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Difficulty: MediumPhysiological Adaptation

A nurse is performing a reassessment on a young adult client admitted with an acute asthma exacerbation. The client initially presented with marked tachypnea, use of accessory muscles, and loud bilateral wheezing. Thirty minutes later, the nurse observes that the client's respirations have become shallow, wheezing is no longer audible, and the client appears drowsy. Arterial blood gas (ABG) results reveal a pH\text{pH} of 7.287.28, a PaCO2\text{PaCO}_2 of 58 mm Hg58\text{ mm Hg}, and an HCO3−\text{HCO}_3^- of 24 mEq/L24\text{ mEq/L}. Which of the following is the priority nursing action?

  1. A
    Administer the prescribed PRN nebulized albuterol treatment immediately
  2. B
    Continue to monitor as the absence of wheezing indicates a positive response to initial therapy
  3. Notify the rapid response team and gather supplies for endotracheal intubationAnswer
  4. D
    Prepare to administer a continuous intravenous infusion of sodium bicarbonate

Answer

Notify the rapid response team and gather supplies for endotracheal intubation.
The combination of a 'silent chest' (absent wheezing with shallow respirations), drowsiness, and respiratory acidosis (pH\text{pH} 7.28, PaCO2\text{PaCO}_2 58) in an asthma patient signifies profound muscle fatigue and impending respiratory failure. Immediate intubation and mechanical ventilation are required to save the client's life.

Step-by-Step Solution

1
Analyze the physical assessment changes.
The client transitioned from tachypnea and loud wheezing to shallow respirations, no audible wheezing ('silent chest'), and drowsiness.
Sudden loss of wheezing with decreased level of consciousness indicates extreme muscle fatigue and complete airway obstruction, a medical emergency.
2
Interpret the arterial blood gas (ABG) results.
The pH is 7.28 (acidosis) and PaCO2 is 58 mm Hg (elevated), indicating uncompensated respiratory acidosis.
Early asthma exacerbations typically present with respiratory alkalosis due to hyperventilation. A shift to respiratory acidosis signifies that the client can no longer maintain adequate ventilation.
3
Determine the priority clinical intervention.
The nurse must immediately call for help and prepare for advanced airway management (intubation and mechanical ventilation).
The client is in impending respiratory failure. Airway and breathing take the highest priority, and pharmacological interventions will not be effective without adequate airflow.

Key Concept

Recognizing impending respiratory failure in asthma (silent chest and respiratory acidosis).
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Topics

Physiological Adaptation

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