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Difficulty: MediumReduction of Risk Potential

A nurse is preparing to remove a client's non-tunneled central venous catheter (CVC). To minimize the risk of an air embolism and ensure client safety, arrange the following nursing actions in the correct chronological sequence.

  1. 1Place the client in a supine position.
  2. 2Instruct the client to take a deep breath and bear down.
  3. 3Withdraw the catheter smoothly and steadily.
  4. 4Apply immediate firm pressure to the site with sterile gauze.
  5. 5Apply an occlusive dressing over the insertion site.

Answer

The correct sequence is to first place the client in a supine position, then instruct them to perform the Valsalva maneuver, followed by withdrawing the catheter, applying immediate firm pressure, and finally securing an occlusive dressing.
Removing a central venous catheter involves a significant risk of an air embolism if intrathoracic pressure falls below atmospheric pressure. By initially placing the client in a supine position and subsequently having them perform the Valsalva maneuver, the nurse artificially raises the central venous pressure. Withdrawing the catheter exclusively during this positive-pressure phase, immediately applying firm pressure to the site, and finally sealing the tract with an occlusive dressing effectively mitigates this life-threatening risk in the correct physiological sequence.

Step-by-Step Solution

1
Place the client in a supine position.
Central venous pressure is increased.
Supine positioning uses gravity to prevent a negative pressure gradient, reducing the risk of air being drawn into the vein.
2
Instruct the client to bear down (Valsalva maneuver).
Intrathoracic pressure increases significantly.
Creates a positive pressure environment in the central veins, blocking potential air entry.
3
Withdraw the catheter smoothly.
The catheter is removed safely.
The device is removed precisely while the protective positive pressure is actively maintained by the client.
4
Apply firm pressure to the site with sterile gauze.
Bleeding is controlled and the tract is compressed.
Promotes hemostasis and prevents any immediate air entry through the newly opened skin tract.
5
Apply an occlusive dressing over the insertion site.
An airtight seal is established.
Prevents delayed air entry as the internal tract fully closes.

Key Concept

Reduction of Risk Potential: Central Venous Catheter Removal
Estimated Time:1m 30s
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Topics

Reduction of Risk Potential

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