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Difficulty: HardPhysiological Adaptation

An intubated client with a severe exacerbation of asthma is receiving volume-controlled mechanical ventilation in the intensive care unit. The ventilator's high peak inspiratory pressure (PIP) alarm begins sounding continuously. Upon rapid assessment, the nurse notes absent breath sounds over the right lung field, prominent tracheal deviation to the left, and subcutaneous emphysema over the right anterior chest. Hemodynamic monitoring indicates a precipitous drop in blood pressure from 124/76 mm Hg to 78/38 mm Hg and a heart rate increase to 142 beats/min. A recent arterial blood gas (ABG) report shows a pH of 7.29, PaCO2 of 62 mm Hg, and HCO3 of 26 mEq/L. Which of the following is the nurse's immediate priority action?

  1. A
    Administer intravenous sodium bicarbonate to correct the uncompensated respiratory acidosis.
  2. B
    Increase the continuous intravenous fluid rate to treat the developing hypovolemic shock.
  3. C
    Perform deep endotracheal suctioning to clear obstructing secretions triggering the ventilator alarms.
  4. Activate the rapid response team and prepare a large-bore angiocatheter for emergency chest decompression.Answer

Answer

The priority action is to activate the rapid response team and prepare a large-bore angiocatheter for emergency chest decompression.
The client is exhibiting the classic triad of a tension pneumothorax: absent breath sounds, tracheal deviation, and severe hypotension. The positive pressure from the mechanical ventilator forced air into the pleural space through a ruptured alveolus (barotrauma). This trapped air creates massive intrathoracic pressure, pushing the mediastinum to the opposite side (tracheal deviation) and compressing the vena cava. This compression halts venous return, causing obstructive shock. The only life-saving treatment is immediate decompression of the pleural space using a large-bore needle (needle thoracostomy) followed by a chest tube.

Step-by-Step Solution

1
Analyze the ventilator alarms and respiratory assessment findings.
The high PIP alarm, unilateral absent breath sounds, and tracheal deviation indicate a massive accumulation of air in the right pleural space (tension pneumothorax) due to barotrauma.
Identifying the structural respiratory failure is necessary to understand the cause of the sudden decompensation.
2
Evaluate the hemodynamic changes (vital signs).
The severe hypotension (78/38 mm Hg) and tachycardia (142 beats/min) indicate the client has entered obstructive shock.
The trapped air under high pressure causes a mediastinal shift, compressing the superior and inferior vena cava. This drastically reduces venous return (preload) and cardiac output.
3
Determine the highest priority life-saving intervention.
The nurse must prepare for immediate release of the trapped air (needle thoracostomy) while notifying the emergency response team.
Without immediate decompression, obstructive shock will rapidly progress to cardiac arrest. Routine troubleshooting (suctioning) or addressing secondary findings (ABGs) will result in death.

Key Concept

Recognition and immediate management of tension pneumothorax and subsequent obstructive shock in mechanically ventilated clients.
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Topics

Physiological Adaptation

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