DIAGNOSTIC TESTS

DIAGNOSTIC TESTS
1. 2. 3. 4. 5. 6. 12-Lead Electrocardiogram Cardiac Marker Studies Echocardiography Cardiac Catheterization Hemodynamic Monitoring Cardiac Output Monitoring

ELECTROCARDIOGRAM
(ECG)

ELECTROCARDIOGRAM (ECG)
It is the most valuable and commonly used diagnostic tool in assessing the cardiovascular system. It measures the hearts electrical activity and records it. A graphic recording of the electrical impulses of the heart.

12 LEAD ECG
Unipolar Limb Leads RA: Red LA: Yellow LL: Green RL: Black Bipolar Standard Limb Leads Leads I, II , III Unipolar Augmented Leads Leads aVR, aVL, aVF

Right arm Left arm Left leg Right leg

Unipolar Precordial Leads

Chest Leads V1 Red 4th ICS RPSB V2 Yellow 4th ICS LPSB V3 Green Midway between V2 and V4 V4 Brown 5th ICS LMCL V5 Black LAAL lateral and horizontal to V4 V6 Violet LMAL lateral and horizontal to V4

MORPHOLOGY OF A HEART BEAT

P Q
S

PROPERTIES OF THE CARDIAC MUSCLE

RHYTHMICITY the ability of the heart to contract at regular timing. CONTRACTILITY the ability to contract in response to stimuli. AUTOMATICITY the ability of the heart to pace or to spontaneously initiate or propagate an action potential (characteristic of a pacemaker cell). EXCITABILITY/IRRITABILITY the ability of the heart to respond to a stimulus with the strongest possible contraction or none at all. REFRACTORINESS the ability of the myocardium to prevent from responding to a new stimulus while the heart is still in a state of contraction in order to reserve cardiac rhythm. EXTENSIBILITY the ability of the heart to stretch during diastole as the heart fills with blood. CONDUCTIVITY the ability of the heart muscle fibers to conduct or transmit an electrical impulse to the next cell.

DEFINITION OF TERMS
INOTROPIC EFFECT change in myocardial contractility CHRONOTROPIC EFFECT change in heart rate DROMOTROPIC EFFECT change in speed of conduction through the AV junction.

THE ECG TRACING

EKG PAPER
The EKG (Electrocardiogram) graph paper is where the heart rhythm is printed where it can be analyzed carefully and treated accordingly. EKG interpretation takes a bit of skill because there are certain EKG rhythm print outs that are difficult to identify.

THE WAVEFORMS

WAVEFORM movement away from the baseline in either a positive of negative direction. SEGMENT a line between wave forms. INTERVAL consists of a waveform and a segment. COMPLEX consists of several waveforms.

THE WAVEFORMS
P WAVE atrial depolarization/systole. PR SEGMENT AV node conduction. PR INTERVAL begins with the onset of the P wave and ends with the on of the QRS complex. QRS COMPLEX ventricular depolarization. ST SEGMENT begins with the end of the QRS complex and ends with the onset of the T wave. T WAVE ventricular repolarization. QT INTERVAL from the beginning of the QRS complex to the end of the T wave. U WAVE repolarization of the Purkinje fibers.

Hearts original electrical impulse (normal pacemaker) originates from the SA node spreading through the atrial muscles called ATRIAL DEPOLARIZATION.

The electrical impulse spreads through the ventricles (Bundle of His) is called VENTRICULAR DEPOLARIZATION.

The recovery or resting phase after ventricular contraction: VENTRICULAR REPOLARIZATION.

CRITERIA FOR A NORMAL SINUS RHYTHM (NSR)

Smooth, upright P waves in Leads I, II, aVF Each P wave is followed by a QRS complex PR interval: normal QRS interval: normal Rhythm: regular Rate: 60-100 bpm

ECG CHARACTERISTIC OF NSR

Atrial Rhythm: Ventricular Rhythm: Atrial Rate: Ventricular Rate: P Wave: PR Interval: QRS Complex: REGULAR REGULAR 60-100 bpm 60-100 bpm Upright 0.12-0.20 secs 0.10 secs or less

ECG RATE CALCULATION

o VERTICAL AXIS voltage in mm or mv o HORIZONTAL AXIS time in seconds

1 small box = 1 mm = 0.04 sec 1 large box = 5 small boxes = 5mm = 0.20sec 5 large boxes = 25 small boxes = 1 sec 30 large boxes = 150 small boxes = 6 secs

STEPS IN EKG INTERPRETATION

DETERMINING THE REGULARITY IN RHYTHM:

Using a caliper, measure the distance between P P and R R. Regular rhythm: BOTH P P and R R intervals are EQUAL.

STEPS IN EKG INTERPRETATION

DETERMINING THE HEART RATE:
REGULAR RHYTHM a. 300 method b. 1,500 method IRREGULAR RHYTHM a. 6-sec method count the number of beats in a 6 sec strip and multiply by 10 (1 sec: 5 big squares)

THE DIVISION METHOD OR 1500 METHOD

FORMULA:

HEART RATE =

, #

Example: 1500/19 = 78.95 = 79bpm 1500/26 = 57.69 = 58 bpm

THE BOX/SQUARE COUNTING METHOD

2 Conditions to satisfy: 1. Rhythm must be regular 2. R wave falls on a heavy line Formula: 1. Place the number values 300-150-100-75-60 2. Note the range 3. HL LV = ? 4. Divide it by 5 5. Multiply by the number small boxes from HV 2nd R wave 6. Subtract from HV

COUNTING THE LARGE BOXES

300

1 big box = 300 beats/min (duration = 0.2 sec) 2 big boxes = 150 beats/min (duration = 0.4 sec) 3 big boxes = 100 beats/min (duration = 0.6 sec) 4 big boxes = 75 beats/min (duration = 0.8 sec) 5 big boxes = 60 beats/min (duration = 1.0 sec)
214 187 167 150 136
125 115 107 100 94 88 83 79 75 71 68 65 62 60

250

FRAMEWORK FOR INTERPRETATION

CONFIGURATION Structure of the ECG (PQRST) RATE Calculation of the heart rate RHYTHM Regular or irregular

PACEMAKERS OF THE HEART

FIRST PACEMAKER THIRD PACEMAKER (AV (SINUS) NODE/JUNCTION) Sinus Brady/Tachycardia Junctional Rhythm Sinus Arrhythmia FOURTH PACEMAKER (VENTRICLES/BUNDLE SECOND PACEMAKER OF HIS) (ATRIA) Ventricular Tachycardia Atrial Tachycardia Ventricular Fibrillation Atrial Fibrillation Idioventricular Rhythm Atrial Flutter

FIRST PACEMAKER: SINUS

Since the beats are within 60-100 (normal), it simply means that the electrical is NORMAL From SA Node AV node Bundle of His Purkinje Fibers/System

SINUS BRADYCARDIA

Configuration: P wave upright, uniform in shape; QRS complex and T wave upright Rate: Below 60bpm Rhythm: Regular (-cardia)

Sinus Bradycardia
1. 2. 3. 4. 5. 6. 7.

SIGNS & Endocarditis SYMPTOMS Heart attack Dizziness Hypothyroidism Fainting CAD Fatigue Heart surgery Increased ICP Shortness of Increased vagal tone due to bowel breath straining, vomiting, mech.ventilation / Palpitations intubation

CAUSES

8. Sick sinus syndrome 9. Medications such as beta-adrenergic blockers, digoxin, morphine

TREATMENT: S. BRADYCARDIA
No treatment needed (patient is usually asymptomatic); if drugs are cause, possible discontinuation. Temporary pacemaker and atropine for low cardiac output, dizziness, weakness, altered LOC, or low BP Dopamine or epinephrine infusion, if indicated Temporary or permanent pacemaker may be needed if condition becomes chronic

SINUS TACHYCARDIA

Configuration: P wave small and upright; QRS complex and T wave normal Rate: Over 100 bpm Rhythm: Regular (-cardia)

Causes of Sinus Tachycardia

Normal physiologic response to fever, exercise, anxiety, pain & dehydration Atropine, epinephrine, quinidine, caffeine, alcohol / nicotine use possibly accompanying shock, left-sided heart failure, anemia, pulmonary embolism, cardiac tamponade, hypovolemia, hyperthyroidism, anterior wall MI

TREATMENT: S. TACHYCARDIA
No treatment necessary if patient is asymptomatic Correction of the underlying cause Beta-adrenergic blocker or CCB, if cardiac ischemia occurs

SINUS ARREST

Configuration: Normal P wave preceding each normal QRS complex Rhythm: Regular, except for missing PQRST

TREATMENT: S. ARREST
No treatment needed if patient is asymptomatic For mild symptoms, possible discontinuation of drugs that contribute to arrhythmia Atropine, if patient is symptomatic Temporary or permanent pacemaker for repeated episodes

SECOND PACEMAKER: ATRIA

Noted for having fast rate Configuration not at the SA anymore, change on the P wave Rate = slow or fast Rhythm = regular or irregular The maximum rate or the boundary of sinus pacemaker is 150 bpm. Over and beyond the impulse is already originating in the ATRIA.

ATRIAL TACHYCARDIA/SVT

Configuration: No definite P wave; QRS and T wave normal; sudden onset and termination of arrhythmia Rate: 150-250 bpm Rhythm: Regular

TREATMENT: A. TACHYCARDIA
Vagal stimulation, carotid sinus massage Priority is decreasing ventricular response with CCB, beta-adrenergic blocker, digoxin, or cardioversion If other treatment are ineffective, amiodarone or procainamide

ATRIAL FIBRILLATION

Configuration: No definite P wave, only a chaotic rhythm (not sure if its a P wave or T); no PR interval; QRS normal Rate: Atrial rate >400 bpm; depends on the ventricular response Rhythm: Not only irregular but highly irregular

NOTES: - AF or fibrillating (quivering) 7x risk for stroke - Given anticoagulant or electrical cardioversion Controlled or slow HR is less than 100bpm Uncontrolled or fast HR is more than 100bpm

Causes of Atrial Fibrillation

Heart failure COPD Thyrotoxicosis Sepsis Constrictive pericarditis Mitral stenosis Pulmonary embolism Hypertension Possible complication of coronary bypass / valve replacement surgery Use of nifedipine / digoxin

TREATMENT: A. FIBRILLATION
Treatment of underlying cause CCB or beta-adrenergic blocker, if stable and heart functions normally Amiodarone, ibutilide, flecainide, propafenone, or procainamide, if arrhythmia is present for less than 48 hours Synchronized cardioversion (treatment of choice) Anticoagulation prior to cardioversion Ablation therapy for recurrent rhythm

ATRIAL FLUTTER

Configuration: No definite P, flutter waves looks like saw tooth or picket fence ; QRS - identifiable Rate: Atrial rate 250-400 bpm; ventricular rate dependent on degree of AV block Rhythm: Atrial rhythm regular; ventricular rhythm variable, dependent on degree of AV block

TREATMENT: A. FLUTTER
SAME with A. Fibrillation

PREMATURE ATRIAL CONTRACTIONS (PAC)

Premature, abnormal P waves (differ in configuration form normal P waves) QRS complexes after P waves, except in blocked PACs P wave commonly buried or identified in preceding T wave

TREATMENT: PAC
No treatment needed if patient is asymptomatic Beta-adrenergic blockers, CCBs, or digoxin, if occurs frequently Treatment of underlying cause; avoidance or triggers (caffeine or smoking) and use of stress-reduction measures

THIRD PACEMAKER: AV NODE/JUNCTION

Nodal is similar to junctional P waves are totally absent followed by normal QRSs Contrary to atrial pacemaker noted for having fast rate, junctional pacemaker is note for having slow rate with an inherent rate ranging from 40-60bpm

JUNCTIONAL ESCAPE RHYTHM

Rhythm: Regular Rate: 40-60 bpm Configuration: P waves before, hidden in, or after QRS complex, inverted if visible; PR interval <0.12 seconds; QRS normal

TREATMENT: J. ESCAPE RHYTHM

Treatment of underlying cause Atropine for symptomatic slow rate Pacemaker, if refractory to drugs

JUNCTIONAL TACHYCARDIA

Rhythm: Regular Rate: 100-200 bpm Configuration: P waves before, hidden in, or after QRS complex, inverted if visible; QRS normal

TREATMENT: J. TACHYCARDIA
Correction of underlying cause Discontinuation of digoxin, if applicable and appropriate Vagal maneuvers, adenosine, amiodarone, beta-adrenergic blocker, CCBs to slow rate Ablation therapy, if recurrent, followed by insertion of permanent pacemaker

Atrioventricular Blocks

R P Q S T

First Degree Atrioventricular Blocks

R P T

Q
Do you have a normal P wave? Do you have a normal PR segment? Do you have a normal PR interval? Do you have a normal QRS-T?

Yes No Prolonged (> 0.20 sec) Yes

FIRST DEGREE AV BLOCK

PR interval > 0.20 sec

0.28 sec

0.28 sec

0.28 sec

FIRST DEGREE AV BLOCK

Second Degree Atrioventricular Blocks

Do you have a normal P wave? Yes No Do you have a normal PR segment? Do you have a normal PR interval? No Will there be intermittent P waves not followed by QRS complex? Yes (dropped beats)

Second Degree Atrioventricular Block

Type I - Mobitz type I or Wenchebach Type II - Mobitz type II

SECOND DEGREE AV BLOCK MOBITZ I

Progressive lengthening of PR interval w/ intermittent drop beats .

0.20 sec

0.28 sec

0.20 sec

SECOND DEGREE AV BLOCK MOBITZ II

Fixed PR interval w/ intermittent drop beats .

BLOCK AT THE Bundle of His

Bilateral bundle branches

Trifascicle

0.18 sec

0.18 sec

0.18 sec

THIRD DEGREE AV BLOCK

Complete atrioventricular block Impulses originate at both SA node and at the subsidiary pacemaker below the block Do you have regularly occurring P waves and QRS complexes? No Are the P waves related to the QRST complexes? Is the atrial rate < = > ventricular rate? greater
Ventricular rate = 83 BPM Ventricular rate = 83 BPM

Yes

Atrial rate = 100 BPM

Atrial rate = 100 BPM

Atrial rate = 100 BPM

LAST PACEMAKER: VENTRICLES/BUNDLE OF HIS

The most dangerous and death forming (lethal) of all dysrrhythmias. It is the leading complication of MI patient leading to death. NOTE: The lower the hearts pacemaker, the more complications and death forming.

VENTRICULAR TACHYCARDIA

Configuration: No P and T wave, wide bizarre QRS noted; may start and stop suddenly Rate: Ventricular rate of 100-250 bpm Rhythm: Atrial rhythm cant be determined; ventricular rhythm usually regular, may be slightly irrregular

TREATMENT: V. TACHYCARDIA
If patient is pulseless, immediate defibrillation and resuscitation If episodes of VT unresponsive to drugs recur, may need a cardioverterdefibrillator

VENTRICULAR FIBRILLATION (COARSE)

Configuration is rapid, chaotic, disorganized ventricular contractions. No P nor T. No normal looking QRS, the ventricles do not contract as a unit wherein the myocardium appears to be just quivering. NO CARDIAC OUTPUT. Rate: Hard to determine accurately Rhythm: Highly irregular

VENTRICULAR FIBRILLATION (FINE)

Configuration: No P and T wave, almost or totally absent QRS complex Rate and Rhythm: Questionable Also known as COARSE ASYSTOLE

TREATMENT: V. FIBRILLATION
Rapid resuscitation defibrillation and COR Epinephrine or vasopressin followed by defibrillation and CPR Implantable cardioverter-defibrillator, if at risk for recurrent ventricular fibrillation Treatment of underlying causes

IDIOVENTRICULAR RHYTHM/ DYING HEART PATTERN

Configuration: Absent P wave, wide and bizarre QRS, questionable T wave Rate: 40 bpm (up to 100 for accelerated IVR) Rhythm: Regular or slightly irregular

Normal Cardiac Depolarization

Premature Ventricular Contraction

Prematurely occurring complex. Wide, bizarre looking QRS complex. Usually no preceding P wave. T wave opposite in deflection to the QRS
complex. Complete compensatory pause following every premature beat.

Premature Ventricular Contraction in Couplets

Two Premature ventricular
contractions occurring consecutively

Premature Ventricular Contraction in Bigeminy

Alternating normal sinus beat and
a PVC

Premature Ventricular Contraction in Trigeminy

PVCs regularly occurring every
third beat

Premature Ventricular Contraction in Quadrigeminy

PVCs regularly occurring every
fourth beat

Multifocal Premature Ventricular Contraction

PVCs coming from different foci in
the ventricle PVCs assuming different polarities in a single lead PVCs of different morphology and coupling interval

Pacemaker Rhythm
No P wave (ventricular impulse origin) Wide QRS complex (>0.10 sec) Pacemaker spike precede the wide
QRS complexes

CARDIAC MARKER STUDIES

CARDIAC MARKER STUDIES

Analysis of cardiac markers (proteins) aids diagnosis of AMI. After infarction, damaged cardiac tissue releases significant amounts of enzymes into the blood.

HEART ENZYMES:
Creatine kinase (CK) and its isoenzyme MB AND lactate dehydrogenase (LD) and its isoenzyme LD1 and LD2. Troponin T and I and myoglobin are more specific to cardiac muscle and can be used to detect damage more quickly, allowing faster and more effective treatment.

MEANING IN MARKERS
MARKER NORMAL VALUE 0-3 ng/ml TIME INCREASED AFTER MI 4-8 hours PEAK TIME RETURN TIME CK-MB After 20 hours Remain elevated for up to 72 hours

LD1 and LD2

Troponin I Troponin T Myoglobin

70-200 IU/L
0-0.4 ng/mL 0-0.1 ng/mL 30 to 90 ng/ml

8-12 hours
3-6 hours 30 minutes4 hours

24-48 hours
14-20 hours 12-24 hours 6-7 hours

10-14 days
5-7 days 10-15 days After 24 hours

NURSING CONSIDERATIONS
Before CK measurement, withhold alcohol, aminocaproic acid, and lithium as ordered. Avoid administering IM injections. After any cardiac enzyme test, handle the collection tube gently to prevent hemolysis and send the sample t the lab immediately.

ECHOCARDIO -GRAPHY

ECHOCARDIOGRAPHY
It is used to examine the size, shape, and motion of cardiac structures. It is done using a transducer placed at an acoustic window (an area where bone and lung tissue are absent) on the patients chest. The transducer direct sounds waves toward cardiac structures.

M-MODE (MOTION MODE) ECHOCARDIOGRAPHY

A single, pencil-like UTZ beam strikes the heart, producing an ice pick, or a vertical, view of cardiac structures. This mode is especially useful for precisely viewing cardiac structures.

2-D ECHOCARDIOGRAPHY
The UTZ beam rapidly sweeps through an arc, producing a cross-sectional, fan-shaped, view of cardiac structures. It is useful for recording lateral motion and providing the correct spatial relationship between cardiac structures.

TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE)

Ultrasonography is combined with endoscopy to provide a better view of the hearts structures.

ECHO ABNORMALITIES
Mitral stenosis Mitral valve prolapse Aortic insufficiency Wall motion abnormalities Pericardial effusion

NURSING CONSIDERATIONS
1. Explain the procedure to the patient and advise him to remain still during the test because movement can distort results. 2. After the procedure, remove the conductive gel from the skin.

CATHETERIZATION

CARDIAC

CARDIAC CATHERIZATION
It involves passing a catheter into the right, left, or both sides of the heart. It permits measurement of BP and blood flow in the chambers of the heart. Its used to determine valve competence and cardiac wall contractility and to detect intracardiac shunts. It also enables collection of blood samples and taking diagnostic films of the ventricles and arteries.

CONFIRMING COMMON PROBLEMS

CAD Myocardial Incompetence Valvular Heart Disease Septal Defects

NURSING CONSIDERATIONS
BEFORE THE PROCEDURE:
1. Explain that this test is used to evaluate the function of the heart and its vessels. Instruct the patient to restrict food and fluids for at least 6 hours before the test. Tell him the procedure takes 1-2 hours and that he may receive a mild sedative during the procedure. 2. Tell the patient that the catheter is inserted into an artery or vein in the arm or leg. Then tell him hell experience a transient stinging sensation when a local anesthetic is injected to numb the incision site for catheter insertion. 3. Inform the patient that injection of the contrast medium through catheter may produce hot, flushing sensation or nausea that quickly passes; instruct him to follow directions to cough or breathe deeply.

NURSING CONSIDERATIONS
3. Make sure that the patient or a responsible family member has signed a consent form. Check for and tell the doctor about hypersensitivity to shellfish, iodine, or contrast media used in other diagnostic tests. 4. Discontinue anticoagulant therapy, as ordered, to reduce the risk of complications from bleeding. 5. Review activity restrictions that may be required of the patient after the procedure, such as lying flat with the limb extended for 4-6 hours and use of sandbags, if a femoral sheath is used. 6. Document the presence of peripheral pulses, noting their intensity. Mark the pulses so they may be easily located after the procedure.

NURSING CONSIDERATIONS
AFTER THE PROCEDURE: 1. Inspect the site for bleeding or oozing, redness, swelling, or hematoma formation. Maintain the patient on bed rest for 1-2 hours. 2. Enforce bed rest for 8 hours if no hemostatic device was used. If the femoral route was used for catheter insertion, keep the patients leg extended for 6-8 hours; at least 3 hours for antecubital fossa. 3. Monitor v/s every 15 minutes for 2 hours, then every 30 minutes for the next 2 hours, and then every hour for 2 hours. 4. Continually assess the insertion site for a hematoma or blood loss and reinforce the pressure dressing needed. 5. Administer IVF as ordered (usually 100 ml/hr) to promote excretion of the contrast medium. Monitor for signs of fluid overload. 6. Watch for signs of complications: chest pain, shortness of breath, abnormal HR, dizziness, diaphoresis, n/v, or extreme fatigue.

MONITORING

HEMODYNAMIC

HEMODYNAMIC MONITORING
It is used to assess cardiac function and determine the effectiveness of therapy by measuring: Cardiac output Mixed venous blood Oxygen saturation Intracardiac pressures Blood pressures

ARTERIAL BLOOD PRESSURE MONITORING

Sites: RADIAL, BRACHIAL, FEMORAL, or DORSALIS PEDIS artery Purpose: Measure BP and CARDIAC OUTPUT or obtain BLOOD SAMPLES for diagnostic tests A transducer transforms the flow of blood during systole and diastole into a waveform, which appears on an oscilloscope.

PREVENTING COMPLICATIONS (A-LINE)

PROBLEMS PREVENTION Continuous infusion of heparinized solution Quick monitoring TROUBLESHOOTING Complete flushing of tubing 1. 2. Ensure line patency Change patients position frequently

DAMPED WAVEFORM LOSS OF WAVEFORM

HEMORRHAGE

1. 2. 3.

Use of luer-locks Close/cap stopcocks Secure catheters

1. 2. 3. 4. 5.

Tighten all connections Provide splint Flush line Estimate blood loss If catheter is removed, apply pressure and sterile dressing

CLOT FORMATION
AIR EMBOLISM

Continuous infusion of heparinized solution

Purge air bubbles (catheter, IVF bag, drip chamber)

Aspirate the line then flush when clot is removed

1. 2. Vent bubbles through the stopcocks Fill drip chamber

INFECTION

1.

2.

Change IVF solution every 4 hours and line set up and disposable transducer every 72 hours Daily dressing and site inspection

1. 2.

Hand washing Infection control

TYPES OF INTRACARDIAC PRESSURES

Central venous pressure (CVP) or right atrial pressure (RAP) Right ventricular pressure Pulmonary artery pressure Pulmonary artery wedge pressure

CENTRAL VENOUS PRESSURE

It is the pressure within the right atrium and represents the filling pressure of the right ventricle. PURPOSES: 1. Determine fluid status. 2. Determines pressure on right side of the heart. 3. Serves as an access for a long term IV drug administration. 4. Route for IV fluids/alimentation.

 Sites: SUBCLAVIAN, JUGULAR, BASILIC, FEMORAL vein NORMAL MEAN PRESSURE: a. Water manometer: 1.34-8 cm H20 b. Mercury system: 1-6 mm Hg

CAUSES OF ABNORMAL CVP PRESSURES

INCREASED PRESSURE DECREASED PRESSURE Right-sided HF Reduced circulating Volume overload blood volume Tricuspic valve stenosis or insufficiency Constrictive pericarditis Pulmonary hypertension Cardiac tamponade RV infarction

PULMONARY ARTERY PRESSURE MONITORING

Continuous PAP and intermittent PAWP measurements provide important information about LV FUNCTION and PRELOAD. INDICATIONS: 1. Hemodynamically unstable 2. Fluid management or continuous CP assessment. 3. Patients receiving multiple or frequently administered cardioactive drugs. 4. Others: shock, trauma, CP disease, multiple organ dysfunction.

NORMAL VALUES

PAP: Systolic pressure normally

ranges from 20-30 mmHg. The mean pressure usually ranges from 10-15 mmHg.

PAWP: The mean pressure

normally ranges from 6-12 mmHg.

PA CATHETER PORTS
The balloon inflation lumen inflates the balloon at the distal tip of the catheter for PAWP measurement. A distal lumen measures PA pressure when connected to a transducer and measure PAWP during balloon inflation. It also permits drawing of mixed venous blood samples. A proximal lumen measures RAP. Thermistor connector lumen contains temperature-sensitive wires, which feed information into a computer for CO calculation. Another lumen may provide a port for pacemaker electrodes or measurement of mixed oxygen saturation.

PAP and PAWP PROCEDURES

The doctor inserts the balloon-tipped, multilumen into the patients internal jugular and subclavian vein. When the catheter reaches the RA, the balloon is inflated to float the catheter through the RV into PA. This permits PAWP measurements through an opening at the catheters tip. The deflated catheter rests in the pulmonary artery, allowing diastolic and systolic PAP readings. The balloon should be totally deflated except when taking a PAWP reading because prolonged wedging can cause pulmonary infarction.

NORMAL PA WAVEFORMS

CARDIAC OUTPUT

MONITORING

CARDIAC OUTPUT
It is the amount of blood ejected by the heart in one minute. It is monitored to evaluate cardiac function. The normal range: 4-8 L/minute. CALCULATION: =
Stroke Volume (SV) is the volume of blood pumped from one ventricle of the heart with each beat (55-100 mL) Heart Rate (HR) refers to the speed of the heartbeat, specifically the number of heartbeats per unit of time (60-100 bpm)

CO MEASUREMENT
To measure the cardiac output, a solution is injected into the right atrium through a port on a PA catheter. The indicator solution (iced or room-temperature injectant) mixes with the blood as it travels through the RV into the PA, and a thermistor on the catheter registers the change in temperature of the flowing blood. A computer then plots the temperature change over time as a curve and calculates flow based in the area under the curve.