Acid-Base Balance

—Body has a remarkable ability to maintain plasma pH with a narrow range of 7.35-
7.45
—Best way to measure is via arterial blood gases (ABG)
—Most important of homeostatic mechanisms

Death – 6.8 Acidosis – 7.35 Normal – 7.45 Alkalosis Death – 7.8

Acidosis
—Low pH (<7.35)
—High H+ concentration
—HCO3- below normal

Alkalosis
—High pH (>7.45)
—Low H+ concentration
—HCO3- above normal

Arterial Blood Gases (ABG) (p. 202 text)

7.40/40/90/26/98%
pH = 7.35-7.45
paCO2 = 35-45 mm Hg
paO2 = 80-100 mm Hg
HCO3- = 21-28meq/L
Oxygen saturation = 95%-100%

Regulation of Acid Base

—Chemical Buffer System
- proteins
- chemicals (bicarbonate and phosphate)
—Lungs
—Kidneys

Regulation
CO2 + H2O = H2CO3
H2CO3 = H+ + HCO3-
—Normal ratio of 20 HCO3- to 1 H2CO3-
—If ratio is disturbed then imbalance will occur and the pH will be changed
—RATIO IS IMPORTANT – NOT ABSOLUTE VALUES
BICARBONATE 20 PARTS: 1 PART CARBONIC ACID

Regulation – Lungs
—Very large surface area from which CO2 can diffuse
—Lungs remove CO2 from the body in response to increases in H+ concentration
—Hyperventilation – CO2 is “blown off”
—CO2 has the most profound effect on respirations
Lungs retain or expel CO2 based on what is needed.
When RR goes high, CO2 level will drop.
When CO2 level increases, RR decreases.
Not as powerful as regulation of kidneys; quick fix.
Regulation – Kidneys – PRIMARY ORGAN FOR ACID-BASE REGULATION
—Works slowly; lasts longer
—Powerful and efficient
—One of major function – HCO3- regulation
—Vital role in pH regulation
—CO2+H2O <->H2CO3 <->H+ + HCO3
Kidney picks up excess CO2 from blood capillary. CO2 combines with H2O in kidney
to create carbonic acid -> turns into bicarbonate.

Disturbances – Metabolic Acidosis

Decrease in pH
HCO3- deficit or H+ excess
Causes: CRF, aspirin overdose, ketoacidosis, diarrhea (losing bicarb, Na, K)
Manifestations: H/A, confusion, ↑ RR, N/V
Interventions: correct underlying problem, IV HCO3-, observe for hyperkalemia

Disturbances – Metabolic Alkalosis

HCO3- excess or loss of H+
High pH
Causes: vomiting (losing hydrogen, postassium), gastric suction, antacids
Manifestations: dizziness, irritability, tingling of digits (hypocalcemia may occur),
decrease RR
Intervention: reverse underlying disorder, increase Cl- to absorb Na+ resulting in
excretion of HCO3-, Observe for hypokalemia

Disturbances – Respiratory Acidosis

H2CO3- excess (CO2 excess)
Causes: cardiac/respiratory arrest, COPD, overdose of sedatives
Manifestations: mental changes, headache, feeling of fullness in head, dizziness,
coma, hyperkalemia
Interventions: IMPROVE VENTILATION!
(bronchodilators, mechanical ventilation, CPT, hydration, incentive spirometer)
administer bicarbonate is questionable – ONLY IF LEVELS LOW

Disturbances – Respiratory Alkalosis

H2CO3- deficit (low CO2 levels)
Causes: hyperventilation, aftermath of severe exercise, anxiety
Manifestations: “Hyperventilation Syndrome” (palpitations, lightheadedness,
sweating, dry mouth, N/V, epigastric pain)
Interventions: eliminate cause, control breathing, breathe into closed system

Compensation Is the ABG ….

Uncompensated – condition has ocurred to change pH but mechanisms have not
kicked in

Partially Compensated – pH is still abnormal but either CO2 or bicarb has changed

Completely Compensated – pH is normal but bicarb and CO2 are abnormal (ratio is
not 20:1)

Steps for ABG Analysis

Look at the pH
if arrow up alkalosis,
if arrow down acidosis

Look at CO2 & HCO3

Determine if values are elevated or down – place arrows

Determine compensation:
1. A normal value in the CO2 or HCO3 = uncompensated
2. No normal values = partially compensated
3. A normal value in pH with other abnormal values = completely compensated

Determine type of imbalance

If all (CO2, HCO3 and pH) arrows are in the same directions = metabolic imbalance
If CO2 and HCO3 are opposite the pH = respiratory imbalance

Sample ABG
Determine Imbalance: 7.48/30/90/24/95% - uncompensated respiratory alkalosis

7.30/50/30 - partially compenstaed respiratory acidosis

7.4/40/90/96% - no imbalance

Student nurse begins to hyperventilate and recalls that her condition unless treated
will result in --- respiratory alkalosis (blowing off CO2)

Which patient is most likely to have respiratory acidosis? The patient --- with rib
fractures (retaining CO2 because of pain when ventilating)