A nurse is preparing to remove a client's non-tunneled central venous catheter (CVC). To minimize the risk of a potential air embolism and ensure client safety, arrange the following nursing actions in the correct chronological sequence.
- 1Position the client flat in a supine or slight Trendelenburg position.
- 2Instruct the client to take a deep breath and bear down (Valsalva maneuver).
- 3Withdraw the catheter smoothly and continuously.
- 4Apply immediate, firm pressure to the insertion site using sterile gauze.
- 5Secure an airtight, occlusive dressing over the insertion site.
Cevap
The correct sequence for removing a central venous catheter is to first position the client supine, then have them perform the Valsalva maneuver, withdraw the catheter, apply immediate pressure, and finally secure an occlusive dressing.
To reduce the risk of an air embolism during central line removal, the nurse must ensure that central venous pressure remains higher than atmospheric pressure. This is achieved sequentially by patient positioning, active breathing techniques, safe withdrawal, and immediate mechanical sealing of the tract.
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Anahtar Kavram
Safe removal of a central venous catheter requires maintaining positive intrathoracic pressure to reduce the risk of a life-threatening air embolism.