Steps

Rationale/Points of Emphasis

1 Proceed with catheter setup and insertion as described in Chapter 45 . Confirm proper placement with chest X-ray after CVP line insertion.

Placement of a CVP catheter is used to monitor and obtain hemodynamic readings for evaluation of intravascular volume status, venous return, and right heart function.

caREminder

When using double- or triple-lumen CVCs, the distal lumen (closest to the RA) is recommended for CVP monitoring.

2 Review baseline data—vital signs, level of consciousness, and hemodynamic stability—of the child.

Assists in identifying any acute changes in child. Fluid volume deficit usually corresponds with a decreased CVP and fluid volume overload usually corresponds with an increased CVP.

3 Assess sedation and pain management needs of the child in collaboration with the healthcare prescriber. Administer sedation and pain management medications as indicated.

Ensures child’s comfort during the procedure.

4 If indicated by anatomical location of the CVC, immobilize the extremity where the catheter is inserted by using an armboard or limb restraint. Keep the catheter site visible at all times—do not allow linens to cover site.

Holds catheter in place and assists in preventing dislodgement.

5 Observe the IV pressure bag and ensure inflation to 300 mm Hg on the pressure bag manometer. Reinflate as necessary. If using an infusion pump, validate the flow rate.

Pressure is required for most flush devices to avoid blood backup and to maintain catheter patency. When inflated to 300 mm Hg of pressure, most flush devices deliver 3 mL/hour of IV fluid. The amount of pressure in the infusion device decreases naturally over time because fluid infuses and must be reinflated periodically.

6 Maintain the position of the transducer stopcock on the IV pole level with the child’s right atrium. While using the leveling device, move the air-fluid interface of the disposable pressure monitoring system, up or down, along the IV pole, so that the chamber is level with the right atrium of the child’s heart, usually at the fourth intercostal space, midaxillary line (phlebostatic axis).

Ensures accuracy of readings by eliminating hydrostatic forces on the transducer (see Chapter 45 , Figure 45-1).

7 Zero balance and calibrate the transducer at the start of each shift by turning the stopcock above the transducer off to the patient line and then pressing the 0 (zero) button on the bedside monitor. Follow manufacturer’s instructions.

Pressing the zero button negates the effects of atmospheric pressure, so that the pressure values reflect only that of the patient.

8 Return transducer stopcock back to monitoring open position to start pressure monitoring. Check that the stopcock above the transducer is now open to monitoring.

Pressure monitoring cannot occur if stopcocks are not in the correct positions. (Refer to manufacturer’s instructions for correct stopcock placement.)

9 CVP waveform and mean reading should be continuously monitored and interpreted, along with electrocardiogram (ECG) and other monitor tracings (Figure 47-1). See Chart 47-1 to assist in identifying and managing problems with the CVP equipment and waveform.

A continuous waveform and readout is provided at the child’s bedside monitor along with ECG and other monitor tracings, which allows the nurse to identify any acute or gradual changes and make clinical decisions based on these changes.

caREminder

Appropriate pressure alarms should be on at all times during monitoring to provide an alert to clinical changes in the child’s condition or equipment malfunction.

The normal mean CVP reading in children is 5 to 15 mm Hg. Normal waveform components of the CVP include the A wave (mechanical atrial systole), C wave (increase in RA pressure from closure of the tricuspid valve), and V wave (mechanical atrial diastole).

Figure 47-1 Typical central venous pressure waveform.

10a Frequently assess that the pressure bag is inflated to 300 mm Hg.

Appropriate inflation is necessary for proper function of flush device to deliver 3 mL/hour of fluid and to prevent blood from backflowing into the catheter.

10b At least once per shift, ensure that there is flush solution in IV bag.

Continuous flush is necessary to keep the CVC from clotting off.

10c Continuously observe CVP waveform quality as viewed from monitor.

Ensures accuracy of pressure waveform and detection of changes in child’s hemodynamic status.

11 Troubleshoot the CVP waveform as problems occur. Notify healthcare prescriber as appropriate. If the CVP waveform suddenly becomes dampened:

• Check the child.

A sudden hypotensive episode can look like a dampened waveform on the monitor and can be potentially life-threatening.

• Check the CVP insertion site for catheter position,

For peripheral insertion of a catheter, movement of the child can cause kinking or dislodgment, resulting in dampened waveform.

• Attempt to aspirate and flush the catheter.

Clots can form at the catheter tip and obstruct flow, causing a dampened waveform or emboli. Aspirate to pull back and dislodge the potential clot formation.