ACID-BASE BALANCE

 Concentration of hydrogen ion is in extracellular fluid is determined by the ratio of bicarbonate to carbonic acid. The normal
ratio is 20:1. Even when arterial blood gases are abnormal, if the ratio remains at 20:1, no imbalance will occur.

Causes of Blood Gas Abnormalities

1. Decreased PO2
a. Collapsed alveoli (atelectasis)
 Airways obstruction
 By the tongue
 By a foreign body
 Failure to deep breaths
 Pain (rib fracture, pleurisy)
 Paralysis of respiratory muscles (spinal cord injury, poliomyelitis)
 Depression of the respiratory center (head injury, drug overdose)
 Collapse of the whole lung (pneumothorax)
b. Fluid in the alveoli
 Pulmonary edema
 Pneumonia
 Near-drowning
 Chest trauma
c. Other gases in the alveoli
 Smoke inhalation
 Inhalation of toxic chemicals
 Carbon monoxide poisoning
d. Respiratory arrest

2. Elevated PCO2
a. Decreased CO2 elimination (hypoventilation)
 Decreased tidal volume
 Pain (rib fractures, pleurisy)
 Weakness (myasthenia gravis)
 Paralysis (spinal cord injury, poliomyelitis)
 Decreased respiratory rate
 Head injury
 Depressant drugs
 Stroke
b. Increased CO2 production
 Fever
 Muscular exertion
 Anaerobic metabolism

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Types of Acid-Base Balance

1. Acidosis (pH ↓7.35)

 Hydrogen ion concentration INCREASES and pH DECREASES

2. Alkalosis (pH ↑7.45)

 Hydrogen ion concentration DECREASES and pH INCREASES

3. Metabolic imbalances (↓↓, ↑↑)

 Bicarbonate (HCO3-) is the problem. In primary conditions, the level of bicarbonate is DIRECTLY PROPORTIONAL to
pH
a. METABOLIC ACIDOSIS (HCO3- ↓, pH ↓)
 Excessive acid is produced or added to the body, bicarbonate is LOST, or acid is RETAINED due to poorly
functioning kidneys
 DEFICIT of bicarbonate
b. METABOLIC ALKALOSIS (HCO3- ↑, pH ↑)
 Excessive acid is LOST or bicarbonate or alkali is RETAINED
 EXCESS of bicarbonate
c. As compensatory mechanism, PCO2 will be low in metabolic acidosis, as the body attempts to eliminate excess
carbonic acid and elevate pH. PCO2 will become elevated in metabolic alkalosis

4. Respiratory imbalances (↑↓, ↓↑)

 Carbonic acid is the problem. In primary conditions, PCO2 is INVERSELY PROPORTIONAL to the pH
a. RESPIRATORY ACIDOSIS (PCO2 ↑, pH ↓)
 Pulmonary ventilation decreases, causing an ELEVATION in the level of carbon dioxide or carbonic acid
 EXCESS of PCO2
b. RESPIRATORY ALKALOSIS (PCO2 ↓, pH ↑)
 Pulmonary ventilation increases, causing a DECREASE in the level of carbon dioxide or carbonic acid
 DEFICIT of PCO2
c. As a compensatory mechanism, the level of bicarbonate will increase in respiratory acidosis and decrease in
respiratory alkalosis

Normal Arterial Blood Gas Values

pH 7.35-7.45
PaCO2 35-45 mm Hg
HCO3- 22-27 mEq/L
PaO2 80-100 mm Hg
O2 Saturation >95%

Acid-Base Imbalances: Usual Laboratory Value Changes

Imbalance pH HCO3- PaO2 PaCO2 K+
Respiratory acidosis ↓ ↑ ↓ ↑ ↑
Respiratory alkalosis ↑ ↓ Normal ↓ ↓
Metabolic acidosis ↓ ↓ Normal Normal or ↓ ↑
Metabolic alkalosis ↑ ↑ Normal Normal or ↑ ↓

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 Disorder and Related Assessment Nursing Care Plan/ Implementation Evaluation/
Conditions Subjective Data Objective Data Outcome Criteria
Respiratory Acidosis
Acute bronchitis Headache *Hypoventilation: ↓ rate or Assist with normal breathing: Normal acid-base balance
Emphysema Irritability rapid and shallow encourage coughing; suction airway; obtained
Respiratory obstruction Disorientation Cyanosis postural drainage; pursed-lip Respiratory rate: 16-20
Atelectasis Weakness Tachycardia breathing; raise HOB No signs of pulmonary
Damage to respiratory Dyspnea on Diaphoresis Protect from injury: O2 as needed; infection (e.g., sputum
center exertion Dehydration encourage fluids; *AVOID sedation; colorless, breath sounds
Pneumonia Nausea Coma (CO2 narcosis) medication as ordered- antibiotic, clear)
Asthmatic attack Hyperventilation to bronchial dilator Demonstrates breathing
Drug overdose COMPENSATE if no Health teaching: identify the cause, exercises (e.g.,
pulmonary pathology prevent future episodes; ↑ diaphragmatic breathing)
present awareness regarding risk factors
*PaCO2 ↑, pH ↓ and early signs of impending
imbalance; encourage compliance

Metabolic Acidosis
Diabetic ketoacidosis Headache *Kussmaul’s respirations: Restore normal metabolism: correct Normal acid-base balance
Hyperthyroidism Restlessness deep, rapid, air hunger underlying problem; *Na HCO3- obtained
Severe infections Apathy, ↑ Temperature PO/IV; Na Lactate; Fl replacement, No rebound respiratory
Lactic acidosis in shock weakness Vomiting, diarrhea LR; diet: ↑ Cal alkalosis following therapy
Renal failure→ uremia Disorientation Dehydration Prevent complications: regular No tetany following return
Prolonged starvation diet; Thirst Stupor→ convulsions→ insulin for ketoacidosis; hourly of normal pH
low CHON diet Nausea, coma outputs; prepare for dialysis if in Alert, oriented
Diarrhea, dehydration abdominal pain *HCO3- ↓, pH ↓, K+ ↓ kidney failure No signs of K+ excess
Hepatitis Health teaching: identify signs and
Burns symptoms of primary illness, prevent
complications, cardiac arrest; diet
instructions

Respiratory Alkalosis
Hyperventilation→ CO2 loss CIrcumoral *Increased respirations Increase carbon dioxide level: *re- Normal acid-base balance
Hypoxia, high altitudes paresthesia Increased neuromuscular breathing into a PAPER BAG; obtained
Fever Weakness irritability; hyperreflexia, adjusting respirator for CO2 retention Recognizes psychological
Metabolic acidosis Apprehension muscle twitching, tetany, and O2 inspired; correct hypoxia and environmental factors
↑ ICP, encephalitis positive Chvostek’s sign Prevent injury: safety measures for causing condition
Salicylate poisoning Convulsions those who are unconscious; RR returns to normal limits
After intensive exercise Unconsciousness hypothermia for ↑ temperature No cardiac arrhythmias
Hypokalemia Health teaching: recognize stressful Alert, oriented
*PaCO2 ↓, pH ↑ events; counseling if problem is
hysteria

Metabolic Alkalosis
K+ deficiencies Lethargy *Respirations: shallow; Obtain, maintain acid-base balance: Normal acid-base balance
Vomiting Irritability apnea, ↓ thoracic irrigate NG tubes with saline; obtained
GI Suctioning Disorientation movement; cyanosis monitor I&O; IV saline, K+ added; No signs of K+ deficit
Intestinal fistulas Nausea Pulse: irregular→ isotonic solutions; monitor VS Respiratory rate: 16-20
Inadequate electrolyte CARDIAC ARREST Prevent physical injury: monitor for No arrhythmias- regular
replacement Muscles: twitching→ K+ loss, side effects of medications pulse
↑ use of antacids tetany, convulsions Health teaching: ↑ sodium when Lists food sources ↑ K+
Diuretic therapy, steroid G.I.: vomiting, diarrhea, loss expected; instructions regarding
↑ ingestion/injection of paralytic ileus self-administration of medications
bicarbonate *HCO3- ↑, pH ↑, K+ ↓ (e.g., baking soda)

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Analysis/Nursing Diagnosis

1. Impaired gas exchange related to hyperventilation

2. Ineffective breathing pattern related to decreased thoracic movements
3. Ineffective airway clearance related to retained secretions
4. Risk for injury related to poorly functioning kidneys
5. Altered renal tissue perfusion related to dehydration
6. Altered injury elimination related to renal failure
7. Fluid volume excess related to altered kidney function
8. Fluid volume deficit related to diarrhea or dehydration
9. Knowledge deficits (learning need) related to self-administration of antacid medications

Arterial Blood Gases

A. Collection of an arterial blood gas specimen

1. Obtain vital signs
2. Determine whether the client has an arterial line in place
3. Perform the ALLEN’S TEST to determine the presence of collateral circulation
4. Assess factors that may affect the accuracy of the results, such as changes in the O 2 settings, suctioning within the last 20
minutes, and client’s activities
5. Provide emotional support to the client
6. Assist with the specimen draw by preparing a HEPARINIZED syringe
7. Apply pressure immediately to the puncture site following the blood draw; maintain pressure for 5 minutes or for 10
minutes if the client is taking anticoagulants
8. Appropriately label the specimen and transport it on ice to the laboratory
9. On the laboratory form, record the client’s temperature and the type of supplemental oxygen that the client is receiving

*PERFORMING THE ALLEN’S TEST

 Apply direct pressure over the client’s ulnar and radial arteries simultaneously
 While applying the pressure, ask the client to open and close the hand repeatedly; the hand should blanch
 Release pressure from the ulnar artery while compressing the radial artery and assess the color of the extremity
distal to the pressure point
 In pinkness fails to return within 6 seconds, the ulnar artery is insufficient, indicating that the radial artery should
NOT be used for obtaining a blood specimen

B. Respiratory acid-base imbalances

1. Remember, the respiratory function indicator is the PaCO2
2. In a respiratory imbalance, you will find an opposite relationship between the pH and the PaCO 2; in other words, the pH
will be elevated with a decreased PaCO2 (ALKALOSIS) or the pH will be decreased with an elevated PaCO2 (ACIDOSIS)
3. Look at the pH and the PaCO2 to determine whether the conditions is a respiratory problem
4. RESPIRATORY ACOSIS: the pH is decreased; the PaCO2 is elevated
5. RESPIRATORY ALKALOSIS: the pH is elevated; the PaCO2 is decreased

C. Metabolic acid-base imbalances

1. Remember, the metabolic function indicator is the bicarbonate ion (HCO3-)

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 2. In metabolic imbalance, you will find a corresponding relationship between the pH and the HCO3-; in other words, the pH
will be elevated and the HCO3- will be elevated (alkalosis), or the pH will be decreased and the HCO 3- will be decreased
(acidosis)
3. Look at the pH and the HCO3- to determine whether the condition is a metabolic problem.
4. METABOLIC ACIDOSIS: the pH is decreased; the HCO3- is decreased
5. METABOLIC ALKALOSIS: the pH is elevated; the HCO3- is elevated

D. Compensation
1. Respiratory acidosis and respiratory alkalosis
a. When COMPENSATION has occurred, the pH will be within NORMAL limits
b. The blood gas results reflects PARTIAL COMPENSATION if the HCO3- is ABNORMAL
c. The blood gas result reflects an UNCOMPENSATED condition if the HCO3- is NORMAL
2. Metabolic acidosis and metabolic alkalosis
a. When COMPENSATION has occurred, the pH will be within NORMAL limits
b. The blood gas result reflects PARTIAL COMPENSATION if the PaCO2 is ABNORMAL
c. The blood gas result reflects an UNCOMPENSATED condition if the PaCO2 is NORMAL

E. Steps for analyzing arterial blood gas results

1. Look at the blood gas report. Look at the pH. Is the pH elevated or decreased? If the pH is elevated, it reflects
ALKALOSIS. If the pH is decreased, it reflects ACIDOSIS
2. Look at the PaCO2. Is the PaCO2 elevate or decreased? If the PaCO 2 reflects an opposite relationship to the pH, then you
know that the condition is respiratory imbalance. If the PaCO2 does not reflect an opposite relationship to the pH, then
move on to step 3
3. Look at the HCO3-. Does the HCO3- reflect a corresponding relationship with the pH? If it does, then the condition is a
metabolic imbalance
4. Remember, COMPENSATION has occurred if the pH is in a NORMAL range of 7.35 to 7.45. If the pH is not within normal
range, look at the respiratory or metabolic function indicators.
5. Respiratory imbalances
a. If the condition is a respiratory imbalance, look at the HCO3- to determine the state of compensation
b. If the HCO3- is NORMAL, then the condition is UNCOMPENSATED
c. If the HCO3-, ABNORMAL, then the condition is PARTIAL COMPENSATION
6. Metabolic imbalances
a. If the condition is a metabolic imbalance, look at the PaCO2 to determine the state of compensation
b. If the PaCO2 is NORMAL, then the condition is UNCOMPENSATED
c. If the PaCO2 is ABNORMAL, then the condition is PARTIAL COMPENSATION