CAROL DVORAK-KING, RN, CCRN PA catheter numbers made easy. If you're less than comfortable interpreting data from pulmonary artery catheters, try using this worksheet. It makes analyzing your patient's cardiac status a snap. CAROL DVORAKKING is an ICU staff nurse at Good Samaritan Hospital in Kearney, Neb. ‘STAFF EDITOR: Amy Slugg Moore Patmonary artery (PA) catheters are one of the most important and reliable assessment tools available to the critical care nurse. Used to monitor hemodynamic status, these catheters directly measure pros- sures inside the right side of the heart and in the pulmonary artery. In doing 80, they yield valuable clues as to how well the heart fune- ‘tions as a pump. For a nurse who is unfamiliar with them, though, PA cathevers cat be a great, source of auaiely, To make hemodynamic intor- pretation easier—for experienced and inexperienced nurses alike—I suggest using the PA catheter worksheet shown on page 46. It can help the ICU nurse track a patient's vandiae status, monitor response to medications, and an- ticipate the appropriate medical intervention, ‘The workshoot has its limita- tions, though. Although itis help- ful in the evaluation of most eam diac patients, particularly those with a diagnosis of myocardial in- farction (MD, congestive heart ail ure (CHF), ur eardivgenicshuck, it doesn't work well for every type of cardine disease or shock state. ‘And it shouldn't be used for diag- nostie purposes. Before you can put the work- Sheet to use, you need to have an understanding of basic hemody- namie principles. Here is a quick review. What the numbers: and acronyms mean Pulmonary artery catheters mea- sure—either directly or through calenlation—the following hemo- dynamic parameters: Right atrial pressure (RAP). This is the pressure in the right atrium during ventricular fling. It’s usually consistent with right ventricular pressure heeause, diir- ing diastole, the open tricuspid valve permits direct communica- tion between the two chambers. The RAP, therefore, isa reflection uf right veutricular” fuuction, It's also essentially the same as the central venous pressure (CVP). ‘Normal RAPis 1 to7mm Hg. It is elovated in conditions like right ventricular failure, tricuspid valve Gisease, pericardial tamponade, and fluid overload; it's decreased {in hypovolemia and vasodilation, Pulmonary artery pressure (PAP). This is usel to evaluate car iae fanction and detect. problems in the pulmonary vaseulature. The systolie (PAS) reading indicates the pressure in the pulmonary ar- tery as blood is being ejected from the right ventticle, A high PAS NOVEMBER 1907 RN 45‘pressure can mean right heart fail ‘ure, cardiac tamponade, or pul- monary hypertension. A decrease indicate hypovolemia "The diastole (PAD) reading rep- resents pressure in the pulmonary artery as blood moves frum the artery into the lung's capillaries. ‘An increase in PAD pressure can indicate left ventricular failure or pulmonary hypertension, A de- erease ean signal hypovolemia, Normal PAP is 20-30/10-15 mm. ‘Hg. The mean PAP is the averaxe pressure in the pulmonary vascu- Iature throughout the cardiac cy- de. It’s usually 10-20 mm Hg. Pulmonary artery wedge pres- ure (PAWP). This parameter re- fleets left ventricular function. It is also called the pulmonary capil- lary weaige pressure (PCWP). To rmeassre it, the balloon at the tip of the PA catheter is inflated. Blood flow pushes Ue ballown vut, of Une pulmonary artery and into tho pulmonary capillaries, where it “wedges” in one of these small vveseels, So, the catheter tip is es sentially looking at. the left atri- uum. Because, during diaswle, the valve between the alrium and ven- Lricle is upen, the PAWP reflects left ventricular pressure, Normal PAWP ranges from 6to 15 mm Hg: Unless the patient has pulmonary disease, the average PAWP should correlate with the PAD. A high PAWP occurs with left. ventricular failure, septal de- fects, and with mitral insufficiency. A low PAWP can be a sign of hypovoletnia, Cardiae output (CO). This is the volume of blood pamped fram the heart in one minute. Normal cardiae output ranges between 4 and 8 L/min, I's equal o the heart rate multiplied by the stroke vol- ume (SV), which is the amount of Normal {Low to normal PAP ‘Subset It towel Low to normal PAWP Carciae index (CI) Uminien? Cbsnerheeenhs buenas PA Catheter Worksheet Subset tit ‘Wocmal Cl High PAWE Na HAS ET Hv WII Tes 16 iSTOIT IOS z0z1 ze 0s zERCET 207990 Pulmonary artery wedge pressure (PAWP) (mm Hg) blood ejected from the left ventri cle with each contraction. Normal SV is between 60 and 130 ml. Stroke volume, in turn, is deter mined by contractility, preload, and afterload. Contractility is the fore with which the heart muscle pumps. As contractility rises, 80 do SV and CO. reload is the amount of strotch on the myocardium at the end of diastole. ‘The KAP reflects the right heart’s preload and the PAWP reflects the lefts According to the Frank-Starling Jaw, the more the myofibrils stretch before systole, the stronger the heart will contract. In other words, increasing preload increases con- tractlity. This holds true, howov- er, only up to a point. Ifthe ventri- des overstretch, contractions actu ally beeome weaker, and stroke volume and cardiac output drop. ‘Afterload is the impedaneeto the é’jection of blood from the ventricle, or the resistance that the ventricle ‘must overcame to eject blood for- ward, Blood viseesty, vasmlar dis. tensibility, and pressure in. the pulmonary vasculature, aorta, and systemic arteries all contribute to stance, Increasing afterload will raise the pressure against which the heart must pamp; so & high afterload makes the heart. work harder, IfaRerlond is too high, SV and CO will probably drop. Systemie vascular resistance (SVR) is a measure of the lef heart's afterload (normal is 900 — 1,400 dynes/sec/em’). Pulmonary vascular resistance (PVR) refleets theafterload of the right heart (it's normally 50 ~ 250 dynesisee/em®). ‘These values are caleulated from other hemadynamie parameters. Cardiac index. This, too, is a calculated value. It’s determined by dividing CO by the patient's body surface area (BSA). ‘The monitoring equipment calenlates BSA from the patient's height and ‘weight. A normal CI is between 46 RN NOVEMBER 1997| Hemodynamic subsets: Possible interventions eT Relow are the treatment options and possible interventions foreach clinical subset, Drugs and other {actors that affect preload, aterioed, contractility, and heart rate are also listed. SUBSET | Normal Cl, low to normal PAWP Monitor regularly ‘Administer 0, Offer prt pai medication Sedation red ‘These interventions are usually necessary since most patients aron’t problem-free; they may just have normal readings.) SUBSET IIL Normal Cl, high PAWP _ Kaminister 0; Decrease pre'oad Offer pen pain medication Sedation as ordered Optimize heart rate Enhance contractility SUBSET II Low Cl, low to normal PAWP SUBSET IV Low Cl, high PAWP. Raministor WV fluids Administer O, Enhance contractility Decrease afterload ABP Optimize heart rate ‘Surgical intervention for a vorectable cardiac problem ‘aiminister Op Decrease preload Decrease afterload Enhance contractility Optimize heart rate ABP Surgicel intervention for a correctable cardiac problem | rao To increase: To increase: Fluids Dovatnine (Inotropin) Vasopressors Norepinephrine (Levephed) To decrease: To decrease: Diuretics ACE inhibitors Fluid restriction Alpha blockers Low-salt diet ‘Amrinone (Inesor) ‘Arterial vasodilators Beta lockers Calcium channel blockers tage Mitrinome (Primeccr) Morphine Nitrates Nitroprusside (Nipride, ‘Nitropress) Positive-end expiratory pressure (PEEP) Venous vasodilators CONTRACTILITY TE To increase/enhance: To increase: ‘Aminone (Inocor) Atropine Dobutamine (Dobutrex) Cardiac. pacing Doparnine (lnotrepin) Calcium Digoxin (Lanoxin) Epinephrine (Adrenalin) Isoproterenol (Isupre!) Milrinane (Primacor) Norepinephrine (Levophed) To decrease. Beta blockers Calciuin channel blockers Epinephrine (Adrenalin) Isouroterenol (Isupret) To decrease: Antiarshythmies Beta blockers Calcium channel blockers Cardiac pacing Digoxin (Lanoxin) | aan evar otra eens = 24-4 Lémin/m®. I like to think of {tas an individualized CO because it takes budy size into account. A tool that helps plot cardiac function tal axis, With these basics in mind, let's take a closer look at the PA ealheler worksheet. The vertical axis measures the patient's car~ iae performance, as the CL. The PAWP, a reflection of preload, is charted on the horizon To use this tool, simply plot your patient's Cl against his PAWP. ‘The point should fall into one of the ‘box's quadrants, or clinical subsets ‘Treatinent options for each subset are listed in the table above. For example, a cardiae patient with a normal CI and low to nor- mal PAWP would bo insubset I. A patient with a low PAWP and a ow CI would be in subset T—an area that may reflect volume depletion. Since this subset also includes pationts with a low CI but ‘a normal PAWP, someone with indicated by NOVEMBER 1997 RN 47plotting the CI and PAWP, be PA Catheter Worksheet (Mr. Jay) iene eee acne other hemodynamic parameters as well si i Subset | Subset It Putting the worksheet tow to rormat Paw [Tf LTE HEH rane to action Day 2 To better understand how to use 10am this tool, consider the case of Mr. Jay, a 69-year-old male with a his. tory ofheart disease. A year and a ydex (CI) Liminien?® oem. half ago, he suffered an uncompli ated but extensive anterior wall MI. He underwent. trple-hypass ‘Subset I Subset IV surgery and went home on med- Low cl Low cl ica ecrease the heart's Low to normal PAIN ign PAE Sr ayers Pa aa Ee wp lov isis 4 1SieT7 18102021 aSaNIESERTINTOIO hibitor captopril (Capoten) and Pulmonary artery wedge pressure (PAWP) (mm Hg) isosorbide dinitrate (Isordil), De- spite these interventions, Mr. Jay has been having increasing dysp- nea on exertion, wealmess, and bradycardia that's compromising subset a patient falls, your goal is fatigue. candine ontpt might als be in th mave him tawani subset T. Now, his wife has hronght. him this box. Let's say, for instance, a patient to the ED because he is so weak ‘A volume overloaded patient has been overly diuresed and is that he cannot maike the trip from with congestive heart failure tachyenrdic; his numbers put him his chair to the nearby bathroom (CHF), for example—who has a in subset II, According to the in- without exporioncing severe short- borderline or normal CI but ahigh terventions. worksheet, you will ness of breath. He has been sleep- PAWP wonld fall into subset 111, administer IV fiuids—eantionsly, ing sitting mp in his chair heeanse ‘The patient in eardiogenie shock thongh, heeanse yon don’t want tit. helps him “breathe better.” His ‘would be in subset IV:he'd have a make things worse—and possibly wife tells you that his legs have high PAWP and a low CI. vasoactive drugs. Each time you become more swollen and he has ‘These subsets are general cate- intervene or make an assessment, gained six pounds in the last few gories that can be helpful to nurs- plot his CI and PAWD. By doing days, even though he hasn't been ‘es who care for patients at risk for this, you will be able to gauge his eating well. He denies any chest low eardine output states. Don't response to medications and other pain. follow them too rigidly, For exam- treatment, Suspecting acute CHF, his car | ple, don’t be lulled into thinking To be truly helpful, the work- diologist admits him to the CCU, ‘that a patient. in subset I is fine sheet must be used before and where a PA catheter is inserted. just because his Cand PAWP are after each intervention and when- In the meantime, Mr. Jay's labs normal. He hasa PA catheter fora ever there is a change in the pa~ and EKG, which were done while ‘reason, und he'l still require regu-tient's condition—not just at reg- he was in the emergency depart- Jarmonitoring and porsibly 0,,prn ularly echeduled intervals ouch aa ment, come back negative for MI, pain relief, and sedation as well. every two hours. Although you affirming the diagnosis of CHF. And keep in mind that not every might not sueceed in getting every You perform a physical assess- patient. will fit neatly into the patient intosubset T, yon still want, ment and obtain the initial PA ‘worksheet's categories, ‘to move them in that direction. catheter readings at 10 a.m. You nee you determine into which And even though you are only nove that Mr. Jay 1s restless and 48 RN NOVEMBER 1997anxious, and he is barely able to speak because of his labored breathing. His skin is pale, warm, and moist. Capillary refil time is four seconds. Vital signs are: RR 30 (with the use of accessory mus- los}, KF YWod; and HE 138, sinus tachyeardia, Jugular vein disten- sion is approximately five centi- meters, You hear crackles posteri- orly and a classic $3 gallop. His PA catheter readings re- veal a PAWP of 26 and a CI of 25. You plot these findings on the worksheet, a8 shown on at lef, and ft places Mr. Jay in subset TIT. He's given IV furosemide (Lasix) and IV digoxin (Lanoxin) STAT; supplemental oxygen that was started in the ED is continued. In some hospitals, Mr. Jay might also have been started on dobutamine, but that is up ta the protocol at your facility. By 2 pm, Mr. Jay's vitals have improved: BP 10264; HR 98, and RR 22. His PAWP is 16 and CT is 2.6, placing him in arms reach of subset I—safe for now. When you return the next day, however, you find that Mr. Jay has taken a tum for the worse. At 8am. his BP has fallen to 7882. “Your assessunent reveals a weak, rapid, and thready pulse. His skin is cool and elammy. He can barely breathe, and his blood gas results are poor. His PAWP is 28 and CI ie 15, with an SVK of 1,956 dynes/seclem®. He is now in sub- set, TV—cardiogenie shoek—and he is immediately intubated. ‘The canliologist asks you to be- ‘gin a dupanine infusion, adminis- ter more furosemide, snd a bolus of amrinone (Inocor). Mr. Jay is also placed on a nitroprusside (ipride, Nitropress) drip. De- spite these interventions, his eon- dition does not get better, so the physician orders an intra-aortic talloon pump (LARP) to maximize perfusion, Once on the pump, Mr. Jay slowly begins to improve. By 4 pam, his BP has inereased but is hovering around 880. Wis TR Muctuates between 102 and 118. Tis PAWP is 20, Cl is 18, and SVR is down to 1,700, He's stil in subset TV and has a way 10 £0 before he is completely stable, but at least he's moving in the desired direction, Because Mr. Jay needs a new heart, he is placed on a transplant, list. If he continues to improve, he will be weaned from the pump and given dobutamine. He may even- tually be able go hame with orders for home infision therapy and skilled nursing care, For the time being, however, he remains in the cou. ‘Although nothing can replace a murze’s judgment, critical thinking skills, and Imowledge, the PA eath- eter worksheet can be dU ‘mendous help when used ws an adjunct to patient assessment. By providing, a visual representation of the patient's progress, the work: sheet helps the experienced maree ‘anticipate the appropriate care and new nurses clearly see how vari- ous treatments affect hemodiymam- iestatus.1 ‘SUGGESTED RFADING 1, Dally, EL. & Schroade, J. , (1994). Tachnigucs in bedside hembajinamic man: Itong (Sth ed). St. Louis: Musby-Year Boot, Ine 2. Davore, G. 0. (1995). Heraxamic ‘monitoring: Invasive and noninvasive clin- {eal appricatint (Zid ws.) Philadelphia. WB, Saunuers Company. 2, ¥itele Cee, J. M, & O'Sulvan, C.K (1997). Herds monitoring. In J. Hartshorn, ML Sole, & ML. Lamborn (Eds), Inoduction to critical care nursing (pp. 86-121), Phiadelpnia: W. 8. Saur- ers Company. NOVEMBER 1997 RN 49 — «SAFE. PERMANENT Nd be 100 MUCH TO ASK? SPEAK UP FOR AN ABUSED AND NEGLECTED CHILD IN COURT. Is 11 Far infoomation on volunteering cat Court lgpointed Special ANebweate call L-NV-028-72 orwrit Navid CAS] 100 Wi: Hare Neth Suite 300 Scuttle WA asity