A client is brought to the emergency department experiencing a severe asthma exacerbation.… — NCLEX-RN

A client is brought to the emergency department experiencing a severe asthma exacerbation. The client is initially restless and tachypneic with an arterial blood gas (ABG) showing a pH of $7.50$ , $PaCO_2$ of $28 \text{ mm Hg}$ , and $HCO_3^-$ of $24 \text{ mEq/L}$ . One hour later, the nurse notes that the client has become lethargic and the respiratory rate has decreased to $10$ breaths per minute. A repeat ABG shows a pH of $7.28$ , $PaCO_2$ of $58 \text{ mm Hg}$ , and $HCO_3^-$ of $24 \text{ mEq/L}$ . Which of the following is the priority nursing action?

Prepare the client for immediate endotracheal intubation and mechanical ventilation.Answer
B
Administer a prescribed dose of intravenous sodium bicarbonate to correct the acidosis.
C
Notify the respiratory therapist to administer a scheduled albuterol nebulizer treatment.
D
Place the client in a supine position to facilitate a comprehensive physical assessment.

Answer

Prepare the client for immediate endotracheal intubation and mechanical ventilation.

The correct action addresses the immediate life-threatening issue. The client's transition from hyperventilation (respiratory alkalosis) to hypoventilation with lethargy and carbon dioxide retention (respiratory acidosis) signals the exhaustion of the respiratory muscles. This is a classic presentation of impending respiratory failure in status asthmaticus, which requires prompt airway management and ventilatory support.

Step-by-Step Solution

Analyze the initial ABG results.

A pH of

7.50

(alkalosis),

PaCO_2

28

(decreased), and

HCO_3^-

24

(normal) indicates uncompensated respiratory alkalosis due to hyperventilation.

Early asthma exacerbations cause hyperventilation, leading to an excessive 'blowing off' of carbon dioxide.

Evaluate the clinical changes and the repeat ABG results.

The client became lethargic with a decreased respiratory rate. The repeat ABG shows a pH of

7.28

(acidosis),

PaCO_2

58

(increased), and

HCO_3^-

24

(normal).

These findings indicate uncompensated respiratory acidosis and a significant clinical deterioration.

Determine the pathophysiological mechanism.

The client has developed respiratory muscle fatigue, leading to hypoventilation, carbon dioxide retention, and impending respiratory failure.

A transition from respiratory alkalosis to respiratory acidosis in a client having an asthma attack is a medical emergency.

Select the priority intervention based on the ABCs (Airway, Breathing, Circulation).

Airway protection and breathing support are the absolute immediate priorities.

Mechanical ventilation is required to restore adequate gas exchange, remove retained carbon dioxide, and prevent cardiac arrest.

Key Concept

Impending respiratory failure in severe asthma is clinically indicated by a transition from respiratory alkalosis to respiratory acidosis accompanied by fatigue, requiring immediate mechanical ventilation.

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