A nurse is performing a routine administration set change for a client receiving continuous parenteral nutrition via a right subclavian central venous catheter. While the nurse is transitioning the tubing, the client takes a sudden, deep inspiration before the connection is secured. The client immediately grasps their chest, reporting severe pain, shortness of breath, and a sense of impending doom. The cardiac monitor shows a heart rate of beats per minute and the blood pressure drops to mmHg. Which of the following is the priority nursing action?
- Clamp the central venous catheter and position the client on their left side in the Trendelenburg position.Answer
- BElevate the head of the bed to the high-Fowler's position and instruct the client to perform the Valsalva maneuver.
- CApply an occlusive dressing directly over the catheter insertion site and administer high-flow oxygen.
- DInitiate a rapid bolus of intravenous normal saline and activate the rapid response team.
Answer
The priority action is to clamp the central venous catheter and position the client on their left side with the head of the bed lowered (left lateral Trendelenburg).
The client is exhibiting classic signs of a venous air embolism, a life-threatening complication that occurs when a central venous catheter is open to atmospheric pressure during a deep inhalation. The immediate priority is to stop further air entry by clamping the catheter. Following this, positioning the client on their left side with the head down (left lateral Trendelenburg or Durant's maneuver) uses gravity to trap the air bubble in the right atrium or the apex of the right ventricle. This prevents the air from migrating into the pulmonary circulation and causing a fatal right ventricular outflow obstruction.
Step-by-Step Solution
Key Concept
Management of Central Venous Catheter Complications (Air Embolism)