Clinical Protocol Page 1 of 5

Clinical Manual - Nursing Practice Manual

John Dempsey Hospital Department of Nursing
The University of Connecticut Health Center

PROTOCOL FOR: Hemodynamic Monitoring: Arterial, Central Venous (CVP) and/or Pulmonary
Artery (PA) Pressures


POLICY: 1. Hemodynami c moni t or i ng vi a a cent r al l i ne ( cent r al venous pr essur e
CVP) and/ or ar t er i al l i ne may be per f or med i n t he f ol l owi ng uni t s:
I CU, PACU, Car di ac Cat h Lab, Labor & Del i ver y, CSDU, and
I nt er vent i onal Radi ol ogy.

2. Hemodynami c Moni t or i ng vi a a pul monar y ar t er y ( PA) cat het er may be
per f or med i n t he f ol l owi ng uni t s: I CU, PACU, Car di ac Cat h Lab.

3. Hemodynami c moni t or i ng l i nes may onl y be i nser t ed and r eposi t i oned
by a t r ai ned pr act i t i oner , and must be sut ur ed or secur ed i n pl ace.

4. Radi al ar t er i al l i nes may be r emoved by an RN; Al l ot her hemodynami c
moni t or i ng l i nes ar e r emoved by a t r ai ned pr act i t i oner .

5. Ar t er i al l i nes must be t r ansduced, wi t h pr essur e al ar ms on at al l
t i mes.

6. I f a cont i nuous ar t er i al t hr ombol yt i c i nf usi on i s or der ed ( i . e.
post - i nt er vent i onal pr ocedur e) t he ar t er i al sheat h must be
t r ansduced i n or der t o have an al ar m. Moni t or al ar mmay be set t o
mean pr essur e, i f a di st i nct pr essur e wave does not di spl ay.

7. Except i ons t o t r ansduci ng ar e:

a. When t he pat i ent i s i n t r anspor t , accompani ed by a RN; Deci si on
whet her t o t r ansduce t he l i ne i s at t he di scr et i on of t he RN.

b. Al ar ms may onl y be t empor ar i l y suspended dur i ng bl ood dr aw f r om
t he l i ne, and al ar ms must i mmedi at el y be r esumed at t he concl usi on
of t he bl ood dr aw.

8. A chest X- r ay i s done post subcl avi an or j ugul ar i nser t i on of a
cent r al l i ne or pul monar y ar t er y cat het er t o conf i r mpl acement
( unl ess pl aced under f l uor oscopy) and t o r ul e out a pneumot hor ax.

9. Except i n an emer gency, i nf usi on of t her apeut i c f l ui ds shoul d not be
i ni t i at ed unt i l conf i r mat i on of l i ne pl acement i s pr ovi ded by t he
pr act i t i oner .

10. The di st al t i p of a pul monar y ar t er y cat het er must be moni t or ed at
al l t i mes, and t he l ock on t he bal l oon por t shoul d al ways be OPEN t o
al l ow ai r t o escape.

DESIRED PATIENT
OUTCOME:

1. Pat i ent wi l l r emai n f r ee of i nf ect i on secondar y t o i nvasi ve l i ne.

2. The pat i ent wi l l mai nt ai n hemodynami c st abi l i t y.

CLINICAL
ASSESSMENTS AND
CARE:


1. Hemodynami c Moni t or i ng Assessment : Al l pat i ent s wi t h hemodynami c
moni t or i ng l i nes wi l l be assessed as f ol l ows:

a. Wave f or manal ysi s at t he begi nni ng of ever y shi f t , and wi t h any
Clinical Protocol Page 2 of 5
Clinical Manual - Nursing Practice Manual
John Dempsey Hospital Department of Nursing
The University of Connecticut Health Center

PROTOCOL FOR: Hemodynamic Monitoring: Arterial, Central Venous (CVP) and/or Pulmonary
Artery (PA) Pressures


change i n t he wave pat t er n. Post wavef or ms ever y shi f t .

b. Pr essur e r eadi ngs mi ni mal l y ever y 4 hour s except : Pul monar y ar t er y
occl usi ve pr essur e ( PAOP) and Car di ac out put ( CO) - obt ai n ever y 4
hour s, or per pr act i t i oner s or der s.

c. Assess dr essi ng f or i nt act ness, dr yness, dr ai nage, pr esence of
sut ur es, ever y 8 hour s.

d. Assess per f usi on di st al t o i nser t i on si t e ever y 4 hour s and pr n.

2. I V Fl ui ds:

a. Al l t r ansduced l i nes wi l l have a nor mal sal i ne f l ush, mai nt ai ned
on a pr essur i zed bag ( set at 300mmHg) . At t hi s pr essur e, a 3- 5
ml / hr f l ush of t he syst emi s mai nt ai ned.

Except i on: t he cent r al l umen ar t er i al l i ne of an i nt r a- aor t i c
bal l oon i s r out i nel y hepar i ni zed, unl ess speci f i cal l y or der ed
r ef er t o I ABP pol i cy.

b. I V f l ui ds and medi cat i ons may be i nf used vi a a cent r al venous
pr essur e ( CVP) l i ne, or t he pr oxi mal por t ( RA por t ) of a pul monar y
ar t er y cat het er ;

I nf usi on of vasoact i ve medi cat i ons vi a t hese por t s i s not
r ecommended, especi al l y i f manual car di ac out put measur ement s ar e
t o be obt ai ned.

c. No I V f l ui ds ( ot her t han NS f l ush) ar e t o be i nf used vi a t he
di st al por t ( PA por t ) of a pul monar y ar t er y cat het er , as t he
wavef or mat t he di st al por t must be cont i nuousl y di spl ayed, i n
or der t o eval uat e t hat t he cat het er i s i n cor r ect posi t i on.

d. NO I V f l ui ds ar e i nf used vi a an ar t er i al l i ne, unl ess speci f i cal l y
or der ed by a pr act i t i oner ( i e. t hr ombol yt i c f or per i pher al
ar t er i al occl usi on) .

3. Level i ng / Zer oi ng & Posi t i oni ng:

a. Al l ar t er i al , CVP and PA pr essur e r eadi ngs must be t aken wi t h t he
t r ansducer s zer o st opcock l evel ed t o t he pat i ent ' s r i ght
at r i um( phl ebost at i c axi s) t hi s i s def i ned as t he 4t h
i nt er cost al space, t he AP di amet er of t he chest mi dchest ) , i f
t he pat i ent i s supi ne.

b. A car pent er s l evel , or l aser l evel shoul d be used t o cor r ect l y
r ef er ence t he syst emt o phl ebost at i c axi s.

c. Zer o t he t r ansducer at l east once per shi f t and any t i me t he
f l ui d- ai r i nt er f ace i s i nt er r upt ed ( i . e. af t er bl ood dr aw or
t ubi ng change) , as wel l as any t i me hemodynami c val ues obt ai ned
ar e i n quest i on.

Clinical Protocol Page 3 of 5
Clinical Manual - Nursing Practice Manual
John Dempsey Hospital Department of Nursing
The University of Connecticut Health Center

PROTOCOL FOR: Hemodynamic Monitoring: Arterial, Central Venous (CVP) and/or Pulmonary
Artery (PA) Pressures


To zer o t he t r ansducer : t ur n t he zer o st opcock of f t o t he pat i ent
and open t he syst emt o ai r by r emovi ng t he dead- end cap. Pr ess
zer o on t he moni t or . Once zer o r e- di spl ays, r epl ace t he dead- end
cap. Ret ur n t he st opcock back t o moni t or i ng and r e- eval uat e t he
squar e wave.

d. The head of t he bed ( HOB) may be el evat ed t o a posi t i on of comf or t
f r om0 t o 60 degr ees f or ar t er i al , CVP, PA, PAOP measur ement s,
wi t h t he pat i ent supi ne. When possi bl e, r eadi ngs shoul d be
obt ai ned wi t h t he HOB at a consi st ent hei ght , r ecor ded on t he
Nur si ng Assessment For m.

e. Car di ac out put measur ement s shoul d be obt ai ned wi t h t he pat i ent
supi ne, and HOB 20- 45 degr ees.

f . I n t he 30 degr ee l at er al posi t i on, t he zer o r ef er ence poi nt i s
t he di st ance f r omt he sur f ace of t he bed t o t he l ef t st er nal
bor der , and measur ement s shoul d be obt ai ned wi t h t he HOB
f l at . ( Si nce cl i ni cal l y si gni f i cant changes i n CO can occur i n t he
l at er al posi t i on, af f ect i ng ot her hemodynami c par amet er s, t he
hemodynami c r esponse t o t he posi t i on change shoul d be compar ed t o
t he st andar d supi ne posi t i on, bef or e any deci si on i s made whet her
t o t r end/ t r eat pr essur es obt ai ned when i n l at er al r ot at i on. )

4. Assessi ng/ Mai nt ai ni ng Dynami c Response

a. Check t hat t her e i s adequat e f l ui d i n t he pr essur e bag each shi f t ,
and mai nt ai n t he pr essur e bag at 300mmHg.

b. Ver i f y t he accur acy of t he syst em( dynami c r esponse) by per f or mi ng
a squar e wave t est at i ni t i al set - up, at l east once per shi f t ,
af t er openi ng t he pr essur e syst em( i . e. bl ood dr aw, t ubi ng
change) , and whenever pr essur e wave appear s t o be damped or
di st or t ed.

c. Check t hat al l ai r i s out of t he bag & f l ush syst emand t hat al l
connect i ons ar e secur e t o pr event ai r f r oment er i ng syst em. Ai r
bubbl es can di st or t t he wavef or m, and al t er dynami c r esponse.

5. Bl ood Sampl i ng:

a. RNs may obt ai n bl ood sampl es f r oman ar t er i al l i ne, cent r al l i ne,
or PA cat het er .

b. Bl ood may be dr awn f or l ab anal ysi s f r omt he pr oxi mal ( RA) por t of
t he PA cat het er i f no ot her access i s avai l abl e.

c. A mi xed venous bl ood gas sampl e i s dr awn f r omt he di st al por t of
t he PA cat het er .

6. Li ne Car e:

a. Al l por t s of t he moni t or i ng l i ne must be capped wi t h ei t her a
dead- ended cap or needl el ess access devi ce.
Clinical Protocol Page 4 of 5
Clinical Manual - Nursing Practice Manual
John Dempsey Hospital Department of Nursing
The University of Connecticut Health Center

PROTOCOL FOR: Hemodynamic Monitoring: Arterial, Central Venous (CVP) and/or Pulmonary
Artery (PA) Pressures



b. Change t r ansducer f l ush syst em( t ubi ng and sol ut i on) ever y 72
hour s.

c. Ar t er i al l i ne t ubi ng shoul d be changed down t o t he st opcock
cl osest t o t he pat i ent .

d. Chl or hexi di ne gl uconat e ( CHG) pr ep must be used, as per cent r al
l i ne pol i cy, when accessi ng a hemodynami c moni t or i ng l i ne. Usi ng
f r i ct i on, vi gor ousl y scr ub t he access por t wi t h CHG f or 15- 30
seconds.

e. Dr essi ngs must be mai nt ai ned per cent r al l i ne pol i cy.

7. Compl i cat i ons:

a. The nur se shoul d be al er t f or any of t he f ol l owi ng compl i cat i ons
whi ch may be secondar y t o a hemodynami c moni t or i ng l i ne.

1) ai r embol i

2) vessel t r auma

3) dysr hyt hmi as

4) al t er ed ski n i nt egr i t y

5) phl ebi t i s

6) pul monar y embol i

7) pneumot hor ax

8) coi l ed cat het er

8. Repor t abl e Condi t i ons:

a. The f ol l owi ng condi t i ons ar e t o be r epor t ed t o t he pr act i t i oner :

1) Change i n wave f or m, dampened wave, or l oss of pr essur e wave.

2) Det er i or at i on i n pr essur e r eadi ngs i ndi cat i ng hemodynami c
i nst abi l i t y.

3) Dysr hyt hmi as secondar y t o cat het er pl acement .

4) I nabi l i t y t o aspi r at e bl ood f r omcat het er .

5) I V f l ui d l eaki ng f r omcat het er .

6) Li ne not sut ur ed or secur ed.

7) Cont i nuous PAOP ( wedge) wave f or meven af t er bal l oon i s
def l at ed ( t hi s i s consi der ed an emer gency, si nce per manent
Clinical Protocol Page 5 of 5
Clinical Manual - Nursing Practice Manual
John Dempsey Hospital Department of Nursing
The University of Connecticut Health Center

PROTOCOL FOR: Hemodynamic Monitoring: Arterial, Central Venous (CVP) and/or Pulmonary
Artery (PA) Pressures


wedgi ng can l ead t o pul monar y i schemi a/ i nf ar ct i on) .

8) Compl i cat i ons secondar y t o moni t or i ng.

APPROVAL: I CU St andar ds Commi t t ee
Nur si ng St andar ds Commi t t ee
Car di ac St ep- Down St andar ds Commi t t ee

EFFECTIVE DATE: 2/ 88

REVISION DATES: 1/ 94, 11/ 94, 3/ 96, 8/ 97, 8/ 99, 8/ 11

REVIEWED DATES: