ACID-BASE BALANCE

An overview
Respiratory acidosis and alkalosis
overview
• carbon dioxide---an acid
• carbon dioxide + water =carbonic acid.
• get rid of carbon dioxide exhaling
Respiratory acidosis and alkalosis
overview
Lungs: carbon dioxide.
In an acid–base imbalance such as respiratory
acidosis or alkalosis, the lungs are sick.
compensating organs:kidneys
manipulating the chemicals bicarbonate and
hydrogen to correct the imbalance and bring the pH
back into normal range
Respiratory acidosis and alkalosis
overview
This is done by secreting bicarbonate and
excreting hydrogen.
Kidneys: slow but effective
Metabolic acidosis and alkalosis
overview
• Kidneys: ORGANS in metabolic acidosis and
metabolic alkalosis
• Bicarbonate and hydrogen are considered
the
problem chemicals when the kidneys are
sick.
• compensating organs: lungs
• Lungs can blow off or retain carbon Dioxide
NORMAL VALUES:
• pH level
• 7.35 – 7.45

• PaCO2
• 35- 45 mmhg

• HCO3
• 22 – 26 mmhg
Respiratory acidosis
Respiratory
acidosis
• An acid–base imbalance that occurs when the
pH is decreased, partial pressure of carbon
dioxide (PCO2) is increased—greater than 45
mm Hg.
• When you hypoventilate…?
Carbon dioxide builds up in the blood:
Hypercapnia--buildup of carbon dioxide in the blood to
levels greater than 45 mm Hg.
Cause
s
• respiratory acidosis: “breathing”
• Decreased alveolar ventilation: carbon dioxide
retention
• Anytime poor gas exchange exists, CO2 builds up
in the blood Respiratory acidosis
Cause
s
• Respiratory arrest
• Some drugs (narcotics, sedatives hypnotics,
anesthesia, ecstasy)
• Sleep apnea
• Excessive alcohol
• Surgical incisions (especially abdominal), broken
ribs
Cause
s
• Collapsed lung (pneumothorax, hemothorax)
• Weak respiratory muscles (myasthenia gravis,
Guillain–Barré syndrome)
• Airway obstruction (poor cough mechanism,
laryngeal spasm)
• Brain trauma (specifically medulla)
• High-flow O2 in chronic lung disease
• Severe respiratory distress syndrome
Signs and
symptoms
Vary depending on the initial cause:
• Neurological changes: headache, confusion,
blurred vision, lethargy coma,
• Papilledema
• Hyperkalemia
• Decreased muscle tone; decreased DTRs
• Acute respiratory acidosis causes hyperkalemia.
With chronic respiratory acidosis, the K+ may
be normal as the kidneys have time to readjust
and get the K+ back into the normal range.
Signs and
symptoms
• Vary depending on the initial cause:
• Neurological changes: headache, confusion,
blurred vision, lethargy coma,
• Papilledema
• Hyperkalemia
• Decreased muscle tone; decreased DTRs
Signs and
symptoms
• Hypotension
• Restlessness; tachycardia
• Arrhythmias
• Cardiac arrest
• Acidic urine
• Warm skin
Diagnostic tests and treatments
• Treat the cause.
• Airway clearance: possible intubation.
• Administer drugs to open up the airways and
thin out secretions so they can be coughed up.
•
Increase fluids to liquefy secretions so they
can be coughed up more easily.
• Oxygen therapy.
Diagnostic tests and treatments
• Respiratory therapy: breathing treatments.
• Elevate head of bed (HOB) for lung expansion.
• Monitor ABGs.
• Monitor for electrolyte imbalances.
• Monitor pulse oximetry.
• Administration of Pulmocare: a tube feeding
sometimes used to decrease CO2 retention.
Diagnostic tests and treatments
MORE ON OXYGEN THERAPY
• low-dose oxygen-- chronic lung conditions
• high dose oxygen– acute lung conditions
What do the ABGs look
like?
• pH
• Less than 7.35
• PaCO2
• Greater than 45 mm Hg
• PaO2
• Less than 80 mm Hg
• HCO3
• Normal until kidney compensation starts; then will
start to rise above 26 mEq/L
What can harm my
client?
Respiratory arrest.
Arrhythmias: leading to cardiac arrest and shock.
Severe decrease in LOC.
Recap of respiratory
acidosis
• The name “respiratory” tips you off to the fact that a
lung problem exists
• Since it is a lung problem, the problem chemical is the
acid carbon dioxide
• Acidosis from a lung problem is due to irregular
breathing. Perhaps the client is hypoventilating—
breathing only 2 to 4 times a minute, causing
retention of carbon dioxide (CO2).
Recap of respiratory
acidosis
• Maybe the client has stopped breathing
altogether—possibly not exhaling carbon dioxide
(CO2) at all. The client retains all of this carbon
dioxide (CO2), which causes a buildup of acid in
the body
• This buildup of acid causes the pH to decrease.
Respiratory Alkalosis
Respiratory
alkalosis
• an acid–base imbalance where the PaCO2 is less
than 35 mm Hg and the pH is greater than
7.45.
• Decrease PaCO2 in the blood: excessive
exhalation—hyperventilation.
• When the lungs are impaired, the kidneys
compensate with their own chemicals—
bicarbonate and H+.
Respiratory
alkalosis
• The kidneys will excrete bicarbonate because
this is base/alkalotic.
• This excretion of the base will help raise acid
levels and restore the body to a normal pH.
• Respiratory alkalosis means that the client has
lost excessive CO2 (acid), thus making the client
alkalotic.
• Hypocapnia: occurs when the CO2 is low
Cause
s
• High altitudes • Hysteria; anxiety

• Anemia • High mechanical ventilator

setting
• Hypoxia • Aspirin overdose
• Labor and delivery • Fever
measures! • Sepsis
Signs and
symptoms
• Hyperventilation
• Light-headedness, dizziness fainting
• Rapid pulse
• Hypokalemia
• Arrhythmias
• Hypocapnia stimulates the autonomic nervous
system, which cause anxiety, changes in
respiration, tingling, and sweating.
• Calcium acts like a sedative. Hypocapnia
decreases serum calcium so the muscles may get
tight. This can lead to tetany and seizures!
Why do you breathe into the brown bag when
you are hyperventilating?
Diagnostic tests and treatments
• Treat the cause.
• Monitor vital signs, especially respirations.
• Monitor electrolytes.
• Administer antianxiety medications as ordered.
Diagnostic tests and treatments
• Place on mechanical ventilator to control
respiratory rate in severe cases.
• Monitor ABGs.
• Calm the client.
• Have client breathe into paper bag or rebreather
mask to encourage CO2 retention.
What do the ABGs look
like?
• pH
• Greater than 7.45 (alkalosis makes pH go up)
• PaCO2
• Less than 35 mm Hg (because it is being exhaled)
• PaO2
• Greater than 100 mm Hg
• HCO3
• Normal until kidney compensation starts; then will be
less than 22 mEq/L
Complication
s
• Life-threatening arrhythmias.
• Seizures.
Recap of respiratory
alkalosis
• The name “respiratory” tips you off to the fact that a
lung problem exists
• Since it is a lung problem, the problem chemical is the
acid carbon dioxide (CO2)
• Excessive exhalation causes PaCO2 to decrease in the
blood. Acid is lost.
• When the lungs are impaired, the kidneys compensate
with their own chemicals—bicarbonate and H+. The
kidneys will retain H+ because this is acid.
Recap of respiratory
alkalosis
• We want to keep acid since the body is losing acid
from the excessive exhalation.
• The kidneys will excrete bicarbonate—a base—in
order to create a more acidic environment and return
the pH to normal
• Respiratory alkalosis means that the client has lost
excessive CO2 (acid), thus making the client alkalotic
Metabolic Acidosis
Metabolic
acidosis
• An acid–base imbalance where the pH is less
than 7.35 and the bicarbonate level is less than
22 mEq/L.
• Acid (H+ ions) builds up in the body, or too
much bicarbonate has been lost from the body.
Metabolic
acidosis
• The less bicarb you have in the body, the more
acid you will be.
• Kidneys: Metabolic disorders
• Bicarbonate and H+
• The decrease in the alkaline substances (bases)
causes a build up of acids in the body, causing
acidosis.
• Lungs: compensate in just a few minutes
Cause
s
• Diabetic ketoacidosis, malnutrition, starvation
• Lactic acidosis
• Shock
• Kidney illness
Cause
s
• Gastrointestinal (GI) illness: diarrhea
• Drugs: Diamox, Aldactone
• Aspirin overdose
Signs and
symptoms
• if renal failure is the initial cause, you will see
signs and symptoms related to renal failure;
• if diabetic, ketoacidosis is the initial cause
Signs and
symptoms
• Hyperkalemia
• Arrhythmias
• Increased respiratory rate
• Headache, decreased LOC, coma
Signs and
symptoms
• Muscle twitching and burning, oral numbness,
weakness, flaccid paralysis (severe hyperkalemia)
• A Kussmaul’s respiration is an increase in rate and
depth of respiration.
• When Kussmaul’s respirations are present, CO2 is
being blown off in increased amounts.
Diagnostic tests and treatments
• Monitor ABGs.
• Treat the cause.
• Monitor and manage hyperkalemia.
• Monitor and manage arrhythmias.
• Monitor and manage hypercalcemia.
Diagnostic tests and treatments
• Administer sodium bicarbonate IV to decrease
acidity of blood.
• Monitor LOC closely.
• Administer lactated Ringers (LR) given IV to
increase base level.
• Institute seizure precautions (brain doesn’t like it
when the pH is messed up).
What do the ABGs look
like?
• pH
• Less than 7.35
• PaCO2
• Will decrease to less than 35 mm Hg as it is blown off
• PaO2
• Normal
• HCO3
• Less than 22 mEq/L
• Sodium bicarbonate:
• should be used only as a quick, temporary fix for
increased acid levels and should be given
according to specific ABG values rather than
generously as we used to do in the past during
code situations.
Complication
s
• Life-threatening arrhythmias.
• Cardiac arrest.
Recap of metabolic
acidosis
• The problem is with the kidneys, not the lungs.
• Bicarbonate (base) and H+ (acid) are associated
with the kidneys.
• Metabolic acidosis can be caused by loss of
bicarbonate through diarrhea, and renal
insufficiency.
Recap of metabolic
acidosis
• The decrease in the alkaline substances (bases)
causes a buildup of acids in the body. It can also
be caused by diseases that increase acid levels
(OFA)
• The lungs compensate increasing respiratory
rate and depth to blow off CO2 and increase pH.
This is called a Kussmaul’s respiration.
Metabolic alkalosis
Metabolic
alkalosis
• an acid–base imbalance where the pH is greater
than 7.45 and the bicarbonate level is greater
than 26 mEq/L.
• There is an excess of base in the body and a loss
of acid.
• Basically, pH is increased and bicarbonate is
increased.
Metabolic
alkalosis
• Metabolic: kidneys, which involve bicarbonate
and H+.
• The lungs compensate by retaining CO2 by
means of hypoventilation.
• This compensates for the alkalosis and helps the
pH go down into normal range.
Cause
s
• Vomiting; bulimia; nasogastric (NG) tube
suctioning
• Excess antacid ingestion
• Blood transfusions
• Sodium bicarbonate
• Thiazide and loop diuretics
Cause
s
• Baking soda
• Hypokalemia
• Activation of renin–angiotensin system
• Steroids
• Dialysis
• Licorice
Signs and
symptoms
• Arrhythmias, flattened T-wave
• Decreased respirations, hypoventilation
• Hypokalemia
• Tightening of muscles, tetany, LOC changes,
seizures, tingling in fingers and toes
• LOC changes
• Hepatic encephalopathy
What do the ABGs look
like?
• pH
• Greater than 7.45
• PaCO2
• Normal; increases with compensation
• PaO2
• Remains the same
• HCO3
• − Greater than 26 mEq/L
Diagnostic tests and treatments
• Treating the cause of the acid–base imbalance
(antiemetics for vomiting, etc.).
• Monitoring ABGs for further complications.
• Treating arrhythmias.
• Stopping client bicarbonate intake.
• Monitoring potassium levels and correcting
hypokalemia.
Diagnostic tests and treatments
• Monitoring respirations and LOC.
• Assessing for hypotension.
• Treating dehydration if present.
• Assessing DTRs.
• Administering ammonium chloride IV in severe cases
to increase acidity (increases H+).
• Administering acetazolamide (Diamox) to increase
excretion of bicarbonate through the kidneys.
Complication
s
Metabolic alkalosis can cause the following life-
threatening illnesses:
• Arrhythmias.
• Cardiac arrest.
• Seizures.
Recap of metabolic
alkalosis
• The problem is with the kidneys, not the lungs
• Bicarbonate (base) and H+ (acid) are associated
with the kidneys
Recap of metabolic
alkalosis
• Metabolic alkalosis can be caused by increased
bicarbonate through diuretic therapy, prolonged
nasogastric suctioning, and excessive vomiting,
resulting in ↑ pH levels
• The lungs compensate by retaining CO2 by
means of hypoventilation. This compensates for
the alkalosis
• Metabolic alkalosis is the most common acid–
base imbalance.
• It accounts for 50% of all acid–base
disturbances.
SUMMA
RY
• The respiratory and renal systems can be both
the cause and “cure” for pH imbalances.
• Remember that the lungs control carbon dioxide
levels and the kidneys control bicarbonate levels.
• By monitoring your client’s carbon dioxide,
bicarbonate, and pH levels you can successfully
prevent and treat any acid–base imbalances.
SUMMA
RY
• Acidosis:
• Think hyperkalemia and hypercalcemia.
• Alkalosis:
• Think hypokalemia and hypocalcemia.
EN
D