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Life Support # 3

Direct Pressure Monitoring

QuestionAnswer
What 2 types of catheters are inserted into central veins for direct pressure monitoring of central circulation? Central venous catheter(CVP), and Pulmonary artery cath (BTFDC)
What is BTFDC? Balloon tipped flow directed catheter
Central venous catheters have how many lumens? they can have single, double or triple lumens
Central venous catheters sit at what junction in the body? at the SVC and RA junction
What are the indications for central venous caths? RAP monitoring, drug/fluid/nutrition/electrolyte infusion, blood and blood product admin, phlebotomy access, and lack of accessible veins
What can cause a lack of accessible veins? trauma, sclerosis, thrombosis, or inflamed peripheral veins
The site of insertion for a CVC is dependent upon what? physician preference, regional trauma, or burns
Specific circumstances of insertion sites are? anticoagulation, coagulation abnormalities, presence of lung hyperinflation secondary to airway obstruction
What are the 3 main insertion sites for a CVC? internal jugular, subclavian, and femoral veins
What are the advantages of inserting a CVC into the subclavian vein? easy to access, maintain sterility and intact dressing, unrestricted movement and less likely to develop thrombus d/t rapid venous blood flow
What are the disadvantages of subclavian central venous access? Risks of air emboli, pneumothorax, hemothorax, nerve injury, tracheal puncture, ETT cuff puncture and puncture or laceration of subclavian artery
Advantages of Internal jugular central venous access short, direct pathway; reliable site, unlikely to be displaced, less likely to develop thrombus d/t rapid blood flow, and lower risk of art puncture and pneumo than subclavian site
Disadvantages of Internal jugular central venous access risk of air emboli, puncture of common carotid artery, pneumothorax (more common in left), and thoracic duct injury (left IJ only)
Advantages of femoral vein central venous access readily accessible, familiar site (used for central access longer than any other site), greater ease of insertion, no risk of pneumo and minimal risk of air emboli
Disadvantages of femoral central venous access inadvertent cannulation of smaller veins, increased risk of infection, difficult to maintain intact dressing, difficult to locate in obese patients, high risk of thrombus and PE, and difficulty immobilizing
What is a PICC line? peripherally inserted central catheter used for long periods of time
What are PICC lines used for? ABT regimen, chemotherapy
5 Complications of PICC lines catheter occlusion, phlebitis, infection, hemorrhage, and thrombus
What is the main reason for a Pulmonary Artery Cath? measure PA pressure
What is a Swan-Ganz or BTFDC? multi lumen catheter inserted through central vein and passively directed into a brach of the PA
The PAC is __-__cm in length 60-110cm
The PAC is marked in __cm increments 10cm
A PAC, Swan-Ganz or BTFDC usually has how many lumens/ports? 5
What are the 5 ports of the PAC? Proximal infusion port, Proximal injectate port, Distal port, Balloon inflation port and Thermistor connector
The proximal injectate and infusion ports open to a lumen that terminates how far from the tip? 30cm
The opening of the lumen for the injectate and infusion ports lies where within the body? RA when the tip is in the PA
What pressure can you measure through the proximal ports? RAP(CVP)
What can you administer through the proximal ports of the PAC? medications, fluid, electrolytes, blood and blood products
What can you take samples of therough the proximal ports of a PAC? RA blood
This opening of the proximal ports inside the RA receive the injectable solution for what measurement? CO
What does the distal port of the PAC open to? a lumen that runs the length of the catheter abd ebds at the cath tip
What pressures can you measure at the opening of the distal port within the body? PAP and PCWP (upon inflation of the balloon)
The distal port samples what type of blood? mixed venous
What cant you use the distal port of a PAC for and why? admin of meds d/t PA segment rupture, vascular and tissue reaction and damage
What is the thermistor? temp sensitive wire that terminates 4-6cm from tip of PAC and measures core temp
What does the thermistor allow for determination of and how? CO using thermodilution technique
Describe thermodilution technique Inject 10cc of solution less than body temp into proximal port then measure the magnitude of temp change over time to predict CO
An average of __ injections that produce a CO of no more than __% difference 3 injections; < 10% diff
When do you Inflate the balloon on a Pulm Artery Cath? for insertion from RA-PA and to measure the PCWP
What is the safety feature on the balloon inflation port? special syringe to only allow 1.5cc air and port lock to prevent inadvertent inflation
Overinflation of the ballon on a PAC can cause what 3 things? PA segment rupture, balloon herniation over cath tip resulting in erroneous pressure reading, and balloon rupture
What does it indicate if you have a PCWP wave w/o inflation of the balloon and how do you fix it cath too far into PA segment, withdraw until PAP appears
What does it mean if you don't get a PCWP with inflation and how do you fix it cath not in far enough or balloon not intact, floar cath or advance in unless rupture suspected
How does CCO work thermal filament warms surrounding blood causing a washout curve, the area under curve is proportional to CO
How does a PAC help assess pulmonary status It allows you to see changes in PASP/PADP to assess for COPD, ARDS, Pulm Htn, Pulm emboli, Pulm edema
PAC indications for use Peripoperative monitor, fluid and drug admin, lack of peripheral veins, emergency placement of transvenous pacemaker
Large veins used for PAC allow what to occur that doesnt in peripheral veins dilution of caustic or hypertonic soultions (KCL, Levophend, hyperalimentation, Chemo)
What type of heart block called for emergency placement of transvenous pacemaker thru PAC third degree
Contraindications for PAC use severe coagulation defects, Prosthetic right heart valve, pacemaker, severe peripheral vascular disease, high pneumo risk, and pulm htn
What causes a high rick of pneumothorax to happen on PAC insertion increased PEEP, emphysema, air-trapping and subclavian insertion
What happens during Pulmonary Htn that makes it a contraindicaiton for PAC PA is distended causing an increased risk of rupture
What port is located at the 30cm mark and what does it do proximal port in RA, monitors fluid volume status, CVP/RAP/ Preload of RV, estimates venous return, intravascular volume
What 5 problems can we monitor for/ or progression of with the proximal port trauma, burns, hypovolemia, sepsis, renal failure
CVP estimates ______ and cannot be used as an estimate in what disorders RVEDP; tricuspid valve disorders
Formula for PVR and normals PVR=(MPAP-PCWP)/CO x 80 Norms: 20-120 dynes/sec/cm-5
Formula for SVR and Normal range SVP=(MAP-CVP)/CO x80 Norm:770-1500 dynes/sec/cm-5
PVR is an indications of what RV afterload and myocardial work
CVP=RVEDP= Formula RVEDP= (LVEDP-2mmHg)/2
LEVDP formula (RVEDPx2)+2
How do you assess and treat for hemorrhage from PAC oozing at site, bruising, swelling treat with pressure and decrease number of attempts
What is the most common bacteria for nosocomial infection of PAC Staph aureus
How do you assess and treat for nosocomial infection of PAC fever, redness, swelling, increased WBC, treat with proper sterile/aseptic technique, keep dressing and line dry, ABT and culture tip
How do you assess for and treat a pneumothorax d/t PAC dyspnea, elevated HR and RR, decreased BP and SpO2, increased PIP, decreased Vt and BS, treat with chest tube
How can a PAC cause arrhythmia and how do you assess and treat irritation of endocardium d/t migration into RV or during insertion. assess:presusre tracing, ecg, loc. Treat:reposition PAC, and antiarrythmics
What can cause a thromboembolism to form?# kinks in PAC tubing and decreased pressuree in bag
Assess and treat for thromboembolism chest pain, dyspnea, tachy, dampened waveform, poor med infusion, inability to aspirate from port. Trea:heparin therapy, removal of cath
How can you prevent a thromboembolism if port not used for continuous med infusion aspirate and flush port QS
What is one way to decreased risk of air embolism during PAC insertions place pt in trendelenburg
AIr embolism treatment place pt left side down to prevent air from moving into pulm circulation, aspirate air from RA into cath, PPV 100% hyperbaric to enhance air reabsorption
How do you assess for balloon rupture absence of normal resistance felt during inflation, blood in balloon lumer, failure to wedge, syringe does not fill with air when released
Tx for balloon rupture label cath port, notify MD and use PADP to estimate PCWP
Where is knotting or looping most likely to occur RV
What causes knotting or looping of PAC repeated advances and withdraws, dilated cardiac chambers, excessively long cath
Assess for knotting or looping ventricular arrythmias, dampened waveform, PA distal reads CVP wave, difficulty aspirating or flushing, CXR
Treatment for knotting or looping PAC undo under fluoroscopy, surgical removal
What causes Rupture of PA segment advancing PAC with balloon deflaated, rapid or forceful ballon inflation, spontaneous migration of cath
How do you assess for and treat PA segment rupture hemoptysis(blood in ETT), treat by pulling cath back, control airway, O2, place effected side down to prevent blood from entering other lung, PEEP to compress hemorrhage and surgery
What can cause pulmonary infarct or ischemic injury in relation to PAC PA occlusion by clot or persistently wedged cath
What is the RT job when assisting physician with insertion of PAC set up bag, zero, check ports, inflate balloon, deflate balloon
Describe the Seldinger technique constant, negative pressure on syringe so that a flash of blood will be observed upon vein entry.
After entrance into the vein and intravenous position of needle confirmed what happens a guide wire is passed thru needle and threaded to a distance of no more than 20cm
MPAP formula and normal value MPAP=[(PADPx2)+PASP]/3 norm:10-15mmHg
Cardiac index formula and norm CI=(CO/BSA) Norm: 2.5-4.2 LPM/m2
4 things to remember when measuring hemodynamic pressures with PAC HOB no greater than 30 degrees, remain consistent, level and zero QS, and measure at end-exhalation
CVP measureswhat 3 things intravascular volume, venous return and RV preload
CVP reflects ____ in the absence of ___ ____ disorders RVEDP; Tricuspid valve disorders
PAC waveform: This wave indicates late ventricular diastole, RA contraction; atrial kick; and occurs after P wave A
PAC waveform: This indicates waveform descent; atrial relaxation X wave
__ wave= small crest that distorts descent; upward bulging of the AV valves during early systole C wave
Whay is the C wave not usually visibile? due to damping
__wave= atrila filling during ventricular systole; occurs after QRS V wave
__ wave= atrium emptying; filling ventricle with pressure gradient Y wave
What causes increased CVP? fluid overload, RV failure, Right sided valve disorders, cardiac tamponade/ effusion, and Obstructive RA tumor
What causes decreased CVP? hypovolemia and shock
What test can you perform to determine true volume status in response to fluid therapy? fluid challenge
Fluid challege = ___-___ml bolus 300-500
CVP response to fluid challene in normovolemic patient is CVP increased 2-4mmHg and returns to baseline within 10-15 mins
CVP response to fluid challenge in hypervolemic patient cvp rapidly increases but does not return to baseline within 10 mins
CVP response to fluid challene in hypovolemic patient CVP fails to increase
This pressure is normally only measured on insertion of PAC RVP
What does the RVP waveform look like? no dicrotic notch, lg ventricular wave, sharply contrasted to small RA waveform
What is the anacrotic rise early systol, inotropic component
What is the anacrotic nothc? volume displacement curve= indicator of SV; mid systole
Waht is the sloping descent? late systole, diastole
What is the dicrotic nothc? end systole, begin diastol, closure of aortic valve
What causes increased PAP? lung dysfunction, LH failure, hypervolemia
PCWP is an indication of what? LV preload/ LVEDP
PCWP>18= pulmonary vascular congestion
PCWP>30= pulmonary edema
When can PADP be used as an estimate of PCWP? in the absence of pulmonary disease and with a normal PVR
When is the balloon inflated to measure PCWP? exhalation
Wha causes increased PCWP? LH failure, intravascular volume overlaod, cardiac tamponade/effusion, Obstructive LA tumor
Anytime PADP is higher than PCWP it indicates what? increased PVR
High PCWP with normal PADP= LV problem not yet affecting lungs
High PCWP and PADP= LV causing lung dysfunction
High PADP with normal PCPW= lung dysfunction
A wide PADP, PCWP gradient = lung dysfunction and increased SVR
Where do you get mixed venous blood sample? Distal port of PAC
Normal Mixed venous Blood gas is 7.3-7.4/41-50/40/65-75%
Created by: Dabi2