Metabolic Acidosis
The
Metabolic Acidosis
-Metabolic Acidosis in Simple Terms: a
metabolic problem due to the buildup of acid in
the body fluids which affects the bicarbonate
(HCO3 levels) either from:
-increased acid production (ex: DKA where
ketones (acids) increase in the body which
decreases bicarbonate)
-decreased acid excretion (ex: renal failure
where there is high amount of waste left in the
body which causes the acids to increase and
bicarb can’t control imbalance)
loss of too much bicarb (diarrhea)
-When this acidic phenomena is taking place in
the body other systems will try to compensate
to increase the bicarb back to normal. One
system that tries to compensate is the
respiratory system.
-In order to compensate, the respiratory system
will cause the body to hyperventilate by
increasing breathing through Kussmaul’s
respirations. Kussmaul respirations are deep,
rapid breathes. The body hopes this will help
expel CO2 (an acid) which will “hopefully”
increase the pH back to normal.
Lab values expected in Metabolic Acidosis:
-HCO3: decreased <22
-Blood pH: decreased <7.35
-CO2: <35 or normal (may be normal but if it is
decreased this is the body’s way of trying to
compensate). **Remember the respiratory
system is causing hyperventilation.
respiratory system tries to increase the pH from
its acidotic states through tachypnea with
Kussmaul’s breathing. The goal is to “blow off”
the CO2 which is acidic to help alleviate the
already acidotic conditions in the body.
-Memorize these normal values for ABGs:
-pH 7.35-7.45
-PaCO2 35-45
- HCO3 22-26
Causes of Metabolic Acidosis
High anion gap & Normal anion gap problems:
-What is an anion gap? Simplified this is where
the doctor look at various lab results from a
patient’s lab work (such as electrolytes
(chloride, bicarbonate, sodium) and calculates
them to see the difference between the anions
and cations.
-If there is a gap (>14 mEq/L from normal
(normal is: 10-14 mEq/L) there is high anion gap
metabolic acidosis going on. In other words the
anion gap tells us what type of acidosis we have
going on which is important so it can be treated
appropriately.
-High Anion Acidosis is conditions that cause the
body to produce too much acid or NOT enough
bicarb (DKA, Aspirin toxicity, renal failure, high-
fat diet, low carb diet, malnutrition)
-Normal Anion acidosis is loss of the
bicarbonate from the body. Examples: diarrhea
via GI fluids, ostomies or fistula drainage
(ileostomies or pancreatic fistula)…which are
rich in alkalotic fluids, however when lost it
causes acidosis, or drugs ingestion: Diamox
(diuretic)…. carbonic anhydrase inhibitor which
reduces reabsorption of bicarb.
Combine all of this to form the Mnemonic
“Acidotic”
-Aspirin toxicity: (high anion gap) which
increases the acid in the body and this also
causes respiratory alkalosis (hyperventilation)
-Carbohydrates not metabolized (high anion
gap): when there isn’t enough oxygen to break
down carbs the pyruvic acids (that supplies the
cells with energy) starts to turn into lactic acid
and when you get acid building up you get
acidosis
-Insufficiency of kidneys (high anion gap):
kidneys are failing to filter out metabolic waste
products, acids increase, and bicarb cannot
keep up so it depletes
-Diarrhea (normal anion gap): profuse diarrhea
leads to loss bicarbonate, DKA (diabetic
ketoacidosis) body is breaking down ketones
and is not metabolizing glucose correctly which
leads to high blood glucose levels and
breakdown of acids in the blood
-Ostomy drainage (excessive) ileostomies,
Ureteroenterostomies (normal anion
gap)…ostomies are an opening of an organ to
allow drainage…depending on where the
ostomy is these fluids are rich in bicarb and if
loss directly at this spot (instead of travelling
through the body to form into stool (which
doesn’t lose much bicarb)…it can deplete the
bicarb fast.
fisTula (pancreatic fistula) (normal anion gap)
fistula : a fistula is a passage between an hollow
organ and body surface or between two
organs….same concept with the ostomy…losing
fluids where you shouldn’t be and they are not
being absorbed by the body…you are wasting
the bicarb
-Intake of high-fat diet: eating too much fat
leads to the building-up of waste product which
in turn leads to buildup of ketones and acids
-Carbonic anhydrase inhibitors (Diamox):
diuretic which reduces the reabsorption of
bicarb
Signs & Symptoms of Metabolic Acidosis
****Kussmaul’s respiration (body’s way of
trying to compensate by exhaling the excessive
CO2…in hopes of increasing bicarb and blood
pH)
-Confused, weak, low blood pressure, cardiac
changes (if hyperkalemic …can happen EXCEPT
with diarrhea or with Diamox usage which
causes hypokalemia), n & v
Nursing Interventions for Metabolic Acidosis
Vary depending on the causes of acidosis:
-Watch respiratory system and ABGs closely…if
too bad may need intubation
-Assess other electrolyte levels (esp. potassium
because during active acidosis it will be
high…however when it resolves there is an
extracellular to intracellular shift of K+ back into
the cell which will causes hypokalemia)
-Watch neuro status, safety, and place in
seizure precaution
-Dialysis may be needed if they patient is
experiencing acidosis (high anion gap issue ex:
renal failure)
-Diabetic ketoacidosis: administer prescribed
insulin to help glucose go back into cell which
will help the body start regulating how it
metabolizes glucose…hence not more ketones
(acids)
Metabolic Alkalosis
-Metabolic alkalosis in simple terms: a
metabolic problem caused by the excessive loss
of acids (H+) or increased amount of bicarb
(HCO3) produced in the body that leads to an
alkalotic state in the body. Disease processes
and drugs can cause metabolic alkalosis.
-When metabolic alkalosis happens in the body
other systems try to compensate by hopefully
fixing the blood’s pH and bicarb level. One
system that does this is the respiratory system
by stimulating the respiratory system to
hypoventilate (decrease respirations) which will
retain PCO2 (carbon dioxide) so it will decrease
the pH back to normal, hence you will start to
see bradypnea in your patient.
If a patient is experiencing metabolic alkalosis
they will present with the following labs:
-HCO3: increases >26
-Blood pH: increases >7.45
-CO2: >45 or normal (may be normal but if
increased this is the body’s way of trying to
compensate. Remember the respiratory system
tries to decrease the pH from its alkalotic state
by causing hypoventilation ( bradypnea). The
respiratory system hopes that if the CO2
increase enough it will cause the pH to decrease
and the kidneys will start to excrete the bicarb
which will hopefully decrease the overall HCO3.
Remember what normal values are:
pH 7.35-7.45
PaCO2 35-45
HCO3 22-26
Causes of Metabolic Alkalosis
Causes: ALKALI
-**Aldosterone production excessive
(hyperaldosteronism) activates renin-
angiotensin-aldosterone system : the adrenal
cortex is releasing too much aldosterone which
causes the renal tubule in the kidneys to keep
sodium which wastes hydrogen ions (ex:
potassium) and this causes you to keep bicarb
(HCO3)
-Loop **diuretics (Lasix) or thiazide therapy:
causes the kidneys to waste hydrogen ions and
chloride through the urine (ALSO LOSING K+)
which in turn increases the bicarb
-alKali ingestion of food (baking soda, milk,
antacids) increases bicarb level in the blood
-Anticoagulant “citrate” (used as a storage
agent in blood and during continuous forms of
renal replacement therapy) Caused from a
massive transfusion of whole blood (patient
needs several bags of blood) and the body
metabolizes the citrate used in the blood as
bicarb which increases the HCO3 level in the
body. Also, patients who undergo continuous
forms of renal replacement therapy (CRRT) (an
alternative therapy for patients who can’t
undergo hemodialysis) are affected by the
citrate used in the therapy.
-Loss of fluids (**vomiting and **GI suctioning)
hence this fluids are rich in K+ and when you
lose them you are losing hydrogen ions and this
causes the body to increase the bicarb level,
Low potassium levels cause reabsorption of
HCO3-
-Increased sodium bicarb administration (trying
to correct metabolic acidosis)
 -The diaphragm also plays a role in allowing
lungs into inflate and deflate.
Signs and Symptoms of Metabolic alkalosis

-Bradypnea (hypoventilation) <12 bpm

-Note: if there is any problem with the patient
-Many symptoms due to low potassium –
breathing rate (too fast), alveolar sacs
(dysrhythmia), tetany, tremors, muscle
(damaged), hyperventilation, or a brain injury
weakness/cramping, tired, irritable, vomiting,
that affects the respiratory center a patient is at
Depression ST, flat or inverted T wave and
risk for respiratory alkalosis
prominent u-wave)

Nursing Interventions for Metabolic Alkalosis

*Main cause of respiratory alkalosis is
-Based on the cause: vomiting (give antiemetic
tachypnea (fast respiratory rate >20 bpm
ex: Zofran, Phenergan), stop diuretics
which causes CO2 to decrease in the lungs)
-Doctor may order Diamox (Carbonic anhydrase
-When this happens the following lab values are
inhibitors): a diuretic which reduces the
affected:
reabsorption of bicarb

-Watch ABGs and signs of respiratory distress

-Blood pH increases (>7.45)
-Monitor potassium and chloride levels (wasted
in this condition) -Carbon dioxide levels increase (<35)

-**To compensate for this the Kidneys start to

excrete bicarbonate (HCO3) to hopefully
Respiratory Alkalosis
decrease the blood’s pH back to normal…..so
-What’s involved:…let’s look at normal HCO3 becomes <22.
breathing:
-REMEMBER (memorize) these lab values:
1. Oxygen enters through the mouth or nose

2. down through the Pharynx

pH 7.35-7.45
3. into the Larynx (the throat)
PaCO2 35-45
4. then into the Trachea
HCO3 22-26
5. and the Bronchus (right and left) which
branches into the bronchioles and ends in
alveoli sac Causes of Respiratory Alkalosis

-The alveolar sacs are where gas exchange takes
place (oxygen and carbon dioxide diffuse across
the membrane). The oxygen enters into your
blood stream and CARBON DIOXIDE CO2 is
exhaled through your nose or mouth.
-Remember: TACHYPNEA (fast breathing leads
to “hyperventilation” which leads to respiratory
alkalosis)
-Temperature increase (fever) due to increased
metabolic needs of the body which causes the --
-respiratory center (medulla and pons) to try to
compensate by making the respiratory rate
increased…hence exhaling too much carbon
dioxide (CO2)
-Aspirin toxicity: too much aspirin in the body
leads to hyperventilation due to the stimulation
of the respiratory center and fever
-Controlled ventilation (excessive
usage)…mechanical
ventilation****hyperventilates the patient with
too much oxygen and depletes carbon dioxide
-Hyperventilation (excessive respirations)
expelling too much carbon dioxide
-hYsteria (anxiety) leads to rapid breathing and
expelling of carbon dioxide
-Pain…rapid breathing (blowing off too much
carbon dioxide), Pregnancy (especially in 3rd
trimester due to changes of the respiratory
tract), Pneumonia
Neurological injuries from a head injury or
stroke (affects the respiration system of the
brain which is located in the medulla and pons)
-Embolism or Edema in the lungs
-Asthma due to hyperventilation (however,
asthma can cause respiratory acidosis as well
due to bronchospasms which is causing the
alveoli to not properly deflate)
Signs and Symptoms of Respiratory Alkalosis
-***Classic Assessment Sign is fast respiratory
rate (normal for adult is 12-20) TACHYPNEA
(>20 bpm)
-Neuro changes: Tired, lethargy, fast heart rate
-**Tetany, dysrhythmias, muscle cramps,
positive Chvostek’s sign due to hypocalcemia
and hypokalemia
Nursing Interventions for Respiratory Alkalosis
-Teach patient breathing techniques to slow
down breathing, holding breath…”rebreathing
into a paper bag or re-breather mask
-Watch potassium levels
(hypokalemia..remember hyperkalemia in
respiratory acidosis & hypocalcemia) and for
signs and symptoms of low calcium and
potassium levels.
-**Closely watch patients on mechanical
ventilation to ensure breaths are not
hyperventilating the patient
Respiratory Acidosis
-ABG-arterial-blood-gas-quizWhat’s
involved:…let’s look at normal breathing:
1. Oxygen enters through the mouth or nose
2. down through the Pharynx
3. into the Larynx (the throat)
4. then into the Trachea
5. and the Bronchus (right and left) which
branches into the bronchioles and ends in
alveoli sac
-*The alveolar sacs are where gas exchange
takes place (oxygen and carbon dioxide diffuse
across the membrane). The oxygen enters into
your blood stream and CARBON DIOXIDE CO2 is
exhaled through your nose or mouth.
-The diaphragm also plays a role in allowing
lungs into inflate and deflate.
-Note: if there is any problem with the patient
breathing rate (too slow), alveolar sacs
(damaged), or diaphragm (weak) the patient
can experience respiratory acidosis.
*Main cause of respiratory acidosis is
bradypnea (slow respiratory rate <12 bpm
which causes CO2 to build-up in the lungs)
-When this happens the following lab values are
affected:
-Blood pH decreases (<7.35)
-Carbon dioxide levels increase (>45)
-**To compensate for this the Kidneys start to
conserve bicarbonate (HCO3) to hopefully
increase the blood’s pH back to normal…..so
HCO3 becomes >26.
REMEMBER (memorize) these lab values:
pH 7.35-7.45
PaCO2 35-45
HCO3 22-26
Causes of Respiratory Acidosis
-Remember “DEPRESS” Breathing (anything that
causes you to breathe slowly, blocks the airway,
or causes the diaphragm not to work properly
will cause respiratory acidosis)
Drugs (opioids (fentanyl, morphine), sedation
(versed), ….causes respiratory depression
“hypoventilation….retain carbon
dioxide….increase PaCO2 and decreased pH” ) &
Diseases of the neuromuscular
system…Myasthenia gravis, Guillain–Barré
syndrome (weakness of voluntary muscles
-affects the diaphragm…. can’t expelled the
carbon dioxide)
-Edema (pulmonary) extra fluid in the lung
causes impaired gas exchange
-Pneumonia…excessive mucous production
affect gas exchange…the alveoli are majorly
affected because they are filled with pus and
fluid
-Respiratory center of brain damaged (brain
injury, stroke)
-Emboli (blocks the pulmonary artery or branch
of the lungs causes carbon dioxide to increase)
-Spasms of bronchial tubes (asthma)
bronchioles constrict and you have decreased
gas exchange
-Sac elasticity of alveolar sac are damaged and
this restricts air flow in and out of the lungs and
this increases carbon dioxide (Emphysema &
COPD)
Signs and Symptoms of Respiratory Acidosis
-Major neuro changes: Confused, very drowsy,
and reports a headache
-respiration rate less than 12
-low blood pressure
Nursing Interventions for Respiratory Acidosis
-Administer oxygen
-encourage coughing and deep breathing
-suction (pneumonia)
-may need respiratory treatment (asthma)
-hold respiratory depression drugs (know the
category of drugs used opiods, sedatives etc)
-****Watch potassium levels that are
>5.1…remember in hyperkalemia video we
talked about how respiratory acidosis caused
increase potassium ….can cause dysrhythmias)

-administer antibiotics for infection

-may need endotracheal intubation if CO2 rise

above 50 mmhg or respiratory distress is
present