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Dr. Aidah Abu Elsoud Alkaissi
An-Najah National University
Nursing College

Diagram of placement of central venous

catheter: the catheter is tunneled under skin
and enters the superior vena cava into the
right side of the heart

Tunneled CVC



In central venous pressure monitoring, the physician inserts a catheter

through a vein and advances it until its tip lies in or near the right atrium.

Because no major valves lie at the junction of the vena cava and right atrium,
pressure at end diastole reflects back to the catheter.

When connected to a manometer, the catheter measures central venous

pressure (CVP), an index of right ventricular function.

CVP monitoring helps to assess cardiac function, to evaluate venous return to

the heart, and to indirectly gauge how well the heart is pumping.

The central venous (CV) line also provides access to a large vessel for rapid,
high-volume fluid administration and allows frequent blood withdrawal for
laboratory samples.

CVP monitoring can be done intermittently or continuously.

The catheter is inserted percutaneously or using a cutdown method.

Typically, a single lumen CVP line is used for intermittent pressure


To measure the patients volume status, a disposable plastic water

manometer is attached between the I.V. line and the central catheter
with a three- or four-way stopcock.

CVP is recorded in centimeters of water (cm H2O) or millimeters of

mercury (mm Hg) read from manometer markings.

Normal CVP ranges from 5 to 10 cm H2O or 2 to 6 mm Hg.

Any condition that alters venous return,

circulating blood volume, or cardiac
performance may affect CVP.


circulating volume increases (such as with

enhanced venous return to the heart), CVP


circulating volume decreases (such as

with reduced venous return), CVP drops.


For intermittent CVP monitoring: Disposable CVP manometer set leveling device (such as
a rod from a reusable CVP pole holder or a carpenters level or rule) additional stopcock (to
attach the CVP manometer to the catheter) extension tubing (if needed) I.V. pole I.V.
solution I.V. drip chamber and tubing dressing materials tape.

For continuous CVP monitoring: Pressure monitoring kit with disposable pressure
transducer leveling device bedside pressure module continuous I.V. flush solution 1 unit/1 to
2 ml of heparin flush solution pressure bag.

For withdrawing blood samples through the CV line:

Appropriate number of syringes for the ordered tests 5- or 10-ml syringe for the discard
sample. (Syringe size depends on the tests ordered.)

For using an intermittent CV line: Syringe with normal saline solution syringe with heparin
flush solution.

For removing a CV catheter: Sterile gloves suture removal set sterile gauze pads
povidone-iodine ointment dressing tape.


Gather the necessary equipment.

Explain the procedure to the patient to reduce his anxiety.
Assist the physician as he inserts the CV catheter.
(The procedure is similar to that used for pulmonary
artery pressure monitoring, except that the catheter is
advanced only as far as the superior vena cava.)

Obtaining intermittent CVP

with a water manometer

With the CV line in place, position the patient flat.

Align the base of the manometer with the previously determined zero reference point by using a
leveling device.

Because CVP reflects right atrial pressure, you must align the right atrium (the zero reference point)
with the zero mark on the manometer.

To find the right atrium, locate the fourth intercostal space at the midaxillary line.

Mark the appropriate place on the patients chest so that all subsequent recordings will be
made using the same location.

If the patient cant tolerate a flat position, place him in semi-Fowlers position.
When the head of the bed is elevated, the phlebostatic axis remains constant but the midaxillary line
Use the same degree of elevation for all subsequent measurements.
Attach the water manometer to an I.V. pole or place it next to the patients chest.
Make sure the zero reference point is level with the right atrium.



To ensure accurate central venous pressure (CVP)

readings, make sure the manometer base is aligned with
the patients right atrium (the zero reference point).

The manometer set usually contains a leveling rod to allow

you to determine this quickly.

After adjusting the manometers position, examine the

typical three-way stopcock.
By turning it to any position shown at right, you can control
the direction of fluid flow.
Four-way stopcocks also are available.


openings blocked


to patient


solution to manometer


solution to patient



Zero point
Three-way stopcock

Verify that the water manometer is connected to the I.V. tubing.

Typically, markings on the manometer range from 2 to 38 cm

However, manufacturers markings may differ, so be sure to

read the directions before setting up the manometer and
obtaining readings.

Turn the stopcock off to the patient, and slowly fill the
manometer with I.V. solution until the fluid level is 10 to 20 cm
H2O higher than the patients expected CVP value.
Dont overfill the tube because fluid that spills over the top can
become a source of contamination.

Turn the stopcock off to the I.V. solution and open to the patient.

The fluid level in the manometer will drop.

When the fluid level comes to rest, it will fluctuate slightly with respirations.

Expect it to drop during inspiration and to rise during expiration.

Record CVP at the end of expiration, when intrathoracic pressure has a

negligible effect.

Depending on the type of water manometer used, note the value either at the
bottom of the meniscus or at the midline of the small floating

After youve obtained the CVP value, turn the stopcock to resume the I.V.

Adjust the I.V. drip rate as required.

Place the patient in a comfortable position.

Obtaining continuous CVP

with a water manometer

Make sure the stopcock is turned so that the I.V. solution port, CVP
column port, and patient port are open.

Be aware that with this stopcock position, infusion of the I.V. solution
increases CVP.

Therefore, expect higher readings than those taken with the

stopcock turned off to the I.V. solution.

If the I.V. solution infuses at a constant rate, CVP will change as the
patients condition changes, although the initial reading will be

Assess the patient closely for changes.

Obtaining continuous CVP

with a pressure monitoring
Make sure the CV line or the proximal lumen of a pulmonary artery catheter is attached to
(If the patient has a CV line with multiple lumens, one lumen may be dedicated to
continuous CVP monitoring and the other lumens used for fluid administration.)
Set up a pressure transducer system.
Connect noncompliant pressure tubing from the CVP catheter hub to the transducer. Then
connect the flush solution container to a flush device.
To obtain values, position the patient flat.
If he cant tolerate this position, use semi-Fowlers position.

Locate the level of the right atrium by identifying the

phlebostatic axis.

Zero the transducer, leveling the transducer air-fluid

interface stopcock with the right atrium.

Read the CVP value from the digital display on the

monitor, and note the waveform.

Make sure the patient is still when the reading is taken to

prevent artifact.

Be sure to use this position for all subsequent readings.

Removing a CV line

You may assist the physician in removing a CV line.

(In some states, a nurse is permitted to remove the catheter

with a physicians order or when acting under advanced
collaborative standards of practice.)

If the head of the bed is elevated, minimize the risk of air

embolism during catheter removalfor instance, by placing the
patient in Trendelenburgs position if the line was inserted using
a superior approach.

If he cant tolerate this, position him flat.

Turn the patients head to the side opposite the catheter

insertion site.

The physician removes the dressing and exposes the

insertion site.

If sutures are in place, he removes them carefully.

Turn the I.V. solution off.

The physician pulls the catheter out in a slow, smooth
motion and then applies pressure to the insertion site.


the insertion site, apply

povidone-iodine ointment, and cover it
with a dressing as ordered.

Assess the patient for signs of

respiratory distress, which may indicate
an air embolism.

Special considerations

As ordered, arrange for daily chest X-rays to check

catheter placement.

Care for the insertion site according to your facilitys


Typically, youll change the dressing every 24 to 48 hours.

Be sure to wash your hands before performing dressing

changes and to use aseptic technique and sterile gloves
when re-dressing the site.

When removing the old dressing, observe for signs of

infection, such as redness, and note any patient complaints
of tenderness.

Apply ointment, and then cover the site with a sterile gauze
dressing or a clear occlusive dressing.

After the initial CVP reading, reevaluate readings frequently

to establish a baseline for the patient.

Authorities recommend obtaining readings at 15-, 30-, and

60-minute intervals to establish a baseline.

If the patients CVP fluctuates by more than 2 cm

H2O, suspect a change in his clinical status and report
this finding to the physician

Change the I.V. solution every 24 hours and the I.V.

tubing every 48 hours, according to facility policy.

Expect the physician to change the catheter every 72


Label the I.V. solution, tubing, and dressing with the

date, time, and your initials.


of CVP monitoring include:

pneumothorax (which typically occurs
upon catheter insertion)
vessel or adjacent organ puncture, and
air embolism


Document all dressing, tubing, and solution changes.

Document the patients tolerance of the procedure,

the date and time of catheter removal, and the type of
dressing applied.

Note the condition of the catheter insertion site and

whether a culture specimen was collected.
Note any complications and actions taken.

Film of CVC

Film of CVC