A nurse is removing a central venous catheter (CVC) from a client's subclavian vein. Immediately after the catheter is removed, the client reports acute, severe shortness of breath, grasps their chest, and exhibits cyanosis. The vital signs indicate sudden tachycardia and hypotension. Suspecting an air embolism, arrange the following nursing actions in the priority order they should be performed.
- 1Apply an impermeable, occlusive dressing over the catheter insertion site.
- 2Place the client in a left lateral Trendelenburg position.
- 3Administer high-flow oxygen via a non-rebreather mask.
- 4Notify the rapid response team and the primary healthcare provider.
Cevap
The correct sequence is to first occlude the source of air entry, then position the client to trap the air, followed by administering oxygen, and finally notifying the provider.
In any acute emergency, the nurse must follow the airway-breathing-circulation (ABC) framework and the principle of source control. When a central line is removed and an air embolism is suspected, the immediate priority is to stop more air from entering by sealing the site. The very next step is to prevent the air already in the system from causing fatal obstruction by placing the client in the left lateral Trendelenburg position. Once the mechanical threat is stabilized, oxygen is applied to treat the resulting hypoxia. Finally, the provider is notified to escalate medical care.
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Anahtar Kavram
Prioritization of life-saving interventions for a suspected central line air embolism.
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