Acid Base Balance

Ana Corona, MSN, FNP-C

Nursing Instructor
September 2007
Definitions
 Acidosis (acidemia) occurs when pH drops below
7.35

 Alkalosis (alkalemia) occurs when the pH rises

above 7.45

 A primary respiratory problem is determined if the

PaC02 is less than 35mmHg(alkalosis) or greater
than 45 mmHg(acidosis).

 A primary metabolic problem is when the HC03 is

less than 22mEq/L (acidosis) or greater than
26mEq/L(alkalosis).
Metabolic Acidosis
Clinical Manifestations
 hyperkalemia: shift of acid to ICF and K+ to
the ECF
 anorexia, nausea, and vomiting

 warm, flushed skin

 cardiac dysrhythmias & CNS dysfunction

 headache, diarrhea, tremors

Metabolic Acidosis: Etiology
 Loss of base: such as in cases of severe diarrhea
or
Gain of metabolic acids: Anaerobic metabolism;
Drug overdose (e.g.salicylates); Renal failure;
Diabetic ketoacidosis

 Decreased blood pH;

 decreased HCO3
 normal PaCO2 or decreased if compensation is
occurring.
Metabolic Acidosis Nursing
Intervention
 Assess the clinical symptoms, health history, and
lab results.
 Identify the underlying cause to intervene
appropriately.
 When there is severe acidosis (pH < 7.1), sodium
bicarbonate is necessary to bring the pH to a safe
level.
 Correct the sodium and water deficits, as well.
Metabolic Alkalosis
Clinical Manifestations
 cardiac dysrhythmias; seizures; confusion;
muscle twitching, agitation
 >pH;>HC03; normal PaCo2 or elevated if
compensation occurs
Metabolic Alkalosis: Etiology
 Loss of metabolic acids: such as in cases of
prolonged vomiting or gastrointestinal suctioning.
Hyperaldosteronism can cause sodium retention
and loss of hydrogen ions and potassium.
or
Gain of Base: an increased intake of bicarbonate.
Diuretics (e.g. Lasix) can cause sodium, potassium,
and chloride excretion more than bicarbonate
excretion.
Metabolic Alkalosis
 Increased blood pH
 increased HCO3
 normal PaCO2 or elevated if compensation is
occurring.
Metabolic Alkalosis Nursing
Intervention
 Assess the clinical symptoms, health history, and
lab results.
 Identify the underlying cause to intervene
appropriately.
 If potassium levels are decreased administer
potassium as ordered per physician.
 If acid-base disturbance is due to hypochloremic
alkalosis with volume depletion, administer a sodium
chloride IV solution.
 If the condition is caused by hyperaldosteronism,
administer potassium.
Respiratory Acidosis
Clinical Manifestations
 > PaCo2; HCO3 is normal or > with renal
compensation
 vasodilatation; cardiac dysrhythmias,
tachycardia, somnolence, decreased
ventilation
Respiratory Acidosis etiology
 Carbon dioxide is retained when
ventilation is depressed; therefore,
leading to acidosis and hypercapnia
(excess PaCO2).
 Decreased blood pH
 Increased PaCO2
 Normal HCO3 or elevated if compensation is
occurring.
Respiratory Acidosis Nursing
Intervention
 Assess the clinical symptoms, health history,
and lab results.
 Identify the underlying cause to intervene
appropriately.
 Restore alveolar ventilation (this will remove
excess CO2), and if spontaneous ventilation
is compromised (e.g. due to drug overdose or
neuromuscular disorders) provide mechanical
ventilation.
Respiratory Acidosis Nursing
Intervention
 Monitor the pH, PaCO2, PaO2, and HCO3 very
closely.
 A rapid decline of the PaCO2 can lead to respiratory
alkalosis with seizures and death.
 Check for hypoxemia and hypercapnia when
administering oxygen.
 Oxygen can work as a respiratory depressant when
the person's respiratory center is no longer
stimulated by a low pH and elevated PaCO2.
 Renal buffering generally corrects an uncomplicated
chronic respiratory acidosis.
Respiratory Alkalosis
Clinical Manifestations
 > pH; < PaC02; HCO3 normal or low due to
compensation
 nausea, vomiting, tingling of fingers
Respiratory Alkalosis Etiology
 Occurs when there is alveolar
hyperventilation and a decrease in PaCO2
(hypocapnia).
 Hypoxemia (caused by pulmonary disease,
high altitudes, or congestive heart failure),
hypermetabolic conditions (fever or anemia),
gram-negative sepsis, hysteria, or cirrhosis of
the liver can stimulate hyperventilation.
Respiratory Alkalosis
 Increased blood pH
 Decreased PaCO2
 Normal HCO3 or decreased if compensation
is occurring.
Respiratory Alkalosis Nursing
Interventions
 Assess the clinical symptoms, health history,
and lab results.
 Identify the underlying cause to intervene
appropriately.
 Correct the hypoxemia and reverse the
hypermetabolic states if present.
 Correct symptoms from hysterical
hyperventilation by rebreathing from a paper
bag (increases PaCO2).
Basic Questions
 There are three critical questions to keep in mind
when attempting to interpret arterial blood gases
(ABGs).
First Question: Does the patient exhibit acidosis or
alkalosis?
Second Question: What is the primary problem?
Metabolic? or Respiratory?
Third Question: Is the patient exhibiting a
compensatory state?
In order to understand ABG analysis and remember
what is abnormal, you need to review what is
normal.
Remember Definitions
 Acidosis (acidemia) occurs when pH drops below
7.35

 Alkalosis (alkalemia) occurs when the pH rises

above 7.45
 A primary respiratory problem is determined if the
PaC02 is less than 35mmHg (alkalosis) or greater
than 45 mmHg (acidosis).

 A primary metabolic problem is when the HC03 is

less than 22mEq/L (acidosis) or greater than
26mEq/L (alkalosis).
Assessment Step 1
 Step One: Determine the acid/base status of the
arterial blood. Keep in mind what is Normal

If the blood's pH is less than 7.35 this is an acidosis,

and if it is greater than 7.45 this is an alkalosis.

You may hear nurses or doctors say: "The patient is

'acidotic' or 'alkalotic'
Assessment Step 2
 Once you have determined the pH, you can
move on to determine the 'primary' problem,
or which system, respiratory or metabolic is
the prime messenger.
Respiratory System
 Carbon Dioxide acts as the ‘acid’ of the human
body, you will be able to determine if the primary
acid-base imbalance is respiratory.
 Chemically speaking, there is an equilibrium
between carbonic acid and bicarbonate.
 Therefore, just remember that an increased PaCO2
(>45mmHg) along with an acidosis (pH < 7.35)
represents a RESPIRATORY ACIDOSIS.
 If you have a situation where there is a decreased
PaCO2 (less than 35mmHg) and an alkalosis (pH
greater than 7.45) you will have a RESPIRATORY
ALKALOSIS! Easy. Right?
Metabolic System
 Keep in mind that HCO3 represents a ‘base’
situation, and if there is an increased HCO3 (greater
than 26 mEq/L) in an alkalotic environment (pH
greater than 7.45) there is a METABOLIC
ALKALOSIS.
 On the opposite side of the coin, if there is a
decreased HCO3 (less than 22 mEq/L) in an acidic
environment (pH less than 7.35) this will be
representative of METABOLIC ACIDOSIS.
Compensation
 Our bodies have compensatory mechanisms
that assist us to return to a state of
homeostasis (equilibrium).
 The body attempts to compensate for
whatever the primary problem is in an effort
to return the acid-base balance to normal.
An illustration of COMPENSATION
is given below:
 A newly diagnosed Type 1 diabetic client has a
‘primary’ problem of metabolic acidosis (pH 7.29;
HCO3 16 mEq/L) due to an increase in ketone
bodies (ketoacidosis).
 The nurse notes that the ABGs show a below
normal PaCO2 value (27mmHg) and the client is
breathing faster in an attempt to ‘blow off’ the carbon
dioxide (CO2:’acid’) to create a respiratory alkalosis,
the opposite of metabolic acidosis!
 Hint! In order to recognize ‘compensation’ look for a
change in the buffering system that was not involved
in the ‘primary’ problem.
 Review the three essential
steps of ABG analysis
 Number One:
Determine if the client is demonstrating an acidotic (remember: pH
less than 7.35) or alkalotic (pH greater than 7.45).
 Number Two:
 What is the 'primary problem?

 If the client is acidotic with a PaC02 greater than 45 mmHg it is

RESPIRATORY

 If the client is acidotic with a HC03 less than 22 mEq/L it is

METABOLIC!

 If the client is alkalotic with a PaC02 less than 35 mmHg it is

RESPIRATORY!

 If the client is alkalotic with a HC03 greater than 26 mEq/L it is

METABOLIC!
 Number Three:
Is the client compensating?

 Are both components (HCO3 and PaCO2) shifting in

the same direction?
 Up or down the continuum?
 Above or below the normal ranges?
 If this is noted, you know that the client’s buffering
systems are functioning and are trying to bring the
acid-base balance back to normal.
Case Study 1
A client recovering from surgery in the post-anesthesia care unit is
difficult to arouse two hours following surgery. The nurse in the PACU
has been administering Morphine Sulfate intravenously to the client for
complaints of post-surgical pain. The client’s respiratory rate is 7 per
minute and demonstrates shallow breathing. The patient does not
respond to any stimuli! The nurse assesses the ABCs (remember Airway,
Breathing, Circulation!) and obtains ABGs STAT! The STAT results
come back from the laboratory and show:

pH = 7.15
Pa C02 = 68 mmHg
HC03 = 22 mEq/L
1. Compensated Respiratory Acidosis
2. Uncompensated Metabolic Acidosis
3. Compensated Metabolic Alkalosis
4. Uncompensated Respiratory Acidosis
Answer
 The answer is #1
uncompensated respiratory acidosis
Case Study 2
 An infant, three weeks old, is admitted to the Emergency Room.
The mother reports that the infant has been irritable, difficult to
breastfeed and has had diarrhea for the past 4 days. The infant’s
respiratory rate is elevated and the fontanels are sunken. The
Emergency Room physician orders ABGs after assessing the
ABCs.
 The results from the ABGs come back from the laboratory and
show:

pH = 7.37
Pa C02 = 29 mmHg
HC03 = 17 mEq/L
1. Compensated Respiratory Alkalosis
2. Uncompensated Metabolic Acidosis
3 Compensated Metabolic Acidosis
4 Uncompensated Respiratory Acidosis
Answer
 Answer is #3
 Compensated Metabolic Acidosis
Case Study 3
 A client, 5 days post-abdominal surgery, has a nasogastric tube.
The nurse notes that the nasogastric tube (NGT) is draining a
large amount (900 cc in 2hours) of coffee ground secretions.
The client is not oriented to person, place, or time. The nurse
contacts the attending physician and STAT ABGs are ordered.

The results from the ABGs come back from the laboratory and
show:
 pH = 7.52
Pa C02 = 35 mmHg
HC03 = 29 mEq/L
1. Compensated Respiratory Alkalosis
2. Uncompensated Metabolic Acidosis
3. Compensated Metabolic Acidosis
4. Uncompensated Metabolic Alkalosis
Answer
 Answer is #4
 Uncompensated Metabolic Alkalosis
Case Study 4
 A client is admitted to the hospital and is being prepared for a
craniotomy (brain surgery). The client is very anxious and
scared of the impending surgery. He begins to hyperventilate
and becomes very dizzy. The client looses consciousness and
the STAT ABGs reveal:

 The results from the ABGs come back from the laboratory and
show:
 pH = 7.57
 Pa C02 = 26 mmHg
 HC03 = 24 mEq/L

1. Compensated Metabolic Acidosis

2. Uncompensated Metabolic Acidosis
3. Uncompensated Respiratory Alkalosis
4. Uncompensated Respiratory Acidosis
Answer
 The answer is #3
 Uncompensated Respiratory Alkalosis
Case Study 5
 A two-year-old is admitted to the hospital with a diagnosis of
asthma and respiratory distress syndrome. The father of the
infant reports to the nurse that he has observed slight tremors
and behavioral changes in his child over the past three days.
The attending physician orders routine ABGs following an
assessment of the ABCs. The ABG results are:

 pH = 7.36
 Pa C02 = 69 mmHg
 HC03 = 36 mEq/L

1. Compensated Respiratory Alkalosis

2. Uncompensated Metabolic Acidosis
3. Compensated Respiratory Acidosis
4. Uncompensated Respiratory Alkalosis
Answer
 Answer is #3
 Compensated Respiratory Acidosis
Case Study 6
 A young woman, drinking beer at a party, falls and
hits her head on the ground. A friend dials "911"
because the young woman is unconscious,
depressed ventilation (shallow and slow
respirations), rapid heart rate, and is profusely
bleeding from both ears.
 Which primary acid-base imbalance is this young
woman at risk for if medical attention is not
provided?

1. metabolic acidosis
2. metabolic alkalosis
3. respiratory acidosis
4. respiratory alkalosis
Answer
 Correct answer is #3
 Respiratory Acidosis
Case Study 7
 An 11-year old boy is admitted to the hospital with
vomiting, nausea and overall weakness. The nurse
notes the laboratory results: potassium: 2.9 mEq.
 Which primary acid-base imbalance is this boy at
risk for if medical attention is not provided?

1. metabolic acidosis
2. metabolic alkalosis
3. respiratory acidosis
4. respiratory alkalosis
Answer
 Correct Answer is #2
 Metabolic Alkalosis
Case Study 8

 An elderly gentleman is seen in the emergency

department at a community hospital. He admits to taking
many tablets of aspirin (salicylates) over the last 24-hour
period because of a severe headache. He complains of
an inability to urinate. His vital signs are: Temp = 98.5;
apical pulse = 92; respiration = 30 and deep.
 Which primary acid-base imbalance is the gentleman at
risk for if medical attention is not provided?

1. metabolic acidosis
2. metabolic alkalosis
3. respiratory acidosis
4. respiratory alkalosis
Answer
 Correct Answer is #1
 Metabolic Acidosis
Case Study 9
 A young man is found at the scene of an automobile accident in
a state of emotional distress. He tells the paramedics that he
feels dizzy, tingling in his fingertips, and does not remember
what happened to his car. Respiratory rate is rapid at
34/minute.
 Which primary acid-base disturbance is the young man at risk
for if medical attention is not provided?

1. metabolic acidosis
2. metabolic alkalosis
3. respiratory acidosis
4. respiratory alkalosis
Answer
 Correct Answer is #4
 Respiratory Alkalosis
ACID BASE PARAMETERS
Respiratory PH PCO2 HCO3
Acidosis

Respiratory PH PCO2 HCO3

Alkalosis

Metabolic PH PCO2 HCO3

Acidosis

Metabolic PH PCO2 HCO3

Alkalosis