ECCO: Hemodynamic Monitoring Critically Ill Patients: Part 2
Which pulmonary artery pressure might a nurse observe when caring for a patient with ARDS?
48/23 mm Hg
A patient with heart failure is receiving milrinone. For which should the nurse observe?
? Milrinone increases contractility and decreased preload and afterload.
Measure the PAP shown on the waveform. The patient is on mechanical ventilation.
?28/15 Measure peak systole and end-diastole for a mechanically ventilated patients at end-expiration - usually the low point in the tracing just before the next positive pressure breath pushes the waveform tracing upward.
Measure the PAOP shown on the waveform. The patient is on mechanical ventilation.
?46 To measure the PAOP, locate the A wave near or after the QRS complex. Measure the top and the bottom of the A wave and average these values.
A patient with septic shock is hypotensive and his ScvO2 trended from 72% to 85% over the last hour. Norepinephrine and vasopressin (Pitressin) are at high dose. Which interventions do you anticipate?
?Administer analgesia for pain; Assess temperature for hypothermia Hypothermia and tissue extraction failure are both possible causes of increasing ScvO2
Which condition could be contributing to a drop in ScvO2 from 74% to 63% in a patient postoperative abdominal aneurysm repair?
?Administration of morphine for pain level of 5 on a 1-10 scale Dressing changes can increase oxygen demand by 10%
A nurse observes ventricular ectopy on a patient's PA waveform. What might this indicate?
?Catheter slipped back into RV after insertion; Catheter passing through the RV. Ventricular ectopy may occur as the PA catheter passes through the right ventricular (RV), if the catheter slips backwards into the RV, or due altered electrolytes.
A nurse administers an ACE inhibitor to a patient with left ventricular failure and BP 92/60 (71). What is the likely end result.
?Preload and afterload decrease; CO and BP decrease. ACE-inhibitors decrease SVR (afterload) and CVP (preload), resulting in an increase in cardiac output and increasing the BP.
A nurse observes the new onset of giant V waves in the PAOP waveform of a patient who is post-MI. What is the clinical significance?
?Re-infarction The abrupt onset of mitral insufficiency due to papillary muscle rupture is associated with large increase in the amplitude of the V wave in the PAOP waveform.
A change in the PA waveform and pressure are noted. A dicrotic notch is no longer visible. Values change from 36/15 to 30/3. What action should the nurse anticipate?
?Removing the syringe from the balloon port. A sudden drop in the waveform's values, accompanied by a loss of the dicrotic notch, could indicate catheter slippage from PA to RV. Inflating the balloon may help the catheter float forward into the PA. Notify the provider for possible catheter repositioning.
Which of these interventions or factors should a nurse manage in order to lower a patient's oxygen demand?
?Shivering; Endotracheal suctioning Shivering, bathing and endotracheal suctioning are just a few of the factors that increase oxygen demand.
A patient is receiving nicardipine for a SVR 1,600. For which should the nurse observe?
?Signs of aortic stenosis and cyanide toxicity Nicardipine may cause reflex tachycardia and hypotension.
A nurse places a patient on a 50% venti-mask to improve tissue oxygenation. What should be the goal for the patient's SvO2 and ScvO2?
?SvO2 >80% and ScvO2 >85% Generally, the goal for SvO2 is >65% and the goal for ScvO2 is >70%
How should a nurse interpret a patient's continuous PAOP waveform when the balloon is deflated?
?Waveform shows artifact; relevel and rezero. The continuous PAOP waveform is a medical emergency since the catheter has migrated into an arteriole which could result in pulmonary infarction.
A patient with a history of COPD is admitted with right-sided heart failure. PAP 62/38, PVR 400. Which intervention is indicated?
Administration of milrinone.
A patient is tachycardic HR 118, BP 88/52 (64), with stroke volume variability (SVV) trending upward from 12% to 18%, and urine output at 0.35 mL/kg/hr. SVV decreases to 13% when the passive leg maneuver is applied. What intervention should the nurse expect?
Fluid administration
An alert patient with a bowel infarction is admitted. Vitals are: BP 70/40 (50), HR 112, RR 24, Temp 39C (102.2F), and ScvO2 64%. Which is initially indicated?
Fluid bolus to increase preload
What intervention should a nurse expect to initiate to improve contractility in a patient with acute decompensated heart failure.
Dobutamine 5 mcg/kg/min, up 2.5 mcg/kg/min every five minutes
After tracheostomy suctioning, a nurse notes a patient's cooler skin, lethargy, and ScvO2 drop from 65% to 43%. What intervention could have prevented the ScvO2 change?
Hyperoxygenate before and after suctioning.
A patient with dilated cardiomyopathy asks the nurse why dobutamine was ordered. The nurse's best response is:
It improves the pumping action of your heart.
A patient has an ScvO2 of 50%. Which nursing intervention is indicated?
Perform patient care activities at intervals.
Which should the nurse anticipate when caring for a patient with dilated cardiomyopathy and a cardiac output of 2.5 L/min?
SVR 2,300; cool, mottled extremities
What factors produce cardiac output?
Stroke volume x Heart rate
Which is true regarding oxygen supply and demand?
Tachycardia causes an increase in O2 demand.
