A nurse is assessing a client who has a central venous catheter (CVC) in place. The client suddenly reports acute chest pain and shortness of breath, and the nurse observes a loose connection at the catheter hub. Suspecting a catheter-related air embolism, arrange the following nursing actions in the priority order they should be performed. (Arrange from first action to last action.)
- 1Clamp the central venous catheter immediately.
- 2Place the client in a left lateral Trendelenburg position.
- 3Administer 100% oxygen via a non-rebreather mask.
- 4Notify the rapid response team and the healthcare provider.
- 5Obtain baseline vital signs and monitor oxygen saturation.
Answer
The correct sequence is to first clamp the catheter, then place the client in the left lateral Trendelenburg position, administer high-flow oxygen, notify the rapid response team, and finally monitor vital signs.
An air embolism is a life-threatening complication of central venous catheters. The absolute priority is to stop more air from entering by clamping the line. Next, positioning the client on their left side with the head down (left lateral Trendelenburg) traps the air in the right ventricle, preventing it from entering the pulmonary circulation. Administering 100% oxygen helps relieve hypoxia and decreases the size of the air bubble. Calling for help ensures advanced care is on the way, and subsequent vital sign monitoring guides ongoing resuscitation efforts.
Step-by-Step Solution
Key Concept
Emergency Management of a Central Venous Catheter Air Embolism