INTRODUCTION

✘ Acid–base disturbances are commonly encountered in

clinical practice, especially in critical care units.
Identification of the specific acid–base imbalance is
important in ascertaining the underlying cause of the
disorder and determining appropriate treatment.
✘ Plasma pH is an indicator of hydrogen ion (H+)
concentration and measures the acidity or alkalinity of the
blood (Grossman & Porth, 2014). Homeostatic
mechanisms keep pH within a normal range (7.35 to 7.45)
(Emmett, 2014). These mechanisms consist of buffer
systems, the kidneys, and the lungs.
 LEARNING OBJECTIVES:
At the end of the class the students will be able
to:
1. Have an understanding of the difference between acid
and base.
2. Identify the normal values for ABG.
3. Know what is the importance of the Buffer system.
4. Differentiate the types of Acid-base Imbalance/
Disturbance.
5. Know the appropriate Nursing intervention associated
with Acid-Base Disturbance problems.
GLOSSARY
✘ Acid- is a type of compound that contains
the hydrogen ion and are hydrogen donors.
✘ Base- is a compound that contains no
hydrogen ion and are hydrogen acceptors.
Hydrogen Ions (H+)
✘ The more Hydrogen ions, the more acidic
the solution and the lower the pH.

✘ The lower Hydrogen concentration, the

more alkaline the solution and the higher
the pH.
pH
✘ The Acidity or Alkalinity of a solution that
is measured as pH
✘ The more acidic a solution, the lower the
pH
✘ The more alkaline a solution the higher the
pH
✘ The normal pH lebel of Arterial Blood is
7.35-7.45
 Buffer System
✘ Buffer systems prevent major changes in the pH of
body fluids by removing or releasing H+; they can act
quickly to prevent excessive changes in H+
concentration. Hydrogen ions are buffered by both
intracellular and extracellular buffers. The body’s
major extracellular buffer system is the bicarbonate–
carbonic acid buffer system, which is assessed when
arterial blood gases are measured.
 Respiratory Regulation
✘ The lungs, under the control of the medulla, control
the CO2 and thus the carbonic acid content of the
ECF. They do so by adjusting ventilation in
response to the amount of CO2 in the blood.
✘ ph may be regulated by altering the sate and
respirations.
✘ Changes in ph may change within minutes
✘ Normal CO2 level: 35-45mmHg
 Renal Regulation
✘ The kidneys regulate the bicarbonate level in the
ECF; they can regenerate bicarbonate ions as well
as reabsorb them from the renal tubular cells.
✘ Long-term regulator of acid-base balance
✘ Have a slower response, may take hours to days
to correct.
✘ They maintain balance by excreting or conserving
HCO3 and H+
Factors Affecting Balance
✘ Age- especially infants and elderly
✘ Gender and body size
✘ Environmental Temperature
✘ Lifestyle
Acid-Base Imbalances
✘ Metabolic Acidosis
✘ Metabolic Alkalosis

✘ Respiratory Acidosis
✘ Respiratory Alkalosis
METABOLIC
ACIDOSIS
 Metabolic Acidosis
✘ Metabolic acidosis is a common clinical disturbance
characterized by a low pH and a low plasma bicarbonate
concentration.
✘ It can be produced by a gain of hydrogen ion or a loss of
bicarbonate. It can be divided clinically into two forms,
according to the values of the serum anion gap: high anion
gap acidosis and normal anion gap acidosis.
✘ The anion gap refers to the difference between the sum of all
measured positively charged electrolytes (cations) and the
sum of all negatively charged electrolytes (anions) in blood.
Risk factors/ Etiology
✘ Conditions that increase acids in the blood
✗ Renal failure
✗ DKA
✗ Starvation
✗ Lactic acidosis

✘ Prolonged diarrhea
✘ Toxins
✘ Carbonic anhydrase inhibitors- diamax
Metabolic Acidosis
✘ Symptoms
✗ Kussmaul’s respiration
✗ Lethargy, confusion, headache, weakness
✗ Nausea and Vomiting
✗ pH < 7.35
✗ HCO3 < 22
✘ Treatment
✗ Treat underlying cause
✗ Monitor ABG, I and O, VS, LOC
METABOLIC
ALKALOSIS
 Metabolic Alkalosis
✘ Metabolic alkalosis is a clinical disturbance
characterized by a high pH and a high
plasma bicarbonate concentration. It can be
produced by a gain of bicarbonate or a loss
of H+ (Grossman & Porth, 2014; Rogers &
McCutcheon, 2013).
Risk factors/ Etiology
✘ Acid loss due to
✗ Vomiting
✗ Gastric suction

✘ Loss of potassium
✗ Steroids
✗ Diuresis

✘ Antacids
Metabolic Alkalosis
✘ Symptoms:
✗ Hypoventilation
✗ Dysrhythmias, dizziness
✗ Parenthesia, numbness, tingling of extremities
✗ Hypertonic muscles, tetany
✗ pH >7.45
✗ HCO3 >26

✘ Treatment
✗ Treat underlying cause
✗ I and o, VS, LOC
✗ Give potassium
RESPIRATORY
ACIDOSIS
 RESPIRATORY
ACIDOSIS
✘ Respiratory acidosis is always owing to
inadequate excretion of CO2 with inadequate
ventilation, resulting in elevated plasma CO2
concentrations and, consequently, increased
levels of carbonic acid. In addition to an
elevated PaCO2, hypoventilation usually
causes a decrease in PaO2 (Rogers &
McCutcheon, 2013).
 RESPIRATORY
ACIDOSIS
✘ Acute respiratory acidosis occurs in emergency
situations, such as acute pulmonary edema,
aspiration of a foreign object, atelectasis,
pneumothorax, and overdose of sedatives, as well as
in nonemergent situations, such as sleep apnea
associated with morbid obesity and administration
of oxygen to a patient with chronic hypercapnia
(excessive CO2 in the blood), severe pneumonia,
and acute respiratory distress syndrome.
ETIOLOGY
✘ COPD
✘ Neuromuscular Disease
✘ Respiratory Center Depression
✘ Late ARDS
✘ Inadequate mechanical ventilation
✘ Sepsis or burns
✘ Excess carbohydrate intake
Respiratory Acidosis
✘ Symptoms ✘ Treatment
✗ Dyspnea, ✗ Treat underlying
disorientation or cause
coma, ✗ Support
dysrhythmias ventilation
✗ Hyperkalemia or ✗ Correct electrolyte
hypoxemia imbalance
✗ pH <7.35 ✗ IV sodium bicarb
✗ PaCO2 >
45mmHg
Respiratory
Alkalosis
 Respiratory Alkalosis
✘ Always caused by hyperventilation, which
causes excessive “blowing off” of CO2 and,
hence, a decrease in the plasma carbonic acid
concentration. Causes include extreme anxiety,
hypoxemia, early phase of salicylate
intoxication, gram-negative bacteremia, and
inappropriate ventilator settings.
Risk factors/ Etiology
✘ Hyperventilation due to:
✗ Extreme anxiety, stress or pain
✗ Elevated body temperature
✗ Overventilation
✗ Hypoxia
✗ Hypoxemia
✗ CNS trauma or tumor
Respiratory Alkalosis
✘ Symptoms
✗ Tachypnea or hyperpnea
✗ Complains of SOB, chest pain
✗ Lightheadedness, syncope, some, seizure
✗ Numbness and tingling of extremities
✗ Difficult concentration, tremors, blurred vision
✗ Weakness, paresthesia, tetany
✗ pH > 7.45
✗ CO2 < 35
Respiratory Alkalosis
✘ Treatment
✗ Treat underlying cause
✗ Monitor VS and ABG
✗ Help client breath slowly
✗ sedation
Mixed Acid-Base
Disorder
 Mixed Acid-Base
Disorder
✘ Patients can simultaneously experience two or
more independent acid–base disorders. A normal
pH in the presence of changes in the PaCO2 and
plasma HCO3− concentration immediately
suggests a mixed disorder.
 Mixed Acid-Base
Disorder
✘ An example of a mixed disorder is the
simultaneous occurrence of metabolic acidosis
and respiratory acidosis during respiratory and
cardiac arrest. The only mixed disorder that
cannot occur is a mixed respiratory acidosis and
alkalosis, because it is impossible to have
alveolar hypoventilation and hyperventilation at
the same time.
 Compensation
✘ Generally, the pulmonary and renal systems compensate
for each other to return the pH to normal. In a single
acid–base disorder, the system not causing the problem
tries to compensate by returning the ratio of bicarbonate
to carbonic acid to the normal 20:1. The lungs
compensate for metabolic disturbances by changing CO2
excretion. The kidneys compensate for respiratory
disturbances by altering bicarbonate retention and H+
secretion.
How to interpret ABG results
ABG interpretation
✘ Look at the ph level
✘ Check the CO2 ( respiratory indicator)
✘ Check the HCO3 (metabolic indicator)
✘ Identify what is the primary disorder
✗ If pH is low (acidosis), then see if the CO2 or HCO3 is acidosis
✗ If the pH is high (alkalosis), then see if the CO2 and HCO3 is
Alkalosis

✘ Identify if its compensated or

uncompensated
✘ pH-7.25 ✘ pH- 7.25 ✘ pH 7.56
✘ PaCO2-50 ✘ PaCO2- 37 ✘ PaCO2- 40
✘ HCO3-24 ✘ HCO3 21 ✘ HCO3- 35
✘ pH- 7.35 ✘ pH-7.44 ✘ pH-7.50
✘ PaCO2- 49 ✘ PaCO2- 48 ✘ PaCO2- 50
✘ HCO3- 30 ✘ HCO3-35 ✘ HCO3- 41