A nurse enters a client's room and observes that the client's central venous catheter tubing has disconnected from the hub. The client is gasping for air, appears cyanotic, and reports severe, sudden-onset chest pain. Arrange the following nursing actions in the priority order they should be performed to reduce the risk of cardiopulmonary collapse.
- 1Clamp the central venous catheter immediately.
- 2Place the client in the left lateral Trendelenburg position.
- 3Administer 100% oxygen via a non-rebreather mask.
- 4Activate the rapid response team.
- 5Obtain a full set of vital signs and prepare for possible resuscitation.
Answer
The correct sequence is to clamp the catheter, position the client in the left lateral Trendelenburg position, administer oxygen, activate the rapid response team, and obtain vital signs.
In the event of a disconnected central venous catheter leading to a suspected air embolism, the immediate priority is to stop further air entry by clamping the line. The next critical step is positioning the client in the left lateral Trendelenburg position to trap the air bubble in the right ventricle, preventing it from migrating into the pulmonary circulation. Oxygen therapy is then applied to address hypoxemia and help shrink the air embolus through nitrogen washout. Once these rapid, independent, life-saving measures are implemented, help is summoned, and baseline parameters are established to guide further medical management.
Step-by-Step Solution
Key Concept
Management of Suspected Air Embolism in Central Venous Catheters