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Zorluk: ZorPhysiological Adaptation

A nurse is caring for a client who is 24 hours post-operative following a right total hip arthroplasty. The client suddenly reports sharp, right-sided chest pain and acute shortness of breath. The client appears highly agitated and diaphoretic. Vital signs are: heart rate 128 bpm, blood pressure 92/64 mm Hg, respiratory rate 30 breaths/min, and oxygen saturation 84% on room air. An arterial blood gas (ABG) is obtained with the following results: pH 7.52, PaCO2 28 mm Hg, PaO2 54 mm Hg, and HCO3 24 mEq/L. Which of the following is the priority nursing action?

  1. Apply high-flow oxygen via a non-rebreather maskCevap
  2. B
    Instruct the client to take slow, deep breaths into a paper bag
  3. C
    Elevate the head of the bed to 90 degrees and have the client lean forward
  4. D
    Initiate a rapid intravenous fluid bolus of 0.9% sodium chloride

Cevap

The priority action is to apply high-flow oxygen via a non-rebreather mask.
The client is exhibiting classic signs of a pulmonary embolism, a critical complication of orthopedic surgery. The ABG reveals severe hypoxemia (PaO2 54 mm Hg), which is driving a compensatory hyperventilation resulting in respiratory alkalosis. According to the ABCs (Airway, Breathing, Circulation) of emergency care, addressing the profound hypoxemia with high-flow oxygen is the absolute highest priority to prevent tissue ischemia and cardiac arrest.

Adım Adım Çözüm

1
Analyze the clinical presentation and vital signs.
Sudden chest pain, dyspnea, tachycardia, hypotension, and severe hypoxemia (SpO2 84%, PaO2 54 mm Hg) in a post-operative orthopedic client strongly suggest a massive pulmonary embolism.
Identifying the underlying medical emergency dictates the necessary life-saving interventions.
2
Interpret the arterial blood gas (ABG) results.
The ABG shows pH 7.52 (alkalemia) and PaCO2 28 mm Hg (respiratory alkalosis), with severe hypoxemia (PaO2 54 mm Hg).
Understanding that the respiratory alkalosis is a compensatory mechanism for the profound lack of oxygen prevents implementing contraindicated therapies like rebreathing CO2.
3
Evaluate the proposed interventions against safety constraints.
Hip flexion of 90 degrees or greater is contraindicated post-hip arthroplasty, eliminating high Fowler's positioning as a safe option.
Nurses must integrate surgical safety precautions even during acute medical resuscitations.
4
Prioritize the remaining safe actions using the ABC (Airway, Breathing, Circulation) framework.
Immediate correction of severe hypoxemia (Breathing) takes absolute precedence over fluid resuscitation (Circulation).
Failure to immediately correct a PaO2 of 54 mm Hg will lead to rapid tissue ischemia, cardiac dysrhythmias, and cardiac arrest.

Anahtar Kavram

Prioritization in Pulmonary Embolism and Orthopedic Precautions
Tahmini Süre:1m 30s
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Konular

Physiological Adaptation

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