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Chapter 34: Problem 815

The nurse is caring for a client who has received conscious sedation for elective cardioversion. Following the procedure the arterial blood gas results are as follows: pH 7.32; \(\mathrm{PaO}_2 95 \mathrm{~mm} \mathrm{Hg} ; \mathrm{PaCO}_2 62 \mathrm{~mm} \mathrm{Hg}\); \(\mathrm{HCO}_3 19 \mathrm{meq} / \mathrm{L} ; \mathrm{O}_2\) Sat \(95 \%\). Based on these values which action would the nurse take? A. Chart the values and continue assessing the client B. Start supplemental oxygen at 2 liter per minute via nasal cannula C. Have the client perform deep breathing exercises D. Have the client breathe into a paper bag

Short Answer

Expert verified
Have the client perform deep breathing exercises.

Step by step solution

01

Understand the values

Review and understand the patient's arterial blood gas (ABG) values: - pH: 7.32 (low, indicating acidosis) - \(\text{PaO}_2\): 95 mm Hg (normal) - \(\text{PaCO}_2\): 62 mm Hg (high, indicating hypercapnia) - \(\text{HCO}_3\): 19 meq/L (low, indicating metabolic component) - \(\text{O}_2\) Sat: 95% (normal)
02

Identify the primary issue

Recognize that the patient has respiratory acidosis with a metabolic component, as indicated by the high \(\text{PaCO}_2\) and low pH, along with the low \(\text{HCO}_3\). This suggests that the patient may have hypoventilation.
03

Evaluate the normal oxygen levels

Given the normal \(\text{PaO}_2\) and \(\text{O}_2\) saturation values, there is no immediate need for supplemental oxygen.
04

Assess the correct intervention

Deep breathing exercises can help remove excess \(\text{CO}_2\) by improving ventilation. Therefore, the nurse should have the client perform deep breathing exercises.
05

Review the options

Based on the intervention identified, review the options provided: A. Continue assessing the client B. Start supplemental oxygen C. Have the client perform deep breathing exercises D. Have the client breathe into a paper bag Option C is the correct intervention.

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Key Concepts

These are the key concepts you need to understand to accurately answer the question.

arterial blood gas interpretation
Arterial blood gas (ABG) interpretation is an essential skill for nurses, especially when caring for patients with respiratory issues. ABG measurements provide information about the levels of oxygen (PaO2), carbon dioxide (PaCO2), and bicarbonate (HCO3-) in the blood. These levels indicate the acid-base balance and oxygenation status.
An ABG test typically includes values for:
  • pH: Measures the acidity or alkalinity of the blood. Normal range: 7.35-7.45
  • PaO2: Partial pressure of oxygen in arterial blood. Normal range: 80-100 mm Hg
  • PaCO2: Partial pressure of carbon dioxide in arterial blood. Normal range: 35-45 mm Hg
  • HCO3-: Bicarbonate level in arterial blood. Normal range: 22-26 meq/L
  • O2 saturation (O2 Sat): Percentage of hemoglobin saturated with oxygen. Normal range: 95-100%
Interpreting these values helps determine if the patient is in a state of acidosis or alkalosis and whether the primary issue is respiratory or metabolic.
respiratory acidosis
Respiratory acidosis occurs when there is an excess of carbon dioxide (CO2) in the blood due to hypoventilation. This can result from various conditions, such as chronic obstructive pulmonary disease (COPD), sedative overdose, or neuromuscular disorders.
Key indicators of respiratory acidosis in ABG results include:
  • Low pH: Indicates an acidic state (below 7.35)
  • High PaCO2: Suggests CO2 retention (above 45 mm Hg)
  • Normal or slightly elevated HCO3-: Shows the kidneys' attempt to compensate by retaining bicarbonate
In the given exercise, the patient's ABG values (pH 7.32, PaCO2 62 mm Hg, HCO3- 19 meq/L) clearly indicate respiratory acidosis with a metabolic component. The high PaCO2 confirms that the primary issue is respiratory in nature, likely due to hypoventilation.
nursing interventions
When dealing with respiratory acidosis, it is crucial to address the underlying cause and improve ventilation to reduce CO2 levels. Effective nursing interventions for respiratory acidosis might include:
  • Encouraging deep breathing exercises: This helps increase ventilation and expel CO2 from the lungs.
  • Monitoring ABG values: Regularly check ABG results to assess the patient's response to interventions.
  • Positioning the patient: Sitting the patient up can help improve lung expansion and ventilation.
  • Avoiding unnecessary oxygen: Oxygen supplementation may not be required if oxygen saturation levels are normal.
In the described case, the appropriate intervention is to have the patient perform deep breathing exercises, which helps alleviate the respiratory acidosis by improving ventilation. Other options, like using a paper bag or supplementing oxygen, might not address the primary issue of CO2 retention and could potentially be harmful.

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