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Soru

Zorluk: OrtaReduction of Risk Potential

A nurse is preparing to remove a non-tunneled central venous catheter (CVC) from the subclavian vein of an alert, cooperative adult client. Arrange the following actions in the correct chronological order to minimize the risk of a venous air embolism and bleeding. (First action to last action)

  1. 1Position the client flat in a supine position.
  2. 2Instruct the client to take a deep breath, hold it, and bear down.
  3. 3Withdraw the catheter smoothly and continuously.
  4. 4Apply firm manual pressure to the insertion site with sterile gauze.
  5. 5Secure an air-occlusive dressing over the site.

Cevap

The correct sequence for removing a central venous catheter is to first position the client supine, instruct them to perform the Valsalva maneuver, withdraw the catheter during the maneuver, apply immediate firm pressure, and finally apply an air-occlusive dressing.
Removing a central venous catheter (CVC) carries a high risk of venous air embolism and bleeding. To minimize these risks, the nurse must manipulate pressure gradients to ensure venous pressure is higher than atmospheric pressure. Positioning the client supine increases central venous pressure. Instructing the client to perform the Valsalva maneuver (bearing down) further raises intrathoracic pressure. Withdrawing the catheter during this positive-pressure state prevents air from entering the vein. Immediately applying firm pressure stops bleeding and seals the tract, and finally, placing an air-occlusive dressing ensures the site remains sealed while the skin and vein heal.

Adım Adım Çözüm

1
Position the client flat in a supine position.
Central venous pressure increases in the upper body.
Keeping the insertion site at or below the level of the heart prevents a negative pressure gradient that could draw air into the vein.
2
Instruct the client to take a deep breath, hold it, and bear down.
Intrathoracic pressure is temporarily increased.
This Valsalva maneuver creates positive pressure within the venous system, actively pushing against atmospheric pressure.
3
Withdraw the catheter smoothly and continuously.
The catheter is removed from the vein.
Removing the catheter while the client holds their breath ensures air cannot enter the open venous tract.
4
Apply firm manual pressure to the insertion site with sterile gauze.
Bleeding is controlled and the tract is sealed.
Firm pressure for at least 5 to 10 minutes achieves hemostasis and physically prevents air entry.
5
Secure an air-occlusive dressing over the site.
The insertion site is completely sealed from the environment.
An occlusive dressing prevents delayed air entry while the tissue tract heals.

Anahtar Kavram

Prevention of Venous Air Embolism During CVC Removal
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Konular

Reduction of Risk Potential

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