Mary Jean, a first year nursing student, was rushed to the clinic department due to hyperventilation. Which nursing intervention is the most appropriate for the client who is subsequently developing respiratory alkalosis?
A. Administering sodium chloride I.V.
B. Encouraging slow, deep breaths.
C. Preparing to administer sodium bicarbonate.
D. Administer low-flow oxygen therapy.
Correct Answer: B. Encouraging slow, deep breaths.
The client who is hyperventilating and subsequently develops respiratory alkalosis is losing too much carbon dioxide. Measures that result in the retention of carbon dioxide are needed. Encourage slow, deep breathing to retain carbon dioxide and reverse respiratory alkalosis. Encourage the patient to breathe slowly and deeply. Speak in a low, calm tone of voice. Provide a safe environment. May help reassure and calm the agitated patient, thereby aiding the reduction of respiratory rate. Assists the patient to regain control.
Option A: Administering sodium chloride is appropriate for metabolic alkalosis. Demonstrate appropriate breathing patterns, if appropriate, and assist with respiratory aids or a rebreathing mask/bag. Decreasing the rate of respiration can halt the “blowing off” of CO2, elevating Pco2 level and normalizing pH.
Option C: Administering sodium bicarbonate is appropriate for treating metabolic acidosis. Provide comfort measures; encourage the use of meditation and visualization. Use a tepid sponge bath/cool cloths. Promotes relaxation and reduces stress. Control and reduction of fever reduce the potential for seizures and helps reduce respiration rate.
Option D: Administering low-flow oxygen therapy is appropriate for chronic respiratory acidosis. Administer CO2, or use a rebreathing mask as indicated. Reduce respiratory rate and tidal volume, or add additional dead space (tubing) to a mechanical ventilator.
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