Acid and Bases

1. Terms and Formulas

a. Ventilation: Exchange of air between the lungs and the atmosphere so that oxygen

can be exchanged for carbon dioxide in the alveoli

b. Hyperventilation: Rapid breathing that can cause an abnormal loss of carbon

dioxide

c. Kussmaul Respirations: Deep and labored breathing

d. HCO3-: Bicarbonate

e. CO2: Carbon dioxide

f. H2CO3: Carbonic acid

g. pH: Potential hydrogen

h. mmHg: Millimeters of mercury

i. BE: Base excess

j. O2: Oxygen

k. H+: Hydrogen

l. PaCO2: Partial pressure of CO2 in arterial blood

m. ABG: Arterial Blood Gas

n. ECF: Extracellular Fluid

2. Normal acid-base balance

a. Acid-base balance is critical to maintain homeostasis and optimal cellular

function.

b. Acid Base Balance: What the healthy body needs to maintain homeostasis

c. Metabolic Processes: Chemical reaction in body that transfer food into energy
 d. Homeostasis: Balance in body

e. To maintain acid-base balance, the hydrogen ion (H+) concentration of body

fluids must be kept in a narrow range. Hydrogen ions determine the relative

acidity of body fluids.

f. Acids: Release hydrogen ions in solution

g. Bases (alkalis): Accepts hydrogen ions in solution

h. PH: The hydrogen ions concentration of a solution is measured as its pH

i. As hydrogen ion concentration increases, the pH falls, the solution becomes more

acidic

j. As hydrogen ion concentration decreases, the pH rises, the solution becomes more

basic

k. The normal pH of body fluids ranges from 7.35 to 7.45. pH below 7 and above

7.6 even for a short time can cause death.

l. On pH scale 0-6 is acidic, 7 is neutral, and 8-14 is alkaline

m. Volatile Acid: Can be eliminated from the body as a gas and is only produced

from carbon dioxide.

n. Non-volatile Acid: Must be metabolized or excreted to eliminate from the body

and is produced from other sources besides carbon dioxide.

o. Carbonic acid is the only volatile acid produced in the body. It separates into CO2

and H20, the lungs eliminate the carbon dioxide.

3. Physiology

a. Buffers: Substances that prevent major changes in pH by releasing/binding

hydrogen ions
b. Normal serum bicarbonate level is 24-28 mEq/L and normal serum carbonic acid

is 1.2mEq/L. Ratio of bicarbonate (HCO3) to carbonic acid (H2CO3) is 20:1.

c. Bicarbonate is a weak base. When an acid is added to the system, the hydrogen

ion in the acid combines with bicarbonate, and the pH changes only slightly.

d. Carbonic acid is a weak acid produced when carbon dioxide dissolves in water.

e. Acidosis: Adding strong acid to extracellular fluid depletes bicarbonate, changing

the 20:1 and causing the pH to drop below 7.35.

f. Alkalosis: Adding a strong base depletes carbonic acid, as it combines with the

base, again disrupting the 20:1 ratio.

g. Three systems that help maintain pH within normal ranges are the buffer system,

respiratory system, and renal system.

h. Base Excess: Amount of Acid/Base added to achieve pH of 7.4. Normal range for

arterial blood is -3 to +3.

i. Also called buffer base capacity

ii. Measures substances that can accept or combine with hydrogen ions.

iii. Reflects the degree of acid base imbalance by indicating the status of the

body’s total buffering capacity.

i. Hypocapnia: PaCO2 is less than 35

j. Hypercapnia: PaCO2 is greater than 45

k. PaO2: Measure of the pressure exerted by oxygen that is dissolved in the plasma.

i. Normal range is 80-100

l. Respiratory System

i. Regulates carbonic acid by eliminating or retaining carbon dioxide

 ii. PaCO2: Partial pressure of CO2 in arterial blood. 35-45 mmHg is normal

range

iii. Lungs regulate blood levels of CO2 to form H2CO3

iv. Breathing faster and deeper eliminates CO2 from lungs

v. The more CO2 lost, the less H2CO3 is made then pH rises

vi. The body detects the pH change and reduces the CO2 excretion by

breathing slower

vii. Carbon dioxide is a potential acid when combined with water, which

becomes a carbonic acid, a volatile acid.

viii. Acute increases in carbon dioxide or hydrogen ions in the blood stimulates

the brain’s respiratory center, increasing both the rate and depth of

respiration. As a result, carbon dioxide is eliminated and carbonic acid

levels fall, bringing the pH to a more normal range.

ix. How to Assess Effectiveness of Ventilation:

1. Look at Arterial Blood Gasses (ABGs)

2. Partial Pressure of CO2 (PaCO2)

a. Normal is 35-45 mmHg

3. Restore normal pH temporarily

x. Serum Bicarbonate Level

1. Is 22-26 mEq/L

2. Regulated in kidneys

3. Weak base
 4. When acid added to system, H+ in acid combines with HCO3, pH

changes slightly

xi. Serum Carbonic Acid

1. The ratio of HCO3 to H2CO3 ia 20:1

a. As long as this ratio is maintained, the pH stays in normal

range

2. Weak acid

3. When base added to system, pH remains within normal range

m. Renal System

i. Responsible for long term acid-base balance.

ii. Kidneys eliminate the excess nonvolatile acids produced during

metabolism.’

iii. Kidneys regulate bicarbonate levels in ECF by regenerating or reabsorbing

bicarbonate ions in the renal tubules.

iv. Responds slowly to changes in pH (hours to days)

v. Effectiveness changes with age

4. Alterations and Manifestations

a. Respiratory Acidosis

i. Can be caused by disease of airway, disease of chest, drugs that suppress

breathing, and sleep apnea

ii. Consistently high CO2 levels

iii. PaCO2 is 47 mmHg

iv. How Do Lungs Respond?

 1. Increased rate and depth of breathing occurs to blow off excess

CO2

2. CO2 eliminated, H2CO3 is decreased

3. Bringing pH to more normal range

b. Respiratory Alkalosis

i. Can be caused by brain stem injury, elevated body temperature, anxiety,

hypoxia, increased basal metabolic rate, overventilation from mechanical

ventilator, salicylate overdose

ii. Consistently low CO2 levels in blood

iii. PaCO2 is 33 mmHg

iv. How Does the Body Respond?

1. Depress respiratory center

2. Decrease rate and depth of breathing

3. Cause CO2 retention

4. The retained CO2 combines with H2O to restore H2CO3

5. Brings pH back to normal

c. Metabolic Acidosis

i. Can be caused by: Increase in chloride levels, abnormal bicarbonate

losses, fluid imbalance, and accumulation of metabolic acids

ii. When metabolic acidosis occurs, the respiratory system attempts to return

the pH to normal by increasing the rate and depth of respirations

iii. Excess nonvolatile acid

iv. pH below 7.35

 v. PaCO2 < than 35 mmHg

vi. Bicarbonate < than 24mEq/L

d. Metabolic Alkalosis

i. Can be caused by excessive acid loss due to vomiting or gastric suction,

excessive use of potassium-losing diuretics, excessive adrenal corticoid

hormones

ii. Excess bicarbonate

iii. Respiratory attempts to bring pH to normal by slowing the respiratory rate

but end up retaining CO2 and PaCO2 increases.

iv. pH above 7.45

v. PaCO2 > than 45 mmHg

vi. Bicarbonate > than 28mEq/L

e. Compensations: Occurs to restore a normal pH balance and homeostasis. Change

in pH affects HCO3 conservation and H+ elimination

f. Respiratory Compensation: Changes in pH affects rate and depth of respirations.

Affects CO2 elimination and PaCO2 to restore ratio. Compensatory changes in

respiration occur in minutes of change in pH.

g. Renal Compensation: Kidneys compensate for simple respiratory imbalances.

Responses take longer to restore pH. More effective long-term.

h. Fully Compensated: Body has fixed the imbalance by bringing pH back to normal

i. pH is normal (7.35-7.45)
ii. PaCO2 and HCO3 are both out of range
iii. The cause of the disorder is out of range, and the other value is
significantly out of range indicating compensation is occurring.
 iv. Recall the respiratory rate quickly compensates for metabolic disorders,
and the kidneys take longer to compensate for respiratory disorders.
i. Partially Compensated: the body is working to fix the imbalance but hasn’t yet

brought the pH back to normal

i. pH is abnormal (<7.35 or >7.45)

ii. PaCO2 and HCO3 are abnormal

iii. The cause of the disorder is out of range and the other value is moving out
of range, indicating compensation is occurring.
j. Uncompensated: The body is not yet working to bring the pH back to normal

i. pH is abnormal (<7.35 or >7.45)

ii. PaCO2 or HCO3 is abnormal, but not both

iii. The cause of the disorder is out of range but the other value is not yet out
of range, indicating compensation is not yet occurring.
5. Assessment Related to Acid Base Balance

a. Identifying risks

i. Electrolyte imbalance

ii. Gain/loss of acids

iii. Gain/loss of bases

iv. Ventilation abnormalities

v. Abnormal kidney function

vi. Metabolic malfunction

b. Vital signs

i. Count respirations for full minute

ii. Consider rate and depth of respirations

c. Are their any underlying respiratory or metabolic problems

d. Level of Consciousness

e. Fluid balance and kidney function

f. Do findings correlate with dx?

g. Physical Exam

i. Vital Signs

ii. Pulse Ox

1. O2 Sat 90% = PaCO2 of 60 mmHg

iii. Mentation

iv. Skin color & temperature

v. Respirations

vi. Lung sounds

vii. Bowel sounds

viii. Urine output

h. Diagnostics

i. ABGs: Used to measure the acid-base balance in the entire body. Also

shows how much oxygen and carbon dioxide are in your blood.

ii. Metabolic Panel: Blood test that gives doctors information about the

body's fluid balance, levels of electrolytes like sodium and potassium, and

how well the kidneys and liver are working.

iii. Modified Allen Test: Used to measure ulnar patency by applying digital

occlusive pressure over the radial and ulnar arteries and determine if the

color returns to the hand when pressure is removed. Determines if an

arterial puncture can safely be performed.

 i. Independent Interventions

i. Taking weight daily

ii. Monitoring intake and output

iii. Assessing respiratory and renal function

iv. Maintaining a patent airway

v. Monitoring oxygen saturation

vi. Taking vital signs

vii. Assessing LOC and neurologic functions

viii. Prompt reporting of changes in patient conditions

6. Interpreting ABGs

a. Step 1

i. Look at pH (7.35-7.45)

1. If pH is abnormal, does it reflect acidosis or alkalosis?

2. Is it <7.35 (acidosis) or >7.45 (alkalosis)?

b. Step 2

i. Look at PaCO2 (35-45)

1. If PaCO2 is abnormal, is it low or high?

2. If PaCO2 < 35mmHg, then hypocapnia; more CO2 is being

exhaled than normal.

3. If PaCO2 is > 45mmHg, then hypercapnia; CO2 is being retained.

c. Step 3:

i. Evaluate the pH - PaCO2 relationship for a possible respiratory problem.

 1. If the pH < 7.35 (acidosis), and the PaCO2 > 45mmHg

(hypercapnia), then retained CO2 is causing increased H+

concentration and respiratory acidosis.

2. If the pH > 7.45 (alkalosis) and the PaCO2 is < 35mmHg

(hypocapnia), then low CO2 levels and decreased H+

concentration are causing respiratory alkalosis.

d. Step 4

i. Look at the bicarbonate

1. If the HCO3 is < 24 mEq/L, HCO3 levels are lower than normal.

2. If the HCO3 is > 28 mEq/L, HCO3 levels are higher than normal.

e. Step 5

i. Evaluate the pH, HCO3, and BE (Base Excess) for a possible metabolic problem.

1. If the pH is less than 7.35, the HCO3 is less than

24 mEq/L, and the BE is , −3 mEq/L, then low HCO3

levels and high H+ concentrations are causing

metabolic acidosis.

2. If the pH is greater than 7.45, the HCO3 is greater than 28 MEq/L,

and the BE is +3 mEq/L, then high HCO3 levels are causing

metabolic alkalosis