Critical Care questions

papawjohn · Jul 6, 2006

Hey Angelique!!

#1. You are correct, this is in a 'normal' person. But remember that the Pts you will see with PACatheters have had a long time to develop heart/lung disease and to compensate for it. There was a Pt in a Unit I was working in a year or two ago that had PAPressures like 65/25 and Wedge of 25 to 30. She was not in distress with these numbers. She'd had vascular surgery, had known pre-op Cor Pulmonale and was vulnerable to quick decompensation if anything went wrong--therefore the 'Swan'.

#3 You are correct again. There is a sensitive little pressure-sensor at the end of the catheter. When it just sits there in the Pulm Circulation, it senses that. When you inflate the balloon, you 'trap' a column of blood between the pressure-sensor and the Left side of the heart; for convenience-we call it the 'wedge' pressure. It would be more accurate to say Left Atrial Pressure.

#4 I'd vote for PCWP. When you give lasix (IV of course) you get a quick dilation of some of the arterioles in the kidney. So the kidneys sort of 'open up' and reduce the SVR. There is a 'lag-time' before the urine starts pouring and the actual volume of fluid starts to decrease. There is also a short 'lag' before the reduced SVR results in the Pulm Edema Fluid is absorbed into the blood stream and the 'crackles' go away. (This is one of those silly questions that turn up in textbooks and such. Cause if the lasix is going to work it'll work pretty darn quick.)

Hope that helps

Papaw John

Critical LPN · Jul 8, 2006

Great reply, also note the whole deal about the edema in the extremities depends on a multitude of other considerations. Is the edema just regular swelling. Note that is usually the last thing to show up if the pump is not working well unless there is a vascular problem also. So it takes a while for it to go away.

If the edema is what we refer to as "Third-Spaced", that 's a whole other problem to deal with as there may be nutrition ploblems to note. (Might have to do the old Albumin before lasix trick.) Not as commonly done anymore as studies show not the best thing to do and expensive. But I'll tell you that if you have a compromised patient that has been sick for a long time, this old trick still works great. After all, if you are nutritionally deficit, nothing works! :bluecry1: And if you can get them with a better albumin level, the heart usually as well as the kidneys, profuse better with any meds you give. A starved body goes into defense mode to protect the vital organs, but if it is weak, the pathways of defense sometimes get skrewed up and it's like beating a dead horse to do the regular things you think will work:deadhorse.

Also note the beginning PCWP on admintion as well as when the patient states they feel better so that you will know what their tolerative baseline is. Like PaPaw John said, note any long term health, heart problems that have an effect on all your readings. Also there is the argument over the lay patient flat to read verses as long as you adjust the level of the transducer to the proper position in relation to how the patient is sitting or laying, to take your readings, the reading is correct. I say you have to do what your policy states but any patient that has problems when you lay them flat with either post-op pain or back/joint pain or just plain old shortness of breath is an argument to get the reading in the most comfortable position you can. Any stress, pain, shortness of breath or splinting that the patient does will have an adverse and most likely incorrect reading when obtained. Don't know if others agree but I have found that charting the exact degree of the head of bed and balancing the transducer to the proper level makes for more consistant readings. It helps to post a sign on the transducer as well as the chart to let other nurses know at what level the HOB was and mark the patient with a marker at the proper spot to always be consistant .

Also let the Dr. know the problems with stress of patient and readings so they do not automatically lower HOB to look at SWAN pattern or try to check themselves. Again you have to go with the policies that you have but remember each patient is different and the norm does not always give you the best results to medically treat the patient. I have seen the old lay them flat in all kinds of distress for whatever reason, done and then the Dr. based the amount of medicine on this reading and then they crashed from hypovolemia because too much lasix or cardiac meds given. Some patients will always huff and puff laying flat, no matter what there values are. Sorry so long a post but since Angelique said this would be fairly new to her area, just thought I'd pass on a few tidbits for thought. Again, just my experiences and findings, but you have to go with your policies but you might check with the head of your area or Clinical Specialist for Critical care if you have patients that the SWAN readings are hard to get a grip on. :bugeyes:

steelydanfan · Jul 17, 2006

The joke answer is; "I have no idea what a normal PWCP is. I have never seen one"