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Difficulty: MediumPhysiological Adaptation

A nurse is assessing a client with diabetic ketoacidosis (DKA) who is receiving a continuous intravenous regular insulin infusion. The client is lethargic and has deep, rapid respirations at 2828 breaths/min. The most recent arterial blood gas (ABG) results are: pH 7.297.29, PaCO 2_2 3030 mm Hg, PaO 2_2 9494 mm Hg, and HCO 3−_3^- 1515 mEq/L. Which of the following is the most appropriate action by the nurse?

  1. Document the findings and continue to monitor the client's compensatory respiratory pattern.Answer
  2. B
    Prepare to administer a prescribed sedative to decrease the client's work of breathing.
  3. C
    Administer intravenous sodium bicarbonate to rapidly correct the arterial pH.
  4. D
    Instruct the client to breathe slowly into a paper bag to reverse the hyperventilation.

Answer

Document the findings and continue to monitor the client's compensatory respiratory pattern.
Kussmaul respirations (deep, rapid breathing) are an expected, physiological compensatory mechanism in metabolic acidosis (such as DKA). The lungs increase the rate and depth of ventilation to exhale carbon dioxide, which acts as an acid in the body, in an attempt to raise the blood pH back toward normal. Because the ABG indicates partially compensated metabolic acidosis, the most appropriate action is to continue monitoring this vital adaptation while the insulin infusion treats the underlying ketoacidosis.

Step-by-Step Solution

1
Analyze the arterial blood gas (ABG) results.
The pH (7.297.29) is low (acidosis), and the HCO 3−_3^- (1515 mEq/L) is low, identifying the primary disorder as metabolic acidosis. The PaCO 2_2 (3030 mm Hg) is also low, which indicates partial respiratory compensation.
Accurate interpretation of ABGs is essential to determine the client's current acid-base status and physiological response.
2
Evaluate the clinical presentation in relation to the ABGs.
The client is experiencing deep, rapid breathing known as Kussmaul respirations.
This is a necessary physiological adaptation where the lungs attempt to blow off excess carbon dioxide (an acid) to bring the blood pH back toward a normal range.
3
Determine the most appropriate nursing intervention.
The nurse should allow the compensatory breathing to continue while the underlying cause (DKA) is treated with the ongoing insulin infusion.
Intervening to slow the respiratory rate or neutralize the acid prematurely can lead to dangerous complications and a sudden worsening of the acidosis.

Key Concept

Respiratory compensation in metabolic acidosis (Kussmaul respirations)
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Topics

Physiological Adaptation

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