While assessing a client receiving intravenous fluids via a central venous catheter (CVC), the nurse notes that the intravenous tubing has completely disconnected from the catheter hub. The client suddenly gasps, becomes severely dyspneic, and exhibits circumoral cyanosis. Arrange the following nursing actions in the correct order of prioritization.
- 1Clamp the central venous catheter.
- 2Place the client in the left lateral Trendelenburg position.
- 3Administer 100% oxygen via a non-rebreather mask.
- 4Activate the rapid response team.
- 5Monitor vital signs and pulse oximetry continuously.
Cevap
The correct priority sequence is to first clamp the catheter, then position the client in the left lateral Trendelenburg position, administer high-flow oxygen, activate the rapid response team, and finally continuously monitor vital signs.
When a central venous catheter becomes disconnected, the negative intrathoracic pressure during inspiration can draw a lethal amount of air into the venous system, creating an air embolism. The nurse's absolute first priority is to stop the influx of air by clamping the catheter. Once the source is secured, the nurse must immediately position the client in the left lateral Trendelenburg position. This specific positioning traps the air in the apex of the right atrium, preventing it from entering the right ventricle and pulmonary artery. Next, administering 100% oxygen helps treat the resulting hypoxia and promotes the resorption of the nitrogen gas within the air bubble. After these immediate life-saving measures are rapidly executed, the nurse should activate the rapid response team to obtain advanced medical support. Finally, the nurse must provide continuous monitoring of the client's vital signs and oxygen saturation to carefully assess for ongoing hemodynamic instability while awaiting the team's arrival.
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Establishing Priorities: Emergency Management of a Central Venous Air Embolism