A nurse is caring for a client who is receiving intravenous fluids through a central venous catheter. The client suddenly develops severe dyspnea, chest pain, and a feeling of impending doom. The nurse suspects a central line-associated air embolism. In what order should the nurse take the following actions to reduce the risk of a life-threatening complication? Arrange the steps from first to last.
- 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 healthcare provider and the rapid response team.
- 5Remain with the client and continuously monitor vital signs.
Answer
The correct order is: 1) Clamp the catheter, 2) place the client in a left lateral Trendelenburg position, 3) administer oxygen, 4) notify the healthcare provider, and 5) remain with the client.
When an air embolism is suspected, the nurse must rapidly intervene using the 'stop, position, oxygenate' approach to reduce the risk of a fatal pulmonary obstruction. The absolute first priority is to stop more air from entering by clamping the line. The second step is to trap the existing air in the right atrium by placing the client in the left lateral Trendelenburg position. Following this, administering 100% oxygen treats hypoxia and helps absorb the air bubble. Finally, the nurse calls for medical assistance and provides continuous monitoring.
Step-by-Step Solution
Key Concept
The emergency management of a suspected central venous catheter air embolism requires stopping further air entry, properly positioning the client to prevent pulmonary obstruction, and providing oxygenation.