3. Arterial line
• Hemodynamic monitoring is initiated to assess
the patient’s response to treatment. In many
institutions, this is performed in the intensive
care unit, where an arterial line can be inserted.
• The arterial line enables accurate and continuous
monitoring of blood pressure and provides a port
from which to obtain frequent arterial blood
samples without having to perform repeated
arterial punctures.
4. WHAT IS AN ARTERIAL LINE?
• AN ARTERIAL LINE IS A
CANNULA USUALLY
POSITIONED IN A
PERIPHERAL ARTERY
• SUCH AS
• Radial artery
• brachial artery
• dorsalis pedis artery
• femoral artery
5. INDICATIONS FOR USING ARTERIAL
LINE
• Ease of access
• Continuous monitoring of
arterial blood pressure
– if patient is on intropic
drugs
– if patient is on
vasoactive drug
– if patient requires
frequent arterial blood
sampling
6. • HYPOVOLAEMIA
• ACCIDENTAL INTR-ARTERIAL INJECTION OF
DRUGS
• LOCAL DAMAGE TO ARTERY
COMPLICATIONS ASSOCIATED WITH
ARTERIAL LINES
7.
8.
9.
10. Nurse Role
• A major role of the nurse is monitoring the
patient’s hemodynamic and cardiac status.
Arterial lines and electrocardiographic
monitoring equipment must be maintained
and functioning properly.
• Changes in hemodynamic, cardiac, and
pulmonary status are documented and
reported promptly.
11. THE ARTERIAL WAVEFORM
• The arterial waveform
reflects the pressure
generated in the
arteries following
ventricular contraction
and can be described as
having:-
– Peak systolic pressure
– Diastolic pressure
12. • THIS IS AN ASEPTIC PROCEDURE
• REMEMBER UNIVERSAL PRECAUTIONS
• THE PROCEDURE SHOULD BE EXPLAINED TO THE PATIENT
• TAKE DRESSING OFF LINE
• REMOVE ARTERIAL LINE ENSURING THAT THE ENTRY SITE IS
COVERED WITH GAUZE
• APPLY DIGITAL PRESSURE FOR AT LEAST 5 MINUTES TO
ENSURE HAEMOSTASIS
• DRESS SITE WITH GAUZE AND MICROPORE
• ASSESS THE PERIPHERAL CIRCULATION AS THROMBOSIS CAN
OCCUR AFTER REMOVAL
REMOVAL OF ARTERIAL LINE
14. WHAT IS A CENTRAL LINE
• It is a catheter that
provides venous access
via the superior vena
cava or right atrium
15. • Right internal jugular
• left internal jugular
• right subclavian
• left subclavian
• femoral (as a last resort)
COMMON CENTRAL LINE INSERTION
SITES
16. TYPES OF CENTRAL LINE
• SINGLE LUMEN
• TRIPLE LUMEN
• QUADRUPLE LUMEN
• QUINTUPLE LUMEN
17. • Indications for CVP lines are:-
– fluid resuscitation
– Parenteral feeding
– measurement of central venous pressure
– poor venous access
– administration of irritant drugs
CENTRAL LINES
18.
19.
20.
21.
22.
23. 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
28. CENTRAL VENOUS PRESSURE
MONITORING
• 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.
29. • 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 readings.
• To measure the patient’s 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.
30. • Any condition that alters venous return,
circulating blood volume, or cardiac
performance may affect CVP.
• If circulating volume increases (such as with
enhanced venous return to the heart), CVP
rises.
• If circulating volume decreases (such as with
reduced venous return), CVP drops.
31. Equipment
• For intermittent CVP monitoring: Disposable CVP manometer set leveling device (such as a
rod from a reusable CVP pole holder or a carpenter’s 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.
32. Implementation
• 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.)
33. Obtaining intermittent CVP readings
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 patient’s chest so that all subsequent recordings will be
made using the same location.
• If the patient can’t tolerate a flat position, place him in semi-Fowler’s position.
• When the head of the bed is elevated, the phlebostatic axis remains constant but the midaxillary
line changes.
• 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 patient’s chest.
• Make sure the zero reference point is level with the right atrium.
34. MEASURING CVP WITH A WATER
MANOMETER
• To ensure accurate central venous pressure (CVP) readings,
make sure the manometer base is aligned with the patient’s
right atrium (the zero reference point).
• The manometer set usually contains a leveling rod to allow
you to determine this quickly.
• After adjusting the manometer’s 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.
40. • Verify that the water manometer is connected to the I.V. tubing.
Typically, markings on the manometer range from –2 to 38 cm H2O.
• However, manufacturer’s 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 patient’s expected CVP value.
• Don’t overfill the tube because fluid that spills over the top can
become a source of contamination.
41. • 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
• After you’ve obtained the CVP value, turn the stopcock to resume the I.V.
infusion.
• Adjust the I.V. drip rate as required.
• Place the patient in a comfortable position.
42. 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
physician’s 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 removal—for instance, by placing the
patient in Trendelenburg’s position if the line was inserted using a
superior approach.
• If he can’t tolerate this, position him flat.
43. • Turn the patient’s 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.
44. • Clean 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.
45. Special considerations
• As ordered, arrange for daily chest X-rays to check catheter
placement.
• Care for the insertion site according to your facility’s policy.
• Typically, you’ll 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.
46. • 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.
47. • If the patient’s 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 hours.
• Label the I.V. solution, tubing, and dressing with the date,
time, and your initials.
48. Complications
• Complications of CVP monitoring include:
• pneumothorax (which typically occurs upon
catheter insertion)
• sepsis
• thrombus
• vessel or adjacent organ puncture, and air
embolism
49. Documentation
• Document all dressing, tubing, and solution changes.
• Document the patient’s 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.
