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Difficulty: HardPhysiological Adaptation

A nurse is evaluating a client admitted with a severe urinary tract infection who is now increasingly confused. Current vital signs include a blood pressure of 90/72 mm Hg, a heart rate of 128/min, a respiratory rate of 28/min, and a temperature of 39.2°C (102.6°F). Arterial blood gas (ABG) analysis on room air reveals a pH of 7.28, a PaCO2 of 28 mm Hg, a HCO3- of 14 mEq/L, and a PaO2 of 88 mm Hg. Based on these findings, which of the following is the most appropriate interpretation and priority nursing action?

  1. The client is experiencing metabolic acidosis and septic shock; administer a rapid bolus of prescribed intravenous isotonic crystalloids.Answer
  2. B
    The client is experiencing uncompensated respiratory acidosis; prepare the client for immediate endotracheal intubation.
  3. C
    The client is demonstrating respiratory compensation for metabolic alkalosis; instruct the client to perform pursed-lip breathing.
  4. D
    The client is in the progressive stage of cardiogenic shock; administer a prescribed intravenous loop diuretic.

Answer

The clinical data indicates the client is in septic shock with secondary lactic acidosis (metabolic acidosis), requiring immediate intravenous fluid resuscitation.
The ABG reveals a low pH (acidosis) and a low HCO3- (metabolic origin), indicating metabolic acidosis. The low PaCO2 indicates the respiratory system is compensating by blowing off acid (CO2) through tachypnea. The combination of a known infection, high fever, hypotension with a narrow pulse pressure (18 mm Hg), marked tachycardia, and altered mental status (confusion) are classic signs of septic shock, a type of distributive shock. Poor tissue perfusion in shock leads to anaerobic cellular metabolism and lactic acid production, causing the metabolic acidosis. The immediate life-saving priority in septic shock is aggressive volume resuscitation with isotonic crystalloids (e.g., 0.9% sodium chloride) to restore intravascular volume, increase mean arterial pressure, and improve tissue perfusion.

Step-by-Step Solution

1
Analyze the arterial blood gas (ABG) values.
pH is 7.28 (acidemia), HCO3- is 14 mEq/L (primary metabolic acidosis), and PaCO2 is 28 mm Hg (compensatory respiratory alkalosis).
To determine the primary acid-base imbalance and the presence of compensation.
2
Analyze the vital signs and clinical presentation.
The client has a severe infection, high fever (39.2°C), hypotension (90/72 mm Hg) with a narrow pulse pressure, marked tachycardia (128/min), and altered mental status (confusion).
To identify the underlying physiological crisis driving the acid-base imbalance.
3
Synthesize the data to formulate a priority action.
The client is in septic shock, leading to poor tissue perfusion and subsequent lactic acidosis. The priority is to restore intravascular volume.
Isotonic fluid resuscitation is the first-line treatment for distributive (septic) shock to reverse hypovolemia and improve tissue oxygenation.

Key Concept

Septic Shock and ABG Interpretation
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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