A patient presenting with ABG values of pH 6.95, PaCO₂ 60 mmHg, and HCO₃⁻ 15 mEq/L is in a state of profound, life-threatening acidemia from a mixed respiratory and metabolic acidosis. Immediate nursing intervention is required to prevent cardiovascular collapse.
Immediate Actions
- Assess airway, breathing, and circulation (ABCs) immediately.
- Notify the rapid response team and primary provider.
- Prepare for emergency intubation and mechanical ventilation to correct respiratory acidosis.
- Ensure patent IV access for fluid resuscitation and potential administration of sodium bicarbonate if ordered.
Ongoing Monitoring
- Continuously monitor cardiac rhythm for dysrhythmias caused by severe acidosis (e.g., ventricular tachycardia).
- Monitor blood pressure closely; anticipate hypotension due to myocardial depression and vasodilation.
- Track urine output as an indicator of end-organ perfusion.
- Obtain serial ABGs and serum lactate levels to evaluate response to interventions.