134 partiii criticalcareequipmentcompetencies
chapter11 pulmonaryarterycatheters 135
test should be completed before any type of radial artery access.
Protocols for Performing an ABG Blood Draw From Either an Arterial Stick or an A-Line A heparinized blood gas syringe is required.
•
Note facility policy to ensure the proper amount of
•
blood to be wasted prior to the specimen draw.
Remove all air from the syringe.
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Place the specimen on ice immediately after it is drawn.
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• Document the time and date of the specimen, patient’s temperature, type of O2 delivery device, O2 amount, and vent settings, if applicable.
Wait 20 minutes before obtaining blood for ABG
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analysis following any type of O2 change. This ensures adequate time for changes to be reflected.
Following an arterial stick, pressure is applied to the site until hemostasis, approximately 5 minutes. If anticoagu- lants have been administered, expect the time to increase to 10 to 15 minutes. A secure, noncircumferential dressing is applied to the site once hemostasis is achieved. A pressure dressing is not applied. Monitor the site for a palpable pulse, bleeding, ecchymosis, changes in skin color, coolness of the extremity, and patient complaints of numbness or tingling.
A-LINE
If the patient is to have an A-line inserted, a small-bore flex- ible-tip catheter is placed in the radial, femoral, brachial, or axillary artery. The radial is most desirable for infection prevention purposes. When preparing to assist with an A-line insertion, note that it is a sterile procedure.
Fast Facts in a nutshell
136 partiii criticalcareequipmentcompetencies
A few sutures are made at the insertion site to help keep the catheter in place. An occlusive dressing covers the site.
The catheter is connected to specific tubing and a facility- specified heparinized saline. A pressure bag is applied to the outside of the bag, applying 300 mmHg of force on the fluid, maintaining a flush of approximately 3 cc/hour to ensure line patency.
A single transducer system is attached to the line to moni- tor blood pressure (BP). A “box” attached to the monitor, a transducer cable, the transducer, and an air-fluid interface (stop-cock) are parts of the system. A stop-cock holder is often used via an IV pole. The transducer system is calibrated prior to A-line insertion per manufacturer/facility instructions.
The stop-cock should be level with the phlebostatic axis to zero the monitoring system after the A-line is inserted.
The phlebostatic axis is approximately the level of the right atrium (RA). It can be located by finding the fourth inter- costal space, midaxillary line. Once zeroed, the square-wave test will be completed:
Initiate the fast flush mechanism.
1.
Flush rapidly for 1/2 a second.
2.
Note the square-wave pattern on monitor. The waveform 3.
should rise quickly, level out (become flat) on top, then drop back down, looking like a square box on the A-line tracing (Figure 11.1).
Next, observe for an adequate A-line waveform.
4.
(Adapted from Ehlers, 2007; Mobile Infirmary Medical Center, n.d.;
Stillwell, 2006.)
Systole
Diastole Dicrotic Notch
A-line waveform
FIGURE 11.1 A-line waveform.
chapter11 pulmonaryarterycatheters 137
Ensure that A-line alarms are on and set to appropri- ate parameters for the patient. Re-level the transducer with patient/transducer movement and PRN. Check stopcocks/
connections frequently to ensure secureness. Dressings are changed according to the type of dressing applied and facil- ity policy.
A-line waveforms may become “damp,” which means that it appears either too short or too tall. Steps can be taken to correct these readings:
1. Assess the patient.
2. Perform non-invasive BP (NIBP) reading.
3. Overdamped waveform: A short, peaked waveform with minimal dicrotic notch. This depicts a low systolic BP with a high diastolic BP in relation to a true reading.
a. Assess pressure bag for 300 mmHg pressure and ade- quate reserve in flush bag.
b. Complete square-wave test.
c. Check insertion site for catheter position, drainage, kinks, and so on.
d. Assess tubing and A-line system for bubbles, and clear (do not flush air toward patient), if needed.
e. Check system for leaks, disconnection, and so on.
f. Aspirate blood from tubing (using aseptic technique), then flush the line well.
4. Underdamped waveform: A tall, peaked waveform. This depicts a high systolic BP with a low diastolic BP in rela- tion to a true reading.
a. Assess patient for low BP; check other hemodynamics if possible.
b. Complete square-wave test.
c. Assess system for air bubbles, and clear (do not flush air toward patient), if needed.
d. Assess length of tubing and make shorter, if possible.
e. Note number of stopcocks in use and decrease, if possible.
(Adapted from Alspach, 2006; Chohan & Munden, 2007; Ehlers, 2007;
Kerner, 2007; Nettina, 2010; Stillwell, 2006.)
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If problems persist, notify the physician. The catheter may need to be removed. It is within the registered nurse’s scope of practice to discontinue or remove an arterial line.
The procedure is as follows:
1. Confirm physician order.
2. Verify patient identity via two identifiers.
3. Review patient’s coagulation and hematology results.
4. Provide patient and family education.
5. Put on necessary PPE.
6. Remove dressing.
7. Aspirate 3–5 ml of blood from the port into a syringe;
leave syringe attached.
8. Apply pressure 1 to 2 finger widths above catheter inser- tion site.
9. Remove catheter in one swift stroke, noting if catheter tip is intact.
10. Apply pressure to site with a sterile 4 × 4.
11. Hold pressure until hemostasis; 5 to 10 minutes, or lon- ger if needed.
12. Apply a transparent dressing to site. Do not wrap dress- ing circumferentially around the wrist. No pressure dressing is needed.
13. Limit patient activity with associated limb for approxi- mately 1 hour.
14. Continue to monitor BP with an NIBP.
(Adapted from Alexander, 2006; Chohan & Munden, 2007; Ehlers, 2007; Kerner, 2007; Stillwell, 2006.)
Assess the site frequently for a palpable pulse, bleeding, ecchymosis, changes in skin color, coolness of the extremity, and patient complaints of numbness or tingling. Document education, procedure, and patient tolerance.
A vamp is often attached to an A-line. It makes main- taining aseptic technique easier and reduces the amount of blood wasted. If this type of device is not available, a port for blood draws can be used to access the line. Follow aseptic technique and ensure that an adequate flush fol- lows blood withdrawal regardless of the method used. For
chapter11 pulmonaryarterycatheters 139 systems without a vamp, apply a new, nonvented, sterile cap to the port with each access.