While performing morning rounds, a practical nurse discovers that a client's intravenous tubing has disconnected from their central venous catheter hub. The client is suddenly gasping for air, extremely anxious, and cyanotic. To reduce the risk of a life-threatening complication, place the following nursing actions in the correct priority sequence.
- 1Clamp the central venous catheter immediately.
- 2Position the client in the left lateral Trendelenburg position.
- 3Administer high-flow supplemental oxygen.
- 4Notify the registered nurse and activate the emergency response team.
- 5Obtain a complete set of vital signs including oxygen saturation.
Cevap
The correct priority sequence is to clamp the catheter, position the client in the left lateral Trendelenburg position, administer oxygen, activate the emergency response team, and finally obtain vital signs.
In the event of a disconnected central venous catheter accompanied by sudden respiratory distress, the nurse must suspect an air embolism. The immediate priority is risk reduction by stopping the source of harm. Clamping the catheter prevents more air from entering the heart. Positioning the client on their left side with the head down (Durant's maneuver) traps the air in the right ventricle, preventing it from blocking the pulmonary artery. Oxygen is then applied to treat severe ischemia. Only after these immediate physical stabilization steps are complete should the nurse call for emergency assistance and gather vital signs.
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Anahtar Kavram
Emergency management and risk reduction for suspected air embolism via central line.