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Zorluk: ZorPhysiological Adaptation

A nurse is monitoring a client diagnosed with Guillain-Barré syndrome who reports increasing weakness in the upper body. The client's forced vital capacity (FVC) has decreased from 40 mL/kg to 14 mL/kg over the past shift. The most recent arterial blood gas (ABG) results on room air reveal a pH of 7.29, PaCO2 of 58 mm Hg (7.7 kPa), PaO2 of 64 mm Hg (8.5 kPa), and HCO3- of 25 mEq/L (25 mmol/L). Based on these findings, what is the priority nursing action?

  1. A
    Administer a prescribed intravenous bolus of sodium bicarbonate to correct the pH imbalance
  2. B
    Apply supplemental oxygen via nasal cannula to improve the partial pressure of oxygen
  3. Prepare the client for immediate endotracheal intubation and mechanical ventilationCevap
  4. D
    Position the client in high-Fowler's and instruct them to perform incentive spirometry

Cevap

The correct action is to prepare the client for immediate endotracheal intubation and mechanical ventilation.
The client is experiencing acute respiratory failure due to the ascending paralysis characteristic of Guillain-Barré syndrome. The ABG results demonstrate uncompensated respiratory acidosis (pH 7.29, PaCO2 58 mm Hg), indicating that the client is retaining carbon dioxide due to severe hypoventilation. A forced vital capacity (FVC) less than 15 mL/kg is a critical clinical threshold that signals imminent respiratory muscle fatigue. Because the primary pathophysiological issue is a mechanical inability to ventilate, the priority action is to secure the airway and initiate mechanical ventilation.

Adım Adım Çözüm

1
Analyze the arterial blood gas (ABG) results to determine the client's acid-base status.
The ABG shows uncompensated respiratory acidosis (low pH, high PaCO2, normal HCO3-) with hypoxemia.
Identifying the primary physiological disturbance is the first step in clinical prioritization.
2
Evaluate the client's clinical progression and forced vital capacity (FVC) trend.
The FVC has dropped to 14 mL/kg, and upper body weakness is increasing.
An FVC below 15 mL/kg in a client with a neuromuscular disorder indicates imminent respiratory muscle failure.
3
Synthesize the data to determine the most appropriate intervention.
The combination of severe acute respiratory acidosis and critical FVC decline requires immediate artificial airway placement.
Supplemental oxygen or positioning will not overcome the mechanical failure of the diaphragm and intercostal muscles.

Anahtar Kavram

Management of acute respiratory failure and ABG interpretation in neuromuscular disorders.
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Physiological Adaptation

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