AMADA, KEVIN MOOR N.

BSN - III Source: BOOK & research

ACUTE AND CHRONIC METABOLIC ACIDOSIS

(Base bicarbonate deficit)

CHRONIC:

Metabolic acidosis is a common clinical disturbance characterized by a low pH (Increased H+

Concentration) 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.

AMADA, KEVIN MOOR N. BSN - III Source: BOOK & research

-> 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 the blood.
*The sum of cation (+) is typically greater than anions (-).
Because the blood does not carry an electrical charge, the anion gap reflects normally
unmeasured anions (P.S.P. - or phosphates, sulfates & proteins) in the plasma that increases the
gap by replacing bicarbonate.

THUS, measuring the anion gap is essential in analyzing acid base disorder: FORMULA

Anion Gap: {Na(pos) + K (pos) - [CI (NEGA) + HCO3 (NEGA)]}

OR
Anion Gap: {Na(pos) - [CI (NEGA) + HCO3 (NEGA)]}
*The normal value for an anion gap is 8 to 12 mEq/L if without potassium in the equation.
If K is included then normal values does 12 to 16 mEq/L.

PATHOPHYSIOLOGY\
Normal anion gap results from direct loss of bicarbonate: diarrhea, lower intestinal fistulas,
ureterostomies, and the use of diuretics; early renal insufficiency; excessive administration of
chloride & administration of parenteral nutrition containing bicarbonate and non-bicarbonate
solutes.
Normal anion gap acidosis is also referred to as hyperchloremic acidosis.
High anion gap acidosis results from excessive accumulation of fixed acid.
if increased to 30mEql or more, then a high anion gap metabolic acidosis is present regardless of
the values of pH and HCO3- .
High anion gap occurs in ketoacidosis with starvation. The hydrogen is buffered by HCO3-,
causing the bicarbonate concentration to fall.
In all of these instances abnormally high levels of anions flood the system, increasing the anion
gap above normal limits.

METABOLIC ACIDOSIS IS CHARACTERIZED BY A LOW pH AND LOW PLASMA

BICARBONATE CONCENTRATION.

/////////////////////////////// Produced or negative Normal anion gap High anion gap

//////////// anion gap
Anion gap w/OUT K <8 8-12 mEq//L > 12
AMADA, KEVIN MOOR N. BSN - III Source: BOOK & research

Anion gap w/ K <12 12- 16 mEq/L >16

Clinical significance Hypoproteinemia Normal anion gap High anion gap
metabolic acidosis metabolic acidosis

Clinical Manifestation:
Sign and symptoms of metabolic acidosis vary with the severity.
-Headache; confusion; Drowsiness; Increased respiratory rate and depth; Nausea & vomiting.

-Peripheral vaso dilation and decreased cardiac output occur when the pH drops to less than 7.
-additional physical assessment findings include decreased blood pressure, cold and clammy
skin, dysthymias and shock.

* Chronic metabolic acidosis is usually seen with chronic kidney disease.

ASSESSMENT AND DIAGNOSTIC FINDINGS:

Arterial blood gas are measured and the expected blood gas changes include low bicarbonate
level (less than 22meql) and a low pH (less than 7.35). The cardinal feature of metabolic acidosis
is a decrease in the serum bicarbonate level.

MEDICAL MANAGEMENT:
AMADA, KEVIN MOOR N. BSN - III Source: BOOK & research

Treatment is directed at correcting the metabolic imbalance. If the problem results from
excessive intake chloride, treatment is aimed at eliminating the source of the chloride.
If necessary, gives sodium bicarbonate, However the administration of sodium bicarbonate can
create or cause cardiac arrest during administration and can result into a paradoxical intracellular
acidosis. Therefore, serum potassium is monitored and hypokalemic is corrected and acidosis is
reversed. (balance the piso)

* In chronic metabolic acidosis, treating low serum calcium level comes first to avoid tetany
during the treatment of chronic metabolic acidosis, resulting from an increased pH and decreased
ionized calcium.
> Alkalizing agents may be given.
Medication
Alkalinizing agents: Used to correct the acidosis. (Sodium bicarbonate)
****Therapy
>Intravenous therapy: Set a central venous line for aggressive rehydration.
>Self-care
**Avoid medicinal agents that cause metabolic acidosis like salicylates, acetazolamide and find
alternative medication if necessary
***Avoid alcohol
***Nutrition
***Foods to eat:
Alkaline forming foods like apples, avocados, berries broccoli, onion
***Foods to avoid:
Acid forming foods - alcohol, barley, canned fruits, dried cereal, soft drinks
Foods with excess sugars and calories like biscuits, sausages

> Treatment modalities also includes hemodialysis or peritoneal dialysis.

NURSING CARE PLAN

AMADA, KEVIN MOOR N. BSN - III Source: BOOK & research

ASSESSME DIAGNOSIS PLANNING INTERVEN RATIONAL EVALUATI

NT TION E ON

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ACUTE AND CHRONIC RESPIRATORY ACIDOSIS

Acute and Chronic Respiratory Acidosis (Carbonic Acid Excess) Respiratory acidosis is a
clinical disorder in which the pH is less than 7.35 and the PaCO, is greater than 42 mm Hg and a
compensatory increase in the plasma HCO3 occurs. It may be either acute or chronic.

PATHOPHYSIOLOGY
Pathophysiology 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 PaCO, hypoventilation usually
causes a decrease in PaO2.
*****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 non-emergent situations, such as sleep apnea associated with morbid obesity
and administration of oxygen to a patient with chronic hyper capnia , severe pneumonia, and
acute respiratory distress syndrome.
Respiratory acidosis occurs in diseases that impair respiratory muscles, such as muscular
dystrophy, multiple sclerosis, myasthenia and Guillain-Barré syndrome. Mechanical ventilation
be associated with hypercapnia if the rate of ventilation is inadequate and CO2 retained.

CLINICAL MANIFESTATION
Clinical signs in acute and chronic respiratory acidosis vary.
>Sudden hypercapnia can cause increased pulse and respiratory rate, increased blood pressure,
mental cloudiness or confusion, and a feeling of fullness in head, or a decrease in the level of
consciousness.
>An elevated PaCO2, greater than 60 mm Hg, causes cerebrovascular vasodilation and increased
cerebral blood flow.
***Ventricular fibrillation may be the first sign of respiratory acidosis in anesthetized patients.
AMADA, KEVIN MOOR N. BSN - III Source: BOOK & research

***If respiratory acidosis is severe, intracranial pressure may increase, resulting in papilledema
and dilated conjunctival blood vessels.
Hyperkalemia may result as the hydrogen concentration overwhelms the compensatory
mechanisms and H* moves into cells, causing a shift of potassium out of the cell.
Chronic respiratory acidosis occurs with pulmonary diseases such as chronic emphysema and
bronchitis, obstructive sleep apnea, and obesity.
As long as the PaCO2 does not exceed the body's ability to compensate, the patient will be
asymptomatic. However, if the PaCO, increases rapidly cerebral vasodilation will increase the
intracranial press cyanosis and tachypnea will develop.
Patients with pulmonary disease (COPD) who gradually accumulate a prolonged period (days to
months) may not develop symptoms of hypercapnia because compensatory renal changes have
had time to occur.

Assessment and Diagnostic Findings

Arterial blood gas analysis reveals a pH less than 7.35. PC greater than 42 mm Hg, and a
variation in the bicarbon level, depending on the duration of the acute respiratory acidosis.
When compensation (renal retention of bicarbonate) has fully occurred, the arterial pH is within
the lower limits of normal.
**Depending on the cause of respiratory acidosis, other diagnostic measures include monitoring
of serum electrolyte levels, chest x-ray for determining any respiratory disease, and a drug screen
AMADA, KEVIN MOOR N. BSN - III Source: BOOK & research

if an overdose is suspected. An ECG to identify any cardiac involvement as a result of COPD

may be indicated as well.

Medical Management Treatment

It’s directed at improving ventilation; exact measures vary with the cause of inadequate
ventilation. Pharmacologic agents are used as indicated.
*** treatment for respiratory acidosis
No drugs are used specifically to treat respiratory acidosis. Medical therapies are directed at the
underlying disease or disorder causing hypoventilation and, therefore, respiratory acidosis.

For example, bronchodilators help reduce bronchial spasm, antibiotics are used for respiratory
infections, and thrombolytics or anticoagulants are use pulmonary emboli.

Naloxone hydrochloride (Narcan) May be useful in arousing patient and

Sodium bicarbonate (NaHCO3)
Potassium chloride (KCl)
Bronchodilators
Provide low-carbohydrate, high-fat diet
(Pulmocare feedings), if indicated.
stimulating respiratory function in
presence of drug overdose and
sedation, or acidosis resulting from
cardiac arrest.
May be given in small IV doses in
emergency situations to quickly correct
acidosis if pH is less than 7.25 and
hyperkalemia coexists. Note: Rebound
alkalosis or tetany may occur.
Replaces potassium that shifts out of
cells during acidotic state. Correction of
the acidosis may cause a relative serum
hypokalemia as potassium shifts back
into cells. Potassium imbalance can
impair neuromuscular or respiratory
function, causing generalized muscle
weakness and cardiac dysrhythmias.
Helps open constricted airways to
improve gas exchange.
Helps reduce CO2 production and
improves respiratory muscle function
and metabolic homeostasis.
AMADA, KEVIN MOOR N. BSN - III Source: BOOK & research

Pulmonary hygiene measures are initiated, when necessary, to clear the respiratory tract of
mucus and pure drainage. Adequate hydration (2 to 3 L/day) is indicated to keep the mucous
membranes moist and thereby facilitate the removal of secretions. Supplemental oxygen is given
as necessary.
Mechanical ventilation, used appropriately, may improve pulmonary ventilation. Inappropriate
mechanical ventilation may cause such rapid excretion of CO2 that the kidneys are unable to
eliminate excess bicarbonate quickly enough to prevent alkalosis and seizures.
* For this reason, the elevated CO2 must be decreased slowly.
Placing the patient in a Semi-Fowler position facilitates expansion of the chest wall.
Treatment of chronic respiratory acidosis is the same as for acute respiratory acidosis.

NURSING CARE PLAN

IMPAIRED GAS EXCHANGE

Asessment Diagnosis Planning Intervention Rationale Evaluation
S:o/ Impaired Gas After 4 to 8 >Monitor >Alveolar Goal met,
Exchange hours of respiratory hypoventilati after 4 to 8
o: related to nursing rate, depth, on and hours of
hypercapnia; Ventilation intervention, and effort. associated nursing
dyspnea and perfusion patient will hypoxemia intervention,
exertion imbalance as demonstrate lead to patient
evidenced by improved respiratory demonstrate
Dyspnea with ventilation distress or d improved
exertion, and failure. ventilation
hypercapnia adequate and
oxygenation > Auscultate > Identifies adequate
of tissues as breath areas of oxygenation
evidenced by sounds. decreased of tissues as
ABGs within ventilation evidenced by
patient’s (atelectasis) ABGs within
acceptable or airway patient’s
limits and obstruction acceptable
absence of and changes limits and
symptoms of as patient absence of
respiratory deteriorates symptoms of
distress. or improves, respiratory
reflecting distress
AMADA, KEVIN MOOR N. BSN - III Source: BOOK & research

effectiveness
of treatment,
dictating
therapy
needs.

> Encourage > These

and assist measures
with deep- improve lung
breathing ventilation
exercises, and reduce
turning, and or prevent
coughing. airway
Suction as obstruction
necessary. associated
Provide with
airway accumulation
adjunct as of mucus.
indicated.
Place in semi-
Fowler’s
position

> Monitor
and graph > Evaluates
serial ABGs, therapy need
pulse and
oximetry effectiveness.
readings; Hb, Note:
serum Bedside
electrolyte pulse
levels. oximetry
monitoring is
used to show
early changes
in
oxygenation
before other
signs or
symptoms
are observed.

> Assists in
AMADA, KEVIN MOOR N. BSN - III Source: BOOK & research

> Maintain correction of

hydration acidity and
(IV/PO) and thinning and
provide mobilization
humidificatio of respiratory
n. secretions

> Aids in
>Provide clearing
appropriate secretions,
chest which
physiotherap improves
y, including ventilation,
postural allowing
drainage and excess CO2 to
breathing be
exercises. eliminated.