A nurse is caring for a -year-old client receiving total parenteral nutrition via a right subclavian central venous access device. While the nurse is changing the intravenous tubing, the catheter temporarily disconnects from the infusion line. The client immediately reports severe chest pain, shortness of breath, and a sense of impending doom. The client's heart rate is bpm, blood pressure is mmHg, and oxygen saturation is on room air. The nurse immediately clamps the catheter. Which of the following is the priority nursing action?
- Place the client in a left lateral Trendelenburg position.Answer
- BElevate the head of the bed to a high-Fowler's position and administer high-flow oxygen.
- CAuscultate the client's lung fields to confirm absent breath sounds before initiating interventions.
- DActivate the rapid response team to obtain an immediate electrocardiogram and arterial blood gas.
Answer
Place the client in a left lateral Trendelenburg position.
The client's presentation (sudden dyspnea, hypotension, sense of doom) immediately following a central venous catheter disconnection is the classic presentation of an air embolism. After clamping the catheter to halt further air entry, placing the client in a left lateral Trendelenburg position (Durant's maneuver) is the most critical independent nursing action. This position utilizes gravity to trap the air bubble in the apex of the right ventricle, preventing it from migrating into the pulmonary artery and causing a right ventricular outflow obstruction.
Step-by-Step Solution
Key Concept
Management of a Central Venous Air Embolism