The nurse in the intensive care unit is caring for a 47-year-old male client.
1000:A left subclavian central venous catheter has just been inserted. Before insertion, breath sounds were equal and the client was comfortable on room air. Client now reports abrupt left-sided chest pain and severe difficulty breathing. Left chest movement is reduced and left breath sounds are absent; right breath sounds remain audible. Neck veins are distended. The trachea appears midline. The pulse is rapid and blood pressure has fallen markedly. The rapid response team has been activated and supplemental oxygen is being applied. No chest tube is present. An emergency decompression kit and chest drainage supplies are available.
The nurse is reviewing the client's assessment data to prepare the client's plan of care.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Action to TakeAction to Take
Condition Most Likely ExperiencingParameter to MonitorParameter to Monitor
Actions to Take
Prepare for emergency needle decompression.
Prepare anticoagulation as the initial treatment.
Prepare for chest tube insertion after decompression.
Obtain a chest radiograph before preparing treatment.
Wait for tracheal deviation before preparing decompression.
Potential Conditions
cardiac tamponade
pulmonary embolism
tension pneumothorax
acute pulmonary edema
Parameters to Monitor
blood pressure
sputum purulence
left breath sounds
pericardial friction rub
unilateral calf circumference