Adult Care Nursing I / Theory

Faculty of Nursing
First Semester
2021-2022

Lecture 2:
Fluid and Electrolytes: Balance
and Disturbance
 # Maintaining Acid–Base Balance

• Normal plasma pH 7.35 to 7.45, reflects hydrogen

ion concentration
• Kidneys and lungs balance the levels of carbon
dioxide, bicarbonate, and carbonic acid in the blood.
• Major extracellular fluid buffer system;
bicarbonate (HCO3)–carbonic acid (H2CO3) buffer
system, that keeps the pH of blood from becoming
too acidic or too basic

• With acidosis, chemical reaction goes to the left

• With alkalosis, chemical reaction goes to the right
The normal ratio of bicarbonate to carbonic acid is 20:1. As long
as this ratio is maintained, the pH remains within the normal
range of 7.35 to 7.45.
Maintaining Acid–Base Balance (cont’d)
• Kidneys regulate bicarbonate (HCO3) in ECF
– E.g.,in acidosis the kidneys excrete hydrogen
ions and conserve bicarbonate ions. In alkalosis,
the kidneys retain hydrogen ions and excrete
bicarbonate ions
• Lungs under control of medulla regulate CO2,
carbonic acid in ECF
– E.g., In metabolic acidosis, the RR rate
increases, causing greater elimination of CO2 (to
reduce the acid load). In metabolic alkalosis, the
RR decreases, causing CO2 to be retained
• Healthy regulatory systems (kidneys and lungs) will
attempt to correct ABI by a process called
Compensation
Maintaining Acid–Base Balance (cont’d)

• Other buffer systems

– ECF: inorganic phosphates, plasma proteins
– ICF: proteins, organic, inorganic phosphates
– Hemoglobin
Arterial Blood Gases (ABG)
Maintaining Acid–Base Balance (cont’d)

• Acidosis: an acid–base imbalance characterized by an

increase in H+ concentration (decreased blood pH) (A
low arterial pH due to reduced bicarbonate concentration
is called metabolic acidosis; a low arterial pH due to
increased PCO2 is called respiratory acidosis).
• Alkalosis: an acid–base imbalance characterized by a
reduction in H+ concentration (increased blood pH) (A
high arterial pH with increased bicarbonate concentration
is called metabolic alkalosis; a high arterial pH due to
reduced PCO2 is called respiratory alkalosis).
• Metabolic disorders:
– Concentration change of bicarbonate
 Metabolic Acidosis

• Low pH <7.35
• Low bicarbonate (HCO3) <22 mEq/L
• Causes: increased acids (e.g., uremia, ketoacidosis with
starvation, lactic acidosis), decreased Hco3 (e.g.,
diarrhea, diuretics)
• Manifestations:
– Headache, confusion, drowsiness, hyperkalemia
– Increased RR and depth (for compensation)
– Decreased BP, CO and dysrhythmias, shock in PH <
7
– patient may be asymptomatic until bicarbonate is 15
mEq/L or less
Metabolic Acidosis (cont’d)

• Management: Correct underlying problem, Bicarbonate

may be administered
• As acidosis is corrected, potassium shifts back into cell,
thus potassium levels decrease
• Monitor potassium levels
• Serum calcium levels may be low with chronic metabolic
acidosis
– Must be corrected before treating acidosis to avoid
Metabolic acidosis. Excess nonvolatile acids such as ketones or
lactic acid or a loss of bicarbonate ions increases H+ levels in body
fluids, causing the pH to fall.
 Metabolic Alkalosis

• High pH >7.45
• High bicarbonate (HCO3) >26 mEq/L
• Causes: gain of HCO3 (e.g., antacids containing Hco3, or
HCO3 use during CPR), a loss of H+ (e.g., vomiting,
gastric suction, hypokalemia). May also be due to
medications, especially long-term diuretic use
• Manifestations: symptoms related to decreased calcium,
respiratory depression (for compensation)and
hypoxemia, symptoms of hypokalemia, arrhythmias,
Metabolic Alkalosis (cont’d)

• Correct underlying disorder

• Supply chloride fluids to allow excretion of excess

bicarbonate

• Because of volume depletion from GI loss, the patient’s

I&O must be monitored carefully, restore fluid volume
with sodium chloride solutions

• Potassium chloride in patients with hypokalemia,

Metabolic alkalosis. Loss of acids (for example, loss of stomach
acid with vomiting) or excess bicarbonate ingestion decreases H+
levels in body fluids, causing the pH to rise.
Common Causes of and Compensation for Primary Acid–Base
Imbalances
 Respiratory Acidosis
• Low pH <7.35
• PaCO2 >45 mm Hg
• Always due to respiratory problem with inadequate
excretion of CO2, inadequate ventilation
• Causes of hypoventilation (pulmonary edema, COPD,
Atelectasis, overdose of sedatives, diseases that impair
respiratory muscles [e.g., myasthenia gravis)
• Symptoms may be suddenly increased pulse, respiratory
rate and BP, mental changes, high ICP, feeling of
fullness in head, or decreased level of consciousness,
hyperkalemia.
• With chronic respiratory acidosis (e.g. chronic obstructive
pulmonary disease (COPD)), CO2 gradually accumulate
over a prolonged period, thus body may compensate by
increase in the plasma HCO3 and the patients may be
asymptomatic
Respiratory Acidosis (cont’d)

• Treatment aimed at improving ventilation

(Bronchodilators, antibiotics for respiratory infection,
Pulmonary hygiene measures)
• Mechanical ventilation to improve ventilation
Respiratory Acidosis (cont’d)
Respiratory Acidosis. Hypoventilation and retained CO2
(increased PaCO2) increase H+ levels in body fluids, causing the
pH to fall.
 Respiratory Alkalosis
• High pH >7.45
• PaCO2 <35 mm Hg
• Always due to hyperventilation (excessive blowing off of
CO2).
• Causes: extreme anxiety, hypoxemia, inappropriate
ventilator settings, high fever
• Manifestations: lightheadedness, inability to concentrate
due to vasoconstriction and decreased cerebral blood
flow, numbness and tingling from hypocalcemia,
sometimes loss of consciousness, dysrhythmias
• Management: Correct cause of hyperventilation
• Anxiety-Instruct patient to breath more slowly or breath
into closed system (paper bag) to allow CO2 to
accumulate
Common Causes of and Compensation for Primary Acid–Base
Imbalances
 Arterial blood gas (ABG) analysis
1. Evaluate PH
– Less than 7.35 then acidosis
– More than 7.35 then alkalosis
– b/w 7.35 – 7.45 then normal or compensated
2. Determine the source of PH imbalance in relation to PH
– If Pco2 is abnormal then respiratory
– If Hco3 is abnormal then metabolic
3. Determine the source of compensation
– If Pco2 is abnormal then respiratory
– If Hco3 is abnormal then metabolic
 Maintaining Acid–Base Balance

– pH + HCO3 = Metabolic Acidosis

– pH + PaCO2 = Respiratory Acidosis
– pH + HCO3 = Metabolic Alkalosis
– pH + PaCO2 = Respiratory Alkalosis
 Maintaining Acid–Base Balance

• Example
– PH = 7.30, PCO2 = 50, Hco3 = 28
• Evaluate PH. It is less than 7.35 then acidosis
• Determine the source of PH imbalance. Pco2 is
high indicating acidosis while HCO3 is high
indicating alkalosis . The source is respiratory as
PH indicates also acidosis
• Determine the source of compensation. It is
metabolic
• It is respiratory acidosis, uncompensated
Examples

• Example 1:
– PaO2 = 90 mm Hg
– pH = 7.25
– PaCO2 = 50 mm Hg
– HCO3 = 22 mEq/L
– O2 sat = 96%
Interpretation

• Uncompensated respiratory acidosis

Examples

• Example 2:
– PaO2: 90 mmHg
– pH = 7.3
– pCO2 = 35 mm Hg
– HCO3- = 18 mEq / L
Interpretation

• Metabolic acidosis