A nurse is discontinuing a client's central venous catheter (CVC). Immediately after the catheter is removed, the client gasps, reports sudden severe chest pain, and becomes distinctly cyanotic. The nurse suspects a venous air embolism. Arrange the following nursing interventions in the correct order of priority from first to last.
- 1Apply a sterile, occlusive dressing immediately over the insertion site.
- 2Position the client in the left lateral Trendelenburg position.
- 3Administer 100% oxygen via a non-rebreather mask.
- 4Notify the healthcare provider and activate the rapid response team.
- 5Obtain a complete set of vital signs and continuously monitor oxygen saturation.
Cevap
The correct sequence of actions for a suspected air embolism is: 1) Apply a sterile, occlusive dressing, 2) Position the client in the left lateral Trendelenburg position, 3) Administer 100% oxygen, 4) Notify the healthcare provider, and 5) Obtain a complete set of vital signs.
A venous air embolism is a life-threatening emergency requiring immediate, sequential actions to prevent cardiac arrest. The first priority is always to stop the source of the problem by occluding the central line insertion site. Next, Durant's maneuver (left lateral Trendelenburg) is utilized to mechanically trap the air in the right ventricle apex, preventing pulmonary outflow obstruction. Only after securing the site and positioning the client should the nurse administer 100% oxygen to treat hypoxemia and reduce the nitrogen bubble size. Finally, the nurse calls for advanced help and continues to closely monitor the client's hemodynamic status.
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Anahtar Kavram
Management of a venous air embolism prioritizes stopping the air source, utilizing gravity to trap the air in the right ventricle (Durant's maneuver), and treating severe hypoxia.