Central Venous Pressure CVP and Arterial Pressure

Nursing ICU

Central Venous Pressure


–    The central venous pressure reflects the right atrial pressure (RAP) and is similar to measuring the JVP clinically
–    May be used to assess volume
–     Sites for insertion:
   Internal jugular, subclavian and femoral vein; ‘Long lines’ are also inserted in the brachial vein.

Site Selection For Central Venous Pressure
Site Selection For Central Venous Pressure

Factors affecting the CVP

–    Systemic vasodilatation and hypovolaemia,
which leads to reduced venous return in the
vena cava and reduced RAP
–    Right ventricular failure
–    Tricuspid and Pulmonary valve disease
–    Pulmonary hypertension
–    Right ventricular dysfunction and pulmonary hypertension leads to raised
right atrial pressure, as does tricuspid and  pulmonary stenosis.

Indications Central venous line (CVL)


–    Need for IV access and failure of peripheral access
–    Peripheral access too painful or very difficult
–    Long term IV access anticipated
–    Infusion of drugs which may cause peripheral problems e.g. vasoconstriction, phlebitis
–    Hemodynamic monitoring
–    Volume resuscitation with large bore central lines
–    CVP measurement, Rt atrial pressure
–    To obtain frequent blood sample
–    To determine how much fluid is needed in 24 hr
–    Insertion of a pacing wire.

Normal CVP measurements


–    The normal CVP is between 5 – 10 cm of H2O (it increases 3 – 5 cm H2O when patient is being ventilated)
–    CVP normal range:
–    (2-5) mmHg
–     (3-8)cm H2O

Increase of CVP

–    Over hydration
–    Right-sided heart failure
–    Cardiac tamponade
–    Constrictive pericarditis
–    Pulmonary hypertension
–    Tricuspid stenosis and regurgitation
–    Stroke volume is high


Decrease of CVP –    Hypovolemia
–    Decreased venous return
–    Excessive veno or vasodilation
–    Shock ?
–    If the measure is less than 5 cm water that mean that the circulating volume is decrease.


Nursing Care Function

Prepare all equipment needed:
–     Sterile gloves, gown, suture pack
–    Iodine solution.
–    10 ml syringe, 2% lidocaine, 10 ml N.S.
–    Catheter special size.
–    H2O manometer.
–    Flush solution with complete CVP line.
–    Dressing set

The Procedure: Insertion CVL
–    Patient position:
–    Patient is moved to the side of the bed so physician would not lean over
–    The bed is high enough so physician would not have to stoop over
–    Patient should be flat without a pillow, Trendelenburg position if patient is hypovolemic
–    The head is turned away from the side of the procedure
–    Wrist restraints if necessary
The Procedure
–    Skin preparation:
–    Prepare before putting sterile gloves
–    Allow time for the sterilizing agent to dry
–   Drape:
–    Large enough  and Handed sterilely by the assistant
–    Hole in the area of placement
–    Prepare the tray:
–    Prepare the equipment before starting
–    Anesthesia:
–    Use local anesthesia with lidocaine

YOUR ROLE AFTER THE INSERTION


–    Dispose all sharps
–    Place an occlusive sterile dressing
–    Flush lumens to maintain patency
–    Obtain a chest x-ray (ask for order if physician doesn’t mention it)
–    Monitor site for bleeding
–    Assess breath sounds
–    Assess circulation
–    Assess for hematoma
–    Document insertion, site, dressing and flushing

USING THE CENTRAL LINE

–    Flush q shift, before and after use with NS. Some places also require heparin flush
–    Close clamps when not is use
–    Dressing is usually changed every days
–    Line can be used for blood drawing – withdraw and waste 10 cc, then withdraw blood for samples
–    If port becomes clotted, do not use – sometimes ports can be opened up

Complications “insertion CVL”


–    Immediate
–    Hemothorax
–    Pneumothorax: most common, noticed after CXR, “hypoxemia and absent breath sound” requires chest tube placement
–    Bleeding : More common in patients with  coagulopathy“easily control femoral”
–    Arterial puncture
–    Vessel erosion: Large vessel perforation “Dialysis”
–    Nerve Injury
–    Dysrhythmias
–    Catheter malplacement
–    Embolus
–    Cardiac tamponade

Complications
Delayed


–    Dysrhythmias
–    Infection “Late, Femoral > IJ > subclavian
–    Catheter malplacement
–    Vessel erosion
–    Embolus
–    Cardiac tamponade
–    Thrombosis

Nursing Care Function (Measuring CVP)

Prepare all equipment needed:
–     Sterile gloves, gown, suture pack
–    Iodine solution.
–    10 ml syringe, 2% lidocaine, 10 ml N.S.
–    Catheter special size.
–    H2O manometer.
–    Flush solution with complete CVP line.
–    Dressing set

How to measure the CVP using a manometer system

How to measure the CVP using a manometer system

2014-12-06_20-00-56
Arterial pressure

– Continuous monitoring of arterial blood pressure evaluation
– Tissue perfusion status
– Trends in blood pressure
– Efficacy of drugs, interventions
– Frequent blood samples required

Arterial pressure

Placement of catheter
– Radial
– Brachial
– Axillary
– Femoral
– Dorsalis pedis

Monitoring of arterial pressure

Useful for:
– sustain hypotension or low blood pressure.
– A pressure difficult to measure by the cuff method.
– When continuous blood pressure readings are desired, e.g during the administration of hypertension or hypotesnive agent.
– When it is desireable to obtain systolic, diastolic and mean Arterial Pressure (MAP)
– MAP, Best indicator of tissue perfusion
– Average driving pressure of blood during cardiac cycle

Special consideration

Inject no medication:
– Artery very susceptible to spasm and stop blood flow, so inject only with heparinzed saline,
– Never force the line: special if the line appears to be clotted, if the clot forced it may travel on down the limbs and cause blockage of circulation
– Check all connections frequently:  any disconnection may result in rapid loss of a large amount of blood.
– Check the site of insertion include assessing: color, temp., edema, movement, capillary refill, leaking, discomfort and pulse

Complications

– Hemorrhage
* Vascular insufficiency
* Catheter too large
– Thrombus or emboli
– Infection
– Thrombosis
– Hematoma
– Ischemia

Swanz Ganz Catheter

– Is a flow directed, balloon (2-3 or 4 lumen catheter) allowing for ease of Rt heart catheterization at the bedside and permitting continuous monitoring of Rt and Lt ventricular function, pulmonary artery pressure, cardiac output and arterial venous oxygen difference.
– Normal pulmonary capillary wedge pressure (PCWP) is 8-12 mmHg at the diastole and 15-25 at systole the mean is (average of pulmonary artery pressure) is 10-20

 

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Posted in Cardiovascular, Nursing Care Plans, Nursing Intervention

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