While responding to a pump occlusion alarm, a nurse discovers that a client's continuous enteral nutrition formula has been erroneously connected to the proximal port of a peripherally inserted central catheter (PICC) and is actively infusing. Arrange the following nursing actions in the priority order to mitigate this adverse event and prevent further injury. All options must be used.
- 1Stop the infusion pump delivering the enteral nutrition.
- 2Disconnect the enteral administration set from the central venous catheter.
- 3Assess the client's vital signs, oxygen saturation, and level of consciousness.
- 4Notify the healthcare provider and activate the rapid response team.
- 5Complete a facility incident report detailing the misconnection.
Cevap
The correct sequence is to first stop the infusion pump, then disconnect the tubing, assess the client's cardiopulmonary and neurological status, notify the healthcare provider and rapid response team, and finally complete the facility incident report.
In the event of an active route administration error (a 'never event' such as infusing tube feeding into a central line), the absolute first priority is to stop the source of harm. Halting the pump immediately prevents further formula from entering the bloodstream. Disconnecting the tubing ensures no residual fluid enters via gravity. Only after the source of harm is secured should the nurse assess the client's physiological status, as this baseline data is crucial before notifying the healthcare provider and rapid response team. Completing the incident report is an administrative risk-management task that is always performed last, after the client's safety is secured.
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Anahtar Kavram
Priority Management of Route Administration Errors and Tubing Misconnections