Hemodynamic status is important in knowing the current state of a patient’s circulatory system and blood flow. Hemodynamic stability is reflected by a stable blood flow and cardiac pump consistency.
On the other hand, hemodynamic instability is marked by the need for physiological and mechanical assistance to ensure that cardiac output and blood pressure remain within therapeutic ranges.
Any disruption in a patient’s cardiac function can result in diminished cardiac performance, insufficient perfusion, and aberrant vital signs.
For patients with unstable hemodynamic status (also known as circulatory collapse), typical manifestations might range from unstable homeostatic mechanisms to life-threatening complications.
Immediate effects of the uncompensated phase include lack of vigor, hypoperfusion, and shock, which, if not appropriately managed, could lead to irreversible damage or death.
Parameters of Hemodynamic Status
An assessment of the patient’s hemodynamic status (HS) provides vital information regarding the presence or absence of hemodynamic instability (HI).
In addition to providing information on the prognosis and course of the patient’s condition, it is a useful hemodynamic measure for comparing the clinical responses to vasoactive therapy, hormonal modulation, drugs, etc.
Circulatory shock is one of the most common clinical manifestations of hemodynamic instability. When tissue oxygen uptake exceeds tissue oxygen supply, it can result in a decline in oxygen utilization and cellular metabolism, which can lead to energy failure, metabolic arrest, and organ failure.
Shock is frequently confused with HI; however, it is a medical condition with distinct types and degrees.
- Compensated shock. This disease state is marked by normal BP due to increasing CO. However, perfusion is still insufficient to meet the body’s metabolic needs.
- Hypotensive shock. Hypotensive shock. This disease state can culminate through four principal types, each with different mechanisms: cardiogenic, hypovolemic, obstructive, and distributive shock. The pathophysiology and treatment requirements for each of these pathways are notably distinct.
Although hypotension is commonly attributed to shock, there are circumstances in which shock can occur even in the absence of hypotension and instead may be a marker of shock that occurs late in the course of the condition. The following factors are frequently considered by healthcare professionals:
- Level of consciousness. Patients with a stable HS have a clear and coherent degree of consciousness, whereas, in hypotensive shock, they may become agitated and combative.
- Respiratory rate (RR). RR gives diagnostic information for probable respiratory failure or shock, similar to temperature states. Symptoms of compensated shock often include tachycardia in the absence of fever and tachypnea. For hypotensive states, metabolic acidosis (hyperpnea) can be noted. Although RR is a valuable sign of hemostatic state, it is not a diagnostic test in and of itself, and further tests may be necessary.
- Capillary refill time (CRT). CRT is frequently used to evaluate the degree of hemodynamic stability in symptomatic patients. Perfusion and coolness of the extremities can be evaluated and used as an indicator of filling pressures. The test is performed by compressing or applying pressure to the fingernail bed, and the time it takes for the color to return to normal is measured for about >3 seconds. However, CRT can vary based on the following variables: age, ambient temperature, and gender. For a more accurate result, it is typically conducted in conjunction with the cardiac index and urine output determination.
- Extremities. The decrease of blood flow to the skin’s surface and the accompanying diaphoresis as a result of stress are indicated by pallor and coolness. The extremities should be warm and pinkish in normal physiological states. However, sticky or clammy skin may indicate hypotensive shock.
- Peripheral pulse (PP). Variations in PP may serve as an initial indicator that a patient’s hemodynamic status is unstable. This measure can be altered by a variety of variables, including temperature, exertion, drugs, and thyroid hormone levels. High amounts of endogenous catecholamines, blood loss, and dehydration are further indicators of an increased heart rate. A faint and diffracted pulse is diagnostic of compensative shock, whereas a weak or nonexistent PP is predictive of hypotensive shock.
- Heart rate (HR). The increase in sympathetic tone can raise the HR that operates during increased exertion, anxiety, and the presence of illness. Increased HR (Tachycardia) is also a mechanism that compensates for reduced tissue perfusion and occurs due to increased oxygen demand.
Other clinical assessments of hemodynamic status are also provided:
In terms of general examination, patients are evaluated to determine if they exhibit hypotension.
- Temperature. Temperature extremes may be suggestive of hemodynamic instability, although it is not a sensitive indicator. In addition to being a contributing factor, it is a good predictor of illness severity.
- Urine Output (UO). Activation of the SNS in response to circulatory failure ensues to preserve perfusion to essential organs. The kidney is one of the organs most affected by this process. Dark-colored urine output can be attributed to emerging symptoms of poor perfusion in the kidneys. Patients who have experienced both septic shock and cardiac surgery may exhibit a markedly diminished UO.
Oliguria is one of the symptoms of hypoperfusion that suggests insufficient renal perfusion or cardiac output. It has been incorporated as risk stratification for blood flow and is a good tool for assessing whether increased volume challenges will improve cardiac output. However, it may not be a sensitive or specific marker of hemodynamic instability caused by a variety of etiologies.
- Stress response (Fight or Flight Syndrome). In the event of circulatory failure, the body’s first response to fend off a perceived threat and maintain homeostasis is through activation of the sympathetic nervous system (SNS). It is principally activated via the surge of hormones particularly, by adrenaline and noradrenaline, in response to stress. As the sympathetic nervous system is stimulated, it causes blood flow to be concentrated in muscle groups in the upper and lower limbs, preparing the body for a fight or flight response. This may result in numerous reactions, including an increase in blood pressure and circulation to the brain, while gastrointestinal activity diminishes. Rate of breathing increases as a result of the dilation of airways in the lungs. The heart rate accelerates to allow more blood flow to the muscles, brain, and other organs.
Monitoring of Hemodynamic Status
- Blood pressure (BP). Routine BP checks are a primary hemodynamic monitoring tool in critical care and emergency medicine.
- Electrocardiography (ECG). Electrode patches are placed on the patient’s chest to monitor the heart’s electrical activity. This device provides a predictive electrical pattern in relation to heart rate and regularity.
- Pulmonary artery catheter (Swan-Ganz catheter). Involves the insertion of a catheter into a large vein. It is typically administered to patients in the chronic stages. It is connected to the patient’s bedside monitor and provides the healthcare team with continuous information about cardiac functioning and response to treatment.
- Arterial catheter. Involves the insertion of a catheter into an artery in the wrist, foot, or groin area.
- Photoplethysmography. Monitors changes in blood flow into and out of the tissue’s microvascular bed, which is predominantly made up of capillaries.
- Echocardiography. Utilizes ultrasound waves to examine and visualize the myocardium. It is capable of detecting heart muscle and structural valve defects, circulation problems, blood volume, and cardiac output.
Causes of Unstable Hemodynamic Status
- History of ischemic stroke and pre-existing cardiovascular disorders
- Cardiovascular compromise. Includes maladaptation, poor heart contractility, cardiac tamponade, underdeveloped myocardium, as well as dilated and hypertrophic cardiomyopathy.
- Left ventricular dysfunction
- Prior cardiac surgery or valve repair. Surgery is a significant risk factor for developing atelectasis. Following surgery, loculated hematomas may also develop, a condition that may result in ventricular hypertrophy and hypotension.
- Diabetes
- Smoking. Contributes to the development and progression of cancer, typically pulmonary squamous cell carcinoma. The tumor may induce pericardium invasion, and further metastases may encase coronary arteries.
- Trauma. Intracavitary and cerebral hemorrhage, airway obstruction, thoracic damage, and other life-threatening traumas contribute to hemodynamic instability.
Nursing Considerations for Unstable Hemodynamic Status
- Monitor for hemodynamic changes in the patient’s blood profiles (e.g., hematocrit, platelets, hemoglobin, etc.)
- Monitor circulatory function. Instruct the patient to report signs of compensated shock to ameliorate deterioration or progression.
- As indicated, administer fluids and medications in conformity with the type of shock and the clinical condition.
- Before catheterization, evaluate distal circulation at peripheral sites. Ensure proper perfusion and take note of the color and temperature.
- Provide supportive care and a safe environment by frequently repositioning the patient, educating the patient and family, alleviating anxiety, and raising the head of the bed.
- Check the position of the transducer. The nurse should ensure the patency of the pressure monitor system.
- Regularly inspect the catheter site for signs of local infection. Showering is permissible as long as an impenetrable cover is in place.
Hemodynamic Status Nursing Diagnosis
Hemodynamic Status Nursing Care Plan 1
Nursing Diagnosis: Decreased Cardiac Output related to an unstable hemodynamic status secondary to cardiogenic shock, as evidenced by changes in the level of consciousness, metabolic acidosis, mottling of the skin, oliguria, and tachycardia.
Desired Outcome: The patient will demonstrate improved cardiac output as evidenced by normal HR of 60-100 beats per minute, BP 90/60 mm/Hg, and strong peripheral pulses.
| Hemodynamic Status Nursing Interventions | Rationale |
| Assess variations in the level of consciousness (LOC). | Shock is characterized by changes in mentation, hypotension, and oliguria. Low cardiac output, the presence of arrhythmias, and the absence of pulses are hallmarks of cardiogenic shock, which may result in circulatory failure and end-organ complications (ischemia). In the final phases of cerebral hypoxia, loss of consciousness occurs. |
| Assess the patient’s BP, HR, pulse pressure, and capillary refill. Use direct intra-arterial pressure monitoring as ordered. | Significant findings of decreased cardiac output include decreased BP, increased HR, and symptoms such as chest pain and dyspnea. These parameters are observed in response to decreased cardiac output (CO) and as the condition progresses. |
| Review oxygen saturation levels using pulse oximetry and arterial blood gasses (ABGs). | During shock, metabolism stalls, and lactic acidosis ensues. Decreased pH and carbon dioxide levels can lead to myocardial ischemia, heart failure, and cardiac arrest. |
| Check the urinary output of the patient. | Water retention is a typical response to hypotension. Reduced renal perfusion resulting from low CO frequently appears as oliguria, particularly in elderly patients. Reduced renal perfusion can activate neurohormonal pathways, resulting in increased synthesis of catecholamine and aldosterone. |
| Administer electrolyte replacement as prescribed. Encourage intake of fluid. | Imbalances in serum electrolytes are often manifestations of cardiac conditions. This state of imbalance should immediately be corrected via the provision of electrolytes as it may cause dysrhythmias and other pathological states. In addition, maintaining fluid balance will assist in correcting acid-base and electrolyte imbalances. |
| Provide mechanical assistive devices (MADs) such as ventricular assist devices (VAD) or intra-aortic balloon pumps (IABP). | IABP and VAD are potential therapy choices when pharmaceutical interventions are unable to control or reverse the deterioration. MADs can increase tissue oxygenation and decrease myocardial workload, consequently improving cardiac output and coronary artery perfusion to prevent further deterioration or development of complications. These devices assist in the circulation; however, they do not necessarily provide an adequate means of treatment. |
Hemodynamic Status Nursing Care Plan 2
Ineffective Tissue Perfusion (Cardiovascular)
Nursing Diagnosis: Ineffective Tissue Perfusion (Cardiovascular) related to an unstable hemodynamic status secondary to disseminated intravascular coagulation (DIC), as evidenced by a capillary refill of more than 3 seconds, hematuria, angina, oliguria, and dyspnea
Desired Outcome: The patient will maintain adequate peripheral and cardiac perfusion as evidenced by normal HR (100 beats per minute), strong, palpable pulses and sensation, normal color of extremities, adequate CRT, and absent pain.
| Hemodynamic Status Nursing Interventions | Rationale |
| Assess for homeostatic imbalance (coagulation and bleeding). | The disseminated deposition of fibrin clots in the microcirculation is caused by the extensive activation of the clotting system or coagulation mechanism. Simultaneously, the concurrent consumption of clotting factors and platelets can lead to bleeding. |
| Review laboratory tests, particularly prothrombin time and partial thromboplastin time | Indicates the presence and progression of coagulation disorder |
| Ask about the patient’s chest pain, headaches, and abdominal pain. | These are indications that blood clots have possibly accumulated in the blood veins of the heart or lungs, obstructing normal blood flow. Typical symptoms of pulmonary embolism include abrupt breathing difficulties, excessive coughing, and chest pain. In the case of coronary artery blockage, it can cause a heart attack. Symptoms of bleeding, which might be life-threatening, include abdominal pain and headaches. |
| Assess the patient’s HR, BP, and peripheral pulses. | Decreases or irregularities in these parameters can reveal thromboembolism, which may result in tissue ischemia. |
| Provide oxygen support as necessary. | Saturates hemoglobin, supports metabolic needs, and corrects hypoxia |
| Administer anticoagulants per the physician’s guidelines. If the patient is already on anticoagulant medications, the dosages should be double-checked. | Anticoagulation therapy is often indicated for patients with DIC to replenish procoagulant components. It may also be used as a treatment option following myocardial infarction, acute coronary syndromes, chronic stable angina, and coronary artery disease to reduce reinfarction, thromboembolism, and stroke. The prevention of bleeding and clot formation can be assisted by verifying the correct dosages. Continuous monitoring and routine blood draw may also be necessary. |
| Reposition the patient every 2 hours in a semi or high-Fowler’s position as tolerated. | Position changes promote circulation and tissue perfusion. It also provides an opportunity to assess for any bleeding or changes in skin integrity. Moreover, an upright position facilitates lung expansion and alveolar gas exchange. The nurse should avoid elevating the patient’s knees on the bed, as this could increase the risk of vascular stasis and thrombosis. |
Hemodynamic Status Nursing Care Plan 3
Risk for Decreased Cardiac Output
Nursing Diagnosis: Risk for Decreased Cardiac Output related to an unstable hemodynamic status secondary to aortic aneurysm.
Desired Outcome: The patient will maintain effective cardiac output as evidenced by normal HR (60-100 bpm), strong, palpable pulse, and a normal level of consciousness.
Hemodynamic Status Nursing Care Plan 4
Risk for Ineffective Tissue Perfusion (Cerebral)
Nursing Diagnosis: Risk for Ineffective Tissue Perfusion (Cerebral) related to an unstable hemodynamic status secondary to cerebrovascular accident or stroke.
Desired Outcome: The patient will maintain an improved level of consciousness and motor/sensory function and will demonstrate stable vital signs with an absent increase of intracranial pressure.
| Hemodynamic Status Nursing Interventions | Rationale |
| Assess the patient’s respiratory and neurovascular status. | Routine assessment will help plan interventions for the modification of these functions. Tachypnea and fatigue are early indicators of hypoxia. Patients may appear with acute neurologic symptoms, such as rapid deterioration of motor, sensory, or visual function, as a result of transient ischemia to a specific portion/area of the brain. |
| Monitor alterations in BP, HR, and rhythm. Check for the presence of murmurs. | The presence of bradycardia and changes in blood pressure can be caused by damage or injury to the brain. Hypertension is a major risk factor for stroke, while hypotension can result from circulatory collapse (hemodynamic instability). Dysrhythmias and murmurs may indicate cardiac dysfunction, potentially triggering a cerebrovascular accident (CVA). |
| Monitor changes or trends in neurological status. | Determines increased intracranial pressure, its location, and progression of damage. It may also indicate a transient ischemic attack, which might culminate in thrombotic stroke or CVA. |
| Elevate the head of the bed (HOB) slightly and have the patient assume a neutral position. | Reduces arterial pressure to improve venous drainage and cerebral perfusion. A mean arterial pressure below normal levels results in ischemia. Possible end-organ manifestations like infarction can also result. Inadequate perfusion in cerebral tissues may lead to neuronal death and loss of consciousness. |
| Avoid hyperextension or flexion of the head or neck. Instruct the patient to refrain from assuming a Trendelenburg position. | These measures promote venous blood return to the heart and minimize cerebral congestion. |
| Encourage bed rest and an environment that promotes rest. Limit the frequency of visits and duration of procedures, and schedule rest periods between care activities. | An environment that is calm and relaxing can help maintain blood pressure and intraabdominal pressure within therapeutic limits and reduce stress, both of which can elevate ICP and promote rebleeding. |
Hemodynamic Status Nursing Care Plan 5
Nursing Diagnosis: Impaired Gas Exchange related to unstable hemodynamic status secondary to acute respiratory distress syndrome (ARDS), as evidenced by dyspnea, labored breathing, cyanosis, rapid pulse rate, and hypoxia.
Desired Outcome: The patient will maintain optimal gas exchange and oxygenation, as evidenced by normal oximetry, arterial blood gas, and heart rate.
| Hemodynamic Status Nursing Interventions | Rationale |
| Evaluate ventricular function and assess the patient’s RR. Note: depth, effort, breathing patterns. | Abnormal respiration patterns (such as shallow and rapid breathing) can impair gas exchange. In hypoxic situations, increased inspiratory effort and use of accessory muscle are observed. Meanwhile, spontaneous inspiration might increase abdominal pressure and the pressure gradient in the right atrium, thereby inhibiting venous return. |
| Auscultate for abnormal breath sounds (crackles, wheezes) | Abnormalities in normal breath sounds may indicate the cause of impaired gas exchange and the likelihood of airway obstruction, which may induce or exacerbate hypoxia. |
| Note any alterations in the patient’s HR and BP. | These parameters increase in the presence of hypercapnia and hypoxia. |
| Examine the color of the patient’s skin, including the nail bed, for cyanosis. | The presence of peripheral cyanosis in the extremities can reveal hypoxia, provide insight into the patient’s hemodynamic status, and indicate the likelihood of shock. |
| Assist the patient in assuming a semi-Fowler’s position with the head of the bed raised as tolerated. | This position enhances lung expansion and prevents abdominal contents from compressing. |
| Provide reassurance and aid the patient in reducing stress and anxiety. | Anxiety can increase RR, work of breathing, and dyspnea. |
| Incorporate rest periods in the patient’s schedule and pace activities to prevent fatigue. Encourage mobilization therapy. | Increasing the patient’s mobility with range-of-motion exercises increases activity tolerance, promotes ambulation, and reduces ventilator use. It may also be required to reduce sedation in order for the patient to participate in ADLs. ADLs increase the patient’s oxygen use and should be planned to prevent hypoxia. |
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
