CHAPTER 45

UNIT 6 NURSING CARE OF CLIENTS WHO HAVE FLUID/ MAINTENANCE OF ACID‑BASE BALANCE
ELECTROLYTE/ACID‑BASE IMBALANCES
Acid‑base balance is maintained by chemical, respiratory,

CHAPTER 45 Acid‑Base and kidney function.

Imbalances Chemical (bicarbonate and intracellular fluid) and

protein buffers (albumin and globulins)
●● First line of defense

●● Either bind or release hydrogen ions as needed

For cells to function optimally, metabolic ●● Respond quickly to changes in pH

processes must maintain a steady balance Respiratory buffers

●● Second line of defense

between the acids and bases found in the body. ●● Control the level of hydrogen ions in the blood through

Acid‑base balance represents homeostasis of the control of CO2 levels

●● When a chemoreceptor senses a change in the level of

hydrogen (H+) ion concentration in body fluids. CO2, a signal is sent to the brain to alter the rate and
Hydrogen shifts between the extracellular and depth of respirations.
◯◯ Hyperventilation: Decrease in hydrogen ions (helps to

intracellular compartments to compensate blow of excess hydrogen ions)

for acid‑base imbalances. Minor changes in ◯◯ Hypoventilation: Increase in hydrogen ions

hydrogen concentration have major effects on Kidney buffers

●● Kidneys are the third line of defense.

normal cellular function. ●● This buffering system is much slower to respond, but

it is the most effective buffering system with the

Arterial pH is an indirect measurement of longest duration.
hydrogen ion concentration and is a result of ●● Kidneys control the movement of bicarbonate in

the urine. Bicarbonate can be reabsorbed into the

respiratory and kidney compensation function. bloodstream or excreted in the urine in response to
Arterial blood gases (ABGs) are most commonly blood levels of hydrogen.
●● Kidneys can also produce more bicarbonate

used to evaluate acid‑base balance. The pH is when needed.

the expression of the balance between carbon ◯◯ High hydrogen ions: Bicarbonate reabsorption

and production
dioxide (CO2), which is regulated by the lungs, ◯◯ Low hydrogen ions: Bicarbonate excretion

and bicarbonate (HCO3-), a base regulated by

the kidneys. The greater the concentration of COMPENSATION
hydrogen, the more acidic the body fluids and Compensation refers to the process by which the body
attempts to correct changes and imbalances in pH levels.
the lower the pH. The lower the concentration of ●● Full compensation occurs when the pH level of the

hydrogen, the more alkaline the body fluids and blood returns to normal (7.35 to 7.45).
●● If the pH level is not able to normalize, it is referred to

the higher the pH. as partial compensation.

45.1  Insufficient compensation

Respiratory compensation Metabolic compensation

H2O + CO2 H2CO3 H+ + HCO3‑

Water Carbon Carbonic Hydrogen Bicarbonate
dioxide acid ion

Expelled by lungs Expelled by kidneys

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 45  Acid‑Base Imbalances 281

 EXAMPLES Respiratory alkalosis: Hyperventilation
●● Metabolic alkalosis, metabolic acidosis, respiratory RESULTS FROM
alkalosis, and respiratory acidosis are examples of ●● Hyperventilation due to fear, anxiety, intracerebral
acid‑base imbalances. trauma, salicylate toxicity, or excessive
●● Acid‑base imbalances are a result of insufficient mechanical ventilation.
compensation. Respiratory and kidney function play a ●● Hypoxemia from asphyxiation, high altitudes, shock, or
large role in the body’s ability to effectively compensate early‑stage asthma or pneumonia.
for acid‑base alterations. Organ dysfunction negatively
RESULTS IN
affects acid‑base compensation. (45.1) ●● Decreased CO2
●● Decreased or normal H+ concentration

HEALTH PROMOTION AND MANIFESTATIONS

DISEASE PREVENTION ●● Vital signs: Tachypnea
●● Neurological: Inability to concentrate, numbness,
●● Encourage a healthy diet and physical activity.
tingling, tinnitus, and possible loss of consciousness
●● Limit the consumption of alcohol. ●● Cardiovascular: Tachycardia, ventricular, and atrial
●● Encourage drinking six to eight cups of water daily.
dysrhythmias
●● Maintain an appropriate weight for height and ●● Respiratory: Rapid, deep respirations
body frame.
●● Promote smoking cessation. NURSING CARE: Oxygen therapy, anxiety reduction
interventions, and rebreathing techniques

ASSESSMENT Metabolic acidosis

RESULTS FROM
RISK FACTORS ●● Excess production of hydrogen ions
●● Diabetic ketoacidosis (DKA)
Respiratory acidosis: Hypoventilation ●● Starvation
●● Lactic acidosis can result from:
RESULTS FROM ◯◯ Heavy exercise
●● Respiratory depression from opioids, poisons, ◯◯ Seizure activity

anesthetics ◯◯ Hypoxia
●● Clients who have brain tumors, cerebral ●● Excessive intake of acids
aneurysm, stroke or overhydration, trauma, ◯◯ Ethyl alcohol

or neurological diseases (myasthenia gravis, ◯◯ Methyl alcohol

Guillain‑Barré when respiratory effort is affected) ◯◯ Acetylsalicylic acid (aspirin)

●● Inadequate chest expansion due to muscle weakness, ●● Inadequate elimination of hydrogen ions
pneumothorax/hemothorax, flail chest, obesity, sleep ◯◯ Kidney failure

apnea, tumors, or deformities ◯◯ Severe lung problems

●● Airway obstruction that occurs in from neck edema, ●● Inadequate production of bicarbonate
or localized lymph node enlargement, foreign bodies ◯◯ Kidney failure

or mucus ◯◯ Pancreatitis
●● Alveolar‑capillary blockage secondary to a pulmonary ●● Impaired liver or pancreatic function: Liver failure
embolus, thrombus, acute respiratory distress syndrome, ●● Excess elimination of bicarbonate: Diarrhea
chest trauma, drowning, or pulmonary edema
●● Inadequate mechanical ventilation RESULTS IN
●● Decreased HCO3‑
RESULTS IN ●● Increased H+ concentration
●● Increased CO2
●● Increased or normal H+ concentration MANIFESTATIONS
●● Dysrhythmias
MANIFESTATIONS ●● Vital signs: Bradycardia, weak peripheral pulses,
●● Vital signs: Tachycardia (severe acidosis can lead to
hypotension, tachypnea
bradycardia), tachypnea, increased blood pressure ●● Neurological: Headache, drowsiness, confusion
●● Dysrhythmias: Ventricular fibrillation can be the first ●● Respiratory: Rapid, deep respirations
indication in a client receiving anesthesia.
(Kussmaul respirations)
●● Neurological: Anxiety, irritability, confusion, coma ●● Skin: Warm, dry, pink
●● Respiratory: Ineffective, shallow, rapid breathing
●● Skin: Pale or cyanotic NURSING CARE: Varies with causes. If DKA, administer
●● Chronic respiratory acidosis can be seen in clients who insulin. If related to GI losses, administer antidiarrheals
have pulmonary disease, sleep apnea, and obesity. and provide rehydration. If serum bicarbonate is low,
administer sodium bicarbonate 1 mEq/kg.
NURSING CARE: Oxygen therapy, maintain patent
airway, and enhance gas exchange (positioning
and breathing techniques, ventilatory support,
bronchodilators, mucolytics).

282  CHAPTER 45  Acid‑Base Imbalances CONTENT MASTERY SERIES

 Metabolic alkalosis PATIENT‑CENTERED CARE
RESULTS FROM
●● Base excess NURSING CARE
●● Oral ingestion of excess amount of bases (antacids)
For all acid‑base imbalances, it is imperative to treat the
●● Venous administration of bases (blood transfusions,
underlying cause.
total parenteral nutrition, or sodium bicarbonate)
●● Acid deficit
◯◯ Loss of gastric secretions (through prolonged INTERPROFESSIONAL CARE
vomiting, nasogastric suction) ●● Respiratory services can be consulted for oxygen
◯◯ Potassium depletion (due to thiazide diuretics,

therapy, breathing treatments, and ABGs.

laxative overuse, Cushing’s syndrome, ●● Pulmonology services can be consulted for
hyperaldosteronism)
respiratory management.
●● Increased digitalis toxicity

RESULTS IN
●● Increased HCO3‑
CLIENT EDUCATION
●● Decreased H+ concentration ●● Education can vary in relation to the client’s condition.
●● Encourage adherence to the prescribed diet and dialysis
MANIFESTATIONS
regimen for clients who have kidney dysfunction.
●● Vital signs: Tachycardia, normotensive or hypotensive ●● Encourage the client to weigh daily and notify the
●● Dysrhythmias: Atrial tachycardia, ventricular issues
provider if there is a 1‑ to 2‑lb (0.5 to 0.9 kg) gain in
when pH increases
24 hr or a 3‑lb (1.4 kg) gain in 1 week.
●● Neurological: Numbness, tingling, tetany, muscle ●● Promote smoking cessation if the client is a smoker.
weakness, hyperreflexia, confusion, convulsion ●● Teach the client to take medication as prescribed.
●● Respiratory: Depressed skeletal muscles resulting in
Encourage adherence to the medication regimen for
ineffective breathing
clients who have COPD.
NURSING CARE: Varies with causes (GI losses: administer ●● Set up referral services (home oxygen).
antiemetics, fluids, and electrolyte replacements). If related
to potassium depletion, discontinue causative agent.
COMPLICATIONS
DIAGNOSTIC PROCEDURES Convulsions, coma, and respiratory arrest
To determine the type of imbalance, follow these steps. (45.2)
NURSING ACTIONS
STEP 1: Look at pH. ●● Implement seizure precautions, and perform
●● If less than 7.35, identify as acidosis. management interventions if necessary.
●● If greater than 7.45, identify as alkalosis. ●● Provide life‑support interventions if necessary.

STEP 2: Look at PaCO2 and HCO3‑ simultaneously.

●● Determine which is in the expected reference range.
●● Conclude that the other is the indicator of imbalance.
●● Identify PaCO2 less than 35 or greater than 45 mm Hg as
respiratory in origin.
●● Identify HCO3‑ less than 22 or greater than 26 mEq/L as
metabolic in origin.

STEP 3: Combine diagnoses of Steps 1 and 2 to name the

type of imbalance. 45.2  Types of results
STEP 4: Evaluate the PaO2 and SaO2. If the results are less The following are the five classic types of ABG
than the expected reference range, the client is hypoxic. results demonstrating balance and imbalance.

STEP 5: Determine compensation as follows.

Step 2: Step 3:
●● Uncompensated: The pH is outside the expected Step 1: Determine which is Combine
reference range, and either the HCO3‑ or the PaCO2 is Look at pH in the normal range names
outside the expected reference range. pH PACO2 HCO3− DIAGNOSIS
●● Partially compensated: The pH, HCO ‑, and PaCO
3 2 are
7.35 to 7.45 35 to 45 22 to 26 Homeostasis
outside the expected reference range.
Less than Greater Respiratory
●● Fully compensated: The pH is within the expected 22 to 26
7.35 than 45 acidosis
reference range, but the PaCO2 and HCO3‑ are both outside
Less than Metabolic
the expected reference range. Looking at the pH will 35 to 45 Less than 22
7.35 acidosis
provide a clue as to which system initiated the problem, Greater Respiratory
Less than 35 22 to 26
respiratory or metabolic. If the pH is less than 7.40, think than 7.45 alkalosis
“acidosis,” and determine which system has the acidosis Greater Greater Metabolic
35 to 45
value. If the pH is greater than 7.40, think “alkalosis,” than 7.45 than 26 alkalosis
and determine which system has the alkalosis value.

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 45  Acid‑Base Imbalances 283

 Application Exercises
1. A nurse is caring for a client 2. A nurse is caring for a client who 4. A charge nurse is teaching a
admitted with confusion and was in a motor‑vehicle accident. The group of nurses about conditions
lethargy. The client was found at client reports chest pain and difficulty related to metabolic acidosis.
home unresponsive with an empty breathing. A chest x‑ray reveals the Which of the following statements
bottle of aspirin lying next to her client has a pneumothorax. Which by a unit nurse indicates the
bed. Vital signs reveal blood pressure of the following arterial blood gas teaching has been effective?
104/72 mm Hg, heart rate 116/min findings should the nurse expect? A. “Metabolic acidosis can occur
with regular rhythm, and respiratory A. pH 7.06 due to diabetic ketoacidosis.”
rate 42/min and deep. Which of PaO2 86 mm Hg B. “Metabolic acidosis can
the following arterial blood gas PaCO2 52 mm Hg occur in a client who has
findings should the nurse expect? HCO3− 24 mEq/L myasthenia gravis.”
A. pH 7.68 B. pH 7.42 C. “Metabolic acidosis can occur
PaO2 96 mm Hg PaO2 100 mm Hg in a client who has asthma.”
PaCO2 38 mm Hg PaCO2 38 mm Hg
HCO3− 28 mEq/L D. “Metabolic acidosis can
HCO3− 23 mEq/L
occur due to cancer.”
B. pH 7.48 C. pH 6.98
PaO2 100 mm Hg
PaCO2 28 mm Hg
PaO2 100 mm Hg 5. A nurse is assessing a client who has
PaCO2 30 mm Hg pancreatitis. The client’s arterial blood
HCO3− 23 mEq/L HCO3− 18 mEq/L gases reveal metabolic acidosis.
C. pH 6.98 D. pH 7.58 Which of the following are expected
PaO2 100 mm Hg PaO2 96 mm Hg findings? (Select all that apply.)
PaCO2 30 mm Hg PaCO2 38 mm Hg A. Tachycardia
HCO3− 18 mEq/L HCO3− 29 mEq/L
B. Hypertension
D. pH 7.58
PaO2 96 mm Hg 3. A nurse is obtaining arterial blood C. Bounding pulses
PaCO2 38 mm Hg gases for a client who has vomited for D. Hyperreflexia
HCO3− 29 mEq/L 24 hr. The nurse should expect which
E. Dysrhythmia
of the following acid‑base imbalances
to result from vomiting for 24 hr? F. Tachypnea
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis

PRACTICE  Active Learning Scenario

A nurse is caring for a client who has liver cancer. The client’s
arterial blood gases reveal metabolic acidosis. Use the ATI Active
Learning Template: System Disorder to complete this item.
RISK FACTORS: Include three conditions related to metabolic acidosis.
NURSING CARE: Include two nursing actions.
COMPLICATIONS: Identify one.

284  CHAPTER 45  Acid‑Base Imbalances CONTENT MASTERY SERIES

 Application Exercises Key
1. A. These arterial blood gases indicate metabolic alkalosis. PRACTICE Answer
B. These arterial blood gases indicate respiratory alkalosis.
C. CORRECT: An aspirin overdose would result in Using ATI Active Learning Template: System Disorder
arterial blood gas findings of metabolic acidosis.
RISK FACTORS
D. These arterial blood gases indicate metabolic alkalosis. Metabolic acidosis results from:
NCLEX® Connection: Reduction of Risk Potential,
●●
Excess production of hydrogen ions
Laboratory Values ●●
Diabetic ketoacidosis (DKA)
●●
Starvation
2. A. CORRECT: A pneumothorax can cause alveolar Lactic acidosis can result from:
hyperventilation and increased carbon dioxide levels, ●●
Heavy exercise
resulting in a state of respiratory acidosis. ●●
Seizure activity
B. These ABGs are within the expected reference ●●
Hypoxia
range and reflect homeostasis. ●●
Excessive intake of acids such as the following:
C. Metabolic acidosis is not indicated for this client. Ethyl alcohol
◯◯

D. Metabolic alkalosis is not indicated for this client. Methyl alcohol

◯◯

Acetylsalicylic acid (aspirin)

◯◯

NCLEX Connection: Reduction of Risk Potential,

®
●●
Inadequate elimination of hydrogen ions
Laboratory Values
Kidney failure
◯◯

3. A. Respiratory acidosis is not indicated for this client. Severe lung problems
◯◯

B. Respiratory alkalosis is not indicated for this client.

●●
Inadequate production of bicarbonate
Kidney failure
◯◯

C. Metabolic acidosis is not indicated for this client.

Pancreatitis
◯◯

D. CORRECT: Excessive vomiting causes a loss of gastric acids and an Impaired liver or pancreatic function
◯◯

accumulation of bicarbonate in the blood, resulting in metabolic alkalosis.

Liver failure
◯◯

NCLEX® Connection: Physiological Adaptation, ●●

Excess elimination of bicarbonate (diarrhea)
Fluid and Electrolyte Imbalances Metabolic acidosis results in:
●●
Decreased HCO3‑
4. A. CORRECT: Metabolic acidosis results from an excess production ●●
Increased H+ concentration
of hydrogen ions, which occurs in diabetic ketoacidosis.
NURSING CARE: Varies with causes. If DKA, administer
B. Respiratory acidosis can occur in a client who has myasthenia gravis.
insulin. If related to GI losses, administer antidiarrheals
C. Respiratory acidosis can occur in a client who has asthma. and provide rehydration. If serum bicarbonate is low,
D. Respiratory acidosis can occur due to cancer. administer sodium bicarbonate 1 mEq/kg.

NCLEX® Connection: Physiological Adaptation, COMPLICATIONS: Convulsions, coma, and respiratory arrest
Fluid and Electrolyte Imbalances Nursing Actions
Implement seizure precautions, and perform
●●

5. A. Tachycardia is an expected finding for a client who management interventions if necessary.

has respiratory acidosis or metabolic alkalosis. Provide life‑support interventions if necessary.
●●

B. Hypertension is an expected finding of respiratory acidosis.

NCLEX® Connection: Physiological Adaptation,
C. Bounding pulses is an expected finding for Fluid and Electrolyte Imbalances
respiratory acidosis due to hypertension.
D. Hyperreflexia is an expected finding for a
client who has metabolic alkalosis.
E. CORRECT: Dysrhythmia is an expected finding in a
client who has pancreatitis and metabolic acidosis.
F. CORRECT: Tachypnea is an expected finding in a
client who has pancreatitis and metabolic acidosis.

NCLEX® Connection: Physiological Adaptation,

Illness Management

RN ADULT MEDICAL SURGICAL NURSING CHAPTER 45  Acid‑Base Imbalances 285