A nurse is preparing to remove a non-tunneled central venous catheter (CVC) from a client's internal jugular vein. Place the following nursing actions in the correct chronological order to ensure client safety and prevent complications during the procedure.
- 1Place the client in a supine or slight Trendelenburg position.
- 2Remove the transparent dressing and any securement devices.
- 3Instruct the client to take a deep breath and bear down (Valsalva maneuver).
- 4Withdraw the catheter smoothly and continuously.
- 5Apply immediate, firm pressure to the insertion site using sterile gauze.
- 6Inspect the distal tip of the removed catheter to verify it is intact.
Answer
The correct sequence for removing a central venous catheter is to position the client supine, remove the dressing, instruct the client to bear down, withdraw the catheter, apply firm pressure, and finally inspect the catheter tip.
The safe removal of a central venous catheter prioritizes the prevention of an air embolism. The procedure begins by placing the client flat or in a slight Trendelenburg position to increase central venous pressure. After removing the dressing to free the catheter, the nurse instructs the client to bear down (Valsalva maneuver) to elevate intrathoracic pressure. The catheter is withdrawn exactly during this maneuver to ensure the vein remains under positive pressure. Immediate manual pressure is then applied to the site to achieve hemostasis and form an airtight seal over the tract. Finally, the nurse inspects the catheter tip to ensure no fragments were retained in the patient.
Step-by-Step Solution
Key Concept
Safe removal of a central venous catheter requires strict adherence to procedural steps that prevent air embolism, primarily through patient positioning and the utilization of the Valsalva maneuver.