A nurse is removing a central venous catheter (CVC) from a client's right subclavian vein. Immediately after the catheter is withdrawn, the client gasps, reports sudden severe chest pain, and becomes acutely tachycardic and dyspneic with a rapidly dropping oxygen saturation. The nurse suspects a venous air embolism. Arrange the following nursing interventions in the correct order of clinical priority from first to last.
- 1Immediately apply an impermeable, occlusive dressing over the insertion site.
- 2Place the client in the left lateral Trendelenburg position.
- 3Administer high-flow 100% oxygen via a non-rebreather mask.
- 4Activate the rapid response team and notify the healthcare provider.
- 5Initiate continuous hemodynamic monitoring and prepare equipment for emergency intubation.
Cevap
The correct sequence of prioritized interventions is to first occlude the insertion site, then place the client in the left lateral Trendelenburg position, followed by administering 100% oxygen, activating the rapid response team, and finally preparing for continuous monitoring and potential intubation.
In the event of a venous air embolism, standard ABC (Airway, Breathing, Circulation) prioritization is temporarily modified to address the immediate mechanical threat. The absolute first action must be to stop further air from entering the vessel (occluding the site). The immediate second action is to prevent the air already in the system from blocking the right ventricular outflow tract, which is achieved by placing the client in the left lateral Trendelenburg position (Durant's maneuver). Only after these two mechanical safeguards are in place should the nurse proceed to treat the resulting hypoxia with high-flow oxygen, followed by escalating the situation to the rapid response team, and finally preparing for advanced resuscitation.
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Anahtar Kavram
Prioritization of nursing interventions for a venous air embolism (CVC complication)