Name: CALMA, Mary Ann C.

Section: BSN – IV LEININGER Date: SEPTEMBER 25, 2021

Central Venous Pressure Measurement

Formulate a Nursing Care Plan from the given clinical problems below. Choose one problem to work on.

Clinical problems Critical thinking options

⮚ Air enters central vein, producing air
embolism from system being open to
atmosphere
⮚ Clamp catheter
⮚ Place a client in a head down position (turned to the left so
right atrium is uppermost
⮚ Immediately inform the physician
⮚ Monitor until physician arrives
⮚ Administer high flow )2 as necessary
⮚ Valsalva manuever any time catheter is open to air or use
in line catheter clamp

⮚ CVP reading vary greatly ⮚ Assess patency of set up

⮚ Assess client’s level of pain, pain increases the CVP reading
⮚ Assess if position of client has been changed, raising the
head of the bed alters the reading unless the setup is
adjusted
⮚ Check the marked area at mid-axilliary level of client’s right
atrium (4th ICS)
⮚ Note if client has COPD, heart failure or hypovolemia,
expect readings to differ from normal range

SMART NCP

3- very good (with critical thinking)

2- good (with knowledge and understanding)
1 average (with perceived idea)

Assessment Nursing Diagnosis Plan Intervention Evaluation

Subjective: Actual: At the end of the  Every 4 At the end of the
 The patient  Acute Pain intervention, The hours, verify intervention, The
verbalize client will: the insertion client:
“Hirap ako  Verbalizes site  Verbalized
huminga. the relief of alternatively, that the pain
Parang pain as needed if is already
kinukulang  Report pain there are relieved.
ako sa is signs of  The client is
paghinga eh relived/contr irritation and comfortable
tapos parang olled pain. and the
hinahabol ko  Clamp a reported
yung hininga catheter pain is
ko”
  The patient  Avoid tight already
verbalized bandaging of relieved
“Masakit the affected  GOAL MET
yung dibdib extremity
ko palagi kasi  Perform
nga active and
hinahabol ko passive range
yung of motion
paghinga ko.  Valsalva
Ang hirap” manuever
any time
Objective: catheter is
 Pallor / open to air or
Cyanosis use in line
 Rapid, Weak catheter
pulse (PR: clamp
53bpm)  Administer
 Hypotension high flow )2
(BP: 80/60 as necessary
 Strong
feelings of
anxiety
Risk For: At the end of the  Place a client At the end of the
 Risk for intervention, the in a head intervention, The
Injury: client will: down client:
impaired  Client’s position  The client’s
catheter catheter (turned to catheter
function function is the left so function is
maintained maintained
right atrium
is uppermost

 Examine the
catheter for
integrity,
patency,
leakage, and
gravitational
force.

 Monitor until
physician
arrives

 Flush the
catheter
according to
established
institutional
policy and
procedures
  Use
mechanical
IV pumps

 Avoid blood
pressure
measuremen
ts in the arm
with PICC

 Immediately
inform the
physician

 Risk for At the end of the  Check the At the end of the
infection intervention, The catheter site intervention, The
client will: for infection client:
 Be free from  Assess the  Are free from
infection as vital signs infection as
evidenced by  If doing evidenced by
normal catheter- the normal
temperature, related care, temperature
no signs of always follow (36.8°C), no
redness. the signs of
instructional redness.
policy and
procedure