2571central venous pressure

7/28/2019 2571central Venous Pressure

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CENTRAL VENOUSPRESSURE

MONITORING

Dr. Aidah Abu Elsoud Alkaissi

An-Najah National University

Nursing College


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Diagram of placement of central venouscatheter: the catheter is tunneled under skin

and enters the superior vena cava into the

right side of the heart


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Tunneled CVC


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CVP monitoring can be done intermittentlyorcontinuously.

The catheter is inserted percutaneously or using a cutdown method.

Typically, a single lumen CVP line is used for intermittent pressurereadings.

To measure the patients volume status, a disposable plastic watermanometer is attached between the I.V. line and the central catheterwith a three- or four-way stopcock.

CVP is recorded in centimeters of water (cm H2O) or millimeters of

mercury (mm Hg) read from manometer markings.

Normal CVP ranges from 5 to 10 cm H2O or 2 to 6 mm Hg.


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Any condition that alters venous return,circulating blood volume, or cardiacperformance may affect CVP.

If circulating volume increases (such aswith enhanced venous return to the

heart), CVP rises.

If circulating volume decreases (suchas with reduced venous return), CVP

drops.


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Equipment For intermit tent CVP mon i tor ing:Disposable CVP manometer set leveling

device (such as a rod from a reusable CVP pole holder or a carpenters level orrule) additional stopcock (to attach the CVP manometer to the catheter)extension tubing (if needed) I.V. pole I.V. solution I.V. drip chamber and tubingdressing materials tape.

For cont inuou s CVP moni tor ing:Pressure monitoring kit with disposablepressure transducer leveling device bedside pressure module continuous I.V.flush solution 1 unit/1 to 2 ml of heparin flush solution pressure bag.

For wi thdrawing b lood s amples throu gh th e CV l ine:

Appropriate number of syringes for the ordered tests 5- or 10-ml syringe for thediscard sample. (Syringe size depends on the tests ordered.)

For usin g an interm it tent CV l ine:Syringe with normal saline solution syringewith heparin flush solution.

For remov ing a CV catheter:Sterile gloves suture removal set sterile gauzepads povidone-iodine ointment dressing tape.


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Implementation Gather the necessary equipment.

Explain the procedure to the patient to reduce hisanxiety.

Assist the physician as he inserts the CV catheter.

(The procedure is similar to that used for pulmonaryartery pressure monitoring, except that the catheteris advanced only as far as the superior vena cava.)


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Obtaining intermittent CVP readingswith a water manometer With the CV line in place, position the patient flat.

Align the base of the manometer with the previously determined zero reference point byusing a leveling device.

Because CVP reflects right atrial pressure, you must align the right atrium (the zeroreference point) with the zero mark on the manometer.

To find the right atrium, locate the fourth intercostal space at the midaxillary line.

Mark the appropriate place on the patients chest so that all subsequent recordings will be

made using the same location.

If the patient cant tolerate a flat position, place him in semi-Fowlers position.

When the head of the bed is elevated, the phlebostatic axis remains constant but themidaxillary line changes.

Use the same degree of elevation for all subsequent measurements.

Attach the water manometer to an I.V. pole or place it next to the patients chest.

Make sure the zero reference point is level with the right atrium.


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MEASURING CVP WITH AWATER MANOMETER To ensure accurate central venous pressure (CVP)

readings, make sure the manometer base is alignedwith the patients right atrium (the zero reference

point).

The manometer set usually contains a leveling rodto allow you to determine this quickly.

After adjusting the manometers position, examinethe typical three-way stopcock.

By turning it to any position shown at right, you cancontrol the direction of fluid flow.

Four-way stopcocks also are available.


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All openings blocked


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Manometer to patient


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I.V. solution to manometer


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I.V. solution to patient


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I.V.

solution

bottle

Manometer

Zero point

Three-way stopcock


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Verify that the water manometer is connected to the I.V.tubing. Typically, markings on the manometer range from2 to 38 cm H2O.

However, manufacturers markings may differ, so be sureto read the directions before setting up the manometerand obtaining readings.

Turn the stopcock off to the patient, and slowly fill themanometer with I.V. solution until the fluid level is 10 to20 cm H2O higher than the patients expected CVP value.

Dont overfill the tube because fluid that spills over the topcan become a source of contamination.


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Turn the stopcock off to the I.V. solution and open to the patient.

The fluid level in the manometer will drop.

When the fluid level comes to rest, it will fluctuate slightly withrespirations.

Expect it to drop during inspiration and to rise during expiration.

Record CVP at the end of expiration, when intrathoracic pressure hasa negligible effect.

Depending on the type of water manometer used, note the value eitherat the bottom of the meniscus or at the midline of thesmall floating ball.

After youve obtained the CVP value, turn the stopcock to resume theI.V. infusion.

Adjust the I.V. drip rate as required.

Place the patient in a comfortable position.


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Obtaining continuous CVP readingswith a water manometer Make sure the stopcock is turned so that the I.V. solution port,

CVP column port, and patient port are open.

Be aware that with this stopcock position, infusion of the I.V.solution increases CVP.

Therefore, expect higher readings than those taken with thestopcock turned off to the I.V. solution.

If the I.V. solution infuses at a constant rate, CVP will changeas the patients condition changes, although the initial readingwill be higher.

Assess the patient closely for changes.


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Obtaining continuous CVP readingswith a pressure monitoring system Make sure the CV line or the proximal lumen of a pulmonary artery catheter is attached to

the system.

(If the patient has a CV line with multiple lumens, one lumen may be dedicated tocontinuous CVP monitoring and the other lumens used for fluid administration.)

Set up a pressure transducer system.

Connect noncompliant pressure tubing from the CVP catheter hub to the transducer. Thenconnect the flush solution container to a flush device.

To obtain values, position the patient flat.

If he cant tolerate this position, use semi-Fowlers position.


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Locate the level of the right atrium by identifying thephlebostatic axis.

Zero the transducer, leveling the transducer air-fluid

interface stopcock with the right atrium.

Read the CVP value from the digital display on themonitor, and note the waveform.

Make sure the patient is still when the reading is taken toprevent artifact.

Be sure to use this position for all subsequent readings.


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Removing a CV line You may assist the physician in removing a CV line.

(In some states, a nurse is permitted to remove the catheter

with a physicians order or when acting under advancedcollaborative standards of practice.)

If the head of the bed is elevated, minimize the risk of airembolism during catheter removalfor instance, by placing

the patient in Trendelenburgs position if the line was insertedusing a superior approach.

If he cant tolerate this, position him flat.


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Turn the patients head to the side opposite the catheterinsertion site.

The physician removes the dressing and exposes the

insertion site.

If sutures are in place, he removes them carefully.

Turn the I.V. solution off.

The physician pulls the catheter out in a slow, smoothmotion and then applies pressure to the insertion site.


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Clean the insertion site, applypovidone-iodine ointment, and cover itwith a dressing as ordered.

Assess the patient for signs ofrespiratory distress, which may indicatean air embolism.


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Special considerations As ordered, arrange for daily chest X-rays to check

catheter placement.

Care for the insertion site according to your facilityspolicy.

Typically, youll change the dressing every 24 to 48hours.

Be sure to wash your hands before performing dressingchanges and to use aseptic technique and sterile gloveswhen re-dressing the site.


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When removing the old dressing, observe for signs ofinfection, such as redness, and note any patientcomplaints of tenderness.

Apply ointment, and then cover the site with a sterile gauzedressing or a clear occlusive dressing.

After the initial CVP reading, reevaluate readingsfrequently to establish a baseline for the patient.

Authorities recommend obtaining readings at 15-, 30-, and60-minute intervals to establish a baseline.


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If the patients CVP fluctuates by more than 2 cmH2O, suspect a change in his clinical status andreport this finding to the physician

Change the I.V. solution every 24 hours and the I.V.tubing every 48 hours, according to facility policy.

Expect the physician to change the catheter every72 hours.

Label the I.V. solution, tubing, and dressing with thedate, time, and your initials.


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Complications Complications of CVP monitoring

include:

pneumothorax (which typically occursupon catheter insertion)

sepsis

thrombus vessel or adjacent organ puncture, and

air embolism


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Documentation Document all dressing, tubing, and solution

changes.

Document the patients tolerance of theprocedure,

the date and time of catheter removal, and the

type of dressing applied.

Note the condition of the catheter insertion site

and whether a culture specimen was collected.

Note any complications and actions taken.


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Film of CVC

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NR=1

http://www.youtube.com/watch?v=nBNnS_0kC6o&NR=1

http://www.youtube.com/watch?v=Lb1Z3bndmA8
http://www.youtube.com/watch?v=Lb1Z3bndmA8&NR=1http://www.youtube.com/watch?v=Lb1Z3bndmA8&NR=1http://www.youtube.com/watch?v=p_0MQ75PK5U&NR=1http://www.youtube.com/watch?v=p_0MQ75PK5U&NR=1http://www.youtube.com/watch?v=m7ppMf3JnoE&NR=1http://www.youtube.com/watch?v=m7ppMf3JnoE&NR=1http://www.youtube.com/watch?v=nBNnS_0kC6o&NR=1http://www.youtube.com/watch?v=nBNnS_0kC6o&NR=1http://www.youtube.com/watch?v=nBNnS_0kC6o&NR=1http://www.youtube.com/watch?v=nBNnS_0kC6o&NR=1http://www.youtube.com/watch?v=nBNnS_0kC6o&NR=1http://www.youtube.com/watch?v=nBNnS_0kC6o&NR=1http://www.youtube.com/watch?v=nBNnS_0kC6o&NR=1http://www.youtube.com/watch?v=nBNnS_0kC6o&NR=1http://www.youtube.com/watch?v=nBNnS_0kC6o&NR=1http://www.youtube.com/watch?v=m7ppMf3JnoE&NR=1http://www.youtube.com/watch?v=m7ppMf3JnoE&NR=1http://www.youtube.com/watch?v=m7ppMf3JnoE&NR=1http://www.youtube.com/watch?v=m7ppMf3JnoE&NR=1http://www.youtube.com/watch?v=m7ppMf3JnoE&NR=1http://www.youtube.com/watch?v=m7ppMf3JnoE&NR=1http://www.youtube.com/watch?v=m7ppMf3JnoE&NR=1http://www.youtube.com/watch?v=p_0MQ75PK5U&NR=1http://www.youtube.com/watch?v=p_0MQ75PK5U&NR=1http://www.youtube.com/watch?v=p_0MQ75PK5U&NR=1http://www.youtube.com/watch?v=p_0MQ75PK5U&NR=1http://www.youtube.com/watch?v=p_0MQ75PK5U&NR=1http://www.youtube.com/watch?v=p_0MQ75PK5U&NR=1http://www.youtube.com/watch?v=p_0MQ75PK5U&NR=1http://www.youtube.com/watch?v=p_0MQ75PK5U&NR=1http://www.youtube.com/watch?v=p_0MQ75PK5U&NR=1http://www.youtube.com/watch?v=Lb1Z3bndmA8&NR=1http://www.youtube.com/watch?v=Lb1Z3bndmA8&NR=1http://www.youtube.com/watch?v=Lb1Z3bndmA8&NR=1http://www.youtube.com/watch?v=Lb1Z3bndmA8&NR=1http://www.youtube.com/watch?v=Lb1Z3bndmA8&NR=1http://www.youtube.com/watch?v=Lb1Z3bndmA8&NR=1http://www.youtube.com/watch?v=Lb1Z3bndmA8&NR=1http://www.youtube.com/watch?v=Lb1Z3bndmA8&NR=1


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Film of CVC

http://www.youtube.com/watch?v=-

ycJPmyHLuM&NR=1

http://www.youtube.com/watch?v=FXJvv

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http://www.youtube.com/watch?v=-ycJPmyHLuM&NR=1http://www.youtube.com/watch?v=-ycJPmyHLuM&NR=1http://www.youtube.com/watch?v=-ycJPmyHLuM&NR=1http://www.youtube.com/watch?v=-ycJPmyHLuM&NR=1http://www.youtube.com/watch?v=-ycJPmyHLuM&NR=1

2571central venous pressure

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