A nurse is changing the administration set for a client's central venous catheter. The client suddenly gasps, reports sharp chest pain, and becomes profoundly dyspneic and tachycardic. Suspecting a central line-associated air embolism, arrange the following nursing actions in the correct priority sequence to minimize physiological risk.
- 1Clamp the central venous catheter tubing immediately.
- 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 healthcare provider.
- 5Assess continuous vital signs and prepare for potential cardiopulmonary resuscitation.
Cevap
The correct sequence is to first clamp the catheter, then position the client in a left lateral Trendelenburg position, followed by administering high-flow oxygen, notifying the Rapid Response Team, and finally assessing continuous vital signs.
In the event of a suspected air embolism, the nurse must prioritize immediate actions that physically stop the embolism from worsening. Clamping the line prevents more air from entering. The left lateral Trendelenburg position traps the existing air in the right atrium/ventricle. Oxygen administration supports tissue perfusion and shrinks the nitrogen bubble. Only after these life-saving nursing interventions are applied should the nurse escalate the situation to the medical team and proceed with ongoing monitoring.
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Anahtar Kavram
Management of a central venous catheter air embolism requires immediate source control and specific client positioning to prevent circulatory collapse.