Care of Clients under ECG Monitoring

I. DEFINITION

Electrocardiogram - is a standardized noninvasive diagnostic tool used to record the electrical activity of the heart.
Assesses the electrical conduction system of the heart.
ECS- it gets your heart to contract and pump blood throughout your body.
Continuous Cardiac Monitoring

Cardiac monitoring is performed to provide continuous observation of the heart in patients who are at risk of
developing dysrhythmias, and those with unstable medical conditions.
Cardiac monitoring is done using three or five electrodes. The chest leads are most commonly used for monitoring
because these appear upright and are easiest to read.

2 Types of Monitoring
1. Hardwire Monitoring
The patient's heart rhythm is displayed on both a monitor at the bedside and another at the nurse's station.
Manual of Nursing Procedures: A Compilation
2. Telemetry
Enables the patient to be ambulatory. A small transmitter sends a signal to a location, where the patient's
cardiac rhythm is displayed on a monitor screen.
The ECG provides a continuous graphic picture of cardiac electrical activity. The ECG can be used for diagnostic,
documentation and treatment purposes.
II. RATIONALE
1. To record the electrical activity of a large mass of atrial and ventricular cells as specific waveforms and complexes.
2. To detect current flow as measured on the patient's skin.
III. EQUIPMENT

Cardiac Monitor

V. PLANNING AND IMPLEMENTATION

ACTION RATIONALE

Assessment

1. Assess the patient's peripheral pulses, vital signs, heart

sounds, level of consciousness, lung sounds, neck vein
distention, presence of chest pain or palpitations, and To provide baseline data.
peripheral circulatory disorders (i.e., clubbing, cyanosis,
and dependent edema).

2. Assess if the patient has a history of To provide baseline data and may guide the selection
cardiac dysrhythmias or cardiac problems. of monitoring leads.

3. Assess landmarks for identification of the correct

To ensure interpretation.
placement of electrodes.

Patient Preparation
1. Ensure that the patient and family understand pre- To evaluate and reinforce the understanding of
procedural teaching. previously taught information.

To enable easy access to the chest for electrode

2. Assist the patient to the supine position.
placement.

Implementation

To reduce the transmission of microorganisms;

1. Wash hands.
standard precaution.

2. Make sure there are no loose pins at the end of the ECG
To provide safety and accurate recording of the heart
cable and no frayed or broken cable or lead wires.
activity.
Make sure the monitor has an adequate paper supply.

3. Connect the ECG cable to the machine. Connect the lead

wires to the ECG cable (if not already connected).

Turn the power on to the monitor. Adjust contrast on the

screen if necessary.

4. Open the package of ECG electrodes. Make sure the gel

of the electrode in the electrodes to be used is
moist. Attach an electrode to each lead wire.

5. Prepare the patient's skin to minimize distortion of

the ECG tracing. Do this by briskly rubbing the skin with a
dry gauze pad. If electrodes will be applied to the patient's
chest instead of limbs, shave a small amount of chest hair,
if needed, before applying electrodes to ensure good
contact.

6. Remove the backing from the pre-gelled electrodes and

To allow for impulse transmission.
test the center of the pads for moistness.

7. Apply electrodes to the sites, ensuring a seal.

To prevent external influences from affecting the ECG.
Avoid pushing on the gel pads.
8. Evaluate the ECG monitor pattern for the presence of P
waves, QRS complexes, a clear baseline, and the absence
To make accurate judgments about the patient's status and
of artifact or distortion. Obtain a rhythm strip on
treatment.
admission, every shift (as per institution protocol), and
with rhythm changes.

Assessing changes in the ECG pattern may

9. Assess the ECG pattern continually for
indicate significant problems for the patient and may
dysrhythmias, assess patient tolerance of the change, and
require immediate intervention or additional diagnostic
provide prompt nursing intervention.
tests such as 12-lead ECG.

10. Evaluate skin integrity around the electrodes on a daily To have a clear picture of the ECG. Replacing electrodes
basis, and change the electrodes every 48 hours. every 48 hours prevent drying of the gel and may prevent
skin breakdown. It may be necessary to change to different
Rotate sites when changing electrodes. Monitor the skin leads if sites become irritated. Electrode resistance changes
for any allergic reaction to the adhesive or gel. Change all as the gel dries, so changing all electrodes at once prevents
electrodes if a problem occurs with one. differences in resistance between electrodes.

To have an accurate interpretation of many

11. Check electrode placement every shift. dysrhythmias depends on the proper placement of the
electrodes and knowing which lead is being viewed.

12. Obtain tracing and inspect the resulting printout

for clarity. Repeat the procedure if tracings To provide for a review of ECG by a cardiologist.
contain artifacts.

V. EVALUATION AND DOCUMENTATION

1. It is important to note and document if the client is experiencing any chest discomfort during the procedure.

2. Report any unexpected outcomes immediately.

 Basic ECG Rhythm Interpretation

I. Definition

ECG

An electrocardiogram or ECG records electrical activity in the heart. An ECG machine records these electrical signals
across multiple heartbeats and produces an ECG strip

II. EQUIPMENT

ECG Machine ECG Conduction Gel

ECG Chest and Limb Leads Alcohol wipes

ECG tracing paper Gloves

III. ECG ESSENTIALS

A. Adult heart rates:

 Normal = 60 – 100 bpm

 Tachycardia > 100 bpm

 Bradycardia < 60 bpm

B. Conduction System

The heart’s conduction system is the network of nodes (groups of cells that can be either nerve or muscle tissue),
specialized cells, and electrical signals that keep your heart beating.

The cardiac conduction system sends the signal to start a heartbeat. It also sends signals that tell different parts of the
heart to relax and contract (squeeze). This process of contracting and relaxing controls blood flow through the heart and
to the rest of the body.

Steps of the heart conduction pathway

1. Sinoatrial node

Generate electrical conduction

Your sinoatrial node is sometimes called your heart’s natural pacemaker.

It sends the electrical impulses that start the heartbeat. The SA node is in
the upper part of your heart’s right atrium. It is at the edge of your
atrium near your superior vena cava (the vein that brings oxygen-poor
blood from your body to your heart).

2. Atrioventricular node

“gatekeeper”

The atrioventricular node delays the SA node’s electrical signal. It delays

the signal by a consistent amount of time (a fraction of a second) each
time. The delay ensures that your atria are empty of blood before the
contraction stops. The atria are the heart’s upper chambers. They
receive blood from your body and empty it into the ventricles.

Your AV node is located in an area known as the triangle of Koch (located

between the septal leaflet of the tricuspid valve, the coronary sinus, and
the membranous portion of the interatrial septum). This is near the
central area of the heart.

3. Bundle of His

The bundle of His is also called the atrioventricular bundle. It is a branch

of fibers (nerve cells) that extends from your AV node. This fiber bundle
receives the electrical signal from the AV node and carries it to the
 Purkinje fibers.

The bundle of His runs down the length of the interventricular septum,
the structure that separates your right and left ventricles. The bundle of
His has two branches:

 The left bundle branch sends electrical signals through the

Purkinje fibers to your left ventricle.

 The right bundle branch sends electrical signals through the

Purkinje fibers to your right ventricle.

4. Purkinje fibers

The Purkinje fibers are branches of specialized nerve cells. They send
electrical signals very quickly to your right and left heart ventricles. Your
Purkinje fibers are in the subendocardial surface of your ventricle walls.
The subendocardial surface is part of the endocardium, the inner layer of
tissue that lines your heart’s chambers.

When the Purkinje fibers deliver electrical signals to your ventricles, the
ventricles contract. As they contract, blood flows from your right
ventricle to your pulmonary arteries and from your left ventricle to your
aorta. The aorta is the body’s largest artery. It sends blood from your
heart to the rest of your body.

 EKG strips- made of small boxes; represents measurement of time

 Each small squares represents 0.04 seconds; large squares represents 0.20 seconds

Depolarization- contract ang heart muscle

Repolarization- going to resting state; relaxation
C. Components:

● It is waveform components that consist of the electrical events during one

heartbeat

● The waveforms are labeled as P, Q, R, S, T, and U.

P wave

● Atrial Depolarisation

● P wave is the first short upward movement of the ECG tracing. It indicates that the atria are contracting, pumping
blood into the ventricles.

● Amplitude: 2-3 mm high

The P-wave should be 2–3 small squares in duration Duration: 0.06 - 0.12 sec

QRS complex

● Ventricular Depolarisation

● The QRS complex normally begins with a downward deflection, Q; a larger upwards deflection, a peak (R); and then a
downwards S wave. The QRS complex represents ventricular depolarization and contraction.

● Amplitude: 5-30 mm high

● Duration: 0.06 - 0.10 sec

PR interval

● The PR interval indicates the transit time for the electrical signal to travel from the sinus node to the ventricles.

● Duration: 0.012 - 0.20 sec

● The PR interval should be 3–5 squares in duration

QT interval

● The QT interval should be 9–11 small squares

T wave

● T wave is normally a modest upwards waveform representing ventricular repolarization

● Amplitude: 0.5 mm in limb leads Duration: 0.1 - 0.25 sec

D. Measurements:

Assuming a standard paper speed of 25 mm/s, then one

small square = 0.04 s

The QRS complex should be 1.5–2.5 small squares in

duration
D. Rate Estimation:

 To calculate the rate of a regular ECG, simply divide 300 by the number of large squares between two
complexes.

 For irregular rhythms, count the number of complexes between 30 large squares and multiply by 10 (30 large
squares = 6 seconds, assuming the standard paper speed of 25 mm/s).

 if the rhythm is irregular:

The first method of calculating the heart rate doesn’t work when the R-R interval differs significantly throughout the ECG
and therefore another method is required

o ▪ Count the number of complexes on the rhythm strip (each rhythm strip is 10 seconds long)

o ▪ Multiply the number of complexes by 6 (giving you the average number of complexes in 1 minute)

e.g. 10 complexes on a rhythm strip X 6 = 60 beats per minute

V. BASIC ECG RHYTHMS

Take Note:

Follow this systematic approach.

Rate
Rhythm
P Waves
PR Interval
P and QRS Correlation QRS Rate

PQRS
Rate Rhythm P Waves PR Interval
Correlation

Constant,
Before each QRS regular Interval
60-100 Regular
Look alike Interval .12- =/<.10
.20
Normal Sinus Rhythm

Constant,
Before each QRS regular
Interval
>100 Regular Look alike Interval .12-
=/<.10
.20

Sinus Tachycardia

Constant,
Before each QRS regular
Interval
<60 Regular Look alike Interval .12-
=/<.10
.20

Sinus Bradycardia

60-100 Regular >.20;

Before each QRS
Prolonged

First Degree AV Block

Both atrial
and ventricular
complexes are Sawtooth Typically Varies; may
regular unless Appearance Atrial immeasurab be a slow
there is a rate can range le; also, may or rapid
variable block from 200- 300 be variable ventricular
Atrial Flutter Ratio 2:1,3:1 or response
variable
<.10

Chaotic,
pulseles unable
Chaotic Absent Absent
s to quantify,
poorly
defined
Ventricular Fibrillation

Both atrial and Varies; may

No distinct P
ventricular be a slow or
waves— chaotic, Absent or
60-100 complexes are rapid
undulating indiscernible
irregularly ventricular
fibrillation waves
irregular response <.10
Atrial Fibrillation

Normally
similar
"monomorphic
" Rare; If present, Wide (>.12)
>170 Absent
dissociated from and bizarre >1
Varied appeara
20
nce termed
“polymorphic”

PEA is a rhythmic display of some type of Pulsele Any P wave Any PR Any PQRS
electrical activity other than VT/VF, but Any rhythm
ss appearance interval correlation
without an accompanying pulse that can be
palpated by any artery.

No
electric
None Absent Absent None
al
activity!

Asystole
Monitoring Oxygen Saturation (Pulse Oximeter)

I. DEFINITION
ACTION RATIONALE
Pulse oximetry
 is the indirect measurement of oxygen 1. Introduce yourself to the
saturation for a patient's vital sign database patient
 is a simple non-invasive method of monitoring
the percentage of hemoglobin (Hb) saturated 2. Obtain an oximeter and To prevent mixing probes
with oxygen. appropriate probe for the from different manufacturers
The pulse oximeter consists of a probe attached to the patient, and place them at that will result in burn injury
patient's finger or ear lobe which is linked to a the bedside. to patients.
computerized unit.
3. Explain the purpose of
Oximeter the procedure to the patient
To promote patient
 is a photo sensor with a light-emitting diode and how you will measure
cooperation and increase
(LED) connected by a cable to an oximeter. oxygen saturation. Instruct
compliance.
the patient to breathe
The Principle of Pulse oximetry is based on the red normally.
and infrared light absorption characteristics of
oxygenated and deoxygenated hemoglobin. To reduce transmission of
4. Perform hand hygiene.
Oxygenated hemoglobin absorbs more infrared light microorganisms.
and allows more red light to pass through.
Deoxygenated (or reduced) hemoglobin absorbs more 5. Position the patient To ensure probe positioning
red light and allows more infrared light to pass through. comfortably. If the finger and decreases motion
monitoring site is chosen, artifact that interferes with
A pulse oximeter uses a light emitter with red and support the lower arm. SpO2 determination.
infrared LEDs that shine through a reasonable
translucent site with good blood flow.
6. If the finger is to be used, To ensure good reading.
Typical adult/pediatric sites are the finger, toe, pinna remove fingernail polish Opaque coatings can
(top), or lobe of the ear. from the digit with acetone decrease light transmission.
or polish remover. Acrylic Nail polish containing blue
Infant sites are the foot or palm and the big toe or nails without polish do not pigment absorbs light
thumb. Opposite the emitter is a photodetector that interfere with SpO2 emissions and may falsely
receives the light that passes through the measuring determination. alter saturation.
site.
7. Attach the sensor to the
II. RATIONALE monitoring site. Instruct the
To select sensor sites based
patient that clips on the
1. To obtain oxygen saturation measurements at on peripheral circulation and
sensor will feel like a tight
appropriate times to determine the patient's conditions extremity temperature.
elastic band on the finger or
such as the onset of labored breathing or cyanosis. ear but will not hurt.
2. To determine the need to measure the patient’s
8. Once the sensor is in
oxygen saturation.
place, turn on the oximeter
3. Assess for factors that generally influence the by activating To detect valid pulse or
measurement of SpO2 such as oxygen therapy, power. Observe pulse presence of interfering
respiratory therapy such as postural drainage and waveform/ intensity display signal.
percussion, hypotension, hemoglobin level, body and audible
temperature, and medications. beep. Correlate the
4. To determine the previous baseline from the oximeter pulse rate with the
patient’s record. patient’s radial pulse.

III. EQUIPMENT IV. IMPLEMENTATION

 Oximeter
 Oximeter probe appropriate for the patient
and recommended by the oximeter Critical Decision Point:
manufacturer
If Oximeter pulse rate, patient's radial pulse, and apical
 Acetone or nail polish remover if needed
pulse are different, reevaluate oximeter probe
 Pen, vital sign flow sheet, or record
placement and reassess pulse rates.

ACTION
9. Inform the patient that
the oximeter will alarm if
the sensor falls off or if the
patient moves the sensor.
10. Leave the sensor in
place until the oximeter
readout reaches a constant
value and the pulse display
reaches full strength during
each cardiac cycle. Read
SpO2 on the digital display.
11. If the patient requires
continuous SpO2
monitoring, verify SpO2
alarm limits and alarm
volume, which are preset
by the manufacturer at a
low of 85% and a high of
100%. Verify that alarms
are on. Assess skin
integrity under the sensor
every 2 hours. Relocate
the sensor at least every 24
hours or more frequently if
skin integrity is altered or
tissue perfusion is
compromised.
12. Discusss findings with
patient as needed.
13. Assess the patient in
returning to a comfortable
position.
14. Perform hand hygiene.
V. EVALUATION
1. To compare SpO2 readings with patient baseline
and acceptable values.
RATIONALE
To evaluate the
reading. Readings take 10
to 30 seconds, depending
on the site selected.
Ensure that alarms are set
at appropriate limits and
volumes to avoid
frightening patients and
visitors.
To promote participation in
care and understanding of
health status.
To restore comfort and
promote a sense of well-
being.
To reduce transmission of
microorganisms.
1. Right-sided cardiac function is assessed
through the evaluation of CVP.
2. Left-sided heart function is less accurately
reflected by the evaluation of CVP but
may be useful in assessing chronic right-
and left-sided heart failure and
differentiating right and left ventricular
infarctions.
Requires the threading of a catheter into a large
central vein (subclavian, internal jugular, median
basilica, or femoral). The catheter tip is then
positioned in the right atrium, the upper portion of the
superior vena cava, or the inferior vena cava (femoral
approach only).
II. RATIONALE
1. To serve as a guide for fluid replacement.
2. To monitor the pressure in the right atrium
and central veins.
3. To administer blood products, total
parenteral nutrition, and drug therapy
contraindicated for peripheral infusion.
4. To obtain venous access when peripheral
vein sites are inadequate.
5. To insert a temporary pacemaker.
6. To obtain central venous blood samples.
III. EQUIPMENT
Heparin flush
system and
Venous pressure
IV pole pressure bag (if
tray
transducer to be
used)
Arm board (for Manometer level
Cutdown tray antecubital (for establishing
insertion) zero point)
Gowns, masks, ECG monitor Sterile dressing
caps, and sterile
and tape
gloves
Infusion solution/infusion set with CVP manometer
(Electronic CVP monitoring does not use a manometer
Nursing Alert:

2. During continuous monitoring, assess skin integrity A CVP line is a potential source of septicemia.
underneath the probe at least every 2 hours, based on
CLABSI
the patient’s peripheral circulation.
Central Line-Associated Bloodstream Infection
3. Document SpO2 value nurse’s notes, vital sign flow
sheet, or electronic medical record. A laboratory-confirmed bloodstream infection not related
to an infection at another site that develops within 48
Central Venous Pressure Monitoring
hours of a central line placement.
I. DEFINITION
Manometers
Refers to the measurement of right atrial pressure or
CVP is measured using an indwelling central venous
the pressure of the great veins within the thorax
catheter (CVC) and a pressure manometer or transducer.
(normal range: 5 to 10 cm H2O or 2 to 8mmHg).
Both methods are reliable when used correctly. Wards
generally use manometers.
IV. ESSENTIALS
 The normal range for CVP is 5-10cm H2O
 (2-6mmHg) when taken from the mid-
axillary line at the fourth intercostal space.
o Many factors can affect CVP,
including vessel tone
(sclerotic ang site),
medications, heart disease,
and medical treatments.
o A CVP measurement should
be viewed in conjunction with
other observations such as
pulse, blood pressure,
respiratory rate, and the
patient's response to
treatment.
o Evaluate the patient’s
Prothrombin Time (PT),
Partial Thromboplastin time
(PTT), and Complete Blood
Count (CBC) before the
procedure. Esp hgb
o XRAY is the confirmatory test
after the procedure.
Insertion sites
CVC insertion sites include:
 Internal jugular vein
 Subclavian vein
 Femoral vein
 Medial Brachial
- chosen frequently
- low incidence of complications such
internal jugular as pneumothorax
veins
- short, straight, and relatively large
- irritation in conscious patients
- often chosen = recognizable
anatomical landmarks
Subclavian veins
- beneath the clavicle= pneumothorax
during insertion
- rapid central access during an
emergency = cardiac arrest
- CVC is placed in a vein near the
Femoral veins groin= increased risk of associated
infection
- uncomfortable
- discourage the conscious patient
from moving
- has been associated with a higher
incidence of deep vein thrombosis.
Medial Brachial
- Generally recommended.
Vein
- Usually, use in the Philippine setting
for a better view of access.
Potential complications
 Hemorrhage from the catheter site -if it
becomes disconnected from the infusion.
Patients who have coagulation problems
such as those on warfarin or those with
clotting disorders are at risk.
 Catheter occlusion
 by a blood clot or kinked tube
 regular flushing of the CVC line and a
well-secured dressing should help to avoid
this.
 Infection-redness, pain, and swelling
around the catheter insertion site may all
indicate infection. Careful asepsis is
needed when touching a CVC site. Swabs
for C&S should be taken if the infection is
suspected.
 Air embolus-if the infusion or monitoring
lines become disconnected there is a risk
that air can enter the venous system.
 All lines and connections should be
checked at the start of every shift to
minimize the risk of this occurring.
 Catheter displacement-if the CVC moves
into the chambers of the heart then
cardiac arrhythmias may be noted, and
should be reported.
 If the CVC is no longer in the correct
position, CVP readings and medication
administration will be affected.
CVP Recording
 CVP is usually recorded at the mid-axillary
line where the manometer arm or
transducer is level with the hemostatic
axis.
V. IMPLEMENTATION
ACTION RATIONALE
A. Preparatory Phase
(By Nurse)
1. Assemble equipment
according to the
manufacturer’s
directions. Evaluate the
To assess for coagulopathies
patient’s Prothrombin Time
or anemia.
(PT), Partial
Thromboplastin time (PTT),
and Complete Blood Count
(CBC).
2. Explain the procedure
to the patient and ensure
that informed consent is
obtained.
a. Explain to the patient
how to perform the
Valsalva maneuver.
b. NPO 6 hours before
insertion.
3. Position the patient
appropriately.
a. Place in a supine
position.
b. Arm vein – extend the
arm and secure it on the
arm board.
Jugular veins – place the
patient in Trendelenburg’s
position. Place a small
rolled towel under the
shoulder (subclavian
approach).
4. Flush IV infusion set
and manometer (measuring
device) or prepare heparin
flush for use with a
transducer. Secure all
connections to prevent air The level of the right atrium
emboli and bleeding.
a. Attach manometer to IV
pole. The zero point of the b. To mark the midaxillary
manometer should be on a line with indelible ink for
level with the patient’s right subsequent readings to
atrium.
b. Calibrate/ zero
transducer and level port
with patient’s right atrium.
5. Institute
electrocardiogram
monitoring.
To gain cooperation from the
patient
To provide maximum visibility
of veins. Trendelenburg’s
position reduces the risk of air
emboli. Anatomic access and
clinical status of the patient
are considered in site
selection.
a. To level the manometer.
is at the fourth intercostal
space midaxillary line.
ensure consistency of the
zero level.
To note any dysrhythmias
during insertion as the
catheter is advanced.
B. Insertion Phase (By physician)
1. Physician puts on the
gown, cap, and mask.
To maintain sterility.
2. The CVP site is
surgically cleaned. The To protect against the risk of
physician introduces the air embolus, the patient may
CVP catheter be asked to perform the
percutaneously or by direct Valsalva maneuver
venous cutdown.
3. Assist the patient in
remaining motionless during
insertion.
4. Monitor for dysrhythmias,
To assess signs of
tachypnea, and tachycardia
pneumothorax or arterial
as the catheter is threaded to
puncture.
a great vein or right atrium.
5. Connect the primed IV
tubing/heparin flush system To verify catheter placement
to the catheter and allow the before hypertonic or blood
IV solution to flow at a products can be
minimum rate to keep the administered.
vein open (25 ml maximum).
To prevents inadvertent
6. The catheter should be
catheter advancement or
sutured in place.
dislodgement.
7. Place a sterile occlusive
dressing over the site.
To verify the correct catheter
8. Obtain a chest x-ray. position and absence of
pneumothorax.
C. To Measure CVP
Taking CVP with a Manometer
1. Introduce yourself and
To reduce the anxiety of the
explain the procedure to the
client.
client.
2. Wash hands and apply To reduce transmission of
gloves. microorganisms.
 the stopcock off to the the manometer to the client.
To maximize efficiency and normal saline.
3. Gather equipment needed minimizes the chance
to bedside. of breaking sterility once
started. The fluid will stabilize at a
level equal to the pressure
12. Watch as the fluid falls in
of the central veins or right
4. Position the client in a the manometer. Take the
atrium. If the fluid
supine or flat position. If central venous pressure
level fluctuates with the
this is not tolerated and the reading when the
client's respirations, take
client is in a semi- fluid stabilizes.
the reading at the end of the
Fowler's position, take all client's expiration.
measurements at the same
angle. Mark the right atrium The manometer should
(at the midaxillary line always be zeroed at the "X" 13. Turn the stopcock off to To re-establish fluid flow
about one-third of the to minimize variance in the manometer. from the IV to the client.
distance from the anterior to measurements.
the posterior chest wall, in
the fourth intercostal 14. Store the manometer in
The top of the manometer is
space) with an imaginary "X". an upright position
open to the air. If
The term phlebostatic (usually hanging from the IV
the manometer is not
axis may be used to identify pole) to prevent air bubbles
properly stored,
the level of the atrium. from entering the fluid
contaminants or air can enter
column or the client and
the manometer and be
prevent contamination of the
To force air out of the flushed into the client.
manometer.
stopcock. Fluids with
5. Connect the IV fluid
glucose are stickier than
(usually normal saline) to a
normal saline and may To prevent the spread of
three-way stopcock and flush 15. Wash hands.
cause the manometer to microorganisms.
the other two ports.
stick; thus, glucose should
be avoided.
16. Document reading. To provide continuity of care.

An aseptic technique should

6. Apply sterile gloves and
be used to VI. EVALUATION AND DOCUMENTATION
mask.
minimize infection.

1. Prevent and observe for complications.

7. Connect the CVP To insert the CVP
manometer to the upper port manometer into the central a. From catheter insertion: Pneumothorax,
of the stopcock. line system. hemothorax, air embolism, hematoma, and cardiac
tamponade.

8. Connect the CVP tubing b. From indwelling catheter: infection, air embolism,
To establish an IV line from central venous thrombosis.
from the client to the
normal saline to CVP
second side port of the
catheter.
stopcock.
2. Make sure the cap is secure on the end of the CVP
monitor and all clamps are closed when not in use.
9. Allow normal saline to
To establish that the CVP
drip rapidly into the client for
line is patent. Fluids must 3. If air embolism is suspected, immediately place the
a few seconds, with the
flow freely for reading to be patient in the left lateral Trendelenburg’s position and
stopcock closed to the
accurate. administer oxygen
manometer.

4. Carry out ongoing nursing surveillance of the insertion

10. Turn the stopcock off to
site and maintain an aseptic technique.
the client and fill the
The normal CVP reading
manometer with normal a. Inspect the entry site twice daily for signs of local
varies from 5-12 cm of
saline to the 20-cm mark inflammation and phlebitis. Remove the catheter
water.
above the immediately if there are signs of infection.
anticipated reading.
b. Make sure sutures are intact.

11. Hold the manometer at c. Change dressings as prescribed.

The system is open from
the phlebostatic axis and turn
 d. Label to show the date and time of change. hematoma formation.

e. Send the catheter tip for bacteriologic culture when

it is removed.

5. When discontinued, remove the central line.

a. Position patient flat with head down.

b. Remove dressing and sutures.

c. Have the patient take a deep breath and hold it

while the catheter is gently pulled out.

d. Apply pressure at the catheter site and apply to

dress.

e. Monitor site and vital signs for signs of bleeding or