OBJECTIVES:

a. To serve as a guide for fluid replacement in seriously ill patients. b. To administer blood products, total parenteral nutrition, and drug therapy (contraindicated for peripheral infusion) . c. To determine pressures in the right atrium and central veins. d. To evaluate for circulatory failure (in context with total clinical picture of a patient) e. To obtain venous pressure access when peripheral vein sites are inadequate. f. To obtain central venous blood samples. g. To insert a temporary pacemaker.

Indications: Patients having Cardiovascular disorders. Hypervolemia Hypovolemia

Hemodialysis Failure
Contraindications: None Charting: a.Location of insertion site

Congestive Heart

b.Type and size of needle or cannula used for insertion

c.Time of insertion
d.Appearance of needle insertion site

Nursing Alert: Dont rely on CVP alone, use them

VEIN USED;
Subcalvian Vein Jugular Vein Femoral Vein

EQUIPMENT'S:
a. Venous pressure tray, b. Cutdown tray, c. Infusion solution and infusion set, d. 3-way- or 4-way stopcock (a pressure transducer may be used), e. IV pole attached to bed, f. Arms board, adhesive tape, g. ECG monitor, h. Infusion set with CVP manometer i. Steril dressing/tape j. Heparin flush system k. Carpenters level (for establishing zero point)

PROCEDURE (Preparatory Phase) 1. Assemble equipment's. Evaluate clients PTT, PT and CBC. 2. Explain the procedure to the client and obtain informed consent a. Explain to client how to perform the Valsalva Maneuver. b. NPO for 6 hours before insertion 3. Position client appropriately; a. Arm vein place client in supine & extend arm & secure on arm board. b. Neck Veins place client in trendelenburgs position. Place a small rolled towel under shoulders ( subclavian vein approach) 4. Flush IV infusion set and manometer. Secure all connections to prevent air emboli. a. Attach manometer to IV pole. The zero point of the manometer should be on a level with the clients right atrium. b. Calibrate / zero level port with clients right atrium. 5. Place client on ECG monitor.

PROCEDURE (INSERTION PHASE) A. Physician dons cap, masks, gloves and gowns. B. CVP site is surgically cleaned, CVP catheter is introduced percutaneously or by direct venous cut down. C. Client may be asked to perform valsalva maneuver. D. Assist client to remain motionless during insertion. E. Monitor for dysrhythmias as catheter is threaded to great vein or right atrium. F. Connect IV tubing / heparin flush system to catheter and allow IV solution to flow at a minimum rate to KVO (Max. of 25ml.) G. The catheter is sutured in place. H. Place a sterile occlusive dressing over site. I. Do a chest x-ray.

PROCEDURE (TO MEASURE THE CVP) a. Place the client in a comfortable position.
b. Position the zero point of the manometer at the level of the right atrium c. Turn the stop cock so that the IV solution flows into the manometer, fill in to about 20 25 cm level. Then turn the cock so solution in manometer flows into the client. d. Observe fluctuation of liquid in the manometer. e. Record the level at which the solution stabilizes or stop moving downward. Record CVP and the position of the client. f. The CVP may range from 5-12 cm H2O. g. Turn the stop cock again to allow IV solution to flow from solution bottle into the clients vein.

PROCEDURE
(Follow Up Phase) 1. Observe for complications; a. From catheter insertion; Pneumothorax, Hemothorax, Air embolism b. From indwelling catheter; Infection, Air embolism ( Place client in left lateral trendelenburgs position & administer Oxygen if with air embolism) 2. Carry Out ongoing surveillance of the insertion site and maintain aseptic technique. a. Inspect entry site 2x daily for signs of local inflammation/phlebitis b. Label to show date/ time of change.

ACTIONS:
1.Assemble equipment according to manufacturers directions. 2.Explain that the procedure is similar to an IV and that the patient may move in bed as desired after passage of the CVP catheter. 3.Place the patient in a position of comfort. This is the baseline used for subsequent readings. Rationale: Serial CVP readings should be made with the patient in the same position. Inaccuracies in CVP readings can be produced by changes in positions, coughing, or straining during the reading. 4.Attached manometer to the IV pole. The zero point of the manometer should be on a level with the patients right atrium. Rationale: The right atrium is at the midaxillary line, which is about 1/3 of the distance from the anterior to the posterior chest wall. Mark the midaxillary line on the patient with an indelible pencil. Rationale: The maxillary line is an external reference point for the zero level of the manometer (which coincides with level of the right atrium). 5.The CVP catheter is connected to a 3-way stopcock that communicates to an open IV and to a manometer. Rationale: Or, the CVP catheter may be connected to a transducer and an electric monitor CVP wave either digital or calibrated CVP wave read out. 6.Start the IV flow and fill the manometer 10 cm above anticipated reading (or until the level of 20cm, HOH is reached). Turn the stopcock and fill the rubbing with fluid.

7.The CVP site is surgically cleansed. The physician, introduces the CVP catheter percutaneously or by direct venous cutdown and threaded through an antecubital, subclavian, or internal or external jugular vein into the superior vena cava just before it enters the right atrium.
Rationale: If the catheter is inserted through the subclavian or internal jugular vein, place patient in a head-down position to increase venous filling and reduced risk of air embolism. The correct catheter placement can be confirmed by fluoroscopy or chest x-ray. 8.When the catheter enters the thorax an inspiratory fall and expiratory rise in venous pressure are observed. Rationale: The fluid level fluctuates with respiration. If rises sharply with coughing/straining. 9.The patient may be monitored by ECG during catheter insertion. Rationale: When the tip of the catheter contacts the wall of the right atrium it may produce aberrant impulses and disturb cardiac rhythm. 10.The catheter may be sutured and taped in place. A sterile dressing is applied. Rationale: Label dressing with time and date of catheter insertion. 11.The infusion is adjusted to flow into the patients vein by a slow continuous drip. Rationale: The infusion may cause a significant increase in venous pressure if permitted to flow too rapidly.

TO MEASURE CVP;
1.Place the patient in the identified position and confirm zero point. Intravascular pressures are measured to the atmospheric pressure at the middle of the right atrium; this is the zero point or external reference point.

Rationale: The zero point or baseline for the manometer should be on level with the patients right atrium. The middle of the right atrium is the midaxillary line in the 4th intercostals space.
2.Position the zero point of the manometer at the level of the right atrium. Rationale: All personal taking the CVP measurement use the same zero point. 3.Turn the stopcock so that the IV solution flows into the manometer filling to about the 20-25cm level. Then turn the stopcock so that the solution in manometer flows into the patient. 4.Observe the fall in the height of the column of fluid in the manometer. Record the level at which the solution stabilizes or stops moving downward. This is the central venous pressure. Record CVP and the position of the patient. Rationale: The column of fluid will fall until it meets an equal pressure (i.e. the patients central venous pressure). The reading is reflected by the height of a column of fluid in the manometer when theres open communication between the catheter and the manometer. The fluid in the manometer will fluctuates slightly with the patients respirations. This confirms that the CVP is not obstructed by clotted blood.

5.The CVP my range from 5-12cm. H20.

Rationale: The change in CVP is a more useful indication of adequacy of venous blood volume and alterations of cardiovascular function. CVP is a dynamic measurement. The normal values may change from patient to patient. The management of the patients not based on one reading but on repeated serial readings in correlation with patients clinical status. 6.Assess patients clinical condition. Frequent changes in measurements (interpreted within the context of the clinical situation) will serve as a guide to detect whether the heart can handle its fluid load and whether hypovolemia or hypervolemia is present. Rationale: CVP is interpreted by considering the patients entire clinical picture, hourly urine output, heart rate, blood pressure, cardiac output measurements. a. A CVP zero indicates that patient is hypovolemia (verified if rapid infusion causes patient to improve) b. A CVP above 15-20cm. H20 may be due to either hypervolemic or poor cardiac contractility. 7.Turn the stopcock again to allow IV solution to flow from solution bottle into the patients veins. Rationale: When readings are not being made, flow is from a very slow microdrip to the catheter, by-passing the manometer.