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The body has the remarkable ability to maintain plasma pH within the narrow range of
7.35ƛ7.45. It does so by means of chemical buffering mechanisms by the kidneys and the
lungs. Although single acid-base (e.g., metabolic acidosis) imbalances do occur, mixed acid-
base imbalances are more common (e.g., metabolic acidosis/respiratory acidosis as occurs
with cardiac arrest).
Metabolic acidosis (primary base bicarbonate [HCO3] deficiency) reflects an excess of acid
(hydrogen) and a deficit of base (bicarbonate) resulting from acid overproduction, loss of
intestinal bicarbonate, inadequate conservation of bicarbonate, and excretion of acid, or
anaerobic metabolism. Metabolic acidosis is characterized by normal or high anion gap
situations. If the primary problem is direct loss of bicarbonate, gain of chloride, or
decreased ammonia production, the anion gap is within normal limits. If the primary
problem is the accumulation of organic anions (such as ketones or lactic acid), the condition
is known as high anion gap acidosis. Compensatory mechanisms to correct this imbalance
include an increase in respirations to blow off excess CO2, an increase in ammonia
formation, and acid excretion (H+) by the kidneys, with retention of bicarbonate and
sodium.
High anion gap acidosis occurs in diabetic ketoacidosis; severe malnutrition or starvation,
alcoholic lactic acidosis; renal failure; high-fat, low-carbohydrate diets/lipid administration;
poisoning, e.g., salicylate intoxication (after initial stage); paraldehyde intoxication; and
drug therapy, e.g., acetazolamide (Diamox), NH4Cl.
Normal anion gap acidosis is associated with loss of bicarbonate form the body, as may
occur in renal tubular acidosis, hyperalimentation, vomiting/diarrhea, small-
bowel/pancreatic fistulas, and ileostomy and use of IV sodium chloride in presence of
preexisting kidney dysfunction, acidifying drugs (e.g., ammonium chloride).
CARE SETTING
This condition does not occur in isolation but rather is a complication of a broader problem
that may require inpatient care in a medical-surgical or subacute unit.
RELATED CONCERNS
Plans of care specific to predisposing factors
Renal dialysis
ACTIVITY/REST
CIRCULATION
ELIMINATION
FOOD/FLUID
NEUROSENSORY
RESPIRATION
SAFETY
TEACHING/LEARNING
(Questran)
Discharge plan
DIAGNOSTIC STUDIES
Anion gap: Higher than 14 mEq/L (high anion gap) or range of 10ƛ14 mEq/L (normal anion
gap).
Urine pH: Decreased, less than 4.5 (in absence of renal disease).
NURSING PRIORITIES
1. Achieve homeostasis.
2. Prevent/minimize complications.
3. Provide information about condition/prognosis and treatment needs as appropriate.
DISCHARGE GOALS
Because no current nursing diagnosis speaks clearly to metabolic imbalances, the following
interventions are presented in a general format for inclusion in the primary plan of care.
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