A nurse enters the room of a client receiving intravenous fluids via a central venous catheter (CVC). The nurse discovers that the intravenous tubing has disconnected from the CVC hub. The client is suddenly experiencing severe dyspnea, tachycardia, and a feeling of impending doom. Arrange the following nursing actions in the correct order of priority to manage this complication.
- 1Clamp the central venous catheter.
- 2Place the client in a left lateral Trendelenburg position.
- 3Administer high-flow oxygen via a non-rebreather mask.
- 4Notify the rapid response team and healthcare provider.
- 5Assess the client's vital signs and oxygen saturation.
Answer
The correct sequence is to first clamp the catheter, then position the client in left lateral Trendelenburg, administer high-flow oxygen, notify the rapid response team, and finally assess vital signs.
The client's sudden onset of dyspnea, tachycardia, and feeling of impending doom immediately following a CVC disconnection strongly indicates an air embolism. The priority is to mitigate physiological risk by preventing further air entry (clamping), trapping the existing air to prevent fatal outflow obstruction (left lateral Trendelenburg), treating hypoxia and shrinking the embolus (high-flow oxygen), securing advanced help (rapid response team), and evaluating the client's status (vital signs).
Step-by-Step Solution
Key Concept
Management of a central venous catheter-related air embolism requires immediate source control, specific client positioning (Durant's maneuver) to trap the air, oxygenation, and rapid escalation of care.