LEARNING ACTIVITY #2 FOR RELATED LEARNING EXPERIENCE

Nursing Care Plan for a Person with Acute Respiratory Acidosis

Name: Serquina, Johniza Hope G. Date: September 27, 2020 Score: ___________________

Case Scenario:

Marlene Moreno, age 76, is eating lunch with her friends when she suddenly begins to choke and is
unable to breathe. After several minutes of trying, an attendant at the senior centre successfully
dislodges some meat caught in Ms Moreno’s throat using the Heimlich manoeuvre. Ms Moreno is taken
by ambulance to the emergency department for follow-up because she was apnoeic for 3 to 4 minutes,
her respirations are shallow and she is disoriented.

Assessment
Ms Moreno is placed in an observation room. Oxygen is started at 4 L/min per nasal cannula. David
Love, the nurse admitting Ms Moreno, makes the following assessments: T 37.6°C, P 102, R 36 and
shallow, BP 146/92. Skin is warm and dry. Alert but restless and not oriented to time or place; she
responds slowly to questions. Stat ABG s are drawn, a chest x-ray is done and D5 1/2 NS is started
intravenously at 50 mL/h.

The chest x-ray shows no abnormality. ABG results are pH 7.38 (normal: 7.35 to 7.45), PaCO2 48
mmHg (normal: 35 to 45 mmHg), PaO2 92 mmHg (normal: 80 to 100 mmHg) and
HCO3 – 24 mEq/L (normal: 22 to 26 mEq/L).

Diagnoses
1. Impaired gas exchange related to temporary airway obstruction.
2. Anxiety related to emergency hospital admission.
3. Risk of injury related to confusion.

Planning
1. Explain the need to monitor vital and the need for oxygen therapy to the person and significant
others.
2. Explain the purpose for follow-up treatments of ABG s and continuous monitoring.
3. Maintain a calm, quiet environment.
4. Provide reorientation and explain all activities.
5. Explain the importance of keeping the side rails in place and call bell within reach.

Expected outcomes
1. Regain normal gas exchange and ABG values.
2. Be oriented to time, place and person.
3. Regain baseline mental status.
4. Remain free of injury.

Implementation
1. Monitor ABG s as per doctor’s orders and collect ABG every 2 hours and report findings to the
doctor.
2. Review ABG collection site pre and post collection of bloods.
 3. Monitor vital signs and respiratory status (including oxygen saturation) every 15 minutes for
the first hour then every hour.
4. Assess color of skin, nail beds and oral mucous membranes every hour.
5. Provide mouth hygiene hourly while O2 being administered.
6. Assess mental status and orientation every hour.
7. Monitor anxiety level as evidenced by restlessness and agitation.

Evaluation
Ms Moreno remains in the emergency department for 6 hours. Her ABG s are still abnormal and David
Love now notes the presence of respiratory crackles and wheezes. She is less anxious and responds
appropriately when asked about her name, time and place. Because she has not regained normal gas
exchange, Ms Hurd is admitted to the hospital for continued observation and treatment.

Critical thinking in the nursing process

1. Describe the pathophysiological process that leads to acute respiratory acidosis in Ms
Moreno.
When there is an increase CO2, the hydrogen level in the body also increases thus becoming more
acidic. In Ms. Moreno’s situation, chemoreceptors detect high CO2 and triggers the body to increase
respiratory rate. When the respiratory center is depressed, it won’t function properly, and CO2 levels
will rise, resulting in respiratory acidosis. When Ms. Moreno begins to choke and was unable to
breathe, acute respiratory acidosis occurred due to a sudden failure of ventilation.
2. Describe the effect of acidosis on mental function.
If an increase in acid overwhelms the body's acid-base control systems, the blood will become acidic.
As blood pH drops (becomes more acidic), the parts of the brain that regulate breathing are stimulated
to produce faster and deeper breathing (respiratory compensation). Thus, mental status and brain
function are affected increasing the risk of injury leading to confusion, stupor and a decreasing level of
consciousness.
3. What teaching would you provide to Ms Moreno to prevent future episodes of choking?
Choking happens when something—food or another item—is caught in the back of the throat. If the
object (or food) blocks the top of the trachea a person may be unable to breathe just like what
happened to Ms. Moreno. To prevent that from happening again, these are some of the teachings I will
provide to her.
- Prevent yourself from choking by chewing your food completely.
- Avoiding talking or laughing while eating
- Always keep a water near you while eating.
REFLECTION ON THE NURSING PROCESS
1. Identify and outline what you have learned from this case study and how you will apply
it to your future nursing practice.
Respiratory acidosis is a state in which decreased ventilation (hypoventilation) increases the
concentration of carbon dioxide in the blood and decreases the blood's pH. In the case of Ms. Moreno,
she experienced a choke while she was eating which lead her to have an acute respiratory acidosis.
What I learned in this study is that in acute respiratory acidosis, the rapid rise in PaCO2 levels causes
manifestations of hypercapnia. Cerebral vasodilation causes manifestations such as headache, blurred
vision, irritability and mental cloudiness. If the condition continues, the level of consciousness
progressively decreases which is present to Ms. Moreno and rapid and dramatic changes in ABGs can
lead to unconsciousness and ventricular fibrillation, a potentially lethal cardiac arrhythmia. Also, the
skin of the person with acute respiratory acidosis may be warm and flushed and the pulse rate is
elevated. That is the reason why, while we are still a student nurse, it is very important to identify the
underlying cause of the acid-base imbalance to know the treatment that will be used like restoring
adequate ventilation and gas exchange.
2. As the Registered Nurse, what communication and education strategies can you use to
ensure Ms Moreno is able to prevent further episodes of choking?
As I read some articles in the internet, the role of the nurse to a patient who has history of choking is to
ensure that the patient remains free from injury and aspiration, be oriented to time, place and person
and regain baseline mental status. In connection to that, to treat a person who’s choking, the use of
“five-and-five” method must be observed.
 Hit the person’s back with the heel of your hand five times between the shoulder blades.
 Next, perform the Heimlich maneuver five times.
 Alternate between the two until the person is no longer choking.
Assessment on the other hand is vital as well. In order for the nurse to have a good nursing
intervention, she/he must assess the level of consciousness because the primary risk factor of
aspiration is decreased level of consciousness. Also, monitor respiratory rate, depth, and effort. Note
any signs of aspiration such as dyspnea, cough, cyanosis, wheezing, or fever. For the health education,
it is important to instruct the patient to chew the food properly, avoid talking or laughing while eating
and always keep a water near them while eating.
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