Central venous pressure monitoring

-CVP is the one of invasive hemodynamic monitoring through insertion of the catheter in large vein to right atrium.

-to provide a good assessment of right- sided cardiac function and venous return to the right side of the heart.

-The CVP are indirect method to determining right ventricles filling pressure[ preload].

-This is inserted by a physician when the patient needs more intensive cardiovascular monitoring.

Normal CVP is 5-12cm H2Oor 2-6mmHg.CVP is elevated by :

-overhydration which increases venous return.-heart failure or PA stenosis which limit venous outflow and lead to

venous congestion.-positive pressure breathing, straining.

CVP decreases with :-hypovolemic shock from hemorrhage, fluid shift, dehydration.

-negative pressure breathing which occurs when the patient demonstrates retractions or mechanical negative pressure which is sometimes used for high spinal cord injuries.

Description: The catheter is usually held in place by a suture or staple and an occlusive dressing. Regular flushing with saline or a heparin-containing solution keeps the line patent and prevents infection.

Purposes: a. To serve as guide for fluid replacement. b. To monitor pressure in the right atrium and central veins.c. To administer blood products, TPN and drug therapy contraindicated for peripheral infusion. d. To obtain venous access when peripheral veins sites inadequate.e. To insert a temporary pacemaker. f. To obtain central venous blood sampler.

Possible cannulation sites for central venous access include:Basilic (arm) vein Femoral vein Subclavian vein External jugular vein Internal jugular vein

Equipment:1-CVPkit

2-Flush system composed of intravenous solution [ contain heprain],tubing ,stopcocks and flush device

3-Pressure bag place around the flush solution is maintained 300 mmgh pressure , pressurized flush system delivers 3 to 5 ml solution per hours through cathter to prevent clotting.

4 -Transducer to convert the pressure from right atrium into electrical signal.

5-Monitor which increase size of signal for display on oscilloscope. 6 -IV pole.

Monitoring CVP: 1 -Pressure monitoring system.

2 -Water manometer system. Procedure guidelines:

Nursing action Rationale Preparatory phase ( by the nurse )

1 -Explain the procedure to patient. 2 -Position patient appropriately.

-Place patient in supine position . -Provides for maximum visibility of veins.

-Neck veins place in - To reduces risk of air trendelenburg,s position . emboli.

3 -Flush IV infusion set and manometer or prepare heparin flush for use with

transducer . Secure all connections to prevent air emboli and bleeding.

Procedure: ( continued ) Nursing action Rationale

a. Attach manometer to IV pole .The - The level Rt atrium is at 4th zero point of the manometer should intercostals space midaxillarybe on level with the patient right atrium. Line.b. Zero transducer & level port with pt

right atrium.4 -Place ECG monitoring. 4-Dysrhythmias may be

noted during insertion.Insertion phase : ( by physician )

1 -The CVP site is surgically cleaned . 1- CVP insertion is a sterile procedure.

2 -Assist the patient to remaining motionless during insertion.

3 -Monitor for dysrhythmias , 3- indicted for signs of tachypnea, tachycardia as catheter pneumothorax or arterial puncture.threaded to great veins . is

4 -connect primed IV tubing to 4- To keep the vein open. catheter and allow IV solution

to flow . 5 -The catheter should be suture 5- To prevent dislodgement.

in place. 6 -Place a sterile occlusive

dressing over site .7 -Obtain a chest x-ray. 7- Verifies correct catheter

placement and absence of pneumothorax .

To measure CVP1 -Place the patient in supine position.

2 -Position the zero point of the manometer should be on level with the patient right atrium .

Procedure guideline : ( cont..)Nursing Action Rationale

3 -Turn the stopcock so the IV solution

flow into manometer ,to about 20 – 25 cm level . And the turn stopocock so the solution

in manometer flow to the patient.

4 -Record the level the at which the solution stabilizes .this CVP reading

.5 -CVP catheter connect to transducer

and electrical monitor with CVP wave readout.

6 -CVP may range from 5 to 12 cmH2O 6- Any changes indicate of or 2 to 6 mm Hg. Adequate venous blood volume

and alteration of cardiovascular function .

7 -Assess patient condition.

8 -Turn the stopcock again to allow IV 8- To keep vein open and solution to follow to patient veins and prevent fluid overload.

should monitor infusion hourly.

follow up phase: 1 -Prevent and observe for complication.

a. From catheter insertion : pneumothorax. hemothorax , air embolism . hematoma

and cardic temponade.b. From indwelling catherer : infection ,

air embolism, central venous thrombosis.

2 -Make sure cap is secure on the end of 2- Reducing risk of air embolus the CVP monitor and all clamps are close

when not in use.

3 -If air embolism is suspected , 3- To prevent air bubbles from immediately place patient in left lateral moving into lungs and will

trendelenburg position and administer absorbed in 10 to 15 minutes inO2. right ventricular outflow tract. Procedure guideline : ( cont..)

Nursing Action Rationale

4 -Carry out ongoing nursing intervention of the insertion site and maintain aseptic technique.

a. Inspect site twice daily for signs of a. Local infection may lead local inflammation and phlebitis . to systemic infection .

Remove the catheter immediately if there are signs of infection .

b. Make sure sutures are intact . b .if catheter dislodges into right atrium , dysrhythmias may

result. c. Change dressing as prescribed.d. label to show date and time of change.e. Send the catheter tip for bacteriological e. To detect bacterial

culture when removed. colonization.

5 -When discontinued , remove central line.

a. Position patient flat with head down. a. Prevents air from entering blood vessel.b. Remove dressing and suture.c. Have patient take deep breath and c. Prevents air emboli by

hold it while catheter is removed. creating positive chest pressure.d. Apply pressure at catheter site d. To prevent bleeding .and apply dressing.e. Monitor site and vital signs for

signs of bleeding or hematoma formation.

References: 1-Suzanne C.Semltzer,Brenda G.bare,(2004), Textbook Medical surgical

nursing ( 10th edition ).2 -Lippincott Williams & Wilkins, ( 2006 ), Manual nursing practice ( 8th

edition ).