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Difficulty: HardReduction of Risk Potential

An adult client is receiving care in the emergency department for a severe asthma exacerbation. Following one hour of continuous albuterol nebulization and intravenous corticosteroids, the client's respiratory rate is 32 breaths per minute, and auscultation reveals that the previously loud, bilateral expiratory wheezes are now significantly diminished. The most recent arterial blood gas (ABG) analysis on room air reveals a pH of 7.36, a PaCO2 of 44 mm Hg, and a PaO2 of 61 mm Hg. Which action should the nurse take to reduce the client's immediate risk of physiological deterioration?

  1. A
    Continue current monitoring, as the diminished wheezing indicates effective airway dilation and a therapeutic response.
  2. Gather emergency airway supplies and notify the healthcare provider of impending respiratory failure.Answer
  3. C
    Lower the head of the bed to a flat, supine position to promote relaxation of the accessory respiratory muscles.
  4. D
    Conclude the client is in uncompensated respiratory alkalosis and initiate interventions to slow the breathing rate.

Answer

The priority action is to gather emergency airway supplies and notify the healthcare provider of impending respiratory failure.
The correct action is to prepare for immediate intubation and mechanical ventilation. This client is demonstrating two classic signs of impending respiratory arrest: the 'silent chest' (diminished wheezing due to a lack of airflow) and pseudo-normalization of arterial blood gases. A tachypneic asthmatic should have a low PaCO2; therefore, a 'normal' PaCO2 (44 mm Hg) indicates profound fatigue and an inability to sustain ventilation.

Step-by-Step Solution

1
Analyze the client's physical assessment findings.
The client is highly tachypneic (32 breaths/minute) but has diminished wheezing.
In acute asthma, a sudden decrease in wheezing without overall clinical improvement indicates a 'silent chest' where airflow is severely restricted, representing a life-threatening emergency.
2
Interpret the arterial blood gas (ABG) results in the context of the clinical presentation.
The ABG shows a 'normal' pH (7.36) and PaCO2 (44 mm Hg), with mild hypoxemia (PaO2 61 mm Hg).
During an asthma attack, tachypnea typically causes a low PaCO2 (respiratory alkalosis). A rising or 'normal' PaCO2 (pseudo-normalization) in a struggling, tachypneic client signals respiratory muscle fatigue and impending failure.
3
Determine the most appropriate risk reduction nursing intervention.
The nurse must anticipate the need for advanced airway management.
Because the client is deteriorating and losing the ability to ventilate adequately, the immediate priority is to prepare for endotracheal intubation to secure the airway and prevent cardiopulmonary arrest.

Key Concept

Early recognition of impending respiratory failure in severe asthma exacerbation, specifically identifying the 'silent chest' phenomenon and pseudo-normalization of ABG values.
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Reduction of Risk Potential

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