About
An acid-base disturbance characterized by low arterial pH and high arterial CO2.
Assess
Hypoventilation; shallow, ineffective respirations; weak, thready pulses, decreased blood pressure; lethargy, confusion, coma, muscle weakness ranging to paralysis; pale, dry skin.
Complications
Respiratory depression, coma, death
Mechanical ventilation
Diagnosis
- Acute confusion related to acid base disturbance and electrolyte imbalances
- Impaired physical mobility related to muscle weakness
- Impaired breathing pattern related to shallow, rapid respirations and muscle weakness
Goals
- The client will maintain a clear airway.
- The client will remain free from injury.
- The client will have a return of ABG's to normal or compensated levels.
Interventions
- Assess lung sounds frequently.
- Encourage coughing and deep breathing and position changes to facilitate movement of respiratory secretions.
- Administer oxygen, as ordered.
- Administer other agents, as ordered, to facilitate a clear airway.
- Maintain a patent airway.
- Institute safety precautions to prevent injury.
- Monitor for signs/ symptoms of complications.
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