A nurse is removing a client's central venous access device (CVAD). As the catheter is withdrawn, the client suddenly gasps, reports severe chest pain, and becomes acutely dyspneic. The oxygen saturation drops abruptly to 83%. Suspecting a venous air embolism, in what order should the nurse perform the following actions? (Arrange the items in the correct sequence from first to last.)
- 1Immediately apply a sterile occlusive dressing over the CVAD insertion site.
- 2Position the client in the left lateral Trendelenburg position.
- 3Administer 100% oxygen via a non-rebreather mask.
- 4Activate the rapid response team and notify the healthcare provider.
- 5Continuously monitor vital signs and prepare for potential cardiopulmonary resuscitation.
Cevap
The correct sequence for managing a suspected venous air embolism is: 1) Apply an occlusive dressing, 2) Position in left lateral Trendelenburg, 3) Administer 100% oxygen, 4) Activate rapid response, and 5) Monitor and prepare for CPR.
In the event of a venous air embolism, the nurse must act immediately to prevent cardiovascular collapse. The first action is always source control: sealing the entry point (occlusive dressing) to prevent more air from entering. The second immediate action is positioning the client in the left lateral Trendelenburg position (Durant's maneuver), which uses gravity to trap the air in the apex of the right ventricle, away from the pulmonary valve. Third, administering 100% oxygen treats hypoxia and shrinks the nitrogen-rich air bubble. Only after these immediate, life-saving nursing actions are taken should the nurse leave the client's side to call the rapid response team and continue monitoring for cardiac arrest.
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Anahtar Kavram
Venous Air Embolism Emergency Management (Durant's Maneuver)