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Zorluk: ZorReduction of Risk Potential

A 72-year-old client with a history of severe chronic obstructive pulmonary disease (COPD) is admitted to the progressive care unit with a respiratory infection. The client is lethargic and confused. Vital signs are: blood pressure 86/52 mmHg, heart rate 122 beats/min, respiratory rate 32 breaths/min, and oxygen saturation 83% on room air. The arterial blood gas (ABG) results are: pH 7.25, PaCO2 68 mmHg, HCO3 29 mEq/L, and PaO2 50 mmHg. To reduce the risk of further physiological decompensation, which actions should the nurse take? Select all that apply.

  1. Elevate the head of the bed to a high-Fowler's position to maximize diaphragmatic excursion.Cevap
  2. Prepare the client for immediate initiation of noninvasive positive pressure ventilation (NIPPV).Cevap
  3. Establish large-bore intravenous access to facilitate rapid crystalloid fluid resuscitation.Cevap
  4. D
    Administer intravenous sodium bicarbonate to correct the uncompensated metabolic acidosis.
  5. E
    Place the client in a flat, supine position to increase venous return and improve the hypotensive blood pressure.
  6. F
    Withhold immediate interventions until a comprehensive head-to-toe physical assessment is completed.

Cevap

The correct actions are elevating the head of the bed, preparing for noninvasive positive pressure ventilation, and establishing large-bore intravenous access.
The client is experiencing acute respiratory failure, evidenced by partially compensated respiratory acidosis and severe hypoxemia, alongside early signs of shock indicated by hypotension and tachycardia. To reduce the risk of physiological collapse, the nurse must immediately address the airway, breathing, and circulation (ABCs). Elevating the head of the bed maximizes chest expansion and gas exchange. Noninvasive positive pressure ventilation (NIPPV) is indicated to improve oxygenation and reduce carbon dioxide levels. Establishing large-bore intravenous access is critical for rapid fluid resuscitation to manage hypovolemia and improve systemic perfusion.

Adım Adım Çözüm

1
Analyze the arterial blood gas (ABG) results and vital signs to determine the client's current physiological state.
The ABGs indicate partially compensated respiratory acidosis with severe hypoxemia. Vital signs reveal hypotension and tachycardia, indicating early shock.
Accurate interpretation of clinical data is necessary to identify life-threatening conditions and prioritize interventions.
2
Prioritize interventions based on the Airway, Breathing, and Circulation (ABC) framework.
Respiratory support and hemodynamic stabilization are identified as the highest priorities.
Addressing the ABCs immediately reduces the risk of cardiopulmonary arrest.
3
Select the specific evidence-based interventions that mitigate the identified risks without causing further harm.
Elevating the head of the bed, initiating noninvasive positive pressure ventilation, and establishing large-bore IV access are selected.
These actions directly correct hypoxia, assist ventilation, and restore intravascular volume while avoiding contraindicated positions or medications.

Anahtar Kavram

Risk Reduction in Acute Cardiopulmonary Decompensation
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Konular

Reduction of Risk Potential

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