A nurse is changing the needleless connector caps on a client's central venous catheter. The client suddenly gasps, becomes extremely tachycardic, and reports a feeling of impending doom. The client's blood pressure drops to 82/48 mm Hg. Suspecting a central line-associated air embolism, arrange the following nursing actions in the sequence they should be performed. All options must be used.
- 1Clamp the central venous catheter.
- 2Place the client in a left lateral Trendelenburg position.
- 3Administer 100% oxygen via a non-rebreather face mask.
- 4Activate the rapid response team and notify the healthcare provider.
- 5Initiate continuous monitoring of vital signs and oxygen saturation.
Cevap
The correct sequence is to first clamp the catheter, then place the client in a left lateral Trendelenburg position, followed by administering 100% oxygen, activating the rapid response team, and finally initiating continuous vital sign monitoring.
An air embolism is a life-threatening emergency characterized by the sudden entry of air into the venous system, causing cardiovascular collapse. The nurse must prioritize interventions based on immediate survival. First, the source of air must be stopped by clamping the catheter. Second, the client must be placed in Durant's maneuver (left lateral Trendelenburg) to keep the air trapped in the right ventricular apex, preventing pulmonary artery occlusion. Third, providing 100% oxygen combats hypoxia and helps shrink the air bubble by washing out nitrogen. After these immediate life-saving actions are complete, the nurse activates the rapid response team and continuously monitors the client's hemodynamic status.
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Anahtar Kavram
Air Embolism Emergency Management