Alterations in Tissue Perfusion

HYPERTENSIVE CRISIS ASSESSMENT

Who are vulnerable to Hypertensive Crisis? Hemodynamic Monitoring

Hypertensive crisis may occur in clients with:  Extremely close hemodynamic monitoring of the
patient’s blood pressure and cardiovascular status is
1. poorly controlled hypertension required during treatment of hypertensive emergencies
2. undiagnosed hypertension and urgencies
3. abrupt discontinuance of antihypertensive
medications
 Exact frequency of monitoring is a matter of clinical
Necessary: A complete evaluation (to review the patient’s judgment and varies with the patient’s condition
ongoing treatment plan and strategies to minimize the occurrence
of subsequent hypertensive crises) once the hypertensive crisis has
been managed  Taking vital signs every 5 minutes is appropriate if the
blood pressure is changing rapidly
What are the Classifications of Hypetensive Crisis?

Two classes of hypertensive crisis that require immediate

 Taking vital signs at 15- or 30- minute intervals in a
more stable situation may be sufficient
intervention:



hypertensive emergency
hypertensive urgency (pressures above 180 mm Hg
 A precipitous drop in blood pressure can occur that
systolic and/or above 120 mm Hg diastolic) would require immediate action to restore blood
pressure to an acceptable level
1. Hypertensive emergency

 Acute, life-threatening blood pressure elevations that require

prompt treatment in an intensive care setting because of the
 Critically ill patients require continuous assessment of
serious target organ damage that may occur their cardiovascular system to diagnose and manage
their complex medical conditions
 Therapeutic goals:

 reduction of the mean blood pressure by 20% to  This type of assessment is achieved by the use of direct
25% within the first hour of treatment pressure monitoring systems, referred to as
 a further reduction to a goal pressure of about hemodynamic monitoring
160/100 mmHg over a period of up to 6 hours
a more gradual reduction in pressure over a period
 Common forms: CVP, pulmonary artery pressure, and

of days
intra-arterial BP monitoring
Exceptions to these goals: treatment of ischemic stroke (in
which there is no evidence of benefit from immediate
pressure reduction) and treatment of aortic dissection (in
which the goal is to lower systolic pressure to less than 100  Patients requiring hemodynamic monitoring are cared
mm Hg if the patient can tolerate the reduction) for in critical care units

2. Hypertensive urgency

 A situation in which blood pressure is very elevated but  To perform hemodynamic monitoring, a CVP,
there is no evidence of impending or progressive target pulmonary artery, or arterial catheter is introduced into
organ damage the appropriate blood vessel or heart chamber.
 Elevated blood pressures associated with severe
It is connected to a pressure monitoring system that
headaches, nosebleeds, or anxiety are classified as
has several components
urgencies

 Oral agents can be given with the goal of normalizing Components of the pressure monitoring system
blood pressure within 24 to 48 hours
o Recommended treatment: Oral doses of fast-
acting agents such as beta-adrenergic blockers
 A disposable flush system: composed of IV normal
saline solution (which may include heparin), tubing,
(i.e., labetalol [Trandate]), ACE inhibitors (i.e., stopcocks, and a flush device, which provides
captopril [Capoten]), or alpha2-agonists (i.e., continuous and manual flushing of the system.
clonidine [Catapres])
  During this sterile procedure, the physician threads a
 A pressure bag: placed around the flush solution single-lumen or multilumen catheter through the vein
into the vena cava just above or within the right atrium
that is maintained at 300 mm Hg of pressure

The pressurized flush system delivers 3 to 5 mL of  Once the CVP catheter is inserted, it is secured and a
solution per hour through the catheter to prevent dry sterile dressing is applied
clotting and backflow of blood into the pressure
monitoring system  Position of the catheter is confirmed by a chest x-ray


Central Venous Pressure Monitoring
A transducer: converts the pressure coming from
the artery or heart chamber into an electrical signal

 An amplifier or monitor: increases the size of the

electrical signal for display on an oscilloscope
A. The phlebostatic axis is the reference point for the
atrium when the patient is positioned supine.

1. Central Venous Pressure Monitoring It is the intersection of two lines on the chest wall:
(1) the midaxillary line drawn between the anterior
 CVP is a measurement of the pressure in the vena cava and posterior surfaces of the chest and
or right atrium (2) the line drawn through the fourth intercostal
space.
 The pressure in the vena cava, right atrium, and right
ventricle are equal at the end of diastole; thus, the CVP Its location is identified with a skin marker. The stopcock of
also reflects the filling pressure of the right ventricle the transducer used in hemodynamic monitoring is “leveled”
(preload) at this mark prior to taking pressure measurements.
 Normal CVP: 2 to 6 mm Hg B. Measurements can be taken with the head of the bed
 It is measured by positioning a catheter in the vena (HOB) elevated up to 60°. Note the phlebostatic axis
cava or right atrium and connecting it to a pressure changes as the HOB is elevated; thus, the stopcock and
monitoring system transducer must be repositioned after each position change.

 The CVP is most valuable when it is monitored over

time and correlated with the patient’s clinical status 2. Pulmonary Artery Pressure Monitoring

 A CVP greater than 6 mm Hg indicates an elevated

right ventricular preload  Used in critical care for:
 assessing left ventricular function,
There are many problems that can cause an
elevated CVP, but the most common problem is  diagnosing the etiology of shock, and
hypervolemia (excessive fluid circulating in the body)  evaluating the patient’s response to medical
or right-sided HF interventions (e.g., fluid administration, vasoactive
medications)
 A low CVP (less than 2 mm Hg) indicates reduced
right ventricular preload, which is most often from  A pulmonary artery catheter and a pressure monitoring
hypovolemia system are used
o Dehydration, excessive blood loss, vomiting or
diarrhea, and over diuresis can result in
 A variety of catheters are available for cardiac pacing,
hypovolemia and a low CVP oximetry, cardiac output measurement, or a
combination of functions
o This diagnosis can be substantiated when a
rapid IV infusion of fluid causes the CVP to
increase.  Pulmonary artery catheters are balloon-tipped, flow-
directed catheters that have distal and proximal lumens
 Before insertion of a CVP catheter, the site is prepared o The distal lumen has a port that opens into the
 The preferred site is the subclavian vein; the femoral pulmonary artery
vein is generally avoided o Once connected by its hub to the pressure
 A local anesthetic agent is used monitoring system, it is used to continuously
measure pulmonary artery pressures
o The proximal lumen has a port that opens into the
right atrium
  The catheter is then passed into the vena cava and
o It is used to administer IV medications and fluids right atrium
or to monitor right atrial pressures (i.e., CVP)
 In the right atrium, the balloon tip is inflated, and
 Each catheter has a balloon inflation hub and valve the catheter is carried rapidly by the flow of blood
 A syringe is connected to the hub, which is used to through the tricuspid valve into the right ventricle,
inflate or deflate the balloon with air (1.5-mL capacity) through the pulmonic valve, and into a branch of
 The valve opens and closes the balloon inflation lumen the pulmonary artery

 When the catheter reaches the pulmonary artery,

 A pulmonary artery catheter with specialized
capabilities has additional components the balloon is deflated and the catheter is secured
with sutures.
For example, the thermodilution catheter has three
additional features that enable it to measure cardiac output: Pulmonary artery (PA) catheter and pressure monitoring
o a thermistor connector attached to the cardiac systems
output computer of the bedside monitor,
o a proximal injectate port used for injecting fluids
when obtaining the cardiac output, and
o a thermistor (positioned near the distal port)

Pulmonary Artery Pressure Monitoring

The pulmonary artery catheter used for obtaining

pressure measurements and cardiac output.
A. Bedside monitor that connects with cables to the pressure
A. The pressure monitoring system is connected to the distal monitoring systems (includes intravenous [IV] solution in a
lumen hub. pressure bag, IV tubing, and two transducers with stopcocks
and flush devices)
B. Intravenous solutions are infused through the proximal
infusion and injectate lumen hubs. C. An air-filled syringe B. This system connects to the proximal infusion port that
connected to the balloon inflation valve is used for balloon opens in the right atria
inflation during catheter insertion and pulmonary artery
wedge pressure measurements. C. and is used to infuse fluids or medications and monitor
central venous pressures and the distal infusion port
D. To obtain cardiac output, the thermistor connector is
inserted into the cardiac output component of the bedside D. This port opens in the PA and is used to monitor PA
cardiac monitor, and pressures.
5 to 10 mL of normal saline is injected in 4 seconds into the
proximal injectate port. E. The thermistor located near the E. The thermistor connector is attached to the bedside
balloon is used to calculate the cardiac output. cardiac monitor to obtain cardiac output.

 The pulmonary artery catheter, covered with a F. An air-filled syringe is attached to the balloon inflation
sterile sleeve, is inserted into a large vein, valve during catheter insertion and measurement of PA
preferably the subclavian, through a sheath wedge pressure.

 The femoral vein is avoided; insertion techniques G. PA catheter positioned in the pulmonary artery. Note the
and protocols mirror those used for inserting a sterile sleeve over the PA catheter. The PA catheter is
CVP catheter threaded through the sheath until it reaches the desired
position in the PA. The side port on the sheath is used to
infuse medications or fluids. ECG, electrocardiogram; RA,
 The sheath is equipped with a side port for
right atrium.
infusing IV fluids and medications
 Once the catheter is in position, the following are
measured:
  Traditionally,
 right atrial,
 pulmonary artery systolic, collateral circulation to the involved
 pulmonary artery diastolic, extremity was assessed by using the Allen test
 mean pulmonary artery, and
 pulmonary artery wedge pressures  The hand is elevated and the patient is asked to
make a fist for 30 seconds
 Monitoring of the pulmonary artery diastolic and  The nurse compresses the radial and ulnar arteries
pulmonary artery wedge pressures is particularly simultaneously, causing the hand to blanch
important in critically ill patients because they are used  After the patient opens the fist, the nurse releases
to evaluate left ventricular filling pressures (i.e., left the pressure on the ulnar artery
ventricular preload
 Allen test result: If blood flow is restored (hand
 It is important to note that the pulmonary artery wedge turns pink) within 6 seconds, the circulation to the
pressure is achieved by inflating the balloon tip, which hand may be adequate enough to tolerate
causes it to float more distally into a smaller portion of placement of a radial artery catheter
the pulmonary artery until it is wedged into position
 Evidence suggests that pulse oximetry and
 This is an occlusive maneuver that impedes blood plethysmography are additional reliable methods for
flow through that segment of the pulmonary artery assessing circulation to the hand
 Therefore, the wedge pressure is measured
immediately and the balloon deflated promptly to  Site preparation and care are the same as for CVP
restore blood flow catheters
Quality and Safety Nursing Alert  The catheter flush solution is the same as for pulmonary
artery catheters
 After measuring the pulmonary artery wedge  A transducer is attached, and pressures are measured in
pressure, the nurse ensures that the balloon is millimeters of mercury (mm Hg)
deflated and that the catheter has returned to its
normal position  The nurse monitors the patient for complications (local
 This important intervention is verified by obstruction with distal ischemia, external hemorrhage,
evaluating the pulmonary artery pressure massive ecchymosis, dissection, air embolism, blood
waveform displayed on the bedside monitor loss, pain, arteriospasm, and infection)

3. Intra-Arterial Blood Pressure Monitoring NURSING

 Intra-arterial BP monitoring is used to obtain direct and
continuous BP measurements in critically ill patients
DIAGNOSIS
who have severe hypertension or hypotension  Deficient knowledge regarding the relation between the
treatment regimen and control of the disease process
 Arterial catheters are also useful when arterial blood gas  Noncompliance with therapeutic regimen related to side
measurements and blood samples need to be obtained effects of prescribed therapy
frequently
Collaborative Problems
 The radial artery is the usual site selected  Risk for complications of hemodynamic monitoring

 However, placement of a catheter into the radial artery 

(pneumothorax, air embolism, infection)
Left ventricular hypertrophy
can further impede perfusion to an area that has poor
circulation  Myocardial infarction

 As a result, the tissue distal to the cannulated artery can
Heart failure

become ischemic or necrotic  TIA

 Cerebrovascular disease (stroke or brain attack)
 Patients with diabetes, peripheral vascular disease, or  Renal insufficiency and chronic kidney disease
hypotension, receiving IV vasopressors, or having had
previous surgery are at highest risk for this
complication
 Retinal hemorrhage
 The nurse helps ensure safe and effective care by
PLANNING and adhering to the following guidelines:

GOALS  Ensuring that the system is set up and maintained

properly. For example, the pressure monitoring system
The major goals for patients include:
must be kept patent and free of air bubbles

 understanding of the disease process and its  Checking that the stopcock of the transducer is
positioned at the level of the atrium before the system is
treatment
used to obtain pressure measurements

 participation in a self-care program o This landmark is referred to as the phlebostatic


axis
absence of complications
o The nurse uses a marker to identify this level on
the chest wall, which provides a stable reference
IMPLEMENTATIO point for subsequent pressure readings.

N  Establishing the zero-reference point in order to ensure

that the system is properly functioning at atmospheric

Medical
pressure

o This process is accomplished by placing the

Management stopcock of the transducer at the phlebostatic axis,

opening the transducer to air, and activating the
The medications of choice in hypertensive emergencies are zero function key on the bedside monitor
those that have an immediate effect

Initial treatment: Intravenous vasodilators, including:

 Measurements of CVP, BP, and pulmonary artery
 sodium nitroprusside (Nitropress), pressures can be made with the head of the bed elevated
 nicardipine (Cardene), up to 60°; however, the system must be repositioned to
 clevidipine (Cleviprex), the phlebostatic axis to ensure an accurate reading
 enalaprilat (Vasotec), and
 nitroglycerin have immediate actions that are
short-lived (minutes to 4 hours), and they are Complications of hemodynamic monitoring
therefore frequently used for initial treatment. (uncommon): PNEUMOTHORAX
 The nurse observes for signs of pneumothorax during
 Nicardipine and labetalol (Trandate) have the insertion of catheters using a central venous
demonstrated safety and effectiveness in treating approach (CVP and pulmonary artery catheters)
hypertensive crises, with nicardipine
demonstrating more predictability in controlling
blood pressure. Complications of hemodynamic monitoring
(uncommon): AIR EMBOLISM
 Volume replacement: Experts also recommend
assessing the patient’s fluid volume status  Air emboli can be introduced into the vascular system if
the stopcocks attached to the pressure transducers are
If there is volume depletion secondary to mishandled during blood drawing, administration of
natriuresis caused by the elevated blood pressure, then medications, or other procedures that require opening
volume replacement with normal saline can prevent the system to air
large sudden drops in blood pressure when o Therefore, nurses handling this equipment must
antihypertensive medications are given demonstrate competence prior to caring
independently for a patient requiring hemodynamic
monitoring

Look at last page Complications of hemodynamic monitoring:

INFECTION

Nursing Management  The longer any of these catheters are left in place (after
72 to 96 hours), the greater the risk of infection
Nurses caring for patients who require
hemodynamic monitoring receive training prior to using this
sophisticated technology
 Catheter-related bloodstream infections are the most for the site of insertion. If a full-size drape is not
common preventable complication associated with available, two drapes may be applied to cover the
hemodynamic monitoring systems patient, or the operating room may be consulted to
determine how to procure full-size sterile drapes,
 Collaborative Practice Interventions to Prevent Central because these are routinely used in surgical settings.
Line–Associated Bloodstream Infections (CLABSIs)
 Nurses should be empowered to enforce use of a central
o Current best practices can include the line checklist to be sure that all processes related to
implementation of specific evidence-based bundle central line placement are properly executed for every
interventions that when used together (i.e., as a line placed.
“bundle”) improve patient outcomes
Antiseptic to be used to prepare the patient’s skin for
o This chart outlines specific parameters for the central line insertion:
central line bundled collaborative interventions that
have been found to reduce central line–associated  Chlorhexidine skin antisepsis has been proven to
bloodstream infections (CLABSI) provide better skin antisepsis than other antiseptic
agents, such as povidone–iodine solutions.
FIVE KEY ELEMENTS OF THE CENTRAL LINE
BUNDLE:  An alcohol chlorhexidine antiseptic should be applied
using a back- and-forth friction scrub for at least 30
seconds; this should not be wiped or blotted dry.
 Hand hygiene
 Maximal sterile barrier precautions during line insertion  The antiseptic solution should be allowed time to dry
(see later discussion) completely before the insertion site is
 Chlorhexidine skin antisepsis punctured/accessed (approximately 2 minutes).
 Optimal catheter site selection with avoidance of using
the femoral vein for central venous access in adult Essential nursing interventions to reduce the risk of
patients infection:
 Daily review of line necessity, with prompt removal of
unnecessary lines  Maintaining sterile technique when changing the central
When to perform hand hygiene in the care of a patient line dressing
with a central line:  Always performing hand hygiene before manipulating
or accessing the line ports
All clinicians who provide care to the patient  Wearing clean gloves before accessing the line port
should adhere to good hand hygiene practices, particularly:  Performing a 15- to 30-second “hub scrub” using
chlorhexidine or alcohol and friction in a twisting
 Before and after palpating the catheter insertion site motion on the access hub (reduces biofilm on the hub
 With all dressing changes to the intravascular catheter that may contain pathogens)
access site  Using chlorhexidine-containing dressings in patients
 When hands are visibly soiled or contamination of older than 2 months
hands is suspected  Consider using antiseptic-containing port protectors to
 Before donning and after removing gloves cover connectors

Changes that can be made to improve hand hygiene: When to discontinue central lines:

 Implement a central line procedure checklist that  Assessment for removal of central lines should be
requires that clinicians perform hand hygiene as an included as part of the nurse’s daily goal sheets.
essential step in care.  The time and date of central line placement should be
 Post signage stating the importance of hand hygiene. recorded and evaluated by staff to aid in decision
 Have soap and alcohol-based hand sanitizers making.
prominently placed to facilitate hand hygiene practices.  The need for the central line access should be reviewed
 Model hand hygiene practices. as part of multidisciplinary rounds.
 Provide patient and family education and engage family  During these rounds, the “line day” should be stated to
in hand hygiene practices during visitation. remind everyone how long the central line has been in
place (e.g., “Today is line day 6”).
Maximal sterile barrier precautions implemented during  An appropriate time frame for regular review of the
central line insertion: necessity for a central line should be identified, such as
weekly, when central lines are placed for long-term use
 For the primary provider, this means strict compliance (e.g., chemotherapy, extended antibiotic
with wearing a cap, mask, sterile gown, and sterile administration).
gloves. The cap should cover all hair, and the mask
should cover the nose and the mouth tightly. The nurse
should also wear a cap and a mask.

 For the patient, this means covering the patient from

head to toe with a sterile drape, with a small opening
Nursing  Continued education and encouragement are usually
Management: needed to enable patients to formulate an acceptable
plan that helps them live with their hypertension and
adhere to the treatment plan

INCREASING The effort needed to follow the therapeutic plan

may seem unreasonable to some, particularly when they
KNOWLEDGE have no symptoms without medications but do have
side effects with medications

 The patient needs to understand the disease process

 Compromises may have to be made about some aspects
and how lifestyle changes and medications can control of therapy to achieve higher-priority goals
hypertension. The nurse needs to emphasize the concept
of controlling hypertension rather than curing it. The nurse can assist with behavior change by
supporting patients in making small changes with each


visit that moves them toward their goals
The nurse can encourage the patient to consult a
dietitian to help develop a plan for improving nutrient
intake or for weight loss. The program usually consists
of restricting sodium and fat intake, increasing intake of
 Another important factor is following up at each visit to
see how the patient has progressed with the plans made
fruits and vegetables, and implementing regular at the prior visit
physical activity.
If the patient has had difficulty with a particular

 Explaining that it takes 2 to 3 months for the taste

aspect of the plan, the patient and nurse can work
together to develop an alternative or modification to the
plan that the patient believes will be more successful
buds to adapt to changes in salt intake may help the
patient adjust to reduced salt intake.

 Support groups for weight control, smoking cessation,

 The patient should be advised to limit alcohol
and stress reduction may be beneficial for some
patients; others can benefit from the support of family
intake, and tobacco should be avoided because anyone and friends.
with high blood pressure is already at increased risk for
heart disease, and smoking amplifies this The nurse assists the patient to develop and adhere

Nursing Management: to an appropriate exercise regimen, because regular

activity is a significant factor in weight reduction and a
blood pressure–reducing intervention in the absence of
PROMOTING any loss in weight

ADHERENCE TO THE Nursing Management:

THERAPEUTIC PROMOTING HOME,
REGIMEN COMMUNITYBASED,
 Adherence to the therapeutic regimen increases when AND TRANSITIONAL
patients actively participate in self-care, including self-
monitoring of blood pressure and diet, possibly because CARE
patients receive immediate feedback and have a greater Educating Patients About Self-Care
sense of control

 Nurse-led wellness programs that are tailored to take  The nurse can help the patient achieve blood pressure
into account patients’ behaviors and eating and exercise control through education about managing blood
practices are more effective than generic programs pressure (see earlier discussion), setting goal blood
pressures, and providing assistance with social support.

 Patients with hypertension must make considerable

effort to adhere to recommended lifestyle modifications
and to take regularly prescribed medications
 Involving family members in education programs Nursing Management:
enables them to support the patient’s efforts to control
hypertension. MONITORING AND
 Providing written information about the expected MANAGING
POTENTIAL
effects and side effects of medications is important.
When side effects occur, patients need to understand the
importance of reporting them and to whom they should
be reported
COMPLICATIONS
 Patients need to be informed that rebound hypertension  Symptoms suggesting that hypertension is progressing
(i.e., abnormally high blood pressure) can occur if to the extent that target organ damage is occurring must
antihypertensive medications are suddenly stopped be detected early so that appropriate treatment can be
initiated

o Patients should be advised to have an adequate o When the patient returns for follow-up care, all body
supply of medication, particularly when traveling systems must be assessed to detect any evidence of
and in case of emergencies such as natural disasters vascular damage
o If traveling by airplane, patients should pack the
medication in their carry-on luggage o An eye examination with an ophthalmoscope is
particularly important because retinal blood vessel
damage indicates similar damage elsewhere in the
vascular system
 All patients should be informed that some medications,
such as beta-blockers, might cause sexual dysfunction
and that other medications are available if problems
o The patient is questioned about blurred vision, spots
in front of the eyes, and diminished visual acuity
with sexual function or satisfaction occur.

o The heart, nervous system, and kidneys are also

 The nurse can encourage and educate patients to

carefully assessed

measure their blood pressure at home

 Any significant findings are promptly reported to
o This practice involves patients in their own care and determine whether additional diagnostic studies are
required
emphasizes that failing to take medications may
result in an identifiable rise in blood pressure  Based on the findings, medications may be changed to
improve blood pressure control
o Patients need to know that blood pressure varies
continuously and that the range within which their
pressure varies should be monitored

EVALUATION
Continuing and Transitional Care
Expected Patient
 Regular follow-up care is imperative so that the
disease process can continue to be optimally
assessed and treated
Outcomes
o A history and physical examination should be 1. Reports knowledge of disease management
sufficient to maintain adequate tissue perfusion
completed at each clinic visit

o The history should include all data pertaining to

any potential problem, specifically medication-
A. Maintains blood pressure at less than
140/90 mm Hg (or less than 150/90 mm Hg for
related problems such as postural (orthostatic) adults older than 60 years of age) with lifestyle
hypotension (experienced as dizziness or modifications, medications, or both
lightheadedness on standing)
 B. Demonstrates no symptoms of angina,
palpitations, or vision changes

C. Has stable BUN and serum creatinine

levels

D. Has palpable peripheral pulses

2. Adheres to the self-care program

A. Adheres to the dietary regimen as

prescribed: reduces calorie, sodium, and fat intake;
increases fruit and vegetable intake

B. Exercises regularly

C. Takes medications as prescribed and

reports any side effects

D. Measures blood pressure routinely

E. Abstains from tobacco and excessive

alcohol intake

F. Keeps follow-up appointments

3. Has no complications

A. Reports no changes in vision

B. Exhibits no retinal damage on vision

testing

C. Maintains pulse rate and rhythm and

respiratory rate within normal ranges

D. Reports no dyspnea or edema

E. Maintains urine output consistent with

intake

F. Has renal function test results within

normal range

G. Demonstrates no motor, speech, or

sensory deficits

H. Reports no headaches, dizziness,

weakness, changes in gait, or falls