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Facts and Definitions 1. Acid-base homeostasis - necessary to maintain life. 2. Acid base balance must be within a definite range for cellular function to occur. 3. The acidity of a substance, determined by the hydrogen ion (H+) concentration; is expressed as pH.
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 pH - measures degree of acidity and alkalinity - indicator of H ion concentration - Normal ph 7.35-7.45

4. Acids a. Release hydrogen ions into solution b. Have pH < 7 5. Alkalines (bases) a. Accept hydrogen ions into solution b. Have pH > 7
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 Acid
- substance that can donate or release hydrogen ions ie Carbonic acid (H2CO3), Hydrochloric acid ** Carbon dioxide combines with water to form carbonic acid
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 Base - substance that can accept hydrogen ions ie Bicarbonate (HCO3)

Body fluids 1. Normally slightly alkaline 2. Normal range is narrow: 7.35 7.45 (pH of 7 is neutral) 3. Arterial blood pH < 7.35 is considered acid 4. Arterial blood pH > 7.45 is considered alkaline
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Acids and Bases in the body

1. Body functions constantly produce acids 2. Most acids and bases in the body are weak 3. Acids include a. Carbonic acid, which is eliminated as a gas, carbon dioxide b. Lactic, hydrochloric, phosphoric, sulfuric acids, which are metabolized or excreted as fluids 4. Bicarbonate is the major base
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Dynamics of Acid Base Balance

Acids and bases are constantly produced in the body They must be constantly regulated CO2 and HCO3 are crucial in the balance A HCO3:H2CO3 ratio of 20:1 should be maintained Respiratory and renal system are active in regulation

Body regulation of acid-base balance Constant response to changes in pH to maintain the pH in the normal range 3 systems in the body, with various response times, to maintain acid-base balance : 1. Buffers/ Chemical Buffers 2. Respiratory System 3. Renal ( metabolic) System
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A.Buffer System 1. Responds immediately, but has limited capacity to maintain 2. Buffers: substances that bind or release hydrogen ions a. When body fluid becomes acid, buffers bind with hydrogen ions to raise pH b. When body fluid becomes alkaline, buffers release hydrogen ions to lower pH

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Buffer systems a. Bicarbonate-carbonic acid buffer system - blood and interstitial fluid CO2 + H20 H2C03 H+ + HC03 weak acid weak base Process is reversible but the ratio of 20 (bicarbonate) to 1 (hydrogen) must be maintained b. Protein buffer system - intracellular and plasma; hemoglobin buffer c. Phosphates buffer system renal tubules

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B.
1. 2. 3. 4.

a. b.

Respiratory System - controls CO2 and Carbonic acid content of ECF Responds within minutes Includes respiratory center of brain stem and lungs Occurs automatically, not under voluntary control Adjusts the depth and frequency of respiration according to the pH of the blood; increases or decreases the amount of carbon dioxide in the blood; controls the amount of carbonic acid formed and adjusts the pH of the blood Hyperventilation: increased depth and frequency of respiration; blows off more CO2 in response to an acid pH Hypoventilation: decreased depth and frequency of respiration; retains more CO2 in response to an alkaline pH

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Respiratory System
H ions and CO2 (blood) Stimulates the Medulla Oblongata RR Hyperventilation (blows off CO2) H ions and CO2 (blood) H ions and CO2 (blood) Stimulates the Medulla Oblongata RR Hypoventilation (retains CO2) H ions and CO2 (blood)

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C.

Renal (Metabolic) System -regulates bicarbonate level in ECF

1.
2.

Responds within hours to days

Adjusts the amounts of hydrogen and bicarbonate (metabolic component) ions Kidneys excrete H+ ions, or generate and reabsorb bicarbonate ions, in response to an acid pH Kidneys retain H+ ions, or generate and excrete bicarbonate ions, in response to an alkaline pH

a.
b.

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How to obtain blood sample?

Allens test - evaluate patency of radial and ulnar artery Heparinized syringe and icefilled container Pressure dressing, no activity at the site and check 5 ps distal to the site of punctured artery Note if patient is under O2 therapy Label the sample and send immediately to the laboratory
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ABG Responsibilities
Arterial blood Radial or ulnar artery Allens test Prepare Heparinized (Syringe, specimen container) Note: 02 therapy Bring specimen to the LAB (ice)
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After injection Maintain extension position, no activity 8H Apply pressure 5-15 min Observe the site Distal, 5 ps (Pulselessness, Pain, Paresthesia, Poikilothermia, Pallor)

Radial artery 30-45 degrees Brachial artery 60 degrees Femoral artery 90 degrees

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Handling of Specimen
Expel all air bubbles immediately Do not agitate the syringe Discard frothy specimen 1:1000 U/ml HEPARIN Place sample in ice Cool sample to 5 C if it can not be analyzed quickly

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Determination of Acid-Base Balance: Analysis of Arterial Blood Gases

pH PaCO2 HCO3

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A.pH 1. Normal: 7.35 3.45 2. Acidic: <7.35 3. Alkaline: >7.45

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B. PaCO2 Partial Pressure of carbon dioxide; respiratory component 1. Normal: 35-45 mm Hg 2. Acidic: > 45 mm Hg (carbon dioxide forms carbonic acid) Hypercapnia: elevated levels of carbon dioxide in blood 3. Alkaline: < 35 mm Hg Hypocapnia: decreased levels of carbon dioxide in blood
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C. HCO3 Bicarbonate; renal or metabolic component 1. Normal: 22 26 mEq/L 2. Acidic: < 22 mEq/L 3. Alkaline: > 26 mEq/L

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D. Base Excess 1. Calculated value for buffer base capacity: the amount of acid or base added to blood to obtain a pH of 7.4 2. Normal: -3 - +3

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E. PaO2 or pO2 Pressure of oxygen in blood 1. Gives data about level of oxygenation; not used to calculate acid-base status of blood 2. Normal: 80 100 mm Hg 3. Hypoxemia: < 80 mm Hg

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F. SaO2 oxygen saturation 95% - 100%

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Interpreting ABG results

1. 2. 3. 4. 5. Check the pH. Determine the PaCO2. Watch the bicarbonate. Look for compensation. Determine PaO2 and SaO2.

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Parameter pH PaCO2 HCO3 PaO2 SaO2

Normal Value 7.35 7.45 35 45 mmHg 22-26 mEq/L 80 100 mmHg 95 100 %

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Interpreting ABG results

1. Check the pH. pH = 7.35 7.45 (normal) pH = < 7.35 (acidosis) pH = > 7.45 (alkalosis)

compensated normal pH uncompensated abnormal pH

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Interpreting ABG results

Determine primary cause of disturbance. Figure out whether the cause is: Respiratory (PaCO2) or Metabolic (HCO3)

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Interpreting ABG results

2. Determine the PaCO2. normal or abnormal - Respiratory component Normal: 35-45 mm Hg

a. PaCo2 < 35 mmHg respiratory alkalosis ? pH > 7.45 hypocapnia

a. PaCo2 > 45 mm Hg respiratory acidosis ? pH < 7.35 hypercapnia

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Interpreting ABG results

3. Watch the bicarbonate. renal or metabolic component Normal: 22 26 mEq/L

HCO3 < 22 mEq/L metabolic acidosis ? pH < 7.35 HCO3 > 26 mEq/L metabolic alkalosis ? pH > 7.45
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Interpreting ABG results

4. Look for compensation: look at the value which does not match the acid base status of the patients pH: a. Within normal range: NO compensation b. Above or below normal AND the pH itself is outside the normal range: PARTIAL c. Above or below normal AND the pH is within the normal range: COMPLETE
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Interpreting ABG results

5. Determine PaO2 and SaO2
PaO2 SaO2 80 100 mmHg 95 100 %

- Reflect bodys ability to pick up oxygen from the lungs

Low hypoxemia; can cause hyperventialtion - Indicate when to make adjustments in the concentration being administered to the patient

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Interpreting ABG results Exercises

ACIDIC dec pH inc PaCO2 or dec HCO3 ALKALINE/ BASIC inc pH dec PaCO2 or inc HCO3

pCO2

pCO2

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1. pH 7.20 2. pCO2 60 3. HCO3 24

dec inc normal

acidic acidic normal*

RESPIRATORY ACIDOSIS no/ absent compensation

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1. pH 7.20 2. pCO2 60 3. HCO3 30

dec inc inc

acidic acidic alkaline*

RESPIRATORY ACIDOSIS partial compensation

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1. pH 2. pCO2 3. HCO3

7.40* 48 24

normal inc normal

acidic* acidic normal*

RESPIRATORY ACIDOSIS no/ absent compensation NOTE: If pH is normal but PaCO2 or HCO3 is abnormal, use 7.4 as a cut off point 7.35 - 7.40 acidosis 7.40 - 7.45 alkalosis
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1. pH 7.60 2. pCO2 20 3. HCO3 18

inc dec dec

alkaline alkaline acidic

RESPIRATORY ALKALOSIS partial compensation

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1. pH 7.50 2. pCO2 60 3. HCO3 34

inc inc inc

alkaline acidic alkaline

METABOLIC ALKALOSIS partial compensation

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1. pH 7.36* 2. pCO2 30 3. HCO3 20

normal dec dec

acidic alkaline acidic

METABOLIC ACIDOSIS complete/ full compensation

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1. pH 7.30 2. pCO2 40 3. HCO3 20

dec normal dec

acidic normal acidic

METABOLIC ACIDOSIS no/ absent compensation

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Acid-Base Imbalance Classifications

1. Acidosis or alkalosis a. Acidosis: Hydrogen ion concentration in blood increases above normal and pH is below 7.35 b. Alkalosis: Hydrogen ion concentration in blood decreases below normal and pH is above 7.45 2. Origin of the problem a. From the respiratory system b. From the metabolic system
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Disorders: Simple or Combined

1. Primary disorders a. Simple b. One cause, either respiratory or metabolic

2. Combined disorders a. More severe b. Both the respiratory and metabolic systems are the cause of the same imbalance
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Compensation 1. Only occurs with primary disorders 2. Response by the system not causing the imbalance to correct the pH Example: with respiratory acidosis, the kidneys would eliminate hydrogen ions in urine to offset the acidosis caused by hypoventilation of lungs. 3. Complete Compensation occurs if the pH is corrected to the normal range (7.35 7.45) 4. Partial Compensation occurs if there is improvement in the pH but not to the normal range. 5. Compensation can be determined by analysis of the arterial blood gas results.
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Treatment

1. Urgency a. Mental ability and level of consciousness is often affected b. Brain function usually affected; brain cells need proper conditions to perform cellular functions c. Cells cannot function properly if significant acidosis or alkalosis occurs
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2. Indirect treatment a. Treating and correcting the precipitating condition often corrects the acid-base imbalance b. Directly treating the acid-base imbalance, by adding or removing hydrogen or bicarbonate ions, may lead to further imbalances c. Not usually first line of treatment

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Types of Acid-Base Imbalances

A. Respiratory Acidosis pH < 7.35 pCO2 > 45 mm Hg (excess carbon dioxide in the blood) Respiratory system impaired and retaining CO2; causing acidosis

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Etiology: pulmonary edema, aspiration, atelectasis, pneumothorax, sleep apnea syndrome, pneumonia, asthma, bronchiectasis, overdose of medications (sedatives, narcotics, anesthetics), neuromuscular d/o ( Guillain Barre), hypoventilation
s/sx: sudden hypercapnia produces inc PR, RR, inc BP, mental cloudinesss, feeling of fullness in head, papilledema and dilated conjunctival blood vessels
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Respiratory Acidosis
Common Stimuli a. Acute respiratory failure from airway obstruction b. Over-sedation from anesthesia or narcotics c. Some neuromuscular diseases that affect ability to use chest muscles d. Chronic respiratory problems, such as Chronic Obstructive Lung Disease
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Respiratory Acidosis
Signs and Symptoms a. Compensation: kidneys respond by generating and reabsorbing bicarbonate ions, so HCO3 >26 mm Hg b. Respiratory: hypoventilation, slow or shallow respirations c. Neuro: headache, blurred vision, irritability, confusion d. Respiratory collapse leads to unconsciousness and cardiovascular collapse

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Respiratory Acidosis
Collaborative Care a. Early recognition of respiratory status and treat cause b. Restore ventilation and gas exchange; CPR for respiratory failure with oxygen supplementation; intubation and ventilator support if indicated c. Treatment of respiratory infections with bronchodilators, antibiotic therapy d. Reverse excess anesthetics and narcotics with medications such as naloxone (Narcan)
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Respiratory Acidosis
e. Chronic respiratory conditions a. Breathe in response to low oxygen levels b. Adjusted to high carbon dioxide level through metabolic compensation (therefore, high CO2 not a breathing trigger) c. Cannot receive high levels of oxygen, or will have no trigger to breathe; will develop carbon dioxide narcosis d. Treat with no higher than 2 liters O2 per cannula f. Continue respiratory assessments, monitor further arterial blood gas results

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Respiratory Acidosis
Nursing Diagnoses a. Impaired Gas Exchange b. Ineffective Airway Clearance

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B. Respiratory Alkalosis pH > 7.45 pCO2 < 35 mm Hg. Carbon dioxide deficit, secondary to hyperventilation

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Etiology: extreme anxiety, hypoxemia, Fever, hyperventilation, hysteria, hypoxia, Salicycates (early)
s/sx: lightheadednes, inability to concentrate, numbness, tingling, loss of consciousness

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Respiratory Alkalosis
Common Stimuli a. Hyperventilation with anxiety from uncontrolled fear, pain, stress (e.g. women in labor, trauma victims) b. High fever c. Mechanical ventilation, during anesthesia

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Respiratory Alkalosis
Signs and Symptoms a. Compensation: kidneys compensate by eliminating bicarbonate ions; decrease in bicarbonate HCO3 < 22 mm Hg. b. Respiratory: hyperventilating: shallow, rapid breathing c. Neuro: panicked, light-headed, tremors, may develop tetany, numb hands and feet (related to symptoms of hypocalcemia; with elevated pH more Ca ions are bound to serum albumin and less ionized active calcium available for nerve and muscle conduction) d. May progress to seizures, loss of consciousness (when normal breathing pattern returns) e. Cardiac: palpitations, sensation of chest tightness
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Respiratory Alkalosis
Collaborative Care a. Treatment: encourage client to breathe slowly in a paper bag to rebreathe CO2 b. Breathe slowly; breathe with the patient; provide emotional support and reassurance, anti-anxiety agents, sedation c. On ventilator, adjustment of ventilation settings (decrease rate and tidal volume) d. Prevention: pre-procedure teaching, preventative emotional support, monitor blood gases as indicated
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C. Metabolic Acidosis pH <7.35 Deficit of bicarbonate in the blood NaHCO3 <22 mEq/L Caused by an excess of acid, or loss of bicarbonate from the body

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Etiology: diarrhea, fistulas, diuretics, TPN w/o Bicarbonate, lactic acidosis, DM, DKA, excessive ingestion of salicylates (late)- aspirin, high fat diet, malnutrition, renal insufficiency/ failure S/sx: headache, confusion, drowsiness, inc RR, dec BP, cold clammy skin, dysrythmia, shock

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Metabolic Acidosis
Common Stimuli a. Acute lactic acidosis from tissue hypoxia (lactic acid produced from anaerobic metabolism with shock, cardiac arrest) b. Ketoacidosis (fatty acids are released and converted to ketones when fat is used to supply glucose needs as in uncontrolled Type 1 diabetes or starvation) c. Acute or chronic renal failure (kidneys unable to regulate electrolytes) d. Excessive bicarbonate loss (severe diarrhea, intestinal suction, bowel fistulas)

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Metabolic Acidosis
e. Usually results from some other disease and is often accompanied by electrolyte and fluid imbalances f. Hyperkalemia often occurs as the hydrogen ions enter cells to lower the pH displacing the intracellular potassium; hypercalcemia and hypomagnesemia may occur

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Metabolic Acidosis
Signs and Symptoms a. Compensation: respiratory system begins to compensate by increasing the depth and rate of respiration in an effort to lower the CO2 in the blood; this causes a decreased level of carbon dioxide: pCO2 <35 mm HG. b. Neuro changes: headache, weakness, fatigue progressing to confusion, stupor, and coma c. Cardiac: dysrhythmias and possibly cardiac arrest from hyperkalemia d. GI: anorexia, nausea, vomiting e. Skin: warm and flushed

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Metabolic Acidosis
f. Respiratory: tries to compensate by hyperventilation: deep and rapid respirations known as Kussmauls respirations

g. 1. 2. 3. 4.

Diagnostic test findings: ABG: pH < 7.35, HCO3 < 22 Electrolytes: Serum K+ >5.0 mEq/L Serum Ca+2 > 10.0 mg/dL Serum Mg+2 < 1.6 mg/dL
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Metabolic Acidosis
Collaborative Care a. Medications: Correcting underlying cause will often improve acidosis b. Restore fluid balance, prevent dehydration with IV fluids c. Correct electrolyte imbalances d. Administer Sodium Bicarbonate IV, if acidosis is severe and does not respond rapidly enough to treatment of primary cause. (Oral bicarbonate is sometimes given to clients with chronic metabolic acidosis) Be careful not to overtreat and put client into alkalosis e. As acidosis improves, hydrogen ions shift out of cells and potassium moves intracellularly. Hyperkalemia may become hypokalemia and potassium replacement will be needed.
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Metabolic Acidosis
f. Assessment 1. Vital signs 2. Intake and output 3. Neuro, GI, and respiratory status; 4. Cardiac monitoring 5. Reassess repeated arterial blood gases and electrolytes
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Metabolic Acidosis
Nursing Diagnoses a. Decreased Cardiac Output b. Risk for Excess Fluid Volume c. Risk for Injury

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D. Metabolic Alkalosis pH >7.45 HCO3 > 26 mEq/L Caused by a bicarbonate excess, due to loss of acid, or a bicarbonate excess in the body

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 Etiology: excessive vomiting, diuretic, hyperaldosteronism, hypokalemia, excessive alkali ingestion, ingestion of excess sodium bicarbonate/ antacids, massive transfusion of whole blood s/sx: tingling of toes, dizziness, dec RR, inc PR, ventricular disturbances
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Metabolic Alkalosis
Common Stimuli a. Loss of hydrogen and chloride ions through excessive vomiting, gastric suctioning, or excessive diuretic therapy b. Response to hypokalemia c. Excess ingestion of bicarbonate rich antacids or excessive treatment of acidosis with Sodium Bicarbonate
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Metabolic Alkalosis
Signs and Symptoms a. Compensation: Lungs respond by decreasing the depth and rate of respiration in effort to retain carbon dioxide and lower pH b. Neuro: altered mental status, numbness and tingling around mouth, fingers, toes, dizziness, muscle spasms (similar to hypocalcemia due to less ionized calcium levels) c. Respiratory: shallow, slow breathing
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Metabolic Alkalosis
d. Diagnostic test findings 1. ABGs: pH> 7.45, HCO3 >26 2. Electrolytes: Serum K+ < 3.5 mEq/L 3. Electrocardiogram: as with hypokalemia

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Metabolic Alkalosis
Collaborative Care a. Correcting underlying cause will often improve alkalosis b. Restore fluid volume and correct electrolyte imbalances (usually IV NaCl with KCL). c. With severe cases, acidifying solution may be administered.

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Metabolic Alkalosis
d. Assessment 1. Vital signs 2. Neuro, cardiac, respiratory assessment 3. Repeat arterial blood gases and electrolytes

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Metabolic Alkalosis
Nursing Diagnoses a. Impaired Gas Exchange b. Ineffective Airway Clearance c. Risk for Injury

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