Hi, this is going to be your first voiceover for module one. There's some learning objectives and outcomes. Do know that here it talks about different medications that are used in the care of complex clients.
We're going to have a separate PowerPoint on that and that you guys will be able to. to use, we thought that that would be helpful to have that on a separate PowerPoint. So we're going to look at the healthcare system as a whole.
At first, as we know, the healthcare system is very complex and Care must be integrated and coordinated across all settings of the health care system. It's usually with this transition of care where problems can arise. So looking out for patients specifically with like chronic diseases who can experience frequent changes in health status and have lots of different transitions. between providers and settings.
These patients are very vulnerable. Vulnerable patients are put at a greater risk during these transitions if care is not coordinated. Communication among professionals is inadequate or socionomic factors are inadequately addressed.
It's also important to make sure and take into consideration the needs, the individual needs. of the patient and the caregivers. So those are some of the struggles is this moving or transitioning within the healthcare system.
And that's what we're going to take a look at. So these next couple of slides are just quick questions that we'll come back to at the end of the PowerPoint. So basically, it's up to the nurse.
The nurse is equipped to address all of these challenges within the coordination of care for especially vulnerable patients. So that transitioning like between acute care setting to long term placement. or a different level of care is where there's a lot of safety concerns.
They've shown with data that there's an increase in adverse events, readmissions. There's more readmissions of these patients, which causes increased strain on the patient, higher costs. There's increased risk for miscare.
That would be like things like medications or. dialysis or something like that. And then there's poor communication.
So one in five, like I said, they monitor data on this and it showed that one in five Medicare patients discharged from the hospital is readmitted within 30 days. They were able to show that 76% of these are preventable and they use this data. by trending it. So data trending readmissions is used to measure the quality of hospital care.
So it's important to know that there's different, because of this, they did put into place and sign into place in 2010, the Patient Protection and Affordable Care Act, the ACA. So increasing access, improving quality and safety, and lowering costs are basic principles of the Affordable Care Act. Transitional care programs have demonstrated that with the prevention of avoidable readmissions, patient safety and quality of care improve and costs are lowered. And for these reasons, transitional care is a high priority in the Act.
So we're going to go over these different transitional care programs that have been instituted. they all focus on the same thing but different models that different places use to try to, because of this ACA that was signed into place in 2010. Okay, so the first one is this transitional care model. The transitional care model is an advanced practice registered nurse coordinated team-based approach for caring for older adults with chronic illness.
The transitional care nurse manages patients as they transition across the care continuum. So it's just kind of like what it says. And this is from, like I said, from inpatient settings to other settings, like maybe going into a skilled nursing facility or maybe even going back home. I already kind of touched upon that the most, the highest time for problems to occur is during transition of care. So this does show that there's an increase in adverse events, like I said, and readmissions.
So it's important to know because of this that although. Although all hospital readmissions may not be related to the most recent hospitalization, there are many insurance companies and other payers that consider unplanned admissions as wasteful spending and in some cases may even deny reimbursement or may charge penalties for readmissions within that 30-day window after discharge. So data trending the numbers of unplanned readmissions after a recent hospital stay.
This data is used to measure the quality of hospital care that is delivered. So the Care Transitions Program, Registered Nurses, used to mitigate this program. It looks at nurses as like coaches, transition coaches to manage chronically ill or seriously ill patients as they move between different healthcare settings.
This coach does not provide direct skilled care, but rather uses effective communication to provide education and guidance to make sure that there's a safe transition. So some things that they will look at is the overall goals of the patient, patient preferences, interdisciplinary communication, follow-up care. This RN coach may visit the patient in the hospital or follow up with home visits, phone calls for like four weeks or so after discharge and educate about quote red flags like medications, follow-up care, things that could make it so if there was a problem with that, that a patient could bounce back into the hospital.
So those are some of the higher watch things by this coach. Okay, another program is this Project Red and Project Boost. So this is a program that is used, again, to help improve care as patients transition from acute care into post-acute care settings by improving the discharge process.
And what they do here is on admission, they identify patients that are at risk for readmission. So they do this right at admission and by doing this they're able to show that or they're able to reduce a 30-day readmission rate, decrease the length of stay, and improve communication of patients during discharge, patient information during discharge. The patient-centered medical home guided care program.
This looks at patients that have multiple comorbidities and helps coordinate and look at an interprofessional team approach for these patients to help decrease readmission to the hospital. Transforming care at the bedside program. This program really looked at improving the quality and safety of patient care on medical surgical units. They focused on nurse retention, delivering safe and reliable care, making sure to do patient-centered care, utilizing an interprofessional team approach.
They also really focused on participation of the patients and their families in their care experiences. So patient education, an essential component of interprofessional care with all of the models is patient education. And it's essential that the patient demonstrate an understanding of what's going on with them, like their diagnosis and their plan of care, in order to safely have that safe transition back to home and to avoid readmission.
So one thing that we really focus on is teach-back. Teach-back is an effective teaching strategy. that is used to enhance patient education. So this would be important to avoid medical jargon, asking patients to repeat back what they understood using their own words and what you just told them.
So it's important to use open-ended questions. don't say things like, do you understand what I'm saying? Do you have any questions where they can just say yes or no, but instead say things like, can you explain to me what I just talked about with your medication? Open-ended questions.
Another thing with patient education is to go back and re-explain anything that's confusing to them. Really take your time when you are providing patient education and then to follow up with providing written resources that they can reference in the future to help with any forgotten details that the patient might come across. Okay, the nurse as patient care coordinator. So this is just like it talks about is the nurse becoming directly involved with the coordination of and the management of care in the acute care setting.
This role is really evolving right now. especially because of how complex healthcare is and because of the growing number of patients requiring chronic care management. So we're going to talk a little bit about interprofessional collaboration. This is where we... utilize the entire healthcare team and the patient, and it's like a partnership.
So every portion of the team is as important as the next. There should be mutual respect, and everybody shares the responsibility of having the best outcome for the patient. So this occurs when two or more professionals work together to solve problems.
they may talk about what's going on for that patient right there in the hospital setting but then they'll also discuss as they transition out and either go to a different long long-term setting or home so this is done in a very scheduled structured environment a lot of times if you think about daily rounds this is what or multi multidisciplinary rounds this is what interprofessional collaboration. This is when that's occurring. Like I said, the goal is to develop a good plan of care for both in the hospital and then transitional care when the patient leaves the hospital.
And this is done to improve the care that they're receiving in the hospital and also reduce unnecessary hospital days, which is decreased length of stay and to prevent readmissions. So one important thing to make this very fast because this can become a very tedious thing but to be is to use really good communication skills. So by following the SBAR technique, the Situation Background Assessment Recommendation technique, this is an effective communication tool. That is used to provide very concise and accurate communication between members of the team. And that's what can be used to go from patient to patient to patient and make sure that this coordination is being used.
Here's another connection check that we'll come back to. So to talk a little bit more about the interprofessional care team. As you can imagine, this can be a very large group. So we're talking about the registered nurse.
You can have unlicensed assistive personnel in there as well, like CNA, different providers, rehab therapists, respiratory therapists. When I talk about rehab, then you're thinking. occupational therapists, physical therapists, dietitians, case management, pharmacists.
So just kind of keep in mind with rehab, rehabilitation therapy, when I talk about physical therapy, sometimes it can be confusing. Oh, how do I know if I need PT or OT or both? So to help with that, with physical therapy, this would be, you can think of an example, like for patients that have been on extended bed rest to kind of get their strength back, then and to start using those limbs, using their muscles again, standing up, sitting. So that would be with physical therapy or occupational therapy. This would be for the patients that are unable to perform or tolerate, let's say, ADLs.
Okay. This next slide, again, can show some of the different members of the interprofessional care team. So you can see here that you have the registered nurse, you can have nurse practitioners, physician assistants, on down to, as I already said, occupational therapists, respiratory therapists, case management. At the bottom of that slide there, it says additional interprofessional care team members and even goes in to talk about chaplains, palliative care coordinator. Substance abuse counselor.
So palliative care coordinator. Just know that these, especially with having more chronic diseases with patients, palliative care is a great resource to utilize. And they help look at the overall plan of care for that patient. So just know that palliative care and hospice care are two different things. palliative care, you can still receive those patients.
can still receive active treatment like dialysis, paracentesis, chemotherapy for oncology patients, but they still, you know, they will meet one-on-one with these patients to figure out together what their goal is for, their individualized goal is for themselves. So they, like I said, it's a discussion regarding overall plan of care for that patient. So with the registered nurse, you know that we utilize the nursing process to care for a patient.
And with this, this is the assess, plan, implement, and evaluate. This is the nursing process. We're one of the first identifiers of changes in patient status and complications. And we're there to help.
be a patient advocate to make sure our patients to ensure their safety and to have optimal outcomes a quick slide on unlicensed assistive personnel so like i said earlier this would be an example this would be like a cna and it's important to know um with these members of the healthcare team we utilize delegation so here this slide talks about the five rights of delegation right task right circumstance right person right direction and communication and right supervision and evaluation so back on that previous slide if i was talking with a cna i would have to make sure i utilized those rights and maybe i would have delegate, I would delegate to them to perhaps record hourly INO or to obtain vital signs, but I would definitely have to make sure that I am using all of these right things with delegation. Down there at the bottom when it talks about right supervision and evaluation, this would lead us to to think about documentation. So even though we're delegating out vital signs, let's say vital signs to a CNA, they document these vital signs.
But then as the nurse, we need to oversee that and supervise them and make sure that they're documenting correctly. So there's a lot that goes into delegating these tasks. So here's just another slide, just kind of looking at some different providers, you know, from a physician to a nurse practitioner.
You have the physician assistant, some different members of rehabilitation. Makes you think of physical therapists, occupational therapists, speech language pathologists. And then, like I already said, just kind of to help with that clarification.
between physical therapy and occupational therapy. We already know that respiratory therapists, these specialize in airway management. Nutrition obviously focuses on the patient's nutritional needs. But it's important to know as the nurse, all of these different roles.
So we, as the registered nurse, it would be up to us to help make sure and ensure that our patients are receiving and utilizing the most out of all the different types of interdisciplinary care that can be provided to them. okay this is another um question that we'll come back to actually i think yeah so let's go back to these questions so the first ones were up here on slide five so this question It says, which phase of care is most critical for medical surgical patients? And what do you think, A, B, C, or D? So we did talk about that transition phase, C. This would be the answer.
All phases of care are important, but the transition phase is critical. as there's handoff of care between phases where an error could occur, and especially if good communication is not utilized. So good communication is crucial. Next question. It says, what is considered the hospital's span of responsibility for the patient?
So. A, admission to discharge, B, admission to 30 days post-discharge, C, admission to 15 days post-discharge, or D, admission to full recovery? So I did talk about the answer would be B.
So the ACA specifies financial penalties for hospitals for what they determine is excessive readmission within 30 days of discharge. So it's important to the answer would be admission to 30 days of discharge. Okay. So then let's go to our next question, which was.
We'll leave here. So this question says, which statement by the nurse indicates understanding of benefits of interprofessional care? Select all that apply. So A, B, C, or D or E. I'll let you read through those for a minute.
So the answers to this are A, I'm glad the social worker can focus on finding a placement for this patient. C, the occupational therapy evaluation made it clear that there are more issues with activities of daily living to resolve before this patient can be discharged. And E, discharge planning is much easier when we talk about it together as a team.
I know that these aren't the most stimulating of questions, but there's an obvious reason why these are in your PowerPoint. Okay, and then here's our next question. The case manager has a caseload of 30 patients on the inpatient unit on a given day.
How should the case manager prioritize the visits? to patients at the bedside for discharge planning? Here are your choices. This first one is one, the second one is two, the third one is three, and the fourth one is four.
So how would you prioritize those? So the answer is A. It would go number four first, three second, one third, and then two last. So number four.
a 75-year-old female patient with a history of heart failure and renal disease being discharged tomorrow after a cholecystectomy. I put the rationale in there for you guys. So this one, it said that this would be the most, you know, this is the one that you would see first because of the several serious comorbidities and will need complex care planning to ensure safe discharge.
The next would be a 35-year-old. Male patient being discharged after a complicated post-operative course following surgery for a ruptured appendix that included a septic episode will need a detailed follow-up, but the patient is younger and previously healthy, so there should be a smooth transition home. Then it says for the third one, a 67-year-old male patient being discharged tomorrow after an uncomplicated transurethral resection or a TURP. With a Foley catheter, we'll need follow-up and teaching about the Foley, but the discharge should be uncomplicated. And then the last one was the 54-year-old female patient being discharged tomorrow after uncomplicated vaginal hysterectomy.
We'll need teaching and follow-up, but the plan should be straightforward. So you guys will need to understand prioritization, and this is a great example of... prioritization.
So next question, the nurse is caring for a patient who has experienced a CVA, which ICT members should be involved in this patient's care? So that's why we went over all of this. You should be able to recognize which interdisciplinary care team members would be appropriate for a patient that's experienced a CVA. So this is again a SATA.
So your answers are A, B, C, and D, rationale, OT and PT, evaluate and support rehab issues, the physician guides the overall care, the case manager coordinates all services, all work together as a team. And that's the answer of that one. And then the last one, which statements?
Which statement by the nurse indicates understanding of the benefits of interprofessional collaboration in providing care for patients with chronic illness? SATA. Select all that apply.
So your answers to this are A, B, C, and D. Okay, so we're done with all of that. We're going to segue quickly into just a couple slides here on delirium and your RAS scale. These are kind of just thrown in there. But if you look at your content outline that's located in your module, you will see that that's part of your content outline is. knowing this.
So delirium, I did give you guys a video here that's all about delirium and the treatment. You can click on this link. If you can't get it to work, I did put the link below in the speaker notes.
And this is a good video about delirium and the treatment. So basically delirium, it means an altered mental state. And this could be over any amount of time.
It's characterized by impaired level of consciousness and reduced awareness of the surroundings. There's also has a decrease in attention and cognition. It can occur around the time of injury, infection or hospitalization and is most commonly noted in older adults. So delirium has well-documented risk factors and associated adverse outcomes, such as increased length of stay and an increased risk for falls. It does go on to talk about how older adults with underlying cognitive impairments like dementia, they're at a higher risk for delirium during their hospital stay and also intensive care unit environment itself.
can lead to the development of delirium because of constant interruption that happens to the patient's sleep and wake cycles. You have invasive lines, monitoring, anxiety, pain, poor nutrition, lots of noise. So they are prime candidates for delirium.
So current recommendations for delirium prevention include it. pain management, minimizing anxiety. For those patients that are intubated, they talk about doing spontaneous breathing trials, and this is something that should occur daily unless contraindicated. Providing environmental cues, early mobility, and family involvement. So some examples of these recommendations would be like not over sedating your patients.
So we can do a spontaneous trial to see if they're ready to be weaned off the ventilator. Having lights on during the day and shutting those lights off during the night, along with having decreased... stimulation at night so they can have these sleep periods.
Weaning and extubating from a ventilator as soon as they're able to do so and getting patients up and moving. And do know that we do do that with patients that are on the ventilator as well. If they don't need to be sedated, then we don't sedate them.
And if we're not sedating them, we do get them up and move them to chairs while they're on the ventilator. Okay, this next slide is your introduction to a RAS scale. This is the Richmond Agitation Sedation Scale. Again, there is a link right below there that talks about the RAS scale. This is a system or a tool that we use to assess sedation and agitation in critically ill patients.
So, this would be used for any patient that is receiving any type of sedation like propofol or prosthetics, continuous sedation for patients that are like on a ventilator. So what physicians or providers will do is they will order their sedation, let's say for instance, propofol, they'll put an order in and it'll say to start the propofol drip at a certain rate. Like I said, this is a sedative, it's used for sedation, and it'll say to maintain a RAS, which is the R-A-S-S there. Maintain a RAS score of a zero to negative one.
And as you can see on here, a zero is alert and calm. And a negative one says drowsy. It says sustained awakening to a voice.
So if I would walk into a room and my patient on the ventilator with propofol infusing opened his eyes or had their eyes open and looked at me. and was calm, could follow commands, that is alert and calm. That is a RAS of zero. That is how you appropriately use sedation.
I'm sure you guys have heard terms of snowing your patient. That is, if you're, quote, snowing your patient or making them very, very sedated, I guarantee you that they're not giving those orders. uh, to do so. And that means that you're practicing outside of your scope of practice because you're not following an order.
So here you can see deep sedation, a negative four, it says no response to voice, but movement or eye opening, or I'm sorry to no response to voice movement or eye opening to physical stimulation. So they're not doing anything. So that is, um, a deeply sedated patient.
to a negative four and the only time really that i would see them do a negative three or negative four is um honestly with paralytics um but we're not going to talk about that right now so propofol if i had an order for propofol drip and they said to titrate my drip to a ras of zero if my patient was flailing in the bed, coughing, breathing very, very fast on the ventilator, moving, trying to pull tubes out, they would be up here, like a three or a two. If my order said to have them at a zero or a negative one, and they were at a three or a two, then according to my order, I could increase my drip by whatever the order said to increase it by. So if I had my patient going at 20 mics or 30, let's say 30 mics of propofol, 30 mics per kilo per minute of propofol.
to maintain a RAS of zero, and they were flailing and trying to pull the breathing tube out, they're clearly at a three, then the orders would go on to say that I could titrate my propofol by like five mics per kilo per minute every so many minutes, like, I don't know, five minutes to obtain a RAS of zero. So that's how you titrate medication. I would then, like if I had my patient at 30 mics, I would go up to 35 mics and wait five minutes until I can move the drip up again to hopefully get them down to a RAS of zero or a negative one.
So in your F.A. Davis book on table 27.11. That is a table that shows medications used when sedation and or paralysis are utilized in the treatment of mechanically ventilated patients. I would take a look at that table so you're aware of which medications we use for that. We'll go over that more as we talk about respiratory, but that will be on your first exam as well.
Okay, we're going to move into hemodynamic monitoring. You're going to get this over the next couple of weeks, so I'm not going to go way in depth, but I'm just going to be lightly covering it here. So in this slide, you do have a link here for a video that is a generalized overview of hemodynamic monitoring. So that will help. with your understanding of it.
This picture just kind of shows the different things that you can utilize. So you guys have already talked about hemodynamic monitoring in semester seven. I know for a fact we talked about it in farm, so we're going to go over it some more, a little more in depth this semester. Okay, so hemodynamic monitoring is utilized basically to evaluate the patient's immediate response to treatments, including inotropic medications and mechanical support.
So here it talks about, shows how we can have early identification and treatment for like, let's say shock and look at their cardiac and lung status. So here's some more terms that's part of hemodynamic monitoring. These terms you will need to be familiar with.
You've heard them all before. Again, we talked about them in PHARM, in PHARM 2. So cardiac output, the amount of blood that's pumped out by the heart over each minute, that equals your cardiac output. Your stroke volume is the volume of blood pumped by the left ventricle with each heartbeat. We have preload, which we said if you think about volume, it's the end diastolic pressure or volume that stretches out the right or the left ventricle and reflects the patient's fluid volume status.
Afterload is We talked about thinking about resistance. So afterload is the force or resistance the ventricles must overcome to eject blood into the pulmonary circuit or aorta. And then contractility is the ability of the heart muscle to contract or pump.
So when I think preload, I know on farm we kind of talked about, think about. volume. If someone had high preload and they, if you think about like a congestive heart failure patient, they would be fluid overloaded.
So their volume, they would have an excessive amount of volume. So they would have a high preload. And then after load, we talked about thinking about resistance or what your heart has to pump out against.
So if somebody had high blood pressure, um, that would be a very high resistance that the heart would have to push out the blood against, this high pressure or high blood pressure. that would mean that they would have a high afterload. Okay, we're going to go into oxygen delivery. So with this slide, I want to talk about, we're not going to be talking about just oxygen anymore.
You need to think about the way your body utilizes it and the way your body consumes it. So. Here we talk about when you think about oxygen consumption, there is a way that we can look at oxygen consumption by the body.
An example that would be obtaining what's called a mixed venous gas. So mixed venous oxygen saturation, this would be equivalent to your SVO2. This is obtained, you can either get it off of a pulmonary artery catheter, or we can get it off of like a central line, getting it from a distal port.
But it says here the sample is obtained in the pulmonary artery after the blood returning from both the superior and inferior vena cava mixes and before blood is oxygenated in the lungs. It's considered a true mix of oxygen returning to the heart and an indicator of total body venous oxygen saturation and tissue oxygen utilization. Okay, so this can be kind of a hard concept to grasp.
But if you think about oxygen in your blood and your heart is pumping the blood throughout your body, the way... It's pumped out of your heart, throughout your body, and then returns to the right side of the heart. The way your body extracts or pulls oxygen out of the blood and utilizes it throughout all of the different organs and tissues in a patient's body, and then comes back to the right side of the heart, they can take a measurement off of that blood returning to the right side of the heart.
and they can see oxygen consumption or that SVO2. So if that number, if I was to have someone with a central line and they had a distal port on it, I could have, let's say, my respiratory therapist obtain a mixed, it's called a mixed venous gas. They obtain blood from that port.
And they will run a blood gas on it. Now, this is not an arterial blood gas. It is venous.
But from looking at those numbers on that blood gas, they can see if the PO2 is pretty low, they can see how much consumption the body did or used of the oxygen throughout for that patient. So SVO2 or oxygen consumption is the most accurate representation of systemic oxygenation. If my SVO2 was low, then I would know that my body was utilizing or having to utilize way too much oxygen. And it would tell me that.
perhaps my patient had some type of process going on, like for instance, cardiogenic shock. A lot of times, this is a very accurate picture of somebody having cardiogenic shock if they have, if their SpO2 is low. So it's kind of a hard concept to grasp, but Oxygen delivery is your DO2, which is the amount of oxygen delivered to the tissues. Your oxygen utilization and consumption is your VO2. So that's a relationship between oxygen delivery and oxygen extraction at the tissue level.
So it should be 60 to 75 percent. If it's less than that, then we know that there's something going on that's causing or an increased oxygen consumption in our like maybe cardiogenic shock or something like that okay let's go on to some other types of hemodynamic monitoring you have an arterial catheter which is like uh we're gonna i'm gonna show that next which would be like um a radial arterial line You can use your central venous catheter, which is your central line, and then a pulmonary artery catheter, which is a catheter that goes into the pulmonary artery, well, before the pulmonary artery within the heart. So first here, this is a picture of somebody with a arterial catheter.
a radial arterial catheter or an art line and this this is just kind of meant for you to understand what it looks like so right here in their wrist is your radial artery this is where usually they'll put the arterial line and then um this is with pressurized pressurized tubing so this tubing looks like iv tubing but when you feel it it's hard So it's special tubing, it's pressure tubing. On it, there's a little transducer there or a flushing system that you will see there. And then this tubing is spiked into a saline bag and that saline bag is placed on, is held in place with a pressure bag. the nurse will pump up to a certain pressure. So with this radial art line, we're able to, you can see it shows it connected to a monitor.
This will give us real time of somebody's blood pressure. So it's a continual monitoring of their blood pressure with every beat of their heart. I see what their blood pressure is at all times in real time. Okay. So as I was talking about that, and I said there's a transducer.
So this transducer needs to be leveled here at the phlebostatic axis. So this is a midpoint of the left atrium and the fourth intercostal space in the mid-axillary line. In other words, kind of like right under their armpit.
So just know nipple line. armpit area this is your phlebostatic axis um this is where we will put the transducer of right here this transducer we typically will roll it up put it on a washcloth or a towel and then we'll lay it right up here where that phlebostatic axis would be it has to be leveled there or your waveform is not accurate okay So arterial line, like I said, this is continuous blood pressure monitoring. They can also obtain blood work from here and ABG samples.
And again, in here, there is a link that I would highly recommend you guys look at these links and watch these videos so you get a good understanding of this stuff. Here's an arterial line video. It's a small catheter that's put into the artery. And like I said, you will be able to hook it up and see the waveform on the monitor.
So you will see a continuous blood pressure measurement. So if we have a critically ill patient with a labile blood pressure, you know, that goes up and down, or if they're hypotensive and we have to put them on pressors like norepinephrine, neosynephrine, dopamine, something like that. continuous vasoactive medications, then we can run those and titrate those up and down according to set order parameters to obtain a blood pressure that we need to obtain. And we can do that in real time. We can also use this catheter to get arterial blood gas or ABGs.
As you know, those are otherwise drawn with a needle that goes into the artery and it's very painful. So if somebody's on a ventilator and we think they're going to be on a ventilator for a few days, then it would be recommended to have an arterial line so we can get blood gas, ABGs or blood gases, so we can efficiently and effectively wean them from the ventilator. So this goes on to talk about sometimes many hospitals now use an inline closed system.
It's called a VAMP. So a VAMP is a venous arterial blood management protection system. It looks kind of like a little accordion. I don't see it on this picture, but we use that to keep everything closed.
But it's just called a vamp if you hear somebody say it. And then I just go on to put a little formula here for calculating your MAP. Those of you who want to know. So before insertion of a radial arterial line, it's important to make sure since that's going into an artery, it's important to make sure that.
the person that's putting in the line, they will do what's called an Allen test to make sure that their ulnar artery has good flow. So this talks about how they have them perform an Allen test. It says here that they elevate the hand, have them make a fist for 30 seconds while the hand is elevated.
In a fist, the ulnar and radial arteries are occluded. While still elevated, the hand is opened and should appear pale or white. While pressure over the radial artery is maintained, pressure over the ulnar arteries released.
Normal color returns in 7 to 10 seconds. This is called a positive Allen's test. So a negative test would mean color does not return, and that would indicate insufficient blood supply through the ulnar artery.
It's important to know that you are looking for a positive Allent test to show that, yes, you would have good blood supply through your ulnar artery to make sure the patient is then safe to have a radial arterial line placed. This slide kind of talks about or shows how they place a radial. arterial line.
Like I said, it's usually inserted into the radial artery. They can do ulnars. They can do axillary, brachials, femorals.
These are not recommended, but they can do them. Sometimes they have to. And then this slide goes on to explain that a mean arterial pressure or a MAP of 65 is considered necessary for end organ perfusion. And that is pretty universal what they go by.
So if you, what this is trying to say is if you have a patient in the ICU, which is the only place where you are going to see arterial lines, like a radial arterial line, and they have an art line in place. they're on a vasopressor, let's say norepinephrine, a lot of times, not always, but a lot of times they will say to titrate the norepinephrine for a MAP of 65 or greater. They usually want it less than 80. But they will say to titrate it for a MAP of 65. That means if my blood pressure... let's say it's you know 110 over whatever 55 if my map it'll say 110 over 55 and then after that it'll have in parentheses a number if that number that parentheses is the map if that map is not 65 or higher then i would know i would need to go up on my norepinephrine if that's how my order read was to titrate it for a map of 65. Even if you have a systolic blood pressure of 100 or 95, if your MAP is not 65, you still need to talk to your provider about that and see if they're okay with that. Okay, this next slide.
So this shows different waveforms. This is a arterial waveform or radial art line. it doesn't have to be radial so a lot of times you'll hear me just say art line so an arterial line in place of a blood pressure this shows the difference between this is what the waveforms look like so this waveform right here on the bottom left is um oh sorry the bottom right here the bottom right here um this is a good waveform um the one here up at the upper top left is over dampened you see that the top of the hump here it's just very round there's not what is called a dichrotic notch.
So here it shows this waveform going up and then it'll come down a little bit and there's like a little notch there and then it'll come down. This is a normal waveform. This is what you are looking for for an arterial line. If you don't have that notch in there, that dichrotic notch, then that's an over dampened waveform.
The one right below it has a very pronounced dichrotic notch. And then it has like, it's not, it's very pointed here at the top. This is a very under dampened or hyperdynamic waveform.
This is inaccurate as well. So it's important as the nurse, if you're dealing with arterial waveforms, that you're able to recognize a normal waveform for your patient. So if you had an adequately Or if you had an over dampened waveform, which is up here, you see this over dampened waveform where and it talks about oscillation.
So remember, I told you that there's a transducer. It has a flush on it. It has like a little pigtail. It's hooked up, like I said, to saline. This pressure tubing is and it's on a pressure bag.
When you pull that little pigtail, it flushes. this arterial line. You have to have pressurized saline on these arterial lines or you'll, they're in an artery, you'll have backflow of blood.
So in order to keep that nice and clean, they have it connected to this pressurized saline bag. So on the transducer, there's like this little pigtail, this little rubber thing sticking out and you can pull on it and that'll quote, flush your A-line. When you pull up on that and then let go, it'll do this little, you'll see it go up and then across. That would be me pulling on the pigtail, letting go, and then it goes bounce, bounce, bounce, bounce. So that's called an oscillation.
There's ways to see if by how many bounces that you have, if you have an over dampened or an under dampened waveform so over here on the right hand lower corner it shows um that pulling of the pigtail goes across and then it you let go of it and it bounces there's like two little bounces there one or two that is a normal well two that is a normal um oscillation If you only have one bounce, which is up here, that is a very dampened or over dampened waveform. That could be indicative that maybe there's a clot in the catheter or there's air bubble in the tubing. If you have this over dampened waveform, you're not going to have an accurate blood pressure. So that's why it's very important.
Maybe you don't have enough pressure on your pressure bag. That could cause this over dampened look here. It would be important to know that though, because like I said, if you had a clot there in the catheter tip or an air bubble, this would be important to rectify and fix.
The other big thing. by the nurse is not only being able to identify the waveform and make sure that there is or isn't a problem, but to also look at the insertion site. So it's important that the insertion site and area distal to the site be monitored for bleeding.
And then also the area distal to the site be monitored for perfusion, you know, that you have an adequate perfusion. So you we would be doing cms checks by look you know and make sure we're looking at color warmth capillary return movement so we would want our capillary refill to be less than three seconds. If it was greater than three seconds, then I would know that there was not good perfusion going to my fingers. You know, if you, here's your site, if I am checking capillary refill on these nail beds and I have it greater than three seconds, then that's decreased perfusion and that could lead to, um, problems with their fingers.
So they would have decreased circulation there. So that is the priority that the nurse has to constantly, continuously observe for adequate perfusion. And then the other thing, obviously, since this is in an artery, the nurse needs to make sure that you have alarm level set on the monitor.
So it would let you know if there was a change in the blood pressure. especially if you had continuous drips going. Okay. Okay, this slide I just threw in there to show you, here's your arterial line.
This is your continuous blood pressure. You can see the dichroic notch here. Maybe this isn't the best one, but it is there, little dichroic notch.
And here's your blood pressure. I don't know what this number is. Let's say it's 58 or something. So you can see 105 over 58 maybe. And then right here, it shows your MAP, 72. So that is a good blood pressure.
I have end organ perfusion because it's greater than 65. And like I said, it's a continuous blood pressure. Okay. There obviously are some potential... complications that you have to look for with patients that have arterial lines. Obviously, it's invasive.
So infection is a complication. This came right out of your book. So box 32.3, infection. If you have occlusion of the artery or like a clot, you could have hemorrhage if that tubing becomes disconnected or if the patient pulls out the art line, they could bleed through their artery. And like I said, it's an artery, so you could desanguinate very fast.
You can have an error embolism if the bag is empty or if you have error in the tubing. Or you can have inaccurate readings or damage to the artery. So the other thing, so it talks about here, it says it's safe practice to have arterial lines clearly marked so that IV medications are not given through this route. And obviously, we do not put any medications through an arterial line. Inadvertently, giving IV infusions can lead to tissue necrosis, gangrene, or even loss of the limb.
So a lot of times we will label these lines, these arterial lines, we will label them and have it say no medications. Okay, central venous monitoring. Again, here is another video for you to watch for central line video. I would suggest that you watch it.
So a central line, obviously, we can give infusions through that. Typically, we see them in the internal jugular. That's your IJ or even a subclavian. We can do a femoral as well. But this is a line that's placed, I'm just going to talk about an IJ.
It's a line that's placed where the tip of the line is in the superior vena cava. It's right at that junction, right before your heart, before the right atrium. So if we do central venous monitoring, this would be called a CVP or a central venous pressure.
This is a right atrial pressure of your heart. It tells me how... the pressure in my right atrium is. It's a measurement also of right ventricular filling pressures and blood return from systemic circulation. So a normal CBP would be two to six.
A CBP is the measurement of your preload, where I talked earlier. If we wanted to know if somebody had high preload, we would do that by. monitoring their CBP or their central venous pressure. That tells me my preload. So here this shows, again, my central line going into the right IJ or the internal jugular.
And I said that the tip rests at the junction of the superior vena cava and the right atrium. So I always told you guys in farm. For preload, I want you to kind of think of volume, but it's an estimate.
The CVP is an estimate of volume returning to the right heart or the right heart preload. Another term that we use is right ventricular end diastolic volume. Remember, our heart is not pumping during diastole. That's when it's at rest. And so it's at full stretch.
You have all that volume in there stretched as far as it can go. That's end diastole. And that measurement, that full stretch or full volume, is what we use the CBP to measure that with.
So if I had somebody that was fluid overloaded and I knew that a normal CBP would be 2 to 6, If I had a congestive heart failure patient, they were fluid overloaded, maybe my CBP was 10. That would be how much volume is in that right side of my heart at full stretch, right at dia in diastole right before it pumps or, you know, pumps and contracts and pushes that blood out. So. That would tell me that if it was 10, that my patient was very volume overloaded.
And to decrease my CBP or to decrease my preload, because that's a measurement of preload, then what medication would I give? And from pharmacology, we talked about giving diuretics to make them pee off the volume. So if you have a congestive heart failure patient with a CBP of 10, then I would know that their fluid volume overloaded, their preload was high, and I would give a diuretic like furosemide, and I would be able to watch this monitoring on the monitor decrease and my CBP come down. So this next slide here, this is a tracing. So here you have your EKG rhythm up at the top.
The next one down, perhaps is like a your arterial line with you can see it's not showing the dichroic notch though but regardless this could be your arterial line and then right below which is why i put this slide up here is your cvp line so it is still a continuous monitoring and tracing that is going to be shown on your monitor and Also, that CBP is also connected, therefore, to pressure tubing and a pressure bag. And it has it has that little transducer that we have to have right at that fleabesthetic access, just like you do your arterial line. OK, it's a lot of information, guys.
So here on this line or on this slide, you guys can click right here. It says video care of this central venous catheter. This is a video that you can watch.
It's basically a refresher talking about care for a central line. But here's some different complications that can occur with a central line. All of those should kind of make sense. And then we're going to move into, we're almost done, into your pulmonary artery catheter. So pulmonary artery catheter would be used to tell me different pulmonary pressures or pressures within the heart.
Another name for this is a PI or PA catheter or. a swan gans catheter this is a flexible balloon tip catheter that's guided to the right side of the heart and if you inject And below up that balloon, it floats up into the pulmonary artery, measuring the pulmonary pressures and telling me left-sided heart pressures. Here's a picture of a pulmonary artery catheter. We're going to pass one around in class. But right here, this is where they would put this, like, this is the introducer and it would go into the right.
like into your IJ, internal jugular, your IJ. And then this portion of it is threaded into the heart. And the next slide, I'm going to show that. So all of this from here out is going to be outside of the patient. And you can see there's different lines here that we use for different things.
A lot of times you'll see cardiac patients with this, especially CV patients, cardiovascular patients have open heart surgery. things like that. Okay, so here again, this line is connected to pressure tubing and a pressure bag and then it's transduced up onto the monitor. And as a nurse, I watch these waveforms.
Here it shows the line going into the right atrium and it has the balloon blown up. Um, it's just kind of showing how it would go. You don't do that when you're inserting it though, but, um, it's just so you can kind of see this progression more, but you go, uh, the line literally goes into the right side of the heart.
Um, as it, as the, um, physician is inserting this line, you will see this waveform up on the monitor. This is your right atrial waveform as a nurse that is, has a patient with this line, you would, um, This would be your responsibility to be able to tell the differences between these waveforms so you know, have an idea of where in the heart that this line is placed. Right atrium as it goes down into the right ventricle.
Here you see this. This is a lot of times you can, if you had an EKG up here, you might see some VTAC up there. But this is right ventricular pressure waveform.
The. the catheter would then go up and sit up here within this pulmonary artery. This is the waveform you would see.
And then if they blew up the balloon and it went into here and occluded the pulmonary artery, then you would see this line or this waveform. So with all that, do you need to know the different waveforms? But no, you don't. But you need to know that this is how this line works. So this line is really good at showing me lots of different pressures within the heart.
As I said, we kind of talked about afterload, which is SVR, systemic vascular resistance. You should know that that your SVR or your systemic vascular resistance is a measurement of afterload, which is the resistance that your heart has to, or that pressure that your heart has to pump against. There is a table in your, or in your book, 14.3, where I kind of talk about these different pressures within the heart. It is important to know this stuff.
So if you have PA pressures, you could have a systolic pressure, a diastolic pressure. Like I said, that would tell me my pulmonary artery pressures. And then here, this PAOP is another way of saying wedge pressure. If I had a patient in cardiogenic shock, um, let's say their heart's failing. So I would think that their cardiac output would be low.
Um, this way or this PA line or the swan Gans line, it will give me those numbers. It will give me, I'll show you this next slide here. It'll give me PA numbers, um, CBP. It'll give me, um, here it says right atrial, but a lot of times you have it connected to a continuous cardiac output machine. where it'll tell me a continuous cardiac output.
So if I had somebody with cardiogenic shock, and had a swan in them or a pulmonary artery line, then I could see that they're CO or their cardiac output is low. And I would also see that maybe their CVP or their preload would be high because they're overloaded because they're in heart failure. And I would also see that maybe my wedge pressure or my PAOP, which is your wedge pressure, just think you blow up the balloon and you wedge it into the pulmonary artery.
That would tell me that my red wedge pressure would be high too. So I could know that there's different things that I could deliver to this patient to help fix those problems. So by looking at those numbers, that kind of gives me an idea.
So maybe a medication like milrinone, something that would increase cardiac output would be a great medication if I had a... PA line and somebody that showed my cardiac output was low, I would know that starting milrinone would be a good medication for that to help fix a decreased cardiac output because milrinone, as we learned, is an inotrope. Okay, so I kind of already showed you that slide, but that's all that's supposed to show you is that there is, like the other waveforms, the PA line is a waveform.
Okay, so here's some different complications that can happen with a pulmonary artery catheter. You guys can kind of look over that. And then the next slide here is a slide that talks about, this is from out of your book, table 32.1.
And this slide is kind of neat because it goes on to talk about the different values. So we've talked about CVP or central venous pressure. We've talked about PA pressures or pulmonary artery. And I told you there's a systolic and a diastolic. You don't have to memorize these, but you can read through these and understand what high levels and low levels mean.
And then it goes on to talk about interventions and have that make sense in your head why you would give these interventions for if these numbers were low or high. It goes in. So after the pulmonary, the PA pressures, then we have this PAOP or pulmonary artery occlusion pressure, which I said is like your wedge pressure when you blow up that balloon on the end of the swan or the PA line and then it occludes the pulmonary artery.
And it goes down to talk about cardiac output index is just more succinct measurement specific to that patient because it looks more at the patient's height and weight and tells you it's kind of the same thing as a cardiac output, but more specific to that patient. Here we have our afterload or our systemic vascular resistance. We said this was a measurement of afterload. So, Knowing if we had low afterload that we would be giving volume or maybe giving pressors to cause constriction of our arterioles.
If we had high afterload, we would give vasodilator therapy to open up or cause dilation of arterioles. Here it talks about PVR. I'm not going to really go into PVR. it's just another measurement of um i guess you could say afterload uh in the heart but i want you guys to focus more on svr and then here we can get mixed venous gases off of our swan which is why they throw this on here too and it talks about what low levels and high levels would be Okay, guys, so that's it in a nutshell. So some final tips and takeaways would be to know that invasive hemodynamic monitoring is important to allow early identification and treatment of complex medical problems of the critically ill patient.
We talked about the use of a central venous or PA catheter that the nurse can. evaluate the patient's immediate response to specific treatments like inotropic medications. or vasopressors and or mechanical support.
By doing ABGs, we said invasive monitoring may also be used. We're going to talk about this, but we will. For transvenous pacemaker insertion, central venous and pulmonary pressure monitoring, we talked about that. We can tell if we're doing good with our volume resuscitation.
If we're using, we can use this type of test. Um, hemodynamic monitoring, if we're doing frequent blood draws, which would, we would use an arterial line for, um, uh, if we need to give long-term antibiotics. So a whole array of things here.
Um, and I think that's pretty much it. So that's everything guys. Again, if you have any questions about any of this, write it down and we can talk about it more in class. And our in-class activities will kind of help connect things together more for you.
And then, like I said before, please watch those videos so you can have a clearer understanding of hemodynamic monitoring. Thank you.