MEDICAL SURGERICAL NURSING

LECTURE / NURS 13
PPTS / BOOK
ACID-BASE BALANCE • Measures the dissolved gases in your blood stream
• Provides one of the best measurements of the acid-base
OUTLINE balance in the body
I Acid-Base Balance
II Acid-Base Imbalances
A. Respiratory Acidosis
B. Metabolic Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
III How to Interpret ABG?
I. ACID-BASE BALANCE
• Homeostasis of the hydrogen ion concentration in the body
fluids
• The balance between input (intake and production) and output
(elimination) of hydrogen ion
• Hydrogen ion concentration is determined by the ratio of HOW TO DRAW ABG?
carbonic acid to bicarbonate in the extracellular fluid 1. Inform the client about the procedure and that there is no food
• The ratio needed for homeostasis is 1 part of carbonic acid to 20 or fluid restriction imposed
parts bicarbonates 2. Note if the client is taking coagulant therapy or aspirin as this
• The symbol used to indicate hydrogen ion balance is pH may affect results
• Measurement of the acidity, and the level of oxygen and carbon 3. Note if the client is receiving oxygen therapy (flow rate, type of
dioxide in the blood administration device), and the client’s current temperature
• Arterial blood gases determine whether a solution is acid, 4. Using a heparinized needle and syringe, collect 1-5 mL of
neutral, or alkaline arterial blood
→ More hydrogen ions = more acid 5. Put the syringe with arterial blood in an ice-water bag to
→ Fewer hydrogen ions = more alkaline minimize metabolic activity of the sample
6. Deliver the blood sample immediately to the laboratory
• The body has three systems that work to keep the pH in the
narrow range of normal 7. Apply pressure to the puncture site for 5 minutes or longer
→ Blood Buffers: Circulate throughout the body in pairs, WHAT IS PH?
neutralizing excess acids or bases by contributing or
accepting hydrogen ions
→ Lungs: By speeding up or slowing down respirations, the
lungs can increase or decrease the amount of CO2 in the
blood
→ Kidneys: They excrete varying amounts of acid or base
→ The three systems work together to maintain a normal
hydrogen ion concentration
• The lungs and kidneys work together to buffer the blood to keep
it from getting too alkaline or too acidotic
→ Carbon Dioxide (CO2) - acid regulated by the lungs
(Respiratory System) • The measurement of hydrogen ions in a solution like our blood
→ Bicarbonate (HCO3) - alkaline regulated by the kidneys • pH is measured on a scale of 0-14
(Metabolic System) • Pure water has a pH of 7.0 which is termed neutral
Terminologies Description • Our body solutions are slightly on the alkaline side but in a very
• Acidosis is an overproduction of acid that narrow range of 7.35-7.45 (normal blood pH)
builds up in the blood < 7.2 < 7.35 > 7.45 > 7.6
• Caused by an excessive loss of bicarbonate Death Acidosis Alkalosis Death
Acidosis from the blood (metabolic acidosis) or by a
buildup of carbon dioxide in the blood that II. ACID-BASE IMBALANCES
results from poor lung function or depressed RESPIRATORY ACIDOSIS
breathing (respiratory acidosis) • An acid-base imbalance characterized by increase partial
• Alkalosis is excessive blood alkalinity (base) pressure of arterial carbon dioxide and decreased blood pH
• Caused by an overabundance of
bicarbonate in the blood or a loss of acid ETIOLOGY
Alkalosis from the blood (metabolic alkalosis), or by a • Chronic obstructive respiratory disorders (COPD), such as
low level of carbon dioxide in the blood that bronchial asthma and emphysema
results from rapid or deep breathing • Acute disorders, such as chest-wall trauma, pulmonary edema,
(respiratory alkalosis) and Guillain-Barre syndrome
• The measure of carbon dioxide within arterial • Any condition that results in hypoventilation
or venous blood
Partial pressure
• It often serves as a marker of sufficient ASSESSMENT FINDINGS
of carbon
alveolar ventilation within the lungs
dioxide (PCO2) Acute Respiratory Acidosis Chronic Respiratory Acidosis
• Value of PCO2 ranges between 35 to 45
Increased pulse and
mmHg → respiratory rate → Weakness
• A byproduct of your body's metabolism
Increased blood
• Blood brings bicarbonate to your lungs, and → pressure → Dull headache
Bicarbonate
then it is exhaled as carbon dioxide Mental cloudiness and
(HCO3)
• Bicarbonate is excreted and reabsorbed by → feeling of fullness in head
your kidneys
NURRSING MANAGEMENT
BLOOD GAS 1. Prepare for and assist with therapy, as prescribed
• Blood drawn from artery (radial, brachial, or femoral) • Monitor ABG values
ASILO, CHESKA LYKA | BSN 3-1 1
 TRANS: MEDICAL SURGICAL NURSING (LECTURE)

• Improve ventilation with bronchodilators, postural IV. RESPIRATORY ALKALOSIS

drainage, antibiotic therapy to treat infection, regular • Acid-base imbalance characterized by decreased partial
coughing, turning and deep breathing, and mechanical pressure of arterial carbon dioxide and increased blood pH
ventilation as appropriate
ASSESSMENT FINDINGS
• Treat the underlying cause
• Treat chronic respiratory acidosis by administering low- Clinical Findings
flow oxygen therapy to prevent respiratory arrest → Lightheadedness •
→ Positive Chvostek’s sign
→ Example: client who has COPD and hypoxic stimulus → Inability to concentrate •
→ Muscle twitching
for breathing
2. Prevent injury → Convulsions
Laboratory and Diagnostic Findings
• Position the client in semi-fowler position or any
comfortable position to ease the working of breathing ABG reveals abnormal values: pH >7.45 and PaCO2 <35
→ mm/Hg
• Maintain a quiet, relaxing environment and cluster
activities to allow periods of uninterrupted rest NURSING MANAGEMENT
• Keep needed items within client’s reach 1. Prepare for and assist with therapy, as prescribed
• Monitor cardiovascular status: blood pressure, pulse rate, • Monitor ABG values
and rhythm, capillary refill time, and temperature and color
• Aim treatment at the underlying cause., such as
of extremities
decreasing pain, fever, and anxiety
• Monitor respiratory status: respiratory rate, rhythm, • Encourage the client to take slow, deep breaths
difficulty of breathing, level of consciousness, and
peripheral and buccal cyanosis • Treat chronic respiratory alkalosis the same with acute
respiratory alkalosis
• Maintain fluid and electrolyte balance → Clients with chronic alkalosis are usually
III. METABOLIC ACIDOSIS asymptomatic
• An acid-base imbalance resulting from excessive absorption of → Chronic respiratory alkalosis from chronic
acid or excessive excretion of bicarbonate (HCO3) hypocapnia (carbon dioxide level in your blood drops
below normal) resulting in decreased serum
EITOLOGY bicarbonate
• Ketoacidosis - develops when your body doesn't have enough 2. Prevent injury
insulin to allow blood sugar into your cells for use as energy • Assess respiratory rate and pattern
(common in T1 diabetes), leading to the liver breaking down fat • Institute and maintain seizure precautions as necessary
for fuel, a process that produces acids called ketones • Assess sources of anxiety and intervene to help reduce
• Lactic acidosis - lactic acid build up in the bloodstream; body anxiety
produces more lactate when your tissues are deprived of • Assist the client with activities as necessary
oxygen; lactate can also build up if your livers and kidneys aren’t
able to metabolize it efficiently V. METABOLIC ALKALOSIS
• Prolonged fasting - long-term fasting reduces the source of • Acid-base imbalance characterized by excessive loss of acid or
blood glucose, and decreases in insulin levels in the body can excessive gain of bicarbonate
mobilize fat decomposition; however, such fasting produces
ETIOLOGY
excessive ketone bodies during the process of fat decomposition
• Salicylic poisoning - it halts the electron transport chain in the • Loss of hydrogen and chloride ions because of prolonged
mitochondria, which results in in a buildup of lactic acidosis vomiting or gastric suctioning
• Oliguric renal disease - urinary output less than 400 ml per day • Excessive intake of alkali
or less than 20 ml per hour; kidneys are incapable of excreting → Antacids or baking soda
the acid load, resulting in a positive H+ balance and low total ASSESSMENT FINDINGS
CO2 concentration
• Abnormal HCO3 losses, which can occur in loss of fluid from Clinical Findings
Tingling of fingers and →
the lower GI tract from surgery, drains, or severe diarrhea → toes • Tetany
ASSESSMENT FINDINGS Dizziness, belligerence, •
→ and confusion
→ Slow, shallow respirations;
Clinical Findings possibly angina
→ Headache → Laboratory and Diagnostic Findings
•
Diminished cardiac output
→ Drowsiness with pH below 7, which Urine chloride
→ Weakness results in hypotension, cold concentrations help to
and clammy skin, and ABG reveals abnormal differentiate between
Increased respiratory
→ rate and depth cardiac arrythmias → values: pH >7.5 and → vomiting or diuretic
HCO3 <26 mEq/L ingestion or one of the
→ Dull headache → Nausea and vomiting causes of mineralocorticoid
Laboratory and Diagnostic Findings excess
ABG reveals abnormal
Serum potassium reveals NURSING MANAGEMENT
→ values: pH <7.35 and →
hyperkalemia
HCO3 <22 mEq/L 1. Prepare for and assist with therapy, as prescribed
• Monitor ABG values
NURSING MANAGEMENT • Monitor intake and output carefully
1. Prepare for and assist with therapy, as prescribed → Use a urometer if necessary
• Monitor ABG values • Provide treatment to correct the underlying cause as
• Administer sodium bicarbonate if appropriate ordered
• Monitor serum potassium level closely as acidosis is • Administer NaCl to restore normal fluid volume
reversed → Continuing volume depletion serves to maintain the
• Treat chronic metabolic acidosis by administering calcium alkalosis
to avoid tetany, use of alkalizing agents, and hemodialysis • Correct electrolyte deficits, particularly potassium and
or peritoneal dialysis sodium
→ Chronic metabolic acidosis is often seen with chronic • Treatment of chronic metabolic alkalosis is aimed a
renal failure treating the underlying acid-base disorder
2. Prevent injury → Chronic metabolic alkalosis is seen in long-term
• Monitor cardiovascular status: blood pressure, pulse rate, diuretic therapy, chronic ingestion of milk and
and rhythm, capillary refill time, and temperature and color calcium carbonate, and external drainage of gastric
of extremities fluids
• Institute safety precautions: keep bed side rails up, keep 2. Prevent injury
bed brakes locked, and secure all invasive lines properly • Monitor respiratory rate and pattern, and auscultate lung
sounds

ASILO, CHESKA LYKA | BSN 3-1 2

 TRANS: MEDICAL SURGICAL NURSING (LECTURE)

• Institute safety: keep bed side rails up, keep bed brakes
locked, and secure all invasive lines properly
III. HOW TO INTERPRET ABG?

Acidosis Normal Alkalosis

pH < 7.35 7.35 – 7.45 > 7.45
CO2 > 45 35 – 45 < 35
HCO3 < 22 22 – 26 > 26
ROME
Respiratory ↑ pH ↓ CO2 Alkalosis
Opposite ↓ pH ↑ CO2 Acidosis
Metabolic ↑ pH ↑ HCO3 Alkalosis
Equal ↓ pH ↓ HCO3 Acidosis

COMPENSATION

Uncompensated
When the pH value is out of normal range and CO2 or HCO3 is
within normal range
Partially Compensated
CO2, HCO3, and pH values are all out of range
Fully Compensated
The pH is within normal range

EXAMPLES
pH = 7.26 PaCO2 = 32 HCO3 = 18
↓ pH ↓ CO2 ↓ HCO3
Metabolic Acidosis, Partially Compensated
pH = 7.44 PaCO2 = 30 HCO3 = 21
↑ pH ↓ CO2 ↓ HCO3
Respiratory Alkalosis, Fully Compensated
pH = 7.1 PaCO2 = 40 HCO3 = 18
↓ pH ↑ CO2 ↓ HCO3
Respiratory Acidosis, Uncompensated

ASILO, CHESKA LYKA | BSN 3-1 3