A nurse is caring for a client who has a central venous catheter. While the nurse is changing the injection caps, the client suddenly becomes extremely restless, gasps for air, and reports severe chest pain. The nurse suspects a venous air embolism. In what order should the nurse perform the following actions? Arrange the items from first to last.
- 1Clamp the central venous catheter immediately.
- 2Place the client in a left lateral Trendelenburg position.
- 3Administer 100% oxygen via a non-rebreather mask.
- 4Activate the rapid response team.
- 5Assess the client's vital signs and continuous pulse oximetry.
Cevap
The correct sequence of actions is to first clamp the catheter, then place the client in a left lateral Trendelenburg position, administer high-concentration oxygen, activate the rapid response team, and finally assess the client's vital signs.
When a venous air embolism is suspected during central line care, the nurse must act rapidly to prevent cardiopulmonary collapse. The immediate priority is to stop further air from entering the circulation by clamping the catheter. Next, the client must be placed in a left lateral Trendelenburg position (Durant's maneuver) to trap the air bubble in the apex of the right ventricle, preventing it from migrating into the pulmonary arterial system. Administering 100% oxygen helps correct hypoxia and speeds the reabsorption of nitrogen gas from the bubble. Once these immediate life-saving physical interventions are complete, the nurse activates the rapid response team to obtain advanced medical support, followed by continuous assessment of vital signs to monitor for hemodynamic deterioration.
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Anahtar Kavram
Emergency Management of Venous Air Embolism