Cebu Institute of Technology

University

N. Bacalso Ave., Cebu City Philippines

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

IN PARTIAL FULFILLMENT OF THE COURSE NCM 301

SUBMITTED BY:
Sunico, Michelle

SUBMITTED TO:

CLINICAL INSTRUCTOR
 Arterial Line Reading

DEFINITION:
 Also known as an art-line or a-line, an arterial line is a thin catheter that is inserted into
an artery.
 Common insertion sites include radial, brachial, and femoral arteries.

PURPOSES:
 It is most commonly used to monitor blood pressure directly and accurately, as with
close and accurate titration of blood pressure medications. It is also used to obtain
samples for arterial blood gas analysis (ABG’s), and is convenient when frequent blood
samples are needed, so the patient does not have to be stuck multiple times.

EQUIPMENT:

 Sterile gloves
 Art-line kit
 Pressure tubing
 500 cc normal saline bag (with air
removed)
 Pressure bag
 IV pole
 Chloraprep
 A-line needle
 Transparent dressing and tape
 Cable to connect transducer to
monitor
 Monitor
PROCEDURE:

Performance rating
Procedure Rationale
5 4 3 2 1
Patient Assessments

1. Understanding of procedure Informed consent (principle of

autonomy)
2. Allen's Test (radial artery) Confirm collateral circulation to
hand
3. History of PVD, vascular Presence of one of these medical
grafts, AV fistula, arterial conditions may increase the risk
vasospasm or thrombosis, of arterial insufficiency distal to
diabetes mellitus
the insertion site.
Insertion Procedure
4. Wash hands. Prevention of nosocomial
infections.
5. Perform modified Allen's Confirm collateral circulation to
Test. the hand through the ulnar
artery.
6. Prepare pressurized and 1-2 units heparin/mL reduces
heparinized flush solution. risk of catheter occlusion
through thrombosis.
7. Flush pressurized closed Removal of ALL air bubbles
transducer tubing with luer- promotes better waveforms and
lok connections and ports. reduces danger of air embolism.
8. Use tubing with inline blood Maintains closed system while
discard reservoir. obtaining blood samples.
9. Don sterile gloves, Arterial line insertion is a sterile
protective gown, and mask. procedure
10. Assist with skin preparation. Reduce normoflora microbes at
insertion site.
11. Facilitate immobilization of Facilitates access to artery
extremity. during insertion.
12. Once catheter is inserted, Prevention of dislodgement of
connect pressure tubing and arterial catheter will reduce risk
secure site with sterile of hemorrhage from an artery.
occlusive dressing &
bandage.
13. Observe waveform and Determines location of the
perform a dynamic response catheter and degree of
test (square wave test). waveform dampness.
14. Level the transducer with Transducer should be leveled
phlebostatic axis with right atrium to provided
accuracy of blood pressure
readings.
15. Zero transducer to air. Insures representation of the
patient's BP on the monitor.
16. Compare arterial line Validates reference point for
pressure with noninvasive arterial readings.
cuff reading of blood
pressure.
Blood Pressure
Measurement
 Performance rating
Procedure Rationale
5 4 3 2 1
17. Check level of transducer Insures accuracy of readings.
with phlebostatic axis.
18. During first assessment of Insures representation of
shift, zero transducer to air. patient's BP on monitor.
19. Assess waveform for Dampness may distort systolic
dampness. and diastolic readings.
20. Record readings on monitor. Systolic/Diastolic (Mean Arterial
Pressure)
21. During first assessment of Verifies reference point for
shift, compare reading with arterial readings.
noninvasive cuff reading of
blood pressure.

Mean Arterial Pressure

Mean Arterial Pressure (MAP) = Systolic BP + 2(Diastolic BP)

3

Normal Ranges:
Systolic Blood Pressure: 90 – 120 mm Hg

Diastolic Blood Pressure: 50 – 80 mm Hg

Mean Arterial Pressure: 70 – 100 mm Hg

SCORE (Actual score over Perfect score X 100%):

NURSING RESPONSIBILITIES

1. Set-Up Hemodynamic Circuit

- RNs in CCTC are responsible for the priming, zeroing, leveling, and maintenance of
hemodynamic pressure monitoring circuits and for the assessment and monitoring of
hemodynamic pressures and waveforms.
- RNs in CCTC may flush hemodynamic monitoring circuits as required to maintain
patency.

2. Maintain Accuracy
- Hemodynamic transducers are zeroed at each initial setup, with the air-fluid interface
(stopcock above transducer) leveled to the mid-axillary line.
- Transducer levels should be validated at the beginning of each shift, prior to each
pressure measurement, following patient repositioning and prn to validate hemodynamic
pressures.
- Document level confirmation in the graphic record. Documentation is required at the
start of each shift and q6h, prior to each CVP and PWP measurement, and following
transducer repositioning.

3. Monitor Blood Pressure

- Continuous arterial pressure monitoring is indicated for patients requiring BP monitoring
>q1h, receiving continuous IV infusion of medications that affect cardiac output/blood
pressure, requiring frequent blood gas monitoring or who are
hemodynamically/neurologically unstable.
- Prior to recording any invasive hemodynamic pressure, evaluate the quality/accuracy of
the pressure waveform, assess the transducer level and ensure that sufficient flush
volume and pressure is present in the system..
- When comparing NIBP to arterial line pressures, Mean BP provides the most appropriate
comparison. Compare cuff to NIBP pressures taken from the same limb.

4. Display Waveforms

- Invasive arterial lines and right heart catheters must be connected to a monitor
that provides a continuous waveform display.

5. Maintain Arterial Line Alarms

- Appropriate alarms must be on for all patients requiring continuous arterial pressure
monitoring. Alarm settings should be selected based on the degree of fluctuation in the
patient's BP. Upper and lower alarm limits that represent clinically important changes
are selected for each individual patient.
- High and low alarm settings must be assessed and documented in the 24 Hour graphic
record each hour to confirm that the alarm was checked hourly and is "on".
- The 24 Hour graphic record has a code to identify whether an arterial line is positional
during the hourly checks.
- Alarms may need to be disabled if an arterial line becomes positional. If an arterial line
alarms is disabled, documentation in the AI record is required. This should include the
reason for disabling the alarm and should describe troubleshooting strategies. The
"positional" code on the graphic can then be used to explain why the arterial line alarm
is turned "off".
- If an arterial line becomes positional or it can no longer be used for blood sampling, the
physician should be notified and line change considered. The plan for line management
should be documented in the Plan of Care and communicated to the oncoming nurse.

6. Maintain Closed System

- All stopcocks must have dead-end (non-vented) luer lock caps or luer lock connected
infusions. This includes stopcocks located on transducers. Alcohol impregnated sampling
port caps should be maintained on all sampling ports.
- Hemodynamic circuits are changed with each new line and prn.

7. Obtain Blood Samples

- RNs may draw blood from indwelling arterial and venous lines. Stopcocks should be
turned to 45 degrees between syringe changes. Luer-lock needleless access caps should
be changed before drawing a blood culture and any time the port has visible blood.
- Flush thoroughly after blood sampling and maintain adequate counter pressure to
prevent thrombus formation. Reconfirm waveform after flushing.

8. Change Dressings
- Arterial line dressings are changed q 7 days and PRN when using CHG transparent
dressings, or Q 24 H when using gauze.
- Dressings should be changed prn if occlusivity is disrupted or if the CHG pad becomes
boggy.
- Record any redness or abnormal findings in the AI record and report to the physician.
See Procedure for Arterial and Central Line Dressings.
- Dressing changes should be performed aseptically. Arterial and Central Venous Dressing
Trays are available for ease of collecting supplies.
- Non-sterile cap, gown and mask with face shield plus sterile gloves are required.

9. Monitor Arterial Site

- Arterial line sites/dressing should be kept as visible as possible. Check the site q1h and
prn to assess for bleeding.
- Use minimal dressing material.
- Assess distal extremity for evidence of compromised color, circulation or motion q1h.
- Lines should be removed if there are signs of infection.

10. Document
- Record S/D and M BP in the graphic record q1h and prn.
 - Assess site and waveform q shift and document in the 12 hour assessment record.
Assess patency q shift and evaluated q 4 h and document in the intravascular device
section of the flow sheet.
- Print a waveform at the start of each shift to record line placement confrmation and
waveform quality.
- Document dressing changes in the graphic record and * and DAR abnormal findings.

______________________________ ____________________________
Signature over printed name of Evaluator Signature over printed name of Student
 CENTAL VENOUS PRESSURE LINE MONITORING

DEFINITION:
 Central venous pressure is considered a direct measurement of the blood pressure in the
right atrium and vena cava. It is acquired by threading a central venous catheter
(subclavian double lumen central line shown) into any of several large veins.

PURPOSES:
 CVP has been considered a reliable indicator of right ventricular preload. It has been
used to assess cardiac preload and volume status in critically ill patients,3 assist in the
diagnosis of right-sided heart failure, and help guide fluid resuscitation.

EQUIPMENT:

 Sterile gloves
 Sterile gown
 Cap
 Sterile gauze
 Sterile saline
 Sterile cleansing solution such as
chlorhexidine
PROCEDURE:

Performance rating
Procedure Rationale
5 4 3 2 1
1. Introduce yourself to the To gain trust from the patient
patient
2. Explain the procedure to the For the patient to understand
patient. and to promote cooperation.
3. Prepare the equipment’s To save time and effort when
needed the procedure has started
4. Wash hands. To eliminate microorganisms or
bacteria.
5. Put on gloves To protect yourself and the
patient.
6. Flush central line with The central line must be flushed
normal saline regularly. This will keep it clean
and prevent blood clots from
blocking the catheter. To flush it,
you will use a syringe to inject
solution into the injection cap of
the catheter.
7. Attach the manometer Manometer is attached to the
cuff to measure a change in
pressure.
8. Fill the manometer line and To be sure all air bubbles are
be sure there is no air eliminated
bubbles
9. Put the patient in supine For comfortability of the patient.
position
10. Locate the phlebostatic It helps to ensure the accuracy
angle of the various pressure readings
11. Open the manometer line to To determine the pressure
the patient measurement
12. Disconnect the mechanical To determine the patient’s
ventilator clinically stable with no signs of
poor tolerance until the end of
the trial
13. Observe the level of the It is important to note the level
fluid inside the manometer of fluid inside the manometer.
14. Take the stable reading and To determine if the breathing is
reconnect the mechanical in stable and to allow the patient
ventilator time to heal
15. Give feedback to the patient To assure the patient that the
procedure is succesful

16. Reconnect the IV fusion Regulation ensures the correct

and resume the previous amount of fluid drips from a bag
rate down the IV into your vein at
the correct rate. Complications
can result from receiving too
much too quickly, or not enough
too slowly
17. Remove and dispose To avoid spreading infection and
gloves, wash hands. contamination.
18. Document the procedure For patient’s evaluation and to
know if the patient’s is satisfied
of the procedure
SCORE (Actual score over Perfect score X 100%):
Nursing Responsibilities:
 Assemble equipment according to manufacturer’s directions.
 Explain that the procedure is similar to an IV and that the patient may move
in bed as desired after passage of the CVP catheter.
 Place the patient in a position of comfort. This is the baseline used for
subsequent readings.
 Attached manometer to the IV pole. The zero point of the manometer should
be on a level with the patient’s right atrium.
 Mark the midaxillary line on the patient with an indelible pencil.
 The CVP catheter is connected to a 3-way stopcock that communicates to an
open IV and to a manometer.
 Start the IV flow and fill the manometer 10 cm above anticipated reading (or
until the level of 20cm, HOH is reached). Turn the stopcock and fill the
rubbing with fluid.
 The CVP site is surgically cleansed. The physician, introduces the CVP
catheter percutaneously or by direct venous cutdown and threaded through
an antecubital, subclavian, or internal or external jugular vein into the
superior vena cava just before it enters the right atrium.
 When the catheter enters the thorax an inspiratory fall and expiratory rise in
venous pressure are observed.
 The patient may be monitored by ECG during catheter insertion.
 The catheter may be sutured and taped in place. A sterile dressing is applied
 The infusion is adjusted to flow into the patient’s vein by a slow continuous
drip.
 BLOOD TRANSFUSION

DEFINITION:
● A blood transfusion is a common medical procedure in which donated blood is
administered via a narrow tube inserted into the vein in the arm. Throughout the
procedure, nurses must keep a close eye on their patients' vital signs.

PURPOSE:
● Many patients who have major surgery will receive a blood transfusion to replace
blood lost during the procedure.
● Patients who have suffered serious injuries in car accidents, natural disasters, or
other traumatic events are typically given blood transfusions

MATERIALS:

 IV Catheters
 Needles
o 20-22 gauge for routine transfusions in adults
o 16-18 gauge for rapid transfusions in adults
o 22- 25 gauge for pediatrics
 Special Y tubing with an in-line filter
 0.9% NaCl (Normal Saline) solution
 Blood warmer
 Infusion Device

PROCEDURE:

STEPS RATIONALE

1. Wash hands 1. To reduce infection

2. Know client’s blood type 2. By taking a blood sample, we can know client’s
blood type to be transfused
3. Assemble supplies 3. To have supplies ready to begin the blood
transfusion
4. Obtain baseline vital signs 4. To know the client’s current health status
5. Verify the blood product 5. To ensure blood compatibility before transfusion
6. Start the transfusion by preparing the Y-tubing 6. Only normal saline can be transfused with blood
with NS solution and have the blood ready in products to increase blood volume
an infusion pump
7. Run the blood slowly for the first 15 minutes at 7. To start the infusion
2mL/min or 120cc/hr
8. Remain with the patient for the first 15 8. This is when most transfusion reactions can
minutes occur
9. Increasing blood transfusion rate can only occur
9. Increase the rate of transfusion after the if the patient if stable
patient is stable and does not display signs of
any transfusion reactions 10. To document the client’s vitals throughout the
10. Document vital signs after first 15 minutes, procedure
then hourly, and at the completion of the
transfusion

Performance rating
Procedure Rationale
5 4 3 2 1
1.Verify the physician’s Order must be verified for
order for the specific blood the type of product; the
or blood product. amount, date, time, and rate
and duration of infusion; any
modifications to a blood
component
2. Verify the type and cross- Past complications may
match require patient to have pre-
and post-transfusion
medications to prevent
further transfusion reactions.
3. Check if the patient has This ensures the transfusion
properly completed and is appropriate for the
signed the transfusion patient.
consent form
4.Verify physician orders Order must be verified to
avoid any medication error
and malpractice during the
procedure.

5. Complete and document Document any clinical sign

cardiovascular assessments or symptom that may be
and initial vital signs. confused with a transfusion
reaction

6. Obtain products from the Plan for pickup or delivery of

transfusion areas within 30 blood and blood products in
minutes of planned order for the procedure to
transfusion. not be delayed.
7. Complete visual Assess blood bag for any
inspection of product. signs of leaks or
contamination, such as
clumping, clots, gas bubbles,
or a purplish discoloration.
Return to blood bank if
blood bag contains any of
the above signs.
 Performance rating
Procedure Rationale
5 4 3 2 1

8. Final Verification All verification numbers must

match exactly. If there are
any discrepancies, stop the
process and contact the TMS
for resolution and direction.
Do not proceed.

Patients who are alert and

oriented should be asked to:

 Spell first and last

name
 State their date of birth

9. Perform hand hygiene. Do not remove the product

Prime the blood product from the presence of the
administration set: patient; prime at bedside. If
product is removed from
 Close clamp. bedside, the final verification
Completely cover the process must be completed
filter with product.
again.
 A straight blood
administration set is
used for all
transfusions.

A Y-type blood administration

set should only be
considered in clinical
situations where additional
fluid volume may be
required.
10. Initiate Transfusion Initiate red cells slowly (25
ml in the first 15 minutes).
 Obtain vital signs For all other blood
immediately prior to transfusions, refer to the
transfusion, then 15 blood and product sheet as
minutes after per your agency policy.
initiation, then every
hour until transfusion
is complete. Complete transfusion within 4
hours of removal from the
 Maintaining asepsis, blood bank.
disconnect the NS
infusion and connect
blood administration
set and start
transfusion.
 Advise patient on the
signs and symptoms
of transfusion reaction
and what and when to
report.
 Performance rating
Procedure Rationale
5 4 3 2 1

11.Monitor: Vital signs must be

monitored:
Assess and observe for
clinical signs and symptoms  Immediately prior to
of reactions up to 24 hours infusion
post-transfusion.
 Within 10 to 15
minutes
Complete all appropriate
clinical documentation.  Every hour until
transfusion is complete

12. Flush administration set Flushing displaces any blood

with maximum of 50 ml of or blood product from the
normal saline and re- administration set. It is not
establish IV or SL as per necessary to flush between
physician orders. units of the same blood
product.
13. Discard waste in This prevents the spread of
biohazard waste container. biohazard waste.
14. Complete all Documentation may include:
documentation as required
by agency.  Transfusion record
form
 All vital signs and
reactions
 Any significant
findings, initiation and
termination of
transfusion

SCORE (Actual score over

Perfect score X 100%):

_____________________________
Signature over printed name of Evaluator

________________________________
Signature over printed name of Student

NURSING RESPONSIBILITIES:
BEFORE
● Ensure that the correct preparation of the patient and the care procedure is
done.
● Double-check the order for transfusion and correlate this with the clinical
diagnosis and care plan of the patient.
 ● Verify the blood type of the patient on the chart. If needed, obtain a request for
blood typing.
● Once blood to be transfused or a donor is available, request for crossmatching to
be done. A sample will be obtained from the patient and from the donor/blood
pack and tested.
● After crossmatching is done, a request for the number of units to be transfused
should be made.
● Obtain consent. The consent must be obtained prior to starting any invasive
procedure or therapy.
● Assess for any allergies the client may have.
● Ask the client for any previous blood transfusion and their reaction to it.
● Verify the BT order. Check the patient record and the order of the physician.
● If there is any discrepancy between patient information, group and screen,
product ordered, etc., do not proceed. Stop and verify any discrepancies.

DURING

● No medications may be added to blood units or through IV tubing.

● Specific blood administration tubing is required for all blood transfusions. Blood
tubing is changed every 4 hours or 4 units, whichever comes first.
● See agency policy for using EID for the administration of blood products.
● Intravenous immunoglobulin (IVIG) is only compatible with D5W.
● All blood products taken from the blood bank must be hung within 30 minutes
and administered (infused) within 4 hours due to the risk of bacterial
proliferation in the blood component at room temperature.
● Be diligent when preparing to infuse blood. Distractions may lead to errors when
verifying information.

AFTER
● Once transfusion is done, the line should be flushed with normal saline solution.
If there are no more succeeding transfusions, the line is discontinued, and the
BT set is disposed of properly.
● Always review your agency’s algorithm for managing mild to severe reactions. If
a reaction is mild (e.g., fever), and without any other complications, a patient
may continue the transfusion if monitored closely. Most other transfusion
reactions require the transfusion to be stopped immediately.
● A blood transfusion reaction may occur 24 to 48 hours post-transfusion.
● Each separate unit presents a potential for an adverse reaction.
● Follow emergency transfusion guidelines when dealing with an emergency blood
or blood product transfusion.
● Be aware of which types of blood or blood products cause the most types of
transfusion reactions.
● Be aware of the types of patients at high risk for blood or blood product
transfusion reactions.
● Always have emergency equipment and medications available during a
transfusion. For example, epinephrine IV should always be readily available.
REFERENCES:

 Blood transfusion - Mayo Clinic. (2020, April 15). MayoClinic. Retrieved October
29, 2021, from https://www.mayoclinic.org/tests-procedures/blood-
transfusion/about/pac-20385168
 Unitek College. (2021, March 22). A Step-by-Step Guide to Blood Transfusions.
Retrieved October 29, 2021, from https://www.unitekcollege.edu/blog/a-step-by-
step-guide-to-blood-transfusion/
 Doyle, G. R. (2015, November 23). 8.7 Transfusion of Blood and Blood Products
– Clinical Procedures for Safer Patient Care. Pressbooks. Retrieved October 29,
2021, from https://opentextbc.ca/clinicalskills/chapter/blood-and-blood-product-
administration/
 Vera, M. (2016, February 1). Measuring Central Venous Pressure. Retrieved
October 29, 2021, from https://nurseslabs.com/measuring-central-venous-
pressure/