Page 487 - Cardiac Nursing

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C HAPTER 2 1 / Hemodynamic Monitoring 463
DISPLAY 21-2 Preparation of Invasive Pressure Monitoring System 22
1. Wash hands
2. Gather supplies: bag of intravenous normal saline, pressure monitoring kit, 10 cc luer-lock syringe, and pressure bag with
self-venting gauge
3. Prime pressure monitoring system to remove all air
a. Remove pressure monitoring kit from package, open blood salvage reservoir, tighten connections, close roller clamp,
turn stopcock OFF to patient (off toward distal end), and remove vented (white) stopcock cap
b. Remove IV port cover and pressure monitoring line spike cover
c. Invert IV bag to orient bag upside down and using sterile technique, insert spike into IV bag
d. Leave the spiked bag upside down, open roller clamp, and simultaneously pull (activate) fast-flush device (pigtail) con-
tinuously while gently squeezing to apply pressure to IV bag to slowly clear air from IV bag and drip chamber.
Completely fill the drip chamber with IV fluid.
e. Turn IV bag upright once fluid is advanced sufficiently past the drip chamber
f. Apply gentle pressure to the IV bag (or hang the bag 30 in. above distal end of tubing) and pull fast-flush device, ad-
vance fluid, priming the stopcock
g. Orient fluid so that air will be completely removed by the advancing fluid (tilt distal end of reservoir upright at
45 angle)
h. Pull (activate) fast-flush device while holding blood reservoir at angle, continuing to flush until the entire line is primed
i. Close blood reservoir, advancing all reservoir fluid through line
(
(
j. Perform Rocket Flush (Do not perform rocket flush if pressure line is attached to patient.)
(1) Turn stopcock off to distal end of catheter (“off to patient”)
(2) Attach a 10-mL syringe to the stopcock near the transducer using sterile technique and slowly withdraw IV fluid to
fill syringe
(3) Turn stopcock off to transducer (“off to monitor”)
(4) Flush line quickly with 10 mL NS from syringe to remove any remaining air bubbles; avoid instilling any air into the
line
(5) Turn stopcock off to port and remove syringe
(6) Cap stopcock using sterile technique with solid blue cap
4. Place IV bag into self-venting pressure bag and inflate to reach 250 to 300 mm Hg and recheck for air in line
5. Inspect line, remove any remaining air by flushing line using Rocket Flush as indicated by the dynamic response of the
system (goal—adequate or optimal system) 23
Reproduced with permission from Bridges, E. J., Schmelz, J., & Kelley, P. W. (2008). Military nursing research: Translation to disaster response and day-to-day critical care nursing.
Critical Care Nursing Clinics of North America, 20(1), 121–131.
evidence-based bundle of the procedures aimed at decreasing CR- A certain degree of damping is desirable for optimal fidelity and
BSI was published. 44 Use of this bundle, which includes hand suppression of unwanted high-frequency vibration or noise. The
F
washing, using full-barrier precautions during the insertion of natural frequency (F n F ) refers to the frequency at which the system
51
central venous catheters, cleaning the skin with chlorhexidine, oscillates when shock excited. As seen in Figure 21-4, the higher
avoiding the femoral site if possible, and removing unnecessary the F n F , the greater the range of acceptable damping. The F n F can
F
F
catheters along with staff education and empowerment and the be quickly assessed by measuring the horizontal distance between
use of champions, significantly decreased the incidence of CR- the points of two oscillations (each small box equals 1 mm) and di-
BSI from 2.7/1,000 catheter days to 1.4/1,000 catheter days viding the paper speed (25 mm/s) by this value. For example, if there
18 months after the intervention. 44,45 Other studies that em- are two small boxes between oscillations, then the F n F 25/2 12.5
F
F
phasize the effect of staff education, multifaceted interventions, Hz, which is marginally acceptable. Optimizing the F n F has the great-
F
and performance feedback have also led to a significant decrease est effect on the reproduction of a waveform. The F n F of the
in CR-BSI. 31,46,47 Despite the risk for CR-BSI from arterial catheter–transducer system decreases over time, 52 indicating the
lines there are only limited recommendations for arterial line need to routinely evaluate the dynamic response characteristics of
insertion and care, and consideration should be given to using the system.
the Centers for Disease Control and Prevention (CDC) recom- An underdamped system results in falsely high systolic (15 to
mendations and procedure bundle for central lines for arterial 30 mm Hg) and low diastolic pressures. An overdamped system
line maintenance. 28,48–50 loses its characteristic landmarks, and the waveform appears un-
naturally smooth with a diminished or absent dicrotic notch. An
Dynamic Response Characteristics overdamped system causes falsely low systolic and high diastolic
F
pressure readings. PA catheters have a decreased F n F compared with
52
The dynamic response characteristics of the catheter–transducer arterial pressure lines ; thus, taking steps to optimize the system
system reflect the system’s ability to faithfully reproduce a pressure is imperative. The simpler the system (e.g., shorter tubing and
waveform. The dynamic response can be determined by evaluat- fewer stopcocks) the better its ability to reproduce faithfully the
ing the system’s damping coefficient and natural (resonant) fre- pressure waveforms. 23,51,53 Use of in-line blood conservation de-
quency (Fig. 21-3). The damping coefficient is a measure of how vices decrease the F n F of the system, resulting in an underdamped
F
quickly the system dampens and eventually arrests the oscillations. system. 54