A nurse is preparing to discontinue a non-tunneled central venous catheter (CVC) from a client's internal jugular vein. To minimize the risk of procedural complications, in what order should the nurse perform the following actions? Arrange the steps in the correct chronological sequence.
- 1Position the client supine with the head of the bed flat.
- 2Instruct the client to take a deep breath, hold it, and bear down.
- 3Withdraw the catheter smoothly in one continuous motion.
- 4Apply immediate, firm pressure to the site with sterile gauze.
- 5Apply a sterile, air-occlusive dressing over the insertion site.
- 6Inspect the distal tip of the removed catheter for intactness.
Cevap
The correct sequence is to position the client supine, instruct them to perform the Valsalva maneuver, withdraw the catheter, apply immediate firm pressure, secure an occlusive dressing, and finally inspect the catheter tip.
The correct sequence prioritizes the reduction of risk potential, specifically preventing an air embolism and hemorrhage. The client must first be positioned supine to increase central venous pressure. Instructing the client to perform the Valsalva maneuver creates positive intrathoracic pressure just before the catheter is withdrawn. Once the catheter is out, immediate pressure ensures hemostasis and prevents air entry. This is followed by securing an air-occlusive dressing for continuous protection. Finally, inspecting the catheter tip ensures no fragments were left behind in the client.
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Anahtar Kavram
Prevention of air embolism and catheter embolus during central line discontinuation.
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