MODULE I

To ensure the accomplishment of the learning outcomes, this module will cover
the following lessons:

Lesson 1 –
Overview of the Core Competency Standards

Lesson 2 –
Critical Care Nursing Concepts

Lesson 3 –
Acute/Critically Ill Patients in Hemodynamic
Monitoring (Assessment)

Lesson 4 –
Acute/Critically Ill Patients in Hemodynamic
Monitoring (Management)

Module I
CCHAMS AY 2020-2021, 1st Semester 2

MODULE I

ELECTIVE 102

INTRODUCTION

This module will focus on the critical care nursing concepts which
presents essential information about how to safely and competently care for
critically ill patients and their families. It recognizes the learners’ needs to
assimilate foundational knowledge before attempting to master more complex
critical care nursing concepts.

LESSON OUTCOMES

After completing this module, you are expected to:

1. Demonstrate safe, appropriate and holistic care utilizing the nursing

process.
2. Identify health needs of clients by demonstrating proper and
effective health assessment and management to care for higher
acuity patients and provide evidence-based interventions.
3. Observe bioethical principles, core values, and standards of nursing
care.
4. Identify own learning needs.

DIRECTIONS/ MODULE ORGANIZER

There are four lessons in the module. Study each lesson carefully then
answer the exercises/activities and assignments to find out how much you have
benefited from your study. Work on these exercises and assignments carefully
and submit your output to me through correspondence.

In case you encounter difficulty, discuss this with me during the face-to-
face meeting. If not, contact me at my cp no.09981769598 or message me via
my messenger/facebook account or email at dinaortega476@gmail.com

Module I
 CCHAMS AY 2020-2021, 1st Semester 3

Lesson 1

OVERVIEW OF THE CORE COMPETENCY

STANDARDS

PVMGOs
UNIVERSITY : Total human development with appropriate competencies.
PHILOSOPHY
UNIVERSITY VISION : A premier and globally competitive university.
UNIVERSITY : Provides relevant quality instruction, research and extension.
MISSION

DEPARTMENT GOALS:
1. To provide quality graduates in the medical and health allied fields.
2. To provide effective community health care services in the field of medical and
health allied courses.
3. To offer courses relevant to the health needs and situation of the times.
4. To reach out to the less privileged but deserving high school graduates who
cannot afford to enroll in the private schools in the region.

PROGRAM OUTCOMES:
1. Apply acquired knowledge of physical, social, natural and health sciences and
humanities in the practice of nursing;
2. Provide safe, appropriate and holistic care to individuals, families, population
groups, and community utilizing nursing process;
3. Utilize evidence-based approach in the delivery of care in accordance with the
guidelines and principles of nursing and other existing laws, legal, ethical, and
moral principles;
4. Work in collaboration with inter-, intra-, and multi-disciplinary and multi-
cultural teams through effective modes of communication across groups of
patients;
5. Document and report up-to-date patient care management comprehensively;
6. Demonstrate efficiency in performing management and leadership skills in the
delivery of care using applicable system approach;
7. Conduct research and other knowledge-creation endeavors necessary for the
furtherance of the profession;
8. Engage in lifelong learning and other professional growth and development to
keep abreast with the latest trends in the profession;
9. Demonstrate responsible citizenship and pride in being Filipino by effectively
managing socio-environment problems;
10. Apply techno-intelligent care systems and processes in health care delivery;
11. Manifest the DMMMSUnian and nursing core values in the practice of the
profession; and
12. Show entrepreneurial skills in the delivery of nursing care.

I took up BS Nursing because ___________________________________

____________________________________________________________________
____________________________________________________________________
___________________________________________________________________.
And I want to pursue this course in DMMMSU because ______________________
____________________________________________________________________
____________________________________________________________________

Module I
CCHAMS AY 2020-2021, 1st Semester 4

_________________________________________________________
_________________________________________________________
_________________________________________________________

Article 3 Sec.9 (c) of R.A. 9173/ ―Philippine Nursing Act 2002‖

The Board shall monitor & enforce quality standards of nursing practice necessary to
ensure the maintenance of efficient, ethical and technical, moral and professional
standards in the practice of nursing taking into account the health needs of the nation.

Nursing competence is an ability acquired through experience and learning and it

includes core abilities that are required for fulfilling one’s role as a nurse. The
concepts surrounding nursing competency are important for improving nursing quality,
however they are still not yet completely developed. Thus, challenges remain in
establishing definitions and structures for nursing competency, competency levels
necessary for nursing professionals, and training methods.

The concept of competence is two-fold: 1) potential abilities that may work

effectively under certain circumstances and 2) motivation to show one’s usefulness
using those abilities.
Yonago Acta Med. 2018

CORE COMPETENCY STANDARDS FOR NURSING PRACTICE IN THE PHILIPPINES

KEY AREAS OF PERFORMANCE INDICATORS

RESPONSIBILITY
1. Safe & quality 1. Demonstrates knowledge based on the health/illness status of
nursing practice individual groups
2. Provides sound decision making in the care of
individuals/groups
3. Promotes wholeness and well-being including safety and
comfort of patients
4. Sets priorities in nursing care based on patients' need
5. Ensures continuity of care
6. Administers medications and other health therapeutics
7. Utilizes the nursing process as framework for nursing
8. Formulates a plan of care in collaboration with patients and
other members of the health team
9. Implements planned nursing care to achieve identified
outcomes
10.Evaluates progress toward expected outcomes
11.Responds to the urgency of the patient's condition
2. Management of 1. Organizes work load to facilitate patient care
resources & 2. Utilizes resources to support patient care
environment 3. Ensures availability of human resources
4. Checks proper functioning of equipment/facilities
5. Maintains a safe and therapeutic environment
6. Practices stewardship in the management of resources
3. Health 1. Assesses the learning needs of the patient and family
education 2. Develops health education plan based on assessed and
anticipated needs
3. Develops learning materials for health education
4. Implements the health education plan
5. Evaluates the outcome of health education
4. Legal 1. Adheres to practice in accordance with the nursing law and
responsibility other relevant legislation including contracts, informed consent
2. Adheres to organizational policies and procedures, local and
national
3. Documents care rendered to patients

Module I
CCHAMS AY 2020-2021, 1st Semester 5

5. Ethico – moral 1. Respects the rights of individuals/groups

responsibility 2. Accepts responsibility and accountability for own decisions
and actions
3. Adheres to the national and international code of ethics for
nurses
6. Personal & 1. Identifies own learning needs
professional 2. Pursues continuing education
development 3. Gets involved in professional organizations and civic activities
4. Projects a professional image of the nurse
5. Possesses positive attitude towards change and criticism
6. Performs function according to professional standards
7. Quality 1. Utilizes data for quality improvement
improvement 2. Participates in nursing audits and rounds
3. Identifies and reports variances
4. Recommends solutions to identified causes of the problems
5. Recommends improvement of systems and processes
8. Research 1. Utilizes varied methods of inquiry in solving problems
2. Recommends actions for implementation
3. Disseminates results of research findings
4. Applies research findings in nursing practice
9. Record 1. Maintains accurate and updated documentation of patient
management care
2. Records outcome of patient care
3. Observes legal imperatives in record keeping
4. Maintains an effective recording and reporting system
10. Communication 1. Utilizes effective communication in relating with clients,
members with the team and the public in general
2. Utilizes effective communication in therapeutic use of self to
meet the needs of clients
3. Utilizes formal and informal channels
4. Responds to needs of individuals, families, groups and
communities
5. Uses appropriate information technology to facilitate
communication
11. Collaboration & 1. Establishes collaborative relationship with colleagues and
teamwork other
members of the health team for the health plan
2. Functions effectively as a team player
http://docshare03.docshare.tips/files

SIGNIFICANCE OF CORE COMPETENCY STANDARDS

 Unifying framework for nursing practice, education, regulation
 Guide in nursing curriculum development
 Framework in developing test syllabus for nursing profession entrants
 Tool for nurses’ performance evaluation
 Basis for advanced nursing practice, specialization
 Framework for developing nursing training curriculum
 Public protection from incompetent practitioners
 Yardstick for unethical, unprofessional nursing practice

How will I manage my study time effectively amidst the covid-19 pandemic?

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
_________________________________________________________________________

Module I
CCHAMS AY 2020-2021, 1st Semester 6

Lesson 2

Critical Care
Nursing
Concepts
TEST YOUR NURSING KNOWLEDGE

Fill in the blanks:

1. The term ________________ is used to describe the electrical stimulation of
the heart.
2. The ability of the cardiac muscle to initiate an electrical impulse is called
___________________.
3. The ability of the cardiac muscle to transmit electrical impulses is called
___________________.
4. The term ____________________________ is used to describe an irregular
or erratic heart rhythm
5. A dysrhythmia common in normal hearts and described by patients as “my
heart skipped a beat” is ___________________________
6. Two factors that determine preload are _____________________ and
________________________.
7. Two factors that determine afterload are _______________________ and
________________________.
8. Gas exchange between the lungs and the blood and between the blood and
tissues is called _________________________________.
9. Hypoxemia usually leads to ________________________, a decrease in
oxygen supply to the tissues.
10. With the progression of shock, damage at the ___________________ and
__________________ level occurs when the blood pressure drops.
11. The earliest sign of increased ICP is _______________________.
12. An altered level of consciousness (LOC) is
______________________________________________________________
______________________________________________________________
______________________________________________________________
_____________________________________________________________.

Critical Care Nursing is the delivery of specialized care to critically ill patients, ones
who have life-threatening illnesses or injuries. Such patients may be unstable, have
complex needs, and require intensive and vigilant nursing care (i.e., cardiovascular
disorders, traumatic injuries, gunshot wounds, cancers, shock, sepsis, respiratory
failure).

Critical Care Nurses are also known as ICU nurses. They treat patients who are
acutely ill and unstable requiring more frequent nursing assessments and the
utilization of life sustaining technology and drugs. They fill many roles in the critical

Module I
CCHAMS AY 2020-2021, 1st Semester 7

care setting, such as staff nurses, nurse-educators, nurse-managers, case-managers,

clinical care specialists, nurse practitioners, and nurse researchers.

Where: wherever critically ill patients are found, including adult, pediatric and
neonatal CCUs; coronary care and progressive coronary care units; emergency
departments, post-anesthesia care units.

What: responsibilities include, being an advocate, using sound clinical judgment,

demonstrating caring practices, collaborating with a multidisciplinary team,
demonstrating an understanding of cultural diversity, providing patient and family
teaching.

Module I
CCHAMS AY 2020-2021, 1st Semester 8

Acute Critical Care Continuum - The patient’s continuum after ICU discharge
must also be taken into account during their ICU stay. Minimal sedation, good
communication, and early mobilization are three factors that can help patients survive
their ICU stay with minimal sequelae. Critical illness therefore needs to be seen as a
continuum, a continuous sequence of interlinked events from the very early moments
of illness, through the ICU stay, and into recovery and rehabilitation.

Cultural considerations – the best way to respond to concerned family

members is to acknowledge their feelings and ambivalences and to lend reality to
their statements. The critical nurse needs to reinforce and acknowledge the family’s
decision and accept their feelings and decisions. You must honor the patient’s cultural
beliefs and values.

Assessing cultural considerations:

 Cultural health beliefs – the patient’s illness is believed to be a punishment
of past transgression, or the result of divine wrath.
 Communication differences – how does the patient want to be addressed?
What are the styles of nonverbal communication? Does the patient need an
interpreter?
 Cultural restrictions – how does the patient’s cultural group express
emotion? How is modesty expressed? How are feelings about death, dying,
and grief expressed?
 Social networks – who makes the decision? What are the roles of each
family member during health and illness?

Module I
CCHAMS AY 2020-2021, 1st Semester 9

 Religion – are there healing rituals or practices that must be followed? Does
the patient believe that special rites or blessings need to be performed?

Holistic health care revolves around a notion of totality. The goal of holistic
care is to meet not just the patient’s physical needs but also his social and emotional
needs. Only by considering all dimensions of a person can the health care team
provide high-quality holistic care, even though his/her physical needs may seem to be
more pressing than his/her other needs.

Various problems or concerns would include:

 Patient and family issues (i.e.,monetary, worry about possible death)
 Cognitive issues (i.e, overwhelmed over technology, effect of disease to
cognition, adverse effect of medication to CNS, sensory perception)
 Pain control issues ( acute or chronic; include in your pain assessment:
location, intensity, quality, onset, duration & frequency, alleviating and
aggravating factors, associated factors, effects on lifestyle)
 Ethics issues (dilemma in the following circumstances: more than one
solution exists, each solution carries equal weight, each solution is equally
defensible. These dilemmas revolve around quality-of-life issues, especially
as they relate to end-of-life decisions.)

THINK!
CLINICAL APPLICATION

Mrs. Reyes is a 65-year old hospitalized client with a history of cerebral vascular
accident (CVA). Upon entering the room, the nurse on duty asks the client how she is
doing today. The client replies, but the wording is unrecognizable. What term is used
for this condition? How will you apply holistic care to meet her physical, social
and emotional needs?

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
_________________________________________________________________________

Mrs. Santos is readmitted to the clinical area after being in the intensive care unit
(ICU). She is recovering from a right pneumonectomy and has a central venous
pressure catheter inserted by the physician. What can the catheter readings help the
nurse to detect? What symptoms will the nurse recognize that would indicate for signs
of impending respiratory insufficiency from the patient? Identify the level, based
from the classification of critical care patients, when impending respiratory
insufficiency is present.

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
_________________________________________________________________________

Use additional sheet of paper when needed.

Module I
CCHAMS AY 2020-2021, 1st Semester 10

Lesson 3

Acute/Critically Ill Patients

in Hemodynamic Monitoring
(Assessment)

Hemodynamics ultimately begins with the heart which supplies the driving
force for all blood flow in the body. Cardiac output propels blood through the arteries
and veins as a function of ventricular contraction. Ventricular motion results from the
shortening of cardiac myocytes concentrically. This squeezing motion is translated into
the cardiac output, which is a function of both heart rate and ejection fraction (the
starting volume after diastolic filling minus the final ventricular volume after systole).
Hemodynamics represents the governing principals of this blood flow and its behavior
in the blood vessels.

Hemodynamic monitoring measures the blood pressure inside the veins,

heart, and arteries. It also measures blood flow and how much oxygen is in the blood.
It is a way to see how well the heart is working. A mean arterial pressure (MAP) of 70
mm Hg may be considered a reasonable target, associated with sign of adequate organ
perfusion, in most clients. The goal of hemodynamic monitoring is to maintain
adequate tissue perfusion and oxygen delivery while maintaining adequate mean
arterial blood pressure.

Technologic advances in miniaturization, biosensors, and computer processing

coupled with an improved understanding of critical illness at the molecular level will
lead to development of new monitoring systems that will integrate physiologic and
biochemical information in a relatively noninvasive manner. When coupled with more
effective therapies, these integrated, closed-loop systems promise to help improve
outcome in critically ill patients.

Hemodynamic Technique:
 Noninvasive, or indirect, hemodynamic monitoring provides physiologic
information without the risks of invasive monitoring and can be used in many
settings.

 Invasive, or direct, measurements are obtained by penetrating the skin and

inserting a cannula or catheter into a blood vessel, chamber of the heart, or both.
The cannula or catheter is attached to a monitoring system, which consists of a
transducer, amplifier, and oscilloscope for the display of the vascular waveforms
and pressure measurements. Invasive, or direct, measurements are obtained by
penetrating the skin and inserting a cannula or catheter into a blood vessel,

Module I
CCHAMS AY 2020-2021, 1st Semester 11

chamber of the heart, or both. The cannula or catheter is attached to a monitoring

system, which consists of a transducer, amplifier, and oscilloscope for the display
of the vascular waveforms and pressure measurements.

The primary hemodynamic parameters include heart rate (HR) and blood
pressure (BP), while the advanced hemodynamic parameters include stroke volume
(SV), cardiac output (CO), and total peripheral resistance (TPR). The measurement
technique for hemodynamic parameters, particularly CO, previously utilized an
invasive pulmonary artery catheter and an arterial or central venous catheter for
gravely ill patient. Recently, non-invasive methods for the evaluation of hemodynamic
parameters have been developed, and the results of these techniques are highly
correlated with those of invasive methods for determining the type of circulatory
shock. Similarly, a number of bedside ultrasonography protocols to estimate the
cardiac preload have become widely used for determining the type of circulatory
shock.

Central venous pressure (CVP) is often used as sole parameter to monitor

hemodynamic. However CVP alone may not differentiate between changes in volume
(different venous return curve) or changes in contractility (different starling curve).
Finally, other techniques such as echocardiography, transesophageal Doppler and
volume-based monitoring system are now available.

images+CVP&tbm

Module I
CCHAMS AY 2020-2021, 1st Semester 12

Patterns of hemodynamic variables often suggest cardiogenic, hypovolemic,

obstructive, or distributive (septic) etiologies to cardiovascular insufficiency, thus
defining the specific treatments required.

Advances in hemodynamic monitoring with focus on oxygen delivery at

the cellular level may ultimately provide the edge to effective
monitoring that can impact outcome.

The ultimate in monitoring that will provide 100% sensitivity to survival

outcome will require the care provider to monitor oxygen delivery to all the tissue
beds at all times when the patient’s life is possibly under threat. Even if we have some
details of the flow in the microcirculation, the actual amount of oxygen a cell receives
still depends on its diffusing in adequate amounts from the capillary all the way to the
mitochondria where it performs the most important task of ATP production with
energy metabolism.

The spectrum of hemodynamic monitoring ranges from simple clinical

assessment and routine bedside monitoring to point of care ultrasonography and
various invasive monitoring devices. The clinician must be aware of the range of
available techniques, methods, interventions and technological advances as well as
possess a sound approach to basic hemodynamic monitoring prior to selecting the
optimal modality.

Various methods and techniques that are used or applied include; clinical
assessment, passive leg raising, blood pressure, finger based monitoring devices, the
mini-fluid challenge, the end-expiratory occlusion test, central venous pressure
monitoring, the pulmonary artery catheter, ultrasonography, bioreactance and other
modern invasive hemodynamic monitoring devices.

Correlation of Pathophysiology to Nursing Assessment

1. Hemodynamic monitoring is primarily used in patients with known or suspected

shock; to identify mechanism responsible for shock, select appropriate therapy,
and evaluate response to therapy.
In shock the circulation is inadequate, blood pressure is low, heart rate is
rapid, and irreversible tissue damage from insufficient blood supply may occur if
the condition is not terminated

Suggestive mechanism of shock based on hemodynamic monitoring findings

1. elevated cardiac output may suggest distributive shock
2. low blood pressure and volumes may suggest hypovolemic shock
3. low cardiac output and increased systemic vascular resistance (SVR) may
suggest cardiogenic shock
4. increased pulmonary artery pressure and dilated right-sided cavities may
suggest obstructive shock or cardiogenic shock
2. In Intracranial pressure (ICP) monitoring, pressure exerted by the brain, blood,
and CSF against the inside of the skull is measured. ICP monitoring enables prompt
intervention, which can avert damage caused by cerebral hypoxia and shifts of
brain mass.

Module I
CCHAMS AY 2020-2021, 1st Semester 13

Indications for ICP monitoring include:

 Head trauma with bleeding or edema
 Overproduction or insufficient absorption of CSF
 Cerebral hemorrhage
 Space-occupying lesions

3. Spinal cord trauma results from acceleration, deceleration, or other deforming

forces.

What to look for?

 History of trauma, a neoplastic lesion, an infection that could produce a spinal
abscess, or an endocrine disorder.
 Muscle spasm and back or neck pain that worsens with movement; in cervical
fractures, pain that causes point tenderness; in dorsal and lumbar fractures,
pain that may radiate to other areas, such as the legs
 Mild paresthesia to quadriplegia and shock, if the injury damages the spinal
cord; in milder injury, symptoms that may be delayed several days or weeks.

4. In intracranial or cerebral aneurysm, a weakness in the wall of a cerebral artery

causes that area of the artery to dilate or bulge. The most common form is the
berry aneurysm, a saclike out-pouching in a cerebral artery.

What to look for?

Occassionaly, your patient may exhibit signs and symptoms due to blood
oozing into the subarachnoid space. The symptoms, which may persist for several
days, include:
 Headache
 Intermittent nausea
 Nuchal rigidity
 Stiff back and legs.

5. Stroke, also known as a cerebrovascular accident or brain attack, is a sudden

impairment of cerebral circulation in one or more blood vessels. A stroke
interrupts or diminishes oxygen supply and commonly causes serious damage or
necrosis in the brain tissues.

What to look for?

A stroke in the left hemisphere produces symptoms on the right side of the
body; in the right hemisphere, symptoms on the left side.
 Hemiparesis on the affected side (may be more severe in the face and arm than
in the leg)
 Unilateral sensory defect (such as numbness, or tingling) generally on the same
side as the hemiparesis.
 Slurred or indistinct speech or the inability to understand speech.
 Blurred or indistinct vision, double vision, or vision loss in one eye (usually
described as a curtain coming down or gray-out of vision).

Fill-in the blanks

Here’s what happens when a hemorrhage causes a stroke:

o Impaired cerebral perfusion causes _________________________________________
_______________________________________________________________________
_______________________________________________________________________
o The brain’s regulatory mechanisms attempt to _______________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Module I
CCHAMS AY 2020-2021, 1st Semester 14

o If the hemorrhage is small, the client may have ______________________________

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
o Initially, the ruptured cerebral blood vessels may constrict to limit the blood loss.
This vasospasm further ___________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
o If a clot forms in the vessel, ______________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
o Blood cells that pass through the vessel wall into the surrounding tissue may
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

6. Hypertensive Crisis refers to the abrupt, acute, and marked increase in blood
pressure from the patient’s baseline that ultimately leads to acute and rapidly
progressing end-organ damage. In the brain, hypertensive crisis can result in
hypertensive encephalopathy because of cerebral vasodilation from an inability to
maintain autoregulaion. Blood flow increases, causing an increase in pressure and
subsequent cerebral edema. This increase in pressure damages the intimal and
medial lining of the arterioles.

What to look for?

Your assessment of a patient in hypertensive crisis almost always reveals a
history of hypertension that’s poorly controlled or has not been treated. Signs and
symptoms may include:
 severe, throbbing headache in the back of the head
 dizziness, nausea, vomiting
 anorexia
 irritability
 confusion, somnolence, or stupor
 vision loss, blurred vision, or diplopia
 dyspnea on exertion, orthopnea, or paroxysmal nocturnal dyspnea
 edema
 angina
 possible left ventricular heave palpated at the mitral valve area
 S4 heart sound
 Acute retinopathy and hemorrhage, retinal exudates, and papilledema

Module I
CCHAMS AY 2020-2021, 1st Semester 15

7. Heart Failure occurs when the heart can’t pump enough blood to meet the
metabolic needs of the body. It results in intravascular and interstitial volume
overload and poor tissue perfusion. An individual with heart failure experiences
reduced exercise tolerance, a reduced quality of life, and a shortened life span.

What to look for?

 Early signs and symptoms of left-sided heart failure include: dyspnea,
orthopnea, paroxysmal nocturnal dyspnea, fatigue, nonproductive cough
 Later-clinical manifestations of left-sided heart failure may include: crackles
on auscultation, hemoptysis, displacement of the PMI toward the left anterior
axillary line, tachycardia, S3 heart sound, S4 heart sound, cool & pale skin,
restlessness and confusion
 Clinical manifestations of right-sided heart failure include: jugular vein
distention, hepatojugular reflux and hepatomegaly, right upper quadrant pain,
anorexia, fullness & nausea, nocturia,weight gain, edema, ascites or anasarca

Fill-in the blanks

All types of heart failure eventually lead to reduced cardiac output, which
triggers compensatory mechanisms that improve cardiac output at the expense of
increased ventricular work. The compensatory mechanisms include:

o Increased ________________________________
o Activation of _____________________________________________________
o Ventricular __________________
o Ventricular __________________

ASSIGNMENT

List several purposes of cardiac catheterization.

 _________________________________________________________________
_________________________________________________________________
 _________________________________________________________________
_________________________________________________________________
 _________________________________________________________________
_________________________________________________________________
 _________________________________________________________________
_________________________________________________________________

Module I
CCHAMS AY 2020-2021, 1st Semester 16

Lesson 4

Acute/Critically Ill Patients in

Hemodynamic Monitoring
(Management)

Hemodynamic monitoring in itself cannot impact survival. Outcome is more

closely related to therapeutic measures that should rightly be instituted to improve
survival with the hemodynamic details that monitoring provides. A new trend in
monitoring—functional hemodynamic monitoring—with emphasis on how the
parameters (e.g., with preload responsiveness) change with treatment strategies holds
promise. Failure to institute the correct therapeutic measure by care providers may
limit the correlation between hemodynamic monitoring and outcome. Care providers
must understand how the hemodynamic parameters impact survival so that they may
make a right choice in using these parameters to guide therapeutic measures in
patient care.

Correlation of Pathophysiology to Nursing Assessment and Management

A. Neurologic – a complete neurologic examination can be long and

detailed. It’s unlikely that you would perform one in its entirety. However, if your
initial screening suggests a neurologic problem, you may need to conduct a more
detailed assessment. Examine the patient’s neurologic system in an orderly way.
Beginning with the highest levels of neurologic function and working down to the
lowest, assess these five areas:
 Mental status
 Cranial nerve functions
 Sensory function
 Motor function
 reflexes

The most common imaging studies used to detect

Neurologic disorders include computed tomog-
Raphy (CT) scan, magnetic resonance imaging
(MRI), positron emission tomography (PET) scan,
And skull and spinal X-rays.

Nursing Management on Imaging Studies:

1. Confirm that the client isn’t allergic to iodine or shellfish to avoid an
adverse reaction to the contrast medium.
2. If the test calls for a contrast medium, tell the client that it’s injected into
an existing I.V. line or that a new line may be inserted.
3. Preprocedure testing should include evaluation of renal function (serum
creatinine and blood urea nitrogen (BUN) levels) because the contrast
medium can cause acute renal failure.
4. Warn the client that he may feel flushed or notice a metallic taste in his
mouth when the contrast medium is injected.

Module I
CCHAMS AY 2020-2021, 1st Semester 17

5. Tell the client that the scanner circles around him for 10 to 30 minutes,
depending on the procedure and type of equipment.
6. Explain that the client must be still during the test.
7. Instruct the client to remove all metallic items, such as hair clips, bobby
pins, jewelry, watches, eyeglasses, hearing aids, and dentures.
8. For MRI: explain that the procedure can take up to 1½ hours, tell the client
that he must remain still for intervals of 5 to 20 minutes.
9. Explain that the test is painless, but that the machinery may seem loud and
frightening and the tunnel confining. The client may receive earplugs to
reduce the noise.
10. Provide sedation, as ordered, to promote relaxation during the test.
11. After the procedure, increase the I.V. flow rate, as ordered, or encourage
the patient to increase his fluid intake to flush the contrast medium from
his system.

ASSIGNMENT
Name five (5) medications/drugs that can cause adverse central nervous system reactions
and affect cognitive function in critically ill patients. Discuss briefly the mechanism of
action of each drug.

B. Cardiovascular – hemodynamic monitoring is used to assess cardiac

function. Follow your facility’s procedure for setting up, zero referencing,
calibrating. Maintaining, and troubleshooting equipment. Common uses of
hemodynamic monitoring include arterial blood pressure monitoring and pulmonary
artery pressure.

5. Arterial blood pressure – in arterial blood pressure monitoring, the doctor

inserts a catheter into the radial or femoral artery to measure blood pressure
or obtain samples of arterial blood for diagnostic tests such as arterial blood
gas (ABG) studies. A transducer transforms the flow of blood during systole and
diastole into a waveform, which appears on an oscilloscope.

Nursing Management:
o Explain the procedure to the patient and his family, including the purpose
of arterial pressure monitoring.
o After catheter insertion, observe the pressure waveform to assess arterial
pressure.
o Assess the insertion site for signs of infection, such as redness and swelling.
Notify the doctor immediately if you note such signs.
o Document the date and time of catheter insertion, catheter insertion site,
type of flush solution used, type of dressing applied, and patient’s
tolerance of the procedure.

Module I
CCHAMS AY 2020-2021, 1st Semester 18

 Pulmonary artery pressure – continuous pulmonary artery pressure (PAP) and

intermittent pulmonary artery wedge pressure (PAWP) measurements provide
important information about left ventricular function and preload. Use this
information for monitoring and for aiding diagnosis, refining assessment,
guiding interventions, and projecting patient outcomes.

PAP and PAWP procedure:

A balloon-tipped, multilumen catheter is inserted into the client’s
internal jugular or subclavian vein. When the catheter reaches the right
atrium, the balloon is inflated to float the catheter through the right ventricle
into the pulmonary artery. This permits the PAWP measurement through an
opening at the catheter’s 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.

Nursing Management:
o Inform the patient he’ll be conscious during catheterization and he may
feel temporary local discomfort from the administration of the local
anesthetic. Catheter insertion takes about 30 minutes.
o After catheter insertion, you may inflate the balloon with a syringe to take
PAWP readings. Be careful not to inflate the balloon with more than 1.5 cc
of air. Over inflation could distend the pulmonary artery causing vessel
rupture. Don’t leave the balloon wedged for a prolonged period because
this could lead to a pulmonary infarction.
o After each PAWP reading, flush the line, if you encounter difficulty, notify
the doctor.
o Maintain 300 mm Hg pressure in the pressure bag to permit a flush flow of 3
to 6 ml/hour.
o If fever develops when the catheter is in place, inform the doctor, he may
remove the catheter and send its tip to the laboratory for culture.
o Make sure stopcocks are properly positioned and connections are secure.
Loose connections may introduce air into the system or cause blood backup,
leakage of deoxygenated blood, or inaccurate pressure readings. Also make
sure the lumen hubs are properly identified to serve the appropriate
catheter ports.
o Because the catheter can slip back into the right ventricle and irritate it,
check the monitor for a right ventricular waveform to detect this problem
promptly.
o To minimize valvular trauma, make sure the balloon is deflated whenever
the catheter is withdrawn from the pulmonary artery to the right ventricle
or from the right ventricle to the right atrium.
o Adhere to your facility’s policy for dressing, tubing, catheter, and flush
changes.
o Document the date and time of catheter insertion, the doctor who
performed the procedure, the catheter insertion site, pressure waveforms
and values for the various heart chambers, balloon inflation volume
required to obtain a wedge tracing, arrhythmias that occurred during or
after the procedure, type of flush solution used and its heparin
concentration, type of dressing applied, and the patient’s tolerance of the
procedure.

Module I
CCHAMS AY 2020-2021, 1st Semester 19

Trends in Hemodynamic Management

Recent developments include the move from static to dynamic variables to
assess conditions such as cardiac preload and fluid responsiveness and the transition to
less-invasive or even noninvasive monitoring techniques, at least in the perioperative
setting. Even though the thermodilution method remains the gold standard for
measuring cardiac output (CO), the use of the pulmonary artery catheter has declined
over the last decades, even in the setting of cardiovascular anesthesia.

The Move From Static to Dynamic Measurements

In the last century, monitoring has developed from initially pressure focused
and noninvasive (eg, finger on the pulse and listening to heart and Korotkoff sounds)
to invasive (eg, central venous pressure, arterial pressure, and pulmonary artery
pressure). However, invasive technology is associated with complications such as
infection and perforation. In recent years, the focus has been on trying to develop
noninvasive technology without losing significant accuracy and precision, avoiding the
complications of invasive monitors, and analyzing flow and response to fluid therapy.

Transition to Minimally Invasive and Noninvasive Hemodynamic Monitoring Techniques

There undoubtedly has been a trend in recent years from more invasive
hemodynamic monitoring tools and techniques (eg, pulmonary artery catheter [PAC]
for measuring CO, mixed venous oxygen saturation, and pulmonary arterial pressures),
to less-invasive techniques (eg, CO monitoring using arterial pressure waveform
analysis or the esophageal Doppler), and even completely noninvasive techniques (eg,
volume clamp using finger cuffs, bioimpedance and bioreactance, carbon dioxide
(CO2)-rebreathing, and pulse wave transit time). This trend became possible through
the technical development of innovative devices that have penetrated the market
with variable success. The core question to be asked is whether less invasiveness also
is accompanied by less accuracy, which would limit the use of these devices markedly.

Introduction of Artificial Intelligence to Predict Hemodynamic Changes

Artificial intelligence, machine learning, big data, and predictive analytics are
key words that infiltrate modern medicine just as they do in any other technology-
associated field of science. These words describe a process of incorporating large
amounts of disparate data into a unified algorithm, which then is used to predict and
solve a clinical problem. Examples of their application include image processing of
radiographic images, analysis of whole-slide pathology images, fully automated
echocardiogram interpretation, and text analysis of clinical notes.

Module I
CCHAMS AY 2020-2021, 1st Semester 20

New methods of hemodynamic monitoring have the potential to improve

management of the cardiovascular patient during anesthesia and postoperative care
because they provide accurate, precise, and repeatable measurements that can be
used to detect hemodynamic alterations and their causes, optimize hemodynamic
conditions such as oxygen delivery to the tissues, and provide feedback on the
adequacy of therapeutic interventions. Recent developments include the move from
static to dynamic variables to assess for conditions such as cardiac preload and fluid
responsiveness and the transition to less-invasive monitoring techniques, at least in
the perioperative setting. Future objectives include wearable sensors and wireless
remote monitoring, broadening continuous vital sign monitoring to lower care units
such as general hospital wards. Furthermore, the introduction of artificial intelligence
and machine learning will, based on big data, allow for predictive analytics of
hemodynamic problems before they actually occur.
https://www.sciencedirect.com/science/article

Fill-in the blanks

1. After having a cardiac catheterization, the patient is to remain in bed for

_______________ to _______________ hours.
2. Three major cardiovascular risk factors are _________________________,
__________________________, and _________________________.
3. The three factors that determine stroke volume are ____________________,
__________________________, and _________________________.
4. Homocysteine, an amino acid is linked to the development of
__________________________ because it can damage the endothelial lining
of arteries and promote thrombus formation.
5. __________________________, _________________________, and
_________________________ are measured to evaluate a person’s risk of
developing coronary artery disease (CAD), especially if there is a family
history of premature heart disease, or to diagnose a specific lipoprotein
abnormality.

Psychosocial Concerns in Acute/Critical Illness

The stress of critical illness may manifest itself in many ways. Patients
may deny or be unable to accept diagnosis or treatment, and they may
persistently ask why there is no improvement. They may express anxiety, often
extreme, with near panic and unspecified fears about dying. They may
experience intense feelings of ambivalence and guilt regarding their personal
relationships.

Religion and spirituality may be most helpful to

patients and families and should therefore be
recognized and encouraged.

A family member may have more difficulty than the

patient in coping with the illness; this may irritate
and distract caregivers and ultimately disrupt the
relationship between the physician and the family.
Therefore, the entire family is the appropriate focus
of treatment.

Module I
CCHAMS AY 2020-2021, 1st Semester 21

Given the difficulties that can follow the disclosure

of a life-threatening illness, it may be tempting to
avoid telling the patient the diagnosis. This tactic
has ancient roots: Hippocrates himself recommended
concealing bad news from patients, lest they
become discouraged. Tell the truth.

The most important component of communication is listening. The real issue

is not what you tell your patients but, rather, what you let your patients tell
you.

Psychological difficulties experienced during acute/chronic illness include:

 persistent worries and fears about the illness and its long-term effects.
 fear of dying.
 fear of the hospital or medical procedures.
 persistent sadness, anger, irritability, or excessive moodiness.
 changes in self esteem.
 powerlessness
 guilt and resentment
 frustration

CLINICAL APPLICATION

Mr. Sibus, a 50-year-old carpenter, is brought to the ER/ED by ambulance with a

suspected diagnosis of MI. He appears ashen, is diaphoretic, has a heart rate of 110
beats per minute (bpm), and reports severe chest pain. The nursing diagnosis is
decreased cardiac output, related to decreased myocardial tissue perfusion.

1. The nurse is aware that there is a critical time period for this patient. When should the
nurse be most vigilant in monitoring this patient?

____________________________________________________________________
2. The nurse is interpreting the results of the ECG. What findings does the nurse
understand are indicative of initial myocardial injury?

_____________________________________________________________________
3. The nurse evaluates a series of laboratory tests within the first few hours. What
laboratory results are positive indicators of myocardial infarction (MI)?

_____________________________________________________________________

Module I
CCHAMS AY 2020-2021, 1st Semester 22

_____________________________________________________________________
4. The nurse should closely monitor the patient for a complication of an MI that leads to
sudden death during the first 48 hours. Which complication should the nurse monitor
for?

_____________________________________________________________________

END OF MODULE 1

 MODULE SUMMARY
There are four lessons in module I.

Lesson 1 outlines the University’s philosophy, vision and mission. Included also
are the Department goals and program outcomes, and an overview of the core
competency standards.

Lesson 2 is an overview of what critical care nursing is and the role of critical
care/ICU nurses. It covers the classification of critical care patients and the
principles of critical care nursing. Assessing cultural considerations and holistic
health care are also emphasized.

Lesson 3 deals with the critically ill patients in hemodynamic monitoring. It

covers the techniques in hemodynamic monitoring, the nurses’ role in assessing
the acute/critically ill patients and how these assessments correlates with the
pathophysiological aspect of underlying conditions.

Lesson 4 covers the nurses’ role in the collaborative management of critically

ill patients in hemodynamic monitoring. Included also are the psychosocial
concerns in the care of the acute/critically ill patients.

Congratulations! You may now proceed to module 2 after taking the

graded quiz.

Module I
CCHAMS AY 2020-2021, 1st Semester 23

 SUMMATIVE TEST

1. Graded quiz, covering the four lessons, will be administered thru

correspondence.

FEEDBACK

After using this module I perceived that this module is

____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
I would recommend that ______________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

Module I