PULMONARY ARTERY CATHETERS (PA):
STANDARDS OF NURSING CARE IN CCTC (SONC)

1. Monitor ECG
2. Provide Emergency Equipment
3. Set-Up Hemodynamic Circuit
4. Maintain Accuracy
5. Display Waveforms
6. Monitor Cardiovascular Function
7. Maintain Closed System
8. Obtain Chest Xray

9. Select Appropriate Ports for Infusions
10. Obtain Blood Samples
11. Change Dressings
12. Reposition PA Catheter
13. Analyze CVP and PWP Waveform
14. Measure Cardiac Output
15. Document Placement
16. Paceport (TM) Catheters

STANDARD OF NURSING CARE

1.

Monitor ECG

All CCTC patients with PA catheters will have continuous ECG monitoring. See Standard for ECG Monitoring.

 1.

To provide continuous monitoring with prompt detection of changes in heart rhythm. PA catheters can slip into the right ventricle and produce ventricular ectope.

 2.

Provide Emergency Equipment

Access to ACLS equipment (e.g., defibrillator, drugs) is required for all patients with a PA catheter.  

 2.

Migration of the right heart catheter into the right ventricle can cause life threatening arrhythmias.

 3.

Set-Up Hemodynamic Circuit

Clinical Nurses in CCTC are responsible for the priming, zeroing, leveling, and maintenance of hemodynamic pressure monitoring circuits and for the assessment and monitoring of hemodynamic pressures and waveforms.

Clinical Nurses may flush hemodynamic monitoring circuits as required to maintain patency

Exception: left atrial lines and intra-aortic balloon pump lumens are maintained with pressurized heparinized saline BUT are not manually flushed by Clinical Nurses.

 3.

Clinical Nurses in CCTC have received additional education in the care of invasive monitoring circuits. Refer to Procedure for Hemodynamic Monitoring Circuits or Removal of a Right Heart Catheter.

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

 4.

Maintain Accuracy

Hemodynamic transducers are zeroed at each initial setup, with the air-fluid interface (stopcock above transducer) leveled to the mid-axillary line.

Transducer levels should be validated at the beginning of each shift, prior to each PWP or CVP measurement, following position changes, and prn to validate hemodynamic pressures.

Document level confirmation in the graphic record. Documentation is required at the start of each shift and q6h, prior to each CVP and PWP measurement, and following transducer repositioning.

 4.

Zeroing eliminates the effect of atmospheric pressure on measured hemodyamic values.

Leveling eliminates the influence of hydrostatic pressure on the transducer. A transducer that is positioned below the patient's heart will produce falsely elevated pressures and a transducer positioned above the patient's heart will produce falsely low pressures.

 5.

Display Waveforms

The tip of the PA catheter must be connected to a monitor that provides a continuous waveform display. Continuous monitoring with waveform display is required during transport.

 5.

The waveform from the tip of the right heart catheter must be displayed continually to demonstrate the catheter tip location within the heart. Continuous monitoring is required to promptly detect catheter migration into the right ventricle or pulmonary wedge position.

 6.

Monitor Cardiovascular Function

Monitor BP (Systolic/Diastolic/Mean), PAP
(Systolic/ Diastolic/ Mean), HR, RR and SpO2 continuously and document q1h in the graphic record, for all new admissions, and for patients with arterial lines or pulmonary artery catheters, who are receiving medications that influence blood pressure, or whose neurological, cardiovascular or respiratory status has varied during the previous 24 hours.

Nurses may decrease the frequency of BP monitoring in patients who remain stable without intervention, and who do not meet any of the requirements noted above. Monitoring frequency must be increased if the patient's condition deteriorates. When the frequency of monitoring is decreased, the rationale used to support the frequency change must be documented in the AI record.

 6.

To ensure prompt identification and documentation of patient status.

See also Standards for Respiratory and Neurological Monitoring.

7.

Maintain Closed System

All stopcocks must have dead-end (non-vented) luer lock caps or luer lock connected infusions. This includes stopcocks located on transducers.

Hemodynamic circuits are changed with each new line and prn.

7.

To prevent accidental entry of air or contaminants. Accidental movement of a stopcock that does not have a dead end luer lock cap can result in hemorrhage/air embolus.

8.

Obtain Chest Xray

Obtain chest xray daily, following all central venous or right heart catheter insertions, or if the right heart catheter is advanced > 5 cm.

8.

To identify complications including: pneumothorax, hemothorax, hydrothorax, catheter kinking, catheter placement (e.g. right atrial placement of CVP catheters or distal placement of right heart catheter), pulmonary infarction or hemorrhage.

Chest xrays do not need to be repeated for simple catheter withdrawals, unless there is ongoing concern regarding placement.

Daily and post-advancement xrays are done to assess for spontaneous catheter migration and to rule out distal placement, or to monitor for complications (e.g., hemorrhage, infarction, pneumothorax). Distal placement may be detected on xray, in the absence of a spontaneous wedge tracing.

9.

Select Appropriate Ports for Infusions

Continuous infusions that affect BP or cardiac output should not be administered via the blue proximal injectate port of the PA catheter.

If the proximal injectate port is the only site available for the administration of vasoactive drugs, utilize the proximal port but do not perform cardiac output measurements.

Although blood products can be infused through any central line, it is preferable that the blue injection port of the right heart catheter be avoided.

9.

During cardiac output measurements, 10 ml of fluid is administered into the proximal injectate port. This would result in the administration of a bolus of vasoactive drug. While performing the cardiac output injections, the infusion would be disrupted. After completion of the cardiac output measurement, a delay would occur before the infusion would reach the patient.

Administration of a vasoactive drug via a peripheral vessel places the limb at risk for injury. This risk outweighs the potential benefit associated with PA catheter monitoring.

Blood products may reduce patency of this lumen making measurement of cardiac outputs impossible.

10.

Obtain Blood Samples

Clinical Nurses may draw blood from the pulmonary artery catheter using a stopcock.

10.

See Procedure for Blood Withdrawal and Blood Gases Venous.

11.

Change Dressings

Central line dressings are changed q 2 days and prn if occlusivity is disrupted. Document date of change in the graphic record and kardex. Record any redness or abnormal findings in the AI record and report to the physician. See Procedure for Arterial and Central Line Dressings.

Lines are changed prn for evidence of site infection or sepsis.

11.

Dressings are change q 2 days in critically ill patients to allow site inspection and to reduce bacterial colonization (CDC recommendation). Skin condition, diaphoresis and site oozing necessitates more frequent dressing changes in critically ill patients.

For stable, long stay patients with central lines, Opsite 3000 (TM) dressings can be changed q7days as per general hospital policy, as long as occlusivity is maintained.

The Centre for Disease Control does not recommend routine line changes.

 12.

Reposition PA Catheter

Clinical Nurses may not insert or advance a right heart catheter. Clinical Nurses in CCTC may partially withdraw a right heart catheter from a persistent PWP or RV position without a physician's order. Clinical Nurses may remove a PA catheter with a physician's order.

Prior to withdrawal of a PA catheter tip from an RV to RA placement, switch proximal infusions to the introducer site.

 12.

Currently, the College of Nurses does not permit advancement of a right heart catheter. Clinical Nurses in CCTC have received additional education in the care of right heart catheters. Refer to Procedure for Partial Withdrawal or Removal of a right heart catheter.

During withdrawal of the PA catheter, or manipulation by the resident, the proximal ports (right atrial, right ventricular ports) may infuse into the introducer or the sleeve. This can cause fluid or blood to backup into the sleeve, with disruption of drug delivery.

13.

Analyze CVP and PWP Waveform

CVP and PWP measurements are obtained from a waveform printout. Waveforms are printed and analyzed to identify the right atrial pressure at end-expiration and the base of the "V" wave.

Waveform analysis is identified on a paper recording of each right atrial and PWP tracing. Each waveform is posted in the clinical record.

13.

The goal for right atrial pressure and PWP monitoring is to identify the pressures during end-expiration and end-diastole. Although the pre-C wave best reflects the end-diastolic pressure, it is often difficult to identify, reducing inter-rater reliability. For consistency, we measure the pressure during mid-diastole (during diastasis) because it is easy to find and reflects a pressure that is similar to the pressure at end-diastole.

14.

Measure Cardiac Output

Measure cardiac output q 6 h and prn following changes in vasoactive drugs, fluid administration or to reassess changes in the patients hemodynamic status.

Measure arterial and venous gases with each cardiac output, and enter data into the Critbase program. Measure hemoglobin OD and prn if indicated (e.g., to assess potential bleeding, following blood transfusion), and utilize most recent value to determine oxygen content variables.

Measure CVP and PWP prior to cardiac output measurement. Obtain a minimum of 3 injections, editing measurements to average 3 samples that have a variance of +/-10%.

14.

See Procedure for Measuring Cardiac Output.

See Procedure for Blood Withdrawal; Blood Gases Arterial.and Blood Gases Venous.

15.

Document

At the start of each shift, identify PA catheter placement and record the distance marker at the entrance point to the introducer hub in the intravascular device section of the flow sheet. Each single black line represents 10 cm, while each thick line represents 50 cm. The markings at the insertion site represents the amount of catheter "in" the patient.

Assess catheter patency and document in the intravascular devices section of the flow sheet at the start of each shift and q 4 h.

Document catheter repositioning procedures in the AI record and record changes to the distance marking in the intravascular device section of the flow sheet.

Monitor waveform continuously. Determine CVP and PWP q 6 h and prn as per #14. Document pressures in the graphic record.

Document intravenous infusion in the 24 hour assessment record and sign for all infusions in the MAR, including heparinized flush solution.

Record IV infusion volumes in the fluid balance record.

Record vasoactive drug doses in the graphic record section of the flow sheet.

Document dressing changes in flow sheet. Star and DAR abnormal findings.

15.

To assist in recognizing when catheter migration has occurred and to ensure distal placements are recognized and corrected.

Waveforms identify the location of the catheter tip. The catheter tip can spontaneously retract into the right ventricle and cause ventricular ectope, or advance into the distal pulmonary circulation and compromise blood flow. Catheter tip movement can occur without a change in the insertion point markings.

16.

Paceport (TM) Catheters

If a Paceport(TM) catheter is being used to pace a patient, the right ventricular side arm patency must be maintained as per any central line. Luer lock connections must be used, and it is recommended that an infusion (verses heparin lock) be used to maintain line patency. A flow rate of 1-2 ml is adequate by volumetric pump. Inotropes and vasoactive drugs may be infused through this lumen during pacing if needed.

Following insertion of a pacemaker wire, wedging should be performed cautiously, observing for any loss of capture of the pacemaker. If capture issues occur, do not use the catheter to perform PWP measurements during pacing.

Cardiac output measurements may be performed as long as capture issues do not occur during injection.

16.

The RV is an excellent location to introduce drugs that require central administration due to the large volume of blood for rapid dilution.

The higher RV pressure increases the potential for line thrombosis. Volumetric pumps at a low flow rate are usually sufficient to maintain the positive pressure that prevents line blockage.

During wedging, the right heart catheter migrates forward at the tip. In some patients, this can cause movement of the pacemaker wire. In some patients, positioning of the right heart catheter to facilitate pacing results in poor placement for wedging; it may not be possible to perform both functions. Assessment should be done on a patient-to-patient basis.