A nurse is independently discontinuing a right subclavian central venous catheter for a 64-year-old client recovering from severe pneumonia. Immediately upon removal of the catheter, the client gasps, becomes intensely diaphoretic, and reports crushing chest pain. Suspecting a central line-associated air embolism, in what order should the nurse perform the following interventions? Arrange from first action to last.
- 1Apply an occlusive dressing over the catheter insertion site.
- 2Place the client in the left lateral Trendelenburg position.
- 3Initiate 100% oxygen therapy via a non-rebreather face mask.
- 4Activate the hospital's rapid response system.
- 5Auscultate heart sounds to assess for a 'mill wheel' murmur.
Cevap
The correct sequence of actions is to first occlude the insertion site, then place the client in the left lateral Trendelenburg position, apply 100% oxygen, activate the rapid response team, and finally auscultate heart sounds.
The correct sequence for managing a suspected air embolism requires the nurse to prioritize immediate, life-saving mechanical interventions over standard ABCs and delegation. The nurse must first occlude the insertion site to prevent further air entry. Second, the left lateral Trendelenburg position is used to trap the air in the right atrium. Third, high-flow oxygen is administered to treat hypoxemia and wash out nitrogen. Fourth, the rapid response team is activated for advanced support. Finally, once the client is stabilized, further diagnostic assessments like auscultation are performed.
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Anahtar Kavram
Management of a central line-associated venous air embolism prioritizes immediate source control (occlusion) and specific physiological positioning (left lateral Trendelenburg) before standard oxygenation and team notification.