Examkin

Question

Difficulty: HardPhysiological Adaptation

An older adult client with a ten-year history of chronic obstructive pulmonary disease (COPD) is brought to the emergency department. The client's family reports a progressive decline in the client's level of consciousness over the past six hours, describing the client as 'extremely difficult to wake up.' The client's current respiratory rate is 88 breaths per minute and shallow. Arterial blood gas (ABG) analysis on room air reveals the following: pH=7.21pH = 7.21, PaCO2=84 mm HgPaCO_2 = 84 \text{ mm Hg}, PaO2=52 mm HgPaO_2 = 52 \text{ mm Hg}, and HCO3−=36 mEq/LHCO_3^- = 36 \text{ mEq/L}. Based on these clinical findings, what is the highest priority nursing action?

  1. A
    Apply high-flow oxygen at 15 L/min via a non-rebreather mask.
  2. B
    Position the client in high-Fowler's and instruct on pursed-lip breathing.
  3. Prepare equipment and medications for immediate endotracheal intubation.Answer
  4. D
    Administer a prescribed intravenous bolus of sodium bicarbonate.

Answer

Prepare equipment and medications for immediate endotracheal intubation.
The correct action is to prepare for immediate intubation. The client's ABG reveals severe, acute-on-chronic respiratory acidosis (pH=7.21pH = 7.21, PaCO2=84 mm HgPaCO_2 = 84 \text{ mm Hg}). The elevated bicarbonate indicates this is a chronic COPD patient, but the extremely low pH and elevated CO2, combined with a respiratory rate of 8 and profound lethargy, indicate carbon dioxide narcosis. The client is losing the ability to protect their airway or maintain adequate spontaneous ventilation. Immediate endotracheal intubation and mechanical ventilation are required to offload the CO2CO_2 and reverse the life-threatening acidemia.

Step-by-Step Solution

1
Analyze the arterial blood gas (ABG) values.
The low pH (7.21) indicates acidemia. The drastically elevated PaCO2 (84 mm Hg) indicates a respiratory cause. The elevated HCO3 (36 mEq/L) indicates chronic compensation that is currently failing due to an acute event.
Accurate interpretation of ABGs establishes the pathophysiological state as acute-on-chronic respiratory acidosis.
2
Evaluate the client's physical presentation alongside the ABG data.
The respiratory rate of 8 breaths per minute is dangerously low, and the severe lethargy ('extremely difficult to wake up') indicates carbon dioxide narcosis.
Clinical signs determine whether the client can manage their own airway non-invasively or if definitive invasive control is required.
3
Select the most appropriate and immediate physiological intervention.
Because the client is obtunded, hypoventilating, and in severe acid-base failure, mechanical ventilation via endotracheal intubation is the only viable method to clear the retained CO2 and secure the airway.
Airway and Breathing take highest priority in the ABC triage framework.

Key Concept

Acute Respiratory Failure and CO2 Narcosis in COPD
Estimated Time:1m 30s
Rate this question

Topics

Physiological Adaptation

More questions from this topic