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Difficulty: MediumReduction of Risk Potential

A 68-year-old client is 24 hours post-operative following an open cholecystectomy. The client has been guarding the abdomen and is reluctant to use the incentive spirometer due to incisional pain. The nurse notes shallow respirations at 2626 breaths/min and an oxygen saturation (SpO2SpO_2) of 89%89\% on room air. A newly drawn arterial blood gas (ABG) reveals the following: pH 7.297.29, PaCO2PaCO_2 5656 mmHg, HCO3−HCO_3^- 2424 mEq/L, and PaO2PaO_2 6262 mmHg. Which immediate action should the nurse implement to reduce the risk of further physiological deterioration?

  1. Elevate the head of the bed to at least 45 degrees and guide the client through deep breathing exercises.Answer
  2. B
    Administer a prescribed intravenous sodium bicarbonate infusion to correct the acid-base imbalance.
  3. C
    Place the client strictly on their back without pillows to minimize physical stress on the surgical site.
  4. D
    Administer the highest prescribed dose of an intravenous opioid to completely eliminate the incisional pain.

Answer

The correct action is to elevate the head of the bed to at least 45 degrees (semi-Fowler's position) and assist the client with deep breathing exercises.
The client is experiencing uncompensated respiratory acidosis (pH 7.297.29, PaCO2PaCO_2 5656 mmHg) and hypoxemia due to shallow breathing (hypoventilation) from post-operative incisional splinting. Elevating the head of the bed promotes optimal lung expansion by allowing the diaphragm to drop, which improves ventilation and gas exchange. Deep breathing exercises directly address the root cause by increasing alveolar ventilation and blowing off the retained carbon dioxide.

Step-by-Step Solution

1
Analyze the client's clinical presentation and arterial blood gas (ABG) values.
The ABG indicates uncompensated respiratory acidosis (low pH, high PaCO2PaCO_2, normal HCO3−HCO_3^-) accompanied by hypoxemia (low PaO2PaO_2 and SpO2SpO_2).
Identifying the specific physiological derangement is the critical first step in prioritizing appropriate nursing care.
2
Determine the root cause of the acid-base imbalance.
The respiratory acidosis is caused by hypoventilation (shallow breathing at 26 breaths/min) secondary to incisional splinting and guarding from the open abdominal surgery.
Interventions must target the underlying cause to effectively reverse the client's physiological decline.
3
Select the safest and most direct nursing intervention to resolve the hypoventilation.
Elevating the head of the bed maximizes diaphragmatic excursion, while deep breathing exercises directly increase alveolar ventilation.
Non-pharmacological positioning and respiratory exercises are the immediate priority to restore adequate gas exchange without risking further central nervous system depression.

Key Concept

Recognition and immediate non-pharmacological management of post-operative respiratory acidosis.
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Topics

Reduction of Risk Potential

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