Purpose
- To assess cardiac function, evaluate venous return to the heart, and indirectly gauge how well the heart is pumping.
- To gain access via the central venous (CV) line to a large vessel for rapid, high-volume fluid administration and for frequent blood withdrawal for laboratory samples.
Assessment
- Assess the physician's order and review the client's medications and treatments.
- Asses for all pertinent allergies.
- Assess CV site for signs of erythema, pain, tenderness, and edema.
- Assess for any conditions that may alter venous return, circulating blood volume, or cardiac performance.
Equipment
- Leveling device
- Pressure monitoring kit with disposable pressure transducer
- Bedside pressure module
- Continuous IV flush solution
- Pressure bag
Procedure
- Gather the necessary equipment.
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Confirm the client's identity, using two client identifiers according to your facility's policy. Do not start the treatment if the client is not wearing an ID bracelet.
Rationale: Checking identification ensures client safety through concept of correct procedure for correct client.
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Provide privacy and explain the procedure to the client.
Rationale: Explanation of procedure protects client's rights and reduces anxiety.
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Wash your hands and don gloves.
Rationale: Handwashing and gloves reduce transfer of microorganisms.
- Make sure the CV line or the proximal lumen of a PA catheter is attached to the transducer system. (If the client has a CV line with multiple lumens, one lumen may be dedicated to continuous CVP monitoring and the other lumens used for fluid administration.)
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With the CV line in place, position the client flat with the bed in its lowest position. The CVP reflects right atrial pressure; you must align the right atrium (the zero reference point) with the transducer air–fluid interface stopcock. To find the right atrium, locate the fourth intercostal space at the midaxillary line. Mark the appropriate place on the client's chest. Align the transducer air–fluid interface stopcock with the zero reference point by using a leveling device.
Rationale: Marking client's chest ensures all subsequent recordings will be made using same location.
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If the client cannot tolerate a flat position, place the client in semi-Fowler's position. When the head of the bed is elevated, the phlebostatic axis remains constant but the midaxillary line changes.
Rationale: Each time client changes position, positioning of transducer air–fluid interface stopcock will need to be readjusted to zero reference point.
- After leveling the transducer, turn the stopcock next to the transducer off to the client and open to air. Remove the cap to the stopcock port. Place the cap inside an opened sterile gauze package to prevent contamination.
- Zero the transducer. To do so, follow the manufacturer's directions for zeroing.
- When finished zeroing, turn the stopcock on the transducer so that it is closed to air and open to the client (the monitoring position). Replace the cap on the stopcock.
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Read the CVP value from the digital display on the monitor and note the waveform. Make sure the client is still when the reading is taken. (See Identifying Hemodynamic Pressure Monitoring Problems.)
Rationale: Having client remain still prevents artifact.
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After the initial CVP reading, reevaluate readings frequently to establish a baseline for the client. Authorities recommend obtaining readings at 15-, 30-, and 60-minute intervals to establish a baseline. If the client's CVP fluctuates by more than 2 cm H2O, suspect a change in clinical status and report this finding to the physician.
Rationale: Reevaluation of readings facilitates intervention for client.
- Place the client in a comfortable position.
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Remove your gloves and wash your hands.
Rationale: Handwashing reduces transfer of microorganisms.
- Document the CVP reading on the flow sheet. Note the condition of the catheter insertion site. Note any complications and actions taken.
Sample Documentation | ||
03/12/10 | 1700 |
CVP reading taken from left subclavian triple lumen catheter, see flow sheet. No redness or swelling noted at the insertion site, dressing is clean, dry, and intact.
Natalie Conway, RN |
Collaboration and Delegation
- As ordered, arrange for chest X-rays after insertion and daily to check catheter placement. The X-ray after initial placement is also used to assess for a pneumothorax, a complication from insertion.
- Procedures related to a CV line are not delegated to unlicensed assistive personnel.
IDENTIFYING HEMODYNAMIC PRESSURE MONITORING PROBLEMS | ||
Problem | Possible Causes | Nursing Interventions |
No waveform | Power supply turned off | Check the power supply. |
Monitor screen pressure range set too low |
Raise the monitor screen pressure range, if necessary. Rebalance and recalibrate the equipment. |
|
Loose connection in line | Tighten loose connections. | |
Transducer not connected to amplifier | Check and tighten the connection. | |
Stopcock off to client | Position the stopcock correctly. | |
Catheter occluded or out of blood vessel | Use the fast flush valve to flush line or try to aspirate blood from the catheter. If the line remains blocked, notify the physician and prepare to replace the line. | |
Drifting waveforms | Improper warm-up | Allow the monitor and transducer to warm up for 10 to 15 minutes. |
Electrical cable kinked or compressed | Place the monitor's cable where it cannot be stepped on or compressed. | |
Temperature change in room air or IV flush solution | Routinely zero and calibrate the equipment 30 minutes after setting it up. This action allows IV fluid to warm to room temperature. | |
Line fails to flush | Stopcocks positioned incorrectly | Make sure stopcocks are positioned correctly. |
Inadequate pressure from pressure bag | Make sure the pressure bag gauge reads 300 mm Hg. | |
Kink in pressure tubing | Check the pressure tubing for kinks. | |
Blood clot in catheter | Try to aspirate the clot with a syringe. If the line still will not flush, notify the physician and prepare to replace the line, if necessary. Important: Never use a syringe to flush a hemodynamic line. | |
Artifact (waveform interference) | Client movement | Wait until the client is quiet before taking a reading. |
Electrical interference | Make sure electrical equipment is connected and grounded correctly. | |
Catheter fling (tip of pulmonary artery [PA] catheter moving rapidly in large blood vessel in heart chamber) | Notify the physician, who may try to reposition the catheter. | |
False high readings | Transducer balancing port positioned below client's right atrium | Position the balancing port level with the client's right atrium. |
Flush solution flow rate is too fast | Check the flush solution flow rate. Maintain it at 3 to 4 mL/hour. | |
Air in system | Remove air from the lines and the transducer. | |
Catheter fling (tip of PA catheter moving rapidly in large blood vessel or heart chamber) | Notify the physician, who may try to reposition the catheter. | |
False low readings | Transducer balancing port positioned above right atrium | Position the balancing port level with the client's right atrium. |
Transducer imbalance | Make sure the transducer's flow system is not kinked or occluded and rebalance and recalibrate the equipment. | |
Loose connection | Tighten loose connections. | |
Damped waveform | Air bubbles |
Secure all connections. Remove air from the lines and the transducer. Check for and replace cracked equipment. |
Blood clot in catheter | Refer to "Line fails to flush" (earlier in this chart). | |
Blood flashback in line | Make sure stopcock positions are correct; tighten loose connections and replace cracked equipment; flush the line with the fast-flush valve; replace the transducer dome if blood backs up into it. | |
Incorrect transducer position | Make sure the transducer is kept at the level of the right atrium at all times. Improper levels give false high- or false low-pressure readings. | |
Arterial catheter out of blood vessel or pressed against vessel wall |
Reposition the catheter if it is against the vessel wall. Try to aspirate blood to confirm proper placement in the vessel. If you cannot aspirate blood, notify the physician and prepare to replace the line. Note: Bloody drainage at the insertion site may indicate catheter displacement. Notify the physician immediately. |