A nurse is caring for a client who is receiving intravenous fluids through a central venous catheter. The client suddenly gasps, reports severe chest pain, and becomes extremely short of breath. The nurse notes a heart rate of 124 beats/min, a blood pressure of 82/50 mm Hg, and auscultates a loud, churning "mill-wheel" murmur over the precordium. Suspecting a venous air embolism, arrange the following nursing actions in the correct priority order.
- 1Clamp the central venous catheter.
- 2Place the client in the left lateral Trendelenburg position.
- 3Administer 100% oxygen via a non-rebreather mask.
- 4Instruct available personnel to activate the rapid response team.
- 5Document the critical event, interventions provided, and the client's response.
Answer
The correct order of actions is to first clamp the central venous catheter, then place the client in the left lateral Trendelenburg position, followed by administering 100% oxygen, activating the rapid response team, and finally documenting the event.
In a suspected venous air embolism, the nurse must prioritize immediate mechanical interventions to prevent cardiac arrest. The absolute first action is to stop the source by clamping the central venous catheter. Immediately after, the client is placed in the left lateral Trendelenburg position (Durant's maneuver) to trap the air in the apex of the right ventricle, preventing pulmonary artery obstruction. Once the air is trapped, administering 100% oxygen addresses hypoxia and creates a nitrogen gradient to shrink the bubble. With the immediate crisis stabilized, the nurse delegates calling for the rapid response team, and finally, documents the event after the situation is fully managed.
Step-by-Step Solution
Key Concept
Management of Venous Air Embolism