Primary Nursing Diagnosis

Decreased cardiac output related to blocked left ventricular filling

OUTCOMES. Cardiac pump effectiveness; Circulation status; Tissue perfusion: Cerebral, Peripheral, Cardiac

INTERVENTIONS. Cardiac care; Circulatory care; Shock management; Hemodynamic regulation

H PLANNING AND IMPLEMENTATION Collaborative

PREVENTION. Several strategies can help prevent development of air embolism. First, maintain the patient's level of hydration because dehydration predisposes the patient to decreased venous pressures. Second, some clinicians recommend that you position the patient in Trendelenburg's position during central line insertion because the position increases central venous pressure. Third, instruct the patient to perform Valsalva's maneuver on exhalation during central line insertion or removal to increase intrathoracic pressure and thereby to increase central venous pressure.

Prime all tubings with intravenous fluid prior to connecting the system to the catheter. Immediately apply an occlusive pressure dressing after catheter removal, and maintain the site with an occlusive dressing for at least 24 hours. To prevent air embolism during surgical procedures, the surgeon floods the surgical field with liquid in some situations so that liquid rather than air enters the circulation.

TREATMENT. If an air embolus occurs, the first efforts are focused on preventing more air from entering the circulation. Any central line procedure that is in progress should be immediately terminated with the line clamped. The catheter should not be removed unless it cannot be clamped. Place the patient on 100% oxygen immediately to facilitate the washout of nitrogen from the bubble of atmospheric gas. Place the patient in the left lateral decubitus position. This position allows the obstructing air bubble in the pulmonary outflow tract to float toward the apex of the right ventricle, which relieves the obstruction. Use Trendelenburg's position to relieve the obstruction caused by air bubbles. Other suggested strategies are to aspirate the air from the right atrium, to use closed-chest cardiac compressions, and to administer fluids to maintain vascular volume. Hyperbaric oxygen therapy may improve the patient's condition as well: This therapy increases nitrogen washout in the air bubble, thereby reducing the bubble's size and the absorption of air. Note that if the patient has to be transferred to a hyperbaric facility, the decrease in atmospheric pressure that occurs at high altitudes during fixed-wing or helicopter transport may worsen the patient's condition because of bubble enlargement or "bubble explosion." Ground transport or transport in a low-flying helicopter is recommended, along with administering 100% oxygen and adequate hydration during transport.

Independent

If the patient suddenly develops the symptoms of an air embolism, place the patient on the left side with the head of the bed down to allow the air to float out of the outflow track. Notify the physician immediately, and position the resuscitation cart in close proximity. Initiate 100% oxygen via a nonrebreather mask immediately before the physician arrives, according to unit policy. Be prepared for a sudden deterioration in cardiopulmonary status and potential for cardiac arrest.

The patient and family need a great deal of support. Remain in the patient's room at all times, and if the patient finds touch reassuring, hold the patient's hand. Provide an ongoing summary of the patient's condition to the family. Expect the patient to be extremely frightened and the family to be anxious or even angry. Ask the chaplain, clinical nurse specialist, nursing supervisor, or social worker to remain with the family during the period of crisis.

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