Monitor Cardiovascular System
Monitor BP (Systolic/Diastolic/Mean), PAP
(Systolic/ Diastolic/ Mean), HR, RR and SpO2 continuously and document
q1h in the graphic record, for all new admissions, and for patients
with arterial lines or pulmonary artery catheters, who are receiving
medications that influence blood pressure, or whose neurological,
cardiovascular or respiratory status has varied during the previous
RNs may decrease the frequency
of BP monitoring in patients who remain stable without intervention,
and who do not meet any of the requirements noted above. Monitoring
frequency must be increased if the patient's condition deteriorates.
When the frequency of monitoring is decreased, the rationale used
to support the frequency change must be documented in the AI record.
Assess Color, Sensation and Movement of extremities
distal to intravascular catheters q 1 h. Assess pulses and capillary
refill q shift and document in 24 hour assessment record. Track
pulses and document findings in graphic record q 1-4 h as required,
for patients with with femoral lines, lower limb trauma, vascular
surgery or impaired circulation.
To ensure prompt identification and documentation of patient status.
See also Standards for Respiratory
and Neurological Monitoring.
RNs in CCTC are responsible for
the priming, zeroing, leveling, and maintenance of hemodynamic pressure
monitoring circuits and for the assessment and monitoring of hemodynamic
pressures and waveforms.
RNs in CCTC may flush hemodynamic monitoring
circuits as required to maintain patency.
See Standard for Arterial
Line Monitoring; Standard for Central
Line Monitoring; and Standard for PA
RNs in CCTC have received additional education in the
care of invasive monitoring circuits. Refer to Procedure for Hemodynamic
Monitoring Circuits or Removal
of a Right Heart Catheter and Removal
of a Central Line and Removal
of Peripheral Arterial Line and Removal of Femeral
See also: Standard for Care of a Patient
on an IABP
Identify Need for
Arterial Pressure Monitoring
Continuous arterial pressure monitoring is indicated for patients
requiring BP monitoring >q1h, receiving continuous IV infusion
of medications that affect cardiac output/blood pressure, requiring
frequent blood gas monitoring or who are hemodynamically/neurologically
Arterial lines with continuous MAP monitoring is also required for patients with Intracranial Pressure Monitoring in order to continuously identify Cerebral Perfusion Pressure.
Prior to recording hemodynamic values, evaluate
pressure waveforms, verify transducer levels, and ensure that sufficient
flush volume and pressure is present.
When comparing NIBP to arterial line pressures, MBP provides the
most appropriate comparison. Compare cuff to NIBP pressures taken
from the same limb.
See Standard for Arterial
Cuff BP measurements become increasing less accurate when hypotension
develops. Accuracy is also affected by user technique and cuff size.
Insertion of an arterial line is easiest when a patient has an adequate
BP. Continuous infusion of vasoactive drugs necessitates continuous
BP monitoring to evaluate response to drug therapy and to identify
NIBP cuffs do not provide continuous pressure
monitoring. Although more accurate than auscultative BP monitoring,
NIBP cuffs can become inaccurate when peripheral circulation is
compromised. NIBP cuffs are uncomfortable and can produce bruising
in susceptible patients; they are not appropriate when >q1h BP
monitoring is required. Repetitive inflation of a BP cuff can lead
to falsely elevated readings.
Systolic BP readings obtained from invasive
arterial catheters are often accentuated, with reduced diastolic
readings. NIBP measurements utilize different technology and may
produce systolic readings that do not match the arterial line systolic
reading. MBP from arterial lines and NIBP circuits provide more
Patients may have differing BPs between left
and right limbs, and peripheral circulation may be reduced in shock.
Arterial pressures may be falsely elevated
if an artery is in spasm. This can occur following repeated insertion
attempts. A warm towel wrapped around the site may help to reduce
must be on for all patients requiring continuous arterial pressure
monitoring. Alarm settings should be selected based on the degree
of fluctuation in the patient's BP. Upper and lower alarm limits
that represent clinically important changes are selected for each
High and low alarm settings must be assessed and documented
each hour in the graphic record.
Alarms may need to be disabled if an arterial
line becomes positional. If an arterial line alarms is disabled,
documentation in the AI record is required. Documentation should
include the reason for disabling the alarm and should describe troubleshooting
Alarms provide prompt notification of both changes in the BP and
accidental disconnection/opening of the circuit (with detection of risk for bleeding or air entry of invasive lines).