Module 05 Written Assignment – Acid-Base Imbalance Competenc ✓ Solved

Module 05 Written Assignment – Acid-Base Imbalance Competenc

Module 05 Written Assignment – Acid-Base Imbalance Competency Describe strategies for safe, effective multidimensional nursing care for clients with acid-base imbalances. Scenario: Tony is a 56-year-old Hispanic male who presented to the Emergency Room with complaints of shortness of breath for two days. He reports a week of malaise, cough, fever, and exhaustion. Past medical history: asthma, chronic obstructive pulmonary disease, and diabetes. On exam: respiratory rate 36/min, labored; heart rate 115 bpm; blood pressure 90/40 mm Hg; pulse oximetry 84% on room air. Oxygen was ordered at 4 L via nasal cannula. Arterial blood gas: pH 7.28; PaCO2 55 mm Hg; PaO2 70 mm Hg; HCO3- 30 mEq/L. Instructions: Determine the acid-base imbalance, describe possible causes, identify the signs and symptoms Tony is exhibiting due to the imbalance, and list multidimensional care strategies appropriate for Tony.

Paper For Above Instructions

Executive diagnosis statement

Tony’s arterial blood gas demonstrates an acidemia (pH 7.28) with an elevated PaCO2 (55 mm Hg) and an increased bicarbonate (HCO3- 30 mEq/L). This pattern indicates a primary respiratory acidosis with metabolic compensation — most consistent with acute-on-chronic (acute exacerbation superimposed on chronic) hypercapnic respiratory failure, commonly seen in patients with chronic obstructive pulmonary disease (COPD) (Kraut & Madias, 2010; GOLD, 2023).

ABG interpretation and rationale

An acute rise in PaCO2 causes increased H+ and reduced pH; initial renal compensation is limited in acute events. In chronic CO2 retention, the kidneys retain bicarbonate over days, producing higher HCO3- values. Tony’s PaCO2 is 15 mm Hg above normal (40 → 55). The magnitude of HCO3- elevation (30 mEq/L) exceeds expected acute compensation and suggests chronic retention with an acute decompensation (Marino, 2014; Kraut & Madias, 2010). Combined with history of COPD and asthma, the ABG supports acute-on-chronic respiratory acidosis.

Likely causes and pathophysiology

Potential causes for Tony’s respiratory acidosis include:

  • Acute COPD exacerbation precipitated by lower respiratory tract infection (pneumonia) — suggested by cough, fever, and exhaustion (GOLD, 2023).
  • Asthma exacerbation with severe airflow obstruction.
  • Airway obstruction or mucus plugging causing hypoventilation and CO2 retention.
  • Respiratory muscle fatigue or hypoventilation from metabolic weakness; less likely if primary lung pathology present (Harrison's, 2018).

Pathophysiologically, airflow limitation leads to alveolar hypoventilation, impaired CO2 elimination, and consequent respiratory acidosis; chronic retention prompts renal bicarbonate retention over time, so an acute event on chronic disease explains Tony’s ABG values (Kraut & Madias, 2010; Marino, 2014).

Signs and symptoms attributable to the acid-base disturbance

Tony exhibits multiple clinical findings consistent with respiratory acidosis and acute respiratory compromise:

  • Shortness of breath and labored respirations (RR 36/min) — direct signs of ventilatory failure and increased work of breathing (Lewis et al., 2017).
  • Hypoxemia (SpO2 84% on room air; PaO2 70 mm Hg) — impaired oxygenation often accompanies CO2 retention in COPD exacerbations (GOLD, 2023).
  • Tachycardia (HR 115 bpm) and hypotension (BP 90/40 mm Hg) — may reflect systemic stress, sepsis, or cardiovascular compromise secondary to hypoxemia (Rhodes et al., 2017).
  • Malaise, fever, and exhaustion — suggest an infectious trigger (pneumonia) that can precipitate an exacerbation (GOLD, 2023).
  • Neurologic signs (not yet documented) such as confusion or somnolence could develop with rising PaCO2 and worsening acidosis and should be monitored (Harrison's, 2018).

Multidimensional nursing and interdisciplinary care strategies

Immediate and priority interventions:

  • Oxygen titration to recommended COPD targets (typically 88–92%) to avoid worsened hypercapnia from over-oxygenation — reassess after any oxygen change and monitor SpO2 and ABG (GOLD, 2023; AARC, 2015).
  • Escalation from simple nasal cannula to more effective support if hypoxemia or hypercapnia persists: consider high-flow nasal cannula or noninvasive positive-pressure ventilation (NIV/BiPAP) for acute hypercapnic respiratory failure, unless contraindicated (BTS/ICS guideline, 2016; Marino, 2014).
  • Administer bronchodilators (short-acting beta-agonists ± anticholinergics) and systemic corticosteroids for suspected COPD/asthma exacerbation per guideline recommendations (GOLD, 2023).
  • Empiric antibiotics if bacterial infection suspected (fever, cough, productive sputum or radiographic consolidation), guided by local antibiogram and sepsis risk (GOLD, 2023; Rhodes et al., 2017).
  • Monitor serial arterial blood gases and continuous pulse oximetry; frequent assessment of respiratory rate, work of breathing, mental status, and hemodynamics to detect deterioration that could mandate intubation (Marino, 2014; UpToDate, 2024).

Supportive medical, nursing, and system-level actions

Nursing and interdisciplinary care should include:

  • Airway support: positioning (upright), chest physiotherapy and suctioning as indicated to enhance secretion clearance (Lewis et al., 2017).
  • Hemodynamic support for hypotension: cautious fluid resuscitation if sepsis suspected, and escalation to vasopressors if persistent hypotension per sepsis guidelines (Rhodes et al., 2017).
  • Glycemic control and diabetic management given Tony’s diabetes to reduce infection risk and support recovery (Harrison's, 2018).
  • Medication reconciliation, inhaler education, smoking cessation counseling, culturally sensitive patient education in Tony’s preferred language, and discharge planning to outpatient pulmonary follow-up (NICE, 2018).
  • Involvement of respiratory therapy for NIV initiation, titration, and weaning; pharmacy for antibiotic selection and dosing; and social work for access-to-care and work-related concerns (interdisciplinary care) (AARC, 2015; Lewis et al., 2017).
  • Escalation of care planning: prepare for rapid sequence intubation and invasive mechanical ventilation if NIV fails or if mental status declines, hypercapnia worsens, or oxygenation cannot be maintained (Marino, 2014).

Monitoring, documentation, and patient-centered considerations

Document responses to therapies, ABG trends, and vital sign changes. Educate Tony and family on the diagnosis, expected interventions, warning signs for return to ED, and outpatient supports (GOLD, 2023). Be mindful of cultural, language, and socioeconomic barriers that influence adherence and access to follow-up care.

Conclusion

Tony’s ABG and clinical presentation are consistent with acute-on-chronic respiratory acidosis due to an acute COPD/asthma exacerbation, likely triggered by infection. Immediate actions prioritize controlled oxygenation, consideration of NIV, bronchodilator and steroid therapy, antibiotic use when indicated, close monitoring with serial ABGs, and multidisciplinary interventions to address ventilation, oxygenation, hemodynamics, infection, and social needs. Nursing care is central to early recognition, escalation, and coordination of evidence-based interventions for optimal outcomes (GOLD, 2023; Kraut & Madias, 2010; Marino, 2014).

References

  • Global Initiative for Chronic Obstructive Lung Disease. (2023). Global strategy for the diagnosis, management, and prevention of COPD. https://goldcopd.org
  • Rhodes, A., Evans, L. E., Alhazzani, W., Levy, M. M., Antonelli, M., Ferrer, R., et al. (2017). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2016. Intensive Care Medicine, 43(3), 304–377.
  • Kraut, J. A., & Madias, N. E. (2010). Metabolic acidosis: pathophysiology, diagnosis, and management. Nature Reviews Nephrology, 6(5), 274–285.
  • Marino, P. L. (2014). The ICU Book (4th ed.). Lippincott Williams & Wilkins.
  • Harrison’s Principles of Internal Medicine (Kasper, D. L., et al., Eds.). (2018). McGraw-Hill Education.
  • Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). Elsevier.
  • British Thoracic Society and Intensive Care Society. (2016). Guideline: Non-invasive ventilation in acute respiratory failure. https://www.brit-thoracic.org.uk
  • American Association for Respiratory Care. (2015). Clinical practice guideline: Oxygen therapy for adults in the acute care facility. Respiratory Care.
  • National Institute for Health and Care Excellence. (2018). Chronic obstructive pulmonary disease in over 16s: diagnosis and management (NG115). https://www.nice.org.uk/guidance/ng115
  • UpToDate. (2024). Approach to adult with abnormal arterial blood gas. Wolters Kluwer. https://www.uptodate.com

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