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Zorluk: OrtaReduction of Risk Potential

An emergency department nurse is evaluating a young adult client who presented with a severe asthma exacerbation. Upon arrival, the client was highly agitated, using accessory muscles to breathe, and had a respiratory rate of 3838 breaths/min. The initial arterial blood gas (ABG) revealed: pH 7.487.48, PaCO2\text{PaCO}_2 2828 mm Hg, and PaO2\text{PaO}_2 6868 mm Hg. After one hour of continuous bronchodilator therapy, the nurse observes that the client has become lethargic and the respiratory rate has decreased to 1414 breaths/min. A repeat ABG reveals: pH 7.297.29, PaCO2\text{PaCO}_2 5656 mm Hg, and PaO2\text{PaO}_2 5252 mm Hg. Which of the following is the priority nursing action to reduce the risk of cardiopulmonary arrest?

  1. Activate the rapid response team and prepare equipment for immediate endotracheal intubation.Cevap
  2. B
    Request a prescription for an intravenous sodium bicarbonate infusion to normalize the blood pH.
  3. C
    Assist the client into a flat, supine position to prepare for a portable chest radiograph.
  4. D
    Delegate the continuous monitoring of the client's vital signs to an unlicensed assistive personnel (UAP).

Cevap

The priority action is to activate the rapid response team and prepare for immediate endotracheal intubation.
The correct answer identifies that the client has progressed to respiratory failure. The initial hyperventilation (respiratory alkalosis) has been replaced by hypoventilation (respiratory acidosis) due to severe muscle fatigue, evidenced by the drop in respiratory rate, rise in carbon dioxide, and lethargy. This is a medical emergency requiring rapid intubation and mechanical ventilation to save the client's life.

Adım Adım Çözüm

1
Analyze the initial assessment findings.
The client presented with severe distress, a high respiratory rate (3838 breaths/min), and respiratory alkalosis (pH 7.487.48, PaCO2\text{PaCO}_2 2828 mm Hg).
Early in an asthma attack, hyperventilation causes excessive exhalation of carbon dioxide, leading to a compensatory respiratory alkalosis.
2
Evaluate the subsequent clinical changes and repeat ABG results.
The client became lethargic with a decreased respiratory rate (1414 breaths/min). The repeat ABG shows respiratory acidosis (pH 7.297.29, PaCO2\text{PaCO}_2 5656 mm Hg) and worsening hypoxemia (PaO2\text{PaO}_2 5252 mm Hg).
These changes indicate profound respiratory muscle fatigue. The client is no longer able to hyperventilate to blow off carbon dioxide, resulting in rapid CO2 retention and severe hypoxia.
3
Determine the priority nursing intervention based on the physiological trend.
The nurse must prepare for definitive airway management via endotracheal intubation.
Lethargy and rising PaCO2\text{PaCO}_2 in a previously hyperventilating asthmatic client are ominous signs of impending respiratory arrest that require immediate mechanical ventilation.

Anahtar Kavram

In severe asthma, a transition from respiratory alkalosis to respiratory acidosis accompanied by lethargy and a dropping respiratory rate indicates impending respiratory failure requiring immediate intubation.
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Reduction of Risk Potential

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