrees, no movement
or flexing of leg with IABP catheter.
c. Explain need for frequent monitoring of vital signs, rhythm, affected extremity, and pulses.
d. Discuss the sounds associated with functioning external console: balloon inflation and deflation and
alarms.
2. Encourage family members to participate in patient’s care.
a. Allow family to visit patient frequently.
b. Solicit family members’ assistance in reinforcing mobility restrictions to patient and notifying nursing
staff of patient comfort needs.
c. Encourage family members to ask questions.
3. Allow patient to verbalize fears regarding therapy and illness.
4. Make sure that informed consent is obtained.
5. Administer anxiolytic medications as prescribed and indicated.
6. Keep the family informed of changes in the patient’s condition.
7. Encourage realistic hope based on the patient’s condition and discuss the patient’s progress with the
family.
8. Determine the family’s previous coping mechanism to stressful situations.

Lesson 4: Artificial Airways

Airway management may be indicated in patients with loss of consciousness, facial or oral trauma,
aspiration, tumor, infection, copious respiratory secretions.
Patients in the ICU often need mechanical assistance to maintain airway patency. Inserting a tube into the
trachea, bypassing upper airway and laryngeal structures, creates an artificial airway.
Types of Airways
1. Oropharyngeal airway
A curved plastic device inserted through the mouth and positioned in the posterior pharynx to move tongue
away from palate and open the airway.
a. Usually for short-term use in the unconscious patient or may be used along with an oral ET tube.
b. Not used if recent oral trauma, surgery, or if loose teeth are present.
c. Does not protect against aspiration.
Position patient on side and suction oral cavity frequently to prevent aspiration of oral secretions or vomitus
when an oral airway is in place Oral pharyngeal airway (OPA), also known as Oropharyngeal airway,
semicircular or tube-like plastic device. It is inserted over the back of the tongue into the lower posterior
pharynx Indication is when a breathing spontaneously but unconscious. It prevents the tongue from falling
back against the posterior pharynx and allows to suction secretions.

2. Nasopharyngeal airway (nasal trumpet)

A soft rubber or plastic tube inserted through nose into posterior pharynx.
a. Facilitates frequent nasopharyngeal suctioning.
b. Use extreme caution with patients on anticoagulants or bleeding disorders.
c. Select size that is slightly smaller than diameter of nostril and slightly longer than distance from tip of
nose to earlobe.
d. Check nasal mucosa for irritation or ulceration, and clean airway with hydrogen peroxide and water.
Nasopharyngeal airways may obstruct sinus drainage and produce acute sinusitis. Be alert to fever and facial
pain. It is a soft plastic or rubber tube designed to pass just inferior of the base of the tongue. Measure from
the tip of the nose to the tip of the ear and always look at diameter of nostril before insertion.

3. Laryngeal mask airway

It is composed of a tube with a cuffed masklike projection at the distal end; inserted through the mouth into
the pharynx; seals the larynx and leaves distal opening of tube just above glottis.
a. Easier placement than ET tube because visualization of vocal cords is not necessary.
b. Provides ventilation and oxygenation comparable to that achieved with an ET tube.
c. Cannot prevent aspiration because it does not separate the GI tract from the respiratory tract.
d. May cause laryngospasm and bronchospasm.
4. Combitube
A double-lumen tube with pharyngeal lumen and tracheoesophageal lumen; pharyngeal lumen has blocked
distal end and perforations at pharyngeal level; tracheoesophageal lumen has open upper and lower end;
large oropharyngeal balloon serves to seal mouth and nose; distal cuff seals the esophagus or trachea.
If the patient is outside the hospital and cannot be intubated in the field, the emergency medical personnel
may insert a Combitube. The tube rapidly provides pharyngeal ventilation, and it functions like an
endotracheal tube.
One of the two balloons around the tube can be inflated. One balloon is large (100 mL) and occludes the
oropharynx. The smaller balloon is inflated with 15 mL of air and can effectively occlude the trachea if
placed there. Breath sounds are auscultated to make sure that the oropharyngeal cuff does not obstruct the
glottis. Patients can be ventilated through either port of the tube, depending on its placement.

5. Endotracheal tube
A flexible tube inserted through the mouth or nose and into the trachea beyond the vocal cords that acts as
an artificial airway
a. Maintains a patent airway.
b. Allows for deep tracheal suction and removal of secretions.
c. Permits mechanical ventilation.
d. Inflated balloon seals off trachea so aspiration from the GI tract cannot occur.
e. Generally easy to insert in an emergency, but maintaining placement is more difficult so this is not for
long-term use.
6. Tracheostomy tube
A firm curved artificial airway inserted directly into the trachea at the level of the second or third tracheal
ring through a surgically made incision.
a. Permits mechanical ventilation and facilitates secretion removal.
b. Can be for long-term use.
c. Bypasses upper airway defenses, increasing susceptibility to infection.
d. Allows the patient to eat and swallow.

Nursing Care for Patients with Artificial Airways

General Care Measures
1. Ensure adequate ventilation and oxygenation through the use of supplemental oxygen or mechanical
ventilation as indicated.
2. Assess breath sounds every 2 hours. Note evidence of ineffective secretion clearance (rhonchi, crackles),
which suggests need for suctioning.
3. Provide adequate humidity when the natural humidifying pathway of the oropharynx is bypassed.
4. Provide adequate suctioning of oral secretions to prevent aspiration and decrease oral microbial
colonization.
5. Use clean technique when inserting an oral or nasopharyngeal airway, and take it out and clean it with
hydrogen peroxide and rinse with water at least every 8 hours.
6. Perform frequent oral care with soft toothbrush or swabs and antiseptic mouthwash or hydrogen peroxide
diluted with water. Frequent oral care will aid in prevention of ventilator-associated pneumonia. The
patient’s lips should be kept moisturized with petroleum jelly to prevent them from becoming sore and
cracked.
7. Ensure that aseptic technique is maintained when inserting an ET or tracheostomy tube. The artificial
airway bypasses the upper airway, and the lower airways are sterile below the level of the vocal cords.
8. Elevate the patient to a semi-Fowler’s or sitting position, when possible; these positions result in
improved lung compliance. The patient’s position, however, should be changed at least every 2 hours to
ensure ventilation of all lung segments and prevent secretion stagnation and atelectasis. Position changes are
also necessary to avoid skin breakdown.
9. If an oral or nasopharyngeal airway is used, turn patient’s head to the side to reduce the risk of aspiration
(because there is no cuff to seal off the lower airway).

Lesson 5: Mechanical Ventilation

The mechanical ventilator device functions as a substitute for the bellows action of the thoracic cage and
diaphragm. The mechanical ventilator can maintain ventilation automatically for prolonged periods. It is
indicated when the patient is unable to maintain safe levels of oxygen or CO2 by spontaneous breathing
even with the assistance of other oxygen delivery devices.
Clinical Indications
Mechanical Failure of Ventilation
 Neuromuscular disease
 CNS disease
 CNS depression (drug intoxication, respiratory depressants, cardiac arrest)
 Inefficiency of thoracic cage in generating pressure gradients necessary for ventilation (chest injury,
thoracic malformation)
 When ventilatory support is needed postoperatively
Disorders of Pulmonary Gas Exchange
 Acute respiratory failure
 Chronic respiratory failure
 Left-sided heart failure
 Acute lung injury
Underlying Principles
1. Variables that control ventilation and oxygenation include:
a. Ventilator rate—adjusted by rate setting.
b. VT—volume of gas required for one breath (ml/kg)
c. Fraction of inspired oxygen concentration (FiO2)— set on ventilator and measured with an oxygen
analyzer.
d. Ventilator dead space—circuitry (tubing) common to inhalation and exhalation: tubing is calibrated.
e. PEEP—set within the ventilator or with the use of external PEEP devices; measured at the proximal
airway.
2. CO2 elimination is controlled by VT, rate, and dead space.
3. Oxygen tension is controlled by oxygen concentration and PEEP (also by rate and VT).
4. In most cases, the duration of inspiration should not exceed exhalation.
5. The inspired gas must be warmed and humidified to prevent thickening of secretions and decrease in body
temperature. Sterile or distilled water is warmed and humidified by way of a heated humidifier.

Types of Ventilators
Negative Pressure Ventilators
1. Applies negative pressure around the chest wall. This causes intra-airway pressure to become negative,
thus drawing air into the lungs through the patient’s nose and mouth.
2. No artificial airway is necessary; patient must be able to control and protect own airway.
3. Indicated for selected patients with respiratory neuromuscular problems, or as adjunct to weaning from
positive pressure ventilation.
4. Examples are the iron lung and cuirass (shell unit) ventilator.
Positive Pressure Ventilators
During mechanical inspiration, air is actively delivered to the patient’s lungs under positive pressure.
Exhalation is passive. Requires use of a cuffed artificial airway.
 Pressure cycled.
 a. Delivers selected gas pressure during inspiratory phase.
b. Volume delivered depends on lung compliance and resistance.

Modes of Operation
Controlled Ventilation
1. Patient receives a set number and volume of breaths/ minute.
2. Provides a fixed level of ventilation, but will not cycle or have gas available in circuitry to respond to
patient’s own inspiratory efforts. This typically increases work of breathing for patients attempting to
breathe spontaneously.
3. Generally used for patients who are unable to initiate spontaneous breaths.
Assist/Control
1. Inspiratory cycle of ventilator is activated by the patient’s voluntary inspiratory effort and delivers a
preset full volume.
2. Ventilator also cycles at a rate predetermined by the operator.
3. Indicated for patients who are breathing spontaneously, but who have the potential to lose their respiratory
drive or muscular control of ventilation. In this mode, the patient’s work of breathing is greatly reduced.
Intermittent Mandatory Ventilation (IMV)
1. Allows patients to breathe at their own rate and volume spontaneously through ventilator circuitry.
2. Periodically, at preselected rate and volume or pressure, cycles to give a “mandated” ventilator breath.
3. Ensures that a predetermined number of breaths at a selected tidal volume are delivered each minute.
4. Gas provided for spontaneous breaths usually flows continuously through the ventilator.
5. Indicated for patients who are breathing spontaneously, but at a VT and/or rate less than adequate for their
needs. Allows the patient to do some of the work of breathing.
Synchronized Intermittent Mandatory Ventilation (SIMV)
1. Allows patient to breathe at their own rate and volume spontaneously through the ventilator circuitry.
2. Periodically, at a preselected time, a partial mechanical breath assistance is delivered. The mandatory
breaths are synchronized with the patient’s inspiratory effort.
3. Gas provided for spontaneous breathing flows continuously through the ventilator.
4. Ensures that a predetermined number of breaths at a selected VT are delivered each minute.
5. Indicated for patients who are breathing spontaneously, but at a VT and/or rate less than adequate for their
needs. Allows the patient to do some of the work of breathing.
Pressure Support
1. Augments inspiration to a spontaneously breathing patient.
2. Maintains a set positive pressure during spontaneous inspiration.
3. The patient ventilates spontaneously, establishing own rate, VT, and inspiratory time.
4. Pressure support may be used independently as a ventilatory mode or used in conjunction with CPAP or
synchronized intermittent mandatory ventilation.
Positive Pressure Ventilation Techniques
 Positive End-Expiratory Pressure
1. Maneuver by which pressure during mechanical ventilation is maintained above atmospheric at end of
exhalation, resulting in an increased functional residual capacity. Airway pressure is therefore positive
throughout the entire ventilatory cycle.
2. Purpose is to increase functional residual capacity (or the amount of air left in the lungs at the end of
expiration). This aids in:
a. Increasing the surface area of gas exchange.
b. Preventing collapse of alveolar units and development of atelectasis.
c. Decreasing intrapulmonary shunt.
d. Improving lung compliance.
e. Improving oxygenation.
f. Recruiting alveolar units that are totally or partially collapsed.
3. Benefits:
a. Because a greater surface area for diffusion is available and shunting is reduced, it is often possible
to use a lower FiO2 than otherwise would be required to obtain adequate arterial oxygen levels. This
reduces the risk of oxygen toxicity in conditions such as acute respiratory distress syndrome
(ARDS).
b. Positive intra-airway pressure may be helpful in reducing the transudation of fluid from the
pulmonary capillaries in situations where capillary pressure is increased (ie, left-sided heart failure).
c. Increased lung compliance resulting in decreased work of breathing.
4. Hazards:
a. Because the intrathoracic pressure is increased by PEEP, venous return is impeded. This may result
in:
i. decreased cardiac output and decreased oxygen delivery to the tissues (especially noted in
hypovolemic patients)
ii. decreased renal perfusion
iii. ICP
iv. iv. hepatic congestion.
b. The decreased venous return may cause antidiuretic hormone formation to be stimulated, resulting in
decreased urine output.
5. Precautions:
a. Monitor frequently for signs and symptoms of respiratory distress—shortness of breath, dyspnea,
tachycardia, chest pain.
b. Monitor frequently for signs and symptoms of pneumothorax (increased PAP, increased size of
hemothorax, uneven chest wall movement, hyper resonant percussion, distant or absent breath
sounds).
c. Monitor for signs of decreased venous return (decreased BP, decreased cardiac output, decreased
urine output, peripheral edema).
d. Abrupt discontinuance of PEEP is not recommended. The patient should not be without PEEP for
longer than 15 seconds. The manual resuscitation bag used for ventilation during suction procedure
or patient transport should be equipped with a PEEP device. In-line suctioning may also be used so
that PEEP can be
e. maintained.
f. Intrapulmonary blood vessel pressure may increase with compression of the vessels by increased
intra airway pressure. Therefore, central venous pressure (CVP), PAP, and pulmonary capillary
wedge pressure may be increased. The clinician must bear this in mind when determining the clinical
significance of these pressures.
Newer Modes of Ventilation
Inverse Ratio Ventilation
1. I:E ratio is greater than 1, in which inspiration is longer than expiration.
2. Potentially used in patients who are in acute severe hypoxemic respiratory failure. Oxygenation is thought
to be improved.
3. Very uncomfortable for patients; need to be heavily sedated.
4. Pressure-controlled inverse ratio ventilation—used in ARDS and acute lung injury.
Airway Pressure Release Ventilation
1. Ventilator cycles between uses a longer inspiratory time.
3. Uses a short expiratory time.
4. Used in severe ARDS/acute lung injury.
Non-invasive Positive Pressure Ventilation
1. Uses a nasal or face mask, or nasal pillows. Delivers air through a volume or pressure-controlled
ventilator.
2. Used primarily in the past for patients with chronic respiratory failure associated with neuromuscular
disease. Now is being used successfully during acute exacerbations. Some patients are able to avoid invasive
intubation. Other indications include acute or chronic respiratory distress, acute pulmonary edema,
pneumonia, COPD exacerbation, weaning, and post-extubation respiratory decompensation.
3. Can be used in the home setting. Equipment is portable and relatively easy to use.
4. Eliminates the need for intubation, preserves normal swallowing, speech, and the cough mechanism.
5. The system has a rate setting as well as inspiratory and expiratory pressure setting.
High-Frequency Ventilation
1. Uses very small VT (dead space ventilation) and high frequency (rates greater than 100/minute).
2. Gas exchange occurs through various mechanisms, not the same as conventional ventilation (convection).
3. Types include:
a. High-frequency oscillatory ventilation.
b. High-frequency jet ventilation.
4. Theory is that there is decreased barotrauma by having small VT and that oxygenation is improved by
constant flow of gases.
5. Successful with infant respiratory distress syndrome, much less successful with adult pulmonary
complications.
Nursing Assessment and Interventions
1. Monitor for complications:
a. Airway aspiration, decreased clearance of secretions, ventilator-acquired pneumonia, tracheal
damage, laryngeal edema
 b. Impaired gas exchange
c. Ineffective breathing pattern
d. ET tube kinking, cuff failure, mainstem intubation
e. Sinusitis
f. Pulmonary infection
g. Barotrauma (pneumothorax, tension pneumothorax, subcutaneous emphysema,
pneumomediastinum)
h. Decreased cardiac output
i. Atelectasis
j. Alteration in GI function (stress ulcers, gastric distention, paralytic ileus)
k. Alteration in renal function
l. Alteration in cognitive-perceptual status
2. Suction the patient as indicated.
a. When secretions can be seen or sounds resulting from secretions are heard with or without the use of
a stethoscope
b. After chest physiotherapy
c. After bronchodilator treatments
3. Provide routine care for patient on mechanical ventilator. Provide regular oral care to prevent ventilator-
associated pneumonia. Provide humidity and repositioning to mobilize secretions.
4. Assist with the weaning process, when indicated (patient gradually assumes responsibility for regulating
and performing own ventilations.
a. Patient must have acceptable ABG values, no evidence of acute pulmonary pathology, and must be
hemodynamically stable.
b. Obtain serial ABGs and/or oximetry readings, as indicated.
c. Monitor very closely for change in pulse and BP, anxiety, and increased rate of respirations.
d. The patient is awake and cooperative and displays optimal respiratory drive.
5. Once weaning is successful, extubate and provide alternate means of oxygen.
6. Extubation will be considered when the pulmonary function parameters of VT, VC, and negative
inspiratory pressure are adequate, indicating strong respiratory muscle function.
Community and Home Care Considerations
Patients may require mechanical ventilation at home to replace or assist normal breathing. Ventilator support
in the home is used to keep patient clinically stable and to maintain life.
1. Candidates for home ventilation are those patients who are unable to wean from mechanical ventilation,
and/or have disease progression requiring ventilator support. Candidates for home mechanical ventilator
support:
a. Have a secure artificial airway (tracheostomy tube).
b. Have FiO2 requirement 40%.
 c. Are medically stable
d. Are able to maintain adequate ventilation on standard ventilator settings.
2. Patients may choose not to receive home ventilation. Examples of inappropriate candidates for home
ventilation include patients who:
a. Have a FiO2 40%.
b. Use PEEP 10 cm H2O.
c. Require continuous invasive monitoring.
d. Lack a mature tracheostomy.
e. Lack able, willing, appropriate caregivers, and/or caregiver respite.
f. Lack adequate financial resources for care in home.
g. Lack adequate physical facilities:
i. Inadequate heat, electricity, sanitation.
ii. Presence of fire, health, or safety hazards.
3. For patients on mechanical ventilation in the home, a contract and relationship with a home medical
equipment company must be developed to provide:
a. Care of ventilator-dependent patient.
b. Provision and maintenance of equipment.
c. Timely provision of disposable supplies.
d. Ongoing monitoring of patient and equipment.
e. Training of patient, caregivers, and clinical staff on proper management of ventilated patient and use and
troubleshooting of equipment.
4. Equipment required:
a. Appropriate ventilator with alarms (disconnect and high pressure).
b. Power source.
c. Humidification system.
d. Manual resuscitation bag with tracheostomy adapter.
e. Replacement tracheostomy tubes.
f. Supplemental oxygen, as medically indicated.
g. Communication method for patient.
h. Backup charged battery to run ventilator during power failures.
5. Lay caregiver training and return demonstration must include:
a. Proper setup, use, troubleshooting, maintenance, and cleaning and infection control of equipment and
supplies.
b. Appropriate patient assessment and management of abnormalities, including cardiopulmonary
resuscitation, response to emergencies, power and equipment failure.
6. Potential complications include:
a. Patient deterioration, need for emergency services.
b. Equipment failure, malfunction.
c. Psychosocial complications, including depression, anxiety, and/or loss of resources (caregiver, financial,
detrimental change in family structure or coping capacity).
7. Communication is essential with local emergency medical services (fire, police, rescue) and utility
(telephone, electric) companies from whom the patient would need immediate and additional assistance in
event of emergency (eg, power failure, fire).

Lesson 6: Acute/Critically Ill Patients in Hemodynamic Monitoring

(Assessment and Management)
Assessment
Hemodynamics ultimately begins with the heart which supplies the driving force for all blood flow in the
body. Cardiac output propels blood through the arteries and veins as a function of ventricular contraction.
Ventricular motion results from the shortening of cardiac myocytes concentrically. This squeezing motion is
translated into the cardiac output, which is a function of both heart rate and ejection fraction (the starting
volume after diastolic filling minus the final ventricular volume after systole).
Hemodynamics represents the governing principals of this blood flow and its behavior in the blood vessels.
Correlation of Pathophysiology to Nursing Assessment
1. Hemodynamic monitoring is primarily used in patients with known or suspected shock; to identify
mechanism responsible for shock, select appropriate therapy, and evaluate response to therapy.
In shock the circulation is inadequate, blood pressure is low, heart rate is rapid, and irreversible tissue
damage from insufficient blood supply may occur if the condition is not terminated
Suggestive mechanism of shock based on hemodynamic monitoring findings:
a) elevated cardiac output may suggest distributive shock
b) low blood pressure and volumes may suggest hypovolemic shock
c) low cardiac output and increased systemic vascular resistance (SVR) may suggest cardiogenic shock
d) increased pulmonary artery pressure and dilated right-sided cavities may suggest obstructive shock
or cardiogenic shock
2. In Intracranial pressure (ICP) monitoring, pressure exerted by the brain, blood, and CSF against
the inside of the skull is measured. ICP monitoring enables prompt intervention, which can avert
damage caused by cerebral hypoxia and shifts of brain mass.
Indications for ICP monitoring include:
 Head trauma with bleeding or edema
 Overproduction or insufficient absorption of CSF
 Cerebral hemorrhage
 Space-occupying lesions
3. Spinal cord trauma results from acceleration, deceleration, or other deforming forces.
What to look for?
  History of trauma, a neoplastic lesion, an infection that could produce a spinal abscess, or an
endocrine disorder.
 Muscle spasm and back or neck pain that worsens with movement; in cervical fractures, pain that
causes point tenderness; in dorsal and lumbar fractures, pain that may radiate to other areas, such as
the legs
 Mild paresthesia to quadriplegia and shock, if the injury damages the spinal cord; in milder injury,
symptoms that may be delayed several days or weeks.
4. In intracranial or cerebral aneurysm, a weakness in the wall of a cerebral artery causes that area of
the artery to dilate or bulge. The most common form is the berry aneurysm, a saclike out-pouching in
a cerebral artery.
What to look for?
Occasionally, your patient may exhibit signs and symptoms due to blood oozing into the
subarachnoid space. The symptoms, which may persist for several days, include:
• Headache
• Intermittent nausea
• Nuchal rigidity
• Stiff back and legs.
5. Stroke, also known as a cerebrovascular accident or brain attack, is a sudden impairment of
cerebral circulation in one or more blood vessels. A stroke interrupts or diminishes oxygen supply
and commonly causes serious damage or necrosis in the brain tissues.
What to look for?
A stroke in the left hemisphere produces symptoms on the right side of the mbody; in the right
hemisphere, symptoms on the left side.
• Hemiparesis on the affected side (may be more severe in the face and arm than in the leg)
• Unilateral sensory defect (such as numbness, or tingling) generally on the same side as the
hemiparesis.
• Slurred or indistinct speech or the inability to understand speech.
• Blurred or indistinct vision, double vision, or vision loss in one eye (usually described as a curtain
coming down or gray-out of vision).
6. Hypertensive Crisis refers to the abrupt, acute, and marked increase in blood pressure from the
patient’s baseline that ultimately leads to acute and rapidly progressing end-organ damage. In the
brain, hypertensive crisis can result in hypertensive encephalopathy because of cerebral vasodilation
from an inability to maintain autoregulation. Blood flow increases, causing an increase in pressure
and subsequent cerebral edema. This increase in pressure damages the intimal and medial lining of
the arterioles.
What to look for?
Your assessment of a patient in hypertensive crisis almost always reveals a history of hypertension
that’s poorly controlled or has not been treated. Signs and symptoms may include:
• severe, throbbing headache in the back of the head
• dizziness, nausea, vomiting
• anorexia
 • irritability
• confusion, somnolence, or stupor
• vision loss, blurred vision, or diplopia
• dyspnea on exertion, orthopnea, or paroxysmal nocturnal dyspnea
• edema
• angina
• possible left ventricular heave palpated at the mitral valve area
• S4 heart sound
• Acute retinopathy and hemorrhage, retinal exudates, and papilledema
7. Heart Failure occurs when the heart can’t pump enough blood to meet the metabolic needs of the
body. It results in intravascular and interstitial volume overload and poor tissue perfusion. An
individual with heart failure experiences reduced exercise tolerance, a reduced quality of life, and a
shortened life span.
What to look for?
• Early signs and symptoms of left-sided heart failure include: dyspnea, orthopnea, paroxysmal
nocturnal dyspnea, fatigue, nonproductive cough
• Later-clinical manifestations of left-sided heart failure may include crackles on auscultation,
hemoptysis, displacement of the PMI toward the left anterior axillary line, tachycardia, S3 heart
sound, S4 heart sound, cool & pale skin, restlessness and confusion
• Clinical manifestations of right-sided heart failure include: jugular vein distention, hepatojugular
reflux and hepatomegaly, right upper quadrant pain, anorexia, fullness & nausea, nocturia, weight
gain, edema, ascites or anasarca
Management
Hemodynamic monitoring in itself cannot impact survival. Outcome is more closely related to
therapeutic measures that should rightly be instituted to improve survival with the hemodynamic details that
monitoring provides. A new trend in monitoring—functional hemodynamic monitoring—with emphasis on
how the parameters (e.g., with preload responsiveness) change with treatment strategies holds promise.
Failure to institute the correct therapeutic measure by care providers may limit the correlation between
hemodynamic monitoring and outcome. Care providers must understand how the hemodynamic parameters
impact survival so that they may make a right choice in using these parameters to guide therapeutic
measures in patient care.
Correlation of Pathophysiology to Nursing Assessment and Management
A. Neurologic – a complete neurologic examination can be long and detailed. It’s unlikely that you would
perform one in its entirety. However, if your initial screening suggests a neurologic problem, you may need
to conduct a more detailed assessment. Examine the patient’s neurologic system in an orderly way.
Beginning
with the highest levels of neurologic function and working down to the lowest, assess these five areas:
 Mental status
 Cranial nerve functions
 Sensory function
 Motor function
  reflexes
The most common imaging studies used to detect Neurologic disorders include computed tomography (CT)
scan, magnetic resonance imaging (MRI), positron emission tomography (PET) scan, and skull and spinal
X-rays.

Nursing Management on Imaging Studies:

1. Confirm that the client isn’t allergic to iodine or shellfish to avoid an adverse reaction to the contrast
medium.
2. If the test calls for a contrast medium, tell the client that it’s injected into an existing I.V. line or that a
new line may be inserted.
3. Pre-procedure testing should include evaluation of renal function (serum creatinine and blood urea
nitrogen (BUN) levels) because the contrast medium can cause acute renal failure.
4. Warn the client that he may feel flushed or notice a metallic taste in his mouth when the contrast medium
is injected.
5. Tell the client that the scanner circles around him for 10 to 30 minutes, depending on the procedure and
type of equipment.
6. Explain that the client must be still during the test.
7. Instruct the client to remove all metallic items, such as hair clips, bobby pins, jewelry, watches,
eyeglasses, hearing aids, and dentures.
8. For MRI: explain that the procedure can take up to 1½ hours, tell the client that he must remain still for
intervals of 5 to 20 minutes.
9. Explain that the test is painless, but that the machinery may seem loud and frightening and the tunnel
confining. The client may receive earplugs to reduce the noise.
10.Provide sedation, as ordered, to promote relaxation during the test.
11.After the procedure, increase the I.V. flow rate, as ordered, or encourage the patient to increase his fluid
intake to flush the contrast medium from his system.
B. Cardiovascular – hemodynamic monitoring is used to assess cardiac function. Follow your facility’s
procedure for setting up, zero referencing, calibrating. Maintaining, and troubleshooting equipment.
Common uses of hemodynamic monitoring include arterial blood pressure monitoring and pulmonary artery
pressure.
1. Arterial blood pressure – in arterial blood pressure monitoring, the doctor inserts a catheter into the radial
or femoral artery to measure blood pressure or obtain samples of arterial blood for diagnostic tests such as
arterial blood gas (ABG) studies. A transducer transforms the flow of blood during systole and diastole into
a waveform, which appears on an oscilloscope.
Nursing Management:
 Explain the procedure to the patient and his family, including the purpose of arterial pressure
monitoring.
 After catheter insertion, observe the pressure waveform to assess arterial pressure.
 Assess the insertion site for signs of infection, such as redness and swelling. Notify the doctor
immediately if you note such signs.
  Document the date and time of catheter insertion, catheter insertion site, type of flush solution used,
type of dressing applied, and patient’s tolerance of the procedure.
2. Pulmonary artery pressure – continuous pulmonary artery pressure (PAP) and intermittent pulmonary
artery wedge pressure (PAWP) measurements provide important information about left ventricular function
and preload. Use this information for monitoring and for aiding diagnosis, refining assessment, guiding
interventions, and projecting patient outcomes.
PAP and PAWP procedure:
A balloon-tipped, multilumen catheter is inserted into the client’s internal jugular or subclavian vein.
When the catheter reaches the right atrium, the balloon is inflated to float the catheter through the right
ventricle into the pulmonary artery. This permits the PAWP measurement through an opening at the
catheter’s tip.
The deflated catheter rests in the pulmonary artery, allowing diastolic and systolic PAP readings. The
balloon should be totally deflated except when taking a PAWP reading because prolonged wedging can
cause pulmonary infarction.
Nursing Management:
 Inform the patient he’ll be conscious during catheterization, and he may feel temporary local
discomfort from the administration of the local anesthetic. Catheter insertion takes about 30 minutes.
 After catheter insertion, you may inflate the balloon with a syringe to take PAWP readings. Be
careful not to inflate the balloon with more than 1.5 cc of air. Over inflation could distend the
pulmonary artery causing vessel rupture. Don’t leave the balloon wedged for a prolonged period
because this could lead to a pulmonary infarction.
 After each PAWP reading, flush the line, if you encounter difficulty, notify the doctor.
 Maintain 300 mm Hg pressure in the pressure bag to permit a flush flow of 3 to 6 ml/hour.
 If fever develops when the catheter is in place, inform the doctor, he may remove the catheter and
send its tip to the laboratory for culture.
 Make sure stopcocks are properly positioned and connections are secure. Loose connections may
introduce air into the system or cause blood backup, leakage of deoxygenated blood, or inaccurate
pressure readings. Also make sure the lumen hubs are properly identified to serve the appropriate
catheter ports.
 Because the catheter can slip back into the right ventricle and irritate it, check the monitor for a right
ventricular waveform to detect this problem promptly.
 To minimize valvular trauma, make sure the balloon is deflated whenever the catheter is withdrawn
from the pulmonary artery to the right ventricle or from the right ventricle to the right atrium.
 Adhere to your facility’s policy for dressing, tubing, catheter, and flush changes.
 Document the date and time of catheter insertion, the doctor who performed the procedure, the
catheter insertion site, pressure waveforms and values for the various heart chambers, balloon
inflation volume required to obtain a wedge tracing, arrhythmias that occurred during or after the
procedure, type of flush solution used and its heparin concentration, type of dressing applied, and the
patient’s tolerance of the procedure.
Trends in Hemodynamic Management
Recent developments include the move from static to dynamic variables to assess conditions such as cardiac
preload and fluid responsiveness and the transition to less invasive or even noninvasive monitoring
techniques, at least in the perioperative setting. Even though the thermodilution method remains the gold
standard for measuring cardiac output (CO), the use of the pulmonary artery catheter has declined over the
last decades, even in the setting of cardiovascular anesthesia.
Psychological difficulties experienced during acute/chronic illness include:
 persistent worries and fears about the illness and its long-term effects.
 fear of dying.
 fear of the hospital or medical procedures.
 persistent sadness, anger, irritability, or excessive moodiness.
 changes in self-esteem.
 Powerlessness
 guilt and resentment
 frustration