A nurse is removing a non-tunneled central venous access device (CVAD) from a client's right subclavian vein. Immediately after the catheter is withdrawn, the client exhibits sudden, severe dyspnea, diaphoresis, and a loud, continuous "churning" murmur over the precordium. To mitigate the risk of fatal hemodynamic collapse, arrange the following nursing actions in the priority order they should be performed. (Place the first action at the top and the last action at the bottom.)
- 1Occlude the insertion site immediately with a sterile occlusive dressing.
- 2Position the client on their left side with the head of the bed lowered (Trendelenburg).
- 3Administer 100% oxygen via a non-rebreather mask.
- 4Activate the facility's rapid response team.
- 5Ensure immediate availability of the emergency crash cart.
Cevap
The correct priority sequence is: 1) Occlude the insertion site, 2) Position the client in left lateral Trendelenburg, 3) Administer 100% oxygen, 4) Activate the rapid response team, and 5) Ensure availability of the emergency crash cart.
An air embolism is a critical complication characterized by sudden respiratory distress and a 'mill wheel' (churning) murmur. The highest priority is to stop the entry of air by sealing the site. Following this, the left lateral Trendelenburg position uses gravity to keep the air bubble away from the right ventricular outflow tract. Administering oxygen is next to combat hypoxia and shrink the embolus. Once the client is temporarily protected from immediate death, calling for emergency assistance and preparing for a potential code are the next logical steps.
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Anahtar Kavram
Management of a suspected air embolism requires immediate source control (occlusion), specific physiological positioning (left lateral Trendelenburg) to prevent pulmonary outflow obstruction, and rapid oxygenation before delaying care to summon help.