The nurse reviews the record after central venous catheter p… | MyMerci
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Medical Emergencies

The nurse reviews the record after central venous catheter placement. Which findings require immediate follow-up for possible tension pneumothorax? Highlight the findings that support rapid obstructive deterioration.

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Nurses' Notes 1015: A right internal jugular central venous catheter is placed without immediate difficulty. At 1030, new severe shortness of breath begins. The temperature is 37.1 °C. The nurse documents that the temperature remains unchanged from the preprocedure value. Before the procedure, chest expansion was symmetric with clear breath sounds. At 1035, right-sided breath sounds are absent. The insertion dressing is dry and intact. The client reports mild tenderness limited to the catheter insertion site. At 1040, the respiratory rate increases from 18/min to 34/min. The nurse notes that the earlier respiratory rate was 18/min at rest. At 1042, blood pressure is 78/46 mm Hg; hypotension occurs with new tracheal deviation. The oxygen saturation had been 97% on 2 L/min before the change. The record confirms that oxygen saturation was stable before the procedure. The catheter lumens flush without resistance. The nurse documents that each lumen flushes and has a labeled cap. Emergency equipment is brought to the bedside.
Nurses' Notes 1015: A right internal jugular central venous catheter is placed without immediate difficulty. At 1030, new severe shortness of breath begins. The temperature is 37.1 °C. The nurse documents that the temperature remains unchanged from the preprocedure value. Before the procedure, chest expansion was symmetric with clear breath sounds. At 1035, right-sided breath sounds are absent. The insertion dressing is dry and intact. The client reports mild tenderness limited to the catheter insertion site. At 1040, the respiratory rate increases from 18/min to 34/min. The nurse notes that the earlier respiratory rate was 18/min at rest. At 1042, blood pressure is 78/46 mm Hg; hypotension occurs with new tracheal deviation. The oxygen saturation had been 97% on 2 L/min before the change. The record confirms that oxygen saturation was stable before the procedure. The catheter lumens flush without resistance. The nurse documents that each lumen flushes and has a labeled cap. Emergency equipment is brought to the bedside.
Explanation
Follow up on sudden severe dyspnea, absent right breath sounds, and hypotension with tracheal deviation. This pattern can indicate tension pneumothorax and requires emergency treatment without waiting for routine imaging.
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