NUTRITION AND DIET

| Chapter 6

Topic Outline:
● Acid-base imbalances
● Fluids requirement by weight

ACID BASE IMBALANCES

ACID-BASE BALANCE
 Acid - Base balance is primarily concerned with
two ions:
o Hydrogen (H+)
o Bicarbonate (HCO3-)
 Derangements of hydrogen and bicarbonate
concentrations in body fluids are common in
disease processes
Regulatory mechanisms to maintain normal pH
 Normal blood pH: 7.35-7.45
CHEMICAL BUFFERS
 Normal acid-base ratio is 1:20; 1 part acid to 2
 Carbonic acid-bicarbonate buffer system
parts bicarbonates
 Hemoglobin-oxyhemoglobin buffer system
 The concentration of hydrogen ions in body
 Protein buffer
fluids determines acidity or alkalinity
 Phosphate buffer system
 Acids release H+ ions, alkaline accepts H+ in
solution  React very rapidly (less than a second)
 pH reflects the balance between:  The body uses pH buffers in the blood to guard
o carbon dioxide (regulated by the lungs); against sudden changes in acidity
and  A pH buffer works chemically to minimize
o bicarbonates (regulated by the kidneys) changes in the pH of a solution
ACID-BASE REGULATION
H+ ION
1. The Bicarbonate (HCO3-) Buffer System
 has special significance because of the narrow
ranges that it must be maintained in order to be
H+ + HCO3- H2CO3 H2O + CO2
compatible with living systems
 reversible depending on the equilibrium between
EFFECTS OF PH
the substrates and products.
 The most general effect of pH changes are on
 The lungs constantly remove CO2
enzyme function
REGULATORY MECHANISMS TO MAINTAIN NORMAL
o Also affect excitability of nerve and pH
muscle cells RESPIRATORY COMPENSATION
o v pH v Excitability  Second-line defense against acid-base imbalance
o ^pH ^Excitability  Works within seconds to minutes
 Partial pressure of carbon dioxide in arterial
blood (PaCO2) reflects carbon dioxide levels
RESPIRATORY REGULATION
 Carbon dioxide is an important by-product of
 metabolism and is constantly produced by cells
 The blood carries carbon dioxide to the lungs
where it is exhaled
 When breathing is increased, the blood carbon
dioxide level decreases and the blood becomes
more Base

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  When breathing is decreased, the blood carbon oCardiac arrest, trauma, ingestion of
dioxide level increases and the blood becomes foreign body
more Acidic  Chronic: long term pulmonary disease
 By adjusting the speed and depth of breathing, o Emphysema, asthma
the respiratory control centers and lungs are able CAUSES: RESPIRATORY ACIDOSIS
to regulate the blood pH minute by minute  Drugs that depress the respiratory control
 Lungs regulate the respiratory side of acid base center’s sensitivity (narcotics, sedatives,
disturbances anesthetics)
o Lungs are fast  CNS trauma/ lesions which impair ventilatory
o Indicator is carbon dioxide (CO2) drive
o Carbon dioxide is POTENTIAL ACID  Chest wall trauma leading to pneumothorax
RENAL COMPENSATION  Neuromuscular disorders (GBS, MG,
 Regulate HCO3 ion concentration in ECF and poliomyelitis)
excrete acid by-products of metabolism  Asphyxia
 Reacts slowly (minutes to hours)  Parenchymal lung disease (COPD)
 Acidemia results in renal elimination of excess  Iatrogenic factors
hydrogen ions which may combine with
phosphate or ammonia to form titratable acids,
thus increasing blood pH
 Alkalosis results in renal elimination of
bicarbonates usually with sodium ions thus
decreasing Ph
KIDNEY REGULATION
 Excess acid is excreted by the kidneys, largely
in the form of ammonia
 The kidneys have some ability to alter the
amount of acid or base that is excreted, but this
generally takes several days S/Sx: RESPIRATORY ACIDOSIS
ARTERIAL BLOOD GAS  Dyspnea
 Reflects acid-base balance throughout the entire  Shallow, rapid respirations
body better than venous blood
 Tachycardia
 Provides information about the effectiveness of
 Headache (dull)
the lungs in oxygenated blood
 Sleep disturbances
 Diaphoresis
Elements Normal Significance  ↓ deep tendon reflexes
Measured Value  Confusion – stupor – coma
pH 7.35 – 7.45 Reflects H+ ion  Cyanosis
concentration  Tachypnea, hypoventilation with hypoxia
PaCO2 35 – 45 Partial pressure of CO2 Dx TEST RESULT
mmHg in arterial blood  ABG:ph<7.35 and PaCO2>45 mmHg
PaO2 80 -100 Partial pressure of O2 in  S.electrolytes: K+ mEq/L – Hyperkalemia
mmHg arterial blood *<80 ABG FINDINGS: RESPIRATORY ALKALOSIS
mmHg - hypoxemia pH PaCO2 HCO3-
Uncompensated
HCO3- 22- 26 Bicarbonate Above
7.45
Below
35
normal

mEq/L concentration in plasma Partially Above Below Below

RESPIRATORY ACIDOSIS Compensated 7.45 35 22

 PaCO2 is greater than 45 mmHg and pH <7.35 Below Below

Normal or 22
Compensated above 7.45 35

 Underlying mechanism: alveolar NURSING INTERVENTIONS

hypoventilation
 Acute: sudden failure in ventilation

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  Stay with the patient during periods of extreme  Reduce environmental stimuli, orient pt. as
stress and anxiety, decrease environmental needed
stimuli  Provide good oral hygiene
 Administer sedatives or anti-anxiety drugs  Monitor respiratory function and ABG results
 Administer O2  Eliminate underlying condition e.g. insulin to
 Instruct client to breathe in a paper reverse DKA
bag/rebreather mask  Monitor I & O
 Provide undisturbed sleep periods METABOLIC ALKALOSIS
METHABOLIC ACIDOSIS  Characterized by bld pH > 7.45 accompanied by
 Base bicarbonate deficit serum HCO3 level above 26 mEq/L
 Bld pH: < 7.35 and serum bicarbonate less than  Underlying mechanism:
22 mEq/L o dec metabolic acids
o Inc base bicarbonates

CAUSES: METABOLIC ACIDOSIS

 Ketoacidosis
 Lactic acidosis
 Renal insufficiency and failure
 Excessive GI losses
 Poisoning and drug toxicity
 hypoaldosteronism
S/Sx: METABOLIC ACIDOSIS
 Confusion, stupor, coma
 Hypotension
 Tachypnea: Kussmaul’s respiration – deep &
rapid
 Warm flush skin
 Diminished deep tendon reflexes
 Arrhythmias, bradycardia, cardiac arrest
 Weakness, fatigue
Dx TESTS
 ABG: ↓pH ↓PaCO2
 Serum K+ elevated
 Glucose and ketones ↑ in DM
pH PaCO2
Uncompensated
Above
normal
7.35
CAUSES: METABOLIC ALKALOSIS
 Excessive acid losses from the GI tract
 Drugs: diuretics, corticosteroids and antacids
 Massive blood transfusion
 Cushing’s disease – causes Na and Cl retention
and loss of H+ and K+
 Chronic vomiting – excessive loss of H+ ion
 Continuous GI suctioning
S/Sx: METABOLIC ALKALOSIS
 Paresthesia
 Slow, shallow respirations
 Tetany
 Seizures
 Bradycardia
 Irritability progressing to confusion and coma
Dx TESTS
 ABG: ↑ pH ↑ HCO3
HCO3-  S. electrolytes: decrease serum K+, Ca++ and
Below Cl-
 ECG: low T wave
22

Partially Above Below Below

Compensated 7.35 35 22
ABG FINDINGS: METABOLIC ALKALOSIS
Compensated
Normal or
Slightly lower
Below
35
Below
22 pH PaCO2 HCO3-
Uncompensated
NURSING INTERVENTION Above
7.45
normal
Below
26

 Administer sodium bicarbonate if prescribed Partially Above Below Below

Compensated 45 26

7.45
Position pt. to promote chest expansion and Below
Normal or Below
facilitate breathing compensated Slightly lower 45 26

NURSING INTERVENTIONS

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 Administer IV solution containing potassium 2. PaCO2 shows circulating CO2 is high, and as
 Observe seizure precautions, provide safe CO2 is related directly to the respiratory system,
environment and orient patient as needed this indicates respiratory acidosis.
 Irrigate NG tube with 0.9% sodium chloride 3. Since there is no HCO3 -, there is no response
instead of plain H2O to prevent loss of gastric yet from the kidneys to the acidosis.
electrolytes example
 Observe ECG for arrhythmias  Respiratory Acidosis: Partial Compensated
 Watch for muscle weakness, tetany Phase With the partial compensated phase, all
 Monitor I&O the values are out of balance and the kidneys
 Assess pts. LOC frequently begin to respond.
QUICK ABG INTERPRETATION o PH - decrease
 Check the pH o PaCO2 - increase
o Below 7.35- acidosis o HCO3 - increase
o Above 7.45-alkalosis 1. pH is still acidotic.
2. PaCO2 is high and shows that the respiratory
 Determine PaCO2
system is still the reason for the acidosis.
o If it’s abnormal
3. The kidneys are starting to respond to the
o Normal = 35-45 mm Hg
acidosis by increasing the amount of circulating
o Hyperventilation < 35 mmHg (“blowing HCO3
it off”)  Respiratory Acidosis: Full Compensation Phase
o Hypoventilation > 45 mmHg With full compensation, the pH returns to a low
(“retaining”) normal range - which was the goal in the first
 Watch HCO3 place, but PaCO2 and HCO3- levels are still
 Look for compensation- more closely high
corresponds to change in pH o PH - Normal
o Complete- pH falls within normal limits o PaCO2 - increase
o Partial- pH outside normal range o HCO3- increase
1. pH has returned to normal.
pH -7.29 ACIDOSIS 2. PaCO2 is still high due to hypoventilation.
PaCO2- 17 ALKALOSIS 3. HCO3- is high to correct the acidosis.
HCO3-19 ACIDOSIS ABG FINDINGS: RESPIRATORY ACIDOSIS
Met. acidosis w/ compensatory respiratory pH PaCO2 HCO3-
alkalosis Uncompensated Below Above


normal
Determine the PaO2 & SaO2 Partially
7.35 45

Below
COMPENSATION Compensated 7.35
Above
45
Above
26

 Uncompensated phase - The onset of the compensated Normal or Above Above

problem ABG FINDINGS:

below 7.35RESPIRATORY ALKALOSIS
45 26

 Partial compensation phase - Shows which pH PaCO2 HCO3-

Uncompensated
system and to what extent the compensatory Above
7.45
Below
35 normal

mechanism is responding Partially Above Below Below

Compensated 35


7.45 22
Full compensation phase - Shows what systems compensated Below
Normal or Below
are involved in the correction of the body's pH above 7.45 35 22

imbalance ABG FINDINGS: METABOLIC ACIDOSIS

 Respiratory Blood Gas Imbalances Respiratory pH PaCO2 HCO3-
Acidosis: Uncompensated Phase Uncompensated Above Below
7.35 normal 22
o PH - decrease Partially Above Below Below

o PaCO2 - increase Compensated 7.35 35 22

compensated Below
o HCO3 - normal Normal or
Slightly lower
Below
35 22

ABG FINDINGS: METABOLIC ALKALOSIS

pH PaCO2 HCO3-
1. pH is low because of the existing acidosis Uncompensated
Above Above
7.45 normal 26

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 2) Total the amount of losses: 1
Partially
Compensated
Above
7.45
Above
45
Above
26
glass=8 oz;1 oz=30 ml 8 glasses x 8
compensated Normal or Above Above oz / glass x 30 ml / oz = 1920ml
3) Then compare with theTBW,
45 26
slightly above

1.92L / 100 L = 1.92% of water loss

= mild DHN
FLUID REQUIRMENTS BY WEIGHT
Weight Water requirement
0-10kg 4ml/kg/hr
10-20kg 40ml/hr+2ml/kg/hr for each kg>10kg
>20kg 60ml/hr+1ml/kg/hr for each kg>20kg
If patient weighs 8 kg, then
= 8 kg x 4 ml / kg / hr
ADDENDUM TO FLUID IMBALANCE = 32 ml/hr or 768 ml/day( 32x24)
FACTORS AFFECTING WATER CONTENT
 AGE If patient weighs 18 kg, then
 Percentage of TBW of human body: = 40ml/hr + (8kg x 2ml/kg/hr)
o Fetus – 100% = 40ml/hr + 16ml/hr = 56ml/hr or 1344ml/day
o At birth – 80% What if, the patient weighs
o Adult male – 60% Weight Fluid requirement by weight
o Elderly – 50% 75kg 60ml/hr + (55kg x 1ml/kg/hr) = 115 ml/hr
DEGREE OF DEHYDRATION 45kg 60ml/hr + (25kg x 1ml/kg/hr) = 85 ml/hr
1. Mild - 1-2L of water lost or 2% of BW 19kg 40ml/hr + (9kg x 2ml/kg/hr) = 58 ml/hr
2. Moderate – 3-5L of water lost or 6% of BW 2.5kg 2.5kg x 4 ml/kg/hr = 10 ml/hr
3. Severe – 5-10L of water lost or 9% of BW 15kg 40ml/hr + (5kg x 2ml/kg/hr) = 50 ml/hr
If for 24 hours,
EXAMPLE OF ASSESSMENT OF DEGREE OF  115 ml/hr * 24 hrs = 2760 ml/day
DEHYDRAAATION  85 ml/hr * 24 hrs = 2040 ml / day
 58 ml/hr * 24 hrs = 1392 ml / day
1) An 8 month old 7 kg infant with who vomited 3  10 ml/hr * 24 hrs = 240 ml /day
times approximately of 200 ml of fluid and had
 50 ml/hr * 24 hrs = 1200 ml /day
5 episodes of diarrhea totaling to about 280 ml.
Assess for the Degree of Dehydration
Answer:
1) Calculate the TBW for patient,
7 kg x .8 (% of TBW) = 5.6kg or 5.6 L
of fluid
2) Total the amount of losses,
200 + 280 ml = 480 ml
3) Then compare with the TBW
480ml / 5600 ml = 8.5% of water loss =
mod. DHN
2) An 200kg elderly client is rushed into the
hospital for severe episodes of diarrhea.
According to the client, he vomited
approximately 8 glasses of water. Assess the
Degree of DHN.
Answer:
1) Calculate the TBW for patient,
kg x .5 (% of TBW) = 100L

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