Abnormal narrative bank — focused / at-risk
Six focused abnormal narratives carrying the full necessity chain — finding, severity, comparison, risk, action, notification, and reassessment.
A1 Central-line-associated infection | Skilled assessment of a PICC site with new purulent drainage and 1.5 cm of surrounding erythema and a temperature of 101.6°F — new findings concerning for a central-line-associated bloodstream infection. Vital signs were obtained and blood cultures drawn per order; the provider was notified at 13:05; orders for possible line removal and antibiotics were received. The infusion was held per order pending direction, the site and temperature will be reassessed, and the patient educated to seek emergency care for rigors, confusion, or worsening fever. |
|---|---|
A2 Air embolism during line manipulation | Skilled assessment during PICC flushing when the patient developed sudden dyspnea, chest discomfort, and light-headedness — findings concerning for air embolism. The line was immediately clamped, the patient placed in a left-lateral Trendelenburg position, and EMS activated; oxygen was applied per order. The provider was notified at 11:40; vital signs and respiratory status were monitored continuously pending transport, and the events documented to inform the plan and prevent recurrence. |
A3 Central line dislodged with bleeding | Skilled assessment finding a partially dislodged central catheter with bleeding at the exit site after the patient caught the line on clothing — a complication risking hemorrhage and loss of access. Direct pressure was applied, the remaining catheter clamped, and the patient kept supine; EMS was activated as bleeding required escalation. The provider was notified at 15:30; the site and the patient’s status were monitored pending transport, and the caregiver re-taught securement and the dislodgement response. |
A4 Feeding tube dislodged | Skilled assessment finding a gastrostomy tube partially out with the securement disc now at 7 cm rather than the documented 4 cm, and the patient unsure when it moved — a dislodgement in which placement can no longer be confirmed. No feeding or flush was given and the tube was not reinserted blindly; the stoma was protected and the provider notified at 10:15. Orders for evaluation and replacement were received; the patient and caregiver were re-taught securement and to report any change in the external length immediately. |
A5 Line occlusion | Skilled assessment of a PICC that would not flush, with resistance and no blood return — findings concerning for occlusion. The flush was not forced; the line was checked for clamps, kinks, and a dependent loop without resolution, and the occlusion managed within protocol and order without success. The provider was notified at 14:20; orders for a declotting agent and possible imaging were received. The infusion was held pending patency, and the line will be reassessed; the patient was educated not to force the line and to report the problem. |
A6 Device-site bleeding on an anticoagulant | Skilled assessment of persistent oozing at a central-line exit site in a patient on warfarin — new and significant given the anticoagulant. Direct pressure was applied and maintained and the bleeding slowed; the dressing was reinforced and the provider notified at 09:50 with bleeding-risk review initiated. The patient and caregiver were taught firm continuous pressure and to activate EMS for bleeding not controlled within the instructed time; the site and the coagulation status will be monitored and the Anticoagulation overlay applied. |