Final answer:
The nurse should instruct the patient to perform a Valsalva maneuver during central line removal to prevent air embolism and apply pressure after removal to prevent bleeding. Usage of a safety checklist and team review ensures adherence to protocols and patient safety.
Step-by-step explanation:
Instructions for a Nurse Assisting with Central Line Removal
When a physician is removing a client's central line, the nurse should provide specific instructions to ensure patient safety and prevent any potential complications. As part of the removal procedure, the nurse should instruct the patient to perform a Valsalva maneuver, or to hold their breath and bear down, if they are able, at the moment the catheter is being withdrawn. This helps prevent air from getting into the bloodstream and causing an air embolism. Additionally, after the line is removed, the nurse should apply pressure to the site to prevent bleeding and assist with the application of a sterile dressing.
In the context of patient care, healthcare providers such as nurses and physicians must adhere to a protocol similar to the World Health Organization's guidelines to ensure safety and reduce the risk of complication. Protocols often include measures like the time out, sign in, and use of checklists similar to aviation's pre-flight checklists, to confirm that all team members have a clear understanding of the procedure and their roles, and to ensure that all safety criteria are met before, during, and after the procedure.
Focus on Clinical Safety
It is important to understand the context of why the port and catheter are being removed. Barbara's symptoms of restlessness, discomfort at the catheter site, redness, and fever suggest a localized infection that needs to be addressed, leading to the removal of the port and catheter. After the procedure, the team should come together to review aloud the recovery and care concerns for the patient to ensure optimal outcomes.