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Difficulty: MediumReduction of Risk Potential

A nurse is evaluating a 6565-year-old client admitted for a severe acute exacerbation of chronic obstructive pulmonary disease (COPD). The client is currently prescribed oxygen at 22 L/min via nasal cannula. During the latest assessment, the nurse discovers that the client is extremely lethargic, difficult to arouse, and breathing at a shallow rate of 1010 breaths/min. The results of a stat arterial blood gas (ABG) draw are as follows:

* pH: 7.227.22
* PaCO 2_2: 7474 mm Hg
* PaO 2_2: 5858 mm Hg
* HCO 3−_3^-: 2929 mEq/L

To mitigate the risk of impending physiological decompensation, which of the following is the priority nursing action?

  1. A
    Increase the supplemental oxygen flow to 1010 L/min via a non-rebreather mask to correct the hypoxemia
  2. B
    Document the findings and continue routine monitoring, as this blood gas pattern is an expected baseline in chronic lung disease
  3. Activate the rapid response team and prepare the client for immediate positive pressure ventilationAnswer
  4. D
    Place the client in a supine position to facilitate a comprehensive assessment of bilateral diaphragmatic excursion

Answer

The correct action is to activate the rapid response team and prepare the client for immediate positive pressure ventilation to address the acute respiratory failure.
The correct answer requires prioritizing airway and ventilation. The client is exhibiting signs of acute, uncompensated respiratory acidosis (pH 7.227.22, elevated PaCO 2_2 of 7474 mm Hg) superimposed on chronic COPD (indicated by the elevated HCO 3−_3^- of 2929 mEq/L). The clinical signs of lethargy and severe bradypnea (1010 breaths/min) indicate hypercapnic encephalopathy and impending respiratory failure. The priority is to establish effective ventilation, which requires rapid response team activation and mechanical support (such as BiPAP or intubation) to clear the excess carbon dioxide.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client is lethargic with a slow, shallow respiratory rate (1010 breaths/min).
These are classic signs of hypercapnic encephalopathy (carbon dioxide narcosis) indicating impending respiratory failure.
2
Interpret the arterial blood gas (ABG) values.
pH is 7.227.22 (acidosis), PaCO 2_2 is 7474 mm Hg (respiratory origin), and HCO 3−_3^- is 2929 mEq/L (partial compensation).
This represents an uncompensated, acute-on-chronic respiratory acidosis.
3
Determine the priority nursing action based on risk reduction.
Recognize that the client can no longer adequately ventilate independently.
Immediate positive pressure ventilation (BiPAP or intubation) is required to reduce the risk of cardiopulmonary arrest.

Key Concept

Recognition and Management of Acute Hypercapnic Respiratory Failure in COPD
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Topics

Reduction of Risk Potential

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