chapter 5

CHAPTER 5
CIRCULATION
Cynthia Howe, RN, CPAN
CHAPTER 5
OVERVIEW
Purpose: The perianesthesia nurse will demonstrate thorough cardiac assessment skills to safely care for
the perianesthesia patient and prevent/intervene related to any cardiac complications.
Competency Statement: Perform a cardiovascular assessment.
Criteria:
1. Obtain a baseline heart rate (HR), blood pressure (BP) and oxygen saturation (SpO2).
Baseline vital signs establish reference points for the nurse to compare to and trend over time. HR, BP
and SpO2 are key components affecting tissue oxygenation and perfusion.
2. Assess skin for color, temperature, turgor, edema and diaphoresis.
Skin assessment is indicative of overall cardiovascular status:
• Pale, cool or clammy skin indicates vasoconstriction
• Warm, dry and flushed skin indicates vasodilation
• Poor skin turgor or decreased elasticity is noted with dehydration
• Extremity edema results as fluid shifts from the intravascular to the interstitial space (3rd
spacing), accumulating in dependent body areas
• Cyanosis of the mucous membranes, earlobes, cheeks and around the lips is termed “central
cyanosis” and is usually reflective of reduced oxygen concentration
• Peripheral cyanosis is observed in the distal extremities and is associated with localized hypoxia
related to poor circulation, reduced blood flow, congestive heart failure or shock. The skin
temperature of the affected areas is usually cold to touch
3. Inspect nail beds for capillary refill.
Capillary refill within 3 seconds reflects adequate blood flow to the extremities.
4. Palpate peripheral arterial pulses for rhythm, amplitude and bilateral equality.
Presence and volume of peripheral pulses reflect extremity perfusion. A discrepancy in volume between
central and peripheral pulses may be due to hypothermia, diminished stroke volume (often seen in
children) or pathogenic changes (contractility or mechanical).
5. Auscultate heart sounds.
Auscultation provides information regarding the functioning of the heart valve and chambers.
Normal Heart Sounds:
• S1, the first heart sound occurs with closure of the mitral and tricuspid valves
o Reflects the onset of ventricular systole
o Almost synchronous with the carotid pulse
o Sound is “Lub” best heard at the apex and right lower sternal border
• S2, second heart sound occurs with closure of the aortic and pulmonic valves
o Signals ventricular diastole
o Sound is “Dub” best heard at the 2nd interspace just to the side of the sternum
Extra Heart Sounds:
• S3 or Ventricular Gallop caused by early rapid filling of the ventricles resulting in vibrations
o Usually indicates decreased compliance of the ventricle
o Common in children and young adults
o May be heard with advanced CHF, ischemia, mitral or tricuspid insufficiency
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o Low pitched sound heard in early diastole immediately following S2 – sound is “Lub-Dub-Up or
like Ken-tuc-ky
o Best heard with bell of stethoscope at apex with patient in left lateral position
• S4 or Atrial Gallop may occur with atrial contraction
o Result of atria working harder to fill a ventricle which is resistant/stiff
o May indicate ventricular hypertrophy, hypertension, mitral/aortic stenosis or coronary artery
disease
o Occurs late in diastole, just prior to S1 – sound is “La-Lub-Dub or Ten-nes-see
• Murmurs – associated with turbulence or blood flow through the heart, such as forward flow through
a constricted valve, backward flow through an incompetent valve, an abnormal connection between
chambers and blood flow into a dilated heart
o Describe as either systolic or diastolic
o Grade on audible scale from I to VI (I indicating faint to VI very loud and may be heard with the
stethoscope just off the chest wall)
• Pericardial Friction Rub – associated with pericarditis
o High pitched, scratching – a “to and fro” sound with each heartbeat
o Auscultate between the apex and left sternal border with the patient sitting upright and leaning
forward
6. Assess for presence of central and peripheral intravenous lines.
The integrity of IV access is assessed for the delivery of fluids, medications, and blood products.
7. Inspect for internal jugular vein distention.
Jugular distention is indicative of congestive heart failure (CHF), cardiac tamponade, or fluid overload.
Inspection should be done with the patient at a 45 degree angle.
8. Obtain and interpret a baseline cardiac rhythm strip.
A baseline rhythm strip allows for comparison of rate or rhythm changes which may be related to
anesthetic agents, medications, pain, myocardial perfusion, metabolic demands, and aberrant pathways.
9. Review patient medications.
• For potential or real interactions with medications to be administered in the perianesthesia setting
• Drug name, dose, and last dose taken
10. Communicate and document all pertinent information per facility/unit specific policy/protocol.
Bibliography
Blach D. Assessment of the Cardiovascular System. In: Ignatavicius, ed. Medical Surgical Nursing Critical
Thinking for Collaborative Care. 5th ed. St Louis, MO: Elsevier Saunders; 2006: 676-683.
Carroll RJ. A&P Review, The Circulatory System. In: Black, ed. Medical Surgical Nursing Clinical
Management for Positive Outcomes. 7th ed. St Louis, MO: 2005: 1465-1478.
Lessig ML. The Cardiovascular System. In: Alspach, ed. Core Curriculum for Critical Care. 6th ed. St
Louis, MO: Saunders Elsevier; 2006: 185-199.
Smartt S. Cardiovascular Care. In: Quinn DM, Schick L, eds. Perianesthesia Nursing Core Curriculum:
Preoperative, Phase I and Phase II PACU Nursing. St Louis, MO: Saunders; 2004: 532-540.
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CARDIAC RHYTHM INTERPRETATION, INTERVENTION, AND TREATMENT
MODALITIES
Purpose: A step-by-step interpretation to enable the nurse to recognize dysrhythmias with correlation to the
patient’s condition.
ECG monitoring provides continuous observation of the patient’s cardiac electrical activity allowing for
the anticipation and treatment of various dysrhythmias associated with recovery from anesthesia. Early
identification, treatment, and termination of potentially life-threatening dysrhythmias are essential to
optimal patient outcomes.
In the perianesthesia setting, both 3 and 5 lead ECG monitoring are acceptable.
• 3-lead monitoring is commonly an MCL-1(modified chest lead) or limb lead II
o Lead II produces upright P waves and QRS complexes
o MCL-1 is excellent for distinguishing ectopy versus aberrance and to identify bundle branch
blocks
• Does not interfere with auscultation or defibrillation
• Produces variable P wave polarity and a negative QRS complex
• 5-lead monitoring system allows rapid ECG monitoring in multiple leads including I-II-III- aVR –
aVL and aVF
Competency Statement: The perianesthesia nurse will demonstrate appropriate assessment,
interpretation, and interventions for the patient experiencing cardiac dysrhythmias.
Criteria:
1. Obtain a baseline ECG tracing – at least 6 seconds in length as a reference point for
comparison and trending over time.
2. Identify components of ECG tracing.
P wave – Indicates SA node function and atrial depolarization, best observed in leads II and V1 where it
is upright. Abnormal configurations or inconsistencies in appearance may indicate a pacemaker other
than the SA node.
PR Interval (PRI) – Indicates atrioventricular conduction.
QRS Complex – Indicates ventricular depolarization and may be positive, negative or biphasic.
• Q wave – First negative/inverted deflection following the P wave
o Represents conduction through the septum
o Not present in all leads
o Abnormal presence represents myocardial necrosis
• R wave – First positive wave following P
o Represents conduction toward the left ventricle
o Prominent R waves are seen in ventricular hypertrophy, thin chest wall patients and in young
adults
• QT interval – Time of complete ventricular depolarization
o Prolonged by ischemia, antiarhythmic drugs, electrolyte imbalances
o A prolonged QT is associated with an increase incidence of polymorphic VT
• S wave – First negative wave after the R wave
o Represents conduction through both ventricles and subsequent contraction
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ST Segment – Indicates initial ventricular repolarization.
• Isoelectric or flat line between end of the S wave and start of the T wave
• Length varies with changes in HR, administration of medications and electrolyte disturbances
• ST changes in a single lead are not diagnostic
• ST changes throughout all leads may be diagnostic
o Elevation of >1mm or depressions of >0.5mm can be caused by myocardial injury, ischemia or
infarction, conduction abnormalities or the administration of medications
T wave – Indicates ventricular repolarization, deflection tends to follow direction of QRS.
• Inverted T wave may indicate infarct, ischemia, hypertrophy
• R on T Phenomenon – ectopic stimulus excites the ventricles during repolarization leading to lethal
dysrhythmias
U wave – Indicates ventricular repolarization of the Purkinje fibers.
• Abnormal prominence suggests hypokalemia
J-Point – The point at which the QRS complex meets the ST wave.
• The J-Point and the ST segment should be at baseline
• If the J-Point and ST segment slope downward and are below baseline, this indicates ischemia
• If the J-Point and ST segment slope upward and are above baseline, this indicates injury or infarct
3. Complete a Rhythm Analysis.
A. Rate determination:
• Atrial and ventricular, is it slow or fast, does it generate a pulse?
B. Rhythm determination:
• If R to R interval is regular, then rhythm is considered regular
• If irregular, is it irregularly irregular or regularly irregular?
• Look for beats that are early or premature, episodic rate variables, sudden or prolonged pause,
group beating
C. Analyze P waves:
• Normal width < 0.10
• Is the shape consistent?
• Is there a P for every QRS – and is there an established relationship between P waves and the
QRS?
• P waves > 2.5 wide = LA enlargement (seen in V4-6)
> 2.5 tall = RA enlargement (seen in II-III-aVF)
D. Measure the P-R interval:
• Normal is 0.12-0.20
• Is the interval constant?
• Short PR indicates impulse origination other than SA Node
• Prolonged PR indicates delay in conduction at AV node
• Irregular PR’s are found only in Wenckebach and 3rd degree block
E. Analyze the QRS:
• Normal width 0.12 seconds
• Is the interval wide? The rhythm is ventricular in origin
• Is the interval narrow? The rhythm is supraventricular in origin
• QRS is absent in ventricular fibrillation and asystole
• Review the QRS relationship with the P wave
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4. Interpret the cardiac rhythm.
Always correlate with clinical observation of the patient.
Initiate interventions/treatments according to ACLS algorithms. Treatments listed below are initial
treatments only. Refer to complete ACLS algorithms.
Rhythm
Hallmark
Clinical
Treatment
CARDIAC ARREST
Ventricular
Fibrillation (VF)
No P, QRS or T.
Up and down pattern.
May be fine or course.
Pulseless.
Shock - *CPR 5 cycles.
Epinephrine or Vasopressin.
Shock – *CPR 5 cycles.
Amiodarone or Lidocaine.
Shock – 5 cycles CPR.
Organized pattern but
does not produce
contraction – NO pulse
with rhythm.
Can be Narrow
(non-cardiac),
Wide (cardiac),
Slow (cardiac),
Fast (non-cardiac).
CPR – 5 cycles.
Epinephrine or Vasopressin.
Consider Atropine – slow
rate.
CPR 5 cycles.
No ventricular activity
of <6 complexes/min.
May come after a
defibrillation as
heart is stunnedthen return to a
spontaneous
rhythm.
CPR 5 cycles.
Epinephrine or Vasopressin.
Atropine for asystole.
CPR 5 cycles.
*Immediate high quality
CPR after every shock.
Pulseless Electrical
Activity (PEA)
Think H’s and T’s
• Hypovolemia
• Hypoxia
• Hydrogen Ion (acidosis)
• Hypo-/hyperkalemia
• Hypoglycemia
• Hypothermia
• Toxins
• Tamponade (cardiac)
• Tension Pneumothorax
• Thrombosis (coronary
or pulmonary)
• Trauma (hypovolemia,
increased ICP)
Asystole
Think H’s & T’s
• Hypovolemia
• Hypoxia
• Hydrogen Ion (acidosis)
• Hypo-/hyperkalemia
• Hypoglycemia
• Hypothermia
• Toxins
• Tamponade (cardiac)
• Tension Pneumothorax
• Thrombosis (coronary
or pulmonary)
• Trauma (hypovolemia,
increased ICP)
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SUPRA-VENTRICULAR
Atrial Fibrillation
Irregularly Irregular
– chaotic, random.
Poses risk for patient
to develop atrial
thrombus/emboli.
Expert consultation.
Atrial Flutter
“Saw-tooth” pattern
rapid rate.
Atrial rate 200-350
with ventricular
rate 150-180.
Expert consultation.
Re-Entry Tachycardias
Narrow complex
tachycardia >150
with sudden onset
and/or cessation.
Occurs without
warning.
Palpitations –
anxious,
uncomfortable.
Reduces cardiac
output / increases
O2 demand and
consumption.
UNSTABLE
=Amiodarone.
Prepare for cardioversion.
Stable Ventricular
Tachycardia (VT)
STABLE = vagal
maneuvers, Adenosine.
VENTRICULAR
TACHYCARDIAS
Monomorphic VT
All QRS look alike
(remember no P wave).
QRS is wide/bizarre.
Patient may be
awake/alert.
Acute ischemic
event.
See VT above.
Polymorphic VT
Variation and
inconsistent QRS.!
Rapidly deteriorates
Most patients
symptomatic.
See VT above.
Torsades de Pointes
Spindle pattern –
amplitude > then <
polarity changes with
each new spindle.
Most commonly
occurs with prolonged
QT intervals –
overdose, alcoholism,
hypomagnesia, etc.
Use Magnesium –
loading dose, not IV push.
Regular complex
with rate < 60.
Treat only if .
symptomatic
No symptoms: observe.
**Sustained = runs
lasting > 30 seconds
BRADYCARDIA
Sinus Bradycardia
Symptomatic: treat.
Prepare to pace.
Consider atropine.
Consider Epinephrine or
Dopamine.
AV BLOCKS
1st Degree
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PR > .20
Can be SR, SB, ST.
Usually
asymptomatic.
May be due to
drugs –blockers:
Beta, Ca channel,
Digitalis.
Can be from
vasovagal reaction.
Observe.
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2nd Degree – Type I
standby
(Mobitz 1 / Wenckebach)
**site is at AV node
shocky.
PR interval is Short,
Atrial regular /
External pacemaker on
long, longer, till a
QRS is dropped.
ventricular irregular.
lest the rhythm further
deteriorates, the block
progresses, or the patient
becomes symptomatic or
“QRS drop-out”
Consider atropine.
Consider Epinephrine or
Dopamine.
2nd degree – Type II
Infranodal* / Mobitz II)
PR constant.
Symptomatic from
ventricular
bradycardia.
“P waves march-out”
* below AV node
QRS narrow = high block
relative
to AV node.
QRS wide = low block
to AV node.
3rd Degree *
*a type of AV
dissociation
No relationship of P to
QRS – no marriage of
wave forms.
PR intervals irregular.
Atrial and Ventricular
rhythms are regular –
but not married.
PACE without delay.
Consider Epinephrine or
Dopamine.
P waves are
completely
independent
from the QRS.
Atrial rate is
usually 60-100.
Ventricular rate
varies on rate
of ventricular
escape beats.
PACE without delay.
Consider atropine.
Consider Epinephrine
or Dopamine.
ACLS Drugs:
Drug
Indications / Actions
Side Effects
Dosage
Adenosine
1st line drug for narrow
complex SVT.
Acts on AV node to slow
conduction and inhibit
reentry pathways.
Transient chest pain,
dyspnea, bradycardia,
flushing and asystole.
6 mg rapid (1-3 seconds) IV
push followed by 20 ml NS
bolus. If no conversion
follow with 12 mg IV.
May repeat 12 mg dose
once.
Amiodarone
VF/VT wide complex
tachycardias.
Both alpha and beta
blocking.
Hypotension,
bradycardia.
Cardiac arrest: 300 mg IV
push, consider repeating
150 mg IV push in 3-5
minutes.
Wide complex tachycardias:
150 mg/250 ml D5W IV
over 10 minutes. Repeat as
needed to max dose of
2.2g/24 hours.
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Atropine
1st line drug for symptomatic
bradycardia.
2nd line drug for asystole
or PEA.
Anticholinergic: reduces
vagal tone, increases
automaticity and AV conduction.
Dopamine
Symptomatic hypotension.
2nd line drug for
symptomatic bradycardia.
Epinephrine
1st line drug for pulseless
arrest/Ventricular Fibrillation.
Also used for Ventricular
tachycardia and symptomatic
bradycardia.
Vasoconstictor which increases
perfusion pressure and
stimulates spontaneous
contraction.
1 mg IV. Repeat every 3 to
5 minutes. 2-10ug/min
infusion.
Lidocaine
Alternative to Amiodarone
in VF/VT.
Decreases sensitivity
(automaticity) of the heart.
1 to 1.5 mg/kg IV initial
dose. Then 0.5 to 0.75 mg/kg
IV push to a max of 3 mg/kg.
Post conversion drip at
1-4 mg/min.
Magnesium
Recommended for Torsades
de pointes and suspected
hypomagnesemia.
Precautions: hypotension.
Loading dose 1 to 2 g
diluted in 10 ml D5W IV
over 5-20 minutes.
Procainamide
Recurrent VF/VT.
PSVT uncontrolled by
adenosine and vagal
maneuvers.
Use in arrest is limited
by the need for slow
infusion and uncertain
efficiacy.
Stop with hypotension,
QRS widening by > 50%
or 17 mg/kg given.
20 mg/min IV infusion to
maximum total dose of
17mg/kg.
Sodium
Bicarbonate
Acidosis.
Hyperkalemia.
Not recommended for
routine use in cardiac
arrest patients.
Administer based on
specific indications only.
1 mEq/kg IV bolus.
Vasopressin
Alternative pressor
to epinephrine in VF.
May be useful in asystole
and PEA.
40 units IV push to replace
1st or 2nd dose of
epinephrine.
One dose for cardiac arrest.
Versed
May be given as a sedative
for synchronized cardio
version.
1 or more mg IV titrated for
sedative effect.
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Symptomatic bradycardia:
0.5 mg IV to a total of 3 mg.
Asystole / PEA: 1 mg IV
push every 3-5 minutes to a
total of 3 mg.
Correct hypovolemia
with volume before
initiating dopamine.
2 to 20 mcg/kg/min infusion.
Mix 400 to 800 mg
in 250 ml.
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Oxygen
Immediately for any
shockable rhythm or
symptomatic patient.
Delivery mode and amount
as indicated.
Transcutaneous
Pacing
Symptomatic or
hemodynamically
unstable bradycardia.
Set rate and MA until capture
achieved. Then increase MA
by 10% to ensure capture
threshold.
5. Assess patient response to dysrhythmia/interventions.
Complete a thorough patient assessment when rhythm change is identified – evaluate if rhythm is
cardiac driven or the effect of another event. Evaluate other pertinent information.
6. Communicate and document all pertinent information per facility/unit specific policy/protocol.
Include a rhythm tracing, patient response to rhythm, interventions, and outcomes.
Bibliography
American Heart Association (AHA). ACLS Provider Manual. AHA; 2006.
Cain A, Melander S. Management of Clients with Dysrhythmias. In: Black, ed. Medical Surgical
Nursing Clinical Management for Positive Outcomes. 7th ed. St Louis, MO: Elsevier Saunder; 2005:
1671-1700.
Carroll RJ. A&P Review, The Circulatory System. In: Black, ed. Medical Surgical Nursing Clinical
Management for Positive Outcomes. 7th ed. St Louis, MO: Elsevier Saunder; 2005: 1468-1475.
Goldberger A. Clinical Electrocardiology, A Simplified Approach. 7th ed. Philadelphia, PA: Mosby;
2006: 157-215.
Lessig ML. The Cardiovascular System. In: Alspach JD, ed. Core Curriculum for Critical Care. 6th
ed. St. Louis, MO: Saunders Elsevier; 2006: 221-326.
Smartt S. Cardiovascular Care. In: Quinn DM, Schick L, eds. Perianesthesia Nursing Core Curriculum:
Preoperative, Phase I and Phase II PACU Nursing. St. Louis, MO: Saunders; 2004: 553-566.
Zickenfoose P. Interventions for Clients with Dysrhythmias. In: Black, ed. Medical Surgical Nursing
Critical Thinking for Collaborative Care. 5th ed. St Louis, MO: Elsevier Saunders; 2006: 708-747.
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FLUID FILLED MONITORING SET UP
Used for Central Venous Pressure (CVP) and Arterial (A-Line)
Competency Statement: Demonstrate set-up, assessment, and interventions for the patient requiring
invasive hemodynamic monitoring.
Criteria:
1. Demonstrate proper set up of a fluid filled monitoring system.
Assemble necessary equipment and supplies to ensure appropriate monitoring, including:
• Flush solution for transducer system
o 500 ml bag of Normal Saline - heparinized based on facility policy
• Pressure transducer system and tubing
o CVP, arterial line alone requires single transducer
o 2 or more lines require a triple transducer set
• Several 3 way stopcocks, pressure extension tubing as desired
• Pressure bag – transducer holder – IV pole
• Carpenter’s level
• Monitor, modules and cables
The pressure tubing system, including transducer, extensions, and all stopcocks should be flushed prior
to inflation of the pressure bag to reduce small air bubbles. Pressure bag inflation to 300mm Hg prior
to attachment to the patient reduces the risk of air embolism. The system will deliver 3 to 4ml/hour of
flush fluids to the patient while maintaining system integrity.
2. Properly calibrate transducer to atmosphere.
A. The zeroing stopcock is leveled to the phlebostatic axis, which approximates the location of the right
atrium.
Identification of the phlebostatic axis:
• Position patient supine
• Palpate the 4th intercostal space at the sternum
• Follow the 4th intercostal space to patient’s side
• Determine midway point between anterior and posterior
• Locate intersection between the midway point and the line from the 4th intercostals
• Mark the spot with an X in indelible ink
Each time the patients position is changed the transducer must be re-leveled.
B. Properly perform zero referencing.
Zero reference procedure eliminates the effects of atmospheric and hydrostatic pressure from the
measured pressure readings. The zero reference procedure should be done at setup, once a shift, any
time the validity of the monitored value is in question or the system is opened to air.
Procedure for zero referencing:
• Allow system to warm up for 5 – 15 minutes
• Check to see that the fluid filled components of the system are free of air
• Turn stopcock off to the patient and open to the atmosphere (air)
• Select zero monitor – wait for display to read 0 (zero)
• When properly zeroed, close stopcock to air and open to patient again, checking that the system is
free of air
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3. Properly select appropriate scale and alarm limits.
Scale selection is based on the invasive line type and monitor. CVP scales are generally set no higher
than 18, arterial line scale set no greater than 20 mm Hg above the systolic reading.
High and low alarm limits must be set and alarms on. High and low limits are variable based on patient
condition, presence of titrating drugs and fluid administration, among other factors.
4. Recognize potential complications and appropriate interventions.
Troubleshoot dampened wave form tracings:
• Assess patient for physiologic alterations
• If patient stable – investigate system
o Check for air in tubing or loose connections
o Ensure pressure is maintained at 300 mm Hg
o Check tubing for kink or knot
o Flush tubing for patency check (positional, clotted tip, etc.)
o Check scale selection
5. Communicate and document all pertinent information per facility/unit specific policy/protocol,
including:
• Date and time of setup
• Scale and alarm parameters
• Times leveled and zeroed
• Type of flush solution
• Flush solution infused
• Complications/interventions associated with insertion
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INVASIVE HEMODYNAMIC MONITORING
Purpose: Hemodynamic monitoring directly measures pressure in the heart and great vessels.
Hemodynamic pressure monitoring provides information reflecting the earliest changes in the circulatory
system that is not yet clinically detectable. Invasive hemodynamic monitoring provides quantitative
information on blood volume, fluid balance, and the hearts pumping ability.
CVP Competency Statement: Demonstrate assessment and interventions for the patient requiring CVP
monitoring.
CVP monitoring reflects pressure in the great veins and is a measurement of right heart preload. Preload
is the amount of blood presented to the heart or when the ventricle is full before the next ejection.
Preload is the right ventricular end diastolic pressure.
1. Recognize indications for CVP monitoring.
• Known cardiovascular disease
• Rapid infusion of fluids or blood
• Fluid status assessment
2. Identify CVP waveform.
A triphasic wave produced by changes in pressure within the right atrium. The waveform consists of
three peaks (a,c,v) and two descents (x,y) that are directly related to the ECG. Proper placement of the
catheter tip is in the lower third of the superior vena cava near the junction of the right atrium.
a wave –
o most prominent peak
o reflects “atrial kick” responsible for loading the right ventricle
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This figure was published in the Journal of PostAnesthesia Nursing, Volume 7, Number 5, 1992. Author
Christensen B, title of article Hemodynamic Monitoring: What it Tells You and What it Doesn’t. Reprinted
with permission from the Journal of PostAnesthesia Nursing, Copyright Elsevier. Permission obtained
February 27, 2009.
3. Identify normal ranges for CVP readings.
CVP readings should always be measured during end-expiration.
Normal right atrial pressures range from 0 to 7 mm Hg.
Vascular Tone
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Blood Volume
Early LV failure.
circulating volume
Vasodilation.
Peripheral pooling.
Septic shock.
Right sided failure.
Chronic LV failure. Pericarditis.
Cardiac tamponade.
Pulmonary hypertension.
Ý
Right side heart
HIGH CVP
LOW CVP
CLINICAL ASSESSMENT
circulating volume.
Vasoconstriction.
Hypertension.
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4. Recognize potential complications and appropriate interventions.
LINE
SITES
CVP
Venous
Jugular
Subclavian
Brachial
Cephalic
Femoral
COMPLICATIONS
Pneumothorax.
Arrythmias.
Cardiac perforation.
Hemorrhage.
Sepsis.
Clot-thrombus.
Air emboli.
INTERVENTIONS
1. Tighten all connections.
2. Continual ECG monitor.
3. Physical assessment: neck veins,
heart sounds, pulse pressure,
cyanosis, dyspnea, and tachypnea
followed with appropriate therapy.
4. Site observation.
5. Alarm limits.
6. CXR post insertion.
7. Continual wave form monitoring.
5. Communicate and document all pertinent information per facility/unit specific policy/protocol.
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Arterial Line Competency Statement: Demonstrate assessments and interventions for the patient
requiring arterial pressure monitoring.
Direct intra-arterial monitoring is considered by many to be the gold standard for blood pressure
measurement. Direct measurement is usually 10-15 mm Hg greater than indirect (cuff) measurements
and provides beat to beat information facilitating the earliest possible recognition of adverse situations.
1. Recognize indications for Arterial Line Monitoring.
• Wide fluctuations in BP are expected (endarterectomies, craniotomies and aneurysms)
• Titration of vasoactive drugs
• Require multiple ABG’s or laboratory tests
• Strict BP control is mandated
• Excessive peripheral vasoconstriction
• Low cardiac output
• Fluctuating hemodynamic status
2. Identify Arterial Line Waveform.
Wave A illustrates the anacrotic limb – inotropic phase.
• Inotropic component reflected by initial steep upstroke
o Indicator of LV contractility
o Reflects ejection of blood from the left ventricle
• Peak – anacrotic notch/rounded shoulder shape
o Represents peak systolic blood pressure
Wave B illustrates the dichrotic notch.
• Represents closure of the aortic valve – ventricle completes systolic ejection and enters diastole
Wave C represents the dichotic limb – end diastolic pressure.
This figure was published in the Journal of PostAnesthesia Nursing, Volume 7, Number 5, 1992. Author
Christensen B, title of article Hemodynamic Monitoring: What it Tells You and What it Doesn’t. Reprinted
with permission from the Journal of PostAnesthesia Nursing, Copyright Elsevier. Permission obtained
February 27, 2009.
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Potential alterations in wave form patterns:
• Vasodilation = rapid upstroke and a narrow systolic peak (a wave)
• Pulsus alterans = pattern of alternating large and small pulse waves (may occur transiently after an
arrhythmia episode)
• Pulsus paradoxus = decrease in systolic BP by 10 mm Hg or more during inspiration – classically
associated with cardiac tamponade, most commonly associated with hypovolemia in the
perianesthesia setting
3. Recognize the importance of correlation of arterial pressure to cuff pressure.
Arterial line monitors the wave of pressure generated by ventricular contraction and is affected by
vascular distensibilty or vasoconstriction. Cuff pressures measure blood flow through the artery as
external pressure is applied and released. An arterial pressure significantly higher than a cuff pressure
often indicates increased sympathetic tone and vasoconstriction.
As blood pressure differences of 10-20 mm Hg can be noted between left and right side readings it is
important to obtain both readings from the same side.
A decision must be made to treat the patient by either the cuff OR the arterial line, not both. If a patient
is going to a critical care unit and/or is receiving vasoactive medications, treatment by arterial pressures
is recommended.
To avoid fluctuations in readings ensure that the line is leveled to the phlebostatic axis and the site is
marked, the transducer is correctly zeroed, and no loose connections, kinks, air, or clots are present.
4. Assess circulation based on arterial insertion site.
Color, pulse, temperature, motor and sensory assessment is completed distal to the arterial line insertion
site for evidence of circulatory compromise.
5. Recognize potential complications and appropriate interventions.
LINE
A-line
SITES
Arterial
Radial
Brachial
Femoral
COMPLICATIONS
Hemorrhage.
Nerve damage.
Sepsis.
Embolization.
Arterial occlusion.
Spasms.
INTERVENTIONS
1.
2.
3.
4.
5.
6.
Tighten all connections.
Motor assessment.
Site observation.
Vascular assessments.
Set alarm limits.
Continual wave form monitoring.
6. Communicate and document all pertinent information per facility/unit specific policy/protocol.
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CHAPTER 5
Bibliography
Blach D. Assessment of the Cardiovascular System. In Ignatavisius, ed. Medical Surgical Nursing Critical
Thinking for Collaborative Care. 5th ed. St Louis, MO: Elsevier Saunders; 2006: 703-705.
Carroll R. A&P Review, The Circulatory System. In Black,ed. Medical Surgical Nursing Clinical
Management for Positive Outcomes. 7th ed. St. Louis, MO: Elsevier Saunders; 2005: 1953-96.
Lessig ML. The Cardiovascular System. In Alspach JD, ed. Core Curriculum for Critical Care. 6th ed. St
Louis, MO: Saunders Elsevier; 2006: 195-214.
Smartt S. Hemodynamic Monitoring. In Quinn, ed. PeriAnesthesia Nursing Core Curriculum. St. Louis,
MO: Saunders; 2004: 497-512.
Vanriper S. Fluid Filled Monitoring System. In Darnovic, ed. Hemodynamic Monitoring: Invasive and
Noninvasive Clinical Application. 2nd ed. Philadelphia, PA: WB Saunders; 1995: 156-174.
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CHAPTER 5
QUESTIONS
CIRCULATION COMPETENCY QUESTIONS
1. This type of cyanosis presents as cyanosis of the mucous membranes, earlobes, cheeks, and lips,
and is reflective of reduced oxygen concentration:
a. Hypoxic cyanosis
b. Central cyanosis
c. Peripheral cyanosis
d. Hypercarbaric cyanosis
2. This heart sound results from the atria working harder to fill against a stiff ventricle:
a. S1
b. S2
c. S3
d. S4
3. The following rhythm is a regular rhythm that is associated with an atrial and ventricular rate
of 150-250:
a. ST
b. SVT
c. Atrial Flutter
d. Atrial Fibrillation
4. The dichrotic notch of the arterial waveform is associated with closure of the:
a. Tricuspid valve
b. Pulmonic valve
c. Mitral valve
d. Aortic valve
5. Pulsus paradoxus in the PACU is most commonly associated with:
a. Severe hypovolemia
b. Sympathetic blockade
c. Cardiac tamponade
d. Tension pneumothorax
6. The most common cause of PEA in the perianesthesia setting is hypovolemia.
a. True
b. False
7. Risks and complications associated with central venous cannulation include:
a. Heart block
b. Valvular damage
c. Ventricular tachycardia
d. Pneumothorax
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CHAPTER 5
8. This naturally occurring anti-diuretic hormone will act as a powerful vasoconstrictor when
given at high doses:
a. Epinephrine
b. Ephedrine
c. Vasopressin
d. Voltaren
9. To avoid erroneous readings, CVP should always be measured at end-inspiration.
a. True
b. False
10. The most common cause of decreased CVP in the PACU is:
a. Sepsis
b. Sympathetic blockade
c. Hypovolemia
d. Lymphatic blockage
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CHAPTER 5
KEY
CIRCULATION COMPETENCY QUESTIONS
1. This type of cyanosis presents as cyanosis of the mucous membranes, earlobes, cheeks, and lips,
and is reflective of reduced oxygen concentration:
a. Hypoxic cyanosis
b. Central cyanosis
c. Peripheral cyanosis
d. Hypercarbaric cyanosis
2. This heart sound results from the atria working harder to fill against a stiff ventricle:
a. S1
b. S2
c. S3
d. S4
3. The following rhythm is a regular rhythm that is associated with an atrial and ventricular rate
or 150-250:
a. ST
b. SVT
c. Atrial Flutter
d. Atrial Fibrillation
4. The dichrotic notch of the arterial waveform is associated with closure of the:
a. Tricuspid valve
b. Pulmonic valve
c. Mitral valve
d. Aortic valve
5. Pulsus paradoxus in the PACU is most commonly associated with:
a. Severe hypovolemia
b. Sympathetic blockade
c. Cardiac tamponade
d. Tension pneumothorax
6. The most common cause of PEA in the perianesthesia setting is hypovolemia.
a. True
b. False
7. Risks and complications associated with central venous cannulation include:
a. Heart block
b. Valvular damage
c. Ventricular tachycardia
d. Pneumothorax
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CHAPTER 5
8. This naturally occurring anti-diuretic hormone will act as a powerful vasoconstrictor when
given at high doses:
a. Epinephrine
b. Ephedrine
c. Vasopressin
d. Voltaren
9. To avoid erroneous readings, CVP should always be measured at end-inspiration.
a. True
b. False
10. The most common cause of decreased CVP in the PACU is:
a. Sepsis
b. Sympathetic blockade
c. Hypovolemia
d. Lymphatic blockage
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