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Difficulty: MediumPhysiological Adaptation

A nurse is caring for a client who has been receiving continuous gastric suctioning for the past 48 hours to manage a small bowel obstruction. The client reports lightheadedness and a new onset of tingling around the mouth and fingers. The most recent arterial blood gas (ABG) analysis shows a pH of 7.54, a PaCO2PaCO_2 of 41 mm Hg, and an HCO3−HCO_3^- of 34 mEq/L. Based on these findings, which of the following is the priority nursing action?

  1. Evaluate the client's cardiac rhythm and assess for muscle spasms.Answer
  2. B
    Coach the client to take slow, deep breaths into a paper bag.
  3. C
    Prepare to administer a prescribed intravenous infusion of sodium bicarbonate.
  4. D
    Empty the nasogastric canister and increase the wall suction pressure.

Answer

Evaluate the client's cardiac rhythm and assess for muscle spasms.
The correct action directly addresses the life-threatening physiological consequences of metabolic alkalosis. Loss of gastric acid leads to metabolic alkalosis, which subsequently causes potassium to shift into cells (hypokalemia) and ionized calcium to bind to albumin (hypocalcemia). The client's perioral and digital tingling are early signs of neuromuscular irritability from low calcium. Therefore, assessing for progressive tetany (muscle spasms) and cardiac dysrhythmias (from low potassium and calcium) is the highest priority.

Step-by-Step Solution

1
Analyze the arterial blood gas (ABG) results.
The pH of 7.54 indicates alkalemia. The normal PaCO2PaCO_2 (41 mm Hg) and elevated HCO3−HCO_3^- (34 mEq/L) indicate uncompensated metabolic alkalosis.
Accurate ABG interpretation is essential to determine the underlying acid-base imbalance.
2
Connect the clinical scenario to the ABG findings.
Continuous gastric suctioning depletes the body of hydrochloric acid (HCl) and potassium, directly leading to metabolic alkalosis.
Understanding the etiology confirms the diagnosis and helps anticipate related physiological changes.
3
Correlate the client's physical symptoms with the physiological imbalance.
Alkalosis causes an increase in calcium binding to albumin, leading to a decrease in ionized calcium. This functional hypocalcemia causes the perioral tingling and lightheadedness.
Identifying the cause of new symptoms guides the appropriate nursing intervention.
4
Determine the highest priority nursing action.
The nurse must prioritize assessing for the most severe complications of hypocalcemia and concurrent hypokalemia, which are tetany (muscle spasms) and cardiac dysrhythmias.
Patient safety principles dictate prioritizing assessments of potentially life-threatening physiological complications (ABCs and severe neuromuscular compromise).

Key Concept

Metabolic Alkalosis and Associated Electrolyte Imbalances
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Topics

Physiological Adaptation

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