Question

A nurse is caring for a client who is postoperative following administration of general anesthesia.

Vital Signs:

0830:
Temperature 36.9° C (98.5° F)
Heart rate 134/min
Respiratory rate 28/min
Blood pressure 92/52 mm Hg
Pulse oximetry 89% on room air
Nurses' Notes:

0830:
Client is postoperative following an inguinal hernia repair.
Apical pulse 134/min and irregular
Client reports dyspnea.
Diagnostic Results:

0835:
Arterial blood gases (ABGs)
pH 7.30 (7.35 to 7.45)
PCO2 64 mm Hg (35 to 45 mm Hg)
HCO3- 26 mEq/L (21 to 28 mEq/L)
PO2 80 mm Hg (80 to 100 mm Hg)
The patient is experiencing malignant hyperthermia upon recognizing client cues of tachycardia, tachypnea, hypotension, & irregular heart rhythm.

What are the nursing interventions?

Option 1:
Administer dantrolene as prescribed and prepare for cooling measures.

Option 2:
Increase the oxygen flow rate and monitor vital signs closely.

Option 3:
Administer a beta-blocker to stabilize the heart rate.

Option 4:
Initiate fluid resuscitation to address hypotension.

Answer 1

The correct nursing intervention for a patient exhibiting signs of malignant hyperthermia after anesthesia is to administer dantrolene and prepare cooling measures to combat the effects of the condition.

Step-by-step explanation:

The patient described is showing signs of malignant hyperthermia (MH), a life-threatening condition often triggered by exposure to certain anesthesia drugs. The symptoms include a rapid increase in body temperature and severe muscle contractions. Immediate intervention is critical. The appropriate nursing intervention in this scenario is Option 1: Administer dantrolene as prescribed and prepare for cooling measures. Dantrolene acts by reducing the increased metabolic activity in muscle cells, which is crucial in treating MH. Cooling measures, such as applying ice packs or cold IV fluids, help to reduce body temperature. While Options 2, 3, and 4 may be supportive measures, they do not directly address the underlying mechanism of MH as Option 1 does.