Measuring Central Venous Pressure

Objectives:
a.To serve as a guide for fluid replacement in seriously ill patients.
b.To estimate blood volume deficits.
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)

Indications: Patients having Cardiovascular disorders

Contraindications: None

Charting:
a.Location of insertion site
b.Type and size of needle or cannula used for insertion
c.Time of insertion
d.Appearance of needle insertion site

Nursing Alert: Don’t rely on CVP alone, use them in conjunction with other assessment data. Report abnormal findings to the doctor.

Equipment: Venous pressure tray, cutdown tray, infusion solution and infusion set, 3-way- or 4-way stopcock (a pressure transducer may be used), IV pole attached to bed, arms board, adhesive tape, ECG monitor, carpenter’s level (for establishing zero point)

ACTIONS:

1.Assemble equipment according to manufacturer’s 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 patient’s 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 patient’s vein by a slow continuous drip.
Rationale: The infusion may cause a significant increase in venous pressure if permitted to flow too rapidly.


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