Summary Nurs 481 Exam 1 Study Guide

Critical Care Nursing - HEMODYNAMIC MONITORING
oCO = SV X HR
oNormal CO = 4-8 L
oCI: CO adjusted to body surface area – more accurate
oCO/Total BSA = CI
oMean arterial pressure (MAP)  average pressure in large vessels of body
MAP = 2 * DBP + SBP / 3
Normal MAP 70-105, 60-65 is BARE MIN
oPreload: the ventricles filling up with blood during diastole (relaxation) – refers to fluid status
Basically STRETCH – volume of blood received by the heart
Increased preload = too much fluid, super wet
Decreased preload = too little fluid, super dry
It is increased in hypervolemia, regurgitation of cardiac valves, heart failure
oAfterload: the amount of pressure that the heart has to push against to eject blood during systole (contraction) – refers to
fluid status
Basically SQUEEZE – pressure/resistance the heart has to overcome to eject blood
Increased afterload – too much fluid, super wet
Decreased afterload = too little fluid, super dry
oPulmonary Artery Wedge Pressure (PAWP) LEFT SIDED PRELOAD
Measurement of pulmonary capillary pressure which reflects left ventricular end diastolic pressure. Measures
pressure in the lungs – left ventricular preload pressure
Normal 25/10 mmHg (quarter over dime)
Rules out cardiac issues (I.E. HF causing fluid overload or capillary membrane issue like ARDS)
<18 mmHg = ARDS
>18 mmHg = Cardiac issue
oCentral Venous Pressure (CVP) RIGHT SIDED PRELOAD
Right ventricular preload or right ventricular end-diastolic pressure
Normal CVP 2-8 mmHg
>8 = too much fluid (CHF patients, fluid overload)
<3 = too dry (hypovolemia, hypotensive patients)
Reflects amount of blood returning to the heart and the ability of the heart to pump blood into the arterial
system
oLeft (PAWP) and Right preloads (CVP) – mini summary
High CVP & PAWP  PATIENT IS TOO WET (fluid overload)
How do you decrease it???
oDIURETICS
oVasodilators
oFluid Restriction
Low CVP & PAWP  Patient is too DRY (poor perfusion, decreased CO)
How do you increase it???
oVasopressors (Norepi, Epi)
oVasoconstrictors
oFluid Administration (Crystalloids: NS, LR)
PopS to my LEFT C my Pussy to the RIGHT
PopS (Left side)
oPAWP – left preload (6-12)
oSVR – left after load
C Pussy (right side)
oCVP – right preload (2-8)
oPVR – right after load
oSystemic Vascular resistance (SVR) LEFT SIDED AFTERLOAD
The opposition to blood flow encountered by the left ventricle
Normal SCVR = 800-1200 dynes/sec/cm
800  vessels are hella dilated and loose
1200  the vessels are constricted and tight

, oPulmonary Vascular Resistance (PVR) RIGHT SIDED AFTERLOAD
The opposition to blood flow encountered by the right ventricle
Normal PVR <250 dynes/sec/cm
oLeft (SVR) & Right (PVR) mini summary
High SVR and PVE  the cardiac system has to work HARDER (fluid overload)
How do you decrease afterload??
oDiuretics
oVasodilators so the heart doesn’t have to push so hard to circulate blood to the body
Low SVR & PVR  there is not enough blood to circulate (decreased CO and decreased preload)
oHow do you increase afterload???
Fluids
oSwan Ganz Catheter (Pulmonary Artery Catheter)
Measures hemodynamics in the body, catheter is advanced into the heart and the balloon sits in the distal tip of
the pulmonary artery
Balloon (1.5 mmHg) should NOT stay inflated – can cause the rupture of the PA and death
What does it tell us?
Co/CI
CVP
SvO2 (mixed venous sample)
Core temperature
PAWP
SVR – great indicator for fluid status
Patient should be supine, CONTINUOUS EKG MONITORING, monitoring coags, ABG, oxygenation
TRANSDUCER positioning  needs to be leveled at the phlebostatic axis (4th intercostal space) & zero-point
referenced (leveled at 0)
The patient can move with the SG catheter but every time they move, we need to revel the transducer
CXR verifies the placement
Complications – ARRHYTHMIAS when the catheter is being thread through, it can touch the ventricle and cause
irritation  vtach, v fib
Rupture, infection, air embolism

Primary Survey - ABCDE; Emergency Severity Index
oPrimary Survey: ABCDE
Airway management
Cardiac emergency
Rapid response team
Triage & Prioritizing
Poisoning
oAirway: maintain airway with cervical spine control
Responsiveness: awake & alert vs. lethargic, stuporous, obtunded, unarousable, unresponsive
Obstructed: foreign body, physical material, inflammation, edema
Assessment findings: stridor, mufÒed/changing voice, drooling, weak or absent gag reflex, facial trauma/surgery,
foreign object present
Head-tilt/Chin-tilt
Jaw thrust: cervical protection
Airway adjuncts:
Nasopharyngeal:
oCI: facial or skull fractures
Oropharyngeal:
oCI: gag reflex present
Endotracheal intubation:
oProcedure:
Gather supplies
Hyperoxygenate w/bag valve mask (100% O2)
Provider places the tube → hyperoxygenate btw attempts
Prelim confirmation → chest rise, breath sounds, ETCO2

, Secure tube
CXR
oConfirmation:
Assess for chest rise
ETCO2 detector (PURPLE TO YELLOW)
Auscultation
Rising SPO2
CXR
oBreathing: assess breathing and ventilation. Apply high flow O2 on non-rebreather.
Assessment:
Rate, Expansion
Effort
Auscultation
SpO2 & ABG
Interventions:
Positioning
O2 administration
Manual ventilation
CPAP/BiPAP/Mechanical ventilation
Pulmonary hygiene
Respiratory treatments
oCirculation: assess circulation with hemorrhage control
Assess:
Heart rate
Blood pressure
Peripheral pulses
Capillary refill
Need to ensure the patient is being perfused!
Problems:
Not pumping (HEART)
oDysrhythmias
oCHF, cardiogenic shock
oCardiac arrest
Not distributing (VESSELS)
oOcclusion
Low volume
oBleeding: internal vs. external
Interventions:
Not pumping (HEART)
oCompressions
oMedications
oElectricity
Not distributing (VESSELS)
oMedications/Treatment per orders
Low volume
oIVF or blood products
oApply direct pressure if bleeding
Cardiac Emergency/Arrest
Rapid assessment and intervention → within 10 seconds
Activation of code blue
PRIORITY INTERVENTIONS:
oIMMEDIATE COMPRESSIONS and EARLY DEFIBRILLATION when indicated
Cause of Cardiac Arrest:
Hs:
oHypovolemia
oHypoxia