ACID-BASE Balance

NUR 108
2014

Acidosis and Alkalosis

General Information
Electrolyte & acid-base balance both are
influenced the H+ ion
Body fluids must maintain a normal acidbase balance to sustain life.
The acidity or alkalinity of a solution is
determined by its concentration of
hydrogen ions and hydroxyl ions.

Acidosis and Alkalosis

General Information
Body fluids must maintain a normal acidbase balance to sustain life.
The acidity or alkalinity of a solution is
determined by its concentration of
hydrogen ions and hydroxyl ions.

Acidosis and
Alkalosis
ACIDcontaining
An acid is a substance
hydrogen ions that can be liberated or
released.

ALKALI (BASE)

An alkali or base is a substance that can

accept or trap a hydrogen ion

Acidosis and Alkalosis

ACIDOSIS

A condition characterized by a excess of

hydrogen ions in the ECF in which the pH
falls below 7.35
An acid releases H ions when dissolved
in water

Acidosis and Alkalosis

ALKALOSIS

A condition characterized by a lack of

hydrogen ions in the ECF in which the
pH exceeds >7.45
A base is a substance that binds to H
ions when dissolved in water

Acid - Base
pH

pH is a unit of measurement used to

describe acid-base balance
Expression of hydrogen ion concentration
and the acidity of a substance
Neutral = 7.0
Normal blood plasma pH is slightly
alkaline = 7.35 -7.45

Acidosis and Alkalosis

BUFFER

A substance that prevents body fluids

from becoming overly acidic or alkaline
Prevents major changes in the ECF by
releasing or accepting H ions
Major chemical buffers found in blood:

Carbonic acid-bicarbonates
Phosphate buffer system
Protein buffer system

Acidosis and Alkalosis

BUFFER

Chemical buffers are present in ICF &

ECF
Found in all body tissues
Act within seconds to maintain acid-base
Normally the body maintains pH by
maintaining a ration of bicarbonate
(HCO3)

CHEMICAL REGULATION
CARBONIC ACID-SODIUM
BICARBONATE BUFFER SYSTEM

First and immediate responder

Occurs unconsciously - an adaptive
system
Has a brief effect - act within seconds
Ratio of carbonic acid to bicarbonate is
1:20

CHEMICAL REGULATORS
PLASMA PROTEIN BUFFER SYSTEM

Proteins can bind with or release H+ ions

Most plentiful and versatile system
A major intracellular buffer
Cannot correct long-term imbalances

CHEMICAL REGULATORS
PHOSPHATE BUFFER SYSTEM

Phosphate salts formed in the kidneys by

exchanging a Na ion for a H+ ion in the
formation of the acid sodium phosphate
which is then excreted
It buffers both ICF and ECF to maintain
normal pH
Also the kidneys add a H+ ion to ammonia
and convert it to ammonium which is
excreted

Biological Regulation
CELLULAR LEVEL

Cellular absorption or release of H+ ions

HEMOGLOBIN-OXYHEMOGLOBIN SYSTEM

Cl1 leaves the cell and HCO3 enters

called the chloride shift

Physiological Regulation
LUNGS

Adapt rapidly
Returns pH to normal if possible before
the action of the biological buffers

KIDNEYS

Takes a few hours to several days to

correct imbalances alone

Factors Influencing Acid-Base

Balance
AGE

Very young and elderly are most

susceptible because of fluid balance and
metabolic activities in these age groups
Aging process changes lung function and
can lead to imbalances

Factors Influencing Acid-Base Balance

LIFE-STYLE

Fad dieting can lead to acidosis

Anxiety can lead to respiratory alkalosis
Chronic alcoholism can lead to acidosis

Factors Influencing Acid-Base Balance

DRUGS

Diuretics
Steroids
Depressants
Stimulants

Factors Influencing Acid-Base Balance

LEVEL OF HEALTH

Clients with pulmonary disease, diabetes

mellitus, or anemia are at risk for acidosis
or alkalosis
Clients taking steroids or diuretics are at
risk
During illness, metabolic activities are
altered and imbalances can occur rapidly

Regulation Acid-Base
pH Balance

Copyright 2012 by Pearson

Education, Inc.

Human
Blood
7.4

Buffers
Body fluids are maintained between pH
of 7.35 and 7.45 by:
Chemical Buffers
Respiratory system
Renal system:
Prevent excessive
changes in pH
Major buffer in ECF is
HCO3 and H2CO3
Other buffers include:

Plasma proteins
Copyright
by Pearson Education, Inc.
2012
Hemoglobin

Carbonic acid-bicarbonate
buffers

Lungs

Regulate acid-base balance by eliminating

or retaining carbon dioxide
Does this by altering rate/depth of
respirations
Faster rate/more depth = get rid of more
CO2 and pH rises
Slower rate/less depth = retain CO2 and
pH lowers

Kidneys

Regulate by selectively excreting or

conserving bicarbonate and hydrogen ions
Slower to respond to change

Factors Affecting Body Fluid

and Acid-Base Balance

Age
Gender
Body size
Environmenta
l temperature
Lifestyle

Chronic diseases
Acute conditions
Medications
Treatments
Extremes of age
Inability to access food
and fluids

Acid-Base Imbalances

Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis

Respiratory Acidosis
ETIOLOGICAL FACTORS

Acute respiratory acidosis

Pulmonary edema, emboli
Airway obstruction; foreign body
Atelectasis
Pneumothorax, hemothorax
Overdose of sedatives or anesthetic
Respiratory depression inadequate
ventilation

Respiratory Acidosis
ETIOLOGICAL FACTORS

Position on OR table that interferes with

respirations
Laryngospasm
Inadequate mechanical ventilation or
chest expansion
Cardiac arrest
Severe pneumonia
Flail chest multiple rib Frx

Respiratory Acidosis

Chronic respiratory acidosis

Emphysema
Cystic fibrosis
Advanced multiple sclerosis
Bronchiectasis
Bronchial asthma
Poliomyelitis
Myasthenia gravis
Guillian-Barre

Respiratory Acidosis

Factors favoring hypoventilation

Obesity or pregnancy
Tight abdominal binders or dressings
Post operative pain from high abdominal or
chest incisions
Abdominal distention from cirrhosis or bowel
obstruction or Ascites
Prolonged open-chest/open-heart operations
Spinal deformities

Respiratory Acidosis
DEFINING CHARACTERISTICS (S&S)

Acute respiratory acidosis

Feeling of fullness in the head
Mental cloudiness, disorientation
Dizziness - Weakness
Palpitations - Muscular twitching
Warm, flushed skin
Unconsciousness

Respiratory Acidosis

Plasma pH below < 7.35

Plasma HCO3 normal or only slightly
above 26
PCO2 greater than 45
Urine pH below < 6
Rapid, shallow or slow shallow resp.
Dyspnea - Asterixis

Respiratory Acidosis:
Hypercapnia

A state of excessive carbon dioxide in the

body.
pH < 7.35
PaCO2: > 45 mmHg (excess CO2 &
carbonic acid)
HCO3: normal, > 26 mEq/L with renal
compensation

Respiratory Acidosis

Chronic respiratory acidosis

Weakness
Dull headache
pH below 7.35
PCO2 greater than 45
HCO3 greater than 26

Respiratory Acidosis
TREATMENT

Directed at improving ventilation exact

measures vary with the cause
Bronchodilators to reduce bronchospasm
Antibiotics for infections
Position client in semi-Fowlers or
orthopneic position
Monitor VS

Respiratory Acidosis
TREATMENT

Adequate hydration 2-3 L/day

Supplemental O2 cautiously in
COPD clients
Provide emotional support

Respiratory Alkalosis
ETIOLOGICAL FACTORS

Extreme anxiety
Hypoxemia-asphyxiation, shock
High fever
Early salicylate intoxication stimulates
respiratory center
Gram-negative bacteremia
Pulmonary emboli

Respiratory Alkalosis
ETIOLOGICAL FACTORS

Thyrotoxicosis
Tetany, Carpopedal spasm
Central nervous systems lesions
involving the respiratory center
Excessive ventilation by mechanical
ventilators
Hyperventilation anxiety

Respiratory Alkalosis
ETIOLOGICAL FACTORS

Neurological conditions such as meningitis

or encephalitis
High environmental temperatures, high
altitudes
Lack of oxygen
Pregnancy high progesterone level
sensitizes the respiratory center to CO2
Tinnitus; Hyperactive DTR

Respiratory Alkalosis
DEFINING CHARACTERISTICS (S&S)

Rapid, deep respirations

Lightheadedness due to cerebral
vasoconstriction and decreased cerebral
blood flow
Inability to concentrate
Numbness and tingling of extremities
Vertigo, Syncope

Respiratory Alkalosis
DEFINING CHARACTERISTICS

A state of excessive loss of carbon dioxide

in the body.
pH > 7.45
PaCO2: < 35 mmHg (inadequate CO2 &
carbonic acid)
HCO3: > 26
HCO3: normal, < 22 mEq/L with renal
compensation
Urine pH above >7

Respiratory Alkalosis

Hyperventilation syndrome

Tinnitus, blurred vision

Palpitations, precordial tightness
Sweating, dry mouth
Tremulousness
Nausea and vomiting
Convulsions, loss of consciousness

Respiratory Alkalosis
TREATMENT

If anxiety is the cause, client needs to be

helped to normalize respirations move
to a quiet area, teaching slow, normal
breathing
Breathing into a paper bag is used only if
unable to calm the client and quieting
measures do not work

Respiratory Alkalosis
TREATMENT

Correct the underlying cause

Monitor VS
Provide emotional support
Administer sedatives, as ordered

Metabolic Acidosis
ETIOLOGICAL FACTORS

Diarrhea
Intestinal fistulas
Ureterosigmoidostomy
Hyperalimentation
Acidifying Drugs
Alcohol intoxication

Metabolic Acidosis
ETIOLOGICAL FACTORS

Renal tubular acidosis

Systemic infections
Ingestion of toxins
Diabetic acidosis
Starvational acidosis
Lactic acidosis
Renal failure

Metabolic Acidosis
ETIOLOGICAL FACTORS

High-fat diet
Decreased tissue perfusion from
trauma and/or burns
K+ conserving diuretics can cause
K+ excess can result in Na+ loss
and HCO3 loss

Metabolic Acidosis
DEFINING CHARACTERISTICS (S&S)

Headache, Confusion changes in LOC

Drowsiness
Kussmaul Respirations; Fruity breath
Nausea and/or vomiting
Peripheral vasodilatation causing
warm, flushed skin
Decreased cardiac output bradycardia
may develop

Metabolic Acidosis

A condition characterized by a deficiency

of bicarbonate ions in the body in relation
to the amt. of carbonic acid in the body
pH < 7.35
PaCO2: normal, < 35 mmHg with
respiratory compensation
HCO3: < 22 mEq/L (inadequate bicarbonate)

Metabolic Acidosis
TEATMENT

Monitor VS; Monitor ABGs

Administer IVs as ordered
Correct the underlying cause
Administer O2 caution in COPD clients
Administer insulin as ordered if cause is
diabetic acidosis
Monitor/assess/reassess for results of
care

Metabolic Alkalosis
ETILOGICAL FACTORS

Vomiting
Excessive NG suctioning
Cushings syndrome
K+ losing diuretic therapy can cause K+
loss can cause Na+ retention
Hypokalemia

Metabolic Alkalosis
ETIOLOGICAL FACTORS

Excessive base ingestion

Hyperaldosteronism
ACTH administration
NaHCO3 administration during CPR

Metabolic Alkalosis
DEFINING CHARACTERISTICS (S&S)

Decreased respiratory rate and depth

Dizziness, confusion, irritability
Paresthesia in fingers and toes
Carpopedal spasm
Nausea and/or vomiting
Agitation seizures; Muscle hypertonicity
Arrhythmias
Coma

Metabolic Alkalosis

A condition characterized by an excess of

bicarbonate ions in the body in relation to
the amt. of carbonic acid in the body
pH > 7.45
PaCO2: normal, > 45 mmHg with
respiratory compensation
HCO3: > 26 mEq/L (excess bicarbonate)
Urine pH above > 7
Often have hypokalemia

Metabolic Alkalosis
TREATMENT

Monitor clients at risk anticipate

problems before they become problems
Assess I & O
Monitor VS
Correct the underlying cause
Provide emotional support
Administer IVs as ordered

Acid-Base Compensation

Sometimes there is a change in both the

pCO2 and the HCO3
One of the levels indicates the primary
source or cause of the change
The other reflects the bodys effort to
compensate

Acid-Base Compensation

The bodys ability to compensate may be

so good that the pH falls within normal
range
Partial compensation occurs when the
pH remains outside of normal

Acid-Base Compensation

Compensation involves opposites

In primary metabolic acidosis, compensation
comes in the form of respiratory alkalosis
The pH:
7.27 = Acidosis

The pCO2:

27

Alkalosis

The HCO3:

10

Acidosis

The bicarb level corresponds to the pH making

the metabolic component the primary problem and
the decrease in pCO2 the attempt at
compensation

Acid-Base Compensation

The lungs are quick to react to problems

and the kidneys are much slower
Partial compensation can be seen in a pH
that is close to normal and in which the
compensatory has started to move from
normal
Full compensation is seen with a normal
pH

Acid-Base Compensation

Uncompensated

Partially compensated

pH is abnormal
either PaCO2 or HCO3 will be abnormal
pH, HCO3 and PaCO2 will be abnormal

Fully compensated

pH is normal
PaCO2 and HCO3 are both abnormal

Respiratory Acidosis

Uncompensated
pH
< 7.35
pCO2
> 45
HCO3
Normal

Compensated
Normal
> 45
> 26

Respiratory Alkalosis

Uncompensated
pH
> 7.45
pCO2
< 35
HCO3
Normal

Compensated
Normal
< 35
< 22

Metabolic Acidosis

pH
pCO2
HCO3

Uncompensated Compensated
< 7.35
Normal
Normal
< 35
< 22
< 22

Metabolic Alkalosis

Uncompensated
pH
> 7.45
pCO2
Normal
HCO3
> 26

Compensated
Normal
> 45
> 26

Nursing History

Current history & past medical history

Diabetes mellitus
Chronic lung diseases
Medications
Functional & socioeconomic factors
Developmental factors
Fluid and Nutritional intake
Fluid output

Nursing History:
Chronic Diseases

Respiratory: COPD, Asthma, Cystic

Fibrosis
Heart failure
Kidney diseases
Cushings syndrome, Addisons disease
Cancer
Malnutrition, Anorexia nervosa, Bulimia
Ileostomy

Nursing History:
Acute Conditions

Acute gastroenteritis
Bowel obstruction
Head injury or decreased LOC
Trauma: burns, crushing injuries
Surgery
Fever, draining wounds, fistulas

Nursing History: Treatments

Chemotherapy

IV therapy and TPN;

Oral or IV calcium supplements

Nasogastric suction

Enteral feedings; diet high in calcium

Mechanical ventilation

Meds: Diuretic, Anti-hypertensive therapy,

Corticosteroids, NSAID drugs
Seizure precautions

Physical Assessment

Focus on the skin

Oral cavity and mucous membranes
Eyes
Cardiovascular system
Respiratory system
Neurologic status
Muscular system

Physical Assessment: SKIN

Color, temp, moist, turgor, edema

Flushed, pale
Warm, very dry or cool, diaphorectic
Poor turgor: remains tented several
seconds.
Eyes: periorbital edema (puffy),
Edema: rings are tight, shoes fit tight or
eave impressions on feet
Fontanels in infants: sunken, soft vs.
Bulging, firm

Physical Assessment:
Oral Cavity

Make a visual inspection

Mucous membranes dry, dull in
appearance
Tongue dry with cracks

Physical Assessment:
Cardiovacular System

HR auscultate sounds, rhythm & rate

Cardiac monitor: tachycardia, bradycardia,
irregular dysrhythmias
Palpate peripheral pulses weal or
thready; bounding
B/P postural hypotension, Korotkoffs
sounds
Breathing rate & patterns, depth, crackels,
or moist rales

Physical Assessment:
Neurological System

Neuro: LOC, lethargy, stupor or coma

Response to stimuli
Disoriented, confused, difficulty
concentrating
Motor function: weakness, decreased
motor stregth
Deep tendon Reflex (DTP) hyperactive
or depressed

Physical Assessment:
Neurological System

Chvosteks sign

tap over facial nerve

Observe twitching of facial muscles
Calcium depletion

Trousseaus sign

Carpal spasm ocurring during inflation of BP

cuff
hypoclacemia

Physical Assessment:
LAB results

Serum electrolytes
CBC hematocrit, 40%-54%
Serum osmolality: Na, glucose, BUN

Urine pH 500-800 mOsm/kg.

Urine pH: Normal pH: 6.0

Urine specific gravity - Indicates urine
concentration

1.010 1.025

Physical Assessment:
ABGs

Evaluates acid-base & oxygenation.

pH: 7.35 - 7.45 - acidic or alkalosis
PaO2: 80-100 mmHg
PaCO2: 35-45 mmHg
HCO3-: 22-26 mEq/L
Base excess: -2 to +2 mEq/L
O2 saturation(SpO2): 95% to 98%

Respiratory Acidosis:
Hypercapnia

A state of excessive carbon dioxide in the

body.
pH < 7.35
PaCO2: > 45 mmHg (excess CO2 &
carbonic acid)
HCO3: normal, > 26 mEq/L with renal
compensation

Respiratory Alkalosis

A state of excessive loss of carbon dioxide

in the body.
pH > 7.45
PaCO2: < 35 mmHg (inadequate CO2 &
carbonic acid)
HCO3: normal, < 22 mEq/L with renal
compensation

Metabolic Acidosis

A condition characterized by a deficiency

of bicarbonate ions in the body in relation
to the amt. of carbonic acid in the body
pH < 7.35
PaCO2: normal, < 35 mmHg with
respiratory compensation
HCO3: < 22 mEq/L (inadequate bicarbonate)

Metabolic Alkalosis

A condition characterized by an excess of

bicarbonate ions in the body in relation to
the amt. of carbonic acid in the body
pH > 7.45
PaCO2: normal, > 45 mmHg with
respiratory compensation
HCO3: > 26 mEq/L (excess bicarbonate)

When Analyzing ABGs

Look @ each number separately

pH: acidosis vs. alkalosis
PaCO2:

If < 35 mmHg, more carbon dioxide is being

exhaled than normal alkalosis
If > 45 mmHg, Less carbon dioxide is being
exhaled than normal - acidosis

When Analyzing ABGs

HCO3 Bicarbonate:

If < 22 mEq/L, bicarbonate levels are

lower than normal, indicting acidosis.
If > < 26 mEq/L, bicarbonate levels
are higher than normal, indicating
alkalosis.

Determine he cause of the acid-base

imbalance (look at pH)
Determine if the origin of the imbalance is

respiratory or metabolic

When Analyzing ABGs

Look for evidence of compensation.

Look at the value that does not match
the pH.

If PaCO2 or HCO3 is within normal range, there is

no compensation.
If PaCO2 or HCO3 is above or below normal range,
the body is compensation..

NANDA Nursing Diagnosis

Deficient or Excess Fluid Volume

Risk for Imbalanced of Deficient Fluid
Volume
Impaired Gas Exchange

NANDA Nursing Diagnosis

Fluid and Acid-base Imbalances as

evidence of: (etiology)
Impaired Oral Mucous Membrane
Impaired Skin Integrity
Decreased Cardiac Output
Ineffective Tissue Perfusion
Activity Intolerance
Risk for Injury
Acute Confusion

Planning

Maintain or restore normal fluid balance

Maintain or restore normal electrolyte
balance intracellular & extracellular
compartments.
Maintain & restore pulmonary ventilation &
oxygenation.
Prevent associated risks: tissue
breakdown, decreased cardiac output,
confusion, other neurological signs.

Electrolyte Replacement

Modify fluids: push

Change diet to meet electrolyte demands
Oral electrolyte supplements
Parenteral Fluid administration

Nursing Intervention

Modify fluids: push

Change diet to meet electrolyte demands
Oral electrolyte supplements
Parenteral Fluid administration

Steps to Determining Imbalances

1.

Look at the Ph first

2.

Look at the PCO2 and HCO3

3.

IF < 7.35 acidic

If > 7.45 alkalosis
Look at PCO2 and HCO3 simultaneously
Determine which one is in the normal range;
The one in the abnormal range is the
imbalanced

Combine diagnosis of step 1 and 2 to

identify type of imbalance

Now we will play with some ABG sets

Interpret the following:

pH 7.30
PaCO2 - 49
HCO3 - 25

pH 7.30 low, acidosis

PaCO2 - 49 high, acidosis
HCO3 25 normal
Uncompensated
Respiratory Acidosis

pH 7.51
PaCO2 - 38
HCO3 - 32

pH 7.51 high, alkalosis

PaCO2 - 38 normal
HCO3 32 high, alkalosis
Uncompensated
Metabolic alkalosis

pH 7.21
PaCO2 - 43
HCO3 - 19

pH 7.21 low, acidosis

PaCO2 - 43 normal
HCO3 19 low, acidosis

Uncomp. Metabolic Acidosis

pH 7.52
PaCO2 - 29
HCO3 - 24

pH 7.52
high, alkalosis
PaCO2 - 29 low, alkalosis
HCO3 24 normal

Uncomp. Respiratory alkalosis

67 y/o client was hospitalized with

AMI. The ABGs are:
Ph

7.36
PaCO2 29
HCO3 20
SaO2 100%

67 y/o client was hospitalized with

AMI. The ABGs are:
Ph 7.36 normal, near acid
PaCO2 29 low, compensated
HCO3 20
low , metabolic
SaO2 100% well oxygenated

Fully Compensated Metabolic Acidosis

Since both the PaCO2 & HCO3 are low,
metabolic acidosis is occurring with a
respiratory alkalosis

Acidosis and Alkalosis

General Information
Body fluids must maintain a normal acidbase balance to sustain life.
The acidity or alkalinity of a solution is
determined by its concentration of
hydrogen ions and hydroxyl ions.

Acidosis and Alkalosis

General Information
Body fluids must maintain a normal acidbase balance to sustain life.
The acidity or alkalinity of a solution is
determined by its concentration of
hydrogen ions and hydroxyl ions.

43 y/o female was admitted to the hospital

c/o dyspnea for the past 3 days. The
ABGs are:
Ph 7.35
PaCO2

60
HCO3 31

43 y/o female was admitted to the hospital

c/o dyspnea for the past 3 days. The
ABGs are:
Ph 7.35
PaCO2

60
HCO3 31

Both PCO2 & HCO3 are elevated; HCO3 is

elevated more than expected in respiratory
acidosis. The patient has compensated for
several days, it is safe to say that she is in
compensatory respiratory acidosis.

43 y/o female was admitted to the

hospital c/o dyspnea for the past
3 days. The ABGs are:
Ph

7.35 normal
PaCO2 60 high,acidosis
HCO3 31
high , alkalosis
Compensated Respiratory acidosis

Practice ABGs Interpretation

Review these websites to help you learn

how to interpret ABGs.
http://www.youtube.com/watch?v=1yHD
tWK9zSo&NR=1
http://www.youtube.com/watch?v=_OpvyEI
lFj8
practice problems in tic-tac-toe
http://www.youtube.com/watch?v=_OpvyE
IlFj8&NR=1&feature=fvwp