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Equipment/Environment
Nurse
Additional protective
clothing may be necessary
if indicated by the
patients condition (see
Chapter 9).
Procedure
1. Assemble all equipment at the bedside.
2. Ask/assist the patient into a comfortable recumbent or semi-recumbent
position and remove clothing as necessary to expose the site PFP3 .
3. Open the pack, and using the sterile disposal bag as a glove, and taking great
care not to dislodge the catheter, remove the old dressing and turn the
bag inside out to contain it (see page 260). Place the bag in a convenient
position to allow easy access without passing used swabs across the open
dressing pack.
4. Put on sterile gloves and, if necessary, clean the site according to local policy
and allow it to dry.
5. Apply the new dressing, making sure that the intravenous tubing is secured
under the dressing, to prevent pulling on the catheter.
6. Remove gloves.
Post procedure
Patient
Equipment/Environment
Nurse
88
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CVP MEASUREMENT
Preparation
Patient
Equipment/Environment
Nurse
Procedure
1. With the patient lying flat or in the same position as adopted for previous
measurements, level the zero point on the manometer with the patients heart.
A spirit level is incorporated into the manometer arm to ensure accurate
levelling (see Figure 4.1).
2. A mark should be made at the mid-axillary line or sternal angle to indicate the
level, so that all subsequent readings are made from the same point. This is in
line with the right atrium.
3. If necessary, turn off any other infusions that may be running through the
central venous catheter.
4. With the three-way tap in position A (Figure 4.1), allow the 0.9% sodium
chloride infusion to run rapidly for a few seconds to check that the line is
patent PFP2 .
5. Stop the infusion by closing the roller clamp. Adjust the three-way tap on the
manometer to position B, so that the fluid can go up the column. Gradually
open the roller clamp to allow fluid to slowly fill the manometer column until
510 cm above the previous measurement. Close the roller clamp.
6. Turn the three-way tap to position C, so that the line to the infusion bag is
closed and the other two lines (to the column and the patient) are open. The
fluid in the column will now start to fall, pausing with each respiration, until
it equalises with the pressure in the right atrium of the heart. The fluid should
continue to rise and fall gently with respiration PFP3 . This level, which is
measured in centimetres of water (cmH2O), is the CVP measurement PFP4 .
7. Turn the three-way tap back to position A, so that the column of fluid is off,
and reset the infusion to the prescribed rate. Reset any other infusions as
appropriate.
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A
B
C
Manometer
3-way tap
35 cm
30 cm
25 cm
20 cm
15
cm
10 cm
cm
Post procedure
Patient
Equipment/Environment
Nurse
91
92
Equipment/Environment
Nurse
Equipment to perform
dressing (page 254).
Sterile air-occlusive
dressing PFP2.
Sterile scissors and
specimen pot (universal
type).
Cleansing solution
according to local policy
(e.g. povidone iodine).
Procedure
1. Ask/assist the patient to lie flat. Tilt the head of the bed down (about 15 ), if
the patients condition will allow. Remove clothing, bedclothes, etc., as
necessary to expose the CVP catheter site.
2. Prepare all equipment (see page 258).
3. Turn off the infusion and loosen but do not remove the dressing covering the
site.
4. Wash and dry your hands thoroughly or clean them with alcohol hand-rub.
5. Open the dressing pack, and using the waste disposal bag as a glove to
protect your hand, remove the dressing and turn the bag inside out to
contain it (see page 260). Place the bag in a convenient position to allow easy
access.
6. Put on the sterile gloves provided in the dressing pack, and using a gauze swab
and cleansing solution, clean around the insertion site PFP4 .
7. Use the stitch cutter to cut the stitch holding the catheter in place and make
sure it is free of the skin.
8. Maintaining sterility, open the specimen pot and place it in an accessible
position.
9. Fold a gauze square two or three times to create an absorbent pad. Holding
this in your non-dominant hand, place it over the insertion site, ready to press
immediately the catheter is withdrawn.
10. Ask the patient to hold their breath during removal of the catheter.
Withdraw the catheter by pulling in a firm, steady movement and press firmly
93
with the gauze pad for several minutes to prevent bleeding and air embolus
PFP1 .
11. Ask an assistant to place the tip of the catheter in the specimen pot, and using
sterile scissors, cut off the tip (about 5 cm) and allow it to fall into the
container. Replace the lid PFP5 .
12. Once the bleeding has stopped, apply the sterile air-occlusive dressing to the
site.
13. Remove gloves.
Post procedure
Patient
Equipment/Environment
Nurse
94
Subclavian vein
Dacron cuff
95
recommended because of the risk of infection from the water. In order to remain
patent, the catheter must be flushed at regular intervals to prevent clotting. Most
hospitals recommend the use of heparinised saline two to three times per week,
but recommended practices vary in both frequency and the solution used.
96
Hamilton H. (2004) Central venous catheters: choosing the most appropriate access route.
British Journal of Nursing 13(14):862870.
A comprehensive examination of the evidence to support the choice of insertion site for CVCs and
the attendant risks and complications.
Ingram P, Sinclair L, Edwards T. (2006) The safe removal of central venous catheters. Nursing
Standard 20(49):4246.
An excellent article that provides detailed guidelines for the removal of CVCs with supporting
rationale. It has a particular focus on reducing the risk of air embolus.
Jones CA. (2006) Central venous catheter infection in adults in acute hospital settings. British
Journal of Nursing 15(7):364368.
This article presents a literature review of recent research on measures used to reduce CVC-related
infections, which is then compared to current best practice. The author concludes that the
evidence mainly backs up current practice but argues that skin disinfection could be improved and
stressed the importance of good hand hygiene and education programmes.
Mennim P, Coyle C, Taylor J. (1992) Venous air embolism associated with removal of central
venous catheter. British Medical Journal 305:171172.
Although this paper is now over 15 years old, it still contains excellent advice about the risks of air
embolus during removal of CVP and ways to minimise that risk.
Pratt R. (2001) Preventing infections associated with central venous catheters. Nursing Times
97(15):3639.
Evidence-based guidelines that focus on the prevention of bloodstream infections. It includes the
choice of type of CVC and the risks associated with each.
Royal College of Nursing. (2003) Standards for infusion therapy. RCN, London.
This document provides a comprehensive overview and best practice guidance on all aspects of
infusion therapy and CVCs including: infection control and safety, equipment, site selection, site
care and complications and removal of CVC.
Simcock L. (2001a) The use of central venous catheters for IV therapy. Nursing Times 97
(18):3435.
This article provides a useful overview of the types of central venous catheters available: tunnelled,
non-tunnelled, peripherally inserted and implantable ports, with diagrams of each.
Simcock L. (2001b) Central venous catheters: some common clinical questions. Nursing
Times 97(19):3435.
This article contains some useful answers to practical questions such as Do I need to wear sterile
gloves when changing the dressing? How often should it be flushed? and How often should I
change the dressing?. It provides a useful table that compares the advantages and disadvantages
of the different types of dressings available.
97
Woodrow P. (2002) Central venous catheters and central venous pressure. Nursing Standard
16(26):4552.
This is a continuing professional development article that addresses all aspects of CVC
management and CVP measurement. This includes: the rationale for CVC insertion, technique
for reading the CVP, reasons for and significance of abnormal readings, complications and
technique for removal of CVC.
Wilson J. (2006) Infection control in clinical practice. 3rd edn. Baillie`re Tindall, Elsevier,
Edinburgh.
A comprehensive text that explains basic microbiology, types of organisms and how they are
spread. It then provides guidance on infection control practices, preventing wound infections and
infections associated with catheters, intravenous cannulae and the respiratory and gastrointestinal
systems.
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