Question

A 54-year-old woman who has a history of COPD presents with a productive cough for the last 3 months and shortness of breath with little exertion. Her blood pressure is 130/90 mm Hg and pulse rate 126 bpm. Arterial blood gas results are as follows: pH 7.29; PaCO2 72 mm Hg; HCO3– 34 mEq/L; PaO2 50 mm Hg.

How do you interpret the patient’s blood gas values?

What treatment would you anticipate?

Outline the nursing plan of care to address the patient’s fluid and electrolyte or acid–base disorders. Give the rationale for the nursing interventions for this patient.

Answer 1

*The pH is 7.29. This is lower than normal, so probably have an acidosis.

*The PaCO2 is 72 mmHg, which is high. So respiratory acidosis.

*normal HCO3- is between 22-28. So the body is trying to fix this problem.Here  HCO3 is 34 mEq/L;

*This ABG is an example of a partially compensated respiratory acidosis.

Treatment is aimed at the underlying disease, and may include:

• Bronchodilator medicines and corticosteroids to reverse some types of airway obstruction
• Noninvasive positive-pressure ventilation (sometimes called CPAPor BiPAP) or a breathing machine, if needed
• Oxygen if the blood oxygen level is low
• Treatment to stop smoking
• For severe cases, a breathing machine might be needed

Nursing Care plan for fluid and electrolyte

• Monitor turgor. Skin and tongue turgor are indicators of the fluid status of the patient.
• Urine concentration. Obtain urine sample of the patient to check for urine concentration.
• Oral and parenteral fluids.Administer oral or parenteral fluids as indicated to correct the deficit.
• Oral rehydration solutions.These solutions provide fluid, glucose, and electrolytes in concentrations that are easily absorbed.
• Central nervous system changes. The nurse must be alert for central nervous system changes such as lethargy, seizures, confusion, and muscle twitching.
• Diet. The nurse must encourage intake of electrolytes that are deficient or restrict intake if the electrolyte levels are exeeded

Nursing Interventions	Rationale
Monitor respiratory rate, depth, and effort.	Alveolar hypoventilation and associated hypoxemia lead to respiratory distress or failure.
Auscultate breath sounds.	Identifies areas of decreased ventilation (atelectasis) or airway obstruction and changes as patient deteriorates or improves, reflecting effectiveness of treatment, dictating therapy needs.
Note declining level of consciousness.	Signals severe acidotic state, which requires immediate attention. Note: In recovery, sensorium clears slowly because hydrogen ions are slow to cross the blood-brain barrier and clear from cerebrospinal fluid and brain cells.
Monitor heart rate and rhythm.	Tachycardia develops early because the sympathetic nervous system is stimulated, resulting in the release of catecholamines, epinephrine, and norepinephrine, in an attempt to increase oxygen delivery to the tissues. Dysrhythmias that may occur are due to hypoxia (myocardial ischemia) and electrolyte imbalances.
Note skin color, temperature, moisture.	Diaphoresis, pallor, cool or clammy skin are late changes associated with severe or advancing hypoxemia.
Encourage and assist with deep-breathing exercises, turning, and coughing. Suction as necessary. Provide airway adjunct as indicated. Place in semi-Fowler’s position.	These measures improve lung ventilation and reduce or prevent airway obstruction associated with accumulation of mucus.
Restrict use of hypnotic sedatives or tranquilizers.	In the presence of hypoventilation, respiratory depression and CO2 narcosis may develop.
Discuss cause of chronic condition (when known) and appropriate interventions and self-careactivities.	Promotes participation in therapeutic regimen, and may reduce recurrence of disorder.
Assist with identification or treatment of underlying cause.	Treatment of disorder is directed at improving alveolar ventilation. Addressing the primary condition (oversedation, lung and respiratory system trauma, pulmonary edema, aspiration) promotes correction of the acid-base disorder.
Monitor and graph serial ABGs, pulse oximetry readings; Hb, serum electrolyte levels.	Evaluates therapy need and effectiveness. Note: Bedside pulse oximetry monitoring is used to show early changes in oxygenation before other signs or symptoms are observed.
Administer oxygen as indicated. Increase respiratory rate or tidal volume of ventilator, if used.	Prevents and corrects hypoxemia and respiratory failure. Note: Must be used with caution in presence of emphysemabecause respiratory depression or failure may result.
Assist with ventilatory aids: IPPB in conjunction with bronchodilators. Monitor peak flow pressure.	Increases lung expansion and opens airways to improve ventilation, preventing respiratory failure.
Maintain hydration (IV/PO) and provide humidification.	Assists in correction of acidity and thinning and mobilization of respiratory secretions.
Provide appropriate chest physiotherapy, including postural drainage and breathing exercises.	Aids in clearing secretions, which improves ventilation, allowing excess CO2 to be eliminated.
Administer IV solutions such as lactated Ringer’s solutionor 0.6 M solution of sodium lactate.	May be useful in nonemergency situations to help control acidosis, until underlying respiratory problem can be corrected.

Administer medications as indicated:
Naloxonehydrochloride (Narcan)	May be useful in arousing patient and stimulating respiratory function in presence of drug overdose and sedation, or acidosis resulting from cardiac arrest.
Sodium bicarbonate(NaHCO3)	May be given in small IV doses in emergency situations to quickly correct acidosis if pH is less than 7.25 and hyperkalemia coexists. Note: Rebound alkalosis or tetany may occur.
Potassiumchloride (KCl)	Replaces potassium that shifts out of cells during acidotic state. Correction of the acidosis may cause a relative serum hypokalemia as potassium shifts back into cells. Potassium imbalance can impair neuromuscular or respiratory function, causing generalized muscleweakness and cardiac dysrhythmias.
Bronchodilators	Helps open constricted airways to improve gas exchange.
Provide low-carbohydrate, high-fat diet (Pulmocare feedings), if indicated.	Helps reduce CO2 production and improves respiratory muscle function and metabolic homeostasis.