A nurse is assessing a client with a central venous access device (CVAD). The nurse observes that the intravenous tubing has become disconnected from the catheter hub. The client suddenly gasps, reports chest pain, and becomes acutely dyspneic and tachycardic. Arrange the following nursing actions in the priority order they should be performed. (First action on top, last action on bottom).
- 1Clamp the central venous access catheter.
- 2Place the client in a left lateral Trendelenburg position.
- 3Apply 100% supplemental oxygen via a non-rebreather mask.
- 4Notify the rapid response team and the healthcare provider.
- 5Document the incident, interventions provided, and the client's response.
Answer
The correct priority sequence for a suspected air embolism is: Clamp the central venous access catheter, place the client in a left lateral Trendelenburg position, apply 100% supplemental oxygen via a non-rebreather mask, notify the rapid response team and the healthcare provider, and finally document the incident.
When an air embolism is suspected due to a disconnected central line, the nurse's priority is governed by the need to immediately halt the progression of the complication. Clamping the catheter is the fastest way to stop more air from entering the circulatory system. The second immediate physical action is positioning the client in the left lateral Trendelenburg position (Durant's maneuver) to trap the air in the right atrium and ventricle, preventing it from blocking the pulmonary artery. Third, the nurse addresses the ABCs by administering high-flow oxygen to treat ischemia and help shrink the air bubble. Fourth, the rapid response team and provider are notified to provide advanced medical management. Finally, the nurse documents the entire event after the client has received all emergency interventions.
Step-by-Step Solution
Key Concept
Prioritization of interventions for a central line air embolism