Vascular Pressure Monitoring
Occurs with atrial contaction
"a" wave
occurs with movement of AV vlave back toward the atrium during systole
"c" wave
occurs with atrial filling during systole
"v" wave
-Reduced circulating blood volume -Vasodilation (reduced venous return) -Leaks in the pressure system -Spontaneous inspiration
-Causes of decreased CVP
-Fluid overload -Right/left heart failure -Pulmonary hypertension -Tricuspid valve stenosis -Pulmonary embolism -Increased venous return
-Causes of increased CVP
PA diastolic pressure
-Normally reflects left heart filling pressures -Does not reflect left heart filling pressures when pulmonary vascular resistance elevated
all of the above
A difference between the pulmonary artery diastolic pressure and the pulmonary capillary wedge pressure greater than 5 mm Hg is seen in which of the following conditions?
Pneumonia
A patient with what condition is least likely to need placement of an indwelling arterial catheter?(septic shock, cardiogenic shock, ARDS, pneumonia)
c: large pleural effusion
A patient with which of the following conditions is least likely to need placement of a CVP catheter? a. Cardiogenic pulmonary edema b. Noncardiogenic pulmonary edema c. Large pleural effusion d. Major trauma
all of the above
A shift to zone I or II may occur if which of the following conditions is present?
Which of the following will cause a tall, narrow arterial pressure waveform? A stiff aorta b. Vasodilation c. Mitral valve stenosis d. Ventricular hypertrophy
A. stiff aorta
2
According to West, which zone is dominant in the supine position?
peripheral vasodilation
All of the following cause an increase in the CVP except 1:
spontaneous inspiration
All of the following cause an increase in the CVP except:
Tricuspid regurgitation
An exaggerated v wave would be found in which of the following conditions?
a mechanical breath
An increase in CVP during inspiration most likely is caused by:
right ventricular failure
An increase in pulmonary artery systolic pressure is seen in patients with all of the following conditions except
Swan-Ganz catheter
Another name for a Pulmonary Artery Catheter
determining cardiac output
Arterial cannulation is indicated for all of the following except:
waves a, c, and v.
Both the CVP and the pulmonary artery wedge pressure waveforms have three waves for each cycle, namely:
a: Right ventricular filling volume
CVP is a reflection of which of the following? a. Right ventricular filling volume b. Left ventricular filling volume c. Left atrial pressure d. Pulmonary artery diastolic pressure
brief disconnection of the ventilator unless PEEP is being applied
CVP monitoring during MV requires?
West Zone 3
Catheter tip must be placed in what zone where the blood flow is continuous?
60
Circulation to the vital organs (kidneys, coronary arteries) may be compromised if the MAP falls to below _____ mm Hg.
atrial septal puncture
Complications involving the use of CVP catheters include all of the following except:
During placement -Bleeding -Pneumothorax Over time -Infection (main potential problem) -Embolus -Air embolus
Complications of CVP monitoring
-During cannulation, hemothorax, pneumothorax, and damage to blood vessels are possible -Dysrhythmias can occur as catheter passes through the heart and during monitoring -Catheter source of infection, thrombus, embolism, bleeding, and hematoma -Pulmonary infarction possible
Complications of PA Monitoring
hypotension
Complications of direct arterial monitoring include all the following except:
-Severe cardiogenic pulmonary edema -Patients with ARDS who are hemodynamically unstable -Patients who have had major thoracic surgery -Patients with septic or severe cardiogenic shock
Conditions for using the PA catheter
When the catheter enters the superior vena cava and right atrium.
During insertion of a pulmonary artery catheter, when is the balloon inflated?
an incompetent tricuspid valve
During systole, the CVP v waveform is exaggerated and the CVP increases. This most likely is due to:
3
For the pulmonary capillary wedge pressure to reflect pulmonary venous and left atrial pressures, blood flow must be uninterrupted between the catheter tip and the left heart. This condition exists only in West zone:
pressure and flow that occurs when the heart contracts and pumps blood throughout the body
Hemodynamics
-Intravascular fluid volume -Cardiac function -Vascular Findings -Identify sudden changes in the patient's hemodynamic status
Hemodynamics monitoring is preformed to evaluate?
>140/90 mm Hg
Hypertension
-Excessive contraction of the left ventricle -Vasoconstriction -Administration of vasopressors -Sympathetic stimulation (as occurs with fear and stress
Hypertension is caused by what?
-Low Blood Volume -Poor Cardiac Function -Low Vascular Resistance
Hypotension is caused by...
left heart failure or mitral stenosis
If the wedge pressure is increased what does that indicate?
continue the insertion because the catheter now has entered the right ventricle.
If, when the pulmonary artery catheter is inserted, there is a rapid increase in the height of the pressure waveforms with the downstroke dropping near zero, the respiratory therapist should:
increase to above normal range
In left ventricular failure, the pulmonary capillary wedge pressure is expected to:
c: Cor pulmonale
In which of the following conditions would an elevated CVP be expected? a. Pneumonia b. Hypovolemia c. Cor pulmonale d. Pleural effusion
d. Reposition the catheter while observing the waveform.
Just after insertion of a radial arterial catheter, you note that the pressure waveform appears dampened. All connecting tubing is secure and free of air. Which of the following actions is appropriate at this time? a: Remove the catheter and cannulate the other wrist. b: Increase the sensitivity setting on the monitor. c: Withdraw and then reinject 5 mL of blood. d: Reposition the catheter while observing the waveform.
...
Know how to fill in this chart
First half PAP second half PAWP top strip ECG
Know where the PAP and PAWP waveforms begin and end
all of the above
Monitoring of the CVP is indicated when there is a need to assess:
120/80 mm Hg
Normal Arterial Pressure
25/8
Normal Pulmonary Artery Pressure
4-12mmHg
Normal Pulmonary Capillary Wedge Pressure
2-6 mmHg
Normal right atrium pressre?
Hemorrhage
Occurs if line becomes disconnected
-Subclavian or internal jugular -Right Atrium -Air placed in balloon -Flow through right atrium -tricuspid valve Right Ventricle -Pulmonary Valve -Pulmonary artery -Into wedge position -Balloon then deflated
Pathway of PA Catheter insertion?
pulmonary embolus
Pulmonary artery catheter monitoring is likely to be considered for patients with any of the following conditions except:
25/0 mmHg
Right Ventricle Normal Pressure
True
T/F: RT' Set up and place Arterial Lines
0.50
The CVP can be used to estimate left ventricular filling pressures if there is no left ventricular dysrhythmia and the ejection fraction is greater than:
subclavian
The CVP catheter insertion site that provides both stability after placement and accurate hemodynamic information is the _____ vein.
female, age 25
The CVP is most likely to correlate well with left ventricular filling pressure in which of the following patients?
all of the above
The CVP represents:
Atrial fibrillation
The a wave would be absent in which of the following dysrhythmias?
b: ventricular contraction
The c-wave of a CVP waveform represents which of the following? a. Atrial contraction b. Ventricular contraction c. Atrial filling d. Ventricular filling
b. Aortic
The dicrotic notch on the arterial pressure waveform represents closure of which of the following heart valves? a. Pulmonic b. Aortic c. Tricuspid d. Mitral
radial
The most common site for arterial catheterization is the _____ artery.
4-12
The normal pulmonary capillary wedge pressure is _____ mm Hg.
8 to 15
The normal range for pulmonary artery diastolic pressure is _____ mm Hg.
20-30
The normal range for pulmonary artery systolic pressure is _____ mm Hg.
d. Measuring stroke volume
The proximal port of a pulmonary artery catheter can be used for all of the following except: a. Measuring the CVP b. Withdrawing blood samples c. Injecting medications d. Measuring stroke volume
all of the above
The pulmonary artery catheter allows assessment of:
left ventricular stroke volume.
The pulse pressure is important hemodynamically because it is an indication of:
obtain wedge pressure measurements
The purpose of the balloon at the tip of the pulmonary artery catheter is to:
Femoral Artery
What A-Line placement is less affected by vasoconstriction but is more difficult to monitor for bleeding?
-Severe hypotension or hypertension -Patients who need frequent ABG assessment -Patients in shock or respiratory failure
What are indications for arterial pressure monitoring?
-To assess circulating blood volume and filling pressures of the heart -To assess right ventricular function -Patients who have had major surgery or trauma need a CVP catheter -Patients with pulmonary edema often benefit from CVP monitoring
What are indications for monitoring CVP measurements?
a, c, v
What are the three normal CVP waveforms?
Low diastolic pressure
What can compromise coronary artery perfusion?
Ischemia
What can occur with embolism, thrombus, or arterial spasm and can result in tissue necrosis?
-Increases with high pulmonary vascular resistance -Decreases with poor right heart function and pulmonary vasodilation
What causes PA systolic pressure increase and decrease?
Minimal changes with inspiration and expiration.
What change in the arterial pressure waveform is normally seen with respiration?
the waveform falls to below baseline
What change is seen on the CVP waveform when the patient takes a spontaneous deep breath?
venous return to Right side of the heart
What does a CVP catheter monitor
-Left ventricular filling pressure -Pulmonary vascular resistance -Arteriovenous oxygen difference -Mixed venous oxygen levels
What does pulmonary artery pressure monitoring allow us to assess?
aortic valve closure
What does the dicrotic notch represent on an arterial pressure waveform?
the dicrotic notch The aortic valve closing
What is important to see on this waveform?
Invasive Monitoring
What is needed to obtain an accurate evaluation of hemodynamics?
1.5 mL
What is the approximate amount of air required to fill the balloon on a pulmonary artery catheter?
7 French with a triple lumen
What is the most popular CVP catheter, depicted in this image?
internal jugular
What is the popular site for CVP catheter insertion?
radial artery
What is the preferred site for insertion of an arterial catheter for continuous pressure monitoring?
to float the catheter in place and to measure left ventricular filling pressures
What is the purpose of the balloon?
allows infusion of medications and port from which to obtain blood samples
What is the triple lumen allow?
PA catheter
What is this an image of?
CVP catheter placement
What is this image showing?
Ischemia
What is this image showing?
Pulmonary artery pressure monitoring
What is this image showing?
- it is normally 4 to 12 mm Hg- it reflects left ventricular preload
What is true about pulmonary artery wedge pressure?
Inotropic Phase
What point in the Arterial Pressure Waveform is Systole-Ventricles are contracting
d. 7 French
What size catheter typically is used for adults to monitor pulmonary artery pressures?
Low blood volume and high alveolar pressures
What two things can cause the wedge pressure readings to be inaccurate?
<60 mm Hg
What value of MAP compromises functions of vital organs?
100mmHg
What will the MAP be if the systolic blood pressure is 140 mm Hg and the diastolic blood pressure is 80 mm Hg?
end of exhalation
When do you measure wedge pressure?
during insertion and pressure readings
When is the balloon inflated?
allow the catheter to float
When the pulmonary artery catheter is inserted, the balloon is inflated in the right atrium before it is inserted further. This is done to:
the end of expiration with the patient in the supine position.
When the water manometer is used to measure the CVP, the reading usually is taken at:
decrease blood flow to the coronary arteries
When vasodilators such as sodium nitroprusside are administered, it is important to monitor the fall in blood pressure because low blood pressure can:
Radial Artery
Where is a arterial line most often placed?
below patients right atrium and phlebostatic axis
Where is the placement of the transducer?
1, 2 and 3
Which of the following are possible complications of arterial cannulation? 1. Infection 2. Arterial spasm 3. Thromboembolism
c. Fluid overload
Which of the following causes the CVP to increase? a. Vasodilator therapy b. Spontaneous inspiration c. Fluid overload d. Air in the pressure-sensing line
Tubing is more stable and is less likely to kink in a patient who is awake.
Which of the following is not an advantage of using the internal jugular vein as the insertion site for the central venous catheter?
c: At end-expiration on the vent.
Which of the following is the correct method of measuring CVP in a patient receiving mechanical ventilation with PEEP? a. At end-inspiration on the vent b. At end-inspiration off the vent c. At end-expiration on the vent d. At end-expiration off the vent
1 and 3
Which of the following is true about MAP? 1. It normally ranges between 70 and 105 mmHg 2. It is the arithmetic average of the systolic and diastolic pressures. 3. Organ perfusion is reduced if MAP is less than 60 mmHg.
1 and 2
Which of the following is true about the CVP catheter? 1. It is commonly inserted by way of the subclavian vein. 2. The catheter can have multiple lumens. 3. A balloon is located on the distal end.
Seldinger technique
Which of the following techniques is used most commonly to insert an arterial pressure monitoring catheter?
a. A stiff aorta.
Which of the following will cause a tall, narrow arterial pressure waveform? a. A stiff aorta b. Vasodilation c. Mitral valve stenosis d. Ventricular hypertrophy
1, 2 and 3
Which of the following will cause the arterial pressure to decrease? 1. Vasodilators 2. Cardiac failure 3. Hypovolemia
1, 2, and 3
Which of the following would increase pulmonary artery pressure? 1. Severe hypoxemia 2. Thromboembolism 3. Acidosis
The first waveform (167/69)(Red-ART) and it should match patients HR
Which waveform is the Arterial Pressure and what should it match with?
Physician
Who places CVP catheters?
COPD
With a properly inserted and positioned pulmonary artery catheter, a systolic pressure reading in the pulmonary artery of 50 mm Hg could be due to:
Which of the following is true about the CVP catheter? 1. It is commonly inserted by way of the subclavian vein. 2. The catheter can have multiple lumens. 3. A balloon is located on the distal end. a. 1 and 2 b. 2 and 3 c. 1 only d. 1, 2, and 3
a. 1 and 2
Which of the following is true about MAP? 1. It normally ranges between 70 and 105 mm Hg. 2. It is the arithmetic average of the systolic and diastolic pressures. 3. Organ perfusion is reduced if MAP is less than 60 mm Hg. a. 1 and 3 b. 2 and 3 c. 1 only d. 1, 2, and 3
a. 1 and 3
What is the normal value for CVP? a. 2 to 6 mm Hg b. 6 to 8 mm Hg c. 8 to 12 mm Hg d. 12 to 18 mm Hg
a. 2 to 6 mm Hg
When obtaining an arterial blood sample from an arterial line, you note that the patient complains of significant tenderness at the insertion site. You should recommend which of the following to the patient's nurse? a. Removal of the dressing and inspection of the site b. Immediate removal of the catheter c. Replacement of the catheter with a new one d. Application of an antibiotic cream to the insertion site
a. Removal of the dressing and inspection of the site
CVP is a reflection of which of the following? a. Right atrial pressure b. Left ventricular filling volume c. Left atrial pressure d. Pulmonary artery diastolic pressure
a. Right atrial pressure
INCREASE
anything that causes pressures in the lungs and R side of the heart will_____ CVP pressure
Which of the following statements is true about pulmonary artery wedge pressure? 1. It is normally 6 to 12 mm Hg 2. It is normally higher than PADP 3. It reflects left ventricular preload a. 1 only b. 1 and 3 c. 2 and 3 d. 1, 2, and 3
b. 1 and 3
What is the approximate amount of air required to fill the balloon on a pulmonary artery catheter? a. 0.5 mL b. 1.5 mL c. 2.5 mL d. 3.5 mL
b. 1.5 mL
The dicrotic notch on the arterial pressure waveform represents closure of which of the following heart valves? a. Pulmonic b. Aortic c. Tricuspid
b. Aortic
What clinical condition is most likely to cause the PAWP to be elevated? a. ARDS b. Left-sided heart failure c. Cor pulmonale d. Pneumonia
b. Left-sided heart failure
Your patient has a pulmonary artery catheter in place and suddenly starts coughing up bloody sputum. What is the most likely cause of this? a. Pneumothorax b. Pulmonary infarction c. Mitral valve stenosis d. Myocardial infarction
b. Pulmonary infarction
The c wave of a CVP waveform represents which of the following? a. Atrial contraction b. Ventricular contraction c. Atrial filling d. Ventricular filling
b. Ventricular contraction
During insertion of a pulmonary artery catheter, when is the balloon inflated? a. Immediately after insertion into the venous site b. When the catheter enters the superior vena cava and right atrium c. When the catheter passes through the tricuspid valve and enters the right ventricle d. When the catheter passes through the pulmonic valve and enters the pulmonary artery
b. When the catheter enters the superior vena cava and right atrium
What would be considered a normal value for pulmonary artery pressure? a. 15/4 mm Hg b. 18/10 mm Hg c. 25/12 mm Hg d. 36/22 mm Hg
c. 25/12 mm Hg
Which of the following is the correct method of measuring CVP in a patient receiving mechanical ventilation with PEEP? a. At end-inspiration on the ventilator b. At end-inspiration off the ventilator c. At end-expiration on the ventilator d. At end-expiration off the ventilator
c. At end-expiration on the ventilator
In which of the following conditions would an elevated CVP be expected? a. Pneumonia b. Hypovolemia c. Cor pulmonale d. Pleural effusion
c. Cor pulmonale
Which of the following causes the CVP to increase? a. Vasodilator therapy b. Spontaneous inspiration c. Fluid overload d. Air in the pressure-sensing line
c. Fluid overload
The proximal port of a pulmonary artery catheter can be used for all of the following except: a. Measuring the CVP b. Withdrawing blood samples c. Injecting medications d. Measuring stroke volume
c. Injecting medications
A patient with which of the following conditions is least likely to need placement of a CVP catheter? a. Cardiogenic pulmonary edema b. Noncardiogenic pulmonary edema c. Large pleural effusion d. Major trauma
c. Large pleural effusion
What is the preferred site for insertion of an arterial catheter for continuous pressure monitoring? a. Femoral artery b. Brachial artery c. Radial artery d. Ulnar artery
c. Radial artery
Which of the following are possible complications of arterial cannulation? 1. Infection 2. Arterial spasm 3. Thromboembolism a. 1 and 2 b. 2 and 3 c. 1 only d. 1, 2, and 3
d. 1, 2, and 3
Which of the following could cause PAWP to be overestimated? 1. PEEP or CPAP greater than 10 cm H2O 2. Mitral valve stenosis 3. Reduced left ventricular compliance a. 1 only b. 2 only c. 1 and 3 d. 1, 2, and 3
d. 1, 2, and 3
Which of the following will cause the arterial pressure to decrease? 1. Vasodilators 2. Cardiac failure 3. Hypovolemia a. 1 and 2 b. 2 and 3 c. 2 only d. 1, 2, and 3
d. 1, 2, and 3
Which of the following would increase pulmonary artery pressure? 1. Severe hypoxemia 2. Thromboembolism 3. Acidosis a. 1 and 2 b. 2 and 3 c. 1 and 3 d. 1, 2, and 3
d. 1, 2, and 3
What complication is most likely to occur during removal of a pulmonary artery catheter? a. Pneumothorax b. Pulmonary infarction c. Pulmonary embolism d. Dysrhythmias
d. Dysrhythmias
What change in the arterial pressure waveform is normally seen with respiration? a. A large decrease with inspiration b. A large increase with inspiration c. A large increase with expiration d. Minimal changes with inspiration and expiration
d. Minimal changes with inspiration and expiration
A patient with which of the following conditions is least likely to need placement of an indwelling arterial catheter? a. Septic shock b. Cardiogenic shock c. ARDS d. Pneumonia
d. Pneumonia
Just after insertion of a radial arterial catheter, you note that the pressure waveform appears dampened. All connecting tubing is secure and free of air. Which of the following actions is appropriate at this time? a. Remove the catheter and cannulate the other wrist b. Increase the sensitivity setting on the monitor c. Withdraw and then reinject 5 mL of blood d. Reposition the catheter while observing the waveform
d. Reposition the catheter while observing the waveform
Hypovolemia
decreased wedge pressure is indicative of?
Pulse Pressure
difference between systolic and diastolic pressures
Spontaneous inspiratory
efforts cause CVP to decrease and are seen on the waveform
<90/60 mm Hg
hypotension
Hypotension
late sign of low cardiac output
subclavian and internal jugular veins
most common sites for PA catheter insertion?
30 to 40 mm Hg
normal pulse pressure
pulmonary capillary wedge pressure
only way to get an idea of whats going on with the left side of the heart
CVP to increase
what do Positive pressure breaths cause?
