CARDIOVASCULAR MONITORING
STANDARDS OF NURSING CARE IN CCTC (SONC)

  1. Monitor ECG
  2. Monitor Cardiovascular System
  3. Maintain Hemodynamic Monitoring Circuit
  4. Identify Need for Arterial Line
  5. Set Alarms

See Also:

STANDARD OF NURSING CARE

RATIONALE FOR STANDARD

Ensure 4 moments of hand hygiene are met when performing assessments and/or managing monitoring equipment.

 Perform risk assessment and select appropriate PPE based on patient diagnosis and procedure being performed.

 1.

Monitor ECG

All CCTC patients have continuous ECG monitoring See ECG Monitoring Standard.

 1.

To provide continuous monitoring with prompt detection of changes in heart rate or rhythm.

 2.

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 24 hours.

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.

 4.



To ensure prompt identification and documentation of patient status.

See also Standards for Respiratory and Neurological Monitoring.

3.

Maintain Hemodynamic Circuit

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 Monitoring.

 3.



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 Arterial Line.

.

See also: Standard for Care of a Patient on an IABP

 

 

4.

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 unstable.

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 Line Monitoring.

4.



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 adverse effects.

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 appropriate correlation.

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 spasm.

5.

Set Alarms

Appropriate
alarms 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 individual patient.

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 strategies.

5.



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).

 

Brenda Morgan,

Last Update: January 20, 2017 ; Reviewed January 20, 2017

 

 

 

LHSCHealth Professionals

Last Updated January 20, 2017 | © 2007, LHSC, London Ontario Canada